Inspection·January 31, 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 interview and record review the facility failed to protect a residents right to be free from resident to resident sexual abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 6. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] with diagnoses including schizophrenia, personal history of other mental and behavioral disorders, and hypertensive heart disease. R1's care plan initiated on 2/4/22 shows she has a language communication barrier and can speak only simple English. The care plan also shows she has a cognitive deficit and prefers to be more independent with activities and chooses to observe from a distance. On 9/25/23 an update to her care plan was initiated identifying R1 is at risk for abuse due to having a mental illness and noncompliance with medications. R2's face sheet shows he was admitted to the facility on [DATE] with diagnoses including abnormality of gait and mobility, muscle weakness, and acquired absence of right leg below knee. R2's care plan initiated on 1/27/23 and revised on 12/26/23 shows that he has impaired cognitive function and decision making. A facility completed incident report shows on 1/19/24 at 12:00 PM, a staff member (identified as V3) witnessed R1 touch R2's breast. A witness statement completed by V2 (Director of Nursing) shows when R2 was interviewed about the incident he replied that he did touch R1's breast, he does not know why he did it and he knew it was wrong to do that. On 1/31/24 at 9:25 AM, V3 (Director of Rehab) said on 1/19/24 she was exiting the door of the therapy gym and noticed R2 sitting at the end of the table right outside the doorway, per his usual routine. R1 was ambulating close to R2 when R2 reached out using his left hand and squeezed R1's left breast. V3 said she is pretty sure R2 was not aware she was behind him coming out of the gym. V3 said she immediately intervened and told R2 you can't do that. V3 said R1 did not stop and just continued walking down the hall. On 1/31/24 at 10:00 AM, V8 (Licensed Practical Nurse/LPN) said R1 at baseline is not someone who talks much and answers simple questions occasionally with yes or no answers and head nods. On 1/31/24 at 10:35 AM, R1 was observed sitting in a chair in the dining area listening to church (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: 146159 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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)