Health inspection·December 18, 2024

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 ensure a resident was free from sexual abuse. This applies to 1 of 3 residents (R1) reviewed for sexual abuse in the sample of 4. The findings include: R1's face sheet shows she is a [AGE] year old Spanish, American Indian woman. Her diagnoses are listed to include: paraplegia, need for assistance with personal care, depression, third degree burn to right toe & cellulitis to right lower limb. The facility's abuse report final form dated December 11, 2024 shows, sexual abuse to R1 by V3 (Kitchen Aide). (V4-Receptionist) reported to (V1-Administrator) that resident was upset about possible discharge. (R1) then stated that maybe it is because one of the kitchen staff (V3) kissed her and touched her chest sometime on 11/15/2024. On December 17, 2024 at 10:13 AM, R1 was lying in bed watching television. She stated, she exchanged her phone number with V3 (Kitchen Aide) who worked at the facility. They originally shared phone numbers until V3 (Kitchen Aide) asked R1 to download an app called Whatsapp (an application for your phone that allows people to message, text or call without using your phone number). They would text/message back and forth on the app. She stated, she was looking for a friend but then it became uncomfortable. He started asking her about her catheter and if she had ever had sex with it. He would text her that he couldn't stop thinking about her and she was real pretty. V3 (Kitchen Aide) came to her room on two different occasions. He touched her leg the first time and the second time he tried to kiss her and touched her breast. They both sent photos of themselves to each other. He would say he was masturbating to her photos. She did not report any of this until December 5, 2024 when she thought the facility was discharging her because of what happened with V3 (Kitchen Aide). On December 18, 2024 at 11:22 AM, V3 (Kitchen Aide) stated, he did exchange phone numbers with R1. She asked for his help and then asked for his phone number. They were texting back and forth. He did send her photos of himself. They did this for a few days when he told her that he was married and he shouldn't be sending or talking with her. He told her it was inappropriate and apologized. They stopped talking after that. He denied ever having any physical contact with R1 only messaging inappropriately back and forth. He also stated, he never received any training regarding abuse and/or relationships with residents however, his personal knowledge is that he shouldn't ever have a personal relationship with a resident. R1's messages with V3 (Kitchen Aide) as translated from Spanish to English shows, the messages Page 1 of 9 145737 145737 12/18/2024 Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525

F 0600 start on November 14, 2024 and continue until November 21, 2024. Level of Harm - Minimal harm or potential for actual harm On November 14, 2024 starting at 9:25 PM, the messages between V3 (Kitchen Aide) and R1 shows: V3- The one with the legs and beautiful smile Residents Affected - Few V3- Well I love your legs V3- Well, would you let me see them again? R1- Well, I don't know that came out as a surprise V3- A very nice surprise that I want to repeat V3- Ok sweetheart V3- Brighten my night let me see your beautiful legs V3- sends a heart emoji and another attached file (not visible in the message feed provided) R1- Are you going to let me see yours? V3- Okay R1- Give me a minute R1- The [NAME] is here V3- Surprise me with a very beautiful and sexy photo V3- Ok sweetheart R1- I am not able to do it ha ha R1- I look like a ball nothing sexy @ V3- ok sweetheart V3- ok sweetheart, you are I can see it V3- No ball, sexy yes and beautiful legs and beautiful smile V3- If you can R1- shows an image was sent. Not visible in the message feed provided. R1- HA HA HA how awful V3- How beautiful 145737 Page 2 of 9 145737 12/18/2024 Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525

