Inspection·January 9, 2025

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 resident (R4) from sexual abuse by another resident. This failure affects one of two residents (R4) reviewed for abuse in a total sample of five residents. Findings include: R4 is a [AGE] year-old female. R4's diagnoses are but not limited to dementia without behaviors, adult failure to thrive, Parkinson's disease, vascular dementia, and high blood pressure. R4's BIMS (Brief Interview for Mental Status) dated [DATE], notes R4 is not alert. R4's care plan notes R4 has impaired cognitive function and Alzheimer's disease. R5 is a [AGE] year-old male. R5's diagnoses are but not limited to Alzheimer's disease, depression, major depression, anxiety disorder, and dementia without behaviors. R5's BIMS (Brief Interview for Mental Status) dated [DATE], notes R5 is alert. R5's care plan notes R5 needs behavior management due to episodes of physical and verbal aggression. R5 has poor impulse control. R5 displays behavioral symptoms related to socially being inappropriate and touching others inappropriately. R5 has impaired cognitive function related to dementia and short-term memory defects. Nurse's note dated [DATE], notes R4 was involved in an inappropriate interaction with another resident. R4 was immediately separated from another resident. R4 not in any mental or physical distress. Behavior notes dated [DATE], notes at around 4:40 PM, it was brought to this writer's attention that R5 was observed acting inappropriate towards another resident in hallway. R4 and R5 were immediately separated from each other, and R5 was placed on 1:1 observation. Police, doctor, family, DON (Director of Nursing) and Administrator all notified. On [DATE], at 12:42 PM, R5 stated, I do not remember this incident. I do not have any other concerns. On [DATE], at 12:55 PM, R4 was in the dining room eating lunch. R4 did not respond to surveyor ' s questions. On [DATE], at 2:53 PM, V2 (Director of Nursing) stated, I did a lot of the investigation with R4 and R5. I was here and staff informed me of the incident. I do not think this was willful abuse. R5 is attracted to R4, and R5 stated she likes him to. R5 is alert but he has impaired judgment. The residents were separated, and R5 was put on a one to one. Law enforcement was contacted. He was sent to behavioral health. According to R5's statement, R4 reminds R5 of his deceased girlfriend that used to reside in the facility. R4 did not have any injuries of any kind and she was smiling. R5 lives on (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 01/09/2025 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)