Health inspection·November 5, 2025

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 observation, interview, and record review, the facility failed to protect the residents' right to be free from physical and mental abuse by another resident (R3). This applies to 3 out of 5 residents (R1, R2, and R4) reviewed for resident-to-resident abuse.The findings include:R3's EMR (Electronic Medical Record) said he was a 35 y.o. (year old) who admitted to the facility on [DATE]. R3's medical diagnoses included autism, schizophrenia, anxiety, and lack of expected normal physiological development in childhood. R3's EMR said he was non-verbal and ambulatory. R3's EMR continued to say that he required supervision for safety due to aggressive behaviors of throwing items, scratching, and hitting others. 1. R2's EMR said he was 70 y.o. with medical diagnoses of right knee osteoarthritis, unspecified intellectual disability, and impaired mobility. R2's EMR said he was cognitively intact and required substantial staff assistance with transfers.On 10/31/2025 at 11:10 AM, R2 was in bed and had linear scratch marks under his right eye. R2 said on 10/27/2025 at approximately 3 AM, R3 came to his room and, without provocation started to scratch his face. R2 said he yelled for help. R2 said facility staff intervened and escorted R3 out of his room. R2 said he feared R3 would return to his room but felt safe now that R3 was discharged from the facility. R2 said R3 had a known history of aggression towards other residents and staff. On 10/31/2025 at 1 PM, V14 (Certified Nurse Assistant/CNA) said R3 had known behaviors of throwing furniture and hurting others. V14 said R3 required constant supervision and had a 1:1 sitter for all shifts days prior, but recently the intervention was changed to only AM and PM shift. V14 said on 10/27/2025, R3 was throwing furniture in the hallway and then entered R2's room. V14 said she immediately responded to R2's call for help. V14 said R3 was attacking R2, and R2 sustained scratches under his right eye. V14 said she then escorted R3 back to his room.On 11/05/2025 at 9 AM, V11 (Nurse) said she was informed of R2 and R3's incident. V11 said R3 was observed prior to the incident, violently throwing furniture in the hallway. V11 said R3 no longer had a 1:1 sitter during the night shift because it was determined he was usually sleeping. V11 said she went to assess R2 after the incident, and R2 said R3 attacked him. V11 said R2 reported R3 had scratched his face and tried to choke him. The facility's investigation report dated 10/31/2025, said on 10/27/2025 at 3:30 PM, R3 entered R2's room. R2 said he was sleeping when he sustained scratches under his right eye from R3. The report said the allegation of physical abuse was not substantiated because no credible evidence that abuse occurred was identified. 2. R1's EMR said she was 81 y.o. with medical diagnoses of a right wrist fracture, falls, anxiety, and impaired mobility. R1's EMR said she was cognitively intact and required the use of wheelchair. On 10/31/2025 at 10:40 AM, R1 was in her wheelchair. R1 said a few weeks ago at approximately 6-7 PM, she encountered R3 in the hallway. R1 said R3 was throwing furniture in the hallway when he then followed her into her room. R1 said she was extremely scared as R3 started to attack her. R1 said she felt that R3 placed his hands on her throat, trying to choke her. R1 said the incident in her room was not Page 1 of 10 145221 145221 11/05/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few witnessed, but staff responded to her screams. R1 said she was extremely scared that evening because she feared R3 would return to her room. R1 said she reported the incident to facility management staff. R1 said she requested a room change and was moved to another unit on a different floor. R1 said she felt safe now because R3 was finally discharged from the facility.On 11/04/2025 at 2 PM, V17 (CNA) said she immediately responded to R1's call for help. V17 said she intervened before R3 made physical contact with R1. V17 said R3 was supposed to be monitored by his 1:1 sitter, but was not. V17 said R1 was emotionally startled and scared after the incident. On 11/04/2025 at 11:15 AM, V16 (CNA) said she was R3's assigned sitter on the evening of 10/17/2025. V16 said R3's behaviors were escalating; he was throwing furniture in the hall and trying to attack her. V16 said she stepped away from R3, and he was left unsupervised when he entered R1's room. V16 said R1 was extremely scared after the incident. On 10/31/2025 at 12:50 PM, V9 (Nurse) said she was discussing R3's 1:1 sitter intervention with V16 when R3 started to charge at R1 and followed her into her room. V9 said staff intervened and stopped R3 from making physical contact with R1. V9 said R1 was extremely upset, that she brought her to the nurse's station for the remainder of the shift (till 10:30 PM) to comfort her and reassure her of