Health inspection·August 22, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 protect a resident's right to be free from resident to resident physical abuse. This failure affected four of four residents (R1, R2, R11, R15) reviewed for staff mistreatment in the sample of 16. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the rights of the residents to be free from abuse. The policy defines physical abuse as hitting, slapping, punching, and kicking. 1. R1's Medical Diagnoses dated August 2023 documents R1 is diagnosed with Dementia. R1's Minimum Data Set, dated [DATE] documents R1 is severely cognitively impaired. R1's Psychosocial Evaluation dated 7/5/23 documents R1 is disruptive, disorientated, experiences difficulty with impulse control, is delusional, gets agitated, angry, aggressive, shows physical aggression, is physically abusive, and verbally abusive. R1's Care Plan dated 3/15/23 documents R1 has a behavior problem when other residents are near the table she eats at or near the bench she sits at, and staff are to intervene when necessary to protect the rights and safety of others. R1's Behavior Note dated 6/14/23 documents V5 Licensed Practical Nurse (LPN) witnessed R1 walk up to another resident (R15) who was resting his head on a table in the dining room where R1 normally sits and R1 smacked R15 on top of the head with force. R1 then walked away cussing and yelling in German. R1's Behavior Note dated 7/30/23 documents V5 Licensed Practical Nurse (LPN) noted R1 was walking down the hall and smacked another resident (R2) on the back of the head. R2 was in her wheelchair wheeling herself down the hall. R1's Behavior Note dated 8/18/23 documents V4 Licensed Practical Nurse (LPN) noted R1 had an altercation with another resident (R11) and shoved R11 in the chest while he was sitting in his wheelchair. 2. R2's Medical Diagnoses dated August 2023 documents R2 is diagnosed with a healing fracture of Page 1 of 4 145466 145466 08/22/2023 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

F 0600 the right lower leg. Level of Harm - Minimal harm or potential for actual harm R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact. Residents Affected - Some On 8/18/23 at 1:58 PM R2 stated she was in her wheelchair moving herself down the hallway when R1 walked by her going in the opposite direction and hit her in the back of the head two times very hard. R2 stated she is no longer comfortable around R1 and tries to avoid her at all costs because R1 is confused and could hit her again if she wanted to. 3. R11's Medical Diagnoses dated August 2023 documents R11 is diagnosed with Dementia with Agitation, Parkinson's Disease, and Anxiety. R11's Minimum Data Set, dated [DATE] documents R11 is severely cognitively impaired. 4. R15's Medical Diagnoses dated August 2023 documents R15 is diagnosed with Dementia and Anxiety Disorder. R15's Minimum Data Set, dated [DATE] documents R15 is severely cognitively impaired. On 8/18/23 at 12:30 PM V5 Licensed Practical Nurse stated he has witnessed R1's physical aggression increase over the last two months or so. V5 confirmed on 6/14/23 he witnessed R1 come up to the table where R15 was sitting with his head down and R1 smacked R15 on the back of his head really hard. R15 was very startled and confused as to what was happening. V5 also confirmed he was the nurse on duty on 7/30/23 when R2 reported that R1 hit her in the back of the head two times when she was propelling herself down the hallway in her wheelchair. On 8/18/23 at 1:20 PM V1 Administrator stated the type of physical aggression and behaviors R1 has been having is not acceptable and the facility has decided they need to transfer her to a more appropriate setting. V1 confirmed it is not ok for R1 to be physically abusive to other residents like she was with R2, R11, and R15. On 8/22/23 at 12:40 PM V4 Licensed Practical Nurse stated she was the nurse on duty on 8/18/23 when R11 yelled out and was holding his chest stating that R1 had just shoved him in his chest and pushed his wheelchair backwards. V4 stated R11 said R1 is crazy and didn't know why she shoved him. V4 stated although R11 is cognitively impaired he is reliable enough to tell you about something like that which just occurred. 145466 Page 2 of 4 145466 08/22/2023 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately report an allegation of resident to resident physical abuse to V1 Administrator. This failure affected four of four residents (R1, R2, R11, R15) reviewed for staff mistreatment in the sample of 16. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the rights of the residents to be free from abuse. The policy defines physical abuse as hitting, slapping, punching, and kicking. The policy documents employees are required to immediately report any potential or alleged abuse to their supervisor and administrator. 1. R1's Medical Diagnoses dated August 2023 documents R1 is diagnosed with Dementia. R1's Minimum Data Set, dated [DATE] documents R1 is severely cognitively impaired. R1's Psychosocial Evaluation dated 7/5/23 documents R1 is disruptive, disorientated, experiences difficulty with impulse control, is delusional, gets agitated, angry, aggressive, shows physical aggression, is physically abusive, and verbally abusive. R1's Care Plan dated 3/15/23 documents R1 has a behavior problem when other residents are near the table she eats at or near the bench she sits at, and staff are to intervene when necessary to protect the rights and safety of others. R1's Behavior Note dated 6/14/23 documents V5 Licensed Practical Nurse (LPN) witnessed R1 walk up to another resident (R15) who was resting his head on a table in the dining room where R1 normally sits and R1 smacked R15 on top of the head with force. R1 then walked away cussing and yelling in German. R1's Behavior Note dated 7/30/23 documents V5 Licensed Practical Nurse (LPN) noted R1 was walking down the hall and smacked another resident (R2) on the back of the head. R2 was in her wheelchair wheeling herself down the hall. R1's Behavior Note dated 8/18/23 documents V4 Licensed Practical Nurse (LPN) noted R1 had an altercation with another resident (R11) and shoved R11 in the chest while he was sitting in his wheelchair. 2. R2's Medical Diagnoses dated August 2023 documents R2 is diagnosed with a healing fracture of the right lower leg. R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact. On 8/18/23 at 1:58 PM R2 stated she was in her wheelchair moving herself down the hallway when R1 walked by her going in the opposite direction and hit her in the back of the head two times very hard. R2 stated she is no longer comfortable around R1 and tries to avoid her at all costs because R1 is confused and could hit her again if she wanted to. 145466 Page 3 of 4 145466 08/22/2023 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. R11's Medical Diagnoses dated August 2023 documents R11 is diagnosed with Dementia with Agitation, Parkinson's Disease, and Anxiety. R11's Minimum Data Set, dated [DATE] documents R11 is severely cognitively impaired. 4. R15's Medical Diagnoses dated August 2023 documents R15 is diagnosed with Dementia and Anxiety Disorder. R15's Minimum Data Set, dated [DATE] documents R15 is severely cognitively impaired. On 8/18/23 at 1:20 PM V1 Administrator stated the allegation of physical abuse on 6/14/23 where R1 smacked R15 on the back of the head was never reported to her by staff. V1 confirmed staff are supposed to immediately report any suspicion or allegation of abuse directly to her so that she can begin the investigation and ensure the resident's safety. 145466 Page 4 of 4