Inspection·October 24, 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 protect a resident (R2) from abuse. This applies to 1 of 3 residents reviewed for abuse in the sample of 9. The findings include: R1's electronic face sheet printed on 10/2424 showed R1 has diagnoses including but not limited to altered mental status, psychosis, and adjustment disorder with mixed anxiety and depressed mood. R1's facility assessment dated [DATE] showed R1 has mild cognitive impairment and experiences verbal behaviors directed towards others. R1's care plan dated 10/10/24 showed, (R1) demonstrates behavioral distress related to generalized anxiety disorder and adjustment disorder. Problems are manifested by exhibiting physical and verbal aggression. Triggers may include poor impulse control, not personally identifying the situation/environment; demonstrate mood lability, showing little ability to self-regulate anger/temper and mood state . R1's care plan dated 8/7/23 showed, (R1) has a behavior problem he asks staff for sexual favors, tries to intimidate staff members, may use profanity towards staff members and tries to start fights with other residents related to diagnosis and noncompliance with treatment. R2's electronic face sheet printed on 10/24/24 showed R2 has diagnoses including but not limited to delusional disorders, chronic kidney disease, and insomnia. R2's facility assessment dated [DATE] showed R2 has no cognitive impairment and experiences verbal behaviors directed towards others. R2's care plan dated 10/26/23 showed, I have a history of mental health problems (psychotic disorder and adjustment disorder) and I display dysfunctional behavior. This problem is manifested by behaving in a derogatory and condescending manner towards others. I am territorial and have a misguided belief that I am entitled to identify areas where peers are allowed to be within the facility. R2's care plan dated 5/23/24 showed, I am challenged by mental illness (psychotic disorder and adjustment disorder) and rigid personality traits. I am impulsive in my judgment/is verbally aggressive & I tend to target female staff with making socially inappropriate comments. I am quick to use provocative words and objectify female staff as a misguided means of asserting my dominance. I have (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: 146071 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 146071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Place of Belvidere 1701 5th Avenue Belvidere, IL 61008 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)