Health inspection·September 6, 2024

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 residents (R2) right to be free from inappropriate touching by another resident (R1), for 1 (R2) out of three residents reviewed for abuse in the sample of five residents. Findings include: The facility policy titled 'Abuse Prevention and Reporting', reviewed 8/2023, documents 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. The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse: Abuse means any physical or mental abuse injury or sexual assault inflicted upon a resident other than by accidental means. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 13, cognitively intact. R1's Other/General Note dated 8/29/24 at 11:10pm documents R1 observed by CNA (Certified Nurses Assistant) in hallway with R2 with what appeared to be inappropriate touching of R2's pants/brief. R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnoses: Guillain-Barre Syndrome, Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Dysphagia, Hyperlipidemia, Syncope and Collapse, Major Depressive Disorder, Insomnia, Unsteadiness On Feet, Abnormalities of Gait and Mobility, Lack of Coordination, Need for Assistance with Personal Care, Edema, HTN (Hypertention), GERD, Muscle Weakness, Urinary Tract Infection, Dementia Moderate with Psychotic Disturbance, Mood (Affective) Disorder, Delusional Disorders, Acute Cough and Hypothyroidism. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 4, severe cognitive impairment. R2's Other General Note dated 8/29/24 at 10:30pm documents R1 noted at end of hall by CNA with what appeared to be another male R2 who may have been inappropriately touching R1, having his hand on her pants/brief (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: 145452 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 145452 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Dwight 300 East Mazon Avenue Dwight, IL 60420 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)