Inspection·October 25, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a staff had reported immediately an allegation of sexual abuse. This applies to 1 of 2 (R1) residents reviewed for abuse in the sample of 5. The findings include: The EMR (Electronic Medical Record) showed R1, a [AGE] year old female with diagnoses included but not limited to unilateral primary osteoarthritis of right hip, COPD (chronic obstructive pulmonary disease), UTI (urinary tract infection), lack of coordination, pain to the right and left arm, CKD (chronic kidney disease), dysphonia, atrial fibrillation, CHF (congestive heart failure), anxiety disorder, major depressive disorder, bariatric surgery status, morbid obesity, nicotine and opioid dependence. R1 was admitted originally admitted to the facility on [DATE] and was readmitted on [DATE]. The Minimum Data Set (MDS) dated [DATE] showed R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 14 out 15. The MDS showed R1 required extensive to total assistance from two staff for bed mobility, transfer, toileting, dressing and hygiene. The facility's abuse investigation initial report dated 10/6/2023 at 6:00 P.M., showed R1 reported to V2 (Director of Nursing) that V3 (CNA/Certified Nurse Assistant/ from staffing agency) had sexually abuse her. The report showed on 10/5/2023 at around 10:00 P.M., V3 had placed his tongue in her (R1) mouth while providing care to (R1). The facility also had interviewed V4 (CNA) on 10/6/2023 at 9:15 P.M., V4 said on 10/5/2023 around 10:00 P.M., V4 and V3 had provided care to R1. During the care, V4 said R1 told V4 not to tell V3 she was wearing a wig since R1 likes the attention. The interview showed V4 left the room to get a blanket with V3 still in the room. When V4 returned to R1's room, R1 told V4, He (V3) kissed me and please do not tell anyone. The facility had continued their investigation, interviews held with other residents and had notified police department. The final investigation dated 10/12/2023 showed sexual abuse cannot be substantiated. However, V4 was suspended. On 10/20/2023 at 11:00 A.M., V1(Administrator) and V2 (Director of Nursing) said they suspended V4 for not reporting to V1, the sexual allegation made by R1 against V3. V1 and V2 added it is the facility's policy to report any alleged abuse, suspicion of abuse to V1 immediately to ensure and prevent abuse to other residents. On 10/20/2028 at 12:28 P.M., V7 (Activity Aide) said on 10/6/2023 at around 5:30 P.M., R1 told V7 on 10/5/2023 at 10:00 P.M., V3 put his tongue in R1's mouth and said, I want to suck your titties. V7 (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: 145433 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 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 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)