Inspection·October 17, 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. This applies to 1 of 3 residents (R2) reviewed for abuse in the sample 3. The findings include: The facility's Incident Report dated 10/13/24 documents R1 was groping R2's breast. V7 (Agency CNA-Certified Nursing Assistant) witnessed R1 groping R2's breast in the dining room. R1's face sheet shows he is an [AGE] year-old male with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, atrial fibrillation, major depressive disorder and metabolic encephalopathy. R2's face sheet shows she is a [AGE] year-old female with diagnoses including ischemia cardiomyopathy, hemiplegia and hemiparesis following cerebral infraction affecting right dominant side, heart failure, aphasia, and dementia. On 10/16/24 at 9:38 AM, R1 was observed in his room lying in bed. He was alert to self, he was confused to the month and year. R1 could not recall the incident with R2. On 10/16/24 at 10:07 AM, R2 was observed in the sunroom sitting in her wheelchair with a flat affect. She responded to her name but could not answer questions. On 10/16/24 at 2:55 PM, V7 said she was entering the dining room. R1 and R2 were both in their wheelchair's sitting next to each other. R1's hand was groping R2's right breast, he was touching and squeezing her breast. R2 sat there and did not say anything. R2 was not wearing a bra under her shirt and is well endowed. R1 was definitely foundling R2's breast. She told R1 not to touch other residents and removed him from the table. She reported the incident to V4 (LPN-Licensed Practical Nurse). On 10/16/24 at 12:15 PM, V4 (LPN) said she was in the dining room preparing medications around 4:30 PM to 5:00 PM. R1 was in the dining room in his wheelchair. She saw R1 using both feet self-propelling towards R2 with a purpose. R2's back was facing her and R1 was positioned next to R2. She continued to prepare her medications and saw V7 leaning towards R1 and removing him from the table. V7 then reported R1 was groping R2's breast. R1 and R2 knew each other from the community and knows R1 recognizes R2. R1 is alert to self, forgetful, he had a stroke and has limitations to his left side. He is on hospice and has declined. R2 is aphasic and does not communicate her needs, she seemed hesitant after the incident. (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: 146140 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 146140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Galena Stauss Nursing Home 215 Summit Street Galena, IL 61036 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)