Health inspection·November 6, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/4/23 at 1:00 PM, V4 (RN) said on 10/5/23, R3 approached her and said he had entered R2's room, and (R2) wanted him to touch her breasts. V4 said she did not see R3 in R2's room but knows he does wander around the facility. V4 said R3 has a history of making sexual comments to staff but unaware he had done the same to any female residents. V4 said she immediately reported the incident to the administrator. She said R3 had begun refusing to take his medications and it seemed to make him hypersexual. On 11/4/23 at 1:20 PM, V1 (Administrator) said before the reported incident, R3 had been verbally inappropriate with staff, but nothing sexual. He would ask for hugs. V1 said upon the report of the incident she notified R2's husband, and he search the video footage from the camera in the room. He located the video and shared it, and it shows R3 entering R2's room and placing his hand under the blankets. V1 said she substantiated the allegation of sexual abuse against R3. On 11/6/23 at 8:30 AM, V13 (R2's husband) said he viewed the footage of the camera from 10/5/23. He said the video showed him (R3) coming into the room and touching her (R2) face and breasts. He said if she were able to move, she would have fought back and called for help, but she was unable to do so. V13 said R3 looked at the door then did his thing and thinks R3 knew what he was doing. On 11/6/23 at 9:00 AM, video footage of the incident was reviewed. The video shows R3 entering R2's room. R2 was lying in bed with a sheet covering her body up to her shoulders. R3 looks back towards the door and approaches R2's bed. He caresses her cheek then lifts the sheet and moves his hand under her gown. He then moves his hand from one breast area to the other and then repeats the same motion again. R3 then removes his hand from under R2's gown and touches her cheek again before leaving the room. 2. On 11/4/23 at 9:55 AM, R4 was sitting up on the side of his bed, with his walker in front of him. R4 said V4 (Certified Nursing Assistant) had made inappropriate sexual comments to him on a couple occasions, about a month ago. R4 said he can't remember what she said the first time. R4 said V4 (CNA) and another CNA (he could not recall her name) helped him get up for therapy. R4 said they assisted him to the wheelchair and as he was leaving the room, V4 made an inappropriate sexual comment. R4 said he's not sure exactly what she said, but he knew it made him uncomfortable and he felt he should tell his girlfriend. R4 said V4 made another sexual joke about Vitamin D. R4 explained that V4, the other CNA (V14), and V15 (Occupational Therapy Assistant/OTA) were in his room. R4 said V15 was showing V4 and V14 (CNAs) how to transfer him without using the lift. R4 said the nurse came in with his pills and he was complaining about how big the Vitamin D pill was. R4 said V4 made a vulgar hand gesture (mimicking a large penis) and made a statement about the size of the Vitamin D she takes. (R4 held one hand above the other, each hand curled in a large, circular shape). R4 said at the time we kind of laughed it off. R4 said he felt he had set appropriate boundaries with V4, but he became concerned after the sexual comments. R4 said V4 crossed a line with her comments and made him uncomfortable. R4 said he went to therapy and was talking to V15 (OTA) about what happened. R4 said V15 told him that she had to report the sexual comments. R4 said he was interviewed by V2 (Director of Nursing/DON), then by V1 (Administrator). R4 said he didn't want to get V4 in trouble, but the more he thought about it, the more uncomfortable he was with her providing his care. R4 stated, I realize I'm not the typical nursing home resident. I'm alert and oriented and she's making sexual statements to me. What is she saying to other people? I know she was making the other CNA (V14) uncomfortable with her comments. She (V4) doesn't work here anymore. R4's Face sheet printed 11/4/23 showed diagnoses to include, but not limited to multiple fractures of the pelvis; right ankle fractures; cellulitis; obstructive sleep apnea; morbid obesity; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145609 If continuation sheet Page 2 of 6 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 145609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560 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 chronic pain syndrome. Level of Harm - Minimal harm or potential for actual