Health inspection·May 27, 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 observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse by a staff member for one (R1) of three residents reviewed for physical abuse from a total sample list of nine residents. Findings include: The facility Abuse Prevention and Reporting-Illinois Policy dated 5/2025 documents the facility affirms the right of our residents to be free from abuse. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent abuse by staff and mistreatment of residents. This will be done by identifying occurrences and patterns of potential mistreatment, immediately protecting residents involved in identified reports of possible abuse and implementing systems to promptly and aggressively investigate all reports and allegations of abuse and making the necessary changes to prevent future occurrences and filing accurate and timely investigative reports. Physical abuse is defined in this policy as the infliction of injury on a resident that occurs other than by accidental means including hitting, slapping, pinching, kicking and controlling behavior. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Minimum Data Set, dated [DATE] documents R1 is dependent for toileting care. The facility provided grievance form dated 5/8/25 documents sensitivity to R1's breastbone area due to V3 Certified Nurses Aide (CNA) being too rough with R1. The facility provided schedules document V3 and V4 CNAs worked on 5/6/25 and that V5 CNA worked on 5/8/25. On 5/27/25 at 10:40AM, R1 stated, That day there were two girls in here changing me and (V3 CNA) pushed down here (pointing to her sternum) real hard. R1's sternum appears to be very bony. R1 stated I feel like it was abusive and that other girl just watched her do it, it upset me. On 5/27/25 at 10:00AM, V13 Family Member stated that she was visiting with her grandmother on Wednesday, May 7, 2025 and R1 told her that when two of the girls were changing her yesterday, they were rough with her and hit her on the chest. V13 stated I called the facility and left a message for them to call me back. The next day (V1 Administrator) called me and told me that she had talked with (R1) and she didn't think it was abuse. We met with (V1) and told her what (R1) told us and then she said she would investigate it. (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 3 Event ID: 145732 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 145732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Normal 509 North Adelaide Normal, IL 61761 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)