Inspection·April 14, 2025

F 0600 hitting me in the forehead a number of times. R2 affirmed he sustained a Bruised forehead. Level of Harm - Minimal harm or potential for actual harm On 4/10/25 at 12:13pm, V13 (Receptionist) stated, I heard a loud thump or somebody falling, so I just came out the door to see what it was, and (R2) was on the floor. (V1) was already there helping him up. I actually didn't see (R3) until after I called the code. He (R2) really didn't say much, but he looked hurt, cause (sic) he fell on the ground. V13 was asked about R3's behaviors. V13 replied, He always like agitated, saying 'I wanna go outside and I wanna smoke.' Most of the time he's upset, because he can't go outside or smoke when he wants to. Residents Affected - Few R3's diagnoses include schizophrenia, anxiety disorder, and altered mental status. On 4/10/25 at 12:20pm, V12 (Registered Nurse) was asked about R3's cognitivie status. V12 stated, He's alert and oriented times 4. He's delusional in his thoughts. Sometimes he will tell you; 'did you know I'm a graduate from UIC (University of Illinois at Chicago)? He's a catholic, and his mom used to do this and that, and the words sometimes don't match up with what he is saying. V12 about the 4/2/25 incident. V12 replied, When he (R3) got up to the unit he was monitored, but he was agitated and not redirectable. He was just so agitated and didn't want to talk. He just said that he got into some sort of altercation downstairs with another patient. On 4/10/25 at 12:46pm, V14 (Licensed Practical Nurse) stated, I only observed redness by the forehead. He (R2) reported pain of 2 by the forehead, and I gave him pain medication. On 4/14/25 at 12:31pm,V15, Physician, was asked about potential harm to a resident that was repeatedly punched in the head V15 stated, The possibility is the patient can have an injury to the brain. The abuse prevention policy (revised 4/13/22) states the resident has the right to be free from abuse. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or anguish. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145244 If continuation sheet Page 2 of 6 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 145244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Lakeshore 7200 North Sheridan Road Chicago, IL 60626 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)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based upon interview and record review, the facility failed to conduct a thorough investigation, and failed to determine the root cause of an altercation for two of four residents (R2, R3) reviewed for abuse. These failures have the potential to affect 241 residents. Residents Affected - Many Findings include: The (4/8/25) facility census includes 241 residents. The (4/2/25) initial FRI (Facility Reported Incident) states resident abuse. (R3) was agitated in the 1st floor common area. While (R2) was exiting the elevator, (R3) was about to enter the elevator. While (R3) was entering the elevator, he swiftly turned around pointing his finger at the elevator and his right hand made contact with (R2) forehead. Both residents were immediately separated. (R2) was noted with redness to his forehead. (R3) will be sent out for a psychiatric evaluation. R2's progress notes include (4/2/25), receptionist notified there is an altercation on the 1st floor between two residents. Nurse on duty performed a head-to-toe assessment observed redness on forehead, resident verbalized pain 2/10 on forehead. (4/3/25), zzz'Patient seen and examined today, noted to have a large bruise on the front of his head. Reports he got into an altercation with another resident. Patient reports he was repeatedly punched in the head.z' On 4/9/25 at 1:38pm, V1 (Administrator) stated, Basically one person was entering, and one person was exiting the elevator and they bumped into each other. (R3's) hand made contact with (R2's) forehead resulting in him (R2) falling to the ground. (R2) said it appeared that it was an accident when I followed-up with him later. (R2) had some redness on his forehead, and I believe when he fell, he hit the back of his head. I believe he also had a bump on the back of his head. (R3) was sent out to the hospital for psychiatric evaluation because he was visually agitated. We (facility) did an immediate discharge on (R3) because of agitation and safety reasons. V1 was asked if the facility reported incident was substantiated abuse. V1 responded, What it was is that they accidentally bumped into each other it wasn't substantiated because it wasn't abuse. V1 was asked for the definition of abuse. V1 replied, Willfully creating injury and harm to another resident or staff and its proven. On 4/8/25 at 2:05pm, V5 (Licensed Practical Nurse) was asked about R2's cognitive status. V5 stated, I would say he's alert and oriented times 3. R2's (3/13/25) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact). On 4/9/25 at 2:17pm, R2 was noted to be alert and oriented x3 ,and responded appropriately during interview. R2 stated, This guy (referring to R3) went out for a smoke break, and he cut in line. I told him he needed to get in line; that's all I said to him. He started talking not to me directly; he was just trying to get other people (residents) on his side, and they would just walk away from him. I don't think he was right in the head. Then, when I was standing by the elevator, he came up, and I don't remember exactly what he said to me, but he had something in his hand; it was silver; I thought he had a knife. He hit me in the head with a closed fist and I fell. He had fell on top of me and started hitting me in the forehead a number of times. It wasn't accidental, he didn't trip over nothing (sic); that's the only way it could have been an accident. R2 was asked if staff immediately intervened. R2 replied, Yes, the office is right here by the elevator; it was (V1) and a female (unknown receptionist) that pulled him off me. This was premeditated from what I can tell. They (staff) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145244 If continuation sheet Page 3 of 6 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 145244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Lakeshore 7200 North Sheridan Road Chicago, IL 60626 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)

