Health inspection·November 7, 2024

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 keep a resident free from physical abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. The findings include: R1's face sheet showed she was admitted to the facility 2/13/24 with diagnoses to include dementia without behavioral disturbance, polyosteoarthritis, atrial fibrillation, hypertension, and frontotemporal neurocognitive disorder. R1's facility assessment dated [DATE] showed she has severe cognitive impairment. R2's face sheet showed she was admitted to the facility 8/28/24 with diagnoses to include age-related osteoporosis, epilepsy, rheumatoid arthritis, anxiety disorder, dementia with agitation, and neurocognitive disorder with behavior disturbance. R2's facility assessment dated [DATE] showed she has severe cognitive impairment. R2's care plan initiated 6/21/24 showed, [R2] has begun to have behaviors related to refusal of direct care. 8/16/24 and 8/17/24: Disruptive, acting out behaviors with staff and peers. Much yelling and throwing of beverages at different people. calmed with removal from environment and reduced stimulation . R2's care plan initiated 10/31/24 showed, The resident is/has, potential to demonstrate physical behaviors related to dementia. Resident noted on 10/27/24 to grab another patients wrists when she mistakenly believed that the other resident was in her room . Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document . Modify environment: Image of hot cup of tea placed on bathroom door to encourage resident to exit shared bathroom toward the correct room . R2's 10/27/24 Behavior Note showed, At 7:20 PM CNAs notified nurse that patient was in [R1's] room being aggressive with another patient. Nurse was also notified that she had injured the other patient. Nurse delegates removal of patient to the nurse desk for monitoring. Patient still being aggressive, did not want to stop yelling and leave room . R1's 10/27/24 Health Status Progress Note showed, Nurse attends to patient after incident. Patient states her left shoulder and hip hurt. Nurse notes 2 cuts on patient: left wrist and right pinky. Also, noted bruise on outer part of left hip. Nurse cleansed, measures and covered skin tears. Patient states being scared and not feeling safe. Nurse comforts patient and reassured patient that she is safe now . NP (Nurse Practitioner) has requested X-rays for hip and shoulder. Page 1 of 2 145312 145312 11/07/2024 Symphony Northwoods 2250 Pearl Street Belvidere, IL 61008

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's 11/2/24 Behavior Note showed, Roommate woke her when using bathroom. Screaming who are you yelling, separate the two in different directions. She came down to the nurse station and continue with yelling . she pushed objects off the desk . demands we all tell who we are . after a while she went away and back to room. On 11/7/24 during this investigation R1 and R2 remain in the same rooms and continue to utilize a shared bathroom. A picture was posted on the door that leads to R2's room of a cup of tea. The facility's investigation dated 10/27/24 showed, On 10/27/24, at approximately 7:15 PM, it was reported to the DON (Director of Nursing) that the staff had heard [R1] repeating Help. Upon entering [R1's] room the staff noted that [R1 was next to their bed and dresser. [R2] was noted to have her hands on [R1's] wrists and was yelling that '[R1] was in my bed.' The residents were immediately separated. [R1] was immediately assessed head to toe and noted to have a scratch to her left wrist and pinky, a bruise to the left hip, and complaints of pain to left hip and shoulder. X-rays performed showed no acute findings. [R2] was placed on 1:1 supervision and sent to the ED for evaluation . On 11/7/24 at 2:36 PM, V15 CNA (Certified Nursing Assistant) said, I heard a little commotion. One of the other CNAs went to check it out because I was with another resident. The CNA called my name and when I went into the room she was already cleaning up [R1's] finger and wrist. While the other CNA was with [R1] and I was trying to get [R2] out of [R1's] room. The nurse assessed [R1] to make sure she was okay. [R1] said her hip and back were hurting a little bit. She said she was pushed. She was in between the bed and the dresser so I think she was pushed up against the dresser or the bed but the height of the dresser matched up to where she was saying she was hurting. [R2] had been very angry all day. [R2] had been physical with staff that day but not with other residents a lot of times little things set her off . She has not shown physical aggression to [R1] before but they have had issues before . It is not a good idea for them to share a bathroom but it is going to happen with any room [R2] is in. On 11/7/24 at 1:11 PM, V8 LPN (Licensed Practical Nurse) said she did not see any of what happened because the CNAs got her after they separated them. V8 said the CNAs told her R2 had increased confusion and was trying to get R1 out of the room. V8 said when she went into the room R1 was sitting on the bed with a CNA and R2 was in her wheelchair continuing to be aggravated and aggressive. V8 said R2 was not accepting redirection and they had to remove her from R1's room. V8 said when she went back in to check on R1 she had a cut on her hand and on her wrist. V8 said they had to calm R1 down because she was really scared and said she did not feel safe. V8 said R1 did calm down. On 11/7/24 at 11:11 AM, V5 (Secured Unit Manager) said R1 and R2 are both confused and they continue to share a connecting bathroom. V5 said both residents believe the bathroom is theirs. The facility's policy and procedure dated 9/2016 showed, Abuse Prevention Program Facility Procedures . The facility desires to prevent abuse, neglect, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment . 145312 Page 2 of 2