Health inspection·March 8, 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. Based on Interview and Record review, the facility failed to prevent an incident of resident to resident physical abuse, re-assess resident's risk for abuse and revise abuse care plans after founded physical abuse occurred for two of three residents (R1, R2) reviewed for abuse in the sample of three. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 8/2024, documents It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes but it not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. This same policy also documents The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The facility's Care Plan Revisions upon Status Change policy, dated 8/2024, documents The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. Care plans will be modified as needed by the MDS (Minimum Data Set) Coordinator or other designated staff member. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. The facility's Abuse Investigation, dated 2/15/25, documents on 2/15/25 between 5:15 PM and 5:30 PM, R2 was slapped on her facial cheek by R1 in the facility's common area day room. This investigation documents V4 (Registered Nurse) was witness to the incident and that the abuse was investigated to be substantiated, without injury to either resident. R1's current Care Plan dated, 2/20/25, documents (R1) has a behavior problem in related to her diagnosis of dementia with behavioral disturbances. She can be uncooperative with care. She may attempt to hit staff or refuse to transfer/refuse care. She may become angry, anxious and agitated. This plan of care has an intervention added on 2/15/25 of If (R1) becomes aggressive with another resident, Page 1 of 2 146063 146063 03/08/2025 Allure of Walnut 308 South Second Street Walnut, IL 61376

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few separate them immediately. This same Care Plan documents a plan of care initiated on 12/4/23 of (R1) is at a low risk for abuse, neglect, exploitation, trauma as noted from Abuse screening related to dementia and anxiety. Intervention: (Facility) Abuse/Neglect/Trauma assessment quarterly or prn (as needed). This plan of cares most recent revision is dated 12/19/24. R2's current Care Plan, dated 2/20/25, documents (R2) has impaired cognitive function. She usually scores in range of moderate cognitive impairment on BIMS (Brief Interview for Mental Status). She has moderate hearing impairment which may affect her cognitive function. (R2) is also easily distracted and can have delusional thinking at times. She also has a diagnosis of dementia. This plan has an intervention added on 2/15/25 of If (R2) becomes aggressive with another resident, separate them immediately. This same Care Plan documents a plan of care initiated on 12/4/23 of (R2) is at a low risk for abuse, neglect, exploitation, trauma as noted from Abuse screening related to dementia, attention and concentration deficit. Intervention: (Facility) Abuse/Neglect/Trauma assessment quarterly or prn (as needed). This plan of cares most recent revision is dated 12/24/24. On 3/7/25 at 12:15 PM, V5 (Registered Nurse/ MDS coordinator) confirmed she did not update the Abuse Care Plans for R1 and R2. V5 stated I added an intervention to their behavior Care Plans that if they are aggressive, to remove them from other resident contact. V5 confirmed that both R1 and R2 are still Care Planned as being at a low risk for abuse. On 3/7/25 at 12:25 PM, V6 (Social Service Director) confirmed she is the person who does Abuse risk assessments and created the Abuse Care Plans for R1 and R2. V6 stated I only update the Abuse specific Care Plan with a re-assessment, either quarterly or on an MDS significant change review. That is when I would complete a new Abuse risk assessment. I guess (V5) would be the one who updates the care plans with new interventions in between that time. V6 confirmed she has not done a new risk assessment for Abuse and has not made any revisions to the Abuse risk care plans for R1 and R2 since the 2/15/25 physical abuse occurred. On 3/7/25 at 1:25 PM, V4 (Registered Nurse) confirmed she was working on 2/15/25 and was witness to a physical altercation between R1 and R2. V4 stated I was the nurse that was present when the altercation took place. The residents were in the day room, which is where the television is. I was at the nurses station and I heard (R2) say Stop that. I looked and could see that (R1) was fiddling with (R2's) wheelchair and (R2) said Stop that again and tried to swat (R1's) hand away. I got up from the desk and I saw (R1) slap (R2) on the face, due to the disagreement. (R2) did say her cheek hurt. (R1) likes to fiddle with stuff and we try to keep her busy and monitored. (R1) just needs closer supervision when around other residents. 146063 Page 2 of 2