Inspection·November 4, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's right arm near inside of wrist. R1 pointed to the empty bed next to R1 and stated, he grabbed my hand rough, and then R1 said, I don't know why. R1 did not remember the name of the resident who grabbed R1's hand. R1 stated he hurt me and stated look! and pointed to R1's arm where steri-strip was. On 11/03/24 at 11:52 AM, V4 (Agency Certified Nursing Assistant) stated around 9:30-10:00 AM on 10/26/24 V4 was providing ADL care to another resident when V4 heard a resident (R3) holler at V4 to come to a room because help was needed. V4 stated when V4 entered the room R1 was lying in bed and R2 was standing over R1 pointing his finger aggressively yelling you are a racist! MF***er, MF***er! my TV, my TV, you're a racist! V4 stated R2 was very mad and angry and was still yelling at R1 racist, MF***er, MF***er! even after V4 separated R1 and R2. V4 stated R2 reported that R1 was changing R2's television with R1's remote on purpose. V4 stated V4 did not see R2 grabbing R1's arm when V4 entered the room but after V4 separated R1 and R2, R1 lifted up R1's right hand and pointed at R1's right hand with his left finger to show V4 R1's arm. V4 stated that there was an opened area the size of nickel, where the skin was pulled back on R1's right arm, near R1's wrist area and it was red from a little bleeding, and it appeared to be a fresh wound. On 11/03/24 at 12:35 PM, R3 stated on 10/26/24 sometime in the morning R3 was walking down the hallway to buy an item at the vending machine and from the hallway saw R2 shaking R1 by the arm and R2 was yelling and swearing at R1 as R2 stood over R1. R3 stated R2 likes to get into with people over small stuff and can go off on people sometimes. On 11/03/24 at 5:50 PM, via phone interview V15 (Registered Nurse) stated V15 was working on 10/26/24 and was called into R1/R2's room around 9:30-10:00 AM. V15 stated V15 immediately went into R1/R2's room and saw that V4 (CNA) had already separated R1 and R2. V15 stated V15 could see R2 was sitting on R2's bed but R2 was upset and getting more and more agitated, V15 stated R2 kept talking and talking in a very angry tone and looked very upset and was still pointing at R1 and swearing and threatening R1. V15 stated R2 was immediately removed from the room and put under supervision with another staff member. V15 stated R1 told V15 that R2 came over and grabbed R1's arm and then R1 pointed to the cut on R1's arm. V15 stated V15 could see a cut on R1's right arm near the wrist and there was some bleeding. V15 stated the cut was a skin tear. V15 stated R1 appeared angry but not scared and told V15 R1 did not want to stay in the room with R2. V15 stated V15 reassured R1 that R1 is safe and R2 would not be allowed back into the room. V15 stated R2 was not allowed back into the room and was taken off the unit and kept busy until the ambulance came to pick R2 up which was around 1:00 PM. On 11/03/24 at 5:00 PM, via phone V12 (Maintenance Director) stated V12 was working last Saturday, 10/26/24 and was asked to do a 1:1 with R2. V12 stated initially R2 was growling, grumbling, muttering under his breath F*** these F******* people. V12 stated V12 asked R2 Is everything okay? and R2 responded with F*** these people and F*** everyone in here. On 11/03/24 at 5:21 PM, via phone interview V13 (Nursing Supervisor/Registered Nurse) stated V13 was the nursing supervisor working on 10/26/24 and when V13 entered R1's room R1 told V13 that R1 did not know why R2 was so mad and why R2 was standing over R1 saying words to R1 that R1 did not know. V13 stated R1 told V13 that R2 grabbed R1 's arm. V13 stated V13 saw a skin altercation on R1's right arm, near wrist area with minimal bleeding. V13 stated R1 was upset about the incident. V13 stated R1 denied pain and discomfort. R1's doctor, family and hospice company was notified. V13 stated V13 went to talk to R2 who had already been removed from the room and when V13 approached R2, R2 was so mad, and frustrated that R1 was changing R2's television with R1's remote and that is why R2 got so (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 2 of 3 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 - Minimal harm or potential for actual harm Residents Affected - Few mad at R1. V13 stated V13 could still see that R2 was still frustrated by the way R2 was talking about the situation and seemed to be getting more agitated, so V13 stopped asking questions to prevent further escalation. V13 stated R2's psych nurse practitioner and primary doctor was notified, and the recommendation was to send R2 out for further evaluation, so the facility initiated an involuntary petition. V13 stated R2 was sent out for verbally and physical aggression toward R1 and to prevent other injury or danger to other residents including himself and staff. On 11/03/24 at 5:08 PM, via phone interview V14 (Wound Care Nurse/Licensed Practical Nurse) stated V14 was told R1's roommate had attacked R1 and V14 was needed to conduct a skin assessment. V14 stated V14 observed R1 to have an open skin tear on R1's right forearm with minimal bleeding. V14 stated V14 cleaned the wound with normal saline and put a dry dressing on it to protect the area. On 11/03/24 at 4:05 PM, V1 (Administrator) stated V1 is the Abuse Coordinator for the facility and the goal of our abuse program is to keep all the residents free from abuse and to make sure they have a safe and comfortable place to live. V1 stated it is the resident's right to be free from abuse while they are living in the facility. V1 stated all residents are at risk for abuse and it is everyone's responsibility to prevent abuse. V1 stated the meaning of abuse is the willful or intentional act of harming someone. V1 stated V1 was made aware of the situation on 10/26/24 and an investigation was opened and submitted to Illinois Department of Health on 10/26/24 within the two-hour window. V1 stated R2 grabbing R1's arm caused harm to R1 by giving R1 a skin tear and that a skin tear is an injury. V1 stated R2 pointing R2's finger and yelling at R1 could be considered verbal abuse. V1 stated R2 was sent out because R2 continued to make verbally inappropriate comments and could not calm down so R2's doctor gave the order to send R2 to the hospital rather than to keep R2 here and potentially have another situation/outburst. Ombudsman Resident Rights for People in Long Term Care Facilities undated documents in part, your rights to safety. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Facility policy titled Abuse & Neglect dated 07/12/24 documents in part, it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires mental attention. Examples include hitting, slapping, kicking, squeezing, grabbing, pinching, poking twisting, and roughly handling. Verbal abuse includes but not limited to the use of oral, written, or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples include name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 3 of 3