Health inspection·October 11, 2023

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. Based on interview and record review, the facility failed to report an alleged accusation of misappropriation of resident narcotics. This applies to 10 of 10 residents (R1-R10) reviewed for misappropriation of property in the sample of 10. The findings include: R1-R10 were on narcotics and resided in zones that V3 RN (Registered Nurse) was scheduled to work per facility nursing assignment sheets. On 10/10/23 at 9:33 AM, and 1:40 PM, V2 (Director of Nursing) stated that during suspension of an employee (V6 Certified Nurses Assistant) related to an altercation that occurred involving her and two other Registered Nurses (V3 and V5). V6 stated V3 was taking narcotics from the carts. V2 stated that the altercation had occurred during overnight shift from 10/03/23 to 10/04/23 at 1:30 AM. V2 stated an investigation [for misappropriation of property] was initiated on 10/04/23 when the suspension occurred [for inappropriate staff behavior]. V2 added that a narcotic count of residents was done and residents on PM narcotics were interviewed and no issues were found. V2 stated documentation of the investigation was not recorded. Per request, a synopsis of the above investigation was submitted at around 1:40 PM on 10/10/23. On 10/10/23 at 12:05 PM, and 3:11 PM, V1 (Administrator) stated as follows: I came to know about it because an irate employee [V6] got suspended because of her behavior and she was terminated. V2 knew about the issue before me and she had already investigated it on 10/4/23. It was brought to my attention on Thursday 10/5/23. V2 thought I knew about it on 10/4/23 as she assumed that I heard the conversation she had over the phone with V6. I was outside the office making photocopies and did not hear. V5 resigned and would not talk to us. Because V6 was terminated, V6 stated 'V3 is taking drugs. Everybody knows about it.' We only do a formal investigation and report it to IDPH if there is an allegation [finding]. On 10/10/23 at 2:41 PM, V10 (Corporate Registered Nurse) stated, When an employee [V6 CNA] was notified that she was suspended, in retaliation she responded and made an allegation about the nurse [V3] taking narcotics. The facility did a narcotic count of the whole building and did not find anything. They interviewed residents on V3's unit and they had no complaints. There was no validation of the allegation. It was not reported as no concerns were found. Facility undated policy and procedure on Conducting a Thorough Investigation included as follows: Page 1 of 4 145538 145538 10/11/2023 Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The following guidance represents the components of an investigation that would constitute a 'thorough investigation'. The facility should document all aspects of their investigation to provide evidence that all allegations were thoroughly investigated. Drawing a reasonable inference or an assumption about what happened does not negate the requirements for a thorough investigation and reporting of the incident. Reporting Requirements: The facility must ensure that all allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility, the State Survey Agency, to other officials in accordance with the state law, and take all necessary corrective actions depending on the results of the investigation. Reporting Timeframe's: All allegations of abuse, neglect, misappropriation of resident property, including injuries of unknown source must be reported immediately. The result of the facility investigations must be reported to the State Survey Agency within five working days of the incident. 145538 Page 2 of 4 145538 10/11/2023 Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to have evidence of a thorough investigation regarding allegation of misappropriation of resident narcotics. This applies to 10 of 10 residents (R1-R10) reviewed for misappropriation of property in the sample of 10. Residents Affected - Some The findings include: R1-R10 were on narcotics and resided in Zones that V3 RN (Registered Nurse) was scheduled to work per facility nursing assignment sheets. On 10/10/23 at 9:33 AM, and 1:40 PM V2 (Director of Nursing) stated that during suspension of an employee (V6 Certified Nurses Assistant) related to an altercation that occurred involving her and two other Registered Nurses (V3 and V5), V6 stated that V3 was taking narcotics from the carts. V2 stated that the altercation had occurred during overnight shift from 10/03/23 to 10/04/23 at 1:30 AM. V2 stated that an investigation [for misappropriation of property] was initiated that same morning when the suspension occurred [for inappropriate staff behavior]. V2 added that a narcotic count of residents was done and residents on PM narcotics were interviewed and no issues were found. V2 stated that V3 was not suspended during investigation and V3 came in for the next shift that evening after investigation was completed with no findings. V2 stated that documentation of the investigation was not recorded. Per request, a synopsis of the above investigation was submitted at around 1:40 PM on 10/10/23. On 10/10/23 at 2:41 PM, V10 (Corporate Registered Nurse) stated When an employee [V6 CNA] was notified that she was suspended, in retaliation she responded and made an allegation about the nurse [V3] taking narcotics. She did not give a date, day, time, shift, medication, or resident. That CNA and Nurse [V5] worked different shifts. The facility did a narcotic count of the whole building and did not find anything. They interviewed residents on V3's unit and they had no complaints. There was no validation of the allegation. It was not reported as no concerns were found. A thorough investigation is all the steps you took. Some lawyers tell us not to write things down. Facility undated policy and procedure on Conducting a Thorough Investigation included as follows: Federal guidelines require that a facility must have evidence that all allegation of abuse, neglect and misappropriation of property, including injuries of unknown source, have been thoroughly investigation. In addition, the facility must take action to prevent potential abuse while the investigation is in progress. The following guidance represents the components of an investigation that would constitute a 'thorough investigation'. The facility should document all aspects of their investigation in order to provide evidence that all allegations were thoroughly investigated. Drawing a reasonable inference or an assumption about what happened does not negate the requirements for a thorough investigation and reporting of the incident. The investigation: 1. Identify the type of reportable incident (injury of unknown source or alleged abuse). 145538 Page 3 of 4 145538 10/11/2023 Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6. Interview the person reporting the incident. Was the incident reported timely? What allegedly occurred? When and where did the alleged incident occur? . 7. Develop a list of known and possible witnesses to the reportable incident. Interview staff, residents and/or visitors or anyone who has or might have knowledge of the incident under investigation Consider who may have seen or heard something and what they think could have happened. Observe and document any unusual demeanor of the person being interviewed. 9. Obtain written, signed, double witnessed or notarized statement from the reporter and all other identified witnesses 10. Review and have documentation of the as worked schedule for 48-hour period prior to the day of the reportable incident. When and where was the alleged abuser(s) working at the time of the incident? Be specific to the hall, section, and room numbers 11. Review the alleged abuser(s) personal record of history of previous disciplinary actions, previous employment evaluations, background investigation, Inservice record and the status of the certification or license 12. Document any action(s) taken by the facility to protect the resident and to prevent possible retaliation during the investigation (maintain punch card reports to show alleged abuser(s) was suspended during the investigation). 13. Document any knowledge of bias between abuser(s) and witnesses . 15. Facility Investigative file: At the onset of the investigation, begin compiling the investigative file, to be maintained as a record. 145538 Page 4 of 4