Health inspection·November 17, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 ensure a female resident was protected from another resident who has a known history of sexual abuse. This failure resulted in the resident entering the room of another female resident, then touching her breasts and face and kissing her. This applies to 1 of 4 residents (R1) reviewed for sexual abuse in a sample of 5. This has the potential to affect all 24 female residents (R1, R3-R25) residing in the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 10/31/23 at 4:00 AM when R2, who has a history of sexual abuse, entered R1's room and put his hands down her gown and touched her breasts. V1 (Administrator) was notified of the Immediate Jeopardy on 11/16/23 at 1:55 PM. Although the immediacy was removed on 11/17/23, the facility remains out of compliance at Severity Level II because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including in-servicing of staff and compliance with 1:1 monitoring of R2. The findings include: The Resident Roster report dated 11/14/23, shows the facility census was 43 residents, and 24 of those residents are female. The facility's 10/31/23 Final Serious Injury Incident and Communicable Disease Report for R1 and R2 showed Final: Upon final investigation, it was determined that resident (R2) entered the room of resident (R1) and touched her face and breast without resident's consent .Resident (R2) remains on 15-minute checks by staff . On 11/14/2023 at 9:43 AM, R1 was in bed watching television. The back of the head of R1's bed is perpendicular to the doorway to her room, and it is immediately to the right of the doorway. R1 is unable to see anyone entering her room from the hall when she is in bed. R1 is Spanish speaking; translation was done by a Spanish speaking surveyor. R1 said two weeks ago on 10/31/23, R2 came to her room around 3:00 AM, stood behind her, and asked her to come out to the hallway. R1 said she told R2 no, and R2 then put his hands down her gown and touched her breasts. R1 said she used her call light, and V3 (Certified Nursing Assistant/CNA) came and asked R2 to leave. R1 said a second incident occurred a week later (11/7/23) where R2 came into her room. R1 stated R2 asked her to go out to smoke, and then from behind, kissed her head, forehead, and eyes, and then put his hands in her gown and touched her breasts again. R1 said she used the call light and staff came to her room and asked R2 to Page 1 of 6 145609 145609 11/17/2023 Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some leave. R1 said the incident made her feel unsafe. R1 said she has had a stroke, which left the left side of her body paralyzed. R1 said she does not feel safe at the facility because residents are able to wander in and out of rooms. On 11/14/2023 at 10:51 AM, V3 (CNA) said when R1's incident occurred on 10/31/23 at approximately 4:00 am, V3 went to R1's room and found R2 in her room, standing over R1. V3 said she asked R2 to leave R1's room. V3 said R1 told her that R2 touched her face. V3 said she asked R1 three times if R2 touched her inappropriately, but R1 said R2 only touched her face. V3 said she informed V6 (Licensed Practical Nurse/LPN) and V6 told her to monitor R2 every 15-minutes. V3 said prior to that incident, she was unaware of R2 being on 15-minute monitoring for wandering. V3 said she taken care of R2 since the incident on 10/31/23. When the Surveyors asked V3 if R2 was still on 15-minute checks, V3 answered no. On 11/15/2023 at 7:50 AM, V6 (LPN) said on 10/31/2023, V3 was doing her rounds, and R2 was in R1's room. V6 said V3 redirected R2 out of R1's room. V6 said she asked R1 if R2 touched her, and R1 said no. V6 said R2 had been on 15-minute monitor checks prior to this incident, and the CNAs are to monitor and redirect R2. On 11/14/2023 at 2:09 PM, V2 (Director of Nursing/DON) said she was informed by V4 (Licensed Practical Nurse/LPN) on 10/31/2023 on the evening shift that R1 had reported to her that an incident had occurred between R1 and R2 during the night. V2 said she spoke to R1, and R1 told her that R2 came to her room on the third shift and touched her left breast. V2 said R1 told her that V3 (CNA) and V6 (LPN) came to her room after the incident occurred. V2 said she reported the incident to V1 (Administrator), and the police were called. V2 said R2 has a