harm R4's MDS assessment dated [DATE] showed he was cognitively intact and required extensive assistance from staff for bed mobility, toilet use, and personal hygiene. Residents Affected - Some R4's Progress Note dated 10/15/23 showed, .He has come a long way but still has a long way to go. His abdominal wounds are healing ever so slowly, and he has been able to take a few steps at this point. He hopes to continue to make progress and he is anticipating discharge obviously at some point . He is alert and pleasant . This patient really has done very well but continues to need assistance . The facility's Abuse Investigation for R4 included a written statement from V14 (CNA). The handwritten document dated 10/4/23 showed a comment was made that was inappropriate. V4 made a comment to R4 about her phone/sexual comment. The comment made R4 uncomfortable. The facility's Incident Report submitted 10/10/23 showed R4 was the victim an incident that occurred on 10/4/23. This document showed R4 was alert and oriented; capable of communication; and transferred with 2 assist to a wheelchair. This document showed the initial report, At approximately 11:30 AM, (R4) reported to (V2 DON) that employee (V4 CNA) engaged in inappropriate conversation with the resident . Final: Interviews conducted with residents and staff regarding care issues/concerns from staff members and residents. During the interview with residents, resident reported that CNA made inappropriate comments in the presence of another staff member . Upon final investigation, it was determined that CNA (V4) made inappropriate statements towards the resident. Following suspension, employee voluntarily terminated their employment with the facility. On 11/4/23 at 12:40 PM, V14 (CNA) said she was working with V4 (CNA) when she made some sexually, inappropriate comments to R4. V14 said V4 (CNA), and V15 (OTA) were in the room with R4. V14 said V15 was showing them how to get R4 up to the wheelchair without the lift. V14 said V6 (RN) came in the room with R4's medications. V14 said R4 was talking about the size of his Vitamin D pill. V14 said R4 was talking about how big it was and it was hard to swallow. V14 said V4 made a hand gesture about the size of the Vitamin D. This surveyor made the same hand gesture R4 demonstrated earlier, and V14 stated, Yes, that is what she did. It was VERY weird and inappropriate. At the time R4 laughed about it but later he told me and V15 (OTA) that it made him very uncomfortable. (R4 and V15) reported it to the DON and I gave my statements to them. She (V4) shouldn't have talked to anyone, let alone a resident, in that way. On 11/4/23 at 1:03 PM, V15 (OTA) said she had been in R4's room on a couple occasions, giving the V4 and V14 (CNAs) in-services on how to transfer R4 safely to the wheelchair. V15 said R4 was in the therapy gym on 10/4/23 and reported inappropriate sexual comments made by V4 (CNA) to him. V15 said R4 reported that V4 was asking him what staff he found attractive and who he would like to have sex with. V15 said R4 told V4 that the question was making him uncomfortable, but V4 would not stop talking about it. V15 stated, I told him (R4) that I had to report this. I reported it to (V2 DON) right away because that is sexual harassment. (R4) was very concerned about telling his girlfriend about it. He said it made him uncomfortable and (V4) would still have to provide care for him. (R4) told me about the inappropriate sexual comments. I didn't hear it. If I did, then I would have told (V4) to zip it. That's just how I am. On 11/4/23 at 2:46 PM, V1 (Administrator) said V2 (DON) notified her of R4's report of inappropriate sexual comments. V1 said she interviewed him the next day, in the therapy gym. V1 said R4 seemed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145609 If continuation sheet Page 3 of 6 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 145609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560 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 - Minimal harm or potential for actual harm Residents Affected - Some to be surprised that V4 had made those comments to him, and he was a little hesitant to report her, at first. V1 said R4 reported that V4 (CNA) made comments about who he finds attractive in management and asked if he wanted to have a threesome with V14 and herself. V1 said R4 continued to say that V4 asked him, How would you feel, if they were in his bed when he came back? V1 said V4 had made another comment about the size of