Health inspection·December 20, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few consent to sexual activity. Policy Implementation: Procedures for Detection and Prevention: 5. Establishment of a Resident Sensitive Environment and Prevention: The facility will establish a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and have policies and protocols in place for preventing sexual abuse. The Residents' Rights for People in Long Term Care facilities, undated, documents Your right to safety - You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually. R1's Minimum Data Set/MDS, dated [DATE], documents R1 is severely cognitively impaired. R1's current Face sheet documents R1 has diagnoses including but not limited to Alzheimer's Disease with late onset; Anxiety Disorder; Depression; Unspecified Dementia, mild, with Agitation. R1's current Care Plan documents R1 has impaired cognitive function/dementia or impaired thought processes related to Dementia. R2's MDS, dated [DATE], documents R2 is moderately cognitively impaired. R2's current Face sheet documents R2 has diagnoses including but not limited to Vascular dementia, Unspecified dementia, Anxiety disorder, and Major Depression disorder. R2's current Care plan includes but is not limited to a focus of (R2) uses psychotropic medications related to Behavior management and an intervention including but not limited to Monitor/record occurrence of target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. The facility's Alleged Abuse incident report, dated 12/12/24, documented by V1 Administrator CNA (Certified Nursing Assistant) (V4) was performing beginning of shift rounds and entered (R2's) room. (R2) was seen lying in bed behind (R1). Both residents had their clothing on. (R2) had his hand in (R1's) pants. (V4) CNA separated both residents and walked (R1) back to her room. During separation, (R1) stated to (V4) 'thank you I was so scared - he is so much older than me.' (R1) was unable to recall any further details. Mental Status - oriented to person. The local police department report, dated 12/12/24, documents V13 local police officer was called to the facility for an incident between two residents (R1 and R2). This report documents the following: (V4 CNA) advised she was doing routine room checks at approximately (7:20pm). (V4) said upon entering (R2's) room, (V4) observed (R2) and (R1) lying on the bed together in a 'spooning position', with (R2) laying behind (R1) facing the same direction. (V4) said she saw (R2's) hand down the front of (R1's) pants and appeared to be using his fingers to enter (R1) aggressively. (V4) said she then separated them both and returned (R1) to (R1's) room. (V4) said while asking (R1) if she was okay, (V4) said (R1) appeared afraid and told (V4) 'Thank you so much. He was older than me.' (V4) said (V4) asked for additional staff because (R2) became upset and kept trying to enter (R1's) room again. (V4) said approximately one month ago (V4) walked into (R2's) room and observed (R2) attempting to pull the shirt off (R1) before (V4) intervened. (V4) said (V4) reported this to the nurse (V5 Registered Nurse/RN) on the floor and was concerned since (R2's) and (R1's) rooms are only two doors away from each other. V12 (R1's Family Nurse Practitioner's/FNP) note, dated 12/13/24, documents History of Present (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 2 of 11 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 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Illness: (R1), [AGE] year-old female is seen today for follow-up dementia and vaginal abrasion. I was notified by social worker at nursing home that (R1) was found yesterday evening by a staff member having a sexual experience with another resident. The patient was brought to the emergency department due to concerns for sexual assault. (R1) reported no recollection of the encounter. The reports and emergency room were reviewed. The patient and her son who is the Power of Attorney/POA declined a SANE (Sexual Assault Nurse Examiner) exam. The exam did reveal a 0.5 cm vaginal abrasion. (R1) was discharged back to the unit following the examination. (R1) is in her room this morning with a CNA (Certified Nursing Assistant). (R1) has no recollection of this encounter. (R1) reports some pain and burning in her mouth. Oral mucosa is dry and erythematous. There are no open lesions or abrasions noted. (R1) otherwise offers no information regarding the history of this visit. F03.C0 - Unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety: Patient seen for follow-up of dementia. No recollection of recent sexual encounter, raising concerns about capacity to consent. V12's (R2's FNP) note, dated 12/13/24, documents the following: R2 is a [AGE] year-old male seen in the office for follow-up dementia and weakness. V12 was notified by V3 Social Service Director/Abuse Officer that an incident had occurred last night where V4 found R2 with his hand down another resident's pants (R1) in a sexual manner. On 12/13/24, at 1:40pm, R1 ambulated into R1's room and sat in a chair. This writer noted that R2's room is two doors down from and on the same hall as R1's room. R1 answered questions in a quiet voice by stating the following: R1 has no friends here or enemies. Has no gentleman friend. Feels safe. Denies being touched inappropriately. When R2's name was mentioned R1 said she's known R2 a long