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 Page 1 of 2 145877 145877 08/02/2024 Aperion Care Dolton 14325 South Blackstone Dolton, IL 60419

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R4. V1 stated it was reported R3 and R4 were in the dining room. V1 stated R3 alleged R4 touched her leg/thigh and her chest. V1 stated she spoke with R3, and she said no one should be touched without their permission, she was upset. V1 stated when she spoke with R4, he said R3 was being friendly to him, and he touched her leg. R4 has an issue with boundaries and a history of sexual behaviors. V1 stated she did not substantiate the abuse, but it was an invasion of her privacy. V1 stated going forward we will make sure R3 and R4 are not seated at the same table, that's what R3 was comfortable with. On 8/2/24 at 9:46 AM, V15 (LPN/ Licensed Practical Nurse) stated R4 has a mental health disorder, and he does not say much. V15 stated R4 has childlike behaviors. V15 stated R4 is horny he has pulled out his private parts in the dining room and will shake and dance inappropriately. When you talk to him and tell him that's inappropriate, he puts his head down and says, I'm sorry. On 8/2/24 at 10:10 AM, V18 (CNA/Certified Nursing Assistant) stated R4 is confused, acts like a big kid, just looks at you and laughs when you talk to him. V18 stated R4 has sexual tendencies and he used to pull his thing out. V18 stated When you tell him not to do that, he would say I'm sorry. The Final Abuse Incident dated 7/16/24 documents on 7/11/24 an incident with R3 and R4 occurred .On 7/12/24, V1 interviewed R3, she alleged that she was touched by somebody (R4) on her leg and her chest, on her shirt, while she was about to have dinner. R3 stated she told the person to move away, she is alert and oriented in 3 spheres. On 7/12/24, R4 stated while at dinner, he thought the young lady (R3) was moving towards him, being friendly or she needed help, and he was just being playful, nothing more to it. R4 is observed alert and oriented to person and place. R3 was reassured of her security during the entire process of this investigation, and she persistently expresses she feels safe and wants to continue to reside at the facility. R4 was educated on the definition of personal spaces and the need to respect such. He voiced his understanding. He was referred for Psych Consult. Both residents' care plans were reviewed and updated. R4's Psychiatric Nurse Practitioner note dated 7/18/24 documents he is high risk for sexual behavior, major neurocognitive disorder without behavioral disturbance, vascular dementia. R4 has been having sexually acting out behavior, touching himself and exposing his privates in the dining room, trying touch other females' breasts while touching himself. She recommends close monitoring when in public area. R4's care plan dated 7/5/24 shows he has maladaptive behaviors at times manifested by exposing himself in appropriate areas such the dining room dated 7/5/24; interventions include to counsel on inappropriate behaviors and proper social skills. The same care plan dated July 11, 2024, documents he has a behavior problem related to poor boundaries, invasion of privacy and touching other inappropriately, with interventions resident monitored by staff, divert attention, remove from situation, and take to alternative location. The facility's Abuse Prevention and Reporting Policy revised 2022, states, This facility affirms the right of our residents to be free abuse .sexual abuse is non-consensual contact of any type with a resident .unwanted intimate touching of any kind especially of breasts or perineal area .sexual contact is nonconsensual if the residents either does not want the contact to occur . 145877 Page 2 of 2