R4's penis. V1 said it had something to do with Vitamin D. V1 said she had just finished interviewing V14 (CNA), and she stated, (V14's) statements were spot on with (R4's). V4 cannot be acting like that. I called her (V4) to inform her that there had been sexual abuse allegations against her, and she was suspended during the investigation. I did not say who made the allegations, but she (V4) said, oh, you're talking about (R4)? The phone conversation was dropped and then I received a text from (V4) that she was voluntarily terminating her employment. She shouldn't have made any sexual comments to a resident. She is responsible for providing the resident's care. (R4) was very matter of fact. He said he realized that he wasn't a typical nursing home resident. He was alert and oriented and if she would talk to him this way, then how was he talking to the other residents. (R4) made it very clear that he and (V14) were uncomfortable. (R4) said he was worried about (V14) because (V14) was worried about retaliation from (V4). On 11/4/23 at 3:16 PM, V2 (DON) said she was called into the therapy gym by R4 and V15 (OTA). V2 (DON) said R4 told her that V4 had suggested a threesome to him and made some other inappropriate, sexual comments. V2 said R4 reported that V4 was asking him what staff he would want to sleep with, and he didn't want to answer, but she wouldn't stop. V2 said R4 told her that's not right and that he had to tell his girlfriend about it. V2 said after V4 was suspended, R4 reported that V4 had sent him a message on social media about the situation. V2 stated, (V4) didn't have a leg to stand on. That's why she quit. The surveyor asked if R4 reported the Vitamin D comment and hand gesture made by V4. V2 replied, Yea, she said something inappropriate and made gestures. I didn't realize what he was talking about at first. I'm naive, I guess. )V4] shouldn't have been doing any of that. It's inappropriate for one and considered sexual abuse for two. V4's Employee Folder contained a termination form that showed V4's date of termination was 10/4/23. This document showed V4 was not eligible for rehire. This document showed V4 (CNA) had an abuse investigation that was founded to substantiate misconduct. 3. On 11/4/23 at 9:42 AM, R5 was lying in bed. R5 had an air bed with a trapeze connected to aide in R5's ability to move in bed. R5 had significant swelling to both his legs. R5 said he can move himself around in bed but needs the two staff members and his walker to ambulate into the bathroom. R5 said he's been getting progressively sicker and was a hospice patient. R5 said around 5:45 AM on 10/2/23 he informed V5 (CNA) that he was incontinent and needed cleaned up. R5 said V5 was rude and yelled at him from the doorway. R5 said V5 was yelling, You're really not going to do this to me at the end of the shift. I know you're a** can go into the bathroom. R5 said he cried and there was no reason for V5 to treat him like that. R5 stated, You can ask everyone here, I'm always respectful and thankful for the care that I receive. I say, yes ma'am or sir. R5 continued to say that he had severe heart and kidney failure. V5 said he takes medications that make him need to urinate more often and fluid weeps from his legs. R5 said he reported what happened to V2 (DON). R5 stated, I told them that I don't want her (V5) in my room every again. I don't want someone like that taking care of me. R5's Face Sheet dated 11/4/23 showed diagnoses to include, but no limited to congestive heart failure, angioneurotic edema, hypertension, history of heart attack, anxiety, diabetes, obstructive sleep apnea, lymphedema, and chronic pain. R5's Physician Order Sheet showed he was admitted to hospice care on 9/3/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145609 If continuation sheet Page 4 of 6 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 145609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560 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 - Minimal harm or potential for actual harm Residents Affected - Some R5's MDS assessment dated [DATE] showed he was cognitively intact; required extensive assistance from staff for mobility, transfers, toilet use and personal hygiene; and was frequently incontinent of bowel and bladder. R5's Progress Notes dated 10/2/23 at 9:45 PM showed it was reported that the night CNA was yelling at the resident. An investigation is ongoing. The facility's Incident Report completed 10/6/23 showed R5 was the victim; required staff