Health inspection·April 2, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety 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 prevent abuse for one resident (R2) of three residents reviewed for abuse in a sample of 15. This failure resulted in R2 being sent to the hospital diagnosed with an orbital fracture and suffering psychosocial harm that any reasonable person would after being abused. This past non-compliance, which involved R2, occurred from 3/09/23 to 3/14/23. This failure resulted in an Immediate Jeopardy. Prior to the survey date of 3/29/2024, the facility had taken the following actions to correct the non-compliance: 1) Immediate actions taken for those residents identified: On 3/9/24, R2 was assessed and sent to the hospital. On 3/11/24, R2's Abuse screening and Care Plan were reviewed and updated accordingly. On 3/9/24 R1 was assessed and placed on a 1:1 until he was sent to the hospital. On 3/9/24 when R1 returned from the hospital R1 was placed on a 1:1 and remains on 1:1. On 3/11/24 R1's Abuse screening and Care Plan were reviewed and updated accordingly. 2) Measures put into place/System changes: On 3/11/24 the Interdisciplinary Team reviewed the Facility's Abuse Prevention Policy with no changes needed at this time. On 3/13/24 V16 (Assistant Director of Nursing) reeducated all staff on the Facility Abuse Prevention Policy. On 3/12/24 the Interdisciplinary Team reviewed and updated all residents current abuse screenings. On 3/13/24 A Quality Assurance and Performance Improvement meeting was held with V12 (Medical Director) to discuss alleged allegation and facility comprehensive follow up. V1 (Administrator), V2 (Director of Nursing), V12 (Medical Director), and V16 (Assistant Director of Nursing) were in attendance. On 3/14/24 the Interdisciplinary Team reviewed and discussed Medical Records of referrals prior to admitting to ensure resident safety and well-being of residents with Dementia. On 3/14/24 the Interdisciplinary Team reviewed and discussed any New Admission's Abuse Screenings and Psychosocial Screenings to ensure resident safety and well-being of residents with Dementia. On 3/13/24 V16 (Assistant Director of Nursing), interviewed all residents to ensure they feel safe and report no similar occurrences. Findings Include: The Abuse Prevention and Reporting policy dated 11/28/16, documents The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and Page 1 of 5 145248 145248 04/02/2024 Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used and this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The Final Abuse Investigation Report sent to (the State Agency) dated 3/9/24, documents that R2 a [AGE] year-old female was physically abused by R1. On 3/9/24, at 1:38 PM, (R1) came out of his room in his wheelchair to use the phone at the nurses station. (R2) was sitting at the nurse's station also. After hanging the phone up (R1) rolled his wheelchair backwards. (R2) moved her chair backward to get out of (R1's) way. When (R1) got turned around (R1) noticed (R2) sitting in her wheelchair. (R1) then moved toward (R2) ultimately making contact. Staff immediately ran to separate the two residents. (R1) then fell out of his wheelchair onto the floor. R2 had an abrasion to the bridge of her nose. On 3/29/24 at 2:40 PM, the video was observed of the incident between R1 and R2. R2 was sitting in the hall near the nurse's desk. R1 wheeled past R2 and went to the nurse's desk to use the phone. When R1 hung the phone up he was backing up in his wheelchair. R2 was backing up to move out of R1's way. R1 turned his wheelchair around and looked like R1 was going to go past R2. Suddenly R1 raised his fist towards R2. R2 put her hands up in front of her face. Quickly R1 grabbed R2's shirt with his left hand at her right shoulder so R2 could not move away from R1. R1 leaned forward in his wheelchair, fully extended his right arm hitting R2 in the face at full force with his fist. R1 hit R2 several times with at least a couple of the hits connecting with R2's face. R1 was trying to stand from his wheelchair as he was hitting R2 and R1 fell to the floor. When R1 fell to the floor R2's wheelchair rolled back and R2's face was out of camera view. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia, Unspecified Severity, with Agitation, Paranoid Schizophrenia, Schizoaffective Disorder, Bipolar Type, Mixed Hyperlipidemia, Type 2 Diabetes Mellitus without Complications, Other Specified Chronic Obstructive Pulmonary Disease, Other Abnormalities of Gait and Mobility, Hemiplegia and Hemiparesis following Non Traumatic Intracerebral Hemorrhage Affecting Left Non Dominant Side, and Dysphagia, Oral Phase. R1's MDS (Minimum Data Set) dated 2/23/24 documents a BIMS (Brief Interview for Mental Status) Score of 4/15, indicating (severe impairment). R2's Face Sheet documents R2 was admitted to the facility on [DATE] with a diagnosis of Dementia in Other Diseases Classified Elsewhere, Moderate, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Familial Hypercholesterolemia, Other Lack of Coordination, Repeated Falls, Essential (Primary) Hypertension, Other Symptoms and Signs Involving the Musculoskeletal System, and Unilateral Primary Osteoarthritis, Right Knee R2's MDS (Minimum Data Set) dated 2/21/24 documents a BIMS (Brief Interview for Mental Status) could not be conducted due to resident is rarely/never understood. R2's primary language is Vietnamese. R2 has Long Term and Short Term Memory Problems. R2's Care Plan documents that R2 has impaired communication: R/T (related to) a language barrier. Date Initiated: 1/29/2021. R2 has an orbital fracture putting her at risk to experience Pain or related discomfort. Date Initiated: 3/11/2024. 145248 Page 2 of 5 145248 04/02/2024 Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 3/29/24 at 1:03 PM, V1 (Administrator) stated that she got a call from V2 (Director of Nursing) that there was an incident between R1 and R2. V1 got on her phone to watch the video of what happened. V1 stated It was disturbing. R1 came out of his room and went to the nurse's station to use the phone. R2 was sitting behind R1 in her wheelchair. R1 started to back up so R2 was backing up also. R1 then turned around and hit R2. The first punch went to R2's face. R2 blocked the second punch, and third punch was in the face also. I have never seen anything like it. R1 fell out of his wheelchair on the third punch. V10 (Agency Licensed Practical Nurse) jumped over R1 to get to R2. The staff got an ice pack and was trying to keep R2 calm. The police were called and 911 was called to take R2 to the hospital. On 3/29/24 at 11:44 AM, V4 (Laundry Assistant) stated that she was going down the hall and saw R1 going towards R2. R1 reached out to grab R2's wheelchair and hit R2 in the face. R1 hit R2 at least twice. R2 does not speak English. It was so fast R2 did not have time to protect herself. R2's glasses pushed into her nose and put a cut on the bridge of her nose. On 3/29/24 at 12:00 PM, V5 (Certified Nursing Assistant) stated that R1 was on the phone at the nurse's station and R2 was behind R1 so she could use the phone next. V5 went into another resident's room and heard a loud commotion in the hall. V5 came out and R1 was on the floor and V6 (CNA) had a towel holding on R2's face. R2 wears safety glasses and sustained cuts on R2's face. On 3/29/24 at 12:16 PM, V6 (Certified Nursing Assistant) stated that she was coming down the hall and heard R2 screaming and saw R1 raised up in his chair with his fist raised towards R2. R1 had already hit R2 and R1 kept hitting R2, R1 only stopped because he fell out of his wheelchair. R1 did not say why he hit R2. R2 does not speak English and did nothing to provoke R1 to hit her. On 3/29/24 at 2:01 PM, V9 (R2's Power of Attorney) (in broken English) stated that a guy punched R2 in the face and R2 got a fracture. On 3/29/24 at 3:04 PM, V10 (agency Licensed Practical Nurse) stated that she was charting and R1 and R2 were both close to the nurse's station. V10 walked to the med room and as V10 was coming back out R1 was attacking R2. R1 was hitting R2 in the face with his fist. R1 fell while he was hitting R2. V4 (Laundry Assistant) was close by R2 and V4 got in front of R2 to protect R2. R2 was pointing at R1, tears were coming from her eyes, and blood was coming from R2's nose. R2 was shocked and afraid. R2 was bleeding from a laceration that R1 caused. When V10 questioned R1, R1 said I didn't do that (R2) did it to herself. The B**** deserved it. On 3/29/24 at 12:27 PM, R1 was asked if he has ever hit anyone at the facility. R1 stated Some Vietnamese woman (R1 laughed). I hit her in the head. R1 was asked why he hit R2, and he stated that R2 talked to him bad in the war. (Unable to confirm if R1 was in the war.) R1's Behavior Note dated 3/9/24 at 4:45 PM, documents that R1 was sitting at the nurse's station with R2. The nurse got up to put a cup of water in the Med room and came back out and witnessed R1 attacking R2. R1 was able to strike R2 with his fist several times before staff members got to both residents. R1 had to be pulled off R2 physically by staff. R2 who was attacked was bleeding from the base of her nose and left hand. R2 was sent out to the hospital for medical attention. A Nurse questioned R1 and ask why he attacked R2. R1 denied doing anything. R1 also stated that R2 did it to herself. R1 was asked again by the nurse why he punched R2 in the face and R1 stated that R2 deserved it. R2's an A*****. R1 also expressed to a Certified Nursing