Inspection·November 13, 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 have a system in place which prevents a cognitive impaired male resident (R1) from making an inappropriate sexual action towards a female resident (R2). This has the potential to affect 2 of 4 sampled residents (R1 and R2). Findings include: The facility submitted an incident report with an incident date of 8/19/24 and a time of 12:30pm involving R1 and R2. The description of occurrence was written as: The Certified Nurse's Aide (CNA) witnessed R2 with his had in the brief of R2. R2 did not appear or verbalize any distress. According to a face sheet, R1 is a [AGE] year-old male with diagnoses including but not limited to Atherosclerotic heart disease, [NAME] ataxia, anxiety disorder, major depressive disorder, mild dementia, and muscular dystrophy. According to R1's minimum data set assessment with the reference date of 7/12/2024, R1 has a BIMS of 11, mildly cognitively impaired. The section for indication for daily decision-making regarding tasks of daily life was not scored. On 10/12/24 at 11:15 AM, R1 was seated in his wheelchair attending an activity in the dayroom area with other residents and V5 (Activity aide) overseeing the residents and heading the activity session. R1 stated that he was fine, knew the year and where he resided. R1 indicated he could not recall the incident several months ago that occurred with R2. According to a face sheet, R2 is a [AGE] year-old female with diagnoses including but not limited to Parkinson's Disease, Hypertension, Vascular dementia, and Alzheimer's Disease. According to the incident report R2 had a BIMS of 06, indicating severe cognitive impairment. On 10/12/2024 during the onsite investigation, R2 was in the hospital but unrelated to the incident of 8/19/24. On 10/11/24 at 10:40 AM, V4 (CNA) was questioned about the incident of 8/19/2024 between R1 and R2. V4 stated, (R1) was at the table and I saw him put his hand in R1's incontinent brief in the dining room so I quickly told him to take his hands off R2 and I called the nurse. Once I told him to back off, R1 had some difficulty taking his hands out. I never seen him do this to anybody before. I pulled him away and I told the nurse, and she did the whole-body inspection, and he (R1) was taken to his room and cops were called. No other staff were around me in the dining room but me. I was (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: 146187 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 146187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Court Nursing & Rehab 1750 Elmhurst Road Des Plaines, IL 60018 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)