Health inspection·April 17, 2025

F 0600 identified trauma related to triggers include people grabbing and observations of other being grabbed. Level of Harm - Actual harm R2's ER (emergency room) documentation, dated 4/14/2025 patient presenting for evaluation of possible sexual assault. Patient was coming from VA (Veterans Association) hospital with transfers apparently, they cannot evaluate any type of sexual assault. Patient reports over the weekend believe was Saturday he was groped by a facility member there. Patient reports he was squeezed on his buttocks reports no handing of his genitalia including testicles or penis. Patient denies anything entering his rectum or any pain around his anus. Patient denies any rash or discharge. Police have been contacted. ED progress note documents patient reports he was groped apparently was squeeze down his buttocks. Did perform visual exam which was unremarkable. Did discuss with patient and family on obtaining forensic evidence such as a rape kit which at this time did not see any need for as there was no insertion injury. Clinical impressions documented: sexual assault by bodily force by caregiver. Residents Affected - Few On 4/16/2025 at 8:15 AM V2, Director of Nursing (DON) stated V1 is the Administrator, and they were notified of residents having an incident on 4/15/2025, that involved (R1) and (R2) and that both resided on the dementia unit and (R2) is not interviewable. She stated (R1) was moved from the dementia unit after the allegation and is now on a 1:1 with staff. V2 stated neither resident have a history of sexual touching between themselves or others. V2 stated (R1) was walking down the hall and came up to (R1) and touched his butt both residents had clothes on at the time and staff separated them immediately. V14, Registered Nurse (RN) was the nurse and V12 was the CNA, this incident occurred on 4/13/2025 at approx. 8:00 PM. V2 stated (R2) is out of the facility for a physician's appointment today and isn't expected back until late this evening. On 4/16/2025 at 9:14 AM V1 stated V11, Case Manager at the veteran's association primary care office called the facility on 4/14/2025 at approximately 10:00 AM and stated (R2) stated he was grabbed on the back side by (R1), he started an investigation at that time. V1 stated neither resident has a history of sexual touching. A Witness Statement dated 4/14/2025 V11, VA (Veteran's Association) Nursing Home Consultant documents (R1) presented to ED for medical evaluation. Another resident attempted to sexually assault him in the facility and stated a hand was fully into his rectum, being sent to another hospital for sexual assault evaluation. On 4/16/2025 at 2:14 PM V11, VA Nursing Home Consultant stated she called the facility to notify them of the allegation of sexual abuse on 4/14/2025 and she reported what was (R2's) VA medical record, that is where she got the information from. The VA social worker referred (R2) to a local ER because they do not do sexual assault kits at the VA. V11 stated she read (R2's) hospital paperwork and noted it documents a different version of what occurred to (R2) and she wasn't sure what actually occurred in the incident but that she reported what (R2's) VA medical record documented. A Witness Statement dated 4/14/2025 V12, Certified Nurse Aide (CNA) documented, Yes, I provided care for him (R2) his family was with him and completed routine checks. Family arrived around 12:00 PM and left and came back. Family was still here when I left at 8:45 PM. V13, R2's family member reported that another resident touched his butt. I reported it to V14, RN around 8:20 PM (R2) stated R1 touched his (R2) butt around 8:15 PM. (R2) stated that resident (R1) came up from behind and first grabbed his arm then grabbed his butt with both hands. On 4/16/2025 at 12:50 PM V12, CNA stated he worked 4/14/2025 day shift and stayed a few hours extra (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145508 If continuation sheet Page 2 of 4 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 145508 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Health Care Center 1450 26th Street Highland, IL 62249 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)