F 0600 V3- Are you in the bathroom? Level of Harm - Minimal harm or potential for actual harm R1- No in my bed V3- Sometimes we do things that we may never think about but feels good with the person you like Residents Affected - Few V3- Imagine that the diaper is a short, I repeat do not feel embarrassed with me I am calm and normal person V3- wowww@ wowww@ V3- How beautiful V3- See, they are beautiful, I make no mistake R1- Why are your pictures deleting? R1- app shows, you updated the message timer. New messages will disappear from this chat 24 hours after they're sent, except with kept. Tap to change. V3- the app shows, V3 turned off disappearing messages. Tap to change. R1- HAHAHA V3- The phone is configured to sent pictures I do not know if I change the settings V3- I am going to look into the settings to avoid this from happening again V3- I had never done anything with pictures before V3- I had never sent photos with anyone before, it feels strange, but with you it feels great and I loved it R1- Well me neither, that is the reason I felt embarrassed V3- Sweetheart do not feel embarrassed with me, feel free and relax They continue to talk, when R1 says she's going to sleep. V3 replies with, are you wearing pajamas. R1 says she doesn't have any and they continue to talk until V3 asks her again, Sweetheart sent me another picture, surprise me R1- I can make you imagine things I did not know. V3- A crazy picture R1- I cannot do it anymore, sorry V3- Why my love 145737 Page 3 of 9 145737 12/18/2024 Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525

F 0600 R1- Cannot do it anymore Level of Harm - Minimal harm or potential for actual harm R1- We have to leave some to mystery R1- I hope you do not get upset Residents Affected - Few V3- OK V3- I understand my sweetheart, I am not upset! I would love a crazy picture R1- Crazy like you? R1- Naked V3-Sweetheart, I wait for you to surprise me R1- Yes, yes, you know V3- do you want a picture of me? How do you want it? V3- I feel very comfortable with you R1-Ok bye V3- Sweetheart, you look so beautiful, thank you for that beautiful surprise V3- 3 kissy face emojis R1- Thank you V3- message says null R1- omg (oh my god) of course I'm going to dream of you thank you V3- I hoped you liked it, sweetheart V3- the one you sent me was beautiful V3- See you are beautiful V3- Please do not be embarrassed V3- sends to files. Not visible in the message feed provided. R1- I loved it but I should not have done it R1- Good night my love V3- I felt strange but I loved it 145737 Page 4 of 9 145737 12/18/2024 Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525

F 0600 V3- God blessed you, good night Level of Harm - Minimal harm or potential for actual harm R1- Thank you the same to you Residents Affected - Few The messages end at 10:56 PM on November 14, 2024. They start messaging again the next day, November 15, 2024 at 6:34 AM with causal conversation. At 10:20 AM, R1 tells V3 (Kitchen Aide), I want to let you know I can only offer you my friendship. V3 replies, I understand, both liked each other and it was a beautiful experience I want to repeat. At 2:09 PM, V3 (Kitchen Aide) starts asking R1 about her catheter. V3- sweetheart do you wear the urinary catheter at night and during the day? R1- yes the entire day V3- I thought it was only at night V3- Is that uncomfortable? R1- very uncomfortable, it irritates my skin R1- Since I am paralyzed I do not have any control R1- I do not have sensation V3- I understand it must be very uncomfortable, do you apply anything in your vagina to help you? V3- you do not have any vaginal sensation?! Thought you did have some V3- Do you have any sensation when you urinate? R1- I am starting to have some sensation V3- Sweetheart that is wonderful V3- do you know your clitoris is the most sensitive part of your body because it has a lot of nerves, you can stimulate it and get sensation back R1- I know all that but I do not want to stimulate me V3- My love you can do it very softly and think of something you like, you can do it very slowly V3- you can activate your nerves V3- sweetheart you can do it V3- tell me how I can help you? V3- doing it is natural, you probably did it before, I understand it is uncomfortable in your condition 145737 Page 5 of 9 145737 12/18/2024 Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525

