Health inspection·May 7, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 for four (R1, R2, R3, R4) of four residents reviewed for physical abuse from a total sample list of nine residents reviewed for abuse. Findings include: The facility provided Resident Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure dated 2025 documents the facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation with the purpose to facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation. 1.) R1's undated diagnosis sheet documents diagnoses of Major Depressive Disorder, Anxiety Disorder, Alzheimer's Disease, and Dementia with Psychotic Disturbance. R1's progress notes dated [DATE] document that R1 died at the facility. R1's Minimum Data Set, dated [DATE] documents R1 as severely cognitively impaired. R1's progress notes dated [DATE] document an altercation involving R1 and R2. R1's care plan dated [DATE] documents that R1 became combative with R2. The facility provided report to the state agency documents an altercation between R1 and R2 dated [DATE]. The Report documents On [DATE] (R1) struck (R2) with an open hand on the left cheek in front of the C/D nurses station. On [DATE] at 11:36AM, V2 Director of Nursing stated that after the altercation, R1 was placed on 1:1 observation until she went to sleep. R2's undated diagnosis sheet documents diagnoses of Traumatic Hemorrhage of the Cerebrum, Anxiety, Schizoaffective Disorders, Aphasia following Cerebral Infarction, and Dementia. R2's Minimum Data Set, dated [DATE] documents R2 as severely cognitively impaired. Page 1 of 5 146046 146046 05/07/2025 Marshall Rehab & Nursing 410 North Second Street Marshall, IL 62441

F 0600 R2's progress notes dated [DATE] document an altercation involving R2 and R1. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 12:13PM, V7 Certified Nursing Assistant stated, I was there, standing in the hallway and before I could get to them, I saw and heard (R1) slap (R2) after hearing (R1) tell (R2) to move. I immediately separated (R1) and (R2) and then reported it to the nurses. (R1) was frightened because she thought that his wheel chair was too close to her wheelchair in the hallway. (R2) was really confused and upset after (R1) slapped him and (R2) just kept apologizing to (R1) even though he was the one who was hit. Residents Affected - Some 2.) R3's undated diagnosis sheet documents diagnoses of Parkinson's Disease, Atherosclerosis, Prostate Cancer and Aphasia. R3's Minimum Data Set, dated [DATE] documents that R3 is cognitively intact. R3's progress notes dated [DATE] document an altercation between R3 and another resident. On [DATE] at 9:50AM, R3 stated that R4 pulled on his arm in the dining room and then he pushed her. She has touched me before but this is the first time that I ever pushed her away. She does it for attention. She touches you and if you don't give her attention, she pulls and I don't like it. On [DATE] at 9:44AM, R5 stated that he was in the dining room when R3 kicked R4. R5 stated that R3 wasn't moving R3 was out of the way but that R3 kicked her (left leg) because he hates her, lots of people do because she touches them. I used to be a Certified Nursing Assistant and I'm afraid that she is going to get hurt. She doesn't understand what she's doing. R4's undated diagnosis sheet documents diagnoses of Dementia, Psychosis and Depression. R4's Minimum Data Set, dated [DATE] documents that R4 is severely cognitively impaired. R4's progress notes dated [DATE] document an altercation between R4 and another resident. On [DATE] at 9:35AM, V3 Registered Nurse stated that R4 is alert to herself only and that she touches everyone. On [DATE] at 9:37AM, V4 Certified Nursing Assistant stated that R4 touches people on the arms. On [DATE] at 9:57AM, V5 Certified Nursing Assistant stated that R4 moves throughout the facility and touches arms but not everyone likes it. On [DATE] at 9:46AM, R6 stated, She (R4) has touched me before and I punched her. I asked her seven times to stop and she just won't stop. I don't like it and I will do it again if she touches me again. On [DATE] at 11:25AM, R8 stated that R4 used to touch him and that he didn't like it. On [DATE] at 11:28AM, R9 stated that he knew R4 and that she touches him but that there isn't anything that can be done. On [DATE] at 11:40AM, V2 Director of Nursing stated that it is not ok for resident's to touch one 146046 Page 2 of 5 146046 05/07/2025 Marshall Rehab & Nursing 410 North Second Street Marshall, IL 62441

F 0600 Level of Harm - Minimal harm or potential for actual harm another without their permission. I have tried to explain to the staff that we have to keep an eye on R4 to protect her. As of today she is a 1:1 observation when out of bed. I know that some residents don't like her touching. Residents Affected - Some 146046 Page 3 of 5 146046 05/07/2025 Marshall Rehab & Nursing 410 North Second Street Marshall, IL 62441

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide effective dementia treatment and services for one (R4) of four residents reviewed for dementia care from a total sample list of nine residents. Residents Affected - Few Findings include: R4's undated diagnosis sheet documents diagnoses of Dementia, Psychosis and Depression. R4's resident census documents admission to the facility on 2/1/22. R4's Minimum Data Set, dated [DATE] documents R4 is severely cognitively impaired. R4's progress notes dated 4/17/25 document an altercation between R4 and another resident. On 5/7/25 at 9:35AM, V3 Registered Nurse stated that R4 is alert to herself only and that she touches everyone when she is out of bed. On 5/7/25 at 9:37AM, V4 Certified Nursing Assistant stated that R4 touches people on the arms. On 5/7/25 at 9:57AM, V5 Certified Nursing Assistant stated that R4 moves throughout the facility and touches arms but not everyone likes it. On 5/7/25 at 9:46AM, R6 stated, She has touched me before and I punched her. I asked her seven times to stop and she just won't stop. I don't like it and I will do it again if she touches me again. On 5/7/25 at 11:25AM, R8 stated that R4 used to touch him and that he didn't like it. R4's undated care plan does not document behaviors including touching other residents, nor interventions to address these behaviors. R4's behavior tracking for April 2025 does not document any behaviors. On 5/7/25 at V2 Director of Nursing stated that the staff did not see R4's touching other residents as a behavior. On 5/7/25 at 2:48PM, V4 and V8 Certified Nursing Assistants stated that they could not recall having dementia training at the facility. On 5/7/25 at 2:50PM, V9 Dietary Aid stated that she had never received dementia training. On 5/7/25 at 2:51PM, V5 Licensed Practical Nurse stated that she had not received dementia training at the facility. On 5/7/25 at 9:45AM, V1 Administrator and V2 Director of Nursing confirmed that the facility does not have a dementia unit, nor a dementia coordinator. 146046 Page 4 of 5 146046 05/07/2025 Marshall Rehab & Nursing 410 North Second Street Marshall, IL 62441

F 0744 On 5/7/25 at 3:37PM, V1 Administrator stated that the facility needed more dementia training including early intervention, dementia behavior management. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146046 Page 5 of 5