Health inspection·May 28, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to investigate allegations of abuse thoroughly for one (R1) of one residents reviewed for physical abuse in a sample of seven. Residents Affected - Few Findings include: The facility's policy titled Abuse, Prevention and Prohibition, dated 03/2025, documents, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. The facility's abuse prohibition program includes the following seven components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the Administrator is not available to address this role, the Administrator will designate a person in charge in their absence to fulfill the role. This person would normally be the Director of Nursing. Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress, except to meet with the administrator as part of the investigation. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process. Initiate investigation including initial reporting to all required agencies. A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift Page 1 of 2 146016 146016 05/28/2025 Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few only will give a statement if indicated. Interview the resident if they are cognitively able to answer questions in a private setting free from any intimidating factors. Request that a staff member who has special rapport participate if possible. If the resident is not interviewable, question the roommate and any family or friends who visit frequently with completion of a questionnaire. Social Services (designee) will complete a Trauma Informed Care assessment and provide follow-up care regardless if allegation is substantiated. Complete and summarize the investigation within five business days. Review outcome of investigation report with the Regional Nurse. Notify the employee in question of their reinstatement or termination. Complete final report and submit to required agencies. Maintain the report in a locked file in the Administrator office. This must be kept private and confidential. R1's admission Record documents the R1's date of admission to the facility was 6/8/23 and her diagnoses on admission include Cerebral Palsy, Hypothyroidism and Cerebrovascular Disease. R1's Minimum Data Set assessment dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) score of 14/15, indicating cognition intact. On 4/10/25 R1 reported to V6 (Case Manager for [NAME]) that a staff member placed a sock in her mouth. On 5/27/25 at 9:30am, R1 stated, about a month ago a female Certified Nursing Assistant/CNA (V4) was helping a male CNA (V3) put R1 on a bed pan. She (R1) did not recall what was being said but a nurse came to the door and V4 (CNA) placed a sock in R1's mouth to keep her (R1) from telling the nurse something about V3 (CNA), R1 stated, I think she thought I was going to tell on the black guy. R1 stated she (R1) pulled the sock from her mouth and V4 (CNA) placed it back in her mouth and held it there for a bit but unsure of how long. On 5/28/25 at 8:15am, V1/Administrator stated, I was notified of the allegation by V6's (Case Manager for [NAME]) that R1 reported that a Certified Nursing Assistant/CNA had placed a sock in R1's mouth. I immediately went down and spoke with R1 who told me that V4 (CNA) did not physically place a sock in her mouth. R1 stated to me that she (R1) had called V3 (CNA) a lazy N word when he had left the room and V4 (CNA) told her (R1) to put a sock in it, we do not use words like that here, that will hurt feelings. V1 (Administrator) also stated R1 stated she (R1) was not afraid of V3 or V4 (both CNA's) and she felt safe in the facility. V4 (CNA) was suspended pending investigation and was told she could return to work. On 5/28/25 at 9:50am, V1 (Administrator) spoke with R1. R1 told V1 at this time that V4 (Certified Nursing Assistant/CNA) had physically placed the sock in her mouth and would not verify what was stated in previous conversation with V1. On 5/28/25 at 12:45pm, V1 (Administrator) stated he only spoke with R1, V3 (Certified Nursing Assistant/CNA), and V4 (CNA) regarding the allegation but did not write down formal statements. V1 also verified that he did not obtain staff interviews, other resident interviews, or have R1 assessed for injury by nursing and Social Services did not do a subsequent Trauma assessment during the investigation but will re-start the investigation due to R1 changing her story back to the sock being physically placed in her mouth. V1 stated, Your right my investigation was lacking. 146016 Page 2 of 2