Health inspection·October 27, 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 the interviews and records review, the facility failed to report and initiate an investigation of alleged abuse in a timely manner by failing to identify and ensure the reporting of a suspected abuse. This failure affected 2 residents (R1, R2) out of 3 residents reviewed for abuse. Finding include: R1's face sheet shows R1's diagnosis in part of hemiplegia, unspecified affecting right dominant side, schizoaffective disorder, overactive bladder, and anxiety disorder. R1's Brief Interview of Mental Status (BIMS) dated 09/08/23 score 14 out of 15, indicating R1 has intact cognitive function. On 10/24/23 at 09:05 am R1 observed lying in bed, alert, oriented to self, place, time and situation. R1 says she can walk a little bit but uses the wheelchair for mobility, needs assistance with transfers and she uses an incontinence brief during the night. R1 says the incident happened in August, and it was about 3 am when a male Certified Nursing Assistant (CNA) came to her room. R1 says the CNA put his hands under her buttock, squeezed it and said something like I thought you were thin, but you are thick, and then the CNA left. R1 says that the next day she told V6 (Social Service) about the incident and V6 had said she would do something. R1 says I guess she did because the CNA has not worked with me since then. R1 says she has seen the CNA after the incident working on her floor, even in her room. R1 describes the CNA as a black, tall man. R1 says it was a one-time incident and she had never seen that CNA before the incident happened. R1 states I just want to leave because of what that man did to me. That made me feel mad. R1 says her leg is hurting and she wants the CNA to come get her up. R1 pulls the call light cord. A few minutes later a CNA goes to R1's room and assists R1 to transfer to the wheelchair. On 10/24/23 at 10: 01 am R1 is in front the elevator. R1 was asked if she recognizes any of the male CNAs that are working on the floor this morning as the alleged perpetrator, R1 says it was none of them. There were 2 male CNAs working the morning shift on the 3rd floor. On 10/24/23 at 10:24 am R2 was interviewed as part of the sample regarding R1's complaint investigation. R2 said I've been here in this facility for a little bit over a month, it happened either Friday or Saturday, (10/20 or 10/21), this guy came to my room about 6:30 am, turned the light on and said what are you doing in bed? I was laying in my side and trying to understand why he was saying that, and then he came close to the bed and uncovered me without asking permission. I was kind of shocked. What is happening? It was still early to get up. I had my shorts and my pajama's top, but I felt very uncomfortable. He said I need to help you to get dressed, I said, I can do it myself. He had no badge or any other identification. Then he said okay and left. I told the nurse (V8) right after Page 1 of 5 145482 145482 10/27/2023 Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few breakfast. I believe she knows his name. I can recognize the nurse. She is very nice. She asked his name. I believe she found out his name and said she would report it. Today (10/24/23) she told me that she has already reported it. I'm nervous if he'll come back today or later. When I talk about this, I get nervous. I'm glad I talked to you. I'm not scared to be here, but I'm nervous about the incident. I want to be respected. I'm a woman and I believe he crossed the line when he uncovered me. As long as he doesn't approach me in the same way, and maybe he doesn't go to my room or say, I was wrong, I shouldn't have done that, acknowledges that, maybe, I'll be okay with him working with me again. He was black, bald, had no hair, average body, not thin, but not fat. A little taller than me, like 5'8. I've seen him before on this floor, but this was the first time this happened. He's never talked to me before. He had not provided any care for me before. On 10/24/23 at 10:55 am V2 (Assistant Administrator-AADM) says the abuse coordinator is the Administrator (V1). The surveyor asked if the reportable folders provided by the facility contained all the reportable incidents, V2 responds yes, these are all the reportable incidents we have. On 10/24/23 at 11:30 am V8 (Licensed Practical Nurse-LPN) states I work 4 days a week, 8 hours a shift, 7am to 3:30pm. I work Saturday, Sunday, Tuesday and Wednesday. On Saturday, as I was getting ready to leave, around 3:30 pm, R2 approached me and said that on Friday night a male CNA came to her room, snatched her cover off and told her to get up. She didn't say what time the CNA came in, but the way she said it was like it was early in the morning. She makes it sounds like it happened early in the morning, late Friday or early Saturday. She didn't give the time. It had to be in the morning, because why did he (CNA) want her to get up during the night? R2 does not need help getting up or getting dressed. R2 does everything herself. I went to find out who was the CNA working that Friday night. I asked security for the schedule. Once they showed me, he was the only male CNA working Friday night and he was bald and short, I figured out who he was. R2 had told me the CNA was short and bald. His last name starts with K. I told