Health inspection·February 14, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident (R1) from sexual abuse by (R2). This applies to 1 of 3 residents reviewed for abuse in the sample of 4. The findings include: R1's electronic face sheet printed on 2/14/25 showed R1 has diagnoses including but not limited to Alzheimer's disease, anxiety disorder, and insomnia. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment. R1's care plan dated 1/24/25 showed, Problematic manner in which I act characterized by inappropriate sexual behavior (verbal or physical) related to need for affection, need for attention, resident touches other residents. I initiate contact with other residents resident given a baby doll for companionship, distract resident if possible . R2's electronic face sheet printed on 2/14/25 showed R2 has diagnoses including but not limited to dementia with agitation, congestive heart failure, pulmonary edema, and alcoholic cirrhosis of the liver. R2's facility assessment dated [DATE] showed R2 has no cognitive impairment. The facility's abuse investigation dated 1/28/25 showed, (V4-Physcial Therapist) reported to abuse coordinator that she witnessed (R2) with his hand under (R1's) sweater. (V4) immediately separated the residents. Interview with (R2) revealed confusion on his part about who (R1) is as he thought and referred to her by a different name .Upon review of the camera footage, (R1) propels herself to (R2) and reaches out her hand and places his hand under her sweater. (R1) doesn't pull away, but staff immediately intervened. Surveyor requested to view the facility's video footage but (V1-Administrator) stated the footage was now unavailable as it is only saved for a short period of time. (Incident occurred on 1/23/25) R2's social service note dated 1/23/25 showed, Writer spoke with resident who was in a relaxed good mood. Resident states he was dreaming of living in his 20s and was sorry . The social worker who spoke with R2 no longer works at facility and was unable to be interviewed. Page 1 of 2 145295 145295 02/14/2025 Goldwater Care Marseilles 578 West Commercial Street Marseilles, IL 61341

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/14/25 at 12:37PM, V4 (Physical Therapist) stated, I was the only witness to the incident with (R1) and (R2). I was walking past the dining room and saw (R2) with his hand inside (R1's) shirt at her breast area. (R1) was giggling and (R2) said they were having fun. (R2) is disoriented when it comes to his situation, but he is oriented to name and place. When I separated the residents, he was calling (R1) by a different name, so I don't even think he knows who she is. (R2) seems to have more issues with short term memory than anything. His long-term memory seems to be okay, and he was very apologetic after the incident because he said he knew it was wrong. On 2/14/25 at 1:00PM, V1 (Administrator) stated, I know (R2) well and he is confused, although he scores high on his BIMS (Brief Interview for Mental Status) exam. I'm not sure how he does but it seems like his short-term memory is more affected than his long-term memory. We knew this incident was going to be an issue because (R2) knew what he was doing and (R1) is disoriented. We have been keeping them separated since the incident but (R1) does go around the facility by herself so we have been keeping an eye on her. This incident does fit the definition of abuse because (R2) acted with intent and knew what he was doing. The facility's policy titled, Abuse prevention and Reporting dated 10/24/22 showed, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment .Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means .Sexual abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault including non-consensual or non-competent to consent sexual activity. Sexual abuse incudes but is not limited to unwanted intimate touching of any kind especially to of breasts or perineal area . 145295 Page 2 of 2