Health inspection·August 4, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review the facility failed to ensure residents were free of physical abuse for 1 of 3 (R2) residents reviewed for abuse in a sample of 6. Residents Affected - Few Findings include: R1's face sheet documented an admission date of 5/3/23 and diagnoses including: lack of expected normal psychological development in childhood, kidney failure, hypertension, hypothyroidism, dementia. R1's 5/30/23 care plan documented R1 has the potential to be physically aggressive related to hitting another resident with right hand closed fist and 7/12/23 care plan documented has the potential to be physically abusive related to dementia and mental/ emotional illness. R2's face sheet documented an admission date of 2/24/23 and diagnoses including: cerebral infarction, hyperlipidemia, speech disturbances, bipolar disorder, atherosclerotic heart disease. R2's care plan with a revision date of 5/10/23 documented R2 has communication deficits related to a Cerebral Vascular Accident (CVA). The facility's Verification of Incident Investigation/ Administrative Summary completed 7/28/23 documented R2 was sitting in the dining room on 7/24/23 when R1 attempted to take food off R2's plate and R1 punched R2 in the back of the head 5 times. The summary documented V8 (Registered Nurse) said she was able to redirect R1 and separate R1 and R2. The summary documented V8 said R1 did have some aggressive behaviors regarding food. On 7/28/23 at 11:21 AM, V8 said she was standing at the nurse's station on the morning of 7/24/23 with a clear view of the dining room. V8 said R2 was sitting at a table eating breakfast when R1 approached R2 and tried to take a piece of sausage off of R2's plate. V8 said she saw R1 punch R2 in the head. On 7/25/23 at 11:25 AM, V7 (Licensed Practical Nurse/ LPN) said on the morning of 7/24/23 she was standing at the medication cart when she heard staff calling for help in the dining room. V7 said she went to the dining room to assist with separating and assessing R1 and R2. When asked if R1 was physically aggressive V7 stated R1 is not one I would turn my back to. V7 said R1 has become physically aggressive with staff and other residents in the past. V7 said R1 will become physically aggressive over food. On 7/28/23 at 12:27 PM, V2 (Director of Nursing/ DON) said it was the responsibility of the facility to make sure all residents are free from abuse. Page 1 of 3 146021 146021 08/04/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0600 The facility's 4/18/23 Abuse Policy documented it is the responsibility of all facility staff to assure that all residents remain free from abuse. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146021 Page 2 of 3 146021 08/04/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to complete serial neurological checks after trauma to the head for 1 of 3 (R2) residents reviewed for quality of care in a sample of 6. Residents Affected - Few Findings include: R2's face sheet documented an admission date of 2/24/23 and diagnoses including: cerebral infarction, hyperlipidemia, speech disturbances, bipolar disorder, atherosclerotic heart disease. R2's care plan with a revision date of 5/10/23 documented R2 has communication deficits related to Cerebral Vascular Accident (CVA). The facility's Verification of Incident Investigation/ Administrative Summary completed 7/28/23 documented R2 was sitting in the dining room on 7/24/23 when another resident attempted to take food off R2's plate and punched R2 in the head 5 times. On 8/2/23 at 1:24 PM, V6 (Licensed Practical Nurse/ LPN) said she was the nurse caring for R2 on 7/24/23 when R2 was punched in the head by another resident. V6 said after R2 was separated from the other resident she assessed R2. V6 said she did not see any injury to R2's head and completed a neurological check at that time. V6 said she did not complete serial neurological checks on R2 because she did not see any injury. V6 said she started serial neurological checks on 7/25/23 at 1:25 PM because management told her any resident with head trauma should have serial neurological checks completed. V6 said she was not aware the facility expected serial neurological checks to be completed any time a resident had head trauma. V6 said she did assess R2 later in the day on 7/24/23 for any injury to R2's head because bruising can show up later after trauma has happened. R2's Electronic Medical Record (EMR) documented serial neurological checks were started on 7/25/23 at 1:25 PM. On 8/2/23 at 12:27 PM, V2 (Director of Nursing/ DON) said R2 should have had serial neurological checks started immediately after being punched in the head by another resident. V2 said if R2 had any neurological changes due to the head trauma they would not have been found if the nursing staff were not completing serial neurological checks. V2 said R2 potentially could have had a brain bleed that would have went unnoticed and untreated. On 8/4/23 at 11:42 AM, V6 (Physician) said he expected the facility to complete serial neurological checks after a resident is punched in the head or any other head trauma occurs. The facility's 1/23/23 Change in Condition Protocol documented the facility direct care staff will be trained to recognize subtle but significant changes in residents. 146021 Page 3 of 3