time, that they are the same age and we have just stayed on as friends. It is better than being married. I shouldn't say that. He is nice and I like him but not to go too far. He holds my hand but no more than that. R1 denies ever lying in bed with R2 and quietly stated I don't want that. Denies ever being intimate with R2 and stated, I think of him as one of my best friends. On 12/13/24, at 2:00pm, R2 was in his room. R2 answered questions by the following: When asked if he liked living here, he said there are too many rules. R2 confirmed he knows R1 and that R1 is his girlfriend and has been since R2 got here. R2 confirmed R1 was in R2's room last night in bed with him. R2 denied any inappropriate touching and stated I don't think she'd let me get in her pants. I tried. R2 confirmed that a staff member came in. R2 said the staff member was mad and said out. R2 thinks the staff member was mad because it is their rule. R2 could not state what rule he was referring to. R2 denies doing anything wrong. R2 denies having any other girlfriends but R1. I like everything about her. I think she chose me. R2 confirmed that R1 has been in his room before and other than last night. On 12/13/24, at 2:50pm, V4 CNA stated the following: Last night I got in to work at 7:05pm, got report and cart ready. I started room checks about 7:15pm. (R1's) is the first room and she wasn't in there, but she is a wanderer. I kept going and got to (R2's) room. When I opened (R2's) door they (R1 and R2) were in a like a spooning position. They were facing the door and (R1) was in front with (R2) behind (R1). One of his hands was holding (R1's) shoulder under (R2's) neck. (R2's) right hand was down (R1's) jeans in the front. (R2) was making some pretty aggressive motions and it was like (R2) was penetrating (R1). (R1) looked very scared with wide eyes and holding herself very tightly like hugging herself. (R2's) expression was just focused. (R2) did not stop when I walked in. As I led (R1) out (R2) started following us and into (R1's) room. (R2) got kind of aggressive and was refusing to go back into his room. (R1) said 'thank you so much, I was so scared - he is much older than me.' It happened before about a month or so ago. I had opened the door to (R2's) room during room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 3 of 11 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 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 checks and I saw (R1's) breasts were exposed, (R1's) shirt was up and (R2's) pants were zipped down. Level of Harm - Immediate jeopardy to resident health or safety On 12/17/24, at 2:18pm, V5 Registered Nurse/RN stated that during nursing shift report V4 and V9 CNAs came in and reported that V4 walked in and saw (R1) laying on the bed in (R2's) room; (R2) had his hands down (R1's) pants and (R2's) hand was moving. Residents Affected - Few On 12/17/24, at 2:20pm, V5 RN stated there was another time when R2 had his shorts unbuttoned with R1 alone in (R2's) room. That was told to me, but I don't remember the exact details. It was not definitive of sexual activity. They (R1 and R2) had a semi-romance and would hold hands. V5 confirmed that if they had not been walked in on it could have led to more. Who knows how many episodes we may not have encountered. On 12/17/24, at 4:03pm, V4 CNA verified that the prior incident (when R1's shirt was up and R2's pants were unzipped) had occurred the night V4 worked a half shift with V5 RN on 9/1/24. V4 stated (V5 RN) has a different thought process on residents doing these things and in (V5's) mind (V5) thinks (R1 and R2) can consent. Maybe I should have known (V5) would not have taken it seriously. On 12/18/24, at 7:15am, V9 CNA confirmed that on 12/12/24 V4 CNA came up to V9 and said that R2 had his hands down R1's pants. V9 stated that after they were separated R2 was agitated. V9 said I asked what was going on and (R2) said 'I just want to be with her.' On 12/18/24, at 9:05am, V1 Administrator stated (as far as the incident last week 12/12/24), I was told that (V4 CNA) had walked into (R2's) room doing rounds. (V4) found (R1) and (R2) lying in bed together. That (R2) was behind (R1) both with clothing on but (R2's) hand was in (R1's) pants. V1 denied any awareness of the 9/1/24 incident between R1 and R2. On 12/20/24, at 11:15am, V1 Administrator produced the facility's Final Report dated 12/20/24. This report documents The facility finds resident to resident contact was substantiated. Consent is unable to be determined based on the cognition of both residents. Neither resident is able to recall an event has taken place nor has expressed harm, pain, or mental anguish, therefore the facility cannot definitively substantiate abuse at this time. The facility will take the course of higher scrutiny and act as if abuse has been substantiated. On 12/18/2024 at 10:30am V1 was notified of the Immediate Jeopardy. On 12/20/2024 it was confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. A head-to-toe assessment was completed on R1 and 1:1 monitoring was initiated for R2. 2. Local police were contacted. 3. R1 was sent out to the local hospital for evaluation and returned from the hospital with findings of a vaginal abrasion. 4. R2 was maintained on 1:1 monitoring. 