Health inspection·September 10, 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 interview and record review, the facility failed to ensure residents were free from abuse for two of four residents (R1 and R4) reviewed for abuse on the sample list of eleven. Findings Include:1. R1's electronic health record (EHR) documented R1 has resided at the facility since 5/3/22. R1's EHR documented R1 has diagnoses including, but not limited to cerebral infarction, major depressive disorder, muscle wasting and atrophy, difficulty in walking, and dysphagia.R1's most recent Minimum Data Set (MDS) dated [DATE] documented R1 has a brief interview for mental status (BIMS) score of 9 indicating R1 is not cognitively intact. R1's MDS also documented R1 is mostly a partial to moderate assistance for all her activities of daily living (ADLs) except a few indicating R1's weakness and difficulty walking. R1's care plan (CP) dated 7/2/25 documents R1 has impaired cognitive function due to history of a stroke. R1's CP also documents R1 has limited physical mobility. R3's admission Record printed 9/9/25 documents R3 was admitted to the facility on [DATE] with diagnosis to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, depression, unsteadiness on feet, cognitive communication deficit. R3's MDS dated [DATE] documents R3 has a BIMS score of 6 documenting R3 has moderately impaired cognition, is independent with mobility in wheelchair and has no impairment to the upper or lower extremities. R3's Care Plan documents R3 has a behavior problem, verbal arguing with other resident. R3 will hit other resident when angry all with date initiated 8/25/25. Facility's final investigation report dated 8/31/25 received by Illinois Department of Public Health (IDPH) documents that as R1 was watching television in the dining room R3 came up to R1 in his wheelchair and stated he would like to have her big titties. The investigation report continued to document R3 then reached over and grasped R1's left breast. Facility's investigation report goes on to document at that time R1 instructed R3 to stop touching her and removed R3's hand from R1's left breast. Facility's final investigation report documented that based on the consistent account of the staff interview statements, the incident was substantiated for sexual misconduct of groping R1's left breast by R3. Facility's risk assessment form dated 8/31/25 documented it was determined R3 did grab R1's breast.On 9/9/25 at 9:54 AM, R1 stated she doesn't remember who assaulted her, but does remember the assault. R1 stated the incident happened after a meal. R1 stated a man wheeled up in his wheelchair and reached over and grabbed her breast. R1 stated she couldn't remember if he said anything before the incident. R1 stated she did tell the man to stop and pushed the man's hand away. R1 also stated she told the man to never to do that again. R1 stated she doesn't ever remember being assaulted in this facility before or after this incident. R1 stated she is not afraid of any person in this facility and if a similar incident happened again, she would stop it and tell someone. R1 stated she hasn't stopped doing the things she likes or going where she wants because of the assault. On 9/9/25 at 9:42 AM, R3 stated he doesn't remember the incident or allegedly touching R1. R3 stated he never touched any female's Page 1 of 2 145813 145813 09/10/2025 Metropolis Rehab & Hcc 2299 Metropolis Street Metropolis, IL 62960

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few breast by accident or on purpose. On 9/9/25 at 9:23 AM, V4, (Licensed Practical Nurse/LPN) stated she witnessed the incident between R1 and R3 that occurred on 8/31/25 in the dining room. V4 stated she was walking down the hall when she heard talking coming from the dining room. V4 stated when she looked in the dining room, she observed R3 grab R1's breast and then rub it. V4 stated she immediately told R1 to stop what he was doing, and he did. V4 stated R3 appeared confused at the time. V4 stated she then had R1and R3 separated and removed from the dining room. V4 stated R1 didn't appear afraid but did appear angry about the incident. V4 stated she had never witnessed that type of behavior from R3 before or after this incident. V4 stated after separating R1 and R3 she checked on their immediate safety and for obvious injuries. V4 stated she notified V1, Administrator and Abuse Coordinator for guidance and to report the incident. V4 stated V1 instructed her to place R3 on immediate one to one supervision for the next seventy-two hours. V4 stated she then notified R1 and R3's nurses of the incident and personally conducted a head-to-toe assessment on R1 at which time she found no injuries. On 9/9/25 at 11:46 AM, V6 (LPN) stated he notified R1's power of attorney, police, and medical doctor of the incident the same date of the incident - 8/31/25. 2. R4's electronic health record (EHR) documents R4 has resided at the facility since 3/16/22. R4's EHR documents R4 has diagnoses including, but not limited to adjustment disorder with mixed anxiety, history of traumatic brain injury, chronic obstructive pulmonary disease, abnormal posture, muscle weakness, and abnormalities of gait and mobility. R4's most recent MDS dated [DATE] documents R4 has a BIMS of 8 indicating he is not cognitively intact. R4's MDS also documents R4 has impairment of his range of motion (ROM) of both lower extremities and R4 is wheelchair bound. R4's MDS also documents R4 requires mostly partial to moderate assistance for all his ADL's (Activities of Daily Living). R4's most recent CP dated 6/19/25 documents R4 is at risk for falls, deconditioning. R4's CP also documents R4 has impaired cognitive function, dementia and impaired thought processes. R4's CP also documents R4 has an ADL self-care performance deficit. R4's CP also documents R4 has limited physical mobility. Facility's final investigation report dated 8/21/25 and sent to IDPH stated V1, Administrator witnessed a physical altercation between R3 and R4. V1's statement in the report stated she witnessed R3 hit R4 with an open hand on the left side of R4's head. On 9/10/25 at 10:36 AM, V1 stated she witnessed R3 hit R4 with an open hand on R4's head. V1 stated she heard talking in the dining room and when she looked in, she saw R3 hit R4 with an open hand in the head. V1 stated as she walked over to the area where the incident was taking place R3 and R4 locked arms and began to struggle. V1 stated she separated them immediately upon arriving to the area. V1 stated there were no obvious signs of injuries to either R3 or R4. V1 stated R3 and R4's power of attorneys, police, and medical doctor were notified of the incident. On 9/10/25 at 9:06 AM, R4 stated he does remember the incident of being hit in the head but not the exact date it occurred on. R4 stated he doesn't remember what led up to the altercation, but he does remember being hit in the head. R4 stated he doesn't remember the name of the man who did it but would recognize him if he saw him. R4 stated he is not afraid of being assaulted again and feels safe in this facility. R4 stated the incident has not stopped him from going where he wants in the facility or interacting in activities he enjoys. R4 denied obtaining any injuries related to the incident. On 9/9/25 at 9:42 AM, R3 stated he did not recall any incidents with R4. Facility's abuse policy dated 3/20/25 documents every resident has the right to be free from abuse. Facility's abuse policy also states the facility prohibits the abuse of residents.1 145813 Page 2 of 2