her safety. V9 said R1 continued to say R3 had attacked and choked her. V9 said R1 did not have any injury, and she reported the incident to V1 (Administrator) and V2 (Director of Nursing/DON). V9 said the following days she checked in on R1 because she was still concerned for her wellbeing, and R1 was still upset but felt better because she was moved to another unit. R3's progress note dated 10/17/2025 said Resident observed displaying aggressive behaviors, attempting to harm self and others.R1's progress note dated 10/18/2025 (after the incident) said R1 was displaying increased anxiety in the AM, and the provider was contacted for an as-needed anxiolytic.3. R4's EMR said he was 71 y.o. with medical diagnoses of left ankle and foot osteomyelitis, falls, and impaired mobility. R4's EMR said he was cognitively intact and supervision with ambulation with the use of an assistive device.On 11/04/2025 at 11:30 AM, R4 was interviewed over the telephone because he had been discharged home on 9/26/2025. R4 said on 9/11/2025 at approximately 10 AM, R3 physically attacked him in the therapy gym. R4 said he tried to block R3, but he sustained minor scratches under his right eye. R4 said the therapy staff was present and escorted R3 out of the gym. On 10/31/2025 at 3 PM, V7 (Physical Therapist Assistant/PTA) said she brought R3 to the therapy gym. V7 said R3 tried to grab her arms, but she avoided contact by walking away. V7 said R3, then turned towards R4 and tried to grab him. V7 said R3 made physical contact with R4, and R4 sustained scratches under his right eye. V7 said R3 was then escorted back to his room and placed on 1:1 for safety monitoring.The facility's investigation report dated 9/17/2025, said on 9/11/2025, R3 approached R4 with his arms. After their brief physical contact staff intervened. R4 sustained scratches under his right eye. The report said the allegation of physical abuse was not substantiated because no credible evidence that abuse occurred was identified.On 11/04/2025 at 10:30 AM, V3 (Assistant Director of Nursing/ADON) said R3 had recently admitted to the facility and required behavior management after he started to display behaviors of throwing items and aggression towards others. V3 said R3 required 1:1 continuous supervision after his aggressive behaviors started to escalate. V3 said R3's behaviors were unprovoked and unpredictable. V3 said R1's incident could have been prevented if R3's 1:1 supervision intervention had been maintained. V3 also said in retrospect, R2's incident could have also been prevented if R3's continuous 1:1 supervision would have been reimplemented after his known ongoing aggression. On 11/04/2025 at 11:50 AM, V2 (Director of Nursing/DON) said she assisted in the incident investigations involving R2 and R4. V2 said the facility determined the physical abuse allegations could not be substantiated. V2 said she was notified on 10/17/2025 of R3's behavior and did not interview or 145221 Page 2 of 10 145221 11/05/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few investigate R1 regarding her alleged statement. V2 said based on the facility staff statements, they did not believe R1's statement regarding the incident had occurred. On 11/04/2025 at 1:25 PM, V1 (Administrator) said she was the facility abuse coordinator. V1 said the facility management team was involved in abuse allegation investigations, and together they determined if abuse was substantiated based on the facility's policy. V1 said they investigate all types of abuse allegations, including physical and mental. V1 said R1's incident was reported to her, but was not investigated because it was reported staff had intervened. V1 said she did not follow up with R1 after the incident and was not aware she was fearful to return to her room after the incident. V1 said R1 was moved to another floor as requested days after the incident. V1 said they did not substantiate R2 and R4's incidents because she felt R3's physical contact was a result of his behavior of reaching out with his hands to get attention. V1 said she did not believe R3's behavior towards others was willful because of his medical condition of autism. V1 continued to say R3's unpredictable and unprovoked behaviors towards others were ongoing, and the facility had difficulty managing him. V1 said R3 was discharged to the hospital for behavioral management after R2's incident. R3's care plan initiated on 8/14/2025 said family reports known aggressive behavior towards others, of throwing, scratching, and hitting others. The care plan said the family to provide a 1:1 sitter. R3's reviewed and updated behavior care plan dated 9/22/2025 said his behavior intervention still required a 1:1 Companion.R3's Social Service progress note dated 10/27/2025, said the facility discharged R3 because he exhibits behaviors, bangs his own head against the wall and the back of his headboard, throws remotes, chairs, and anything he can get