Arcadia Care Toulon

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to walk anymore since he was cold.On 9/16/2025 at 12:30 P.M., V2/Director of Nursing, confirmed on 7/18/25 she received an email concern from V19 that (Resident R2's) jacket was taken from him by V6 because (Resident R2) was attempting to exit the facility. V2 stated she called V6 to get her side of the story, but didn't investigate

the matter any further. V2 confirmed V6 took the jacket and staff shouldn't take personal items from residents to address behaviors.On 9/16/2025 at 3:00 P.M., V15/CNA stated sometime in the middle of June,

during shift change, V6 reported to me she took (Resident R2's) jacket and hung it in the shower room. When (Resident R2) wears his jacket (Resident R2) exit seeks more. I did see (Resident R2's) jacket hanging in the shower room at that time. (Resident R2) always complains of being cold, and (Resident R2) always wants to wear a jacket. For several weeks, back in June and July, (Resident R2) didn't have a jacket, and we were having (Resident R2) use a blanket to keep warm.On 9/16/2025 at 4:00 P.M., V6/Certified Nursing Assistant stated, I did take (Resident R2's) jacket from him because of wandering behaviors. When (Resident R2) has his jacket on (Resident R2) exit seeks more and makes attempts to leave the unit through

the inner doors and doors to the outside. V6 also stated she doesn't think (Resident R2) should have his jacket, since

it causes (Resident R2) to have behaviors.On 9/17/2025 at 10:00 A.M., V1/Administrator confirmed V6 did take (Resident R2's) jacket because of wandering behaviors.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Toulon

700 E Main St Toulon, IL 61483

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 ensure an allegation of abuse was immediately reported to the Administrator and the State Agency for one of three residents (Resident R2) reviewed for abuse in the sample of 5.FINDINGS INCLUDE:The facility's Abuse Prevention and Reporting- Illinois policy, dated 11/2016, documents Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must immediately report it to the administrator. The policy also documents, Any allegation of abuse or any incident that results

in serious bodily injury will be reported to the Department of Public Health immediately, but no more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.A facility Concern/Compliment Form, dated 7/18/2025, documents, Nature of concern, on 6/15/2025, V19/Resident R2's family and V7/Resident R2's Power of Attorney were visiting (Resident R2) and noticed (Resident R2) didn't have his jacket on. (Resident R2) was asking where his jacket was because (Resident R2) was cold. V6/Certified Nursing Assistant informed V19 and V7 that she took (Resident R2's) jacket from him because (Resident R2) wanted to leave the facility. V6 informed V19 and V7 that she hung (Resident R2's) jacket in the shower room and wasn't going to give it back.As of 9/17/2025, the facility has no documentation of Resident R2's allegation of potential abuse being reported to the state agency.On 9/16/2025 at 12:30 P.M., V2/Director of Nursing stated she received the complaint form on 7/17/2025 from V19. However, she didn't notify V1/Administrator until the next day.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Toulon

700 E Main St Toulon, IL 61483

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 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 investigate an allegation of potential abuse for one of three residents (Resident R2) reviewed for abuse, in the sample of 5.FINDINGS INCLUDE:The facility's Abuse Prevention and Reporting- Illinois policy, dated 11/2016, documents, Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.A facility Concern/Compliment Form, dated 7/18/2025, documents, Nature of concern, on 6/15/2025, V19/Resident R2's family and V7/Resident R2's Power of Attorney were visiting (Resident R2) and noticed (Resident R2) didn't have his jacket on. (Resident R2) was asking where his jacket was because (Resident R2) was cold. V7 says (Resident R2) lived with her for 8 years prior to nursing home placement, and (Resident R2) always wore a jacket around the house. V6/Certified Nursing Assistant informed V19 and V7 that she took (Resident R2's) jacket from him because (Resident R2) wanted to leave

the facility and was having exit seeking behaviors. V6 informed V19 and V7 that she hung (Resident R2's) jacket in

the shower room and wasn't going to give it back.As of 9/17/2025, the facility has no documentation of an investigation regarding Resident R2's allegation of potential abuse.On 9/17/2025 at 10:00 A.M., V1/Administrator confirmed she did not investigate Resident R2's allegation of potential abuse.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Toulon

700 E Main St Toulon, IL 61483

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

two-assist stand pivot for transfers. V17/CNA verified that Resident R4's Care Plan shows her (Resident R4) as using a (full mechanical lift) for transfers and R5s shows him as using a (full mechanical lift) for transfers. V17/CNA stated, Well he's (Resident R5) is not a (full mechanical lift) for transfers he is a two assist, he can stand. V17/CNA also stated that a nurse would need to watch the CNAs (Certified Nursing Assistant) do a transfer and document the assessment so it could be changed in the resident's care plan.On 9/17/25 at 10:00 AM, V18 (Certified Nursing Assistant/CNA) stated, (Resident R4) is a sit-to-stand lift for transfers and (Resident R5) is a two-assist stand pivot. I can't verify this as I don't know where to look on POC (Point of Care). I just go by word of mouth from other staff.On 9/17/25 at 10:10 AM, V2 (Director of Nursing/DON) verified that Resident R1, Resident R4 and R5s care plans have them as using the (full body mechanical lift) for transfers. V2/DON stated, There is a lack of communication amongst staff on how residents transfer but all of their (Resident R1, Resident R4 and Resident R5) care plans show them as (full body mechanical lifts). V2/DON also stated that the CNAs (Certified Nursing Assistant) have report sheets that show how each resident is to be transferred for them to refer to and should be using them.

Event ID:

Facility ID:

If continuation sheet