Health inspection·December 12, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse for 1 of 5 residents (R2) reviewed for abuse in the sample of 6.Findings include:R2's Face sheet documented an admission date of 08/16/2025 to the facility. Diagnoses listed include: chronic atrial fibrillation, congestive heart failure, systemic lupus, osteoporosis, hypotension, gastro-esophageal reflux disease, low back pain, shortness of breath, chronic kidney disease stage 4, and aneurysm of ascending aorta.R2'S Minimum Data Set (MDS) dated [DATE] documented that R2 has a Brief Interview for Mental Status (BIMS) of 14, indicating R2 was cognitively intact.R2's Nurse note documented on 09/15/2025 that a call placed to local police department and physician to inform of abuse allegation. R2's nurse notes do not document anything further regarding R2's allegation of verbal abuse.A form titled State of Illinois Department of Public Health Long - term Care Facility and IID Serious Injury Incident Report dated 09-17-2025, documented this is a final reportable following and initial submitted on 09-15-2025 regarding an alleged abuse investigation. R2 alleged that a certified nurse assistant was being verbally abusive. R2's description of the certified nurse assistant did not match any employee that was scheduled on the days she alleged being abused. The facility was unable to substantiate the alleged abuse. Review of V1's (Administrator) abuse investigation file for R2 documented on 09/17/2025 R2 felt a staff member was not being nice to her. It goes on to document that R2 could recall that the girl had dark curly hair and white skin, and that R2 could not recall what was said. The file contained 18 documents that has staff across the top. Of the 18, 12 of the forms have a staff members name documented on it to indicate who was interviewed / asked the questions on the form. The remaining 6 did not have any identifying factors to know who gave the interview / or who filled out the questionnaire.On 12/11/2025 at 3:13 P.M. R2 stated the day she reported the abuse, the cna was wanting to give her a shower and she did not feel like it. R2 stated she was sick that day and did not want a shower. R2 stated the cna got in her face and stated loudly you are not sick. R2 stated another time she was supposed to wait for someone to walk with her from the bathroom to her bed. R2 stated when she finished using the rest room, she turned the call light on, stood up, cleaned herself, pulled her pants up and sat back down. R2 stated the same cna who yelled in her face came in and stated in a mean tone you haven't even went to the bathroom yet. R2 stated she tried to explain to the cna what she did. R2 stated that someone from the facility must have talked to the cna after she reported her because she stayed away from her for a couple days. R2 stated when the cna came back to work with her she was very nice and kind. R2 stated she is not sure what the outcome was after she reported the alleged abuse. R2 stated she did not know the cna's name, but she knew she had dark, curly hair and her skin was a tan light brown color. R2 stated the cna was not white. R2 stated she knew if she did not report it that it would be worse for her. R2 stated she wished she would have reported it the first time when the bathroom incident happened.On 12/11/2025 at 3:51 P.M., V1 (Administrator) stated she completed the abuse Residents Affected - Few Page 1 of 2 145247 145247 12/12/2025 Doctors Nursing & Rehab Center 1201 Hawthorn Road Salem, IL 62881

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few investigation for R2, who alleged she had been verbally abused. V1 stated some of the questionnaires had names on them and some did not. V1 stated she was told by a corporate person from the company that the interviews for the investigation can be anonymous. V1 stated staff did not want to put their names to the questionnaires. V1 stated she immediately starting interviewing staff, but staff did not want to cooperate. V1 stated she cannot force staff to cooperate with the investigation process and several of them would not sign their name to the investigation question sheet. V1 stated she talked to a lot of staff and does not remember who all she had fill out the questionnaire sheet. V1 stated she does not recall who all she interviewed, nor did she keep a list of the staff that was interviewed. On 12/12/2025 at 9:09 A.M. V1 stated she interviewed R2 when the incident happened. V1 stated she was told that the abuse occurred over a weekend, and she thought she talked to the staff that worked the weekend prior to the allegation but she cannot be sure that she did interview everyone who worked. V1 stated R2 told her the staff member was white, not a tan / darker skin person. V1 stated they have no staff that have white skin and dark curly hair. V1 stated she has a dark curly haired staff member with darker skin. V1 stated she thought that she interviewed that V12 (Certified Nurse Assistant) but isn't sure.On 12/12/2025 at 10:16 A.M. V12 (Certified Nurse Assistant) stated she did take care of R2 when she was at the facility. V12 stated she never had issues with R2. V12 stated she has never verbally abused R2 or any other resident. V12 stated she was never made aware that R2 has alleged someone had verbally abused her. V12 stated she was never questioned by V1 or any other staff member regarding R2's allegation. V12 stated she attended the facility meeting regarding abuse. V12 stated she was educated on abuse. V12 is documented on the schedule for working 09/13/2025 and 09/14/2025.On 12/12/2025 at 10:53 A.M. V7 (Regional Operations Director) stated the company has a policy that all staff have to participate in an investigation if they are asked to. V7 stated if a staff member refuses to answer questions about an abuse investigation they can be terminated. V7 stated V1 should know who she interviewed and who she did not interview. V7 stated it is her expectation that any staff member who is asked to fill out a questionnaire form about an abuse investigation sign their name to the sheet. On 12/12/2025 at 11:20 A.M. V13 (Certified Nurse Assistant) stated she worked with R2 some while she was a resident at the facility. V13 stated she was not made aware that R2 made an allegation of verbal abuse against a staff member. V13 stated she was never questioned about the allegation of verbal abuse. V13 is on the schedule for working 09/13/2025 and 09/14/2025. On 12/12/2025 at 12:16 P.M. V14 (Certified Nurse Assistant) stated she took care of R2. V14 stated that she was not aware that R2 had made an allegation of verbal abuse against a staff member. V14 stated she was not interviewed or asked about R2's allegation of abuse. V14 stated she remembers during a meeting, staff was asked about abuse and if they understood the policy and reporting.Facility Policy titled Abuse Prevention Program with a revision date of 11/26/2025 documents under section titled Internal Reporting Requirements and Identification of Allegations Upon learning of the report, the administrator shall initiate an incident investigation. Section 7 titled, Internal investigation of abuse, neglect or misappropriation allegations and response documents: f. Final Abuse Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within 5 working days of the reported incident. The final investigation will contain the following . Facts determined during the process of the investigation, review of the medical record and interview of witnesses .Attach a summary of all interviews conducted, with names, addresses, phone numbers and willingness to testify of all witnesses . 145247 Page 2 of 2