F 0600 R1- no is not for me Level of Harm - Minimal harm or potential for actual harm R1- I am another kind of women hahaha V3- you are beautiful Residents Affected - Few R1- I am not interested in masturbating, I have other things to focus on They continue to talk about R1 going to Walgreens. At 7:24 PM, V3 (Kitchen Aide) starts talking about nude pictures. V3- when you sent me the last nude picture you made me feel excited, nervous and ticklish V3- I even felt like touching myself, I had years without feeling like that R1- I also felt something, in regards to the pictures is very private, I do not send to anyone V3- I had never done with anyone else, it's private, I felt comfortable and confident with you V3- I felt excited something new for me, were you able to reach it? The conversation continues. R1- what are you looking for or want from me? V3- I do not want you to feel uncomfortable, enjoy your time, enjoy the moment like your last day, the future is uncertain V3- you are very special for me V3- I can give you massage in your beautiful legs V3- I thing is very exciting to bite your neck softly V3- also to bite and suck your breast while I penetrate you it will be delicious R1- I have more than 3 years without having sex, I think is something spiritual not only to feel like do it The conversations continue until November 21, 2024. R1's minimum data set shows, she is cognitively intact. R1's care plan dated December 6, 2024 shows, POTENTIAL ABUSE NEGLECT, I have been in declining health & require support of the LTC setting. My personal trauma related factors include my illness, need for on-going care/attention & entering the SNF (skilled nursing facility) setting. Although I have been involved in an allegation/incident, there is no reason to suspect any unusual consideration, risk or concern for mistreatment. I am observed/monitored to mitigate potential risk towards becoming a recipient or perpetrator of abuse/neglect or further trauma. 145737 Page 6 of 9 145737 12/18/2024 Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's abuse and neglect policy dated July 12, 2024 shows, Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment Types of abuse and examples: 5. Sexual: Any sexual behavior or relationship instigated by a staff member with a resident will be viewed as an allegation of sexual abuse, unless there is a pre-existing relationship between the caregiver and the resident prior to admission to the facility 145737 Page 7 of 9 145737 12/18/2024 Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow their abuse policy by completing background checks on 1 of 3 new hires, (V3), reviewed for background checks. This applies to all residents residing in the facility. Residents Affected - Few The findings include: The facility data sheet dated December 17, 2024 shows, there are 99 residents residing in the facility. On December 17, 2024 at 4:00 PM, V1 (Administrator) stated, V3 (Kitchen Aide) was hired at the facility on February 20, 2022. The Illinois State Police background check for V3 (Kitchen Aide) was done on December 9, 2024 (almost 3 years later). The result is no record on file. The Illinois Department of Public Health (IDPH), Health Care Worker Registry (no date) with V3's (Kitchen Aide) social security number shows, no workers found. Another IDPH Health Care Worker Registry (no date) shows, V3 (Kitchen Aide) is eligible to work and had a fee_app (fingerprint) on December 11, 2024. On December 17, 2024 at 2:04 PM, V1 (Administrator) stated, when the allegation of V3 (Kitchen Aide) came about they checked his file. They could not find his original back ground check so she ran another one. They found out he had never been fingerprinted so they also had him fingerprinted. They should be done on date of hire. The facility's abuse policy dated July 12, 2024 shows, Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. 7 steps in abuse prevention: This facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven federal components of prevention and investigation. The seven elements of prevention and investigation include: screening, training, prevention, identification, investigation, protection, reporting/response. I. Screening: Have procedures to: Screen potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries Similarly, prior to placement in the facility, the facility will require background check of prospective consultants, contractors, volunteers, caregivers working in behalf of the facility, and students in its nurse aide training program and students from affiliated academic institutions, including therapy, social, and activity programs to care for residents to be done either the facility itself, the third-party agency, or academic institution. 3. Check the Illinois Nurse Aide Registry how known as Healthcare Worker Registry upon hire, to determine reports of abuse, neglect, and theft, if staff is not a licensed staff. 4. Initiate Illinois State Police fingerprint check for non-licensed applicants or new hires within 10 days of hiring, unless the applicant had been previously finger-printed in accordance to 145737 Page 8 of 9 145737 12/18/2024 Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525

F 0607 the Illinois background Check Act Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145737 Page 9 of 9