**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide adequate supervision for one cognitive impaired resident (R2) who is a high fall risk with a history of falls with injury out of a sample of four [R1, R3, R4] residents reviewed for falls. This failure resulted in R2 falling, transferred to the emergency department, and sustained a left eye orbital fracture.Findings Include, R2 ‘s clinical record indicates the following in part: R2 was admitted with hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, essential hypertension, vitamin D deficiency, restlessness, history of falling, type II diabetes, anxiety disorder, depression, and fracture of upper end of left humerus. R2's minimum data set [MDS] Section [C] Brief Interview Mental Status score [11]. Indicates R2 is mildly cognitively impaired. MDS Section [GG] indicates R2 requires maximal assistance with toileting, personal hygiene, and transfers.R2's Facility IDPH Reportable in part:6/3/26 at 7:05 AM, Upon staff rounds observed R2 on the floor at bedside. R2 noted with left eye and forehead discoloration. Neuro checks initiated. Physician gave order to send R2 to the emergency department. R2 was admitted to the hospital for a left orbital wall fracture.R2's Care Plan in part:12/15/25R2 is a high fall risk.R2 is incontinent of bowel and bladder, requires incontinent care.12/27/25R2 primarily speaks mandarin, understand basic English. R2 is forgetful at times.12/29/25R2 has dementia with impaired decision making.R2 requires the support, care, and services of a long-term care facility. R2 demonstrates symptoms of cognitive impairment.R2 living with chronic psychiatric illness. R2 has ineffective coping modalities, disorganized thought process and mood patterns, delusions, hallucinations, difficulty meeting basic self-care needs. Having reduced insight and judgment related to schizoaffective disorder.R2's Fall Incidents in part:[R2 was admitted on [DATE]]12/16/24, R2 was observed on the floor mat in her bedroom. Intervention: Bed will remain in lowest position, floor mats in place, make sure all needs are met.1/12/25, R2 was observed on the floor in her bedroom lying on the stomach near wheelchair. The wheelchair footrest was on top of R2's calf. R2 was sent to the emergency room and sustained a left arm fracture. Interventions: Monitor for ortho hypertension.1/18/25, R2 was observed on the floor in her room near the closet. R2 said the closet door hit her head. R2 was sent to the emergency room, no injury noted. Intervention: There was no intervention in care plan.2/25/25, R2 was observed siting on the floor in her bedroom, no injury. Intervention: Continue therapy, staff to anticipate needs related to ADL care.Anti-anxiety medications [Power of Attorney refused medications]6/3/25, R2 was observed on the floor in her bedroom. R2 was sent to the emergency room and sustained a left eye orbital fracture. Interventions: [None] R2 did not return back facility.Interviews:On 7/17/25 at 10:20 AM, V13 [Certified Nurse Assistant] stated, On 6/3/25, I was R2's first shift certified nurse assistant. It was around 7:00 AM, I was at the nursing station getting myself together, when I heard a loud noise and heard R2 yell out. I went into her room and looked like she fell out the bed on to the floor. I ran and told the 11PM - 7AM nurse that R2 was on the floor. The nurses assessed R2 and we put her into the wheelchair. Typically, I make rounds when I get to the nursing unit, but I was getting my assignment. R2 has fallen in the past. R2 needs close monitoring all the time. R2 fell during shift change when everyone was at the nursing station, third shift and first shift staff.On 7/17/25 at 10:50 AM, V16 [Certified Nurse Assistant] stated, I was the night shift aide, worked on 6/3/25, when R2 fell. I provided care to R2 around 6:00 AM. Around 7:10 AM, all the first-floor staff was at the nursing station when we heard a noise. I ran into R2's room and she on the floor. R2 left side of her face was discolored dark. R2 needs close monitoring. R2 needs to go to the bathroom frequently and it takes a long time to take her. R2 knows how to place on her call light sometimes, but she does not wait for assistance, she will try to take herself and will fall. Some of R2's fall interventions are, close monitoring, floor mats, low bed and keep the call light in reach. R2 constantly tries to transfer herself all the time.On 7/17/25 at 12:30 PM, V14 [Licensed Practical Nurse] stated, I was R2's third shift nurse. Around 7:05 AM the nursing staff was all at the nursing station. I was giving report to the first shift nurse when we heard a noise came from R2's room. The certified nurse assistance went to her room first to check on the resident. I was called to R2's room I saw R2 on the floor lying on her left side. R2 said she was okay, and after assessing her she was placed into her wheelchair noted with her left side of face was discolored dark. R2 requires constant supervision. Through the night shift the Certified Nurse Assistant sits in a chair outside R2's room to provide one to one monitoring. R2 pulled the call light, but before someone was able to answer her call light, she tried to transfer herself. This happens all the time. I saw her last around 6:00 AM, she was resting in bed. The first shift nurse took over and notified the physician, family, and administration. On 7/17/25 at 2:00PM, V15 [Registered Nurse] stated, I was R2's nurse on 6/3/25, working first shift. I was at the nursing station waiting to get nurse report. Certified Nurse Assistant came and said R2 was on the floor. Everyone ran into R2's room. R2 was lying on the floor with a bruise to her left side of her face. R2 said she was okay. R2 vital signs were with in normal range, and I started neuro checks. R2's physician gave an order to send R2, to the emergency department. Later, the hospital called and said R2 had a left eye orbital fracture. I notified the administration. R2 needs frequent supervision and monitoring. When R2 places on the call light, you have to answer call light immediately or R2 will try to take herself to the bathroom and fall.On 7/16/25 at 11:00 AM, V2 [Director of Nursing/ Fall Coordinator] stated, I been working here since 1/16/25 as the Director of Nursing and Fall Coordinator. On 6/3/25, during shift change, staff heard a noise, went to R2's room and observed her laying on the floor and noted with left side facial discoloration. R2 was sent to the emergency department and R2 was diagnosis with a left orbital eye fracture. R2 had a total of five falls with two falls resulted in an arm fracture and then a left orbital eye fracture. R2 needs supervision, close monitoring, practically one to one supervision. The facility is not able to provide R2 with a one-to-one sitter all the time. R2's fall interventions should be patient centered for each fall to assisted in preventing another fall.On 7/18/25 at 11:00AM, V18 [Physician] stated, R2 is very confused with left sided weakness and need close supervision. R2 has anxiety and needed antianxiety medication. R2's power of attorney refused for R2 to take antianxiety medication. During the examination of R2, it takes two staff members to assist me, because R2 is always trying to get up. R2 had an arm fracture from a fall, and recently a left eye orbital fracture. The falls were avoidable, if R2's power of attorney would have allowed R2 to take antianxiety medication to help her.Policy documents in part:Falls and Fall Prevention:To ensure a fall prevention program will include measures which will determine the individual need of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices as indicated based on assessment.Resident will be reassessed quarterly and after each fall.Immediate change in intervention that were successful.Documentation as indicated.Resident fall risk intervention will be identified on the care plan.The frequency of safety monitoring will be determined by the resident's risk factors and care plan.Resident care plan intervention will be as indicated.IDT [Team] to discuss post incident/accident and or fall incident to ensure prevention from reoccurring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident was free from sexual abuse. This failure affected 1 resident (R1) in the sample of 8. This failure resulted in R1 experiencing psychosocial harm by feeling violated and victimized by R2 due to R2's unwanted touching. Findings include: On 5/29/24 at 2:00 pm, R1 stated that R1 was a resident in the facility for about 2 years. R1 stated, I (R1) did not get out of bed because the electric wheelchair didn't work. I would stay in my bed. R1 stated, (R2) was staring at me (R1). I couldn't sleep. (R2) would try to go under my blanket. Tried to get under my covers. Tried to touch my body. (R2) tried to go and put hands near my privates. I would yell at (R2) to stop. When asked if R2 touched R1's p****, R1 stated, (R2) tried to. (R2) put (R2's) hand under my blanket. I wasn't sleeping. I always had an eye open knowing that I was watched. I left there because I didn't feel safe. R1 stated that R1 recorded a video on R1's cellular phone of R2 touching R1 on 5/6/24 around 6:30 pm. When asked if R1 showed this video (from 5/6/24 around 6:30 pm) to anyone in the facility, R1 stated, Yes, I showed (V4, Social Services Director, SSD) and V1 (Administrator). R1 stated I also showed the cops. R1 stated while in the hospital, I showed them (hospital staff). When asked to describe the video contents, R1 stated that R2 was coming to R1's bed, walking