Health inspection·February 29, 2024

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 observation, interview, and record review, the facility failed to protect the resident's (R2) right to be free from physical abuse by another resident (R1). R1 and R2 are two of three residents reviewed for abuse in the sample of three. Findings include: R2's Diagnosis Sheet (current) includes the following diagnoses: Unspecified Fall, Fracture of the Mandible, Non-Displaced Fracture of Cervical Vertebrae two, Dementia and Anxiety. A facility report titled Final Report dated 2/23/24 documents the following summary: On 2/18/2024, while residents were awaiting breakfast in the facility dining room, resident (R1) grabbed another resident's (R2) shirt sleeve and pulled (R2) to the ground during a behavioral episode. Staff present in and near the dining room immediately intervened and separated (R1 and R2). (R1 and R2) were immediately assessed by unit Nurse (V4 Registered Nurse) and all necessary parties notified. (R2) was sent to (Hospital Emergency Department) for evaluation related to prescribed. (R2) returned to the facility on 2/18/24 following ED (emergency Department) evaluation with no changes noted. (R1) was placed on 1:1 (one on one) staff supervision. R1's Diagnosis Sheet (current) includes the following diagnoses: Violent Behavior, Bipolar Disorder, Depression, Autistic Disorder and Cerebral Vascular Accident. R1's Admitting Diagnosis from the Hospital dated 12/22/23 also includes the diagnosis of Violent Behavior. R1's Minimum Data Set, dated [DATE] documents as follows: Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) with these occurring 1 - 3 days during this assessment period. On 2/28/24 at 12:00 pm, R2 was sitting in R2's wheelchair. R2 has dark bruising on chin and mandible area from a previous personal fall at home. R2 is unable to speak due to R2's jaw being wired shut. R2 was able to nod R2's head in a yes motion when asked if R2 had been pulled to the floor by another resident (there was no Minimum Data Set available for review of R2's mental status). On 2/29/24 at 11:05 am, V4 confirmed that V4 was passing medications and was outside the dining room. V4 stated V4 heard the commotion and went into the dining room. V4 stated R2 and R2's wheelchair Page 1 of 7 145636 145636 02/29/2024 Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were lying on their side on the floor. V4 stated it appeared that R1 had grabbed the arm of R2's wheelchair and pulled R2 and the chair onto the floor. V4 stated R2 was pretty shaken up. V4 stated (R1) is very strong and has very aggressive behaviors toward others. I asked (R1) if (R1) had pulled (R2) to the floor and (R1) replied 'yes' each time (R1) was asked. V4 stated R2 did not appear to be physically hurt, but (R2) was sent to the hospital to make sure because (R2) is on aspirin. V4 stated R2 is confused at times but can answer questions. V4 confirmed the occurrence was reported as an abuse allegation to the Administration. On 2/29/24 at 11:50 am, V5 Certified Nursing Assistant stated on 2/16/24, R1 had hit V5 in the face and had a hold of V5's arm trying to bite V5. V5 confirmed that R1 is strong and is aggressive towards other. V5 also confirmed that V1 Administrator and V2 Director of Nursing was made aware of R1 hitting and trying to bite V5 the same day it occurred. R2's Hospital Records dated 2/18/24 document R2's arrival at 8:30 am with chief complaint of fall and hit head. These same records document that a Computed Tomography (CT) of brain and spine was completed. There was no change on the CT of the spine and Ct of the brain was normal. The facility policy titled Abuse Prevention Program dated 11/28/2016 documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. 145636 Page 2 of 7 145636 02/29/2024 Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920

F 0609 Level of Harm - Minimal harm or potential for actual harm 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 injury of unknown origin/source for one (R1) of three residents reviewed for abuse in the sample of three. Residents Affected - Few Findings include: R1's Diagnosis Sheet (current) includes the following diagnoses: Violent Behavior, Bipolar Disorder, Depression, Autistic Disorder and Cerebral Vascular Accident. R1's Admitting Diagnosis from the Hospital dated 12/22/23 also includes the diagnosis of Violent Behavior. R1's Progress Notes dated 1/24/24 document that Therapy reported R1's right hand as swollen and bruised. Administrator and IDT (interdisciplinary team) informed, investigation initiated. On 2/29/24 at 10:15 am, V2 Director of Nursing and V1 Administrator, confirmed that R1's injury had not been reported to the State Agency. V2 stated when I went to look at (R1's) hand I thought the injury was caused by (R1) dangling the hand between the wall and the wheelchair and hitting it on the wall. The bruise appeared to match the shape of the brake. V2 confirmed V2 did not know for sure that is what happened. No incident report for the above injury of unknown origin to R1's right hand was available for review. The facility policy titled Abuse Prevention Program dated 11/28/2016 documents the following directives to facility staff: Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administration. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries of unknown origin as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing documentation and reporting to the administrator or designee. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. 145636 Page 3 of 7 145636 02/29/2024 Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920

