Inspection·August 23, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dining room and noted light purple bruising to R2's right outer eye area and a small laceration to R2's upper right eyelid. R2 was alert to self and was not interviewable. R2 did not recall any details related to the incident with R1. On 08/23/2025 at 11:05 AM, V3 (Licensed Practical Nurse) said on the day of incident between R1 and R2, she was in the nurse's office on the unit when she heard someone yell out. V3 said she went out into the day area and observed R2 in his wheelchair and saw R1 walking with his cane away from R2. V3 then indicated that V4 (Certified Nursing Assistant) witnessed the incident and informed V3 that R1 whacked R2 across the bridge of his nose with his cane. V3 added that both residents were seen by psych provider; R1 had a medication change that seems to be helping with his aggression. V3 also said that the injuries to R2's right eye were from another incident and not from incident with R2.On 08/23/2025 at 11:13 AM, V4 (CNA) said on day of the incident, she was coming up the short hall on unit when she saw R1 hit the top of R2's nose with his cane, then R2 yelled out ow. V4 added that R1 can be aggressive and uses his cane as a weapon and had hit other residents in the past with his cane. V4 added that R1's cane has since been taken away and R1 now uses a wheeled walker. V4 showed this surveyor R1's cane that was being stored in the nurse's office and indicated that padding was taped around the flat handle but R1 kept removing it. On 08/23/2025 at 04:01 PM, V1 (Administrator) said R1 was transitioned from his cane to a walker because he was using as his cane as a weapon. 2. Final abuse investigation report provided by facility on 08/23/2025 documented on 08/04/2025 at approximately 04:45 PM, V4 (CNA) was walking past R3's room when she observed R3 push R4. Residents were separated and assessed for injuries with no findings. R3's electronic face sheet printed on 08/23/2025 documented an admission date of 03/24/2023 with a past medical history not limited to: post-traumatic stress disorder, anxiety disorder, major depressive disorder, brief psychotic disorder, and dementia with behavioral disturbance. R3's Minimum Data Set (MDS) Section C for Cognitive Patterns provided on 08/23/2025 indicated that R3 has no cognitive impairment, dated 06/29/2025.R3's care plan detail reads in part: uses antidepressant medication, initiated 03/12/2025; has impaired cognitive function related to dementia, last revised 06/26/2025; is/has potential to be verbally aggressive, last revised on 06/29/2025; experiences intermittent episodes of hallucinating, last revised 07/10/2025; diagnosis of post-traumatic stress disorder with triggers of invading personal space/room, initiated 08/06/2025; is/has potential to be physically aggressive related to dementia and has poor impulse control, last revised on 08/06/2025.On 08/23/2025 at 01:48 PM, R3 said R4 is always flailing her arms at people, then said R4 was standing in her doorway, and R3 told her to leave. R3 denied pushing R4 on day of incident, then said she may have lightly touched her back.R4's electronic face sheet printed on 08/23/2025 documented an admission date of 07/02/2024 with a past medical history not limited to: dementia with agitation, major depressive disorder.R4's care plan detail reads in part: is/has potential to be physically and verbally aggressive, last revised on 04/21/2025; risk for falls related to gait/balance problems, last revised 05/29/2025; has behavior problem of wandering into other resident's rooms and personal spaces, last revised on 06/02/2025; has impaired cognitive function related to dementia with agitation, last revised 06/04/2025; high risk for abuse/neglect as noted from abuse screen score of 5 and history of peer involvement, last revised 07/11/2025. R4's Minimum Data Set (MDS) Section C for Cognitive Patterns provided on 08/23/2025 indicated that R4 has severe cognitive impairment, dated 06/16/2025.R4's abuse/neglect screen dated 08/05/2025 indicated that R4 is at high risk for abuse/neglect.On 08/23/2025 at 01:35 PM, V4 (CNA) said on day of the incident, she saw R4 go into R3's room then R3 tried to push R4 out of the room. V4 added that R3 indicated R4 called her a bitch. V4 called for the nurse and both residents were separated, and incident was reported to V1 (Administrator).On 08/23/2025 at 01:38 PM, V3 (LPN) said on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145886 If continuation sheet Page 2 of 4 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 145886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some day of the incident, she was told by V4 (CNA) that R4 went into R3's room and R3 tried to push R4 out of the room; R4 did not fall to the floor. V3 said she assessed R4 then notified all parties including V1, abuse coordinator. On 08/23/2025 at 01:44 PM, observed R4 seated in chair near nurse's office on dementia unit. R4 was alert to self and was not interviewable. R4 did not recall any details of incident with R3. 3. Final abuse investigation report provided by facility on 08/23/2025 documented on 07/28/2025 at approximately 06:00 PM, V5 (CNA) was assisting R6 out of the dementia unit dining room when R5 walked up to R6 and hit her with an open hand. Residents were separated.R5's electronic face sheet printed on 08/23/2025 documented an admission date of 02/16/2024 with a past medical history not limited to: Alzheimer's disease, anxiety disorder, dementia, and bipolar II disorder.R5's Minimum Data Set (MDS) Section C for Cognitive Patterns provided on 08/23/2025 indicated that R5 has severe cognitive impairment, dated 07/20/2025.R5's care plan detail reads in part: has impaired cognitive function/dementia or impaired thought processes, last revised 06/10/2025; has behavior problems that includes restlessness and pacing, last revised 06/17/2025; receives antipsychotic medication, last revised 06/24/2025; potential for aggressive behavior related to dementia and history of aggression towards others, last revised 07/11/2025; has a behavior problem that includes getting into peers personal space, cursing and gesturing/posturing towards others, calling names and pushing