his hands on, has injured a staff member, and had become physically aggressive with two residents without provocation.The facility's policy titled Abuse Prevention Program Policy Definition dated 12/21/2019, said residents had the right to be free from abuse, including physical and mental abuse. The policy defined physical abuse as the infliction of injury on a resident that occurs other than by accidental means. Mental abuse is defined as verbal or nonverbal conduct that has the potential to cause intimidation and fear, which can include yelling or hovering over a resident. The policy also defines abuse as willful infliction of injury resulting in physical harm or mental anguish to a resident, irrespective of any mental or physical condition. The policy said, Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 145221 Page 3 of 10 145221 11/05/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

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 a resident's allegation of abuse by another resident (R3).This applies to 1 out of 5 residents (R1) reviewed for resident-to-resident abuse.The findings include:R3's EMR (Electronic Medical Record) said he was a 35 y.o. (year old) who admitted to the facility on [DATE]. R3's medical diagnoses included autism, schizophrenia, anxiety, and lack of expected normal physiological development in childhood. R3's EMR said he was non-verbal and ambulatory. R3's EMR continued to say that he required supervision for safety due to aggressive behaviors of throwing items, scratching, and hitting others. R1's EMR said she was 81 y.o. with medical diagnoses of a right wrist fracture, falls, anxiety, and impaired mobility. R1's EMR said she was cognitively intact and required the use of wheelchair. On 10/31/2025 at 10:40 AM, R1 was in her wheelchair. R1 said a few weeks ago, at approximately 6-7 PM, she encountered R3 in the hallway. R1 said R3 was throwing furniture in the hallway when he then followed her into her room. R1 said she was extremely scared as R3 started to attack her. R1 said she felt that R3 placed his hands on her throat, trying to choke her. R1 said the incident in her room was not witnessed, but staff responded to her screams. R1 said she was extremely scared that evening because she feared R3 would return to her room. R1 said she reported the incident to facility management staff. R1 said she requested a room change and was moved to another unit on a different floor. R1 said she felt safe now because R3 was finally discharged from the facility.On 11/04/2025 at 2 PM, V17 (CNA) said she immediately responded to R1's call for help. V17 said she intervened before R3 made physical contact with R1. V17 said R3 was supposed to be monitored by his 1:1 sitter but was not. V17 said R1 was emotionally startled and scared after the incident. On 11/04/2025 at 11:15 AM, V16 (CNA) said she was R3's assigned sitter on the evening of 10/17/2025. V16 said R3's behaviors were escalating; he was throwing furniture in the hall and trying to attack her. V16 said she stepped away from R3, and he was left unsupervised when he entered R1's room. V16 said R1 was extremely scared after the incident. On 10/31/2025 at 12:50 PM, V9 (Nurse) said she was discussing R3's 1:1 sitter intervention with V16 when R3 started to charge at R1 and followed her into her room. V9 said staff intervened and stopped R3 from making physical contact with R1. V9 said R1 was extremely upset, that she brought her to the nurse's station for the remainder of the shift (till 10:30 PM) to comfort her and reassure her of her safety. V9 said R1 continued to say R3 had attacked and choked her. V9 said R1 did not have any injury, and she reported the incident to V1 (Administrator) and V2 (Director of Nursing/DON). V9 said all abuse allegations were to be reported to V1. V9 said the following days she checked in on R1 because she was still concerned for her wellbeing, and R1 was still upset but felt better because she was moved to another unit. R3's progress note dated 10/17/2025 said Resident observed displaying aggressive behaviors, attempting to harm self and others.R1's progress note dated 10/18/2025 (after the incident) said R1 was displaying increased anxiety in the AM, and the provider was contacted for an as-needed anxiolytic.On 11/04/2025, the facility did not have an incident investigation regarding R1's abuse allegation. On 11/04/2025 at 10:30 AM, V3 (Assistant Director of Nursing/ADON) said R3 had recently admitted to the facility and required behavior management after he started to display behaviors of throwing items and aggression towards others. V3 said R3 required 1:1 continuous supervision after his aggressive behaviors started to escalate. V3 said R3's behaviors were unprovoked and unpredictable. V3 said R1's incident could have been prevented if his 1:1 supervision intervention had been maintained.On 11/04/2025 at 11:50 AM, V2 (Director of Nursing/DON) said she assisted in