Inspection·September 19, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few Service Director), on 09/09/25, V36 was cleaning a resident's room on the 4th floor when she heard a thud sound, so she went to see what was going on. V36 stated when she went to the 4-North Lounge, she saw R3 lying on his back on the floor and R6 was on top of R3. V36 stated she ran to get help. On 09/16/25 at 2:39 PM, V19 (Social Service Director) stated he was doing rounds on the 4th floor on 09/09/25 and while in the 4-North Lounge, he saw R6 walk into the dayroom aggressively. V19 remembers R3 was the only resident in the lounge at that time. V19 stated R6 was angry and walking quickly. V19 stated at that time, R3 in the process of getting up from his chair, and V19 saw R6 aggressively bump into R3 causing R3 to fall to the ground. V19 stated he asked R6 what was going on and R6 told V19, I'm mad, man. I'm mad. I'm pissed off and I don't want to talk. I'm pissed off. I'm pissed off. V19 stated R6 was not specifically going after R3, it is just that R3 was in the wrong place at the wrong time. V19 stated R6 was angry about something leading up to this, but he does not know what happened. V19 stated the goal is to always protect the residents to keep them safe and free from abuse. V19 stated R6 did make physical contact with R3, which is considered abuse.On 9/17/25 at 12:45 PM, V19 reenacted what he saw on 09/09/25 in the 4-North Lounge with the surveyor acting as R3 and V19 acting as R6. V19 stated it looked as if R3 was in the process of getting up from a chair when R6 made physical contact with R3. V19 acting as R6 charged head on directly toward surveyor as surveyor was attempting to get up from a chair. V19 demonstrated how the front of R6's right shoulder area made contact with R3's face. V19 stated this is what caused R3 to fall, but he not sure if R3 fell backwards or forward. V19 stated R6 was mad and there was some type of trigger that caused R6's anger, but he does not know what it was. V19 stated it was R6's anger that led to R6 willfully and aggressively hit R3 with force. On 09/16/25 at 1:20 pm, V13 (Certified Nursing Assistant) stated the incident happened in the 4-North Lounge right before lunch time on 09/09/25. V13 stated usually R3 sits in the 4-Southwest Lounge, but on that day when staff tried to get R3 to eat in the 4-Southwest Lounge, R3 wanted to go to the 4-North Lounge. V13 stated R3 was the only resident in the 4-North Lounge that she knows of, because all the other residents were in the 4-Southwest Lounge waiting for the lunch trays to arrive and be passed out. V13 stated when the incident occurred, she was sitting at the 4th floor nursing station with some of the other staff because they were waiting for the lunch trays to arrive. V13 stated this was around 12:00-12:30 PM. V13 stated one of the housekeepers was yelling fall, fall so they all got up and ran to the 4-North Lounge. V13 stated when she entered the 4-North Lounge, she saw R3 on the floor and could see that he was trying to get up. R6 was walking out of the 4-North Lounge, and she asked R6 what happened and R6 said to V13, I don't know what happened, he (R3) just fell on the floor.On 09/17/25 at 11:10 AM, V2 (Director of Nursing) stated on 09/09/25, he was called to go up to the unit, and R3 and R6 were already separated by the time V2 arrived on the unit. V2 stated he first went to check on R3 who was in his room with his nurse. V2 stated R3 had an abrasion under his eye with mild swelling. V2 stated R3 appeared calm but irritated and restless. V2 stated R3's doctor was notified and gave order to transfer him to the hospital. V2 stated when he saw R6 he was alert, agitated, irritable. V2 stated R6 said he bumped into R3. V2 stated he does not remember if R6 said it was intentional. V2 stated we think it was an accident because R6 was agitated and aggressively walking and bumped into R3. V2 stated he does not know why R6 was agitated and R6 could be unpredictable and demonstrate aggressive behaviors abruptly; they just happen, there is not necessarily a trigger. On 09/17/25 at 3:33 PM, V1 (Administrator) stated he is the Abuse Coordinator for the facility. V1 stated the goal is to keep the resident's safe and free from abuse. V1 stated it is the resident's rights to be free from abuse while they are residing in the facility and that all residents are at risk for abuse, and it is everyone's responsibility to prevent abuse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145244 If continuation sheet Page 2 of 4 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 09/19/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few