the resident that I was going to report it. I tried to find out who is on duty, as a manager. I knew that V1 (ADM) would come later in the day because she was the manager on duty. I wrote a note and slid it under V1's (Administrator's) door. I wrote down what R2 said happened. I didn't say the name of the CNA, but I wrote the name of the resident. V2 (Assistant Administrator) came in on Sunday morning and I told him the same thing R2 told me. He didn't say anything to me. Once I report it, I don't know what they do. R2 was calm, but said she wasn't feeling good about it. The CNA should first greet residents and then ask if they need help. I believe the CNA was new to the facility and did not know the resident. Even not knowing them, the CNA should have knocked on the door because it is a ladies' room, then he should have greeted them and then asked if they needed help. This morning I saw the Director of Social Services (V5) and reported the incident to him. It was about 2 hours ago. It is 11:32 am, and V8 describes the types of abuse saying: there is verbal abuse, seclusion, financial and sexual abuse. I don't know how to characterize this incident. I just leave it to the big people to characterize. Sexual assault is putting your hands on someone without their consent or a sexual act, period. R2 said the CNA made her uncomfortable. It still warranted me to find out who was the staff involved, because if it was sexual abuse, I don't want to have my residents having sexual abuse. The incident was out of character and that is what I reported. On 10/24/23 at 11:48 am V2 (Assistant Administrator) states I am familiar with investigating abuse. If the staff sees something or suspects any type of abuse, they should immediately take it to V1 (ADM) or me or V5 (Social Services Director- SSD) if they cannot contact V1. If anyone uncovers the resident without permission, staff should report it. The nurse told me that the staff went to the resident's (R2) room in the middle of the night and woke her up. I don't think it's okay. I wrote down the resident's name and was 145482 Page 2 of 5 145482 10/27/2023 Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few going to ask, but I didn't have the chance. We usually investigate right away, but it depends on what is reported to us. I probably should have investigated it right away. It didn't sound like abuse, but I should have investigated it. There is no investigation initiated at this time, not yet. The nurse was V8. I told V1 today. Honestly, I forgot to report this to V1. I didn't think much about it. It was just a resident complaining about someone waking them up during the night, I didn't think of it as abuse. On interview V2 says he is not aware about any allegations of abuse involving R1 and a staff member and denies any knowledge of an investigation being conducted regarding R1's sexual abuse allegation. On 10/24/23 at 12:08 pm V5 (SSD) sates I believe I did speak with the nurse (V8) today. V8 told that me I need to talk to R2, that maybe somebody pulled the covers off of the resident (R2). I'm not sure when. V8 told that R2 told her that somebody pulled the cover off her. I was still getting the information, trying to find out what exactly happened. Going back and talk to R2, talk to V8 to get her statement. If someone brings me any information, I will follow up and report it to the Administrator. I didn't do it because V8 told me she already told V1, DON and ADON. V5 says he is not aware about any allegations of sexual abuse involving R1 and denies any knowledge of an investigation being conducted regarding R1's allegation prior to this day. On 10/24/23 at 12:27 pm V6 (PRSC) was interviewed regarding R1's complaint. V6 states This happened a long time ago. It was not in September. R1 told me that a CNA came into her room in the middle of the night, and I guess he was supposed to give her care, you know turning her or changing her, I don't know. R1 didn't go to any details, and said she was not sure if the CNA had been inappropriate, but she felt like he was inappropriate. I did a concern form and gave it to V5. I give all my concerns to him. After that, the facility does an investigation into any residents who felt someone had been inappropriate. It wasn't specific because of this information; they were doing some kind of sweep of this area. R1 told me it was a male CNA. I can't say he was inappropriate. I think R1 came to me and said she wanted to talk to me, and said she wasn't sure if the CNA was inappropriate, but in the middle of the night he came in and stood by her bed. R1 said the CNA touched her, but I don't remember R1 saying that the CNA had touched her buttocks. R1 said she was not sure he had been inappropriate, but she felt he had been inappropriate. R1 didn't know who he was because it was late and dark. V6 says she had been trained on abuse allegations and says abuse can be sexual abuse, inappropriate touching and comments. V6 says if someone told me that staff touched her inappropriately yes, it is definitely a type of abuse and worth investigating. I thought I had reported it by doing the resident's concerns. If abuse is suspected or reported by a resident, I should call my supervisor. My supervisor is V5. I didn't call him. I did a concern form. I didn't call him because R1 said it was a CNA and she wasn't sure