investigating the facility's abuse allegations. V2 said she was notified on 10/17/2025 of R3's behavior and did not interview or 145221 Page 4 of 10 145221 11/05/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few investigate R1 regarding her alleged statement. V2 said based on the facility staff statements, they did not believe R1's statement regarding the incident had occurred. On 11/04/2025 at 1:25 PM, V1 (Administrator) said she was the facility abuse coordinator. V1 said the facility management team was involved in abuse allegation investigations and reporting based on the facility's policy. V1 said they investigate all types of abuse allegations, including physical and mental. V1 said R1's incident was reported to her but was not investigated or reported because it was reported that staff had intervened. V1 said she did not follow up with R1 after the incident and was not aware she was fearful to return to her room after the incident. V1 said R1 was moved to another floor as requested days after the incident. The facility's policy titled Abuse Prevention Program Facility Policy and Procedure dated 01/04/2019, said the facility desired to prevent abuse by establishing a resident-sensitive environment, following up with identified concerns, and pattern assessments. The policy also said staff were required to report any incident, allegation, or suspicion of potential abuse to the administrator. And for the safety of others, they would take the following steps to protect residents who alleged abuse; initiate an internal investigation and external reporting of all allegations of abuse, including physical and mental. 145221 Page 5 of 10 145221 11/05/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

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 thoroughly investigate residents' allegations of abuse by another resident (R3). This applies to 3 out of 5 residents (R1, R2, and R4) reviewed for resident-to-resident abuse.The findings include:1. On 10/31/2025 at 11:10 AM, R2 was in bed and had linear scratch marks under his right eye. R2 said on 10/27/2025 at approximately 3 AM, R3 came to his room and, without provocation started to scratch his face. R2 said he yelled for help. R2 said facility staff intervened and escorted R3 out of his room. R2 said he feared R3 would return to his room but felt safe now that R3 was discharged from the facility. R2 said R3 had a known history of aggression towards other residents and staff. On 10/31/2025 at 1 PM, V14 (Certified Nurse Assistant/CNA) said R3 had known behaviors of throwing furniture and hurting others. V14 said R3 required constant supervision and had a 1:1 sitter for all shifts days prior, but recently the intervention was changed to only AM and PM shift. V14 said on 10/27/2025, R3 was throwing furniture in the hallway and then entered R2's room. V14 said she immediately responded to R2's call for help. V14 said R3 was attacking R2, and R2 sustained scratches under his right eye. V14 said she then escorted R3 back to his room.On 11/05/2025 at 9 AM, V11 (Nurse) said she was informed of R2 and R3's incident. V11 said R3 was observed prior to the incident, violently throwing furniture in the hallway. V11 said R3 no longer had a 1:1 sitter during the night shift because it was determined he was usually sleeping. V11 said she went to assess R2 after the incident, and R2 said R3 attacked him. V11 said R2 reported R3 had scratched his face and tried to choke him. R3's Social Service progress note dated 10/27/2025, said the facility discharged R3 because he exhibits behaviors, bangs his own head against the wall and the back of his headboard, throws remotes, chairs, and anything he can get his hands on, has injured a staff member, and had become physically aggressive with two residents without provocation.The facility's investigation report dated 10/31/2025, said on 10/27/2025 at 3:30 PM, R3 entered R2's room. R2 said he was sleeping when he sustained scratches under his right eye from R3. The report said the allegation of physical abuse was not substantiated because no credible evidence that abuse occurred was identified. 2. On 10/31/2025 at 10:40 AM, R1 was in her wheelchair. R1 said a few weeks ago at approximately 6-7 PM, she encountered R3 in the hallway. R1 said R3 was throwing furniture in the hallway when he then followed her into her room. R1 said she was extremely scared as R3 started to attack her. R1 said she felt that R3 placed his hands on her throat, trying to choke her. R1 said the incident in her room was not witnessed, but staff responded to her screams. R1 said she was extremely scared that evening because she feared R3 would return to her room. R1 said she reported the incident to facility management staff, but was never formally interviewed by management. R1 said she requested a room change and was moved to another unit on a different floor. R1 said she felt safe now because R3 was finally discharged from