Health inspection·November 22, 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 prevent and protect residents from resident-to-resident physical abuse. This failure affects one (R1) resident out of eight residents reviewed for abuse. As a result of this failure, R2 pushed R1 to the floor. Findings include: Facility reported incident/FRI dated 07/06/2024, documents that the facility reported an altercation between R1 and R2. FRI documents that R1 reported R2 pushed R1 and R1 fell to the floor. R1's face sheet documents that R1 is a [AGE] year-old female with diagnoses not limited to: schizophrenia, depressive disorder, recurrent, mild, hypothyroidism, essential (primary) hypertension. R1's MDS/Minimum Data Set, dated [DATE], documents that R1 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R1 is cognitively intact. R2's face sheet documents that R2 is a [AGE] year-old male with diagnoses not limited to: schizophrenia, restlessness and agitation. R2's MDS/Minimum Data Set, dated [DATE] documents that R2 has a BIMS/Brief Interview for Mental Status score of 09/15, indicating that R1 is moderate cognitively impaired. On 11/20/2024 at 4:29 PM via telephone V9 (Certified Nursing Assistant) stated that she did not witness the altercation between R1 and R2. V9 stated that she just came from the soiled room, I (V9) quickly got there. When I (V9) got there, R1 was on the floor, and the nurse was there. V9 stated that R2 was separated and sent to his room or nurse's station. On 11/20/2024 at 2:15 PM, V4 (Social Services Director) stated R2 doesn't speak too much; he just looks at you and nods at you. V4 stated that R1 reported to her that when she (R1) was walking away, he (R2) grabbed her (R1) and pushed her (R1) down. V4 reports that both residents (R1 and R2) are ambulatory residents. V4 stated with her (R1) behavior, she can provoke people. V4 reports that both have care plans in place regarding behavior and stated that both of their care plans were updated post the incident. On 11/20/24 at 3:23 PM V8 (Licensed Practical Nurse) stated that she was the nurse on duty the night shift that the incident occurred. V8 stated that in the morning about 5:30 AM, R1 came to the nurse's station for her morning medications. V8 proceeded to state R1 went back. After 5 minutes R1 came (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: 145479 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 145479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Health Care Center 1425 West Estes Avenue 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)