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 (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 4 Event ID: 145466 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 145466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944 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)