history of wandering into female resident rooms, touching them inappropriately, and making verbally inappropriate comments to female staff. V2 said prior to this incident with R1, R2 was placed on 15-minute checks monitoring for wandering. R2's Every 15-minute Check Sheet showed that R2 was in R1's room on 10/31/2023 at 4:00 AM. On 11/14/2023 at 3:07 PM, V1 (Administrator) said on 10/31/23, V2 (DON) informed of her the incident that occurred between R1 and R2. V1 said R2 has a history of wandering into female residents' rooms and touching their breasts. V2 said they had moved R2's room and placed him on 15-minute checks prior to this incident due to this behavior. V1 said she initiated the investigations and believed what R1 said had occurred with R2, even though it was not witnessed. R1's face sheet showed that R1 was admitted to the facility on [DATE] and had the following diagnoses of cerebral infarction, occlusion, and stenosis of the left carotid artery, depression, acute respiratory failure, and cognitive communication deficit. R1's 8/08/2023 MDS (Minimum Date Set) showed she is cognitively intact and needs extensive assistance of two or more staff for bed mobility, transfers, toileting, and personal hygiene. R2's sexual abuse history of R21 was known as noted previously in the CMS 2567 with an exit of 11/4/2023: The 10/5/23 facility final incident shows it was determined that R3 (known as R2 for purposes of this investigation) entered the room of R2 (known as R21 for purposes of this investigation) and touched her breast without her consent. On 11/4/23 at 1:00 PM, V7 (RN-Registered Nurse, and known as V19 for purposes of this investigation) said on 10/5/23, R3 (R2) approached her and said he had entered R2's (R21) room, and R2 (R21) 145609 Page 2 of 6 145609 11/17/2023 Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some wanted him to touch her breasts. V7 (V19) said she did not see R3 (R2) in R2's (R21's) room but knows he does wander around the facility. V7 (V19) said R3 (R2) has a history of making sexual comments to staff but unaware he had done the same to any female residents. V7 (V19) said she immediately reported the incident to the administrator. She said R3 (R2) 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 (R2) 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 (R21's) husband, and he searched the video footage from the camera in the room. He located the video and shared it, and it shows R3 (R2) entering R2's (R21's) room and placing his hand under the blankets. V1 said she substantiated the allegation of sexual abuse against R3 (R2). On 11/6/23 at 8:30 AM, V13 (R2's husband, or V20 for purposes of this investigation) said he viewed the footage of the camera from 10/5/23. He said the video showed R3 (R2) coming into the room and touching R2's (R21's) 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 (V20) said R3 (R2) looked at the door then did his thing and thinks R3 (R2) knew what he was doing. On 11/6/23 at 9:00 AM, video footage of the incident was reviewed. The video shows R3 (R2) entering R2's (R21's) room. R2 (R21) was lying in bed with a sheet covering her body up to her shoulders. R3 (R2) looks back towards the door and approaches R2's (R21'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 (R2) then removes his hand from under R2's (R21's) gown and touches her cheek again before leaving the room. R2's face sheet showed that he was admitted to the facility on [DATE] with diagnoses of other sequela of cerebral infarction, vascular dementia mild with agitation and with other behavioral disturbances, and depression. R2's 8/17/2023 MDS showed that his cognition is severely impaired and needs limited assistance with bed mobility, transfers, supervision with toilet use and extensive assistance with one person assist with personal hygiene. R2's care plan (created 10/17/23) showed that R2 exhibits problems as seen by wandering, verbally abusive, socially inappropriate, disruptive, resisting care, making inappropriate sexual comments to staff. The goal of this care plan showed Resident's behavior will not adversely affect self or others through next review date. On 11/14/2023 at 10:00 AM, R2 was observed in bed resting. R2 was confused and not able to be interviewed. Prior to the incident with R1 and after the 10/5/23 incident with R21, R2's 10/24/23 Psychiatric