Parc Joliet

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

anxiety disorder, morbid obesity, opioid abuse, chronic pain due to trauma, impulse disorder, history of traumatic brain injury, lymphedema, and tremor. Resident R2's MDS dated [DATE REDACTED] shows Resident R2 has moderate cognitive impairment, requires setup assistance with eating, oral and personal hygiene, supervision with toilet hygiene and transfers between surfaces, and partial/moderate assistance with showering, dressing, and bed mobility. Resident R2 is occasionally incontinent of bowel and bladder. Multiple attempts were made to interview Resident R2, including on, August 21, 2025 and August 25, 2025. Resident R2 refused to be interviewed. A Petition for Involuntary/Judicial admission dated July 29, 2025 at 7:50 PM, and completed by V17 (LPN) shows, [AGE] year-old male named [Resident R2], who is intermittently confused, became agitated and struck another resident in eye, causing skin tear/injury at 1727 (5:27 PM). On July 29, 2025 at 8:13 PM, V17 (LPN) documented, [Resident R2] discharged to [hospital]. Reason for transfer: increased confusion, aggression, physical altercation. Resident R2's hospital discharge documentation, dated July 29, 2025 at 8:36 PM shows: You were seen today for: agitation. You were seen in the emergency room for an episode of agitation and a fight. There are no signs of serious injury from the fight. There are no signs of serious psychiatric illness that would require any sort of inpatient admission. Your labs are normal. You are being discharged . On August 21, 2025 at 2:38 PM, V14 (LPN) said she was sitting at the nurse's station when Resident R2 and Resident R3 had an altercation at the end of the hall, including arguing and physical hitting. V14 continued to say, [Resident R2] has been having a lot of behaviors. I saw the two residents struggling. The police came to the facility as well. V14 continued to say the nurse assigned to Resident R2 (V17) was on break at the time of the incident and was not present on the resident floor. On August 25 2025 at 9:50 AM, V2 (DON-Director of Nursing) and V1 (Administrator) said, they did not feel the allegation of abuse between Resident R2 and Resident R3 was substantiated despite V14's nursing documentation and the fact nursing staff petitioned Resident R2 out of the facility due to his behaviors. V1 and V2 responded by saying their staff are very dramatic. The facility's final incident report to the State Agency, dated August 4, 2025 shows

the original incident was an allegation of resident-to-resident altercation on July 29, 2025. Witness statements were obtained from Resident R2, Resident R3, V14 and V17. The facility does not have any documentation to show any other residents or facility staff were interviewed during the abuse investigation, or that facility surveillance cameras were used to determine the outcome of the facility's investigation. The facility's Abuse Prevention Program Facility Policy and Procedure, reviewed 4-Jan-19 shows, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Parc Joliet

222 North Hammes Joliet, IL 60435

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 0689 Level of Harm - Actual harm

wear, and state the reason and process for removing lift equipment and slings from service. The staff competency also shows facility staff are expected to know to clear a pathway to allow the lift to pivot and move freely.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Parc Joliet

222 North Hammes Joliet, IL 60435

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

6:09 PM, V8's (LPN) struck out progress notes were reviewed with V8. Each entry was read out loud to V8

during the interview. V8 said, I wrote very detailed notes of what I saw and what I assessed. My notes are accurate. I did not go into the EMR and strike out my notes and label them as incorrect documentation. My documentation is accurate as to what happened. On August 26, 2025, at 10:04 AM, V1 (Administrator) and V2 (DON-Director of Nursing) said V8's documentation was inadvertently struck out when changes were made to the risk management report attached to the incident on July 28, 2025. V1 (Administrator) said, [V8's] notes are her story, and we will have to go back in and figure out a way to rewrite them. On August 27, 2025, at 12:25 PM, V18 (Restorative Nurse), The risk management report for [Resident R4's] incident on July 28, 2025 was struck out by me. Initially, the nurse entered the information into risk management as a fall. I was told by the corporate consultant to strike out the incident and label it as inaccurate documentation because

the incident was not considered to be a fall because the resident was intentionally lowered to the ground. I only struck out the risk management report for the fall in the EMR. I did not realize by striking out the risk management documentation, that the nurse's documentation would be struck out and marked as incorrect documentation as well. That seems like an issue when the nursing documentation gets struck out. I was not aware the progress notes were struck out. The facility's policy entitled Medical Record Policy, dated 6/2025 shows, Purpose: To ensure that a complete, accurate and legal record of the resident's care that's maintained contains justification of diagnoses, treatment results. The record is readily accessible systematically organized to provide a medium of communication among health care professionals involved

in the resident's care and to facilitate retrieval of information. Policy: It is the policy of this facility that an organized, accurate, and complete written record will be maintained for each resident in accordance with applicable State and Federal guidelines and laws. Standards: .5. Progress notes shall be written/entered to ensure an ongoing resident record including progression toward and regression from established resident goals is maintained. Progress notes shall indicate significant changes in the resident's condition and be recorded upon occurrence by the staff person observing the change.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Parc Joliet

222 North Hammes Joliet, IL 60435

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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

inspection sheets. An inspection of all mechanical lifts was completed with V13. Four mechanical lifts were identified, including one rental mechanical lift. V13 said he did not inspect the rental mechanical lift to ensure it was in good working order, and he was unable to say how long the facility had been using the rental mechanical lift. None of the mechanical lifts were labeled with identifiers that corresponded to the inspection logs provided by V13. An unlabeled mechanical lift was found in a common area of the second floor. V13 was unable to lock the mechanical lift shifter lever in place and said the mechanical lift was broken. V13 did not remove the mechanical lift from the resident floor or label the mechanical lift with a sign to indicate the mechanical lift should not be used. On August 25, 2025, at 11:53 AM, a general tour of the facility was completed with V2 (DON-Director of Nursing). Mechanical lifts were observed throughout the facility, in resident hallways and common areas, available for all facility staff to use. V2 said after the incident involving Resident R4 and the mechanical lift, she asked V13 to inspect all mechanical lift devices and label each lift with an identifier to correspond to the inspection sheets. The inspection sheets provided by V13 were shown to V2. The inspection sheets did not correspond with identifier numbers on any of the mechanical lifts observed with V2. V2 was unable to identify if any of the mechanical lifts in use had been inspected.

The mechanical lift with the broken shifter lever, observed with V13 at 10:53 AM, remained in the common area of the second floor and was not labeled with any resident name or a sign to show not to use the device. The undated mechanical lift User Manual provided by V1 (Administrator) shows, the shifter handle must be locked when transferring a resident. Maintenance of the mechanical lifts should include an initial inspection, and monthly inspections and adjustments when used in an institutional setting. The facility's policy entitled Limited Lifting Resident Handling, revised on 1/25 shows: Policy: This facility will use mechanical lifting devices when lifting and moving the residents when indicated and as ordered by the physician. Purpose: To protect the safety and well-being of the staff and residents. Procedure: .4.

Mechanical lift equipment shall undergo routine maintenance checks and be accessible to staff 24 hours a day.8. The policy will be followed at all times. Failure to comply will result in disciplinary action at management's discretion.

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If continuation sheet