to R1's bed and R1 pushing call light. R2 was then over R1's bedside before they (staff) come in my room. R2 was touching my (R1) body, going under my covers. When asked if this happened the one-time R1 recorded it, R1 stated that it occurred different time periods. When asked if facility staff members knew that R2 was coming over unwanted to R1, V1 stated, Staff members and (V1) knew. I have problems with (V4, SSD). I (R1) said that I am being attacked over here. Nothing got done. Now it involved me (R1) taking pictures. No one is protecting me. Yep, I am protecting myself with the video. R1 stated that it's the same video that R1 showed V1 and V4 where R2 went under R1's covers to try to touch R1's private area. R1 stated, (R4) saw everything. When asked if R2 has come over to R1's bedside and tried to touch R1 before R1 making the video, R1 stated, Most definitely. (R2's) done it before. Trying to touch me. Stealing stuff from my table. I would be calling out. I was agitated. (R2) keeps doing the same thing to me. I wasn't alone. (R2) did that to (R4). I saw him do that to (R4). When asked how it made R1 feel when R2 was touching R1's body on 5/6/24, R1 stated, Very uneasy. I (R1) just don't like to be a victim. I'm watching (R2) all night watch (R1). (R2) pulls my (privacy) curtain and keeps coming in. I say, 'Why are you in my space?' It's a violation of my space. Violation of my body. No matter how many times I brought it up (to staff), it keeps happening. R1's Face Sheet documents, in part, diagnoses of hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side; contracture of muscle, multiple sites; unspecified convulsions; chronic kidney disease, stage 3 unspecified; adult failure to thrive; traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, sequela; personal history of traumatic brain injury; essential (primary) hypertension; anxiety disorder, unspecified; hyperlipidemia, unspecified; epilepsy, unspecified, intractable, without status epilepticus; major depressive disorder, recurrent, unspecified; neuromuscular dysfunction of bladder, unspecified; schizoaffective disorder, unspecified; old myocardial infarction; other chronic pain; and muscle weakness (generalized). R1's Minimum Data Sheet (MDS), dated [DATE], documents, in part, that R1's Brief Interview for Mental Status (BIMS) score is 13 which indicates that R1 is cognitively intact. R1's Functional Abilities and Goals for functional limitation in range of motion documents, in part, impairment on one side of upper extremities and impairment on both sides of lower extremities. R1's mobility for bed to chair transfer is coded as Dependent - Helper does all the effort. Resident does none of the effort to complete the activity, and walk 10 feet is coded as Not attempted due to medical or safety concerns. On 5/28/24 at 1:28 pm, R4 stated that R4 remembers R1 as a former roommate, but that R1 is not in the facility anymore. R4 stated that R4 knows R2 and that R2 is still in the facility. R4 stated, (R2) walked towards my bed and (R2) was going under my covers (while pointing towards R4's left lower leg) and I kicked my foot at (R2). I told (R2) no and (R2) stopped. When asked if R4 had reported this incident with R2 to any facility staff, R4 stated, I (R4) told a number of CNAs and told one of the nurses, but R4 didn't remember their names. When asked if R4 had witnessed R2 going over towards R1's bed touching R1 inappropriately on R1's body, R4 stated, I (R4) did see that. R4 stated that R4 couldn't remember the date but that R2 went to R1's bedside, more than one time. R4 stated that R1 told R2, Stop doing that when R2 touched R1 under the covers, and on that same day, R2 tried to touch R4 under R4's cover. R4 said that R2 kept doing it to R1. R4's Face Sheet documents, in part, diagnoses of Parkinson's disease with dyskinesia, without mention of fluctuations; dyskinesia of esophagus; unspecified severe protein-calorie malnutrition; multiple subsegmental pulmonary emboli without acute cor pulmonale; Dysarthria and anarthria; personal history of other venous thrombosis and embolism; cerebral infarction, unspecified; major depressive disorder, recurrent, mild; posttraumatic stress disorder, chronic; polyneuropathy, unspecified; essential (primary) hypertension; venous insufficiency; spinal stenosis, cervical region; hyperlipidemia, unspecified; pain, unspecified; other lack of coordination; cognitive communication deficit; unspecified voice and resonance disorder; muscle weakness (generalized); and need for assistance with personal care. R4's MDS, dated [DATE], documents, in part, that R4's BIMS score is 15 which indicates that R4 is cognitively intact. On 5/7/24 at 3:15 pm, V16 (Hospital Registered Nurse, Sexual Assault Nurse Examiner) documents, in part, in R1's hospital emergency records, (R1) states 'I have been being touched by (R2) and I have told staff, and no one believes me. (R2) has been coming to my bed and touching my leg and chest and is trying to move my gown. I have told (R2) to leave me alone. I told (R2) I don't want to be touched' . (R1) stated (R1) had video on (R1's) phone of (R2) touching (R1) and showed the video to (V16). (V16) observed (R2) wearing a hospital gown walking towards the victim (R1) and touching (R1) on the leg and (R1) telling (R2) to stop touching (R1). The video also shows (R2) also touching (R1) on the abdomen and trying to move (R1's) gown. (R1) states 'I have informed staff, and no one believed me until I told them I had video of (R2) touching me.' R1's Police Report, dated 5/7/24 at 12:00 midnight, documents, in part, the incident of battery; with R1 as the victim; and violent crimes and special victims' units are managing R1's case. On 5/29/24 at 10:11 am, V4 (SSD) stated that on 5/7/24, V4 was doing rounds on the floor and spoke with R1. V4 stated that R1 is alert, oriented, stays in bed and does not ambulate. V4 stated that R1 told V4 that R2 approached R1's bed, tried touching R1's stuff and tried to grab R1's covers. V4 stated that R1 informed V4 that staff members were aware with R1 saying 'I (R1) told everybody.' V4 stated that the only names that V4 can remember from R1 are V10 (Certified Nursing Assistant, CNA) and V14 (CNA). When this surveyor showed a witness statement to V4, dated 5/7/24 with R1's name and statement written on it, V4 stated that V4 authored the document from R1's interview on 5/7/24. After reading aloud this authored witness statement from R1, V4 stated that R1 said that R2 touched R1 above R1's stomach and on the knee. V4 stated that this was the first expressed to me that R2 had been walking over to R1's bedside. V4 confirmed that on 5/7/24, R1 showed V4 the video on R1's cellular phone of R2 coming over to R1's bedside. When asked if R2 is clearly identifiable in R1's video, V4 stated, Yes. It was clear that it was (R2). Facility document titled Witness Statement, dated 5/7/24 with R1's printed name, and signed by R1, documents, in part, (R1) reported that incident occurred on May 6, 2024, around change of 2nd shift. (R1) stated, 'Last night, (R2) standing in window and (R2) walks to my way and tries to touch me. I (R1) see (R2) try to put (R2's) hand here and here but I put my leg up so (R2) can get (R2) away from me.' . (R1) pointed to kneecap and gown. R1's ADT (Admissions, Discharges, Transfers) History document indicates that R1 was admitted to the facility on [DATE] and discharged to another long-term care facility on 5/17/24. R1's room remained the same in the facility from admission to discharge. Facility document titled Census Detail Report, dated 5/6/24, documents, in part, that R1, R2 and R4 were roommates. In R1's Social Services-Screening to Determine Abuse, dated 5/7/24, V4 (SSD) documents, in part, an abuse screening indicator score is 5 which indicates that R1's risk measure for likelihood for a history of previous/recent mistreatment and/or potential future problems/symptoms related to mistreatment is high. In review of R1's complete care plan, printed on 5/28/24, no focus, goal or interventions are documented for R1's allegation of sexual assault from R2 or R1's risk of abuse. On 5/28/24 at 1:25 pm, R2 stated that R2 does not remember R2's former roommate, R1, and that on May 6, 2024, R2 did not touch R1's body. R2 stated that R2 walks around with a walker (observed next to R2's bed). When asked if R2 has recently been hospitalized after incident in facility with R1, R2 stated, No. No. R2's Face Sheet documents, in part, diagnoses of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance; hypothyroidism, unspecified; atherosclerosis of aorta; dysphagia, unspecified; cognitive communication deficit; difficulty in walking, not elsewhere classified; adult failure to thrive; muscle weakness (generalized); need for assistance with personal care personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; pain, unspecified; dehydration; and pneumonia, unspecified organism. R2 resides in a room by himself. R2's MDS, dated [DATE], documents, in part, a BIMS score of 6 which indicates that R2 has severe cognitive impairment. R2's ADT History document indicates that R2 was a roommate of R1's since 1/2/24 and was hospitalized from [DATE] to 5/20/24. On 5/29/24 at 10:11 am, V4 (SSD) stated that R2 does not converse a lot, is not all the way there and is in (R2's) bubble. V4 stated that R2 has not many issues at all, but when asked about R2 being placed in different rooms several times in May 2024 and R1 and R4's statements of R2 coming to their bedsides uninvited, V4 