Inspection·February 29, 2024

F 0600 activity. Level of Harm - Actual harm After the sexual encounter between R1 and R2 occurred, R2's Care Plan was updated with the new focus dated [DATE]: Residents Affected - Few (R2) has a hyper-sexual and flirtatious behavior towards residents and staff. Goal: (R2) will have fewer episodes of hyper-sexual and/or flirtatious behaviors by review date Interventions: Assist (R2) to develop more appropriate methods of coping and interacting with staff and residents. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with her as passing by. If reasonable, discuss with (R2) her behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. (R2) is to have no male caregivers. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. R2's Progress Note dated [DATE] at 11:30 PM documents, When responding to a call light pressed by 110-2, Staff observed (R1) on his knees at the bedside performing oral sex on Resident. She was holding her left leg up and laughing. Staff immediately separated them and (R1) was escorted from the room. Writer was called to the room. Resident nor (R1) was unable to tell Writer what had just happened. She only continued to laugh and run her fingers through her hair. From the hallway (R1) was yelling for cookies. Earlier today, Resident and (R1) was observed by staff attempting to kiss and hold hands in his room. They were redirected and separated at that time. (R3) (110-2) advised Writer that at 2320, (R1) had wheeled himself into the room, began to talk to Resident and soon started to kiss her leg and private area. On [DATE] at 8:45 AM R1 was sitting in the w/c in his room. He stated, I feel good. Just keep an eye on me. I don't want anything to happen to me. R1 stated he gets along with his roommate and other residents just fine. He stated, Just keep an eye on me and make sure I do ok. R1 was unable to recall that he had a different roommate a couple days ago or any interaction between him and any female residents. R1's Face Sheet, printed [DATE], documents his diagnoses as : Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Transient Ishemic Attacks and Cerebral Infarction without Residual Deficits, Abnormalities of Gait and Mobility, Unsteadiness on Feet, Vascular Dementia, ASHD, Insomnia, Cardiac Pacemaker, Anemia, and Hyperlipidemia. R1's MDS dated [DATE] documents he is severely cognitively impaired (BIMS 7), he is independent with bed mobility, transfers and mobility, uses both a wheel chair (w/c) and a walker, able to walk up to 50 feet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146139 If continuation sheet Page 2 of 5 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 146139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care 2120 West Washington Springfield, IL 62702 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)

F 0600 Care Plan: initiated on [DATE], after sexual encounter with R2, documents : Level of Harm - Actual harm (R1) has a hyper-sexual and flirtatious behavior. Residents Affected - Few Goal: (R1) will have no evidence of behavior problems by review date. Interventions for this behavior care plan initiated [DATE]: Anticipate and meet (R1) needs. · Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him as passing by. · If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. · Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. R1's Care Plan was reviewed and he had no other Care Plan regarding inappropriate behaviors prior to [DATE]. R1's Progress Note dated [DATE] at 8:14 AM documents, Behavior Note: Behaviors: Very sexually aggressive to staff. Made several comments to female and male staff that he wanted to kiss it and that they would like it. Non-pharm interventions: Redirected. Writer told Resident that his comments were inappropriate and that he should not say things like that. Writer offered him cookies. Pharm interventions: Summary: Cookie distraction only effective for a short time. Sexual comments resumed. Unable to redirect at this time. R1's Progress Note dated [DATE] at 11:20 PM documents, Resident found in room [ROOM NUMBER]. He was engaged in inappropriate sexual behavior with a female Resident of that room. They were immediately separated and he was placed in 1:1 supervision at the nurse's station. On [DATE] at 8:15 AM, V3, Assistant Director of Nursing (ADON) stated they currently have an investigation going on regarding sexually inappropriate behavior between a male and female resident who were caught during a sexual act. She identified the residents as (R1) and (R2). V3 stated both of these residents have dementia and neither are alert and oriented . V3 stated according to the staff who witnessed it, neither of the residents were resisting and both were enjoying it, and R2 was giggling. V3 stated the staff who initially witnessed the incident, V9, CNA, observed (R1) in (R2's) room and he was performing oral sex on her and she was holding one of her legs up in the air. V3 stated the two residents were separated immediately and the administrator, police, MD and families were notified. V3 stated (R2) was sent to the emergency room for evaluation and she returned with no new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146139 If continuation sheet Page 3 of 5 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 146139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care 2120 West Washington Springfield, IL 62702 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)

