Health inspection·November 15, 2023

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 - Minimal harm or potential for actual harm Based Residents Affected - Some on interview and record review the facility failed to ensure residents were free of verbal and physical abuse for two residents (R1-R4) of five reviewed for abuse in a sample of five. Findings include: The facility's Summary of Abuse and Neglect Prevention policy, undated, documents staff's first responsibility is for the safety of the resident. The facility will not tolerate abuse or neglect of its residents by any individual including staff, family, volunteers or consultant. Abuse refers to any act willfully injuries or hurts a resident and includes unreasonable isolation, intimidation, or punishment of a resident. Examples of physical abuse would include hitting, kicking, pinching, choking, shoving, pushing, slapping, punching striking with an object, burning, hitting or a resident or inappropriate sexual language or conduct. This form also documents verbal abuse includes the use of words, signs, or gestures to intimidate, demean, harass, or threaten the resident. 1. R1's electronic face sheet documents the following diagnosis: Alzheimer's Disease with late onset, Anemia, Chronic Obstructive Pulmonary Disease, Disorientation, Macular Degeneration, Sciatica, Fatigue, Chronic Pain, Rhinitis, Weakness, Palpitations, History of Urinary Tract Infections, Radiculopathy of Lumbar Region, Rheumatoid Arthritis, Spinal Stenosis, Left Artificial Knee, Disease of the Digestive System, Peripheral Vascular Disease, Constipation, Chest Pain, Hypo-Osmolality and Hyponatremia, Atherosclerotic Heart Disease. R1's current care plan documents R1 is at risk for abuse as evidenced by Dementia, Hearing loss, personality characteristics, with being combative with cares. R1's goal is to be abuse free. R1's Progress Notes, dated 10/19/23 documents V13, R1's Family, called V1, Administrator, concerning care was given to R1 on 10/11/23. The facility's final notification of investigation of staff for physical/emotional abuse, dated 10/20/23, documents at V3, Assistant Director of Nursing, determined V5 Certified Nursing Assistant, took care of R1 on 10/11/23. V3 immediately escorted V5 out of the building. This form documents the allegation of physical/mental abuse is substantiated and V5 was terminated. On 11/16/23 at 9:30am, V9, R1's Caregiver, stated on 10/11/23, V9 asked V5, CNA/Certified Nursing Assistant, to transfer R1 from the recliner to her wheelchair. V9 stated V5 told R1 to put her hands around V5's neck. R1 did not understand V5, so V5 pulled R1's hands up and placed them on her Page 1 of 2 145949 145949 11/15/2023 Hillcrest Home 14688 Illinois Highway 82 Geneseo, IL 61254

F 0600 Level of Harm - Minimal harm or potential for actual harm shoulders. V5 picked R1 up and sat her down on the front of the wheelchair. V5 then asked R1 to remove her hands from V5's shoulders, but she did not understand. V9 stated V5 grabbed R1's hands off her shoulders, then yanked R1 back in the chair by the back of her pants. V9 stated V5 did not explain to R1 what she was doing. V9 stated R1 began screaming and yelling. V9 stated it took a several minutes to calm R1 down after the transfer. V9 verified V5 did not use a gait belt for the transfer. Residents Affected - Some 2. V5's signed statement, dated 9/16/23 documents V4 CNA/Certified Nursing Assistant, was trying to get R4 to eat, when R4 would not eat, V4 said You're a psychopath. V4 then asked R3 if she was going to eat. When R3 did not answer, V4 said You're a dumb b .h. V7's signed statement, dated 9/16/23, documents V4 was pushing R2 to breakfast and said, Could you f .g not. R2 was trying to scratch V4. V4 then walked away from R2. The facility's final notification of investigation of staff for verbal abuse, dated 9/16/23, documents R2 and R3 are cognitively impaired and R4 is severely cognitively impaired. V3, Assistant Director of Nursing, escorted V4, CNA/Certified Nursing Assistant, out of the building pending an investigation into allegations of verbal abuse. This form documents the allegation of verbal abuse is substantiated and V4 was terminated. On 11/16/23 at 10:00am, V2, Director of Nursing, stated the facility does not tolerate any type of abuse. V2 verified V5 was terminated because of her demeanor and the improper transfer. V2 stated V4 was terminated because of the verbal abuse. 145949 Page 2 of 2