stated that R2 has poor personal boundary issue. In R2's Progress Notes, dated 5/7/24 at 7:21 pm, V4 (SSD) documents, in part, Resident (R2) was involved in alleged sexually inappropriate behaviors. This resident (R2) has multiple medical diagnoses. Resident (R2) presents with no unusual behaviors . Resident (R2) was interviewed by the appropriate staff. Resident presents with poor insight to (be) interviewed and denies any behaviors. On 5/29/24 at 10:28 am, V3 (RN) stated that V3 was R1 and R2's primary nurse routinely on the day shift. V3 stated that on 5/7/24, V11 (Agency CNA) informed V3 that R1 had taken a video of R2 on R1's phone. V3 stated that on 5/7/24, R1 had not voiced R1's allegation of R2 touching R1, and V3 educated R1 on not taking pictures of fellow residents. V3 stated that V3 did not view R1's cellular phone video of R2. V3 stated that later 5/7/24 at 11:00 am to noon, V4 (SSD) was talking to R1, and then V3 removed R2 from R1's room. This surveyor read V3's progress note from 5/7/24 about R2 being sexually inappropriate towards a care giver, and V3 stated that V11 (Agency CNA) informed V3 on 5/7/24 that R2 has touched V11's body while V11 was rendering R2's care. When asked what part of V11's body did V11 say that R2 touched, V3 stated, (V11) said it was on (V11's) side (pointing to hip) close to buttock area. V3 stated that V3 sent R1 to the hospital for evaluation and that R1 returned to the facility on 5/7/24. V3 also stated that a couple weeks prior, R2 was taking R1's food from R1's bedside and that V3 told R2 to stay on R2's side of room and don't touch other residents' items. In R2's Progress Notes, dated 4/21/24 at 5:52 pm, V3 (RN) documents, Observe resident (R2) taking personal belongings (food items) from roommate's bedside table, educated resident (R2) to keep to (R2's) side of room and not to interfere with roommate's belongings, stated I (R2) know, I know, will continue to monitor and educate. In R2's Progress Notes, dated 5/7/24 at 4:23 pm, V3 (RN) documents, 9;(:)30 am - Resident (R2) sexually inappropriate toward caregiver (V11, Agency CNA), counseled and educated on appropriate behavior, verbalized understanding, will continue to monitor. On 5/29/24 at 12:45 pm V11 (Agency CNA) stated that V11 works in the facility 3 to 4 times a week primarily on R1, R2, and R4's floor. V11 stated that R1 is alert, oriented, normal, always is in bed and needs help with personal care needs. V11 stated that R2 is more confused and walks with an unsteady gait, and that V11 has observed R2 walking unassisted in R1, R2 and R4's room. When asked about V11 reporting to V3 on 5/7/24 that R2 was sexually touching V11, V11 stated that R2 is confused, but then R2 says, I like it. V11 stated that V11 told R2 that it's inappropriate to touch someone like that. V11 stated that R2 touched V11 on the lower back while V11 was rendering activities of daily living care with R2 behind the privacy curtain on the morning of 5/7/24. V11 stated that when V11 told R2 to stop touching V11 inappropriately, V11 heard R1 say from behind the privacy curtain, (R2) do that to me too and (R2) comes to my bed. V11 stated that R1 then showed V11 a video of R2 next to R1's bed. V11 stated that when asked about R2's behavior of touching staff inappropriately, V11 stated that all the CNAs complain about it. V11 stated that V11 provided a statement to V1 for the abuse investigation for R1 and R2 on 5/7/24 and that R1 said that R2 is always trying to be friends with R1. V11 stated that R1 said, I (R1) don't want to be friends with (R2). Those were (R1's) words. On 5/29/24 at 2:54 pm, V15 (Agency RN) stated that V15 was working on 5/6/24 from 3:00 pm to 11:00 pm and remembers R1 and R2. V15 stated that during V15's shift on 5/6/24, V15 heard R1 yelling out, and V15 immediately went to R1's room. V15 stated that V15 observed R2 standing next to R2's bed, and R1 laying in the bed saying that R2 was coming over to R1. When asked what was R1 yelling out to get V15's attention, V15 said that V15 can't recall if R1 said help but what R1 was saying was in a louder tone. V15 stated that when V15 went in R1 and R2's room, Someone (R2) was by (R1) that doesn't belong there. On 5/29/24 at 2:37 pm, V14 (CNA) stated that V14 was working on 5/6/24 from 3:00 pm to 11:00 pm and is familiar with R1 and R2. V14 stated that R2 is a wanderer, confused with R2's mind be all over the place and that R2 just like to get into things a lot of the time. V14 stated that on 5/6/24 during the evening shift, V14 answered R1's call light to observe that R2 was by R1's bed. V14 stated, (R1) would be screaming or on a call light for someone to remove (R2). On 5/29/24 at 3:20 pm, V6 (CNA) stated that V6 was working on 5/6/24 from 3:00 pm to 11:00 pm and that V6 answered the call light two times, for R1, with R2 observed at the end of R1's bed. V6 stated, They (R1 and R4) would pull the light when they see (R2) coming towards in their direction. Both of them (R1 and R4). On 5/29/24 at 2:43 pm, V7 (CNA) stated that V7 was working on 5/6/24 from 3:00 pm to 11:00 pm and that V7 answered R1's call light to observe R2 standing in the middle of their room trying to come over to R1's side of room. V7 stated that V7 takes R2 back to R2's bed saying that R2 can't go over to R1's bedside. On 5/29/24 at 11:05 am, V9 (CNA) stated that V9 was working on 5/6/24 from 3:00 pm to 11:00 pm and that R1 doesn't get out of bed and is a mechanical lift transfer. V9 stated that R2 is confused and walks independent in R2's room. V9 stated that on 5/6/24, V9 stated, I (V9) only heard (R1) shouting, then then nurse (V15) went into R1's room. V9 stated that later on 5/6/24 shift, around bedtime, V9 came into R1's room when R1 was shouting. V9 stated that V9 asked why R1 was shouting, and that R1 said that it was R1's roommate (R2) again. V9 stated that V9 told R1, You (R1) have to calm down. By shouting, think of your head. On 5/29/24 at 11:35 am, V10 (CNA) stated that V10 routinely works on R1 and R2's floor. V10 stated that R1 is alert and oriented, and that V10 assists R1 with all ADL care except feeding R1. V10 stated that R1 would use call light and or would shout out for help, and V10 would come into room. V10 stated that R1 would not want R2 on R1's side of room and that R2 was touching R1's personal belongings. On 5/30/24 at 10:50 am, V2 (Director of Nursing, DON) stated that nursing staff are to treat residents with respect, perform purposeful rounding and there's not subpar nursing in this facility. When asked if R1 has the right to be free from R2 coming into R1's space and touching R1's things or person, V2 stated, Yes, that is correct. V2 stated that R2 would walk in room with a shuffle gait; that R2 would walk over to R1's bedside; and that (R2) is harmless. When asked if a resident should feel safe to not have another resident touching them, V2 stated, No, they should not experience that. V2 further stated, regarding R2 staff know to keep an eye on them, they do purposeful rounding, make sure he is getting enough to eat and give R2 something to do. On 5/30/24 at 12:54 pm, V1 (Administrator) stated that V1 is the abuse coordinator for the facility with the responsibility is to ensure safety of the residents. V1 stated that on 5/7/24, V1 was notified of R1's allegation of R2 touching R1 inappropriately. V1 stated that V1 interviewed R1 on 5/7/24, and asked R1 where R2 touched R1. V1 stated that R1 said that R2 was by R1's bedside and that R1 touched over (R1's) diaper to indicate where R2 had touched R1. V1 stated that R1 then showed V1 the video on R1's cellular phone with no sound, with a date stamped of 5/6/24 after dinner around 6:30 pm, and V1 could clearly see that it was R2 in the video at R1's bedside. Facility policy titled Abuse Prevention and Reporting-Illinois with effective date of 11/28/2016 and last revision date of 10/24/2022, documents, in part, Guidelines: This facility affirms the right of our residents to be free from abuse . or mistreatment. This facility therefore prohibits abuse . and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse . and mistreatment of residents. This will be done by: . Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; Identifying occurrences and patterns of potential mistreatment . Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means . Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions . Sexual abuse includes, but is not limited to, . sexual assault . 'Sexual abuse' is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but is not limited to: Unwanted intimate touching of any kind especially of breasts or perineal area . Generally, sexual contact is nonconsensual if the resident . does not want the contact to occur. Facility policy titled Behavior Management and dated August 2006 documents, in part, Behavior management of residents in the facility is the responsibility of the interdisciplinary team, which includes nurses, nursing assistants, social service staff, activity staff and facility administration. Residents with a diagnosis of dementia or mental illness may display inappropriate or unacceptable behavior.

