Health inspection·February 20, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review the facility failed to keep residents free of abuse from other residents. This applies to 3 of 3 residents (R2, R3, R12) reviewed for abuse in the sample of 12. Residents Affected - Few The findings include: 1. The Facility Incident Report Form dated 11/11/23 states, (R3) reported (R2) was yelling at her and did not let her go to the bathroom, and that she (R2) wasn't supposed to be in the room. (R2) reported (R3) seemed confused and was going into closet which she seemed to think was the bathroom. When she (R2) told her (R3) to get out of there (R3) rolled over to her bed and grabbed her (R2) then (R2) pulled (R3's) hair to try to get her off her. (R2) had bruising around her shoulder and beneath her neck, reported stiffness in neck the next day that resolved. X-ray indicated no significant injury. R2's Progress Notes dated 11/11/23 states, Reported by resident (R2) that approximately 1 AM, roommate (R3) was opening closet door. Resident told roommate that it's all her clothes (and) not hers. She (R3) got upset and came closer to resident (R2) and started putting her hands on her (R2's) throat. Resident (R2) yelled at roommate (R3) to stop but roommate continues. She (R2) grabbed her (R3) hair but wasn't able to stop roommate (R3), so she (R2) pushed the wheelchair and she (R3) rolled back. Then she started yelling, 2 CNAs came and separated roommate. Staff moved roommate (R3) to another room. Upon body assessment, resident (R2) noted with scattered bruise on her neck purplish red in color. Resident (R2) stated that her neck is stiff and hurts upon movement. R3's Progress Notes dated 11/11/23 stated, Reported by peer that allegedly resident (R3) placed her hands into her (R2) neck approximately around 1:00 AM. Upon interview resident (R3) stated that she just wanted to go to the bathroom and peer (R2) pulled her hair. Resident (R3) states that she does not know why peer (R2) pulled her hair. She (R3) was moved to a different room. Assessment done noted with no redness or swelling noted on resident's head. Denies any pain. Resident (R3) has a diagnosis of Dementia. On 2/20/24 at 10:00 AM R3 was seated in her wheelchair in her room. R3 had her eyes closed and was having a full conversation with herself. Surveyor got R3's attention by touching gently her on the arm. R3 stopped talking and smiled at surveyor. R3 offered no complaints and said everything at the facility was wonderful. R2 was unavailable for interview during this survey. On 2/20/24 at 11:30 AM V2 (Director of Nursing) stated, (R2) was in a situation. Her roommate (R3) and her got into an argument. The roommate (R3) was in her closet and (R2) told her to stop so the roommate (R3) grabbed her (R2) by the chest and was yelling at her. The staff came in and separated Page 1 of 3 145715 145715 02/20/2024 Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187

F 0600 them. She (R2) had some bruising around her neck. Level of Harm - Minimal harm or potential for actual harm R2's Physician's Order Sheet dated 1/20/24-2/20/24 shows R2 has diagnoses including Vascular Dementia, Cognitive Communication Deficit, Alcoholic Cirrhosis of the liver with ascites, and Stage 5 chronic kidney disease. Residents Affected - Few R2's Care plan dated 12/28/23 states, (R2) may be at risk for abuse due to serious mental illness, confusion and verbally threatening behavior. R2's X-ray of neck, soft tissue dated 11/11/23 states, Limited study secondary to technique and positioning. Nonspecific radiopaque densities are present overlying the neck soft tissue. Limited study, repeat imaging is recommended. This report was sent to R2's physician and handwritten on the page it states, Repeat. On 2/20/24 at 1:42 PM V2 (Director of Nursing) stated, Unfortunately, they did not repeat the follow-up x-ray so I do not have another one. R3's Physician's Order Sheet dated 1/20/24-2/20/24 shows that R3 has diagnoses including Dementia, Anxiety Disorder and Schizoaffective disorder. R3's Care plan dated 1/8/24 states, (R3) may be at risk for abuse due to residing in a mental health facility with others who exhibit behaviors. R3's care plan states, (R3) displays physical behavioral symptoms directed toward staff when providing care. These behaviors include attempting to hit and kick the staff. (R3) does have grandiose behavior and often will refuse care and can be argumentative. (R3) hitting the staff is new behavior that is now being presented when in her manic state. Update: on 11/11/23 (R3) was physically aggressive towards peer/roommate. 2. The Facility Incident Report Form dated 2/7/24 states, (R3) and (R12) were in an altercation in their room. (R3) reported (R12) had come into her room with a switchblade so she (R3) grabbed her (R12). (Neither (R3) nor (R12) had any weapons). (R3) assessed with a scratch on her left arm. (R12) assessed without injury. Both residents placed on monitoring. R3's Progress Notes dated 2/6/24 state, Resident (R3) noted to be physically aggressive towards peer, peer also became physically aggressive to resident. Staff separated both residents, body assessment done to resident and noted to have a skin tear to left upper extremity and abrasion to right upper extremity, treatment done. Asked resident what happened, She (R12) came in my room and pulled out a switchblade. Peer does not have a switchblade . R12's Progress Notes dated 2/6/24 state, Resident (R12) was alleged to have had a physical altercation with peer/roommate. Resident was noted in her room in her bed when peer/roommate went into the room and grabbed this resident on the arm. Resident stated she was defending herself and struck peer. Resident and peer were immediately separated and assessed; this resident had no injury. On 2/20/24 at 1:50 PM V2 (Director of Nursing) stated, According to (R3), (R12) did not belong there. Although they were roommates. (R3) said (R12) drew a switchblade on her but there were no weapons found on either of them. (R12) said (R3) grabbed her and she tried to get away and they ended up falling in the hallway. (R12) is ambulatory and pretty with it but very Schizophrenic. As far as what happened in the room- I only have their (R3 and R12) descriptions of what happened. (R3) ended up with a skin tear on her arm and (R12) had no injuries. 145715 Page 2 of 3 145715 02/20/2024 Wheaton Village Nrsg & Rhb Ctr 1325 Manchester Road Wheaton, IL 60187

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/20/24 at 2:05 PM V11- LPN- PM Supervisor stated, I was called to the nurse's station because (R12) and (R3) were being aggressive with each other. The staff had separated them, (R3) was by the nurse's station and (R12) was in her room. (R12) said (R3) grabbed her and she tried to defend herself. (R3) had a skin tear on her right upper forearm and (R12) didn't have any injuries. (R3) kept saying that (R12) had a switchblade but there were no weapons found. This had not happened before with those two. We moved (R3) to another room. Both residents are confused and have a mental illness. R12's Physician's Order Sheet dated 1/20/24- 2/20/24 shows that R12 has diagnoses including Paranoid Schizophrenia, Borderline Personality Disorder, Anxiety Disorder and Cognitive Communication Disorder. R12's Care plan dated 2/6/24 states, (R12) displays behavioral symptoms directed toward others as evidenced by on 2/6/2024 (R12) was alleged to have been in a physical altercation with her roommate/peer. (R12) was grabbed by peer and was defending myself. (R12) has no history of physical aggression or behavior in the facility. This was an isolated incident. The facility Abuse Prevention Policy dated 2/2020 states, This facility affirms the right of our resident to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. 145715 Page 3 of 3