Health inspection·November 1, 2023

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's right to be free from physical abuse by another resident. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: R1's admission Record indicated R1 was a [AGE] year-old male with a diagnosis of schizophrenia. A facility assessment that was done on 9/5/23 showed R1's cognitive skills were moderately impaired. R1's Care Plan showed R1 was at risk for abuse. R2's admission Record indicated R2 was a [AGE] year-old male with a diagnosis of dementia and schizophrenia. On 11/1/23 at 11:05 AM, R1 was asked if he felt safe in the building. R1 shrugged his shoulders indicating he did not know. R1 pointed to R2 and said he was punched by R2. R1 indicated he was punched in the right eye/cheek area. R1 said it hurt when he was punched. On 11/1/23 at 10:44 AM, V6 (Receptionist) said on 10/23/23 during dinner she witnessed the following: R2 took some food off R1's plate, R1 pulled his plate away from R2, and R2 made his hand into a fist and punched R1 3-4 times in the eye. V6 said R2 did not accidentally or inadvertently hit R1. A Witness Statement Form dated 10/23/23 and signed by V6 showed V6 saw R2 punch R1 in the face 4 times. On 11/1/23 at 10:55 AM, V7 (Certified Nursing Assistant) said on 10/23/23 during dinner she witnessed R2 punch R1 in the chin one time. V7 said after R1 was hit, R1 stood up and swore at R2. V7 added that R1 seemed, shocked that he was hit. A Witness Statement Form dated 10/23/23 and signed by V7 showed V7 saw R2 hit R1 on the chin. On 11/1/23 at 11:40 AM, V8 (Registered Nurse) said she was taking care of R1 and R2 during the event. V8 said she was informed R2 had punched R1. V8 said she assessed R1 and the white portion of R1's right eye was red. V8 said R1 reported he had blurred vision as the result of being hit and was sent to the hospital. (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: 146159 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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)