5. Head-to-toe assessments were completed for each female resident residing on the memory care unit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 4 of 11 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 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 with no findings. Level of Harm - Immediate jeopardy to resident health or safety 6. Further staff interviews conducted with those who worked on the memory care unit with no findings of sexual abuse between R1 or R2 or any other residents. 7. 12/16/24 R1 was moved to a new room on a different floor. Residents Affected - Few 8. 12/18/24 Care plan training for IDT (Interdisciplinary Team) for care planning requirements for actual/potential resident to resident abuse completed. 9. 12/18/24 Care plan updates completed on R1 and R2. 10. 12/18/24 Head to toe assessments conducted on all residents for signs and symptoms of abuse. 11. 12/18/24 Completion of the trauma abuse screening assessments on all residents to assess for signs and symptoms of abuse. 12. 12/13/24 - 12/18/24 training took place on utilizing the Abuse and Neglect of a resident policy which includes exploitation and the prevention, detection and reporting expectations for all types of abuse. Training of all staff to be completed 12/18/24 in person, or a call to that team member. Administrator was in-serviced by Regional Operations Director. Any team member who has not completed the training will not be able to work until training is completed. 13. Administrator or designee will randomly interview four residents four times a week for any potential abuse allegations for one month; then three days a week for one month; then two times per month for three months. 14. Administrator or designee will interview four staff members four times a week for one month to verify their understanding of the identification and reporting of abuse requirements then four staff member two times a month for three months. 15. Results from the interviews will be reviewed by the QAPI (Quality Assessment and Performance Improvement) Committee on a regular basis for any additional recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 5 of 11 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 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement their abuse prevention program to screen, protect, and report allegations of sexual abuse for two (R1 and R2) of three residents reviewed for abuse in the sample of three. Residents Affected - Few Findings include: The facility's Abuse and Neglect of a Resident policy, last revised 6/16/23, documents Policy Statement: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Definitions: Sexual Abuse is non-consensual sexual contact of any type with a resident, including, but not limited to, assault, rape, or sexual harassment. Examples are: exhibitionism by the service provider, forcing the individual receiving services to view pornographic material, intimate touching of the individual receiving services by the service provider during bathing, molesting the individual receiving services. Capacity and Consent - residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse. These steps will include evaluating whether the resident has the capacity to consent to sexual activity. 5. Establishment of a Resident Sensitive Environment and Prevention: The facility will establish a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and have policies and protocols in place for preventing sexual abuse. All residents will be assessed for risk factors for predisposition to abuse upon admission and will be screened for abuse & neglect in the quarterly social Service Assessment Interview. 6. Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway. Residents who allegedly mistreated another resident will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and associates of the facility. 7. Internal Reporting: If a resident is alleging abuse or neglect (physical, sexual, verbal, emotional, mental), the team member receiving the complaint will immediately notify their direct supervisor and the Coordinator of Abuse Prevention. The Coordinator of Abuse and Prevention will maintain a log of all abuse and neglect allegations and investigations. The Residents' Rights for People in Long Term Care facilities, undated, documents Your right to safety - You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually. R1's Minimum Data Set/MDS, dated [DATE], documents R1 is severely cognitively impaired and independently ambulatory. R1's current Care Plan documents R1 has impaired cognitive function/dementia or impaired thought processes related to Dementia. R1's Progress note, dated 4/30/24, documents Spoke to (R1's Power of Attorney/POA) regarding a witnessed event that occurred on 4/28/24 around 8pm in which a male resident (R2) was attempting to lay in bed with (R1). Education to staff regarding frequent rounding and utilizing CNA (Certified Nursing Assistant) workstation that is closer to their rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 6 of 11 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 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 0607 R1's clinical record does not include any screenings for abuse and neglect since admission on [DATE]. Level of Harm - Minimal harm or potential for actual harm R2's MDS, dated [DATE], documents R2 is moderately cognitively impaired and independently ambulatory. Residents Affected - Few R2's current Care plan documents R2 has target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. R2's clinical