assistance for transfers; and was alert, oriented and able to communicate. This documented showed, .Initial: At approximately 4:15 PM, it was brought to the writer's attention that resident [R5] reported that CNA [V5] spoke to him in a way that offended him . Final: Interviews were conducted with residents and staff members regarding complaint issues. Interview conducted x 2 with resident. Resident reported the CNA was rude and used vulgar language toward the resident when requesting CNA assist to bathroom . Upon final investigation and x 2 resident interviews it was determined that resident is consistent in the details of the incident . Facility decided to terminate employment with employee at this time based on the nature of resident's complaint . On 11/4/23 at 2:20 PM, a voicemail was left for V5 (CNA), but V5 did not call the surveyor. On 11/4/23 at 2:46 PM, V1 (Administrator) stated R5 reported his allegation to V2 (DON) and V2 reported it to her. V1 said she interviewed R5 a couple times, and his recall of the incident remained consistent. V5 (CNA) was terminated because R5 was very clear, and it was evident the incident took place. V1 said R5 was very bothered by the situation and called his family about it. V1 stated, He was not going to allow her (V5) to take care of him ever again. He was very clear. When I spoke with her (V5) she didn't say anything and just accepted the termination. He (R5) was telling everybody. He cried and he wasn't going to let it go. He said she stood in the doorway and screamed at him. She (V5) said something like, You can get you're a** up! I didn't write that exact statement down, but he was consistent with the statement. Get you're a** up. You can walk to the bathroom. She shouldn't have talked to R5 that way. You shouldn't talk to anyone that way. Her job is to provide care. V1 agreed that V5's actions would be considered verbal abuse. On 11/4/23 at 3:16 PM, V2 (DON) said R5 rarely used his call light but would holler at the staff when they walked down the hall. V2 said R5 had notified her on 10/2/23 that R5 had yelled at him from the doorway, earlier that day. V2 said she did not recall R5's exact words, but V5 had made him feel unworthy, and told him he should be able to go to the bathroom himself. V2 said R5 continued to say, How dare she say things like that! V5's Employee File contained a Termination document that showed she was terminated on 10/6/23 for extreme rudeness/abuse. 4. R1's Face Sheet showed he was discharged on 10/27/23. The facility's 10/25/23 final report of R1's abuse allegation investigation showed Upon final investigation, it was determined that spouse (V3) of (R1) slapped resident on cheek when she was unhappy with his behaviors . The report showed the police were notified and R1 was placed on supervised visits. R1's progress notes showed he had no injuries after the incident. On 11/4/23 at 3:05 PM, V1 (Administrator) said V3 admitted to slapping R1 across the face and R1 was placed on supervised visits. V1 stated there was no witness to the event, but she (V3) openly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145609 If continuation sheet Page 5 of 6 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 145609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560 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 - Minimal harm or potential for actual harm Residents Affected - Some admitted the abuse and told multiple people she slapped him. V1 stated the police were notified and have charged her with battery, but she is unsure if R1 will press charges. V1 said after V3 was informed of the pending police charges, V3 had a very mild demeanor when in the facility and no further incidents occurred. On 11/4/23 at 2:45 PM, V2 (Director of Nursing) said V3 (R1's wife) was verbally aggressive with him during R1's stay and V3 did not want to keep R1 at the facility. V2 stated R1 was alert and oriented x 2 and received therapy in the facility, and he was still weak and required a mechanical lift. On 11/4/23 at 9:45 AM, V9 (RN) said R1 was discharged home. V9 stated R1 was wheelchair bound and his wife would visit with him every day. V9 stated V3 would sit in the room with R1, and she never witnessed any abusive behavior. The facility's Abuse Policy (revised 9/29/22) showed, Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Sexual abuse: Sexual abuse is non-consensual sexual contact of any type with a resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145609 If continuation sheet Page 6 of 6