F 0610 had the police come and see me I told them I want to press charges against him. Level of Harm - Minimal harm or potential for actual harm On 4/10/25 at 12:13pm, V13 (Receptionist) stated, I heard a loud thump or somebody falling, so I just came out the door to see what it was, and (R2) was on the floor. (V1) was already there helping him up. I actually didn't see (R3) until after I called the code. V13 was asked if R2 appeared injured. V13 responded, He (R2) really didn't say much, but he looked hurt cause (sic) he fell on the ground. Residents Affected - Many R3's diagnoses include schizophrenia, anxiety disorder, and altered mental status. On 4/10/25 at 12:20pm, V12 (Registered Nurse) stated, When he (R3) got up to the unit, he was monitored, but he was agitated and not redirectable. He was just so agitated and didn't want to talk. He just said that he got into some sort of altercation downstairs with another patient. On 4/10/25 at 12:46pm, V14 (Licensed Practical Nurse) was asked if R2 was injured post (4/2/25) altercation with R3. V14 stated, I only observed redness by the forehead. He (R2) reported pain of 2 by the forehead, and I gave him pain medication. V14 was asked if R2 stated it was an accident. V14 responded, He (R2) didn't tell me it was an accident. The (4/2/25) final FRI states based on follow-up interview (R2) stated, That other man bumped into me and swiped my forehead, I fell to the ground. I don't believe it was intentional. Staff assigned to the area did not witness the incident, however, they did make sure the residents were separated when they arrived. Other residents did not witness the incident. Based on the investigation (R2) bumped into (R3). In result of this (R3's) right hand made contact to (R2's) forehead also resulting in (R2) falling to the ground. Considering reasonable person concept, R3's agitation/involuntary discharge due to safety concerns, staff statements, and documentation R2 reported he was repeatedly punched in the head and sustained injuries, concluding the 4/2/25 incident was an accident and/or residents accidentally bumped into each other is incongruent with the findings. The abuse prevention policy (revised 4/13/22) states any incident or allegation involving abuse neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. The appointed investigator will at minimum, attempt to interview the person who reported the incident anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145244 If continuation sheet Page 4 of 6 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 145244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Lakeshore 7200 North Sheridan Road Chicago, IL 60626 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to revise comprehensive care plans for two of four residents (R2, R4) reviewed for abuse and community access. Findings include: 1. The ([DATE]) Final FRI (Facility Reported Incident) affirms (R3's) right hand made contact to (R2's) forehead. Plan of care will be updated as needed. R2's ([DATE]) progress notes state, patient seen and examined today, noted to have a large bruise on the front of his head. Reports he got into an altercation with another resident. Patient reports he was repeatedly punched in the head. R2's comprehensive care plan (received [DATE]) excludes risk for abuse and/or [DATE] abuse incident. On [DATE] at 1:56pm, V2 (Director of Nursing) was asked about requirements for comprehensive care plan development. V2 stated, Upon admission, we establish their needs especially for people who are coming from a psychiatric hospital. It's individualized and there's a requirement that if there's a significant change, we revise it. V2 was asked if R2's comprehensive care plan was updated post [DATE] incident. V2 reviewed R2's comprehensive care plan and responded, I don't see any care plan about abuse. V2 was asked if risk for abuse was included in R2's care plan. V2 replied, I didn't see it. On [DATE], IDPH (Illinois Department of Public Health) received allegations regarding facility abuse and confinement. R2's ([DATE]) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact). On [DATE] at 2:17pm, R2 was asked about concerns at the facility. R2 stated, The main concern is my community access. R2's ([DATE]) care plan includes supervised community access, Goal Target Date: [DATE] (expired over 3 weeks ago). On [DATE] at 12:27pm, V4 (Social Service Director) was asked when care plans are required to be reviewed and/or revised. V4 stated, Every quarter or with significant change. V4 was asked about concerns with R2's (expired) community access care plan. V4 responded, I see the issue is the target date is 3/18, it needs to be updated. 2. R4's ([DATE]) BIMS determined a score of 13. On [DATE] at 2:26pm, R4 was asked if R4 has community pass privileges. R4 stated No, they (staff) need to get me off restriction because there's nothing wrong with my feet. They claim the Doctor said something's wrong with my feet. They need to get me off of restriction as soon as possible. R4's care plan includes the following: ([DATE]) Resident has been determined by community access (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145244 If continuation sheet Page 5 of 6 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 145244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Lakeshore 7200 North Sheridan Road Chicago, IL 60626 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessment to be able to access the community independently, Goal Target Date: [DATE]. ([DATE]) Abuse/Neglect, Goal Target Date: [DATE] (expired over 2 months ago). On [DATE] at 12:37pm, V4 (Social Service Director) was asked about R4's community access. V4 stated, She had been out in the community, but she got some medical things going on. She needs to rest her legs and needs to be out with someone and be supervised at this point. V4 was asked about concerns with R4's (expired) community access care plan. V4 responded, The target date needs to be updated. V4 was asked if R4's community access care plan includes a hold or supervised access as warranted. V4 replied, It's not on the care plan, no. On [DATE] at 2:07pm, V2 (Director of Nursing) was asked about requirements for care plan revision. V2 stated, Upon admission, every quarterly and whenever there is a significant event that happens. V2 was asked about concerns with R4's (expired) Abuse/Neglect care plan. V2 responded, This target date is on [DATE]st, 2025. The comprehensive care plan policy (revised [DATE]) states a comprehensive care plan must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145244 If continuation sheet Page 6 of 6