Health inspection·December 4, 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 ensure a resident was free from abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. The findings include: R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis, encephalopathy, seizures, obstructive reflux uropathy, atrial fibrillation, hypertension, and weakness. R1's 9/3/24 facility assessment showed he has severe cognitive impairment and is dependent on staff for cares. R1's care plan initiated 7/23/24 showed, [R1] has episodes of being sexually inappropriate verbally and physically with staff particularly during cares . R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include encounter for palliative care, cerebral atherosclerosis, generalized anxiety disorder, hypertension, and vascular dementia. R2's facility assessment dated [DATE] showed she has severe cognitive impairment and is dependent on staff for all cares. The facility's final report to the Illinois Department of Public Health showed, On 11/21/24 at 4:45 PM, staff witnessed resident [R1] sitting next to resident [R2] in the common lounge area. Staff initially observed [R1] patting [R2] arm and talking to her. Staff then observed [R1] lifting [R2] shirt to touch her breast. Staff intervened and redirected [R1] away from [R2] immediately. [R2] was asleep at the time and did not waken nor notice that anything had occurred. [R2] was assessed and there was no injury . On 12/4/24 at 12:07 PM, V5 RN (Registered Nurse) said she was passing medications when the CNAs came and reported to her that R1 was witnessed pulling R2's shirt up and touching her breasts. On 12/4/24 at 11:30 AM, V8 CNA said, I was there when it happened . I was looking for call lights and when I turned around he was fiddling with her breasts . [R2] is in an almost comatose state. She didn't react at all. She wasn't awake . On 12/4/24 at 1:24 PM, V6 CNA said, . We saw him grabbing her breast . I asked him what he was doing and he said 'playing with her tits' . She was not responsive to anything . The facility's policy and procedure revised 11/1/24 showed, . Preventing and Reporting Page 1 of 2 146177 146177 12/04/2024 Resthave Home-Whiteside County 408 Maple Avenue Morrison, IL 61270

F 0600 Level of Harm - Minimal harm or potential for actual harm Abuse/Neglect . Purpose: To provide a safe environment and protect residents and the facility . Policy: [The facility] does not tolerate abuse or neglect of its residents. each resident will be free from abuse . Residents will be not be subjected to abuse by anyone, including but not limited to, facility staff, other residents . Residents Affected - Few 146177 Page 2 of 2