Health inspection·September 24, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews facility failed to follow their policy to ensure residents are free from sexual abuse for 1 (R4) out of 3 residents reviewed for sexual abuse in a sample of 8.Findings include:R5's Facesheet documents in part: R5 is a [AGE] year-old man with a medical diagnosis of schizoaffective disorder and bipolar disorder. R5's Minimum Data Sheet Section C (07/02/2025) documents in part: R5 have a Brief Interview of Mental Status (BIMS) of 11. R5 is moderately cognitively intact.R4's Minimum Data Sheet Section C (07/10/2025) documents in part: R4 have a Brief Interview of Mental Status (BIMS) of 14. R4 is cognitively intact.R3's Minimum Data Sheet Section C (08/22/2025) documents in part: R3 have a Brief Interview of Mental Status (BIMS) of 14. R4 is cognitively intact.On 09/18/2025 at 10:30 AM, surveyor observed R3 in her room. R3 stated that her boyfriend is R5. R3 stated that R5 usually gropes R4 but sometimes its consensual between R4 and R5. They will fool around with each other. R3 stated that last she heard, R4 told R5 that she doesn't like that anymore but R5 still touched her.On 09/18/2025 at 10:32 AM, R7 stated that she has witnessed R5 groping R4's butt.Attached to the basement activity/dining room was the activity office. On 09/18/2025 at 11:50 AM, surveyor asked for R4 to come into come into the activity office. V7 (Activity Aide) was sitting at the entrance of the office. As R4 passed by, V7 playfully tapped R4 on the rear. R4 didn't mind and joined the surveyor in the office. R4 stated that R5 touches her butt and that she doesn't like it. R4 stated that she has not said anything but has told R5 to stop touching her.On 09/18/2025, after speaking to R4, surveyor asked R5 to join him in the activity office. As R5 was walking towards the activity's office, surveyor observed R5 approach V7 (Activity Aide) with both his hands up and V7 gave R5 a hug.On 09/18/2025 at 12:12 PM, R5 stated that R3 is his girlfriend. R5 stated that he has not sexually groped R4.On 09/18/2025 at 12:15 PM, V7 (Activity Aide) stated that he knows R5 very well. V7 stated that she has seen R5 hug and kiss other residents. Sometimes its consensual and other times it is not. V7 stated that R5 will try hug and sometimes give me a kiss on the cheek and then I would redirect him. V7 stated that she has heard R5 touching and kissing R4, but she has never witnessed it. V7 stated that R5 is a guy. They will try to be touchy and feely but that doesn't mean they are being sexually abusive. It's just what guys do.On 09/18/2025 at 2:17 PM, V2 (Director of Nursing) stated that she is familiar with R5. V2 stated that R5 hugs other residents and staff. V2 stated that the intervention in place to for R4 is redirection. V2 stated that R5's care plan is not updated with that intervention. When surveyor told V2 that he witnessed V7 pat R4 on the bottom, V2 stated you're right. I have always seen her do that and she should not be doing that.On 09/23/2025 at 1:22 PM, V1 (Administrator) stated that she is familiar with the incident between R5 and R4. V1 stated that R3's case manager told her that R5 hugs on R4. We did do an investigation. V1 stated that when she interviewed R3, R3 could not give a date and a time. V1 stated that when she interviewed R4 and R5, both residents made it seem like the interaction was consensual. Page 1 of 2 145806 145806 09/24/2025 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V1 stated that at any point R4 could rescind the consent to be affectionate which at that point, R5 should respect her boundaries and should not be touching her. V1 stated that she is aware of V7's behaviors and said that is totally unprofessional and could lead other residents to do the same.R5's behavior care plan documents in part: R5 is alert, aware and coherent and chooses to exercise his right to engage in an intimate/sexual relationship. He has received counseling, as appropriate, regarding safe sexual practices/behavior, only engaging in this type of relationship with a consenting party and monogamy. Resident is aware that he cannot ask for sexual favors in return for material things. Counseling has included education on sexually transmitted diseases. As necessary, he will receive future counseling on condom use, contraceptives, privacy issues and/or respect for his partner. Interventions: Review with appropriate responsible parties quarterly and as needed, behaviors and activities as necessary to protect patient and others. Facility's abuse policy (undated) documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to an individual. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault, including non-consensual or non-competent to consent sexual activity. 145806 Page 2 of 2