F 0600 Level of Harm - Actual harm Residents Affected - Few findings. V3 stated (R2) was seeking (R1) out before she even left for the hospital. V3 stated (R2) ambulates independently and (R1) mostly uses his w/c but is able to ambulate also. V3 stated 1:1 were started immediately. V3 stated when (R2's) son was notified, he stated he is not surprised that she is the instigator. She stated (R1) does not have a POA, just an emergency contact and she just said ok when she was notified. V3 stated since the incident the residents have been kept separated. She stated a few days before the incident, (R2) was started on Trazadone due to not sleeping well . V3 stated a side effect of Trazadone in women can be increased sexual drive and they think this might be why (R2) was sexually inappropriate. V3 stated (R2) has been on 1:1, because she is ambulatory. V3 stated yesterday (R2) was very flirtatious and (R1) was not paying attention to her. V3 stated they are looking into a memory care unit for (R2) to go to. On [DATE] at 10:07 AM , V14, R2's son, during phone interview, stated he received a call Sunday night from the facility to inform him his mother (R2) and a male resident were doing something sexual in her room and she was sent to the hospital to get checked out. He stated he received a call from a nurse at the hospital who stated they didn't find anything, and then the nurse from (the facility) called and let him know she was back in the facility and they had settled her in. V14 stated (V3), ADON followed up with him by phone later and let him know a man had entered (R2's) room and his mother was participating in a sexual act and was not resistant to what was going on. V14 stated his mother has no clue what is going on and if she was in her normal state of mind she would never had participated in sexual activity with that man. He stated his father just passed away in November and (R2) does not even remember him or that he died. V14 stated his mother did not recognize him the last time he visited. He stated the facility is keeping the two of them separated. V14 stated he has not seen any sexually inappropriate behaviors from his mother before. He stated she is happy go lucky, always laughing and giggling. He stated this person is not the mother he knew. He stated it is heartbreaking because his mother would never have done this when she was in her right mind. On [DATE] at 9:40 AM V10, Licensed Practical Nurse (LPN) stated she worked the 200 hall from 7:00 PM until 11:00 PM and then picked up both 100 and 200 Halls for rest of night shift from [DATE] to [DATE]. V10 stated the CNAs on the 100 Hall, (V8) and (V9), called her to (R2's) room. She stated by the time she arrived to the room, (R1) was sitting in his w/c in the hall, and the CNAs were in (R2's) room trying to get her settled down back into bed because (R2) was trying to get up and come out into the hall. V10 stated she asked (R1) what happened and he just asked for cookies and was unable to tell her what happened. She stated the CNAs reported when they went into (R2's) room to answer the call light, (R1) was on his knees next to (R2's) bed. V10 stated up until that morning ([DATE]) the most she heard (R1) say was ,Nurse, give me some cookies. She stated on that morning, prior to this incident, around 5:00 AM, he was saying to her, Just let me lick it and you'll like it repetitively. V10 stated she tried to redirect him and he finally went to his room and went to sleep. V10 stated she returned to work at 7:00 PM and received report from the day shift nurse that (R2) was in (R1's) room and had to be redirected out of his room. She stated (V12), the day shift nurse said (R2) was leaning over (R1) at the time and close to his face, either whispering or trying to kiss him. V10 stated (R1) usually only comes out of his room occasionally to go to the nurses station or the day room, but she had never seen him go into other resident's rooms. V10 stated on the night of the incident between (R1) and (R2), (R2's) roommate, (R3) had put on the light and V10 went back in to talk to her after (R1) and (R2) were separated and (R1) removed from (R2's) room. V10 stated (R3) told her she saw (R1) come into their room, and he kissed (R2) on the leg and then started having oral sex with her. She stated she asked (R3) if she was alright and (R3) stated yes and that she thought maybe (R2) was just lonely. She stated (V3), ADON, asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146139 If continuation sheet Page 4 of 5 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 146139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care 2120 West Washington Springfield, IL 62702 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)

F 0600 Level of Harm - Actual harm Residents Affected - Few her if the sexual contact between (R1) and (R2) was forced and V10 stated she informed her, No (R2) was holding her leg up during the incident. V10 stated it appeared consensual but neither (R1) or (R2) have the cognitive ability to give consent as they are both confused. On [DATE] at 10:15 AM V3, ADON, stated she was first notified of the incident between (R1) and (R2) from (V1), Administrator around 11:30 PM on Sunday night. She stated later the nurse called and told her . V3 stated she was the wound nurse prior to being ADON and had never heard (R1) make sexual comments to anyone. She stated the incident between (R1) and (R2) was consensual, but neither (R1) nor (R2) have the cognitive capacity to consent. She stated the facility does not have an assessment to determine if a resident has the ability to consent, but both (R1) and (R2) are severely cognitively impaired. The facility's policy, Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media, revised [DATE] documents, This facility, for the protection of the residents, utilizes the seven stages of the CMS STRIIPP abuse prevention protocol. These stages include: S, screening potential hires, T, training new and existing employees; R, reporting of incidents, investigations, and facility response to the result of the investigations; I, identification of possible incidents or allegations which need investigation; I, investigation of incidents and allegations; P, protection of residents during investigations; and P, Prevention policies and procedures. 1. All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. 2. All residents have the right to personal privacy of not only their own physical body; but also of their personal space, including personal care, and living accommodations. 14. Sexual abuse is non-consensual sexual contact of any type which includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual coercion shall include any intentional or knowingly touching or fondling a non-consenting resident's sex organs, anus or breast either directly or through clothing for the purpose of sexual gratification or arousal of the accused. 3. All staff are trained that a facility will treat all residents with respect and dignity, promote and protect the rights of all residents and recognized their individuality. 4. All staff will have training on dementia management and abuse prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146139 If continuation sheet Page 5 of 5