Based upon observation, interview and record review the facility failed to provide fall prevention interventions on two of three residents (R1, R8) care plans, failed to ensure staff were aware of (R1, R5, R8) fall prevention interventions and failed to implement fall prevention interventions for two of three residents (R1, R8) reviewed for falls. These failures resulted in R1 sustaining acute rib fractures on the left from a fall on 2/12/23. Findings include: 1.R1's diagnoses include absence of right leg below knee. R1's (2/9/23) fall evaluation determined a score of 60 (high risk). R1's (2/24/23) Physical Therapy Evaluation & Plan of Treatment states patient requiring SUP (Supination) for slide board transfers. Chair/bed to chair transfer = Dependent. R1's (3/2/23) functional assessment affirms (2 person) physical assist is required for transfers. R1's (9/17/20) care plan includes risk for falls related to right leg below knee amputation however interventions exclude SUP for slide board transfers and/or 2 persons assist during transfers. R1's (2/12/23) incident report states patient fell on the floor in her room during transfer. R1's (3/2/23) BIMS (Brief Interview Mental Status) determined a score of 15 (cognitively intact). On 4/10/23 at 1:56pm, R1 stated, I was on my bed, and they (2 staff) went to help me get in the chair. They (staff) tried and then they (staff) dropped me. There was one (staff) on each side by my arm. Four (4) of my ribs got fractured when I fell on the floor. A gait belt was inquired in use during (2/12/23) transfer. R1stated, No, I have a sliding board and affirmed a sliding board was also not in use. On 4/10/23 at 2:24pm, V4 (Certified Nursing Assistant) affirmed she was currently assigned to R1. V4 stated, She calls when she needs assisted. She has a slide board. She has slip resistant socks and a boot that helps her balance. V4, stated Half go on the wheelchair, half on the bed and one side on the wheelchair let up. V4 inquired how many staff are required to transfer R1. V4 replied, One person. [R1 requires 2 persons assistance]. On 4/11/23 at 1:30pm, V13 (Registered Nurse) stated, The CNA (Certified Nursing Assistant) was about to transfer her (R1). I asked her (CNA) to step away and before I stepped next to her (R1) she (R1) had fallen over. It happened essentially as soon as the CNA stepped away. V13 stated, I thought it would be quicker for me to transfer (R1) and the CNA to assist another resident needing help. V13 inquired if R1 transfers by himself. V13 replied, Yes. V13 stated, I don't recall if there's an order to be transferring her (R1) with two (2) individuals or using a lift. V13 reviewed R1's care plan and stated Nope, nothing about a slider board. On 4/12/23 at 11:52am, V17 (Minimum Data Set Coordinator) stated, The intervention when she came back (from the hospital) was to make her a mechanical lift. V17 stated, It will show up on their care plan in PC (electronic program). V17 stated, The DON (Director of Nursing) will usually let the staff know if there's something new. On 4/12/23 at 2:11 pm, V 21 (Medical Director) inquired about potential harm when a resident falls, V21 stated, It could be anything it can be something small it can be something big. I don't have a crystal ball I can't say for sure. V 21 stated, There could be no injury there could be a large injury potentially anything could be possible. A scrape to anything it could be anything. V 21 stated, Right away the patient should be assessed and sent out for evaluation. If there's head trauma, we have to send them right away it depends on the assessment. R1's (2/13/23) Abdomen & Pelvis CT (Computed Topography) includes acute rib fractures on the left. 2. R5's diagnoses include morbid obesity and unsteadiness on feet. R5's (2/6/23) fall risk assessment determined a score of 80 (high risk). R5's (3/20/23) functional assessment affirms set up is required for transfers and locomotion (uses walker). R5's (12/16/22) care plan includes risk for falls. On 4/10/23 at 2:24pm, V 5 (Agency Nurse) affirmed he was currently assigned to R5. V 5 stated, I could find out but the system is down so I can't and affirmed he was unaware. V 5 advised that the facility phone and Internet were not working. R5's (3/20/23) BIMS determined a score of 15 (cognitively intact). On 4/10/23 at 2:26 pm, R5 stated, I did have a couple falls, they (staff) tell me four (4). 3. R8's diagnoses include abnormalities of gait and mobility. R8's (3/21/23) functional assessment affirms (2 person) physical assistance is required for transfers. R8's (3/21/23) fall risk evaluation determined a score of 36 (moderate risk for falling). R8's (3/21/23) BIMS determined a score of 13 (cognitively intact). R8's comprehensive care plan excludes risk for falls and/or fall prevention interventions. On 4/10/23 at 2:44 pm, R8's was lying in bed while in high position. R8's call light was tied to the side rail however dangling below the mattress. R8 attempted to locate the call light and stated, Uh oh, I think I dropped it. It's not there. R8 stated, No, I'm not able to walk. They (staff) need like 2 people to put me in the wheelchair. R8 stated, Oh yes, I've had a few falls. I fell in the room and shortly after that I fell again going to the door to get some money. I got dizzy, collapsed and fell on the floor. On 4/10/23 at 2:55 pm, V5 (Agency Nurse) affirmed he was currently assigned to R8. V5 stated, Off the top of my head I don't know but usually they'll put a pad on the floor and the bed will be at the lowest level, but I can't really see because the system is down. R8's bed was inquired to V5. V5 responded, I would say the bed is all the way up. R8's call light inquired to V5. V5 replied, It should be clipped on her. V5 stated, No floor mats were besides R8's bed. V5 states to R8, I'm going bring your bed down because it should be low and going to give you a call light because it should be by you. R8 responded, Ok. The Fall Prevention Program (revised 11/22/22) states care plan incorporates identification of all risk/issue. Addresses each fall. Interventions are changed with each fall, as appropriate. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. Safety interventions will be implemented for each resident identified at risk. All assigned Nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. The bed will be maintained in a position appropriate for resident transfers.

Based upon record review and interview the facility failed to ensure that three of three residents (R1, R5, R8) reviewed for medication administration were free from significant medication errors. This failure resulted in R1 and R5 sustaining critical high (above 300) blood sugars. Findings include: R5's diagnoses include type II diabetes mellitus with hyperglycemia. R5's (3/20/23) BIMS (Brief Interview Mental Status) determined a score of 15 (cognitively intact). On 4/10/23 at 2:26pm, R5 stated, About a week ago Saturday we had no Nurse on the floor (2nd floor) for all 3 shifts. They (Nurse) did my blood sugar the following day and it was 500 because I didn't get my medication. On (4/7/23) R1's blood sugar was 551 (critical high) at 7:30am. R5's POS (Physician Order Sheet) includes but not limited to (12/17/22) Glipizide (Oral Hypoglycemic) 10mg (milligrams) twice daily, Metformin (Oral Hypoglycemic) 1,000mg twice daily, Humalog (Insulin) 10 units before meals and Lantus 58 units at bedtime. R5's (April 2023) MAR (Medication Administration Record) affirms scheduled medications were not documented on 4/4 and 4/7. R5's (4/7/23) Humalog and/or blood sugar were not documented at 4:00pm, Metformin & Glipizide were not documented at 6:00pm, and Lantus was not documented at 9:00pm (as scheduled). __ R1's diagnoses include diabetes mellitus. R1's (4/2/23) POS includes but not limited to Lantus (Insulin) 10 units every morning and at bedtime for diabetes. R1's (3/2/23) BIMS determined a score of 15. On 4/11/23 at 1:57pm, R1 denied medication administration concerns however R1's (April 2023) MAR affirms scheduled medications were not documented on 4/2, 4/3 and 4/8. On 4/2/23 & 4/3/23, R1's Lantus is not documented at 6:30am and 9:00pm. R1's (6:30am) blood sugars were 347 (critical high) on 4/2/23 and 349 (critical high) on 4/3/23. __ R8's diagnoses include schizoaffective disorder, depressive type. R8's (3/21/23) BIMS determined a score of 13 (cognitively intact). On 4/10/23 at 2:44pm, R8 stated, There was a problem with them not giving me enough Clozapine so I let the Administrator know, he (Administrator) said he would take care of it. R8's POS includes but not limited to (12/21/22) Clozapine (Antipsychotic) 300mg at bedtime and Clozapine 25mg once daily. R8's (April 2023) MAR affirms scheduled medications (including Clozapine) are not documented 4/7, 4/8, 4/9 and 4/10. On 4/18/23 at 12:07pm, V30 (Physician) stated, Both of them could cause some problems. They (residents) could get hyperglycemia or other problems like mental status not being controlled if they're not receiving medication. The (undated) Medication Administration policy states medications are administered in accordance with written orders of the prescriber. The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect residents from sexual abuse by an employee for three of three residents (R1, R2, R3) reviewed for abuse. This deficient practice caused residents to experience fear, shame, and anger. Findings include: An investigation was initiated in response to incident reports submitted to IDPH (Illinois Department of Public Health) on 02.13.2023 and 02.14.2023. Both reports alleged sexual abuse of R1 and R2 by V3 (Contract COTA-Certified Occupational Therapy Assistant). 