Health inspection·June 16, 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. Based on interview and record review the facility failed to follow their abuse policy procedures and prevent a resident-to-resident physical abuse. This affected two of five residents (R3, R4) reviewed for abuse. This failure resulted in R4 slapping R3 in the face after R3 backed into R4 with a wheelchair. Findings include: 1.)R4's diagnoses include schizoaffective disorder bipolar type. R4's (3/28/25) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). R4's (10/21/24) care plan states resident has the potential to be physically/verbally aggressive related to poor impulse control, interventions: when the resident becomes agitated: intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. 2.) R3's diagnoses include schizophrenia. R3's (10/2/24) care plan includes risk for abuse, interventions: observe resident when in company of peers. R3's (6/3/25) BIMS determined a score of 15. The 5/2/25 initial facility reported incident states R3 was scratched by R4. Facility staff were present and intervened immediately. R3 was evaluated by Nursing staff and had minimal scratches on her right cheek with no other injuries. R3 rated her pain at a one. R4 was placed on 1:1 monitoring and petitioned out for a psychiatric evaluation. The 5/25/25 final facility reported incident affirms R3 was provided first aid for minor scratches to right cheek. On 6/10/25 at 4:12pm, surveyor inquired about the 5/2/25 incident. R3 stated (R4) was backing her wheelchair up and ran into my wheel. I said wait a minute and she (R4) hauled off and hit me in my face. I told her you ain't gonna get away with this and punched her in the face. She hit me again and I punched her in the eye as hard as I could. She grabbed a hold of my face, scratched me under my eye and on my nose. On 6/10/25 at 4:22pm, surveyor inquired about the 5/2/25 incident with R3. R4 proceeded to write Page 1 of 2 145197 145197 06/16/2025 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the following statement (due to unintelligible garbled speech) We had a fight about a month ago. She (R3) back into me with her wheelchair and I (R4) hit her on the face. On 6/12/25 at 1:33pm, surveyor inquired about the 5/2/25 incident V6 (Activities Aide) stated The incident happened in the dining room. R4 was trying to leave the dining room but R3 was in the way. So, R4 went to push R3's wheelchair (which was facing away from R4). R3 reached back with her arm, and I think she (R3) hit R4 because R4 turned around and started scratching up her (R3) face. R3 attempted to hit her (R4) back but I intervened. Surveyor inquired if R4 scratched R3 intentionally. V6 responded Yes. On 6/16/25 at 12:04pm, surveyor inquired about potential harm to a resident that gets hit in the face. V7 (Medical Director) stated It depends on the weight of the blow and the position of the patient it's a very subjective question for me, but if it's a point-blank hit in the face it could be bad. It's very difficult to tell. The abuse prevention policy (revised 10/24/22) states in part: physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. This facility desires to prevent abuse by establishing a resident sensitive environment. This will be accomplished by a comprehensive quality management approach involving the following: 1) 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, goals, and approaches, which would reduce the chances of abuse for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. 2.) 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. 145197 Page 2 of 2