Inspection·November 7, 2023

F 0600 tried try to take food off his tray before too. R4 could not recall any other details. Level of Harm - Minimal harm or potential for actual harm On 11/7/23 at 12:12 PM, V2 DON said she was told by V10 Receptionist that R3 hit R4 in the mouth. V2 said they put R3 on 1:1 supervision and began the investigation. V2 said R3 had no injuries. V2 said she reviewed the camera and it showed R4 was by the front door waiting to go outside to smoke when R3 came up was talking to V10 telling her R4 stinks. V2 said then R3 wheels up to R4 and pops R3 in the mouth. R4 starts kicking out trying to propel his wheelchair backward and R3 starts kicking back. V2 said R3 did hit R4 in the mouth. V2 said when R3 was in his room he was verbally threatening to knock out staff and was refusing to go to the hospital. V2 said 911 was called and R3 did leave with the police via ambulance to the hospital. V2 said R3 is at a psych hospital and will not be returning to the facility. Residents Affected - Few On 11/7/23 at 1:23 PM, V10 said R3 came up by the front door and told her to get a nurse to clean R4's coat. V10 said R3 was yelling at R4 to take his coat off it looked nappy. V10 said R4 told her and R3 that he was cold and didn't want to take his coat off. V10 said R3 then started swearing at R4 and then moved over towards R4 and punched R4 in the mouth. V10 said R4 tried to kick out to get away from R3. V10, said she asked the activity person to get staff to come help. V10 said R3 was unprovoked, and she had never seen R3 and R4 argue before. R3's Minimum Data Set, dated [DATE] shows R3 is cognitively impaired and has behaviors not directed at others. R4's Minimum Data Set, dated [DATE] shows R4 is cognitively intact. 3. The facility's Incident Report dated 11/6/23 shows R7 was physically aggressive with R8. On 11/7/23 at 10:03 AM, R7 was in bed sleeping with a staff member sitting outside his door. On 11/7/23 at 11:50 AM, R8 was sitting up in her wheelchair in the dining room watching TV. R8 stated I was sitting right here watching TV and a man came up and smacked my cheek (R8 made a motion with her hand pretending to smack her left cheek). They got him out of here. On 11/7/23 at 11:55 AM, V2 DON said she watched the camera and it showed R8 was sitting in her wheelchair watching the big TV in the dining room and R7 came up to her and hit R8 in the face with a flat hand. V2 said R8 held her hand to her face and was crying. V2 said V9 Receptionist ran over and brought R7 to his room and got the nurse. V2 said R7 has had behaviors before but they have always been about food. V2 said R7 is on 1:1 supervision while we try to find him placement. On 11/7/23 at 12:53 PM, V9 said R8 was watching TV and R7 walked up and slapped her in the face. V9 said R8 was just minding her own business when R7 approached her. V9 said R7 said she was ok and there was no injury. R7's Minimum Data Set, dated [DATE] shows R7 ambulates with limited assistance. R8's Minimum Data Set, dated shows R8 is moderately cognitively impaired and uses wheelchair for extensive assistance for activities of daily living. The facility's Abuse Policy dated 3/2022 shows This facility affirms the right of our consumers to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 2 of 3 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 11/07/2023 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm property, involuntary seclusion, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of consumers. In order to do so, the facility has attempted to establish a consumer sensitive and consumer secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of consumers. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146159 If continuation sheet Page 3 of 3