1)R1's medical record (Face Sheet, MDS-Minimum Data Set) documents R1 is a cognitively intact [AGE] year-old admitted to the facility on 01.24.2023 with diagnoses including but not limited to: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Cerebral Infarction Due to Embolism of Right Middle Cerebral Artery, Diabetes Mellitus Due to Underlying Condition with Diabetic Autonomic (Poly)Neuropathy, and End Stage Renal Disease. On 02.15.2023 at 10:30 AM, V1 said, R1 reported to V1, around 02.08.2023, that R1 initially felt uncomfortable in therapy. A concern form was completed (dated 02.03.2023). Local police were notified but not IDPH because there was no allegation of abuse. An investigation was later initiated and reported to IDPH after R1 alleged V3 touched R1's vaginal area during therapy session. R2 reported to V1 on 02.08.2023 that V3 raped R2 in R2's room after a therapy session. V1 said R1's investigation was in progress; allegation would not be substantiated; R2's allegation was not substantiated. On 02.16.2023 at 12:03 PM, R1 was observed sitting on the side of bed eating lunch. R1 was pleasant, neat, clean, and dressed in-patient gown. R1 agreed to speak with surveyor regarding incident involving V3 (Contract COTA-Certified Occupational Therapist). R1 said, The day it happened (01.31.2023), I was sitting on the bed, like I am now, with my legs closed. I was wearing two gowns (using one as a robe). The door was closed, the privacy curtain was drawn (to end of bed). V3 said we were going to do arm stretches. V3 came in front of me, forcing V3's knee in between my knees. Now V3 is right in my face, my head was on V3's chest. I had to move my head in order to breathe. V3 wrapped V3's arms around me, forcing V3's way to get through my gown, to get at my skin. V3 was breathing heavily into my ear. Somehow V3 got V3's hands under the waist band of my panties, onto my buttocks. V3 grabbed my butt, thrusting into my body. I said (to myself), this isn't right, V3's not supposed to be grabbing my a**. V3 touched my vagina; grabbed my hair as if V3 was going to kiss me. I put my arm between V3 and myself (demonstrated putting arm across chest). I felt V3's erection. I felt uncomfortable. I said to V3, I think I've had enough for today. I did cry out (in pain), I said, 'ow.' Then V3 said let's do some leg stretches. I was flat in bed, one leg over the knee. I had my hand over my forehead (demonstrated hand to forehead, palm out). V3 tickled the palm of my hand. In my culture when someone does that, it means they want to have sex. V3 did this twice. I told V3 it's too much, I can't, I can't, I'm in too much pain in order to end the session. This happened during my third session with V3. The second session was pretty much like the third session. V3 was pushing really close to my body, breathing heavily into my ear. During the first session, V3 did leg stretches, pushing my leg towards my head. I had on a gown but no panties (was recently admitted to facility and did have their clothing). My gown was up to here (indicates groin). I felt uncomfortable. Surveyor asked R1 why they did not report this immediately, R1 said, I was molested by a family member when I was five years old. I asked (myself) am I overthinking this, am I letting my past get the best of me? I needed to process this. After the third session, but before I made the complaint, I was afraid I would run into V3. I told my father the day it happened. I told V4 (RN-Registered Nurse), two-three days after the incident. I told V4 that I had an interaction with V3 that made me feel uncomfortable. V4 did not probe further but did reassure me that I had the right to feel safe in the facility. I reported V3 to V5 (Guest Relations) the next day (after speaking with V4). R1 said, what V3 did was wrong. V3 took advantage over the situation, the power V3 held over me. It was disgusting, horrible. R1 was tearful at times during the interview. R1's abuse/neglect care plan (initiated/revised 02.09.2023) documents in part, R1 demonstrates difficulty in adjustment and general mood distress, observable signs of distress, verbal expressions of distress. Final incident report (02.17.2023) documents in part, R1 informed V1 and V9 (Police Detective) on 02.13.2023 that V3 provided R1 physical therapy on 01.31.2023 and R1 feels that V3 touched R1 inappropriately. The report does not document if allegation was substantiated or unsubstantiated. 2)R2's medical record (Face Sheet, MDS) documents R2 is a cognitively intact [AGE] year-old admitted to the facility on 04.23.2021 with diagnoses including, but not limited to: Major Depressive Disorder, Recurrent; Moderate Bipolar, Current Episode Depressed; Opioid Dependence, Other Sites of Candidiasis. On 02.26.2023 at 1:10 PM, R2 was observed sitting in their room. R2 was neat, clean and dressed appropriately, soft spoken (tracheostomy tube in place, which R2 covered with their finger in order to speak). R2 agreed to speak with surveyor. Surveyor asked R2 if they would tell surveyor about the incident between R2 and V3. R2 became upset, asking surveyor how they knew about the incident and said, I'm so tired of repeating it. How am I supposed to heal? Surveyor explained how they had knowledge of the incident and what the investigative process is in general, involved. R2 said, Okay, I'll talk to you, have a seat. R2 said, when I got here, they told me I needed therapy and I was like, okay. V7 (OT-Occupational Therapist) evaluated me. On 10.25.2022, I had a session with V3 in my room. The door was closed, the privacy curtain was drawn. I was in bed, facing the TV. I got up to walk V3 to the door because my room is my home. V3 threw me on the bed, I landed on all fours. I went to get up and V3 threw me on the bed again. V3 pulled my pants down and played with my nana (genital area) but did not put V3's fingers in my vagina. Then V3 took V3's pants down or off, I was facing the window. I said, what the f*** (V3), what are you doing to me? V3 just rammed into me. The next thing I knew, V3 was pulling out. I saw V3 was coming into a glove (exam glove). V3 said give me a minute then left. I stood there in shock. I said, I can't believe this s**t just happened to me. I didn't tell anyone. I just sat there for a good hour. I felt no one would believe me if I told them. I wrote down what happened and told V5 (Guest Relations) last week. The turning point was when I heard some lady down the hall was calling the police because V3 touched her inapproiately. A bulb went on. I was mad at myself because I let it happen. I felt relieved when I told V5. I had just blocked it out. R2 appeared anxious as evidenced by pacing at times, during the interview. R2's abuse/neglect care plan (initiated 02.08.2023, revised 02.09.2023) documents in part, R2 demonstrates difficulty in adjustment and general mood distress, observable signs of distress, verbal expressions of distress. Final incident report (02.14.2023) documents in part, R2 reported to V1 on 02.08.2023, that V3 allegedly raped R2 in R2's room on 10.25.2022 after providing R2 physical therapy session. The alleged employee has no known record of sexual abuse on file. MD, family, and Ombudsman were notified of the outcome of the outcome of the investigation and are happy with the outcome. The report does not document if allegation was substantiated or unsubstantiated. 3)R3's medical record (Face Sheet, MDS) document R3 is a moderately cognitively impaired [AGE] year-old admitted to the facility on 10.11.2022 with diagnoses including, but not limited to: Alzheimer's Disease, Dementia, Paranoid Schizophrenia with Agitation, Psychosis, and Neurocognitive Disorder. On 02.16.2023 at 2:25 PM, R3 was observed sitting on the edge of bed, eating candy and watching TV. R3 agreed to speak with surveyor about the incident involving V3. R3 was pleasant and spoke clearly and concisely during the interview. V3 said, V3 came here (in resident's room), giving me exercises. Then V3 wanted to unbuckle my bra. V3 said to me, let me unbuckle your bra so you can be more comfortable. I said, no, I'm comfortable. V3 did stop. It made me feel bad. I was going to tell V3 that V3 is a pervert, but I didn't want to hurt V3's feelings. This happened sometime last year in my room. V3 did come back another day and asked me if I wanted therapy. I said no, I didn't want V3 to come and give me therapy after that (incident). V3 would stand in front of me and put V3's hands like this (demonstrated putting hands into R3's sleeves) and massage my back. V3 would massage my back, my legs. I never told V3 that my shoulders hurt. No other therapist ever massaged me. The door was closed, the (privacy) curtain was drawn.I did not report this. I was afraid they would fire V3. I told my daughter a month later. She came to the facility and spoke with V1. On 02.21.2023 at 7:24 PM via Telephone, V11 (R3's Daughter) said, I bring R3 home on weekends. (R3) mentioned, was complaining of, a lot of pain, body hurting. R3 was receiving therapy in R3's room. R3 keeps R3's bra on all the time, even while sleeping. R3 told me V3 came into R3's room and asked to remove R3's bra. Can you remove it or can I remove it so you'll be more comfortable, V3 said. R3 told me V3 was standing so close R3 that R3 could feel V3's hard penis on R3's chest; R3's face was in V3's belly. R3 didn't report V3 because R3 was afraid V3 might get fired. The day after R3 told me this, I told the facility what R3 told me. I went to the facility. I met with V1 and other staff. I told them what R3 told me. R3's Trauma-Informed Care care plan (initiated/revised 12.01.2022) documents in part R3 demonstrates difficulty in adjustment and general mood distress at times. Facility final incident report (11.30.2022) documents in part, on 11.29.2022, R3 notified V1 that V3 