Health inspection·August 2, 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 from a resident (R4) with a history of sexual inappropriate behaviors. This applies to 1 of 2 residents (R3) reviewed for abuse in the sample of 11. The findings include: R3's face sheet shows R3 is a [AGE] year-old female with diagnoses including degenerative disease of basal ganglia, unspecified psychosis, diabetes mellitus, and hypertension. R4's face sheet shows R4 is [AGE] year-old male with diagnoses including cerebral infarction, high risk heterosexual behavior, vascular dementia with other behavioral disturbance, and personality disorder. On 8/2/24 at 10:05 AM, R3 was observed in her room sitting in her wheelchair. R3 stated last month she was touched by R4. R3 stated we (R3 and R4) were in the dining room, he (R4) was rubbing my right leg/thigh area, I told him (R4) to stop. R4 then touched my right breast, I (R3) moved his hand, and told him (R4) to stop again. I reported to a staff member the incident and wanted to move to another table. R3 stated she does feel comfortable sitting at the same table with R4. On 8/2/24 at 11:18 AM, R3 was in the dining room sitting at the same table with R4. At 11:27 AM, R3 and R4 remained seated at the same table. On 8/2/24 at 11:05 AM, V16 (Resident Liaison) stated on 7/11/24, she saw R3 in the dining room upset she was trying to move from her table. V16 stated R3 reported to me R4 touched her leg/thigh and was trying to touch her chest. R3 stated people can't touch you without your permission, R3 was upset. V16 stated she separated the residents and spoke to R4. R4 stated he didn't do anything. R11 was at the table who witnessed the incident. R4 had some behaviors of hypersexual activity recently, he pulled out his private parts in the dining room and exposing himself. V16 stated we keep R3 and R4 separated while in the dining room. V16 stated I don't think it was abuse because R3 moved herself from R4. On 8/2/24 at 11:20 AM, R11 stated she was sitting at the same table when she saw R4 rubbing on R3's leg. R4 was putting his hand on her bosoms trying to get into her shirt. R3 told him to stop, and she moved away. On 8/2/24 at 11:48 AM, V1 (Administrator) stated she was notified about the incident with R3 and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145877 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 145877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Dolton 14325 South Blackstone Dolton, IL 60419 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)