Health inspection·March 7, 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. Based on observation, interview, and record review the facility failed to prevent staff verbal abuse for one (R1) and failed to prevent resident-to-resident physical abuse for two of two (R5 and R6) residents reviewed for abuse in the sample of three. Findings include: The facility's undated Abuse, Neglect and Exploitation policy and procedure documents: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Mistreatment means inappropriate treatment or exploitation of a resident. 1. The facility's Final Incident Investigation Report for R1, dated 2/9/24, documents On 2/3/24, a verbal incident occurred between (V5 Former CNA/Certified Nursing Assistant) and (R1). It was reported to this administrator that (V5 Former CNA) had been verbally inappropriate. (V5) was immediately separated from all residents and subsequently suspended. Upon conclusion of investigation, it was determined that (V5) had been verbally inappropriate with (R1). (V5 Former CNA) has been terminated. (R1) has been scheduled to meet with psychologist. The Face Sheet for R1, includes the following diagnoses: Major Depressive Disorder, Dementia, Delusional disorders, Schizophrenia, Anxiety Disorder, Parkinson's Disease, Anoxic Brain Damage, and Cognitive Communication Deficit. The Quarterly MDS (minimum data set) assessment, dated 1/4/24, documents R1 with moderately impaired cognition and requires assist with activities of daily living and transferring. On 2/28/24 R2 and R3 resided next door to R1 with a shared bathroom. On 2/28/24, 3/5/24, and 3/6/24 there were no identified behaviors noted. On 3/6/24 at 10:23 am, R1 stated I don't think so. I can't remember that when asked if anyone has yelled at her or refused to brush her hair. R1 stated she feels safe at the facility. Page 1 of 4 145987 145987 03/07/2024 Allure of Galesburg 1145 Frank Street Galesburg, IL 61401

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/5/23 at 2:00pm, R2 stated she was lying in bed and heard V5 Former CNA yell out F**k and got up and went to the bathroom and could hear V5 yelling at R1. R2 stated R1 just wanted (V5) to brush her hair and V5 told R1 Your fault you lost it, going to just be wearing a hat. R2 stated she reported it to the Nurse. On 3/5/24 at 2:42 pm, R3 stated she lives next door and shares a bathroom with R1. R3 stated (V5 Former CNA), the boy CNA was not very nice. I was in my room, next to (R1's) room. I heard him yelling, loudly at (R1). I could tell he wasn't being nice. This wasn't the only time I had heard him yelling at (R1). R3 stated even with the bathroom doors shut between the rooms I could still hear him yelling at her. Shouldn't have been. A signed statement from V17 LPN/Licensed Practical Nurse, dated 2/3/24, documents during medication pass, (R2) reported to her that (V5 Former CNA) was yelling and being mean to (R1) and heard the interaction while going to the conjoining bathroom. (R2) stated (V5) was yelling at (R1) for her room being messy and (R1) asking for her hair to be combed and (V5) couldn't find the hairbrush and yelled at (R1) to just wear a hat. R3 (R2's roommate) denied hearing the interaction but has heard (V5 Former CNA) be mean in the past to R1. Administrator was notified, V5 was removed from the hall and then sent home. Signed statements from R1, dated 2/3/24, documenting (V5 Former CNA) started yelling at (R1) because (V5) is impatient and was furious and kept saying do you want to miss breakfast. A second signed, undated interview from R1, documents R1 stated (V5) yelled at me and spun me around in my chair. (V5) wouldn't brush my hair. Signed witness statement from R2 documents she was awakened by loud voices and heard V5 Former CNA saying F**k something and heard R1 wanting her hair combed and (V5) yelling No your just going to wear this hat. V5 Former CNA sounded mean and (R2) felt bad for (R1). When (R1) asked for hair to be brushed (V5) said Well you lost your brush and (R2) stated it seemed like (V5) had no patience for (R1). Signed statement from V5 Former CNA, dated 2/3/24, documents he was trying to assist (R1) in getting up for the day and (R1) was not focused, almost fell during transfer, and (V5) tried to explain that (R1) needed to tell him if she needed something. V5 stated he did not know that (R1) did not like male CNA's but we was short and I was asked to get her up. On 2/28/24 at 11:38 am, V1 Administrator stated he does all the abuse investigations for the facility and he did the investigation regarding V5 Former CNA verbal altercation with R1. V1 Administrator stated he interviewed R1, R2 and R3 the day of the allegation and had V2 DON/Director of Nursing interview R1 again a few days later because R1 had a UTI (urinary tract infection) at the time of the initial interview and was on antibiotics. R1 had the same story when V2 DON interviewed her. V1 Administrator stated V5 Former CNA stated (V5) was trying to help R1 get up and R1 was being resistive. V1 Administrator stated (R2) does have a history of making false allegations but when R3 (R2's roommate) said she was in the bathroom and heard V5 Former CNA yelling at (R1) I decided that we just didn't need to take any chances. V1 Administrator stated V5 was suspended during the investigation, DNR'd (do not return) from the facility and later terminated. V1 stated he did not have any other complaints from the residents about (V5) but did have some staff issues and problems so after this incident I decided to just be done. V1 stated he took the full allotted time to do the investigation which was substantiated and he notified the float pool (company staffing agency) and the float pool terminated V5 Former CNA. V1 Administrator stated he did not terminate V5; the float pool did so all of 145987 Page 2 of 4 145987 03/07/2024 Allure of Galesburg 1145 Frank Street Galesburg, IL 61401

