Health 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 Page 1 of 3 145308 145308 02/04/2025 River View Rehab Center 50 North Jane Elgin, IL 60123

F 0600 Level of Harm - Minimal harm or potential for actual harm move, so I told R1 again to please get out of the way. All of a sudden R2 screamed she backed up on me! she scratched me! R1 screamed she pulled my hair. R1 was cursing f---ing b----ch! R1 and R2 were separated. Scratch marks were noted in R2's arm. Residents Affected - Few V9 said R1 is verbally and physically aggressive. R1 knew what she was doing. On 2/4/25 at 9:05 AM, R1 said she cannot recall the details of what happened between her and R2. Something happened but it was so fast I cannot remember the details. I want to get out of here. On 2/4/25 at 9:45 AM, V4 (Certified Nursing Assistant-CNA) said he was passing by the dining room where activity was going on. V4 said he witnessed R2 and R1 scratching and yelling at each other. V4 said he intervened and separated the residents. A progress note dated 1/22/25 by V12 (RN) said assessment done show R2 had scratches to her right wrist. On 2/4/25 at 12:40 PM, V10 (Psych Rehab Director) said R1 has a tendency to be aggressive to other residents. R1 can be belligerent and aggressive and refused to be hospitalized . Abuse is a mistreatment from one resident to another resident. 2. R3's face sheet printed on 2/4/25 show R3 has diagnoses that include epilepsy, morbid obesity, schizoaffective disorder bipolar type. R3's facility assessment dated [DATE] show R3 has no cognitive impairment. The facility reported incident (FRI) sent to the state agency as final dated 1/30/25 (date of incident 1/25/25) documents, R1 was waiting by the first floor elevator, R3 ran into the back of her wheelchair on accident. In retaliation, R1 swung her plastic cup backwards at R3 hitting her in the back of her head. On 2/4/25 at 9:20 AM, R3 was sitting in her wheelchair. R3 said R1 hit her even though I did not do anything to her. At 9:05 AM, R1 said she was wheeling backwards towards the elevator. When the elevator opened, R3 was coming out bumping on her. R1 said she reached over and hit her three times in the head using a pink empty water pitcher. When asked why she had to hit R3 in the head three times instead of just asking R3 to stop bumping on her, R1 stated I had to hit her three times, that was the only way to get her attention. She (R3) was yelling. On 2/4/25 at 1:50 PM, V11 (Activity Aide) said on 1/25/25, she was on her way to the restroom. She was approximately 25 to 30 feet away from the first floor elevator. R1 and R3 were both wheeling their wheelchair backwards. R1 was going to the elevator and R3 was coming out from the elevator. R1 was hitting R3 in the head using a cup. R3 was yelling she's hitting me, she's hitting me! while R1 continued to hit R3. Staff came over to separate them. 145308 Page 2 of 3 145308 02/04/2025 River View Rehab Center 50 North Jane Elgin, IL 60123

F 0600 Level of Harm - Minimal harm or potential for actual harm On 2/4/25 at 9:40 AM, V3 (Psych Rehab) said she investigated the incident between R1 and R2, and between R1 and R3. R1 and R3 who were both morbidly obese {R1's weight show 392 lbs and R3- 408 lbs) they wheel themselves backwards when in wheelchair. R1 refused to go to the hospital for psych eval. during the incident between her and R2. (1/22/25) Residents Affected - Few R1 was sent out during the incident of her and R3 (1/25/25) R1 does have behaviors of physical aggressiveness towards others. A hospital record dated 1/25/25 show R1 was sent out for psych eval. you were seen today due to aggressive behavior. R1 was sent back to the facility the same day 1/25/25. On 2/4/25 at 3:05 PM, V1 (Administrator) said the facility has been sending referrals to other facilities for R1 due to her behaviors of aggression towards others. So far no one had accepted R1. R1's careplan dated 7/16/24 under behavioral symptoms/ aggression/ violence states, R1 has displayed both physical and verbal aggressive behaviors towards others. Resident has uncontrolled behavior outbursts and requires the utilization of non-pharmacological and pharmacological interventions in order to address and mitigate presented behaviors with intervention of: R1 will refrain from being verbally and physically aggressive through next review date. The facility policy on abuse states, Federal and state laws mandate that a nursing home resident has the right to be free form verbal, sexual, physical and mental abuse, exploitation, corporal punishment and involuntary seclusion. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury unreasonable confinement intimidation or punishment with resulting physical harm, pain or mental anguish to a resident. Physical Abuse includes hitting, slapping, pinching kicking and controlling behavior through corporal punishment. 145308 Page 3 of 3