Health inspection·July 2, 2025

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 prevent verbal abuse for 1 of 5 residents (R9) by (R6) for two residents (R9, R6) reviewed for abuse in the sample of 9. Findings include: R9's Face Sheet documents R9 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, need for assistance with personal care, and vascular dementia. R9's Minimum Data Set (MDS) dated [DATE] documented R9 was cognitively intact and required substantial assistance with bed mobility and transfer. R9's Care Plan dated 11/14/18 documents R9 is at risk for abuse and neglect related to communication deficit, weakness to right side and requirement for assistance with care tasks. R6's Face Sheet documents R6 was admitted to the facility on [DATE] with diagnoses including depression and paranoid schizophrenia. R6's MDS dated [DATE] documented R6 was moderately cognitively impaired and ambulated with supervision. R6's Care Plan dated 10/1/14 documents R6 has a history of peer to peer altercations and is verbally aggressive and hard to redirect at times. R6's Progress Note by V20, Registered Nurse (RN), on 3/24/25 documents R6 was getting an item off the food tray cart and another resident told him he cannot do that without staff permission. R6 made explicit comments and aggressive behaviors walking toward the other resident. V20 attempted to de-escalate and redirect R6, but R6 approached the other resident with his fist balled up to side. V20 stepped in between the resident and R6 and closed the door to provide a barrier. R6 then began speaking toward V20 in an explicit and aggressive tone. R6 was encouraged to go to his room and calm down. On 7/1/25 at 2:20 PM, V20 stated R6 was taking an item off the food cart and R9 told him he should not do that. R6 then became aggressive toward R9 and walked toward him with his hand in a fist. V20 stepped between the two residents and closed the door to R9's room. There was no physical contact, but R6 made verbally abusive comments toward R9. Page 1 of 4 145613 145613 07/02/2025 Bria of Cahokia 3354 Jerome Lane Cahokia, IL 62206

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Facility's Final Report dated 3/24/25 documents, Resident to resident verbal altercation. (R6) was getting his lunch tray off the cart when another resident seen him and stated you were told not to touch that. (R6) and (R9) then had a verbal altercation. Nurse was walking down the hall and shut the door of (R9) to defuse {sic} the situation. MD (Medical Doctor) and POA (Power of Attorney) notified. More to follow pending final investigation. Upon final investigation it was found that the staff told (R6) not to touch the cart full of food that they are in the process of passing it out. When the staff member walked away he tried to be sneaky and get his stuff off the cart. (R6) started a verbal altercation with the resident. Another resident stood by the nurse. The nurse redirected that resident shut (R9)'s door and descalated {sic} (R6). (R6) went back to his room and no further altercation occurred {sic}. (R6) was educated on not touching the food cart to wait for the staff to pass the trays out. (R9) was educated to not partake in negative behavior by other residents. On 7/1/25 at 4:20 PM, V1, Administrator, stated she expects the Facility to follow its abuse policy. The Facility's Abuse Prevention Program reviewed 9/2017 documents the Facility affirms the right of their residents to be from abuse, neglect, exploitation, misappropriation of property or mistreatment of residents, which includes verbal abuse. 145613 Page 2 of 4 145613 07/02/2025 Bria of Cahokia 3354 Jerome Lane Cahokia, IL 62206

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 reasonable suspicion of a crime to law enforcement for 1 of 5 residents (R4) reviewed for abuse policy in the sample of 9. Findings include: 1-R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, alcohol abuse, and poisoning by unspecified drugs. R4's Minimum Data Set (MDS) dated [DATE] documented R4 was severely cognitively impaired and ambulated with supervision. R4's Care Plan initiated 1/20/25 documents R4 is at risk for abuse and neglect related to altered mental status and history of drug and alcohol abuse, having had overdose on Fentanyl in the past, requiring hospitalization. The care plan also documents R4 has a history of criminal behavior R4's Progress Notes for the month of February and March 2025 document R4 had routine leave of absences from Facility. On 6/27/25 at 11:20 AM, V1, Administrator, stated R4 went out a leave of absence with family and returned with a crack rock. V17, Former Director of Nursing (DON), was here at the time, and she flushed it down the toilet. On 6/27/25 at 2:15 PM, V1 stated when R4 came back to the Facility with the white substance V17 flushed, staff did not know what it was but assumed it could have been drugs. On 6/27/25 at 3:23 PM, interviewed V10, Psychosocial Aid, stated a while back R4 came from a home visit and emptied his pockets. There were two crack rocks that were round and white. V17 took the substance from V10, and V10 does not know what happened to the substance after that. On 6/27/25 at 3:30 PM, V11, Activities Aide, stated R4 came back from a home visit with a crack rock in his pocket. The Facility just brushed it under the rug, and the police were not contacted. On 7/1/25 at 10:00 AM, V1, Administrator, stated V10 was the staff who called her and told her there was a substance on R4. The police were not contacted. On 7/1/25 at 11:48 AM, V1, Administrator, stated she reported the allegation to V19, Former Regional Clinical VP Operations. She stated the only thing she could have done differently is call R4's doctor and document the incident. On 7/1/25 at 12:03 PM, V18, Current Regional Clinical VP Operations, stated if we suspected a crime we would have called law enforcement, but V17 didn't think it was a drug. On 7/1/25 at 12:30 PM, V17, Former DON, stated V11 asked her to look at what they found in R4's possession, because she thought it might be drugs. The substance was powdery, and there was no smell or shininess. V17 did not report it to V1 because that was her last day in the Facility, but she 145613 Page 3 of 4 145613 07/02/2025 Bria of Cahokia 3354 Jerome Lane Cahokia, IL 62206

F 0609 normally would have reported it. V17 did not call the police because it was not a drug. Level of Harm - Minimal harm or potential for actual harm On 7/1/25 at 4:20 PM, V1 stated she expects the Facility to adhere to its abuse policy. Residents Affected - Few The Facility's Abuse Prevention Program documents the Facility shall contact local law enforcement authorities within 24 hours of reasonable suspicion of a crime has been committed that does not involve bodily injury. 145613 Page 4 of 4