Health inspection·June 22, 2025

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 interviews and record review, the facility failed to follow its abuse policy to ensure one resident (R1) remained free from physical abuse by another resident (R2) in a sample of three reviewed. This failure resulted in R1 sustaining lacerations to the forehead and swelling to the left eye. findings include: R1 is an [AGE] year-old, originally admitted on [DATE] with medical diagnoses that include and are not limited to: Parkinson's Disease, senile degeneration of the brain, and Alzheimer's disease. Minimum data set (MDS) dated [DATE] reads: Cognitive Skills for daily decision making: severely impaired. Per abuse, neglect, exploitation, and trauma assessments dated: 10-31-2019 and 3-7-2025, read: high risk for abuse: R1 has a diagnosis of delusional disorder, gets easily annoyed with others, especially during care, and will push staff and yell. R2 is a [AGE] year-old, originally admitted on [DATE] with medical diagnoses that include and are not limited to: dementia unspecified severity, with other behavioral disturbance, anxiety disorder and non-st elevation myocardial infarction. Minimum data set (MDS) dated [DATE] reads Brief interview for mental status (BIMS), results read of 4/15 impaired cognition. Per abuse, neglect, exploitation and trauma assessments dated: 6-23-2023 and 3-14-2025, read: high risk for abuse: R2 has a diagnosis of dementia, anxiety and other psychotic diagnoses. On 6-22-2025 at 1:40 pm V14 (Registered Nurse) said, on 5-31-2025, I worked 3-11 and 11-7, I had in my assignment R1 and R2. R2 was in by the nurse station after dinner and told me: My son-in-law is the owner of this place, have everything ready, I am going home. I called R2's wife without an answer, R2 appeared to be more confused than normal. I took R2 to his room, and he went to bed without any concerns. he slept well. On 6-1-2025, at about 6:00 am I was passing my medications and I went into R1-R2's room. I did not see R2 in his bed; I looked in the bathroom since R2 can ambulate to the bathroom independently, but he was not there. The curtain between the beds was pulled, and I was not able to see R1's bed. I went towards R1 bed and I saw R2 standing next to R1's bed holding a pillow in his hand R2's, I asked R2 if everything was ok. R2 answer I am going to kill him. At that time, I noticed R1 had a left eye swelling and lacerations to the forehead; the injuries were new. R1 did not have them at 4:30 am when I saw R1 and R2 sleeping. I asked R2 what he was doing by R1's bed, but he did not answer me. I asked R2 to please come with me I asked him to sit down in his bed, I immediately removed R2 from R1's proximity. I called for help without leaving the room. I applied ice to R1's face since I noticed some swelling to the left eye and a laceration to the forehead. Page 1 of 2 145835 145835 06/22/2025 Bella Terra Wheeling 730 West Hintz Road Wheeling, IL 60090

F 0600 Level of Harm - Minimal harm or potential for actual harm On 6-22-2025 at 6:45 am V8 (Certified Nurse Assistant) said, On 6-1-2025 started making my rounds at about 4:00am. I went into R1 and R2 after 5:00 am. I provided incontinent care to R1. R1 did not have any bruises, scratches, or facial swelling noted. R1 was fine, and R2 was sleeping. I did not provide any care to R2 since he can get up and go to the toilet, and R2 is sleeping. I did not see anything unusual when I was in the room. Residents Affected - Few On 6-22-2025 at 11:00 am, V12 (Licensed Practical Nurse) said, On 6-1-2025, I was the nurse for 7-3 shift, I received a report from V14, in regards to the altercation between R1 and R2, V14 described that at about 6:00 am observed R2 standing next to R1's bed. R2 hit R1, he developed some swelling to the left eye, and scrapes to the forehead. I saw an ice pack in R1's face. R1 is non-verbal, unable to ambulate, and dependent on staff for all activities of daily living. V12 said, R2 was observed with a staff member 1:1, I transferred R2 to a local hospital for evaluation. R2 is not back to the facility. The doctor ordered a facial x-ray to make sure R1 was ok, the results received were negative for fracture. On 6-22-2025 at 11:50 am V2, Director of Nursing, presented: skin wound evaluation dated 6-3-2025 at 7:30 am reads: R1 has bruising to left eye with abrasion to eyebrow, onset: 6-1-2025, measures: 2.0 cm X1.0 cm X 0.0, abrasion to left eyebrow. On 6-22-2025 at 12:30 pm V1 (Administrator), said on 6-1-2025 I received a call from V14 at 6:00 am, V14 reported that when she was going to give the morning medications to R1 and R2, V14 saw R2 standing next to R1's bed holding on a pillow in his hands. R1 had a skin tear to the forehead. V14 did not see any physical contact between R1 and R2. I came to see the residents after V14 reported the incident. R2 appeared very confused when interviewed. R2 was very delusional and talking about how much money his family has, and they own the facility, did not verbalize having any concerns with R1. R2 was unable to verbalize any reason why he did what he did. I called the police, sent the report to IDPH. I am aware our policy indicates: the facility will be free from any type of abuse. On 6-22-2025 at 12:00 pm V2 (Director of Nursing) said, my expectation is for the staff to immediately report, immediately ensure all the patients are safe. I expect that no abuse takes place in the building. V2 presented policy titled: Abuse and Neglect dated: 4-24-2025, reads in part: it the policy of the facility to provide professional care and services in an environment that is free from any type of abuse. Physical abuse includes but not limited to infliction of injury that occurs other than by accidental means and requires medical attention. 145835 Page 2 of 2