Nurse Practitioner progress note showed Seen today upon request by nursing for hallucination and sexually inappropriate behaviors. Per nursing, has been hallucinating at night that he is involved in sexual activity. Patient continues with increased inappropriate sexual behavior toward others . R2's 10/27/23 nursing progress note from 8:49 AM showed Resident having increased hallucinations, stating that a staff member is getting raped, and he needs to save her because she belongs to him. Resident will not stay in his room or in the [letter] hall, repeatedly going to the [name] hall looking for a CNA staff member . The facility's Abuse Prevention Program policy with revision date of 9/29/2023, states Sexual abuse 145609 Page 3 of 6 145609 11/17/2023 Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some is non-consensual sexual contact of any type with a resident The facility will take steps to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress and will immediately take appropriate steps to remediate the non-compliance and protect residents from additional abuse. The facility's Safety and Supervision of Residents policy (revised 12/31/17) showed 5. The facility shall monitor interventions to mitigate accident hazards in the facility modify, as necessary. 6. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS . 8. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers individual resident risk factors, and then adjusts interventions accordingly . 10. The type and frequency of resident supervision may vary among residents and over time for the same resident The facility presented an immediacy removal plan on 11/16/23 at 5:05 PM and it was reviewed by the survey team and returned to the facility without approval. The facility's revised removal plan was received on 11/17/23 at 11:34 AM, and it was not approved and was returned. The facility's revision was presented on 11/17/23 at 12:42 PM and was not accepted after review. The final immediacy removal plan was accepted on 11/17/23 at 1:20 PM. The Immediate Jeopardy that began on 10/31/23 was removed on 11/17/23 when the facility took the following actions to remove the Immediacy. 1. R2 was placed on 1:1 constant observation on 11/14/2023 at 6:00 PM for behavior of wandering and sexual inappropriateness towards other female residents. All direct care staff were in-serviced on R2's updated Care Plan that reflects the 1:1 constant observation implemented on 11/14/2023. The Director of Nursing and/or designee will monitor and document q shift x 7 days for 1 week, daily for 1 week, weekly for 1 month, and monthly for 3 months to ensure 1:1 constant observation is maintained daily on all 3 shifts. Charge nurse will ensure alternative staff replacement for 1:1 Staff Monitor when Staff Monitor takes a break. If 1:1 Staff Monitor is not observed monitoring R2, alternate Monitor will be placed and immediate re-in servicing will take place on all staff on all three shifts. Charge Nurse will immediately notify Administrator or Director of Nursing. 2. The Daily Schedule revised on 11/14/2023 for 2p-10p shift to reflect employee 1:1 constant observation employee assignment to R2 on all shifts, 7 days a week. DON to ensure staffing is followed. 3. All 24 female residents have had a new Trauma Assessment completed on 11/9/2023. 4. R2 Care Plan updated on 11/14/2023. 5. R1 Care Plan updated on 11/14/2023. 6. Administrator and/or Director of Nursing will ensure R2 has an employee assigned to conduct the constant 1:1 observation at all times on all shifts, 7 days a week. 145609 Page 4 of 6 145609 11/17/2023 Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560

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 observation, interview, and record review, the facility failed to report an alleged abuse incident. This applies to 1 of 4 (R1) residents reviewed for abuse allegation reporting in a sample of 5. The findings include: R1's face sheet showed that R1 was admitted to the facility on [DATE] and had diagnoses of cerebral infarction, occlusion, and stenosis of the left carotid artery, depression, acute respiratory failure, and cognitive communication deficit. R1's 8/08/2023 MDS (Minimum Date Set) showed that her cognition was intact, and she needs extensive assistance with two or more staff for bed mobility, transfers, toileting, and personal hygiene. On 11/14/2023 