V1 stated on 09/09/25, R6 walked into the room aggressively and quickly made contact with R3. V1 stated R3 fell straight backwards. V1 stated maybe when R3 fell, he made contact with the floor and that is how R3 injured his eye. V1 stated R3 was sent to the hospital and diagnosed with a fractured eye socket. V1 stated this injury was caused by contact with R6 and he does not know what R6's state of mind was when he made contact with R3. V1 stated it was an observed fall and R6 bumped into him, it was not willful intent, so therefore it was not abuse. V1 stated he does not think R6 had intent to harm R3; R6 happened to aggressively bump into R3 and that caused the injury to R3. V1 stated there is no video footage of the incident because the facility cameras have not been working for a while. V1 stated the facility did an immediate discharge for R6 because of the other incidences he was involved in and because R6 he made contact with a resident. V1 stated he did not want to take a chance R6 could do something like that again. On 09/18/25 at 10:52 AM, V34 (Nurse Practitioner) stated R3 sustained a fall due to an unintentional interaction with another resident and this fall is what caused R3's injury. V34 stated R3 was sent out to the hospital and was diagnosed with an orbital wall fracture of the right eye. V34 stated R3's eye area would have had to come in contact with something to cause the injury, but no one knows what that was because no one witnessed the fall. R3's Nurse's Note titled Fall-Initial Occurrence, dated 09/09/25, documented, resident had a witnessed fall on 09/09/25 12:30 PM in the 4-North Lounge. Resident was watching television in 4-North Lounge, then another resident who was agitated and walking fast toward the 4-North Lounge bumped into this resident resulting him losing his balance and fell on the floor. Witnessed fall, observed to have struck head. An abrasion under the eyes. Send to hospital for further evaluation per doctor's order.R3's hospital records, dated 09/09/25, documented, some concern from nursing staff, as well as myself, with lack of description of mechanism of injury. Nursing facility (name of facility) was called twice but was uncertain as to why patient had blood from his nose. After workup patient with orbital fractures and significant periorbital ecchymosis and periorbital swelling. As a mandated reporter, filed report through the Illinois Department of Public Health, for possible elder abuse. R3's Emergency Department Physical Exam comments documents ecchymosis to inferior aspect of right eye. Raccoon sign on the left eye. Blood from right nare. Contusion and ecchymosis overlying left forehead.R3's hospital records, dated 09/09/25, Quantitative Computed Tomography (CT) completed 09/09/25 impression right medial orbital and likely inferior orbital wall fractures. R6's Petition for Involuntary/Judicial Admission, dated 09/09/25, documents, resident presents with increased agitation and responding to internal stimuli resulting in psychomotor whereby resident was walking very fast towards 4-North Dining Room and bumped into other resident. Also, resident was verbally confrontational with staff, placed on 1:1 monitoring; unable to be redirected, refused a PRN (as needed), may pose as a threat to himself and others. R6's Nursing Progress Note, dated 09/10/25, documents resident is admitted to hospital with diagnosis: aggression. Facility's final incident report submitted to Illinois Department of Health on 09/16/25 listed R3 as the victim and R6 as the perpetrator. Incident category listed as Resident Abuse. Facility final incident report documents in part, based on the investigation that included interviews with staff and residents R6 was agitated and was walking swiftly into the 4-Floor Lounge when he accidentally bumped into R3, resulting with R3 losing his balance and falling to the floor.Facility provided document titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities dated 11/2018 which documents your rights to safety: you must not be abused, neglected, or exploited by anyone financially, physically, verbally, mentally or sexually. Facility provided policy titled Abuse Prevention and Reporting - Illinois reviewed 04/13/22 which documents the resident has the right to be free from abuse, neglect, misappropriation of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145244 If continuation sheet Page 3 of 4 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 09/19/2025 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 0600 resident property and exploitation. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145244 If continuation sheet Page 4 of 4