record does not include any screenings for abuse and neglect since admission on [DATE]. The local police department report, dated 12/12/24, documents V13 local police officer was called to the facility for an incident between two residents (R1 and R2). This report documents the following: (V4 Certified Nursing Assistant/CNA) advised she was doing routine room checks at approximately (7:20pm). (V4) said upon entering (R2's) room, (V4) observed (R2) and (R1) lying on the bed together in a 'spooning position', with (R2) laying behind (R1) facing the same direction. (V4) said she saw (R2's) hand down the front of (R1's) pants and appeared to be using his fingers to enter (R1) aggressively. (V4) said approximately one month ago (V4) walked into (R2's) room and observed (R2) attempting to pull the shirt off (R1) before (V4) intervened. (V4) said (V4) reported this to the nurse (V5 Registered Nurse/RN) on the floor and was concerned since (R2's) and (R1's) rooms are only two doors away from each other. On 12/13/24, at 1:45pm, R1 and R2's resident rooms are located two doors apart on the same hall of the same floor (Dementia unit) of the facility. R1 and R2 were each in their respective rooms. A CNA workstation is located next to R1's room. On 12/13/24, at 1:58pm, this writer and R1 walked out of her room and down the hall. R2 ambulated towards us with a staff member. R2 smiled and reached out his hand towards R1. R1 reached out her hand and they swept hands as they passed each other, both residents smiling. This writer asked R1 if that was R2 and R1 said yes. R1 stated He's a nice guy but that's as far as it goes. On 12/13/24, at 2:55pm, V4 CNA stated It happened before about a month or so ago. I had opened the door to (R2's) room during room checks and I saw (R1's) breasts were exposed, (R1's) shirt was up and (R2's) pants were zipped down. I told the nurse which was (V5 Registered Nurse/RN). I was never asked about this incident by anyone or asked to write a statement or anything. I thought they would have moved their rooms or done preventative measures. Typically, the CNA sits at the other desk so then there is no one over there (CNA station next to R1's room) and they have the corner to themselves. On 12/13/24, at 3:42pm, V10 CNA stated We do know they (R1 and R2) are very friendly with each other. They sit together with others around. They walk around in early evening. If we see them going into a room together, we are to go and open the doors. We can't watch the doorways all the time. If doing cares on others we wouldn't know if they went into each other's room. On 12/17/24, at 9:30am, V6 Registered Nurse/RN stated At night when I leave (R1) is out at the nurses' station on the other side. The one by her door is the CNA station. It is not frequently used. On 12/17/24, at 11:08am, V3 Social Service Director/SSD/Abuse Coordinator stated, If there had been prior exposure of bare skin/genitals/private areas to one another it should have been reported to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 7 of 11 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 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 0607 me; it was not. Level of Harm - Minimal harm or potential for actual harm On 12/17/24, at 2:20pm, V5 RN confirmed there was another time when R2 had his shorts unbuttoned with R1 alone in R2's room. That was told to me, but I don't remember the exact details. V5 does not recall being told that R1's breasts being exposed. They (R1 and R2) had a semi-romance and would hold hands. V5 confirmed that if they had not been walked in on it could have led to more. Who knows how many episodes we may not have encountered. V5 confirmed V5 did not report this to V3 SSD/Abuse Coordinator. Residents Affected - Few On 12/17/24, at 4:03pm, V4 CNA stated I had told (V5) that (R2's) slacks were unbuttoned and unzipped and (R1's) shirt was up. (R2's) hands were at (R1's) elbows, standing and facing each other in the middle of (R2's) room. (V5) went and talked to each of the residents and was in the middle of med pass. I think it should have been reported to the Abuse Coordinator. Maybe a room change could have been done. They are known wanderers. I realized when the second incident happened, and I reported to (V5) (both times), that nothing had happened. Maybe I should have known (V5) wouldn't have taken it seriously. I didn't think (V5's) view would get in the way of (V5) reporting. On 12/18/24, at 9:05am, V1 Administrator stated (V3 SSD/Abuse Coordinator) and (V14 Resident Life Director) had conversations with both (R1 and R2's) families back in April when they (R1 and R2) were seen sitting on a bed together. Families were contacted then just to let them know that they were being friendly with each other. At that time, we were encouraging them to be out in common areas and we educated staff to use the CNA workstation outside R1's room. V1 stated that allegations are to be reported to V3 and V1. V1 confirmed the incident between R1 and R2 in which R2's pants were unzipped and R1's breasts were exposed was not reported to V1 or V3 at the time the incident occurred. On 12/19/24, at 1:25pm, V1 Administrator verified there are no abuse and neglect screenings or quarterly Social Service assessments including trauma/abuse since R1 and R2's admissions. V1 verified their policy stating that abuse neglect screening is to be done on admission then