Health inspection·May 5, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and depression. R1's MDS (Minimum Data Set) dated 4/15/25 shows a BIMS score of 6, which means R1 has severe cognitive impairment. R1's care plan dated 1/16/25 shows he has a psychosocial well being problem related to anxiety. It also documents that he has impaired cognitive function/dementia or impaired thought process related to dementia/impaired decision making. Residents Affected - Few R1's incident report dated 4/27/25 shows: (R1) got into a physical altercation with another resident. (R1) sustained an abrasion to the left side of his neck right below his ear. Scant amount of blood. Area cleansed and pat dry. Unable to recall what happened. Denies pain or discomfort. Both residents were separated and closely monitored. Neck area cleansed and pat dry. Nurse's assessment dated [DATE] documents that R1 had a reddened area to nose, right side of face and left side of face just below the left ear and has a scratch. There was also a reddened, small scratch to the left side of the neck and right back of hand. On 5/1/25 at 10:58 AM, R1stated, We were looking at each other. He hit me. I don't remember what or where it happened. I can't remember if I had bleeding or bruising. I can't remember. I have not seen (R2) since then. I don't remember nothing. R1 and R2's initial abuse incident report dated 4/27/25 shows: At 10:00 AM, (R2) hit (R1). Residents immediately separated. Full body assessment completed on both residents. Families and physicians notified for both (R2) and (R1). (R2) sent to the hospital for psychiatric evaluation. Investigation initiated. On 5/1/25 at 10:16 AM, V1(Administrator) and V2 (DON-Director of Nursing) were interviewed. They both stated the following: (R2) came to us on Friday 4/25/25. He had no prior history of aggression. He had dementia and exit seeking behaviors. On Saturday 4/26/25, (R2) was exit seeking and running towards the door. He put his hands around (V3-LPN/Licensed Practical Nurse) as she stood in front of the door. (V5-LPN) was behind (R2) and she was able to remove (R2)'s hands from (V3)'s neck. (R2)'s son was called on the phone and he came to the facility and sat with (R2). He was able to calm (R2) down. (V1), (V2), and the psychiatric nurse practitioner were notified. (R2) was ordered new medications of Ativan 0.25 MG (Milligrams), Trazodone 25 MG, and Aricept 5 MG. He took the medications from the nurse with the help of his nurse. On Sunday 4/27/25, V4 (LPN, Agency Nurse) called us at home and she said that (R2) hit (R1) on the side of head (right side) outside the dining room. (R1) became verbally abusive with (R2). They both have dementia. (R1) told us that (R2) didn't like him because he was from another country. (R1) had a scratch to the right side of his face and there was a scant amount of bleeding. (R1) didn't hit (R2) back. They were separated and both were given first aid. We did a petition for involuntary/ judicial admission for (R2). (R2) was sent to this hospital where he is supposed to get neuro psychiatric testing. His POA (Power of Attorney) was in agreement with this. (R2) is still in the hospital. On 5/1/25 at 12:07 PM, V3 (LPN) stated, On Saturday 4/26/25, (R2) was trying to leave the building. He was basically sundowning and exit seeking. I was facing him and trying to redirect him. (R2) put his hand around my throat. He was agitated and was trying to leave. My coworker (V5-LPN) pulled him off me by grabbing the back of his shirt. I called (R2)'s POA, (V1) and (V2). (R2) and (V1) came to the facility. We were initially going to send him to the hospital, but the psychiatric nurse practitioner said to not send him. She wanted us to give (R2) some new medications. (R2) took his medications and was able to calm down. The next day at 2 PM, I started my shift. I heard from the morning nurse (V4-LPN) that there was resident to resident contact between (R2) and (R1). I was told that (R2) scratched (R1). I don't know the full details. I remember me and the two managers were working on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 2 of 3 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 145538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beecher Manor Nrsg & Rehab Ctr 1201 Dixie Highway Beecher, IL 60401 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)

F 0600 the paperwork. Level of Harm - Minimal harm or potential for actual harm On 5/1/25 at 12:24 PM, V5 (LPN) stated, I worked with (V3) on Saturday 4/26/25. (R2) was in his wheelchair. He proceeded to get up and go to the doors. I didn't want him to fall. So, I came behind him with the wheelchair. (V3) came in front of him so he wouldn't leave. Then, (R2) grabbed (V3)'s neck. I grabbed (R2) by the shirt and he let go of (V3). We put him back in his wheelchair. The psychiatric nurse practitioner ordered him some medication. He got the medication, and he was able to calm down. The next day I worked from 2 PM to 10 PM. I heard in the morning that (R2) choked (R1) and they sent (R2) to the hospital. Residents Affected - Few On 5/1/25 at 12:45 PM, V4 (LPN, Agency Nurse) stated, I worked on Sunday 4/27/25 in the morning. The housekeeper and other staff members didn't actually see (R2) and (R1) fighting. I think it was outside the dining room. (R1) came to me and told me that (R2) hit and scratched him on the face. He didn't know why. There was a scratch to the left side of the neck below his ear and it was bleeding a little. (R2) had a broken nail bed and it was bleeding a little. V6 (RN-Registered Nurse/Wound Nurse) helped me. She did a head to toe assessment and cleaned them both up. I notified (V1), (V2), and the doctor. We did an involuntary petition and we sent (R2) to the hospital. (V1) and (R1)'s POA agreed to the transfer. On 5/1/25 at 2:05 PM, V1 (Administrator) stated, It's our job to prevent abuse as best as we can and protect our residents. Absolutely! Facility's policy titled Abuse Prevention Policy (Undated) shows: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment. This facility therefore prohibits abuse .abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145538 If continuation sheet Page 3 of 3