Health inspection·January 3, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a residents right (R3) to be free from Abuse by another resident (R1), for two (R1, R3) out of three residents reviewed for abuse in the sample list of nine residents. Findings include: The facility policy titled 'Abuse Prevention and Reporting', reviewed 9/2024, documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse: Abuse means any physical or mental abuse injury or sexual assault inflicted upon a resident other than by accidental means. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 12, moderate cognitive impairment and is able to propel self in wheelchair without assistance. R1's Incident Note dated 12/11/24 at 8:39pm documents V1 Administrator was notified of a R1 to R3 altercation. Residents representatives, Medical Doctor, local police department, and ombudsman notified. Residents separated immediately. Investigation initiated. R1's Nursing Note dated 12/11/24 at 10:15pm documents R1 went down A hall, into R3 and R4's room and kicked R3 in his left shin unprovoked and then attempted to steal property from the R4. R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview for Mental Status (BIMS) score 11, moderate cognitive impairment and is dependent of staff for transfers using a mechanical lift. R3's Incident Note dated 12/11/24 at 9:03pm documents V1 Administrator was notified of a resident-to-resident altercation. Residents representatives, Medical Doctor, local police department, and ombudsman notified. Residents separated immediately. Investigation initiated. R4's Minimum Data Set (MDS) date 12/10/24 documents R4's Brief Interview for Mental Status (BIMS) score 13, cognitively intact. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 145389 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Watseka 715 East Raymond Road Watseka, IL 60970 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)