the facility.On 11/04/2025 at 2 PM, V17 (CNA) said she immediately responded to R1's call for help. V17 said she intervened before R3 made physical contact with R1. V17 said R3 was supposed to be monitored by his 1:1 sitter, but was not. V17 said R1 was emotionally startled and scared after the incident. On 11/04/2025 at 11:15 AM, V16 (CNA) said she was R3's assigned sitter on the evening of 10/17/2025. V16 said R3's behaviors were escalating; he was throwing furniture in the hall and trying to attack her. V16 said she stepped away from R3, and he was left unsupervised when he entered R1's room. V16 said R1 was extremely scared after the incident. V16 said she was never interviewed by management regarding the incident involving R1.On 10/31/2025 at 12:50 PM, V9 (Nurse) said she was discussing R3's 1:1 sitter intervention with V16 when R3 started to charge at R1 and followed her into her room. V9 said staff intervened and stopped R3 from making physical contact with R1. V9 said R1 was extremely upset, that she brought her to the nurse's station for the remainder of the shift (till Residents Affected - Few 145221 Page 6 of 10 145221 11/05/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10:30 PM) to comfort her and reassure her of her safety. V9 said R1 continued to say R3 had attacked and choked her. V9 said R1 did not have any injury, and she reported the incident to V1 (Administrator) and V2 (Director of Nursing/DON). V9 said the following days she checked in on R1 because she was still concerned for her wellbeing, and R1 was still upset but felt better because she was moved to another unit. R3's progress note dated 10/17/2025 said Resident observed displaying aggressive behaviors, attempting to harm self and others.R1's progress note dated 10/18/2025 (after the incident) said R1 was displaying increased anxiety in the AM, and the provider was contacted for an as-needed anxiolytic.On 11/04/2025, the facility did not have an incident investigation regarding R1's abuse allegation. 3. On 11/04/2025 at 11:30 AM, R4 was interviewed over the telephone because he had been discharged home on 9/26/2025. R4 said on 9/11/2025 at approximately 10 AM, R3 physically attacked him in the therapy gym. R4 said he tried to block R3, but he sustained minor scratches under his right eye. R4 said the therapy staff was present and escorted R3 out of the gym. On 10/31/2025 at 3 PM, V7 (Physical Therapist Assistant/PTA) said she brought R3 to the therapy gym. V7 said R3 tried to grab her arms, but she avoided contact by walking away. V7 said R3, then turned towards R4 and tried to grab him. V7 said R3 made physical contact with R4, and R4 sustained scratches under his right eye. V7 said R3 was then escorted back to his room and placed on 1:1 for safety monitoring.The facility's investigation report dated 9/17/2025, said on 9/11/2025, R3 approached R4 with his arms. After their brief physical contact staff intervened. R4 sustained scratches under his right eye. The report said the allegation of physical abuse was not substantiated because no credible evidence that abuse occurred was identified.On 11/04/2025 at 11:50 AM, V2 (Director of Nursing/DON) said she assisted in the incident investigations involving R2 and R4. V2 said the facility determined the physical abuse allegations could not be substantiated. V2 said V1 was the abuse coordinator and made the determination if abuse was determined. V2 said she was notified on 10/17/2025 of R3's behavior and did not interview or investigate R1 regarding her alleged statement. V2 said based on the facility staff statements, they did not believe R1's statement regarding the incident had occurred. On 11/04/2025 at 1:25 PM, V1 (Administrator) said she was the facility abuse coordinator. V1 said the facility management team was involved in abuse allegation investigations, and together they determined if abuse was substantiated based on the facility's policy. V1 said they investigate all types of abuse allegations, including physical and mental. V1 said R1's incident was reported to her, but was not investigated because it was reported staff had intervened. V1 said she did not follow up with R1 after the incident and was not aware she was fearful to return to her room after the incident. V1 said R1 was moved to another floor as requested days after the incident. V1 said they did not substantiate R2 and R4's incidents because she felt R3's physical contact was a result of his behavior of reaching out with his hands to get attention. V1 said she did not believe R3's behavior towards others was willful because of his medical condition of autism. V1 continued to say R3's unpredictable and unprovoked behaviors towards others were ongoing, and the facility had difficulty managing him. V1 said R3 was discharged to the hospital for behavioral management after R2's incident. R3's care plan initiated on 8/14/2025 said family reports known aggressive behavior towards others of