Health inspection·February 23, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report an allegation of employee to resident (R1) physical abuse to the State Agency. R1 is one of three residents reviewed for abuse in the sample of three. Residents Affected - Few Findings include: R1's Diagnosis Sheet (current) includes the following diagnoses: Anxiety, Major Depression, Urinary Retention, Atrial Fibrillation and Atrial Flutter. R1's Physician Order Sheet dated February 2024 includes an order for Apixaban (anticoagulant) 2.5 milligrams twice a day. R1's Progress Notes document the following: 2/13/24 at 3:32 pm Created 2/14/24 at 3:56 pm - Late Entry: CNA (Certified Nursing Assistant) reported bruise to (R1's) right upper arm. I (V9 Registered Nurse) assessed bruise it was purple in color measuring 5 centimeters (cm) by 4 cm with scattered minimal brushing surrounding the large bruised area. (R1) reports that a CNA from previous day shift was rough when rolling (R1) for care. (R1) states (R1) doesn't feel like (R1) was in any harm from the CNA. (R1) states that it was just one CNA in room at time of incident. 2/15/24 at 11:48 am - CNA (Certified Nursing Assistant) reported bruise to (R1's) right upper arm. I (V9 Registered Nurse) assessed bruise it was purple in color measuring 5 centimeters (cm) by 4 cm with scattered minimal brushing surrounding the large bruised area. (R1) reports that a CNA from previous day shift was rough when rolling (R1) for care. (R1) states (R1) doesn't feel like (R1) was in any harm from the CNA. (R1) states that it was just one CNA in room at time of incident. On 2/22/24 at 10:00 am V1 Administrator confirmed the allegation of abuse between an employee and R1 had not been reported to the State Agency or to anyone. V1 also stated that V1 did not receive the information concerning the bruise at the time the bruise was noted on R1's arm. On 2/22/24 at 11:40 am R1 confirmed that one of the CNA's (doesn't know their name) was rough with R1 and believes that is how the bruise got on R1's arm. On 2/22/24 at 11:40 am R1's right lateral upper arm has a dark purple bruise measuring approximately 5 centimeters (cm) in length and approximately 4 cm in width. Page 1 of 2 146046 146046 02/23/2024 Marshall Rehab & Nursing 410 North Second Street Marshall, IL 62441

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/22/24 at 12:10 pm V2 Director of Nursing stated V2 had received the allegation of abuse made by R1 from Registered Nurse V9 on 2/13/24. V2 also stated V2 had immediately reported the allegation to V1. V2 stated V1 was very busy at that time and maybe V1 thought V2 was going to report the allegation to the State Agency, which V2 stated V2 did not report. On 2/22/24 at 12:20 pm V1 stated V1 does recollect receiving R1's allegation of abuse from V2. V1 also stated Corporate had instructed V1 not to report the allegation because V1 believed R1 had recanted the allegation. V1 could not provide documentation of an interview with R1 recanting R1's allegation of abuse. The facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation dated 2022, directs facility staff as follows: When the Facility has identified abuse, the facility will take all appropriate steps to remediate the non-compliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: A. Taking steps to prevent further potential abuse. B. Reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations. See CCG 00309 Elder Justice Act Policy and Procedure. The facility policy titled Elder Justice Act and Reporting Suspected Crimes Against Residents dated 2022, directs facility staff as follows: II. Duty to Report Reasonable Suspicion and or Alleged Violations. A. Covered individuals have a duty to report any reasonable suspicion of a crime (as defined by law of the applicable political subdivision) against any individual who is a resident of or is receiving care care from, the Facility pursuant to Section 1150B of the Social Security Act (the Elder Justice Act). B. The facility has a duty to report all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, as well as the results of all investigations of alleged violations pursuant to 42 CFR 482.12(c). 146046 Page 2 of 2