Health inspection·May 16, 2023

F 0600 R2's medical record documents R2 has a diagnosis of moderate dementia with agitation. Level of Harm - Minimal harm or potential for actual harm R2's MDS documents a BIMS score as a 99. A score of 99 indicates a residents can not complete the assessment due to cognitive impairment. Residents Affected - Few R3's medical record documents R3 has a diagnosis of dementia. R3's MDS documents a BIMS score of two. On 5/15/23 at 8:52 AM, V4, Activities Aide (AA), stated This happened a week ago Friday (5/5/23). I have a small group of ladies I do exercises with in the dining room. I was on the other side of the dining room when I heard a really loud smack. I didn't know what was going on, but when I looked up, I saw V3, Certified Nursing Assistant, (CNA), standing up in front of (R1) bringing her hand down and smacking (R1) on the back of the hand like you would when you discipline a child. A resident should never be treated like that. (R1) has dementia and she doesn't know any better, you don't discipline the residents. I reported it to the administration. (V1, Administrator) told me what I saw was (V3, CNA) pushing (R1)'s hand away. I told him that her hand definitely came down and smacked (R1)'s hand. It wasn't her pushing the hand away. (V3, CNA) was standing, not kneeling. On 5/15/23 at 9:08 AM, V5, Activities Director, On Monday after the incident took place, (V4, AA) came to me because she heard the abuse was unfounded by the facility. I told her that it was, and she told me she can't work here because she can't be in a place that doesn't investigate abuse. After the morning meeting, she handed me a letter and quit. On 5/15/23 at 9:42 AM, V6, CNA stated I've worked here the last six years and (V3, CNA) does make comments to residents that come off rude. There was one comment that she made last week that I reported to (V1, Administrator). (V3, CNA) said If a resident hits me, I'll hit them back. On 5/15/23 at 10:08 AM, V7, CNA, stated (V3, CNA) is rude to the residents. About two months ago, I was working with (V3, CNA) and heard her tell (R2) Why don't you go die. On 5/15/23 at 10:13 AM, V8, CNA, stated A week or two ago I was in (R1)'s room with (V3, CNA) assisting her with transferring (R1). Because of (R1)'s dementia, she repeats phrases. She can also get combative during cares. Well, during the transfer (R1) kept repeating something like Oh, my back hurts over and over. (V3) told (R1) Oh shut up! I couldn't believe she said that. There was another incident I witnessed about a month ago between (V3, CNA) and (R3). I heard (R3) tell (V3, CNA) Don't say damn to me and V3 responded saying I didn't say damn, I said bitch! There is one other thing I heard (V3, CNA) say. It's been within the last month, but I heard (V3, CNA) make a comment and she said, If a resident hits me, I'll hit them back. On 5/16/23 at 7:56 AM, V3, CNA stated I went to get (R1) from lunch to take her to her room and her foot pedal was swung over to the side. So, I bent over and moved the pedal in place and when I picked up (R1)'s leg to put it on the pedal, she smacked me on the forehead. She smacked me hard enough that it rattled me. When she smacked me, I immediately pushed her hand away, stood up and walked away from the situation. I was not kneeling. If I kneel, I'm not getting back up. I was bent over when she smacked me. (R1) hits all time. She sucker punched me about a month ago. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145704 If continuation sheet Page 2 of 4 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 145704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home 1102 West Randolph Roanoke, IL 61561 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 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 verbal abuse to the abuse coordinator for three residents (R1, R2, R3) and failed to submit an accurate report of physical abuse to the state agency for one resident (R1) out of three residents reviewed for abuse in a sample of three. Findings include: The facility's Abuse Prevention policy reviewed 1/1/23 documents Illinois law requires that when any administrator, agent, or employee of a long term care facility has knowledge that a resident has been subjected to abuse or neglect, they should immediately report the allegation to the Administrator, at any time of day or night, or another member of the Abuse Prevention Team in their absence. It is also the responsibility of covered individuals (any owner, operator, employee, manager, agent, or contractor of this facility), to report if they have reasonable suspicion of a crime committed against a resident of the facility. The report must be made to the police and State Survey Agency. In this case, reports should be made to the [NAME] County Sheriff and to the Illinois Department of Public Health. Covered individuals must make the report within 2 hours after first suspecting a crime has occurred if the suspected crime involves serious bodily injury to the individual, or within 24 hours if there is no serious bodily injury involved. Failure to report