Arcadia Care Aledo

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 Resident R6 didn't do anything to provoke Resident 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 Resident R5 was involved in a resident to resident physical altercation where Resident 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 Resident 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 Resident R7 and V8 (Housekeeper) in that Resident R7 had cursed at V8 regarding Resident R7's request for an additional glass of milk. Resident 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. Resident R7's abuse/neglect screen dated 06/24/2025 indicated that Resident R4 is a high risk for abuse/neglect.Resident R7's Minimum Data Set (MDS) Section C for Cognitive Patterns provided on 08/23/2025 indicated that Resident R7 has no cognitive impairment, dated 08/16/2025.Resident 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 Resident 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 Resident R7 had asked V8 for more milk and she informed him that he couldn't have anymore. Resident R7 then cursed at V8, V8 informed Resident R7 that she was not being mean to him and asked Resident 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 Resident 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 Resident 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 Resident R7 began wheeling himself down the hall, V8 yelled at Resident 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 .

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