Health inspection·November 15, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview, and record review the facility failed to prevent staff physical abuse for one resident (R1) of three residents reviewed for abuse in the sample of four. Findings include: The facility's Abuse Prevention and Reporting policy and procedure, dated 9/2024, documents This facility affirms the right of our residents to be from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. This same policy documents Resident-to-Resident Abuse (of any type): A resident-to-resident altercation should be reviewed as a potential situation of abuse. Resident-to-resident altercations that include any willful action that results in physical injury, mental anguish, or pain must be reported in accordance with regulations. R1's medical record documents R1 with the following diagnoses: Dementia, Schizoaffective Disorder, Major Depressive Disorder, Anxiety disorder, and Generalized Idiopathic Epilepsy and Epileptic Syndromes. The Abuse/Neglect Screening for R1, dated 11/10/24, documents R1's risk measure for likelihood for a history of previous/recent mistreatment and/or potential future problems/symptoms related to mistreatment at a 6; Indicating high risk due to score greater than five. On 11/14/24 at 11:00 am, interview attempted with R1. R1 closed his eyes and when he opened his eyes, noted R1's eyes would roll up and only white sclera visible, then would lower eyes. R1 became tearful and began mumbling distorted words and not making sense. The initial Abuse Investigation for R1, dated 11/10/24 documents an allegation of physical abuse to R1 by V8 Agency CNA/Certified Nursing Assistant was reported to V1 Administrator on 11/10/24 at approximately 4:18 am by V7 Agency LPN/Licensed Practical Nurse. V7 Agency LPN reported that (V8 Agency CNA) was assisting (R1) when (R1) became combative during the transition, (V8 Agency CNA's) hand made contact with (R1's) head during assistance. (V8 Agency CNA) suspended immediately. Investigation initiated. Police notified and Responsible Parties notified. 5 day to follow. The Progress Note for R1, dated 11/10/24 at 4:03 am, documented by V7 Agency LPN documents (R1) (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 2 Event ID: 145442 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 145442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Toulon 700 E Main St Toulon, IL 61483 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)