Inspection·June 23, 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 interview and record review, the facility failed to ensure a resident (R2) was not subjected to physical abuse by (R1). R2 is one of 4 residents reviewed for abuse. Findings include: R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses: Hospice, Alzheimer's Disease, Dementia, Protein Calorie-Malnutrition, Hyperlipidemia, Chronic Kidney Disease Stage 3, Muscle Weakness, Dysphagia, Nonexudative Age Related Macular Degeneration, HTN, Disorders of Bone Density, Personal History of Other Venous Thrombosis and Embolism, GERD, Insomnia, Personal History of Pulmonary Embolism, Long Term Use of Anticoagulants, Adhesive Capsulitis of Left Shoulder, Wandering Disorders, Localized Swelling Mass and lump Upper Limb and Pre-glaucoma. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 99, severe cognitively impairment. R1's Care Plan dated 3/14/24 documents R1 exhibits moods/behaviors as evidenced by yelling, screaming outbursts, cursing, resisting care, physical aggression, anxiety, agitation and anger. Due to R1's Dementia, R1's speech is increasingly getting more incoherent and garbled. R1 has trouble understanding others, this also appears to get worse in the evenings. R2's Facility Census documents R2 was admitted on [DATE] to the facility and has the following medical diagnoses: Polyosteoarthritis, Bilateral Primary Osteoarthritis, Hypokalemia, Acute Kidney Failure, Pure Hypercholesterolemia, Iron Deficiency, Vitamin D Deficiency, Mixed Hyperlipidemia, Obstructive Sleep Apnea, Intervertebral Disc Degeneration, Atherosclerotic Heart Disease, HTN, Presence of Left Artificial Hip Joint, Insomnia, Acidosis, Anemia, Cellulitis, Sepsis to Methicillin Susceptible Staphylococcus Aureus, Difficulty in Walking, Acute Posthemorrhagic, Muscle Weakness, Muscle Wasting and Atrophy, Personal History of Endocrine Nutritional And Metabolic Disease Hypermetropies Right Eye, Depression, Fracture of Part of Neck of Left Femur, Glaucoma, Primary Open-Angle Glaucoma, Postmenopausal Atrophic Vaginitis, Age Related Debility, Myopia and Protein-Calorie Malnutrition. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 13, cognitively intact. On 6/22/24 at 11:47am R3 stated a couple of weeks ago after dinner, I R3 observed R1 wheel R1's wheelchair into R3 and R2's room and went over to R2 who was sitting in R2's wheelchair. R2 asked R1 to leave the room, and R1 got angry and slapped R2 in the chest and face and left the room. R3 stated R1 does wander into R3 and R2's room sometimes, and R3 tells R1 to leave and R1 usually leaves the room. R3 said, R3 feels safe living in the facility. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145708 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 145708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Health 2304 C R 3000 N Gifford, IL 61847 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)