Health inspection·November 27, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their abuse policy by not preventing a resident to resident physical assault. This affected two of three residents (R2, R3) reviewed for physical abuse. This failure resulted in R2 being punched in the face, falling backwards, and being transferred to the hospital with a diagnosis of right frontal maxillary process fracture (upper jaw) Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder, dementia, weakness and age-related physical debility. R2's brief interview for mental status dated 11/19/24 documents a score of 4 which indicates severe cognitive impairment. R2's Screening for indicators of aggressive and/or harmful behaviors under abuse factors dated 8/20/24 documents a high risk for abuse due to the following: History of abuse prior to admission; factor increasing residents vulnerability(dementia, confusion, poor insight/poor judgement, poor communication, poor ambulation, frailty/weakness, history of exploitation, heavy care needs, unable to make needs known, psychotropic medications; psychiatric history; resident admits to history of mistreating others. R2's progress note dated 11/4/24 documents: Resident was walking in the hallway pushing his wheelchair when R3 went up to him and struck him on the right side of the face causing him to fall to the floor on his buttocks before staff could intervene. Laceration noted to R2's right inner eye/side of the nose. On 11/26/24 at 11:43AM, R2 who was alert and oriented at time of R2 said he got hit in the nose, lip and right eye by R3. R2 said R3 hit him unprovoked and from behind. R2 said the hit caused him to fall backwards and he had to go to the hospital. R2 was angry that R3 hurt him and wanted to hurt R3 back. On 11/26/24 2:37PM, V1(administrator) said he assisted with investigation for R2 and R3 altercation. R3 came out of the small dining room and approached coffee cart to serve himself coffee at breakfast. Staff stopped him and instructed him to wait for staff to serve the coffee. R3 became upset and swearing at staff. R2 was near R3 at this time. R2 thought R3 was swearing at him and swore back. R3 got upset and hit R2 in response. R2 sustained a maxillary fracture that did not require any further intervention. V1 said the incident was substantiated. R2 did not hit R3. R3 sucker punched R2 and then kept walking. (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: 145220 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 145220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Crest Health Care 3300 West 175th Street Hazel Crest, IL 60429 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)