Health inspection·July 29, 2023

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 a resident (R4) was free from physical abuse by another resident (R5). This failure affects two (R4, R5) residents out of five residents reviewed for abuse in a sample list of five residents. Findings include: R4's undated Face Sheet documents R4 admitted to facility on 11/18/21. This same face sheet documents R4's medical diagnoses of Dementia with Behavioral Disturbance, Need for Assistance with Personal Care, Delusional Disorder, Restlessness and Agitation, Generalized Anxiety Disorder and Depression. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 as requiring supervision with transfers, walking in room/corridor, locomotion on/off unit and limited assistance of one person for personal hygiene and toileting. R4's Care Plan intervention dated 6/5/23 instructs staff to re-direct R4 from other resident's rooms. This same Care Plan does not include a focus area, goal nor interventions for R4's risk of being abused. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as severely cognitively impaired and independent with bed mobility, transfers, walking in room/corridor, locomotion on unit, toileting, and supervision with personal hygiene. R5's Nurse Progress Note dated 6/3/23 at 8:30 AM documents Heard yelling coming from (R5's) room and noted (R5) yelling at (R4) that does not live in (R5's) room but had entered from the bathroom. (R5) then proceeded to push (R4) down. (R5) said (R4) was going through (R5's) stuff. Separated (R4) and (R5). (R4) is just a nice Dementia resident who does not mean to cause any trouble. (R4) just wanders around. We (staff) should have monitored (R4) more closely to make sure he wasn't going into another resident's room. R4's Nurse Progress Note dated 6/3/23 at 10:41 AM documents (R4) was seen by (V18) Licensed Practical Nurse (LPN) coming from (R5's) bathroom and was pushed down to the floor hitting head by (R5). Assessed (R4. (R4) stated he was pushed down and hit back of head. Asked if having pain and (R4) started to rub back of head. Redness noted to back of (R4's) head no raised area at this time. (R4's) end of nose red no tenderness noted. Administrator was notified of incident. On 7/29/23 at 9:30 AM V18 Licensed Practical Nurse (LPN) stated V18 witnessed R5 shake R4 and then push R4 down due to R4 walked into R5's bathroom. V18 LPN stated (R4) has Dementia and sometimes he wanders into other residents' rooms. (R4) walked into (R5's) room to use the bathroom so (R5) got upset. I saw (R5) physically shake (R4) and push (R4) down onto ground. I immediately separated them Page 1 of 3 145494 145494 07/29/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0600 both (R4, R5) and let (V1) know what happened. Level of Harm - Minimal harm or potential for actual harm On 7/29/23 at 11:51 AM V1 Administrator stated, The investigation was done for the 6/3/23 resident to resident abuse incident between (R4) and (R5), but I didn't report (R4, R5) resident to resident abuse allegation. V1 confirmed R4 pushed R5 down to floor. Residents Affected - Few The facility policy titled 'Policy and Procedure regarding Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media' reviewed February 2023 documents all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 145494 Page 2 of 3 145494 07/29/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 report an allegation of resident (R5) to resident (R4) physical abuse to the State Agency. This failure affects two (R4, R5) of five residents reviewed for abuse in a sample list of five residents. Findings include: The facility policy titled 'Policy and Procedure regarding Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media' reviewed February 2023 documents if the incident involves alleged abuse, neglect or incident of unknown origin, the incident will immediately be reported to the Administrator and the Administrator shall provide Illinois Department of Public Health (IDPH) with initial notice of the alleged abuse, neglect or incident of unknown origin by telefaxing the department a copy of the report of the incident completed immediately after the incident becomes known. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 as requiring supervision with transfers, walking in room/corridor, locomotion on/off unit and limited assistance of one person for personal hygiene and toileting. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as severely cognitively impaired and independent with bed mobility, transfers, walking in room/corridor, locomotion on unit, toileting, and supervision with personal hygiene. R5's Nurse Progress Note dated 6/3/23 at 8:30 AM documents Heard yelling coming from (R5's) room and noted (R5) yelling at (R4) that does not live in (R5's) room but had entered from the bathroom. (R5) then proceeded to push (R4) down. (R5) said (R4) was going through (R5's) stuff. Separated (R4) and (R5). R4's Nurse Progress Note dated 6/3/23 at 10:41 AM documents (R4) was seen by (V18) Licensed Practical Nurse (LPN) coming from (R5's) bathroom and was pushed down to the floor hitting head by (R5). Assessed (R4. (R4) stated he was pushed down and hit back of. Asked if having pain and (R4) started to rub back of head. Redness noted to back of (R4's) head no raised area at this time. (R4's) end of nose red no tenderness noted. (V1) Administrator was notified of incident. The facility had no documentation that an abuse allegation involving R4 and R5 was reported to the State Agency. On 7/29/23 at 11:51 AM V1 Administrator stated did not report the incident between R4 and R5. V1 stated The regulations have interpretive guidance that determines if an incident is reportable or not. I followed the interpretive guidance and chose to not report that incident. There was an investigation done but it was not reported. 145494 Page 3 of 3