Health inspection·June 11, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations of staff to resident physical abuse to the Administrator/Abuse Coordinator for one (R1) of four residents reviewed for abuse in a sample of four. Findings include: The facility's Abuse Prohibition Policy, Revised 3/15/18, documents: All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. Reporting - Allegations of Abuse and Neglect: 1. A facility employee or agent or covered individual who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) score of 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) On 6/11/25 at 9:50am, R1 indicated that a couple of weeks ago on Wednesday (5/28/25) two Black Certified Nursing Assistants/CNAs, one male and one female (names unknown-the male later identified by staff as V6 Agency CNA with description), were assisting her at bedtime around 8:30pm. R1 stated that while changing her, (V6) was rubbing her at first and then patted her bottom. R1 stated: I didn't appreciate that; told him to quit, he did and left the room and the girl finished; after that, did not want men taking care of me. Told him to get out and he did. On 6/11/25 at 11:35am, V12 Activity Director stated that at the 6/5/25 Resident Council Meeting, R1 patted R1's right thigh and said, I don't like it when they (Caregivers) do that. V12 stated that she did not get an explanation of R1's statement. V12 stated: Looking back, feel foolish and sorrowful; felt this was about R1's (full mechanical lift); she had also been talking about this, and there was a lot of cross talk with the other residents also talking in the meeting; my mind did not think regarding abuse; would have taken it to (V1 Abuse Coordinator) right away. On 6/11/25 at 12:05pm, V13 Activity Aide stated that when she visited R1 about two weeks ago, that R1 talked to her about two Black caregivers (Certified Nursing Assistants/CNAs), one a Black male. Stated that R1 said she did not like the big black one (male); that on the evening shift, they (two Black CNAs) came in and changed her; and (R1) said she did not like the Black male caregiver. V13 said okay; and then R1 said, I just wanted to let you know I did not like him. V13 stated that she did not let anyone else know about this conversation and did not report this. V13 stated, Thinking back (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: 146068 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 146068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunny Acres Nursing Home 19130 Sunny Acres Road Petersburg, IL 62675 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)