Assistant that he did not like R2's kind because he went to war with them. R1 made a phone call to a family member and expressed to them that 145248 Page 3 of 5 145248 04/02/2024 Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few he just hit a Korean in the face. A Police report was filed and R1 was sent out to the hospital for a psych evaluation. R2's Emergency Department Nurses Note dated 3/9/24 at 2:34 PM documents that R2 arrived at the Emergency Department by Emergency Medical Services from (the facility) due to being assaulted just prior to arrival by another resident. R2 has abrasions on her face and bilateral hands. Staff reports no other reported injuries, no fall, no loss of consciousness. Patient is Vietnamese speaking only -video interpreter used for assessments. R2's Emergency Department Provider Notes dated 3/9/24 at 3:00 PM documents Chief Complaint -Assault Victim. Vietnamese interpreter used throughout visit. R2 is a [AGE] year-old female with past medical history of Hypertension, Hypercholesterolemia, Neurocognitive Disorder, presenting to the emergency department complaining of assault. R2 comes from a (facility), was struck multiple times by another resident with a closed fist in the center of R2's face. R2 was wearing glasses that got pushed into the bridge of her nose causing a superficial laceration. R2 denies any loss of consciousness or fall. R2 was able to lift her hands and block most of the other punches. Endorses pain to the bridge of her nose. R2's Computed Tomography/CT Facial Bone Scan dated 3/9/24 at 4:08 PM, documents [AGE] year-old status post blunt facial trauma. Bones: Acute moderately displaced fracture of the right medial orbital wall, which is depressed into the adjacent ethmoid air cells. Soft tissue: Mild stranding/thickening of the bilateral preseptal soft tissue. Impression: 1. Displaced fracture of the right medial orbital wall. A portion of the abutting right medial rectus muscle extends into the fracture defect. Correlate with ophthalmologic examination to exclude extraocular muscle entrapment. 2. Mild bilateral preseptal stranding/thickening which may suggest post traumatic contusion. Clinical Impressions, Right Orbital Fracture - Assault. R2's Emergency Department Discharge summary dated [DATE] at 6:04 PM documents to expect swelling around the eyes in the next few days, the swelling will die down. An orbital fracture is a break in the orbit or eye socket, which is the bony structure that protects the eye. This fracture usually causes swelling and pain, and it may affect vision. R2's Nursing Notes dated 3/9/24 at 11:26 PM, documents that R2 arrived back at the facility from the hospital at 7:00 PM with a diagnosis of a right orbital fracture. R2's Nursing Note dated 3/11/24 at 12:43 AM, documents that R2 is alert an unable to verbally express her needs due to a language barrier. There are no verbal or nonverbal signs of pain or discomfort. Adhesive strips are intact to the bridge of R2's nose, light bruising around right orbital area, and a small bruise to top of R2's forehead from previous incident. R2's Nursing Note dated 3/11/24 at 11:58 AM, documents that a call was place to an eye care center for R2 to be seen regarding a fracture. R2's 72 hour Follow Up assessment dated [DATE] at 3:48 PM, documents a laceration and hematoma following a resident-to-resident altercation. R2's Eye Appointment Follow Up dated 3/12/24 at 10:05 AM, documents Diagnosis orbital fracture, initial encounter for closed fracture. Comments This does not appear to be an orbital fracture, but if it is, the bones are in place. This can heal on its own. In time, this will heal, and the cheek pain 145248 Page 4 of 5 145248 04/02/2024 Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550

F 0600 will lessen. Order for Maxitrol for right eye four times a day. Level of Harm - Immediate jeopardy to resident health or safety R2's Nursing Note dated 3/13/24 at 12:23 AM, documents that R1 is alert to self with confusion per baseline, and communication is difficult due to R2 not speaking English. R2 has discoloration around her nose, right/left orbital areas, small discoloration spot on top of R2's forehead and bruising to the top of R2's left hand from an incident a few days ago. Residents Affected - Few R1's Physician Psychiatry Progress Note dated 3/21/24 at 9:44 AM, documents that R1 was seen due to physical aggressive behaviors. R1 is a male with a history of Paranoid Schizophrenia and Major Depressive Disorder. R1 is being seen at the request of staff for physically aggressive behaviors. Staff report that R1 struck R2. R1 states, (R2) got in my space and wouldn't let me use the phone so I punched the B****. R1 does not express remorse today, stating (R2) deserved it. 145248 Page 5 of 5