at 9:43 AM, R1 was in bed watching television. The back of the head of R1's bed, is perpendicular to the doorway to her room, and it is immediately to the right of the doorway. R1 is unable to see anyone entering her room from the hall when she is in the bed. R1 said two weeks ago, R2 came to her room around 3:00 AM stood behind her and asked her to come out to the hallway. R1 said she told R2 no, and R2 then put his hands down her gown and touched her breasts. R1 said she used her call light, and V3 (Certified Nurse Assistant/CNA) came and asked R2 to leave. R1 said a second incident occurred again a week later, where R2 came to her room, asked her to go out to smoke, and then from behind, kissed her head, forehead, eyes and put his hands in her gown, and touched her breasts. R1 said she used the call light again and staff V3 came to her room and asked R2 to leave. R1 said the incident made her feel unsafe. R1 said she had a stroke which left the left side of her body paralyzed. R1 said she does not feel safe at the facility because residents are able to wander in and out of rooms. R2's face sheet showed that he was admitted to the facility on [DATE] and had diagnoses of other sequela of cerebral infarction, vascular dementia mild with agitation and with other behavioral disturbances, and depression. R2's 8/17/2023 MDS showed that his cognition is severely impaired, and he needs limited assistance with bed mobility, transfers, supervision with toilet use and extensive assistance with one person assist with personal hygiene. On 11/14/2023 at 10:00 AM, R2 was in bed resting. R2 was confused and was not able to be interviewed. On 11/14/2023 at 10:51 AM, V3 (CNA) said when the incident occurred on 10/31/2023 at approximately 4:00 AM, V3 went to R1's room and found R2 in her room, standing over R1. V3 said she asked R2 to leave R1's room. V3 said R1 told her that R2 touched her face. V3 said she asked R1 three times if R2 touched her inappropriately, but R1 said R2 only touched her face. V3 said she informed V6 (Licensed Practical Nurse/LPN) and V6 told her to monitor R2 every 15 minutes. V3 said prior to that incident, she was unaware of R2 being on 15-minute monitoring for wandering. On 11/15/2023 at 7:50 AM, V6 (LPN) said on the overnight shift 10/30-10/31/2023, V3 was doing her rounds and noticed R2 in R1's room. V6 said V3 redirected R2 out of R1's room and V6 did not report the incident to V1 (Administrator) or V2 (Director of Nursing/DON). V6 said failure to report abuse allegations immediately could put other vulnerable residents at risk for abuse. 145609 Page 5 of 6 145609 11/17/2023 Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/14/2023 at 10:20 AM, V4 (LPN) said on 10/31/2023 on the evening shift, R1 reported to him that R2 had come into her room during the night and touched her. V4 said he reported the incident to V2 (DON). On 11/14/2023 at 2:09 PM, V2 (DON) said she was informed by V4 (LPN) on 10/31/2023 on the evening shift that an incident occurred between R1 and R2. V2 said V6 (LPN) did not report the incident to her during her shift. V2 said V6 thought she had reported the incident to her via text but failed to send the text message to her. V2 said staff are aware to call her directly if there are any daily concerns, including overnight. On 11/14/2023 at 3:07 PM, V1 (Administrator) said on 10/31/23, V2 (DON) informed of her the incident that occurred between R1 and R2. V1 said she is the abuse coordinator, and staff are to report to her immediately if there are any allegations of abuse. V1 said if abuse allegations are not reported immediately, there's a potential for further abuse. The facility's Final Serious Injury Incident and Communicable Disease Report for the 10/31/23 incident showed Upon final investigation, it was determined that resident (R2) entered the room of resident (R1) and touched her face and breast without resident's consent . The facility's Abuse Prevention Program policy with revision date of 9/29/2023, states Sexual abuse is non-consensual sexual contact of any type with a resident .Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator .The facility will take steps to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress and will immediately take appropriate steps to remediate the non-compliance and protect residents from additional abuse. 145609 Page 6 of 6