Inspection·January 5, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to keep a resident free from abuse for 1 of 5 residents (R1) reviewed for abuse in the sample of 5. Findings include: Facility Abuse Investigation: 1/4/24 - Initial report: R2 was in R1's room having a verbal altercation. After a very short time went by R2 pushed R1 into the hallway and R1 fell down. Residents were separated and the investigation started. Final investigation: It was reported on 1/4/24 that resident R2 with identified behaviors for physical/verbal aggression toward staff and resistant to care has allegedly made physical contact with resident R1. R1 had noted skin tear to left elbow with minor bruising noted to shoulder. R1's Face Sheet to include diagnosis of muscle weakness and depression. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately impaired and has physical/verbal behaviors directed towards others. R1's Care Plan dated 12/14/23 documents R1 Displays episodes of physical aggression towards others by evidence of attempting to hit nursing staff (swinging at them and also verbally threatening to hit them). Resident displays episodes of verbal aggression towards others by evidence of yelling at, name calling, and threatening nursing staff. Interventions in place and are personalized to this resident. R1's Behavior Tracking documents: Physical aggression: resident will threaten to hit staff, swing to hit staff. R1's Nursing Note dated 01/04/2024 at 12:49 PM documents, Writer summoned to B Hall at 5:57AM, staff observed resident lying on left side on floor. Mid hallway by room [ROOM NUMBER]. Resident vocal, stated he threw me. Writer observed other resident standing in hallway. Small amount blood noted to resident's 3rd finger left hand, refused assessment did not want to do ROM (Range of Motion), Resident stated just leave me lay here and call my son. Resident remained alert and conscience while lying on floor. Staff kept resident immobile until EMS arrived. No distress, no guarded behavior no grimacing noted. Writer called ambulance 911. Call placed to son, message left for administrator to call facility. 6p to 6a nurse called DON (Director of Nursing). R1's Nursing Note dated 01/04/2024 at 3:16 PM documents, MD notified of resident being on floor this am and sent to ER given report that there no findings at hospital, notified of skin tear to left elbow 1.2 cm (centimeters) x 0.7cm x 0.1cm, shearing to mid back and bruising with small amount bleeding to 2nd finger left hand. Resident did return. On 1/5/24 at 8:25am R1 When asked about the incident with R2, resident stated I'm not talking to (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146052 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Rehab & Healthcare 417 East Main Street, Box 310 Alhambra, IL 62001 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)