Health inspection·March 27, 2024

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 interview and record review the facility failed to ensure residents were free from abuse, for 2 of 2 residents (R2 and R13) reviewed for abuse, in the sample of 18. Findings include: On 3/26/2024 at 10:30AM, V15 (Licensed Practical Nurse/LPN) stated that R2 was aggressive and combative often. She also stated that his roommate, R13, may have been sitting in wheelchair going through doorway, but it wasn't intentional, trying to keep R2 out and that the television was outside the room and R13 was probably just watching it. On 3/27/2024 at 1:25PM, V17 (LPN) stated, I was working the night of the altercation between (R2 and R13). I heard (R13) say He hit me. I did not see (R2) hit (R13). The employees were in the common area with the residents. There were no injuries, and the Administrator came in and moved (R2) to a different floor. On 3/22/2024 at 4:00PM, V1 (Administrator) stated that R2 was the aggressor in the altercation with R13 and that it wasn't even an altercation they just bumped into each other. V1 continued to state that R2 was always accommodated and after the incident with R2 and R13, she had to separate them and R2 was moved to give him space and his own room. She continued to state that she personally came in after the altercation with R2 and R13 and moved R2 herself and his daughter and Grandson came in and that she set the room up so they could spend the night. V1 continued to state that R2 did much better after the move. He had less behaviors but R2 eventually moved back to the original floor because the family could not afford a private room. The facility's investigation, dated 4/29/2023, documented, On 04/29/23 at approximately 7:00PM (R2 and R13) started to get into a verbal argument while sitting in the common space. The nurse alerted the CNA's who immediately went to separate the two residents from each other. During separating the (R2) swatted (R13) in (R13's) face. The nurse assessed (R13) for injury, no visible injuries noted. Skin assessment complete. MD and family made aware. (Local Police department) notified around 7:30PM. Police report #23-11967. Notified (R2's) family that he will need to have a private room, and or a sitter due to behaviors. Arranging private room for (R2). Family present with (R2) for the night. R2's nurse's notes, dated 4/30/2023 at 12:56AM, documented, (R2) was seen bypassing (R13) in common area by the bird cage. (R2 and R13) began to argue with one another. Nurse heard the commotion yelled for staff to separate residents. At this time nurse did observe residents start a scuffle while being separated. Then (R13) yelled that (R2) hit him in the face. CNA (Certified Nursing Assistant), (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: 146142 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 146142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meridian Village Care Center 27 Auerbach Place Glen Carbon, IL 62034 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)