throwing, scratching, and hitting others. The care plan said the family to provide a 1:1 sitter. R3's reviewed and updated behavior care plan dated 9/22/2025 said his behavior intervention still required a 1:1 Companion.The facility's policy titled Abuse Prevention Program Facility Policy and Procedure dated 01/04/2019, said the facility desired to prevent abuse by establishing a resident-sensitive environment, following up with identified concerns, and pattern assessments. The policy also said staff were required to report any incident, allegation, or suspicion of potential abuse to the administrator. And for the 145221 Page 7 of 10 145221 11/05/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few safety of others, they would take the following steps to protect residents who alleged abuse; initiate internal investigation and external reporting of all allegations of abuse, including physical and mental. The policy said the facility investigation procedure included interviewing the person who reported the incident or anyone likely to have direct knowledge of the incident. And the final investigation report's conclusion would be based on known facts, Facts determined during the process of investigation, review of medical record, and interview of witnesses. And after the investigation was completed, the facility would initiate a Quality Management Review with the goal of enhancing the living environment of the resident population. 145221 Page 8 of 10 145221 11/05/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement safety monitoring interventions for a resident with known aggressive behaviors towards others. This applies to 1 out of 4 residents (R3) reviewed for safety and supervision.The findings include:R3's EMR (Electronic Medical Record) said he was a 35 y.o. (year old) who admitted to the facility on [DATE]. R3's medical diagnoses included autism, schizophrenia, anxiety, and lack of expected normal physiological development in childhood. R3's EMR said he was non-verbal and ambulatory. R3's EMR continued to say that he required supervision for safety due to aggressive behaviors of throwing items, scratching, and hitting others. R3's care plan initiated on 8/14/2025 said family reports known aggressive behavior towards others, of throwing, scratching, and hitting others. The care plan said the family to provide a 1:1 sitter. R3's reviewed and updated behavior care plan dated 9/22/2025 said his behavior intervention still required a 1:1 Companion.R3's admission care plan progress note dated 8/26/2025, said R3's family informed the facility of R3's known aggression towards others. The note said, Brother states he is very weak right now, but when he feels better he will get aggressive.1. R4's EMR said he was 71 y.o. with medical diagnoses of left ankle and foot osteomyelitis, falls, and impaired mobility. R4's EMR said he was cognitively intact and supervision with ambulation with the use of an assistive device.On 11/04/2025 at 11:30 AM, R4 was interviewed over the telephone because he had been discharged home on 9/26/2025. R4 said on 9/11/2025 at approximately 10 AM, R3 physically attacked him in the therapy gym, unprovoked. On 10/31/2025 at 3 PM, V7 (Physical Therapist Assistant/PTA) said she brought R3 to the therapy gym. V7 said R3 tried to grab her arms, but she avoided contact by walking away. V7 said R3, then turned towards R4 and tried to grab him. V7 said R3 was then escorted back to his room and placed on 1:1 for safety monitoring.2. R1's EMR said she was 81 y.o. with medical diagnoses of a right wrist fracture, falls, anxiety, and impaired mobility. R1's EMR said she was cognitively intact and required the use of wheelchair. On 10/31/2025 at 10:40 AM, R1 was in her wheelchair. R1 said a few weeks ago at approximately 6-7 PM, she encountered R3 in the hallway. R1 said R3 was throwing furniture in the hallway when he then followed her into her room. R1 said she was extremely scared as R3 started to attack her. On 11/04/2025 at 2 PM, V17 (CNA) said she intervened before R3 made physical contact with R1. V17 said R3 was supposed to be monitored by his 1:1 sitter but was not. V17 said she then provided 1:1 supervision for R3 till the end of her shift at 10:30 PM. V17 said R3 no longer had an assigned sitter for the NOC shift (10:30 PM-6 AM).On 11/04/2025 at 11:15 AM, V16 (CNA) said she was R3's assigned sitter on the evening of 10/17/2025. V16 said R3's behaviors were escalating; he was throwing furniture in the hall and trying to attack her. V16 said she stepped away from R3, and he was left unsupervised when he entered R1's room. On 10/31/2025 at 12:50 PM, V9 (Nurse) said she was discussing R3's 1:1 sitter intervention with V16 when R3 started to charge at R1 and followed her into her room. V9 said staff intervened and stopped R3 from making physical contact with R1. V9 said R1 was extremely upset and continued to say R3 had attacked and choked her. V9 said R3 only had an assigned 1:1 sitter for the AM and PM, not the nighttime shift.R3's progress note dated 10/17/2025 said Resident observed displaying aggressive behaviors, attempting to harm self and others.On 10/31/2025 at 1:45 PM, V15 (CNA) said on 10/21/2025 she was R3's 1:1 sitter on the PM shift when he started attacking her. V15 said R3 was throwing furniture in his room and was difficult to redirect. V15 said R3 then pulled her hair so harshly it caused her severe neck and back pain. V15 said she had to scream for staff assistance because R3 could not be controlled. V15 said she was currently still out on medical leave due to her sustained injury from R3. 