attempted to unstrap R3's bra during Occupational Therapy session in September 2022. R3 did not remember the date, day or tine of alleged incident. The allegation of sexual abuse was not substantiated. Surveyor asked V1 if there had been any prior allegations of sexual abuse involving V3. V1 said yes, there was one last year. R3 alleged V3 attempted to remove R3's bra during therapy. The allegation was not substantiated. On 02.15.2023 at 2:44 PM, V8 (Regional Director of Rehab) said, when these allegations were brought to my attention, I informed the company's compliance department. They deferred the investigation to the facility; there is no internal investigation being conducted. V3 is on administrative leave pending outcome of facility's investigation. On 02.16.2023 at 3:31 PM, V5 (Guest Relations) said, R2 came to me some time last week and ask me what was going on in the therapy department, specifically V3. R2 said, V3 did me. I asked R2 what that meant. R2 responded V3 was in my room doing therapy with me; the door was closed. V3 was leaning over me, massaging my back. I stood up to walk V3 out, my room is like my home. V3 flipped R2 onto the bed, on R2's hands and knees, pulled R2's pants down. R2 said whoa, V3 responded, it's okay (R2), it will be over in a minute. The next thing I knew V3 was inside of me. I asked if V3 finished, R2 said yes. I asked if V3 came inside R2, R2 said in a glove. I reported it to V1. V5 said, on 02.03.2023 I came into work at 8:20 something. V14 (RN) informed me R1 needed to speak with me. I asked R1 what was wrong. R1 said during the 2nd and 3rd sessions of therapy with V3, R1 felt uncomfortable. R1 said V3 would lean over R1; V3 would go under R1's gown; R1 would put R1's arm across R1's chest as a barrier. V5 said Rl told V5 that V3 tried to put V3's knee in between R1's legs; R1 would try to keep R1's legs closed. On 02.16.2023 at 4:00 PM, V6 (Director of Rehab) said, R3's daughter mentioned sometime around Thanksgiving, that R3 was uncomfortable with V3's treatments. The daughter said R3 told her V3 may have pulled R3's bra down. I don't know what would have triggered that (V3 pulling down R3's bra). The next resident was R1. R1 said R1 felt uncomfortable during some sessions with V3; that V3 would stand too close. I don't know why V3 would massage R1 from the front. It made me feel uncomfortable when I heard that. On 2.22.2023 at 1:39 PM, V7 (Contract OTR-Occupational Therapist Registered and Licensed) reviewed the following documents: R1's Occupational Therapy Evaluations and Plan of Treatment (01.25.2022) and Treatment Encounter Notes (01.25.2022, 01.27.2022, 01.30.2022, 02.01.2022), R2's Occupational Therapy Evaluations and Plan of Treatments (10.17.2022) and Treatment Encounter Notes (10.18.2022, 10.19.2022, 10.25.2022-10.27.2022), and R3's Occupational Therapy Evaluations and Plan of Treatments (09.19.2022) and Treatment Encounter Notes (09.19.2022-09.22.2022, 09.26.2022, 09.27.2022, 09.29.2022, 09.30.2022). V7 said I performed Occupational Therapy Evaluations for R1, R2, and R3 and developed their Treatment Plans as well. V7 said that V7 did not include massage therapy as a treatment approach for R1, R2, or R3. V7 said that V3 did not document massage therapy as a therapeutic approach in R1's, R2's, or R3's Treatment Encounter Notes. V7 said, if the resident was sitting in a chair, shoulder massage should be performed while standing behind the resident; if the resident is sitting on the edge of the bed, shoulder massage should be performed while standing next to the resident. V7 said, I think it was unprofessional that V3 massaged the residents while standing in front of the. I need to have some professional distance between myself and the resident. 2)R2's medical record (Face Sheet, MDS) documents R2 is a cognitively intact [AGE] year-old admitted to the facility on 04.23.2021 with diagnoses including, but not limited to: Major Depressive Disorder, Recurrent; Moderate Bipolar, Current Episode Depressed; Opioid Dependence, Other Sites of Candidiasis. On 02.26.2023 at 1:10 PM, R2 was observed sitting in their room. R2 was neat, clean and dressed appropriately, soft spoken (tracheostomy tube in place, which R2 covered with their finger in order to speak). R2 agreed to speak with surveyor. Surveyor asked R2 if they would tell surveyor about the incident between R2 and V3. R2 became upset, asking surveyor how they knew about the incident and said, I'm so tired of repeating it .how am I supposed to heal? Surveyor explained how they had knowledge of the incident and what the investigative process, in general, involved. R2 said, Okay, I'll talk to you, have a seat. R2 said, when I got here, they told me I needed therapy and I was like, okay. V7 (OT-Occupational Therapist) evaluated me. On 10.25.2022, I had a session with V3 in my room. The door was closed, the privacy curtain was drawn. I was in bed, facing the TV. I got up to walk V3 to the door because my room is my home. V3 threw me on the bed, I landed on all fours. I went to get up and V3 threw me on the bed again. V3 pulled my pants down and played with my nana (genital area) but did not put V3's fingers in my vagina. Then V3 took V3's pants down or off, I was facing the window. I said, what the f*** (V3), what are you doing to me? V3 just rammed into me. The next thing I knew, V3 was pulling out. I saw V3 was coming into a glove (exam glove). V3 said give me a minute then left. I stood there in shock. I said, I can't believe this s**t just happened to me. I didn't tell anyone. I just sat there for a good hour. I felt no one would believe me if I told them. I wrote down what happened and told V5 (Guest Relations) last week. The turning point was when I heard some lady down the hall was calling the police because V3 touched her inapproiately. A bulb went on. I was mad at myself because I let it happen. I felt relieved when I told V5. I had just blocked it out. R2 appeared anxious as evidenced by pacing at times, during the interview. R2's abuse/neglect care plan (initiated 02.08.2023, revised 02.09.2023) documents in part, R2 demonstrates difficulty in adjustment and general mood distress, observable signs of distress, verbal expressions of distress. Final incident report (02.14.2023) documents in part, R2 reported to V1 on 02.08.2023, that V3 allegedly raped R2 in R2's room on 10.25.2022 after providing R2 physical therapy session. The alleged employee has no known record of sexual abuse on file. MD, family, and Ombudsman were notified of the outcome of the outcome of the investigation and are happy with the outcome. The report does not document if allegation was substantiated or unsubstantiated. 3)R3's medical record (Face Sheet, MDS) document R3 is a moderately cognitively impaired [AGE] year-old admitted to the facility on 10.11.2022 with diagnoses including, but not limited to: Alzheimer's Disease, Dementia, Paranoid Schizophrenia with Agitation, Psychosis, and Neurocognitive Disorder. On 02.16.2023 at 2:25 PM, R3 was observed sitting on the edge of bed, eating candy and watching TV. R3 agreed to speak with surveyor about the incident involving V3. R3 was pleasant and spoke clearly and concisely during the interview. V3 said, V3 came here (in resident's room), giving me exercises. Then V3 wanted to unbuckle my bra. V3 said to me, let me unbuckle your bra so you can be more comfortable. I said, no, I'm comfortable. V3 did stop. It made me feel bad. I was going to tell V3 that V3 is a pervert, but I didn't want to hurt V3's feelings. This happened sometime last year in my room. V3 did come back another day and asked me if I wanted therapy. I said no, I didn't want V3 to come and give me therapy after that (incident). V3 would stand in front of me and put V3's hands like this (demonstrated putting hands into R3's sleeves) and massage my back. V3 would massage my back, my legs. I never told V3 that my shoulders hurt. No other therapist ever massaged me. The door was closed, the (privacy) curtain was drawn I did not report this. I was afraid they would fire V3. I told my daughter a month later. She came to the facility and spoke with V1. On 02.21.2023 at 7:24 PM via Telephone, V11 (R3's Daughter) said, I bring R3 home on weekends. (R3) mentioned, was complaining of, a lot of pain, body hurting. R3 was receiving therapy in R3's room. R3 keeps R3's bra on all the time, even while sleeping. R3 told me V3 came into R3's room and asked to remove R3's bra. Can you remove it or can I remove it so you'll be more comfortable, V3 said. R3 told me V3 was standing so close R3 that R3 could feel V3's hard penis on R3's chest; R3's face was in V3's belly. R3 didn't report V3 because R3 was afraid V3 might get fired. The day after R3 told me this, I told the facility what R3 told me. I went to the facility. I met with V1 and other staff. I told them what R3 told me. R3's Trauma-Informed Care care plan (initiated/revised 12.01.2022) documents in part R3 demonstrates difficulty in adjustment and general mood distress at times. Facility final incident report (11.30.2022) documents in part, on 11.29.2022, R3 notified V1 that V3 attempted to unstrap R3's bra during Occupational Therapy session in September 2022. R3 did not remember the date, day or tine of alleged incident. The allegation of sexual abuse was not substantiated. On 02.15.2023 at 10:30 AM, V1 said, R1 reported to V1, around 02.08.2023, that R1 initially felt uncomfortable in therapy. A concern form was completed (dated 02.03.2023). Local police were notified but not IDPH because