Inspection·February 4, 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 interview and record review the facility failed to ensure it was free from physical abuse to 3 of 3 residents (R1, R2 and R3) reviewed for abuse in the sample of 3. The findings include 1. R1's face sheet printed on 2/4/25 show R1 has a diagnoses the include hypertension, morbid obesity, diabetes and cannabis use. R1's facility assessment dated [DATE] show R1 has no cognitive impairment. R2's face sheet printed on 2/4/25 show R2 has diagnoses that include stroke, diabetes and depression. R2's facility assessment dated [DATE] show R2 has no cognitive impairment The facility reported incident (FRI) sent to the state agency as final (date of incident 1/22/25) documents, upon investigation, it was discovered that [R2] was walking into the 2nd floor dining room to have dinner, when [R1] lifted her leg and hit R2 in the buttocks. R1 said she was playing around with R2 and the kick was not meant to be malicious but playful. Then when going to bingo. R2 states R1 backed up her wheelchair into her accidentally and R2 admitted to pulling R1's hair R1 scratched her arm. Both were separated and the police were called in. On 2/4/25 at 8:45 AM, R2 was in the 2nd floor dining room with her walker. R2 said last 1/22/25 during the evening activity she was trying to get a bingo card. R1 was blocking the way so she asked V9 (Activity Aide) to tell R1 to let R2 get in for a bingo card. R2 said instead of R1 moving out of the way, R1 suddenly backed up her wheelchair hitting the left side of R2's abdomen. R2 stated that hurts so bad! She was a big lady. I then pulled her hair! And she scratched my arm. R2 also said earlier, while she was in line to get her meal in the dining room, R1 kicked her butt. R2 said she did not like that. She (R1) was not playing, she meant to do that. R2 said R1 was abusive to her. On 2/4/25 at 12:30 PM, V9 (Activity Aide) said on 1/22/25, she was running 2nd floor activity of Bingo in the dining room. R1 was sitting in her wheelchair (morbidly obese) blocking the way for other residents to get a bingo card including R2. V9 stated I told her (R1) to move out of the way repeatedly but she was not moving. (R2) was standing behind R1 with her walker. R2 asked me to tell R1 to (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145308 Printed: 05/15/2026 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 145308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River View Rehab Center 50 North Jane Elgin, IL 60123 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)