Inspection·February 25, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement the facility's abuse policy and report and investigate an allegation of abuse. Residents Affected - Few This applies to one of three residents (R1) reviewed for physical abuse. The findings include: The facility's abuse policy dated 10/14/2016 showed This facility affirms the right of our residents to be free from abuse This facility therefore prohibits mistreatment, neglect, or abuse of its residents and has attempted to establish a resident sensitive and resident secured environment. The purpose of this policy is to ASSURE that the facility is doing all that is within control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This will be done by: .Identifying occurrences and patterns of potential mistreatment, neglect, abuse of resident .immediately protecting residents involved in identified reports of possible abuse; Implementing systems to investigate all reports and allegations of abuse . promptly and aggressively and making necessary changes to prevent future occurrences and filing accurate and timely investigative reports. During the Entrance communication on 2/23/2024 at 9:30 A.M., V2 (Director of Nursing) said that there was no abuse allegation that occurred for the past month (2/1/2024 to current) in the facility. The MR (Medical Record) showed that R1, a [AGE] year-old male resident, was admitted to the facility on [DATE]. R1's diagnoses included alcoholic cirrhosis, diabetes mellitus type 2, idiopathic peripheral neuropathy, major depressive disorder without psychotic features, morbid obesity, insomnia, eating disorder, obstructive sleep apnea, bipolar disorder, and hypertension. The MDS (Minimum Data Set) dated 2/16/2024 showed that R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. On 2/23/2024 at 9:45 A.M, R1 stated to the surveyor that V3 (Registered Nurse) pushed him hard back and forth when V3 was checking his blood sugar on 2/14/2024 between 4:00AM and 5:00AM. R1 then stated he called the administrator (V1) that day 2/14/2024 to inform that (V3) had been rough during the blood sugar check, but V1 did not respond. R1 also added that he did not report the incident to anyone else including the nurse aides and nurse on duty for the night and day shift (V6, V7, V8, Certified Nurse Aides and V5 RN). R1 added that he later spoke with V2 (Director of Nursing) that V3 was rough and rocking him during the blood sugar test the morning of 2/14/24. V2 was interviewed on 2/23/24 at 11:00 A.M, V2 responded that R1 came to her on 2/6/2024 and voiced (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: 145825 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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)