Inspection·July 8, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent resident-to-resident physical abuse. This applies to 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 3. This failure resulted in R2 striking R1 on the nose, resulting in R1 being transferred to the hospital and found to have a fractured nose.Findings include:R1's Face Sheet shows R1 admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, mild intellectual disability, and bipolar disorder. R2's Face Sheet shows R2 admitted to the facility on [DATE] with diagnoses including diabetes, seizures, and depression. The facility's 6/19/25 Final Incident Investigation Report shows an incident between R1 and R2 occurred on 6/15/2025 (Sunday) at approximately 5:15 PM. The report showed, the R1 and R2 were roommates and resident-to-resident contact was reported. The report shows R1 and R2 had a disagreement over the thermostat in the room and that R2 struck R1 on the bridge of his nose, which resulted in R1 receiving a broken nose (closed fracture). The 6/15/25 Reporting Officer Police narrative shows R1 and R2 were arguing about the climate control of their room. The report shows R2 admitted to striking R1, with a closed fist, on the bridge of R1's nose.The facility's investigation shows a statement from R2 dated 6/16/2025. The statement shows, My roommate (R1) turned the air conditioner up to 83 degrees. I told him to turn it down and he said no, so (R2) punched (R1). (R1) pushed (R2) into the dresser .The facility's investigation showed a statement from R1 dated 6/16/2025. The statement showed, My roommate (R2) got mad because (R1) wanted the air in the room warmer. (R1) tried to walk out of the room, then (R2) punched me. I don't remember what happened after that. I feel safe in the facility. (R1) don't want to be (R2's) roommate anymore.R1's 6/15/2025 hospital records showed he sustained a broken nose.On 7/2/25 at 10:47 AM, V4 Certified Nursing Assistant (CNA) stated she was working on 6/15/25. V4 said, at approximately 5:20 PM on 6/15/2025, another CNA and she responded to a door that was slammed shut. V4 said as they walked down the hallway, they witnessed R1 in the hallway with blood on his nose. V4 said they opened the door to R1 and R2's room and observed R2 on one knee in the room. V4 said R2 reported that R1 had punched him. V4 said R1 was outside the room, heard this statement from R2 and R2 responded, I punched you because you punched me. V4 said the argument was over climate controls in the room. V4 said the only cause of R1's broken nose was due to being hit in the face by R2. V4 said R1 had not fallen. On 7/2/25 at 11:28 AM, V7 Nurse Practitioner stated he knows R2 well; however, he was less familiar with R1. V7 said he was not aware of any reason R2 should not have a roommate. V7 said the only possible cause of R1's broken nose was from R2 punching R1 in the face. The facility's abuse prevention policy (dated 10/24/2022) showed that the facility affirms the right of our residents to be free from abuse. The policy defines abuse as physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury . physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical (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 07/08/2025 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)