Health inspection·March 1, 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 record review and interview the facility failed to protect a resident from resident-to-resident verbal abuse for one of three residents (R3) reviewed for abuse in the sample of seven. Findings include: The facility's Abuse Prevention and Reporting policy dated 09/2024 documents, This facility affirms the right of our resident to be free of 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. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. 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, and psychosocial well-being. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse included the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 is cognitively intact. R3's current Care Plan documents R3 has verbal aggression with staff and peers. R3's Nursing Note dated 2-8-25 at 1:01 AM and signed by V4 (Licensed Practical Nurse/LPN) documents, (V4) witnessed (R4) making rude comments to (R3) as (R3) walked down the long hall on (name of hallway). (R3) stated that she felt threatened by (R4's) comments so (R3) walked down to her room grabbed her cellphone and dialed 911. The police arrived and spoke with both residents (R3 and R4) that were involved in the verbal altercation. R3's Social Service Note dated 2-13-25 at 12:38 PM and signed by V7 (Social Service Director) documents, (R3) reported that (R4) Cussed (R3) out in the dining room. R4's MDS assessment dated [DATE] documents R4 is cognitively intact. R4's current Care Plan documents R4 has the potential to be verbally aggressive related to ineffective coping skills and poor impulse control. R4's Social Service Note dated 2-11-25 at 1:28 PM and signed by V7 (Social Service Director) Page 1 of 4 145811 145811 03/01/2025 Arcadia Care Peoria Heights 1629 East Gardner Lane Peoria Heights, IL 61616

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documents, (V7) followed up with (R4) about previously noted incident involving (R3). (R4) reported that (R3) smelled bad and it got to me, so I (R4) cussed (R3) out. R4's Social Service Note dated 2-13-25 at 1:39 PM and signed by V7 documents, (V7) followed up reason: (R3) who had reported (R4) Cussing (R3) out. (R4) admitted to this stating that (R3) Keeps disrespecting me. On 2-25-25 at 11:50 AM R3 stated, Every time I am around (R4) he cusses at me and calls me a b***h, fat, and stinky. I am tired of being harassed by (R4). On 2-27-25 at 11:30 AM V4 (LPN) stated, Every time (R4) walks by (R3), (R4) calls (R3) a f*****g b***. On 2-8-25 (R4) called (R3) a f*****g b***h twice while in the dining room. (R4) makes fun of (R3) for being fat and tells (R3) her feet stink. On 2-27-25 at 11:40 AM V7 (Social Service Director) stated, (R3) reported to me that (R4) cussed at her in the dining room. (R4) said she is f*****g disgusting and that led to a verbal altercation between them (R3 and R4). I spoke to (R4), and he did admit that he called (R3) f*****g disgusting. (R3) reports that (R4) has yelled at her again in the dining room. (R3) says it is distressing to her. (R3) is claiming (R4) is harassing her. On 2-28-25 at 11:18 AM R4 stated, I don't like (R3). (R3) has dirty feet and is fat. I do not give a f**k about (R3). I have freedom of speech. When I see (R3) I tell (R3) she is a fat b***h and nasty. (R3) p****s me off for being so nasty. 145811 Page 2 of 4 145811 03/01/2025 Arcadia Care Peoria Heights 1629 East Gardner Lane Peoria Heights, IL 61616

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 interview and record review the facility failed to implement their Abuse Policy to immediately report an allegation of resident-to-resident abuse to the State Surveying Agency for two of three residents (R3 and R4) reviewed for reporting of abuse in the sample of seven. Findings include: The facility's Abuse Prevention and Reporting policy dated 09/2024 documents, Any allegation of abuse or any incident that results in serious bodily injury will be reported to the (state surveying agency) immediately, but not more than two hours after the allegation of abuse. R3's Nursing Note dated 2-8-25 at 1:01 AM and signed by V4 (Licensed Practical Nurse/LPN) documents, (V4) witnessed (R4) making rude comments to (R3) as (R3) walked down the long hall on (name of hallway). (R3) stated that she felt threatened by (R4's) comments so (R3) walked down to her room grabbed her cellphone and dialed 911. The police arrived and spoke with both residents (R3 and R4) that were involved in the verbal altercation. R4's Social Service Note dated 2-11-25 at 1:28 PM and signed by V7 documents, (V7) followed up with (R4) about previously noted incident involving (R3) on 2-8-25. (R4) reported that (R3) smelled bad and it got to me, so I (R4) cussed (R3) out. R4's Social Service Note dated 2-13-25 at 1:39 PM and signed by V7 documents, (V7) followed up reason: (R3) who had reported (R4) Cussing (R3) out. (R4) admitted to this stating that (R3) Keeps disrespecting me. R3's Social Service Note dated 2-13-25 at 12:38 PM and signed by V7 (Social Service Director) documents, (R3) reported that (R4) Cussed (R3) out in the dining room. The facility's Abuse Investigations along with R3 and R4's Electronic Medical Records dated 2-1-25 through 2-27-25 were reviewed and do not include evidence of R3 and R4's verbal abuse altercations on 2-8-25 and 2-13-25 being reported to the State Surveying Agency. On 2-27-25 at 11:47 AM V1 (Administrator) stated R3 and R4's verbal abuse altercations on 2-8-25 and 2-13-25 were not reported to the state surveying agency. 145811 Page 3 of 4 145811 03/01/2025 Arcadia Care Peoria Heights 1629 East Gardner Lane Peoria Heights, IL 61616

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement their Abuse Policy to thoroughly investigate an allegation of resident-to-resident abuse for two of three residents (R3 and R4) reviewed for investigating abuse in the sample of seven. Residents Affected - Few Findings include: The facility's Abuse Prevention and Reporting policy dated 09/2024 documents, Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. R3's Nursing Note dated 2-8-25 at 1:01 AM and signed by V4 (Licensed Practical Nurse/LPN) documents, (V4) witnessed (R4) making rude comments to (R3) as (R3) walked down the long hall on (name of hallway). (R3) stated that she felt threatened by (R4's) comments so (R3) walked down to her room grabbed her cellphone and dialed 911. The police arrived and spoke with both residents (R3 and R4) that were involved in the verbal altercation. R4's Social Service Note dated 2-11-25 at 1:28 PM and signed by V7 (Social Service Director) documents, (V7) followed up with (R4) about previously noted incident involving (R3) on 2-8-25. (R4) reported that (R3) smelled bad and it got to me, so I (R4) cussed (R3) out. R4's Social Service Note dated 2-13-25 at 1:39 PM and signed by V7 documents, (V7) followed up reason: (R3) who had reported (R4) Cussing (R3) out. (R4) admitted to this stating that (R3) Keeps disrespecting me. R3's Social Service Note dated 2-13-25 at 12:38 PM and signed by V7 documents, (R3) reported that (R4) Cussed (R3) out in the dining room. The facility's Abuse Investigations along with R3 and R4's Electronic Medical Records dated 2-1-25 through 2-27-25 were reviewed and do not include evidence of R3 and R4's verbal abuse altercations on 2-8-25 and 2-13-25 being investigated. On 2-27-25 at 11:47 AM V1 (Administrator) stated R3 and R4's verbal abuse altercations on 2-8-25 and 2-13-25 were not investigated. 145811 Page 4 of 4