Health inspection·June 11, 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 was free from resident to resident physical abuse. This applies to 2 of 6 residents (R3, R6) reviewed for abuse in the sample of 6. The findings include: R3's Face Sheet dated 6/11/24 shows R3 has the following diagnoses: Alzheimer's disease, dementia with moderate agitation, mood disorder due to known physiological condition with mixed features, delusional disorders, major depressive disorder, and anxiety disorder among other conditions. R3's Minimum Data Set (MDS) assessment dated [DATE] shows R3 experienced physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) four to six days, but less than daily, for the seven day look-back period for this assessment. R3's 5/9/24 MDS assessment also shows R3 experienced verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) daily for the seven day look-back period for this assessment. R3's Care Plan focus initiated on 6/2/23 shows R3 has a behavior problem related to dementia and a difficult adjustment to living in a skilled nursing facility. R3's care plan goal for this focus states, R3 will have no evidence of behavior problems and will no longer hit or swear at staff. No new or additional interventions were added for this focus after 6/2/23. R3's Care Plan focus initiated on 1/19/24 shows R3 exhibited sexually inappropriate behaviors. R3's care plan goal for this focus states, R3 will comply with staff redirection and behave in a safe and respectful manner, four of seven (7) days per week by the next review date. No new or additional interventions were added for this focus after 1/19/24. The facility provided Abuse Report- Initial Form dated 4/28/24 states, On 4/28/24 at around 8:55 PM, administrator made aware by V17 (Clinical Supervisor), clinical supervisor that staff observed resident R3 swiped at R6's face . Per the report, V12 (Certified Nursing Assistant - CNA) is the only named witness to the alleged event. V12's witness statement provided in the facility's abuse investigation report dated 4/28/24 states, While I (V12) was putting the dinner tray away, I (V12) overheard R6 and R3 having a conversation just outside the dining room. When I (V12) turned I (V12) saw R3 hit R6 on the face . On 6/10/24 at 3:45 PM, V12 said she was in the third floor dining room collecting dinner trays at approximately 8:30 PM on 4/28/24 when V12 overheard R3 and R6 talking just outside the entrance to Page 1 of 3 145816 145816 06/11/2024 Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047

F 0600 Level of Harm - Minimal harm or potential for actual harm the dining room in front of the third floor nurse's station. Shortly after, V12 witnessed R3 reach out and hit R6 on the face. V12 immediately separated R3 and R6, notified the nurse on duty, and R3 and R6 were assessed. R6 did not sustain any injuries during the incident. Per V12, R3 has a history of exhibiting verbally aggressive behaviors. V12 said when residents or staff enter into R3's vicinity, R3 will use curse words and tell them to get out of here. Residents Affected - Few On 6/10/24 the surveyor requested the contact information for the nurse on duty the evening shift of 4/28/24; however, no contact information for the nurse was provided. R3's Change of Condition (SBAR) note dated 4/28/24 at 20:45 (8:45 PM) states, Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: hit another resident on the face 2. This started on: 04/28/2024 7. Other relevant information: The resident was observed arguing with another resident when (R3) suddenly hit the left face of another resident with her right hand Assessment: Resident Evaluation .1. Mental Status Evaluation .No changes observed 3. Behavioral Evaluation: Physical aggression . R3's Behavior Note dated 5/14/24 at 14:55 (2:55 PM) states, Behavior: yelling and swatting at resident/ staff members with shoe that look at her or pass her in the hallways. Non-Pharmacological Interventions: calming tone and conversation, aromatherapy, calming music, redirection, reassurance, reduced stimuli. Pharmacological Interventions: None. Summary/Outcomes: no change. R3's General Progress Note dated 6/3/24 at 13:35 (1:35 PM) states, Resident observed taking off her shoe trying to hit staff, yelling at staff, calling staff inappropriate names, . stating 'Are you stupid?' (and) 'Come here you idiot.' Resident hard to redirect. Will continue to monitor. POA (Power of Attorney) and MD (Medical Doctor) made aware. R3's Behavior Note dated 6/7/24 at 14:13 (2:13 PM) states, Behavior: screaming at residents 'get the f### out of here' and threatening to hit them with a shoe when they don't. scratching staff members when redirected. Non-Pharmacological Interventions: reassurance, redirection, offering snacks and drinks, calming tone, conversation, calming music. Pharmacological Interventions: None. Summary/Outcomes: no change. R3's Behavior Note dated 6/10/24 at 10:15 AM states, Behavior: screaming at residents 'get the f### out of here' and threatening to hit them with a shoe when they don't. scratching staff members when redirected. spitting on staff members. Non-Pharmacological Interventions: reassurance, redirection, offering snacks and drinks, reduced stimuli, calming music, offering choices. Pharmacological Interventions: None. Summary/Outcomes: no change. On 6/11/24 at 8:41 AM, V2 (Director of Nursing) said that R3 does have known behaviors that have been documented and reported. V2 said that R3 is known to get aggressive and agitated and the exhibited behaviors usually includes screaming and getting anxious when another person invades her space. Since the incident on 4/28/24, V2 said that staff are to watch R3 for behaviors, increase monitoring of R3, and keep R3 engaged in activities. The facility Abuse and Neglect policy with the review date of 7/14/23 states, It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment . Abuse: abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately 145816 Page 2 of 3 145816 06/11/2024 Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047

F 0600 Level of Harm - Minimal harm or potential for actual harm that results in harm may be considered abuse . Types of Abuse and Examples- 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling. Residents Affected - Few 145816 Page 3 of 3