Health inspection·June 18, 2025

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 interviews and record review, the facility failed to ensure that three residents (R2, R4 and R6) were free from physical abuse. This failure resulted in R2, R4 and R6 being attacked by their roommates. R4 stated she does not feel safe. R6 stated R6 was upset and felt helpless. Findings include: 1.) R4 is [AGE] year-old with diagnosis including but not limited to: paraplegia, major depressive disorder, polyneuropathy, cerebral infarction and obesity. R4 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. R5 is [AGE] year-old with diagnosis including but not limited to, other specified disorders of bone, hypokalemia, multiple myeloma and type 2 diabetes mellitus. On 6/16/2025 at 1:36 PM, R4 stated R5 came at me with scissors while I was in bed. I pulled the call light for help, and R5 snatched the call light from me and begin to hit me with it. V9 (Restorative Aide) came in and took the scissors from her. R5 then pulled out a bigger pair of scissors once V9 left the room. I (R4) called for help again and the scissors were taken from her. She was moved to a different room, but I do not feel safe here. On 6/16/2025 at 1:44 PM, V9 (Restorative Aide) stated that she went into R5's room after she (R5) called for help and at that time, R4 had a pair of scissors in which she threw on the bed. V9 also said that she took R5's scissors to prevent R5 from stabbing R4 with the scissors, but found out later that the nurse had recovered a second pair of scissors. On 6/16/2025 at 1:53 PM, R5 stated that she did not want to talk about the incident that occurred between her and R4. On 6/17/2025 at 3:30 PM, V2 (Director of Nursing/DON) stated that she was made aware that R5 had allegedly attacked R4 with a call light and that two pair of scissors were taken from R5. R4's Care plan documents the following, R4 has a diagnosis of paraplegia; R4 is at risk for abuse and neglect related to paraplegia. Facility State Report of Abuse Allegation dated 6/4/2024 documents, alleged victims: R4; alleged Page 1 of 3 145337 145337 06/18/2025 Ryze on the Avenue 3400 South Indiana Chicago, IL 60616

F 0600 perpetrators: R5, a resident-to-resident altercation occurred. Level of Harm - Actual harm Event Investigation Questionnaire dated 6/4/2025 documents the following statement given by V9 (Restorative Aide), Bed one (R4) flagged me down as I was going pass. Bed two (R5) had bed one's call light in hand and I (V9) saw a pair of scissors on her (R5) bed. I took the scissors and told the nurse that there was a disagreement going on with two residents (R4 and R5). Residents Affected - Few 2.) R1 is [AGE] year-old with diagnosis including but not limited to: mood disorder, alcohol abuse, mixed anxiety disorder, restlessness and agitation. R1 is no longer a resident of the facility. R2 is [AGE] year-old with diagnosis including but not limited to: Alzheimer's disease, dementia, adult failure to thrive and generalized stomach pain. On 6/16/2025 at 2:04 PM, V10 (Licensed Practical Nurse/LPN) stated that she was the nurse that intervened when R3 reported the physical altercation between R1 and R2. At that time, V10 stated that she was unaware of how the altercation started, but that R1 and R2 were wrestling on a bed when she (V10) entered the bedroom. On 6/16/2025, R3 (R1 and R2's roommate) stated that R1 and R2 were fighting in the room and that she didn't know why. On 6/16/2025, R2 was not able to recall the details of her (R2) and R1's fight. R2's Care plan documents, potential for abuse and or neglect. Facility Reported Incident dated 4/22/2025 documents, time of incident: 10:30 AM; alleged victims: R1 and R2. The roommate (R3) alleged that a resident (R1) may have hit another resident (R2). The residents (R1 and R2) were separated, and the doctor and family notified. A body check was completed with noted redness. A police report filed. R2 and R1's Police report dated 4/22/2025 documents, simple battery. 3.) R6 is [AGE] year-old with diagnosis including but not limited to: legal blindness, pain in unspecified lower leg, dizziness, heart failure and chronic obstructive pulmonary disease. R6 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. R7 is [AGE] year-old with diagnosis including but not limited to: major depressive disorder, chronic pain, essential hypertension and insomnia. R7 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. On 6/17/2025 at 10:55 AM, R6 stated the following, R7 attacked me. He (R7) approached me and kicked me on the right leg. I (R6) was upset and felt helpless because I'm blind and couldn't defend myself at the time. I notified staff and staff removed R7 from the room. On 6/17/2025 at 11:15 AM, R7 stated that he kicked R6 because he (R7) was having a bad day. 145337 Page 2 of 3 145337 06/18/2025 Ryze on the Avenue 3400 South Indiana Chicago, IL 60616

F 0600 Level of Harm - Actual harm Residents Affected - Few On 6/18/2024 at 11:46 AM, V24 (Nurse Practitioner) Stated, Resident to resident abuse of any kind is not acceptable because the patient can be harmed physically and emotionally. We have to protect each resident that comes into the facility from abuse. On 6/18/2025 at 1:45 PM, V2 (DON) stated that Resident to Resident abuse was not acceptable in the facility. Facility reported incident titled State Report of Abuse Allegation dated 6/5/2025 at 4:30pm, documents in part, Alleged Victim is R6, and Alleged Perpetrator is R7, Resident to Resident altercation. Residents were immediately separated. Facility document titled Event Investigation Questionnaire, dated 6/5/2025 at 4:20 pm documents, R6 activated his call light and informed V23 (LPN) that R7 kicked him (R6). R7 was propelling to the elevator. R7 stated that he did kick R6 because he (R7) was being stupid. R6's progress notes dated 6/5/2025 at 4:30 pm, documents, R6 informed writer that R6 and R7 had a disagreement and R6 alleged that R7 kicked R6's right leg. R6's care plan printed 6/17/2025, documents, R6's Active Range of Motion (AROM) Focus: R6 has impaired functional mobility due to weakness/poor motivation/Cognitive. R6's care plan printed 6/17/2025, documents, R6's Abuse Focus: Risk for abuse and neglect related to Legal Blindness. Facility's Abuse Policy and Prevention Program documents, this facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. 145337 Page 3 of 3