Inspection·December 10, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure applied to two (R1, R2) of three residents reviewed for abuse. Findings include: R1 is [AGE] years old and have resided at the facility since 2016, past medical history includes: Disorganized Schizophrenia, type 2 diabetes, anemia, constipation, Tobacco use, elevated prostate specific antigen, vitamin D deficiency, bipolar disorder, etc. 12/09/2024 at 1:00PM, R1 was observed in his room, alert and oriented and recalled the day he had an altercation with another resident. R1 stated that R2 just walked up to him and hit him in the eye, he did not do anything to him and has never been involved in any altercation with R2 before. R2 is [AGE] years old with past medical history of Other Asthma, Alzheimer's disease with late onset, hyperlipidemia, essential primary hypertension, paranoid schizophrenia, vitamin D deficiency, bipolar disorder, unspecified dementia unspecified severity with other behavioral disturbance, schizoaffective disorder, etc. Per record review, R2 was sent to the hospital for evaluation after he hit R1 in the face for no reason and threatened to hit staff and co-peers as documented in progress note. Facility reported incident dated 11/25/2024 stated that at 8:41AM, R2 walked approximately 6 feet from his table to the table where R1 was sitting and struck R1 on his face without apparent provocation. Care plan for R2 initiated 10/29/2021 states that the resident displays conflictual, difficult behavior with other persons related to becoming physically aggressive towards other residents when agitated. Interventions include: The resident will comply with staff redirection & behave in a safe & respectful manner, (7) of seven (7) days per week by next review. Intervene when any inappropriate behavior is observed. Communicate assertively that the resident must exercise control over impulses & behavior (Social Skills training). Use creative refocusing to alter behavioral patterns if the person suffers from dementia (e.g., provide drawers, laundry basket for rummaging, provide a tube sock with a knot to focus the resident's attention). If the resident becomes preoccupied by hallucinations and/or delusional thoughts, do not attempt to talk him/her out of the delusions. Simply remind him/her that he/she is safe & secure in the facility environment. (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 12/10/2024 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)