Health inspection·November 25, 2025

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 observation, interview and record review the facility failed to protect a resident's right to be free from sexual abuse by another resident. This failure affects two of four residents (R5 R4) reviewed for abuse on the sample list of five. This past non-compliance occurred from 10/17/25 to 10/17/25. Findings Include: The Minimum Data Set, dated [DATE] documents R4 is cognitively intact.The Minimum Data Set, dated [DATE] documents R5 is cognitively impaired.Nursing Progress Notes dated 10/17/2025, document R4 was seen with his hand underneath R5's shirt. The Notes document the Abuse Coordinator, Power of Attorney and the Medical Director were notified. On 11/25/25 at 8:25AM, V5 (Licensed Practical Nurse) stated he was the nurse that day on 10/17/25 when R4 touched R5. V5 stated he was going down the hall by the dining room and saw R4's hand underneath R5's shirt. V5 stated V5 saw R4 moving his right hand up and around R5's breast. V5 stated he immediately separated the two residents and reported to the Administrator. V5 stated that R4 had done this to R5 in December 2024, which V5 stated he reported to the Administrator (previous). On 11/25/25 at 8:35am, V6 (Licensed Practical Nurse) stated that R4 has touched R5 recently and that the residents were immediately separated and the abuse coordinator was contacted. V6 stated, R4 is to be watched at all times while R4 is out of R4's room and is assisted to and from the dining room. On 11/24/25 at 11:35AM, R4 was observed being supervised by the certified nursing staff at the table for lunch, eating with another male resident. At that time R4 stated he put his hand up R5's shirt because R4 missed his wife that only visits occasionally.On 11/25/25 at 10:05AM, V1 (Administrator) stated she started working at the facility on 10/17/25 when this incident happened. V1 stated she immediately started an investigation and sent an initial and final report to Illinois Department of Public Health. V1 stated that when completing a sweep of R4's chart, R4 had an incident documented with R5 on 12-15-24 of R4 putting his hands up R5's blouse. V1 stated V1 completed a facility wide sweep and immediately started education with all staff. Prior to the survey date of 11/25/25, the facility took the following actions to correct the noncompliance:1. On 10/17/25 the facility Quality Assurance Committee developed a plan of correction for the 10/17/2025 abuse allegation incident.2. On 10/17/25 the Quality Assurance Committee and also the facility management completed a whole facility audit of all residents to address high risk and low risk residents who may be prone to sexual abuse. Care plans were put in place for all high-risk residents by V1. 3. On 10/17/25 all management staff received formal training on sexual abuse identification / reporting / suspensions by corporate quality nursing and operations staff. On 11/25/25 at 9:58AM, V2 Director of Nursing confirmed V2 received the training.4. On 10/17/25 all facility staff were Inservice on sexual abuse through one to one trainings with Quality Assurance Compliance staff and through computer based trainings. On 11/25/25 at 8:25AM,V5 confirmed that on 10/17/25 V5 received education on who to report sexual abuse to and when to report it. V5 stated he also completed computer based training. On 11/25/25 at 8:35am,V6 also stated that in-services were Page 1 of 2 145603 145603 11/25/2025 Accolade Hc of Paxton on Pells 1001 East Pells Street Paxton, IL 60957

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few completed on 10/17/25 with the administration and corporate staff on abuse and when and what to report. 5. Sexual abuse allegations on October 17, 2025 were determined by the Quality Assurance Tool to have been timely and directly reported to V1 (Administrator / Abuse Coordinator) and the accused resident was put on continuous supervision when out of the room and from continued access to residents6. On 11/25/25 at 9:58AM, V2, (Director of Nursing) stated R4 has been care planned to be supervised when R4 is out of R4's room. V2 stated care plans/interventions were put in place on 10/17/25. On 11/24/25 at 11:35AM, R4 was observed being supervised by the certified nursing staff at the table for lunch, eating with another male resident. 145603 Page 2 of 2