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. Page 1 of 3 145732 145732 05/27/2025 Arc at Normal 509 North Adelaide Normal, IL 61761

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/27/25 at 11:52 AM, V5 CNA stated she was told by R1 that an employee had abused her by punching her in the chest. V5 stated She used that word, abused. (R1) seemed to be in her right mind and she asked me what she should do about it. I told her that I would report it to (V1) the Administrator and I did. I don't know what happened from there, I was never asked about it again. On 5/27/25 at 10:35AM, V1 Administrator stated she was told of the incident by V5 CNA on 5/8/25 and that she decided to complete a grievance instead of an abuse investigation. On 5/27/25 at 10:45AM, V4 CNA stated, That day I had (V3 CNA) go in with me to change R1 because she hits sometimes when being changed. When she started hitting, V3 held R1 down with her arms crossed over her chest so that I could change R1. We should have asked R1 to stop, or left and got someone else. I had never seen V3 do that to a resident before. On 5/27/25 at 11:30AM, V1 Administrator stated that the abuse should have been investigated as abuse as soon as V5 CNA reported it to V1 and that Knowing what I know now, it was abusive. On 5/27/25 at 11:45AM, V2 Director of Nursing stated the staff are not trained to grab and hold resident's bodies down so they can change them and that they need further education regarding abuse prevention and the abuse policy. 145732 Page 2 of 3 145732 05/27/2025 Arc at Normal 509 North Adelaide Normal, IL 61761

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, interview and record review the facility failed to report an allegation of abuse to the State Agency in a timely manner for one (R1) of three residents reviewed for abuse from a total sample list of nine residents reviewed. 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. When an allegation of abuse has occurred, the resident's representative and the (State Agency) shall be informed by telephone or fax. (The State Agency) shall be informed that an occurrence of potential abuse, has been reported and is being investigated. 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 her. On 5/27/25 at 10:40AM, R1 stated, That day there were two girls in here changing me and (V3) 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 10:45AM, V4 CNA stated, That day I had (V3 CNA) go in with me to change (R1) because she hits sometimes when being changed. When she started hitting, (V3) held (R1) down with her arms crossed over her chest so that I could change (R1). We should have asked (R1) to stop, or left and got someone else. I had never seen (V3) do that to a resident before. On 5/27/25 at 11:52 AM, V5 CNA stated she was told by R1 on 5/8/25 shortly after breakfast that an employee had abused her by punching her in the chest. V5 stated I told her that I would report it to (V1 Administrator) and I did. The facility provided abuse investigation documents an initial report of abuse to the state agency on 5/9/25 at 1:27PM. On 5/27/25 at 10:35AM, V1 Administrator stated she chose to fill out a grievance form on 5/8/25 instead of implementing an abuse investigation for R1's allegation of abuse. I didn't turn it into an abuse investigation until I spoke with the family the next day. On 5/27/25 at 11:30AM, V1 Administrator stated the abuse allegation should have been reported as abuse (to the state agency) as soon as V5 CNA reported it to her. 145732 Page 3 of 3