Health inspection·May 15, 2025

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 prevent physical abuse for 2 of 7 residents (R1, R2) reviewed for abuse in the sample of 7. Findings include: 1. On 5/15/25 at 1:22 PM, R2 is lying in bed. R2 does not speak much. R2 was asked if anyone has ever hurt her, R2 shook her head yes. R2 was questioned if her roommate hit her, R2 shook her head yes. R2 was questioned as to where she was hit, R2 pointed to her face. R2's Verification of Incident Investigation / Administration Summary, dated 5/7/25, documents, A comprehensive investigation was initiated and showed that staff reported that one resident (R2) with a BIMS (Brief Interview of Mental Status) of 9 (moderately cognitively impaired) was heard alleging that she got into an altercation with resident (R3) BIMS of 4 (severely cognitively impaired). It continues, (R2) could recall the incident stating I would like a new roommate she came over and smacked my arm. Neither resident shows signs of psychosocial / mental anguish. V3 Certified Nurses Aide witness statement, dated 4/30/25, documents, I (V3) walked into (R2's and R3's) room, because (R2) was yelling and seen (R3) hitting (R2) in the face with her hand telling her to shut up. R2's admission Record, print date of 5/15/25, documents R2 was admitted on [DATE] and has a diagnosis of Cerebal Palsy and Developmental Disorder. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is moderately cognitively impaired. R2's Health Status Note, dated 4/30/25, documents, This resident alleged abuse from another resident. Admin/DON/ (Administrator, Director of Nursing) on call NM(Nurse Manager)/OSG (Office of State Guardian)/LPD(local police department)/IDPH notified. Investigation pending. R3's Face Sheet, print date of 5/15/25, documents, R3 was admitted on [DATE] and has a diagnosis of Anemia. R3's MDS, dated [DATE], documents, R3 is severely cognitively impaired. R3's Occurrence Note, dated 4/30/2025, documents, Another resident states this resident smacked her in the face. Investigation pending. Page 1 of 2 146059 146059 05/15/2025 Grove Health & Rehab Ctr, The 873 Grove Street Jacksonville, IL 62650

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. R1's Verification of Incident Investigation / Administration Summary, dated 4/24/25, documents, A comprehensive investigation was initiated and showed that staff reported that one resident (R4) with a BIMS of 6 (severely cognitively impaired) was seen smacking fellow resident (R1) BIMS of 6. on top of head. Upon interview R1 did not recall the incident. It continues, R4 stated, I did not hit her, we may have bumped wheelchairs in the hall way, but I did not hit her.Neither resident shows signs of psychosocial / mental anguish. R1's admission Record, print date of 5/15/25, documents, R1 was admitted on [DATE] and has a diagnoses of Dementia. R1's MDS, dated [DATE] documents R1 is severely cognitively impaired. R1's Care Plan, dated 4/21/25, documents, (R1) has been involved in an alleged resident to resident physical altercation .Allow resident to verbalize feelings and thoughts. Notifications to necessary parties. Social services to provide one to one visits as needed to discuss feelings and thoughts. Trauma assessment, as appropriate. R4's admission Record, print date of 5/15/25, documents, R4 was admitted on [DATE] and has a diagnoses of Dementia. R4's MDS, dated [DATE], documents R4 is severely cognitively impaired. R4's Health Status Note, dated 4/19/2025, documents, Residents was preparing to get up and get prepared for supper. Resident was seen hitting another resident in the head and then pushed her wheelchair out the way. Advised resident not to hit another resident and she began to hit writer. Advised resident not to hit the nurse and resident began to swear at the nurse and then started to say racial slurs at the nurse. Advised resident not to speak in that manner and escorted resident to her room. Made the house supervisor on duty of the incident. On 5/15/25 at 2:00 PM, V1, Administrator, stated R3 did hit R2. They are no longer roommates. R3 does have a history of hitting but she has not hit anyone in a very long time. R4 did hit R1 they were in the hallway. In both cases, they were immediately separated, no one was hurt, and I was notified immediately. The Abuse Policy, dated 1/9/24, documents, Purpose to provide guidance and Procedure to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. . 146059 Page 2 of 2