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.
(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:
146059
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
146059
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Grove Health & Rehab Ctr, The
873 Grove Street
Jacksonville, IL 62650
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)
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.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146059
If continuation sheet
Page 2 of 2