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 complete and document a thorough investigation into a resident's (R1) hand injury of unknown source. R1 is one of three residents reviewed for abuse in the sample of three. Residents Affected - Few Findings include: A Progress Note dated 1/24/24 documents Physical Therapy Services reporting that R1's hand is swollen and bruised. This same note documents that Administration was notified of R1's hand injury. R1's Physician Order Sheet, Care Plan and Diagnosis Sheet (current) all document R1 with Violent Behavior and Aggression. On 2/29/24 at 10:15 am, V1 Administrator stated the facility did not have a documented investigation concerning R1's hand injury. On 2/29/24 at 10:15 am, V2 Director of Nursing stated V2 looked at R1's hand and because R1 is often seen dangling the hand while using R1's wheelchair and the hand being between the wall and wheelchair she thought the bruise and swelling came from this. V2 stated the bruise appeared to be matching up to the wheelchair brake. V2 also confirmed that V2 did not know for sure this is how the injury occurred. V1 and V2 present at this time, confirmed again that an investigation had not been done according to the facility Abuse Policy. On 2/29/24 at 11:05 am, V4 Registered Nurse stated V4 is a care provider for R1, but had not been asked how R1's hand could have been injured. On 2/29/24 at 11:45 V6 Certified Nursing Assistant (CNA) stated V6 had not been interviewed about R1's injury to R1's hand. On 2/29/24 at 11:50 am V5 Certified Nursing Assistant also confirmed V5 had not been asked about R1's swollen hand but was aware of it. The facility policy titled Abuse Prevention Program dated 11/28/24 gives the following directives to facility staff: Once the administrator or designee receives an allegation of mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property; the administrator will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident and follow the Resident Protection Investigation Procedures. Resident Protection Investigation Procedure(s) Step 1. Preparation Review any written supporting documents relative to the occurrence. Step 2. Confidentiality 145636 Page 4 of 7 145636 02/29/2024 Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920

F 0610 Level of Harm - Minimal harm or potential for actual harm The investigator shall do as much as possible to protect the identities of any employees and residents involved in the investigation, until the investigation is concluded. After a conclusion based on facts of the investigation is determined, internal reports, interviews, witness statements and identities of individuals involved shall be released only with permission of the administrator or the facility attorney. The administrator shall cooperate with any Department of Public Health Investigation in the matter. Residents Affected - Few Step 5. Investigation Procedures Regardless of the specific nature of the allegation (physical, sexual, verbal/exploitation/mental, theft or neglect), the investigation shall consist of : A review of the initial written reports; Completion of a written report on the status of the investigation of the occurrence; An interview with the person(s) reporting the incident; An interview with the resident; Where appropriate, an interview with the resident's attending physician or psychiatrist; A review of the medical records of any residents involved in the occurrence; An interview with staff members having contact with the resident and accused individual during the period of the alleged incident; Where appropriate, interviews with the resident's roommate, family members, visitors, or others who were in the vicinity of the incident; Interviews with other residents to which an accused individual has regular contact; Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused individual; 145636 Page 5 of 7 145636 02/29/2024 Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to supervise a resident (R1) with known aggression and other inappropriate behaviors towards others while in the facility dining room. This failure resulted in R1 pulling another resident (R2) and the resident's (R2) wheelchair onto the floor. Findings include: R1's Diagnosis Sheet (current) includes the following diagnoses: Violent Behavior, Bipolar Disorder, Depression, Autistic Disorder and Cerebral Vascular Accident. R1's Admitting Diagnosis from the Hospital dated 12/22/23 also includes the diagnosis of Violent Behavior. R1's Progress Notes dated 2/18/24 document an occurrence in the dining room at breakfast with R1 pulling another resident (R2) and R2's wheelchair to the ground. On 2/29/24 at 11:05 am, V4 Registered Nurse confirmed that R1 was in the dining room at breakfast. V4 stated V4 had V4's medication cart outside the dining room behind the wall that divides the lounge from the dining area. V4 stated V4 could not see the residents in the dining room at the time the above occurrence happened with R1 and R2. On 2/29/24 at 11:45 am V6 Certified Nursing Assistant (CNA) confirmed that V6 and V5 CNA were transferring residents from their rooms to the dining area and V6 did not see R1 pull R2 and R2's wheelchair to the ground. On 2/29/24 at 11:50 am, V5 stated that R1 and R2 sit at the same table during meals and V5 was taking a tray off the hall cart because the resident it was intended for had come to the dining room for breakfast. V5 stated V6 was talking with V4 on the other side of the wall when R1 pulled R2 to the floor. V5 confirmed that V5 did not see the incident as V5 was busy across the room. V5 stated V5 heard R2's wheelchair turn over and V4 and V5 must have too, as they both entered the dining room then. V5 stated R1 was not sitting at the table when V5 came to the dining room but saw R1 propelling into the dining room headed to R1's table. V5 also confirmed the facility knew that R1 had behaviors and that R1 could be violent. V5 stated two days before R1 pulled R2 to the ground, R1 had hit V5 in the face and tried to repeatedly bite V5's arm. V5 stated R1 is very strong. V5 added that R1 has disrobed in the dining room several times and in other places. R1's Progress Notes document the following: On 12/25/2023 at 9:51 am - Behavior Note - Resident is A/O x1 removes clothing frequently throughout the day regardless of where she is located. yells out consistently. - attempted redirects. On 12/26/2023 at 3:47 am - Behavior Note - Resident frequently removes clothing, constantly yelling out, unable to be redirected. 145636 Page 6 of 7 145636 02/29/2024 Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920

F 0689 Level of Harm - Minimal harm or potential for actual harm On 1/17/24 at 12:14 pm - Weekly meeting with IDT (Interdisciplinary Team) to discuss improvements, needs or concerns. Behaviors have been an issue at mealtime with (R1) attempting to remove (R1's) clothing at times out in the dining room. On 1/19/24 at 5:36 pm - (R1) took clothing off in the middle of the hallway, then again in the dining room. Residents Affected - Few On 2/29/24 V1 Administrator confirmed that R1 had a diagnosis of Violent Behavior when R1 was admitted . V1 also confirmed knowledge of R1 (previous to the 2/18/24 incident in the dining room) hitting V5 in the face and trying to bite V5. V1 stated I don't know what I should have done. 145636 Page 7 of 7