F 0600 that paperwork is with the company's agency. Level of Harm - Minimal harm or potential for actual harm 2. The facility's Final Incident Investigation Report, dated 1/11/24, documents On 1/3/24 R5 and R6 were in a physical altercation. R5 said R6 walked from R6's room, through the adjoining bathroom, into R5's room. R6 attempted to exit R5's room into the hallway through R5's room. R5 became upset and threw his cup of coffee on R6. Per camera review, R6 exited R5's room with coffee on his shirt. Staff observed R6 with the coffee on his shirt and this admin questioned R5 about the situation. R5 stated he was upset R6 walked into his room and threw the coffee. (V2) DON/Director of Nursing did a skin assessment and no injuries noted to R6. Residents were separated and R5 was sent in for a psychiatric evaluation. Residents Affected - Few The Face Sheet for R5, includes the following diagnoses: Major Depressive Disorder, Traumatic Brain Injury, and Cognitive Communication Deficit. The Quarterly MDS for R5, dated 12/13/23, documents R5 is cognitively intact, requires partial to supervision assist with activities of daily living and supervision for transfers and walking. The Face Sheet for R6, includes the following diagnoses: Schizophrenia, Unspecified Psychosis, Altered Mental Status, and Catatonic Disorder. The Quarterly MDS for R6, dated 12/12/23, documents R6 with moderately impaired cognition and requires partial to supervision assist with all activities of daily living and supervision for transfers and walking. The facility abuse investigation includes R5 and R6's statements. R5 stated R6 was in the bathroom and exited the shared bathroom into R6's room. This upset R5 who then threw his cup of coffee on R6. Interview was attempted with R6 but V1 Administrator was unable to get a clear response from R6. V2 DON did a skin assessment with no injuries noted. The Progress Notes for R5, dated 1/3/24 at 6:24 pm, documents (R5) admitted to throwing coffee on another resident that lives in room next to him. Other resident gets confused and goes into (R5's) room. (R6) does grab (R5's) walker and other personal items when he goes through there. (R5) passed resident in hallway and hit (R6) in the stomach with back of his hand. (R5) tried to grab (R6's) cup of water (Nurse) had given meds (medications) with. (R5) was taken to ER (emergency room) via facility van for evaluation d/t (due to) behaviors. The Progress Note for R6, dated 1/3/24 at 7:06 pm, documents Late Entry Nurse came to DON door to inform of (R6) getting coffee thrown on him. DON went to main core to assess resident. Skin assessment revealed no redness or injury to resident. Resident not complaining of any pain or showing any signs of discomfort. Will continue to monitor (R6). On 2/28/24, 3/5/24, and 3/6/24 R5 and R6 were residing on different hallways with no behaviors identified. On 2/28/24 at 12:40 pm, R6 was sitting in a stationary chair in his room. On 3/5/24 at 11:30 am, R6 was sitting in a stationary chair on the left side of the dining room. There were no behaviors noted. On 2/28/24 at 12:40 pm, R6 stated his name and said I'm calmed down. R6 would not engage in any other conversation however, did say Yes when asked if he feels safe in the facility. On 2/28/24 at 11:52 am, R5 was sitting on the side of his bed. On 3/5/24 at 11:29 am, R5 was lying in bed. There were no identified behaviors. On 2/28/24 R5 stated he has no complaints, 145987 Page 3 of 4 145987 03/07/2024 Allure of Galesburg 1145 Frank Street Galesburg, IL 61401

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feels safe in the facility and hasn't had any problems with anyone and is unaware of anyone being mean to the residents. On 3/5/24 at 3:15 pm, V1 Administrator stated he did the investigation regarding the altercation between R5 and R6. V1 Administrated stated V5 and V6 shared a bathroom and V6 exited the bathroom into R5's room. R5 got upset and threw his coffee on R6. V1 confirmed that R5 hit R6 in the belly, in the hallway and he forgot to add that detail to the final abuse report. V1 stated there were no injuries and room moves were made and there have been no further problems. 145987 Page 4 of 4