F 0600 Level of Harm - Actual harm Residents Affected - Few to help out and was assigned to (R2.) Around 8:20 PM (R2's) family member (V13) reported to him that (R1) grabbed (R2's) buttocks and he reported it to V14, RN immediately. He spoke to (R2) and he told him that (R1) walked up being him and grabbed his buttocks with both hands. V12 stated (R2) is alert with bouts of confusion but that he was very alert when he spoke to him regarding the incident. V12 stated he didn't witness (R1) grope or touch (R2.) An Undated Witness Statement, documented V14, RN, Yes I provided care for (R2). He voiced that (R1) touched him on the butt in the TV room, he doesn't like it because (R2) will trigger him and he doesn't want to hurt her. On 4/16/2025 at 10:40 AM R1 was observed sitting with V15, Activity Aide. R1 stated she doesn't do anything with any man other than her husband and stated she didn't touch anyone inappropriately and she would never do that. On 4/16/2025 at 4:30 PM, V14, RN stated she worked 4/14/2025 and was the assigned nurse to (R1) and R2. Sometime during the evening of 4/14/2025 (R2) was upset and reported to her that (R1) grabbed his buttocks in the activity room, and he stated it wasn't appropriate and that he doesn't want (R1) touching him ever again. V14 stated she didn't witness the incident between the residents, but she reported the incident to V1 immediately. On 4/16/2025 at 4:20 PM, V13 R2's family member stated he came to visit (R2) on the evening of 4/14/2025 and (R2) told him that a lady groped his buttocks with both hands, and it triggered him and he felt embarrassed to tell him about it but he didn't want to be groped by the lady again. V13 reported it to the nurse on duty at that time, V14 and she reported she would let Administration know of the incident. V13 stated he was upset that the VA office he initially took (R2) to be assessed documented that (R2) reported the female put her hands down his pants and touched (R2's) rectum because he was with (R2) the entire time he was at the VA office and (R2) never reported that occurred. V13 stated when they got to the hospital that staff wanted to do a rectal exam on (R2) declined it stating no one touched his rectum. On 4/16/2025 at 4:50 PM R2 was observed walking around his room. He was alert and stated a few days ago (exact date unknown) a female resident ran up from behind him, pulled down his pants and grabbed his buttocks, R2 showed how the female resident (R1) grabbed his buttocks by grabbing a pillow and he showed how she grabbed his buttocks with both fists and squeezed really hard. R2 stated he felt terrible about it and was very embarrassed because it occurred in front of other residents. When (R1) grabbed his buttocks like that he screamed because it hurt. (R1) grabs at him and other residents often and he's told her time and time again don't touch me, I don't like being touched. If it was a man that grabbed me like that he would have been on the floor with a knock out punch to the face but since it was a female I just walked away from the situation but she better not grab me ever again like that. On 4/16/2025 at 11:00 AM V4, Social Services Director stated V2, DON reported to her on 4/14/2025 that (R2) went to an outside physician's appt and the office called and stated (R2) told them that a female resident grabbed his bottom the day before. She spoke to (R2) the same day and he told her he didn't want to be grabbed on his buttocks by other residents he didn't report the name of the resident that grabbed his buttocks he said some old lady grabbed his buttocks. V4 stated (R2) wasn't crying when she spoke to him about the incident, he just stated he doesn't want his buttocks to be grabbed because it could trigger him. V4 stated she will follow up with him with the psychosocial assessment every 3 days for 30 days to see how he's doing regarding the incident. V4 attempted to interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145508 If continuation sheet Page 3 of 4 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 145508 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Health Care Center 1450 26th Street Highland, IL 62249 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)

F 0600 Level of Harm - Actual harm Residents Affected - Few (R1) but she didn't respond to any questions regarding her touching (R2's) buttocks. V4 stated neither resident has a history of sexual touching in the past but (R1) does has a history of grabbing residents but this is the first time she grabbed a resident inappropriately and she's been on 1:1 for this behavior since the incident was reported on Monday 4/14/2025. V4 stated the incident occurred on the dementia unit and since the incident occurred (R1) was moved from the dementia unit. The Facility's Abuse Policy, revised 1/9/2024 documents purpose: to provide guidance and procedures to the facility to assure the residents remain to be free from abuse. This facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse of residents. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse and mistreatment of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145508 If continuation sheet Page 4 of 4