quarterly. V1 confirmed R1 and R2's rooms are two doors apart and have been for some time and that R1 was moved to another hall on 12/16/24, four days after the second incident that occurred on 12/12/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 8 of 11 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 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 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 identify and report a potential allegation of resident to resident (R1 and R2) sexual abuse to the Abuse Coordinator for three residents reviewed for Abuse in a sample of three. Findings include: The facility's Abuse and Neglect of a Resident policy, last revised 6/16/24, documents, Policy Statement: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Sexual Abuse - is non-consensual sexual contact of any type with a resident, including but not limited to, assault, rape, or sexual harassment. Examples are: exhibitionism by the service provider, forcing the individual receiving services to view pornographic material, intimate touching of the individual receiving services by the service provider during bathing, molesting the individual receiving services. Capacity and Consent - residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse. These steps will include evaluating whether the resident has the capacity to consent to sexual activity. Policy Implementation: Procedures for Detection and Prevention: 4. Training: Training for new and existing staff and in-service training for nurse aides in the following topics may include: Identifying what constitutes abuse, neglect, misappropriation of resident property. Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property. Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal. 7. Internal Reporting: If a resident is alleging abuse or neglect (physical, sexual, verbal, emotional, mental), the team member receiving the complaint will immediately notify their direct supervisor and the Coordinator of Abuse Prevention. The Coordinator of Abuse and Prevention will maintain a log of all abuse and neglect allegations and investigations. The local police department report, dated 12/12/24, documents V13 local police officer was called to the facility for an incident between two residents (R1 and R2). This report documents the following: (V4 Certified Nursing Assistant/CNA) advised she was doing routine room checks at approximately (7:20pm). (V4) said upon entering (R2's) room, (V4) observed (R2) and (R1) lying on the bed together in a 'spooning position', with (R2) laying behind (R1) facing the same direction. (V4) said she saw (R2's) hand down the front of (R1's) pants and appeared to be using his fingers to enter (R1) aggressively. This report continues to state (V4) said approximately one month ago (V4) walked into (R2's) room and observed (R2) attempting to pull the shirt off (R1) before (V4) intervened. (V4) said (V4) reported this to the nurse (V5 Registered Nurse/RN) on the floor and was concerned since (R2's) and (R1's) rooms are only two doors away from each other. R1's Minimum Data Set/MDS, dated [DATE], documents R1 is severely cognitively impaired and independently ambulatory. R1's current Care Plan documents R1 has impaired cognitive function/dementia or impaired thought processes related to Dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 9 of 11 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 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 0609 R2's MDS, dated [DATE], documents R2 is moderately cognitively impaired and independently ambulatory. Level of Harm - Minimal harm or potential for actual harm R2's current Care plan documents R2 has target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. Residents Affected - Few On 12/13/24, at 1:45pm, R1 and R2's resident rooms are located two doors apart on the same hall of the same floor (Dementia unit) of the facility. R1 and R2 were each sitting in their respective rooms. On 12/13/24, at 2:55pm, V4 CNA stated It happened before about a month or so ago. I had opened the door to (R2's) room during room checks and I saw (R1's) breasts were exposed, (R1's) shirt was up and (R2's) pants were zipped down. I told the nurse which was (V5 Registered Nurse/RN). I was never asked about this incident by anyone or asked to write a statement or anything. I thought they would have moved their rooms or done preventative measures. V4 continued to state that about an hour and a half after the incident V5 asked V4 if it looked like R1 was enjoying it. We got into a disagreement about it. She (V5 RN) said she had just had an in-service about sexuality and Dementia. (V5) was claiming that it was okay as long as they are enjoying it. I did not back down. They tell us to tell the nurses immediately if we suspect an allegation of abuse. V4 is unaware of who the Abuse Coordinator is. On 12/17/24, at 2:20pm, V5 RN confirmed there was another time when R2 had his shorts unbuttoned with R1 alone in R2's room. That was told to me, but I don't remember the exact details. V5 does not recall being told that R1's breasts being exposed. They (R1 and R2) had a semi-romance and would hold hands. V5 confirmed that if they had not been walked in on it could have led to more. Who knows how many episodes we may not have encountered. V5 confirmed V5 did not report this to V3 Social Service Director/Abuse Coordinator. I think they both know if it