furniture/property, last revised 07/16/2025; has the potential to be verbally and physically aggressive, and have paranoid behaviors (pacing, increased anxiousness) last revised 07/24/2025; behavior problem for impulsiveness and potential to harm others, last revised 08/01/2025. R5's psychiatry note dated 07/30/2025 documented to start quetiapine 25 milligrams (mg) twice daily for bipolar disorder and start quetiapine 25mg every 12 hours as needed for 14 days for breakthrough agitation, insomnia and psychosis. R5's prescriber note dated 08/01/2025 documented to decrease 1:1 supervision to 15 minute checks for impulsivity and potential to harm others.R5's psychiatry note dated 08/18/2025 indicated, bipolar disorder is worsening and unstable at visit then documented to increase lithium to 300mg every morning and 600mg every evening.On 08/23/2025 at 01:42 PM, observed R5 seated in a rocking chair near nurse's office on dementia unit. R5 was alert to self and was not interviewable. R5 did not recall any details of incident with R6.R6's electronic face sheet printed on 08/23/2025 documented an admission date of 12/21/2021 with a past medical history not limited to: dementia with behavioral disturbance, Alzheimer's disease, brief psychotic disorder, anxiety disorder, disorganized schizophrenia, bipolar disorder, and restlessness and agitation. R6's Minimum Data Set (MDS) Section C for Cognitive Patterns provided on 08/23/2025 indicated that R6 has severe cognitive impairment, dated 06/21/2025.R6's care plan detail reads in part: has impaired cognitive function, last revised 06/26/2025; moderate risk for abuse/neglect, last revised 07/30/2025.R6's abuse/neglect screen dated 07/28/2025 indicated that R6 is at moderate risk for abuse/neglect.On 08/23/2025 at 01:46 PM, observed R6 lying in bed. R6 was alert to self and was not interviewable. R6 did not recall any details of incident with R5.On 08/23/2025 at 02:13 PM, V5 (Certified Nursing Assistant) said on day of incident, she was trying to push R6 out of the unit dining room and R5 was in the doorway, pacing back and forth in front of the door and wasn't wanting to clear the doorway. V5 indicated that she asked R5 several times to please move, then R5 started pushing at R6's knees. V5 added that she tried taking R6 out of dining room again when R5 came towards R6, hitting V5's arm but as she blocked R5 from hitting her, R5 hit R6 in the face with an open hand and caused R6 to yell out. V5 said she had called out to V6 (Licensed Practical Nurse) for help because she, couldn't control R5. V5 then said that 15 minute checks were started on R5 after he incident and indicated that R5 has a history of aggression with staff, hitting walls and furniture, etc. and has been on 15 minute checks previously because she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145886 If continuation sheet Page 3 of 4 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 145886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete pushed another resident down. V5 added that R6 didn't do anything to provoke R5. Multiple attempts were made on 08/23/2025 to interview V6 (LPN) without success; however, review of correspondence from V6 to physician dated 07/28/2025 documented that R5 was involved in a resident to resident physical altercation where R5 approached another resident, starting yelling and hitting resident in the head and pushing on the other resident knees. Resident being sent to [emergency department. (Review of progress notes showed R5 returned same day with no new orders). 4. Final abuse investigation report provided by facility on 08/23/2025 documented on 06/21/2025 at approximately 08:20 AM, V9 (Registered Nurse) overheard a verbal altercation between R7 and V8 (Housekeeper) in that R7 had cursed at V8 regarding R7's request for an additional glass of milk. R7's electronic face sheet printed on 08/23/2025 documented an admission date of 05/15/2025, discharge date of 08/16/2025 and a past medical history not limited to: history of transient ischemic attack and cerebral infarction, hypertension, and alcohol/nicotine dependence. R7's abuse/neglect screen dated 06/24/2025 indicated that R4 is a high risk for abuse/neglect.R7's Minimum Data Set (MDS) Section C for Cognitive Patterns provided on 08/23/2025 indicated that R7 has no cognitive impairment, dated 08/16/2025.R7's care plan detail reads in part: has episodes of depression, initiated 05/29/2025; high risk for abuse/neglect and history of involvement in peer incident, initiated 06/25/2025.On 08/23/2025 at 03:17 PM, V1 (Administrator) said R7 wanted more milk and V8 said he already had his milk for the morning, then R7called her a fucking bitch, and she asked him not to call her a fucking bitch. V1 added that V8 was suspended and written up after the investigation was completed because she used curse words at the resident.Multiple attempts were made on 08/23/2025 to interview V8 (Housekeeper) without success; however, facility provided V8's written statement dated 06/21/2025 that indicated R7 had asked V8 for more milk and she informed him that he couldn't have anymore. R7 then cursed at V8, V8 informed R7 that she was not being mean to him and asked R7 to stop peeing on the floor. V8's corrective action form dated 06/27/2025 documented final written warning in regards to disorderly behavior unprofessional language/behavior related to incident with R7 on 06/21/2025.Multiple attempts were made on 08/23/2025 to interview V9 (RN) without success; however, facility provided V9's written statement dated 06/21/2025 that documented V9 overheard V8 yelling at R7 the following, did you just call me a fucking bitch? You told me fuck you yesterday and now you're calling me a fucking bitch. V9 then indicated that while R7 began wheeling himself down the hall, V8 yelled at R7 to stop pissing on the floor. The facility's policy titled, Abuse Prevention and Reporting-Illinois with a revision date of 10/2022 showed, The 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. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by .establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment .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 . Event ID: Facility ID: 145886 If continuation sheet Page 4 of 4