there was no allegation of abuse. An investigation was later initiated and reported to IDPH after R1 alleged V3 touched R1's vaginal area during therapy session. R2 reported to V1 on 02.08.2023 that V3 raped R2 in R2's room after a therapy session. V1 said R1's investigation was in progress; allegation would not be substantiated; R2's allegation was not substantiated. Surveyor asked V1 if there had been any prior allegations of sexual abuse involving V3. V1 said yes, there was one last year. R3 alleged V3 attempted to remove R3's bra during therapy. The allegation was not substantiated. On 02.16.2023 at 2:44 PM, V8 (Regional Director of Rehab) said, when these allegations were brought to my attention, I informed the company's compliance department. They deferred the investigation to the facility; there is no internal investigation being conducted. V3 is on administrative leave pending outcome of facility's investigation. On 02.16.2023 at 3:31 PM, V5 (Guest Relations) said, R2 came to me some time last week and ask me what was going on in the therapy department, specifically V3. R2 said, V3 did me. I asked R2 what that meant. R2 responded V3 was in my room doing therapy with me; the door was closed. V3 was leaning over me, massaging my back. I stood up to walk V3 out, my room is like my home. V3 flipped R2 onto the bed, on R2's hands and knees, pulled R2's pants down. R2 said whoa, V3 responded, it's okay (R2), it will be over in a minute. The next thing I knew V3 was inside of me. I asked if V3 finished, R2 said yes. I asked if V3 came inside R2, R2 said in a glove. I reported it to V1. V5 said, on 02.03.2023 I came into work at 8:20 something. V14 (RN) informed me R1 needed to speak with me. I asked R1 what was wrong. R1 said during the 2nd and 3rd sessions of therapy with V3, R1 felt uncomfortable. R1 said V3 would lean over R1; V3 would go under R1's gown; R1 would put R1's arm across R1's chest as a barrier. V5 said Rl told V5 that V3 tried to put V3's knee in between R1's legs; R1 would try to keep R1's legs closed. On 02.16.2023 at 4:00 PM, V6 (Director of Rehab) said, R3's daughter mentioned sometime around Thanksgiving, that R3 was uncomfortable with V3's treatments. The daughter said R3 told her V3 may have pulled R3's bra down. I don't know what would have triggered that (V3 pulling down R3's bra). The next resident was R1. R1 said R1 felt uncomfortable during some sessions with V3; that V3 would stand too close. I don't know why V3 would massage R1 from the front. It made me feel uncomfortable when I heard that. On 2.22.2023 at 1:39 PM, V7 (Contract OTR-Occupational Therapist Registered and Licensed) reviewed the following documents: R1's Occupational Therapy Evaluations and Plan of Treatment (01.25.2022) and Treatment Encounter Notes (01.25.2022, 01.27.2022, 01.30.2022, 02.01.2022), R2's Occupational Therapy Evaluations and Plan of Treatments (10.17.2022) and Treatment Encounter Notes (10.18.2022, 10.19.2022, 10.25.2022-10.27.2022), and R3's Occupational Therapy Evaluations and Plan of Treatments (09.19.2022) and Treatment Encounter Notes (09.19.2022-09.22.2022, 09.26.2022, 09.27.2022, 09.29.2022, 09.30.2022). V7 said I performed Occupational Therapy Evaluations for R1, R2, and R3 and developed their Treatment Plans as well. V7 said that V7 did not include massage therapy as a treatment approach for R1, R2, or R3. V7 said that V3 did not document massage therapy as a therapeutic approach in R1's, R2's, or R3's Treatment Encounter Notes. V7 said, if the resident was sitting in a chair, shoulder massage should be performed while standing behind the resident; if the resident is sitting on the edge of the bed, shoulder massage should be performed while standing next to the resident. V7 said, I think it was unprofessional that V3 massaged the residents while standing in front of the. I need to have some professional distance between myself and the resident. On 02.21.2023 at 10:10 AM via telephone, V3 said, I was performing my job responsibility with them (R1, R2, and R3). One young lady, R1, I guess, I'm not exactly sure what R1 said. R1 said I touched R1's vagina. I did not. I heard that a complaint was made. Why would do that? I responded to V1. When I start therapy (skilled sessions), look at the evaluation to see what the treatment plan is. I focus on short term goal and core strength is a big part of it. Core activation is a big part of my treatment method to promote sitting and standing balance. Yeah, so I do a lot of stretching of the shoulders, lower back. I did shoulder stretches and massage. I try to get them in the state of mind where they relax. It takes a little to get used to each other when I have a new patient until we figure it out. I'll do the neck and shoulder in front of her while she's sitting on the side of the bed; hamstrings, lower back and hip when supine in bed, I'm on the side of the bed. I didn't touch anybody inappropriately. I wasn't sexually inappropriate to any resident. The facility's Abuse Prevention and Reporting policy and procedures effective 11.26.16 and revision date 10.22.22 included the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. This will be done by but not limited to the following: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. -Sexual Abuse includes, but is not limited to, sexual coercion, or sexual assault including non-consensual or non-competent to consent sexual activity. Sexual abuse includes but is not limited to: Unwanted intimate touching of any kind especially of breasts or perineal area. Generally, sexual contact is nonconsensual if the resident either: appears to want the contact to occur but lacks the cognitive ability to consent; or does not want the contact to occur. Orientation and Annual Training of Employees to cover but not limited to the following: Sensitivity to resident rights and resident needs. Establishing a resident sensitive environment. Concern identification and follow-up: Resident and family concerns will be recorded, reviewed, addressed, and responded to using the facility's grievance procedures. Residents and families will be informed of the facility's grievance procedures. Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS (minimum data set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process staff will identify any problems. Staff Supervision: Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling. or impersonal care will be corrected as they occur. The term staff includes employees, consultants, contractors, volunteers and other caregivers who provide care and services to residents on behalf of the facility. The (Rehab Company) Employee Handbook (Version 2.2021) included the following: It is the policy of (Rehab Company) to assure that all residents be free from physical abuse, sexual abuse, emotional or psychological abuse, financial or material exploitation, neglect, abandonment, self-neglect, and involuntary seclusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement interventions to reduce the risk of accidents for 1 resident (R53) of 6 residents reviewed for falls. This failure resulted in R53 sustaining multiple falls and sustained a hip fracture. Findings include: On 12/06/22 at 12:35 PM, observed R53 pushing wheeled bed table from R53's room toward the doorway of the room wearing dark blue regular socks. There were no non-skid strips on the socks. On 12/06/22 at 12:40 PM, V18 (Restorative Aide) stated that R53 likes to push his over the bed table out of his room and down the hall. V18 stated R53 is sometimes difficult to redirect and is at high risk for falling. On 12/07/22 at 11:24 AM, V14 (MDS/Restorative Coordinator) stated that R53 has dementia and is very confused. V14 stated that R53 has a short attention span, is difficult to redirect and won't stay involved in activities. V14 stated that R53 has been having multiple falls back-to-back. V14 stated that any resident who has a fall is accessed for injury by the nurse on duty, and that the nurse on duty then notifies the doctor and family and completes a post fall evaluation form. V14 stated every fall is discussed with a team made of up the DON, Therapy Director and herself and care plans would then be modified. V14 stated all care plan interventions should be specific and evaluated for effectiveness. During interview on 12/08/22 at 09:42 PM, V18 stated that R53 is allowed to walk unassisted and that R53 is constantly getting up and down throughout the day unless he (R53) is sleeping. V18 stated that R53 does not want to sit down for very long and wants to be constantly walking around. V18 estimated R53 will sit down for a total of 15 minutes and then get up to walk around, and then sit back down for 15 minutes and then get back up again to walk around in his (R53)'s room and on the unit. V18 stated R53 has had multiple falls and that the staff tries to keep a closer eye on him (R53) but that it is hard because he (R53) is so active. V18 stated that she (V18) has known R53 for over one year and that R53's mental status has been decreasing. V18 stated that R53 is more forgetful, has greater difficulty understanding/following direction, and does not always respond to verbal cues. V18 stated R53 now requires extensive assistance with ADL care. V18 stated that interventions in place to help prevent R53 from falling include R53 wearing non-skid socks. On 12/08/22 at 9:54 AM V22 (Director of Rehabilitation) stated that R53 has a history of falls and that R53 was referred to physical and occupational therapy due to falls. Occupational therapy