is welcomed or unwelcomed .I don't think it is up to me if they can consent or not. I think they are able to decide what their feelings are and for both it is hard to express it verbally. Me personally if I saw they were enjoying it I would talk to (V3 Social Service Director/Abuse Coordinator) and talk to the family about it and speak to each in a group, families and (V3) to allow them to have a chance to enjoy this last [NAME] in their life if that is what they want. They are able to communicate their feelings. A few months ago (R1) was holding hands with (R2) and I asked (R1) if (R1) had anything going on with (R2) and (R1) said 'yes, but don't tell anyone.' I never did until now. I am not going to be the one to decide if they can have a romance. Dementia sexuality training is to give them their space if they are able to consent. They both do have dementia and in different ways. They are both progressing and at a higher level of dementia than when they came in. I am just saying that they would be able to relay whether or not it is their will or against their will. I believe they could say if a hug is welcomed or unwelcomed and all the other activities too. We shouldn't tell them to go in a room and do that - it is not their capacity. It is a human nature behavior. They still have feelings even though they have dementia. I did not report the buttons being down and (R1) being with (R2); they were already separated. It was not definitive of sexual activity. On 12/17/24, at 4:03pm, V4 CNA was able to verify that the prior (first known) incident (when R1's shirt was up and R2's pants were unzipped) had occurred the night V4 worked with a half shift with V5 RN on 9/1/24. V4 stated It happened at the beginning of the shift after dinner. I worked 4-9 and it was somewhere between 6-8pm. I am sure I told (V5 RN). I had told (V5) that (R2's) slacks were unbuttoned and unzipped and (R1's) shirt was up. (R2's) hands were at (R1's) elbows, standing and facing each other in the middle of (R2's) room. (V5) went and talked to each of the residents and was in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 10 of 11 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 145801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant View Luther Home 505 College Avenue Ottawa, IL 61350 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the middle of med pass. I think it should have been reported to the Abuse Coordinator. Maybe a room change could have been done. They are known wanderers. I realized when the second incident happened, and I reported to (V5) (both times) that nothing had happened. Since they weren't touching, I wasn't sure if I would have been interviewed. This would be classified as a behavior, so we report to the nurse. It depends on the circumstance, what's happening. (V5) has a different thought process on residents doing these things and, in her mind, she thinks they can consent. I don't think it is okay and they can't consent. Maybe I should have known (V5) wouldn't have taken it seriously. I didn't think (V5's) view would get in the way of (V5) reporting. On 12/18/24, at 7:15am, V9 CNA stated, I always go to the nurse and expect them to call the higher ups. On 12/18/24, at 9:05am, V1 Administrator stated the staff are to report allegations of possible abuse to V1 and V3 Social Service Director/SSD/Abuse Coordinator. V3 is the immediate contact and if they can't get her then call (V1). We train to contact us immediately .A CNA should not assume the nurse is going to call us. V1 confirmed V1 was unaware of the first incident (on 9/1/24). If (V5 RN) would have reported this incident to (V1 or V3), it would have definitely alerted us to have more eyes on them and more discussion with the families. It would not necessarily have warranted an investigation. If we had known it happened and it was reported to us then we would have been on higher alert. V1 stated (as far as the incident last week on 12/12/24) I was told that (V5 CNA) had walked into (R2's) room doing rounds. (V5) found (R1) and (R2) lying in bed together. That (R2) was behind (R1) both with clothing on but (R2's hand was in (R1's) pants. V1 confirmed R1 and R2 are not able to consent. Not anyone with dementia is fully able to consent. They might be able to at one moment then change their mind a minute later. They wouldn't realize what they are doing. I don't feel like anyone with dementia could fully consent without being consistent. V1 stated V1 was unaware of the 9/1/24 incident and said I feel like it would have been a behavior but not reportable. No behaviors are appropriate especially when they don't know what they are doing. The facility's reportable incidents for the past three months did not include any other abuse allegations or incident reports between R1 and R2 besides the incident from 12/12/24. The facility's Final Report, dated 12/20/24, documents The facility finds resident to resident contact was substantiated. Consent is unable to be determined based on the cognition of both residents. Neither resident is able to recall an event has taken place nor has expressed harm, pain, or mental anguish, therefore the facility cannot definitively substantiate abuse at this time. The facility will take the course of higher scrutiny and act as if abuse has been substantiated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145801 If continuation sheet Page 11 of 11