3. R2's EMR said he was 70 y.o. 145221 Page 9 of 10 145221 11/05/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with medical diagnoses of right knee osteoarthritis, unspecified intellectual disability, and impaired mobility. R2's EMR said he was cognitively intact and required substantial staff assistance with transfers.On 10/31/2025 at 11:10 AM, R2 was in bed and had linear scratch marks under his right eye. R2 said on 10/27/2025 at approximately 3 AM, R3 came to his room and, without provocation, started to scratch his face. R2 said R3 had a known history of aggression towards other residents and staff. On 10/31/2025 at 1 PM, V14 (Certified Nurse Assistant/CNA) said R3 had known behaviors of throwing furniture and hurting others. V14 said R3 required constant supervision and had a 1:1 sitter for all shifts, days prior, but recently the intervention was changed to only AM and PM shift. V14 said on 10/27/2025, R3 was throwing furniture in the hallway and then entered R2's room. V14 said R3 was attacking R2, and R2 sustained scratches under his right eye. V14 said she then escorted R3 back to his room.On 11/05/2025 at 9 AM, V11 (Nurse) said on 10/27/2025, R2 said R3 attacked him. V11 said R2 reported R3 had scratched his face and tried to choke him. V11 said prior to the incident, R3 was observed violently throwing furniture in the hallway. V11 said R3 no longer had a 1:1 sitter during the night shift because it was determined he was usually sleeping. V11 said R3 did continue to have a sitter during the AM and PM shifts for his known behaviors of aggression. On 11/04/2025 at 10:30 AM, V3 (Assistant Director of Nursing/ADON) said R3 had recently admitted to the facility and required behavior management after he started to display behaviors of throwing items and aggression towards others. V3 said R3 required 1:1 continuous supervision after his aggressive behaviors started to escalate. V3 said R3's behaviors were unprovoked and unpredictable. V3 said R1's incident could have been prevented if R3's 1:1 supervision intervention had been maintained. V3 also said in retrospect, R2's incident could have also been prevented if R3's continuous 1:1 supervision would have been reimplemented after his known ongoing aggression. On 11/04/2025 at 11:50 AM, V2 (Director of Nursing/DON) said R3's family reported they were unable to manage R3's behaviors at home. V2 said the facility became concerned for the safety of others because R3's behaviors were escalating. V2 said the facility then decided to implement a 1:1 sitter for all shifts on 9/22/2025 because they were unable to manage his behavioral needs. V2 said on 10/10/2025 administration decided to remove his assigned nightshift sitter because it was reported he was sleeping despite knowing that R3's behaviors were difficult to redirect and unpredictable. V2 said in retrospect, R3's 24-hr 1:1 sitter should have continued for the safety of himself and others. V2 said R3 was discharged on 10/27/2025 for behavior management after R2's incident. R3's behavior monitor log for October 2025 said R3 displayed behaviors of screaming, yelling, danger to others/self, and physical aggression on the nightshift on 10/04/2025, 10/10/2025, and 10/12/2025.R3's Social Service progress note dated 10/27/2025, said the facility discharged R3 because he exhibits behaviors, bangs his own head against the wall and the back of his headboard, throws remotes, chairs, and anything he can get his hands on, has injured a staff member, and had become physically aggressive with two residents without provocation.The facility's policy titled Behavior Management dated 01/2024, said the facility would determine the cause of behaviors when possible and initiate interventions to reduce, control, or prevent identified behaviors. In the event the behavior cannot be managed, staff will implement protocols to prevent the residents from harming self or others, which may take precedents over the procedures as written. The facility will initiate behavior monitoring and recording to provide a pattern of behaviors and responses to planned interventions when applicable. The facility to continue with 1:1 until dangerous symptoms are reduced and aggressive acts have been minimized, and no longer harm to self and others. 145221 Page 10 of 10