was discontinued 10/21/22, and physical therapy is still working with R53 on functional ambulation, balance, and transfers. On 12/8/22 at 12:20 PM, V3 (Acting Director of Nursing/Nurse Consultant) stated that anytime a resident has a fall an investigation needs to be done to look at reasons for the fall. V3 stated that The Morse Fall Scale Evaluation is completed by nursing after every fall and that once the root cause for the fall is determine then there should be intervention(s) updated on the resident's care plan. The interventions should be re-evaluated and adjusted as needed or as appropriate for that resident. V3 stated that some of the root causes of falls may be cognition based and that the overall goal of the facility is to prevent future falls. On 12/8/22 at 12:33 PM, V28 (Occupational Therapist) stated R53's falls are related to cognition, mood and behavior and that R53 won't stay in one place for long. V28 states R53's physician ordered for R53 to wear a helmet however R53 refused to wear it. On 12/8/22 at 2:19 PM, V14 (MDS/Restorative Coordinator) stated that R53 required a combination of supervision and limited assistance for bed mobility, transfer, walking in room and locomotion on the unit based on the MDS dated [DATE] which is before R53 started having multiple falls. V14 stated that based on the 09/09/22 Significant Change MDS R53's functional status changed from supervision and limited assistance to extensive assistance for bed mobility, transfers, walking in room, and locomotion on unit. V14 stated that the change in function was caused by the hip fracture injury sustained from the fall. V14 stated that a Morse Fall Scale Evaluation is to be completed by the nurse on duty after every fall and that it is the Director of Nursing responsibility to update the fall care plan within 24-72 hours after every fall. V14 stated that R53's fall on 8/22/22 was not care planned, only the intervention of putting R53 on the Falling Leaf Program was added. V14 stated that the Falling Leaf Program notifies the staff that that particular resident is at high risk for falls by using a visual picture of a leaf outside R53's door but that there are no specific interventions associated with this program. V14 stated there were no changes made to R53's fall care plans interventions after the following falls had occurred: 10/6/22, 10/20/22, 10/31/22, 11/4/22. On 12/8/22 at 3:10 PM, V27 (Nurse Practitioner) stated that R52 sustained a hip fracture from a fall and dislocated his finger due to falls. V27 stated that the injuries were directly related to fall and that the injuries caused a change in R53's condition. V27 stated that R53 is very confused and difficult to redirect. V27 stated that R53 does not have a walking problem and that the falls are attributed to R53's cognition related to dementia. V27 stated R53 is not aware of his (R53) surroundings, does not always respond to redirection and can yell and become physical with staff. V27 stated that R53 needs one on one supervision to prevent continued falls however the facility is not able to provide one on one supervision. R53 was admitted to the facility on [DATE] with diagnosis included but not limited to Unspecified Dementia, Unspecified Protein Calorie Malnutrition, Age Related Cataract Bilateral, Hallucinations. R53's care plan dated 11/2/20 documents R53 is at high risk for falls related to cognitive impairments secondary to dementia, generalized weakness, poor safety awareness and impulsive behavior. R53's MDS (Minimum Data Set) from 07/06/22 BIMS (Brief Interview for Mental Status) score is 06 indicating severe cognitive impairment. R53's MDS from 07/06/22 functional status documents in part R53 required supervision (encouragement, oversight or cueing) for walking in room and locomotion on unit and limited assistance (resident highly involved in activity, staff to provide non-weight-bearing assistance) for bed mobility, transfer and walk in corridor. Per record review, on 08/22/22 at 03:48 AM, R53 had an unwitnessed fall in his (R53)'s room while trying to go to the bathroom with no acute signs of injury. No imaging ordered. R53's fall risk care plan dated 11/02/20 documents in part as an intervention on 08/22/22 as Falling Leaf. Surveyor reviewed records and no other interventions were added at that time. No Morse Fall Scale Evaluation or Post Fall Observation Assessment on 08/22/22 or 08/23/22. Per record review on 08/30/22 at 7:20 AM, R53 had an unwitnessed fall in the hallway. Morse Scale Evaluation (post fall) completed on 08/30/22 documents in part R53's score as 65 indicating high risk. Radiology scans from 08/31/22 documented in part R53 complaining of pain and limping, and findings consistent with intertrochanteric fracture. R53 was sent to the emergency room (ER) for evaluation on 08/31/22. R53's hospital discharge records document in part diagnosis Closed Avulsion Fracture of Greater Trochanter of Femur, Left. R53 was not a surgical candidate and was transferred back to the facility on [DATE]. R53's care plan was updated on 08/31/22 to include in part, provide non-skid footwear, room close to nursing station for observation, and Physical and Occupational Therapy evaluation. On 09/01/22 R53 sustained another fall. Surveyor reviewed records and there was no documentation in progress notes about this fall on this date. At 21:52 on 09/01/22, a Morse Fall Scale Evaluation was completed by nursing post fall. Nurse Practitioner progress note on 09/05/22 documents in part, upon return to the facility from the hospital (8/31/22) the following day R53 had another fall. R53 had new care plan created on 09/01/22 due to significant change status related to left hip fracture. There were no changes made to the fall risk care plan at this time. R53's Significant Change MDS (Minimum Data Set) from 09/09/22 BIMS (Brief Interview for Mental Status) score is 05 indicating severe cognitive impairment. R53's MDS from 09/09/22 section G for functional status documents in part R53 required extensive assistance (staff providing weight-bearing support) walking in room, locomotion on unit, bed mobility, transfer, and walk in corridor. Per nursing progress notes on 09/27/22 at 18:10, R53 had a witnessed fall wherein R53 lost his balance, leaned against bathroom door, and slid down to the floor. Surveyor reviewed fall care plan and the only intervention added was redirection by staff as needed on 09/27/22. Note R53 already had an intervention in place which stated, redirect resident when noted to be agitated from 01/18/21. Per nursing progress notes on 09/29/22 at 08:12 AM, R53 had a witnessed fall in R53's room wherein he(R53) landed on his (R53)'s buttocks. Per nursing progress notes on 09/29/22 at 12:12, documents in part, R53 had another fall in the hallway wherein he (R53) lost his balance and fell to the floor. R53's left hand 4th finger noted to be abnormally aligned and moved left hand with some difficulty. R53 was transferred to the ER and returned with diagnosis Closed Dislocation of Finger of Left Hand, 4th finger with brace on 09/29/22 at 21:46. Surveyor reviewed fall care plan with new intervention added (10/4/22) for titration of Namenda. Per nursing progress notes on 10/06/22 at 17:30, documents in part R53 had a fall. Morse Fall Scale Evaluation (post fall) completed on 10/06/22. Surveyor reviewed fall care plan with no new interventions added. Per nursing process notes on 10/16/22 documents in part, R53 had a recent fall. Morse Fall Scale Evaluation (post fall) completed 10/17/22. Surveyor reviewed fall intervention care plan with new intervention added on 10/17/22 to remove tray immediately after all meals. Per nursing progress notes on 10/20/22 at 8:32, documents in part, R53 observed laying on the floor by the food of bed. Surveyor reviewed fall prevention care plan with no new interventions added. Per nursing process notes on 10/31/22 at 14:18, documents in part, R53 had a recent fall. Morse Fall Scale Evaluation (post fall) completed on 10/31/22. Surveyor reviewed fall prevention care plan with no new interventions added. Per nursing progress notes on 11/12/22 at 7:00, documents in part, R53 had a recent fall. Morse Fall Scale Evaluation (post fall) completed on 11/12/22. Surveyor reviewed fall prevention care plan with new intervention for helmet use added on 11/13/22. Per nursing progress notes on 11/14/22 at 3:10, documents in part, nursing heard a loud boom and observed resident laying on the floor next to the bed and body assessment completed with small laceration to the inside of the left ear and laceration to the left elbow and elbow was swollen. Surveyor reviewed fall prevention care plan with no new interventions added. Facility policy titled, Morse Fall Scale Evaluation and Falling Leaf Program dated 10/18/22 documents in part that the facility targets selected residents who are at risk for falls, fall risk is based on the fall risk factors, the fall scale is completed after a fall. Residents placed on the Falling Leaf Program may have a falling leaf placed outside their door, above their bed to visually identify the resident needing special precautions to avoid falls. Facility policy titled, Fall Prevention Program dated 11/21/17 documents in part, the purpose is to assure the safety of all residents in the facility, implementation of appropriate interventions to provide necessary supervision, care plan to address each fall, interventions are changed with each fall, as appropriate, and a Fall Risk Assessment will be performed after any fall incident.