if he was inappropriate. That's on my part. I can't say it was abuse, but because she told me I should have told V5. The Administrator is the abuse coordinator. On 10/24/23 at 1:53 pm V5 states I spoke to V6 (PRSC) after she had spoken to you (surveyor), and she reported that there was a concern with R1 involving one of the CNAs. The concern is that R1 does not know whether the CNA was inappropriate in providing care to R1. V6 does not know when this information was received. V6 said she wrote it down in the concern form, but she doesn't know where it is. This was just brought to my attention, and I informed V1. The staff has to inform the abuse coordinator about suspected abuse and V1 will delegate who will investigate it. V1 will make the determination if it will be investigated, do a reportable, if it's abuse or not. V1 does the reportable. I believe that situation should have been reported to the Administrator because we don't know if it was abuse or not and the Administrator would do her due diligence. If the resident tells staff that other staff touched her inappropriately, it is an allegation of abuse and should have been reported to V1. 145482 Page 3 of 5 145482 10/27/2023 Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/24/23 at 2:46 pm V1 (Administrator) states, I see R1 all the time, she is in the lobby when I make my rounds, but she never said anything. I spoke with V6 today and she told me that R1 said something to her a month ago and that R1 was not clear of what happened. It was something about Activity of Daily Living/ADL. Then V1 says she will talk to V6 again to make sure she (V1) is getting the right information. V1 said she just learn today about this incident involving R1 and a staff member and that V6 had told her it was about ADLs. V1 states If anybody see's something that looks like abuse or suspected abuse, they should report it to me. Nobody told me R1 has reported being touched inappropriately. We are going to do the initial investigation about R1's allegation. It's unacceptable. Regarding the second incident identified during this investigation involving R2 and a staff member, V1 sates V2 (Assistant Administrator-AADM) told me today that R2 said that a CNA uncovered R2 and asked if R2 needed help getting dressed and that R2 had said no, and that the CNA had left the room. V2 said it was reported by the nurse on Sunday. I never got that incident report. V2 admitted to me that he was supposed to report it. Right now, we are doing the investigation. I'm going to do the initial investigation today, because it should be done ASAP. Any abuse allegation should be investigated right away or in 2 hours, and that is our policy, and it was not done. We had training a few months back for all staff about abuse. We had another one scheduled for October with a consultant, but he has been deployed to [NAME]. We had to reschedule it. I do the abuse training in-house as well. On 10/24/23 V3 (Director of Nursing) and V4 (Assistant of Director of Nursing) denied any knowledge of R1's sexual abuse allegation. On 10/26/23 at 09:00 AM V1 states I was here on Saturday (10/21/23), briefly. I came in. I did some rounds and stayed about an hour. I did not receive any note, I did not receive any call from any staff regarding R2 allegation. R1 told me that the CNA put his hands under her pampers. R1 did not say the CNA squeezed her buttock and made some comments. If a resident is feeling not comfortable, it has to be investigated, the staff suspended, and the resident made safe. The staff knows they have to report any suspected abuse. They are not to determine if there is abuse, they only have to report it. You not reporting things? Putting a note under the door? This is not what should be happening. Review of the reportable binders showed no investigation regarding R1's complaint, nor regarding R2's complaint that was identified during this investigation. The concerns log was reviewed from January 2023 to October 2023. There was no documentation of R1's allegation. V6 provided another batch of copies of concerns forms filled out by her and there is no documentation of this allegation being addressed. Asked where this concern form possibly would be, V6 says she doesn't know. R1 and R2's progress notes and event forms were reviewed and showed no documentation of the alleged abuse situation reported by R1 and R2 and whether it had been reported to the Administrator. All notes found were written after the facility became aware of the allegations during this investigation. Facility's abuse policy and procedure revised in 10/2022 reads: 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. And continues reads: The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This will be done by: Orienting and training employees on how to deal with stress and difficult situations, and how to 145482 Page 4 of 5 145482 10/27/2023 Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660

F 0609 recognize and report occurrences of abuse, neglect, exploitation, misappropriation of property; Level of Harm - Minimal harm or potential for actual harm Implementing systems to promptly and aggressively investigate all reports and allegations pf abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; Residents Affected - Few Filling accurate and timely investigative reports 145482 Page 5 of 5