Inspection·June 12, 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 protect the residents' right to be free from physical abuse by another resident. This failure affects three of seven residents (R1, R2, R5) reviewed for abuse in the sample of seven. Findings Include: The facility's Abuse Prevention and Prohibition Policy dated January 2024 documents the facility affirms the right of its residents to be free from abuse and free from mistreatment by anyone. Resident behaviors will be monitored for changes, which could trigger abusive behaviors. Resident to Resident abuse includes the term willful. The word willful means that the individual's action was deliberate regardless of whether the individual intended to inflict injury or harm. Physical abuse can include such things as hitting, slapping, punching, and kicking. The Abuse Investigation Summary dated 5/9/24 documents on 5/4/24 staff were wheeling R5 to the dining room and wheeled past R1. Unprovoked, R1 reached out and began punching R5 in the arm. R1 and R5 were separated. After the completion of the facility investigation, the allegation was substantiated. On 6/12/24 at 12:45 PM V6 Certified Nurse's Assistant (CNA) stated she witnessed the incident and observed R1 punch R5 in the arm twice and call him a criminal. V6 stated R1 does not like R5 for some reason. The Abuse Investigation Summary dated 6/3/24 documents on 5/28/24 R2 wheeled up to the table that R1 was sitting at. Unprovoked, R1 yelled that R2 was sitting in her spot and began kicking R2 on the leg. R1 and R2 were separated. After the completion of the facility investigation, the allegation was substantiated. On 6/12/24 at 12:21 PM V5 Certified Nurse's Assistant (CNA) stated she observed R2 wheel up to R1's table and she yelled that it was her seat and R1 kicked R2 in the shin three times. R1's Medical Diagnoses sheet dated June 2024 documents R1 is diagnosed with Dementia with Behavioral Disturbance and Delusional Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment. R1's Psychosocial Evaluation dated 2/26/24 documents R1 has had new behaviors such as physical (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: 145842 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 145842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flanagan Rehabilitation & Hcc 201 East Falcon Highway Flanagan, IL 61740 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)