reasonable suspicion of crime can result in a civil monetary penalty of up to $300,000 and/or exclusion from participation in any federal health care program. R1's minimum data set (MDS) documents a brief interview for mental status (BIMS) as a four. A BIMS score of 0-7 indicates the resident is severely cognitively impaired. R2's MDS documents a BIMS score as a 99. A score of 99 indicates a residents can not complete the assessment due to cognitive impairment. R3's MDS documents a BIMS score of two. The facility's abuse investigation reported to the state agency for R1 dated 5/5/23 documents An activity aide reported that she overheard the sound of a slap from across the dining room. When she look towards the sound, she witnessed a CNA (Certified Nursing Assistant) (V3, CNA) pushing the hand of resident (R1). When interviewed, (V3, CNA) reported that she was kneeling down adjusting the foot pedals on the wheelchair of resident (R1). (R1) slapped (V3, CNA) across the face and in response, (V3, CNA) moved (R1)'s hand out of the way. On 5/15/23 at 8:52 AM, V4, Activities Aide (AA), stated This happened a week ago Friday (5/5/23). I have a small group of ladies I do exercises with in the dining room. I was on the other side of the dining room when I heard a really loud smack. I didn't know what was going on, but when I looked up, I saw (V3, Certified Nursing Assistant, (CNA), standing up in front of (R1) bringing her hand down and smacking (R1) on the back of the hand like you would when you discipline a child. A resident should never be treated like that. (R1) has dementia and she doesn't know any better, you don't discipline the residents. I reported it to the administration. (V1, Administrator) told me what I saw was (V3, CNA) pushing (R1)'s hand away. I told him that her hand definitely came down and smacked (R1)'s hand. It wasn't her pushing the hand away. (V3, CNA) was standing, not kneeling. I gave (V1, Administrator) my statement that says I saw (V3, CNA) slap (R1)'s hand and not push it away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145704 If continuation sheet Page 3 of 4 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 145704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home 1102 West Randolph Roanoke, IL 61561 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 0609 Level of Harm - Minimal harm or potential for actual harm V4's, AA, statement dated 5/5/23 documents I was in the dining room sitting with a small group of ladies doing sensory visits near the door leading to the courtyard. I heard (R1) yell out a bit as a CNA came over to talk to her. I heard some commotion coming from the North side of the dining room. As I looked up to see what was happening, I witnessed and heard (V3, CNA) slap (R1)'s hand. (V3, CNA) then took (R1) from the dining room. Residents Affected - Few On 5/15/23 at 9:42 AM, V6, Certified Nursing Assistant (CNA) stated I've worked here the last six years and (V3, CNA) does make comments to residents that come off rude. There was one comment that she made last week that I reported to (V1, Administrator). (V3, CNA) said If a resident hits me, I'll hit them back. On 5/15/23 at 9:51 AM, V4, AA, stated The commotion 'I'm referring to in my statement was when (R1) slapped (V3, CNA). The slap is what made me look up. On 5/15/23 at 9:55 AM, V1, Administrator, stated No one ever reported to me that (V3, CNA) made a comment about hitting a resident. That's considered potential abuse and we would suspend the CNA and do an investigation. On 5/15/23 at 10:08 AM, V7, CNA, stated (V3, CNA) is rude to the residents. About two months ago, I was working with (V3, CNA) and heard her tell (R2) 'Why don't you go die.' I didn't report it to the administration because nothing gets done. They don't do anything about abuse. On 5/15/23 at 10:13 AM, V8, CNA, stated A week or two ago I was in (R1)'s room with (V3, CNA) assisting her with transferring (R1). Because of (R1)'s dementia, she repeats phrases. Well, during the transfer (R1) kept repeating something like 'Oh, my back hurts' over and over. (V3) told (R1) 'Oh shut up!' I couldn't believe she said that. There was another incident I witnessed about a month ago between (V3, CNA) and (R3). I heard (R3) tell (V3, CNA) 'Don't say damn to me' and V3 responded saying 'I didn't say damn, I said bitch!' There is one other thing I heard (V3, CNA) say. It's been within the last month, but I heard (V3, CNA) make a comment. She said, 'If a resident hits me, I'll hit them back.' I didn't report any of them to the administration because things like that are being swept under the rug and they don't look into it. On 5/16/23 at 9:50 AM, V1, Administrator, was asked by the surveyor why the allegation of physical abuse that was reported to the state agency on 5/5/23 documents that V3, CNA, pushed R1's hand away, but the written and verbal statement given to him by V4, AA, on 5/5/23 documents that V3, CNA slapped R1's hand. V1, Administrator, stated I have no answer for you on that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145704 If continuation sheet Page 4 of 4