Inspection·August 25, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to investigate allegations of sexual abuse in a timely manner. The facility also failed to implement their Abuse policy and procedure and conduct a comprehensive investigation of the alleged sexual abuse and report the abuse to the state health department and police department. Residents Affected - Few This applies to 1 of 5 residents (R5) reviewed for sexual abuse in a sample of 12. The findings include: The EMR (Electronic Medical Record) shows that R5, a [AGE] year-old with diagnoses of dementia in Alzheimer's disease, major depressive chronic pain, difficulty in walking, cognitive communication deficit, depressive disorder, autoimmune thyroiditis, osteoporosis, Lyme disease, hypothyroidism, anxiety disorder, hypertension, and spinal stenosis. R1 was admitted to the facility on [DATE]. R5's MDS (Minimum Data Set) dated 8/5/2024, showed R1 had moderate cognitive impairment. The progress notes dated 8/16/2024 showed that R5 was sent to the hospital related to medication regimen to address R5's aggression. The hospital record dated 8/16/2024 showed that R5 was: - A patient admitted from (nursing facility) for increased aggression, refusing to take medications. History of depression. Upon examination, (R5) was alert and oriented times 3. States that they want me on antidepressant, and I am sensitive to medications and only requires low doses. Patient needs inpatient psychiatric hospitalization for mood stabilization and safety. The hospital record also showed that on 8/17/2024, R5 was transferred to the medical floor due to acute pulmonary embolism and acute DVT (deep vein thrombosis). On 8/20/2024 at 10:30 A.M., V1 (Administrator) said that on 8/16/2024, she had received a call from V15 (hospital staff) that R5 made an allegation of sexual abuse towards a male staff working in the facility. V1 said that she did not investigate this sexual allegation because there was an open allegation regarding R1's alleged physical abuse towards a CNA (Certified Nurse Assistant), that R1 felt being rushed on 8/15/2024 at 2:30 P.M. Surveyor verified with V1 if the allegation of being rushed is the same as sexual abuse. V1 then decided to initiate sexual allegation and called the police department. On 8/20/2024 at 11:30 A.M., V18 (Police Officer) came to the facility. V18 said that this case of (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 4 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 08/25/2024 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)