Health inspection·March 25, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to meet the needs of residents by not responding to the nurse call activation in a timely manner in 3 of 10 residents included in the sample. Residents Affected - Few Findings include: Resident Council Meeting Minutes for January 2025 includes a statement that CNAs are not responding to call lights. They are constantly hiding, sleeping, and disappearing especially at meal time. Noted to have nasty dispositions. They are rude and hostile. Always talking on the phone. Concerns are listed every month no changes this far. Residents requesting for ice and water have to go find a CNA. Resident Council Meeting Minutes for February 2025 include statement Residents are not being changed on time. Call lights are on for a very long time. On 3/19/25 at 12:35AM R1 stated, There is a real problem with the CNAs here. They don't answer the nurse calls on any shift and it is worse on the night shift. Sometimes I activate the call and it can take two hours for a CNA to answer. Sometimes they never show up. This is ongoing and other residents are bringing up this issue constantly. On 3/19/25 at 12:50PM R3 stated, The CNAs do not answer the nurse calls. The nurse call takes too long when I activate it, sometimes two hours and that is unacceptable. There are plenty of CNAs they are just too slow. The CNAs are also very rude when I ask them about it. I need ADL care and sometimes lay in my urine for over two hours before getting changed. On 3/24/25 at 10:30AM surveyor entered the 2nd floor. The nurse station nurse call panel was beeping, and one room's signal light was on at the nurses station and above the room on ceiling of corridor. The room entrance was observed, and no staff entered the room to respond to the light during observations 10:30AM to 10:55AM. After inquiring V5 (LPN) and V6 (CNA) on the response of the call light, the nurse call light was still not answered. Surveyor left the floor approximately 11:15AM. On 3/24/25 at 10:55AM R6 stated, I activated my nurse call 1.5 to 2 hours ago and no one answered the call. I need ADL care. I watched two TV programs since the call was activated and no response. On 3/24/25 at 10:56AM V5 (LPN) stated, Yes, I am very busy here and that is why I haven't answered the call light. I am aware that the room nurse call light has been activated. V5 failed to answer the light or see that other staff would answer the call light. Page 1 of 4 145654 145654 03/25/2025 Landmark of Lincoln Park Rehabilitation and Nursin 735 West Diversey Chicago, IL 60614

F 0558 Level of Harm - Minimal harm or potential for actual harm On 3/24/25 at 10: 58AM V6 (CNA) stated, Yes, I am aware that the light has been going off. It goes off all the time. Yes, this is my assigned room. I am just too busy right now. V6 (CNA) failed to answer the call light after being interviewed and alerted about the room nurse call activation. Facility policy and procedure titled Call Lights state including: Residents Affected - Few Procedure: 1. All facility personnel must be aware of call lights at all times. 2. Answer all call lights promptly whether or not the staff person is assigned to the resident. 3. Answer all call lights in a prompt, calm, courteous manner ; turn off the call light as soon as possible. 4. Never make the resident feel you are too busy to give assistance; offer further assistance before you leave the room. 145654 Page 2 of 4 145654 03/25/2025 Landmark of Lincoln Park Rehabilitation and Nursin 735 West Diversey Chicago, IL 60614

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 ensure the right to be free of abuse in 2 (R1, R2) of 4 residents resulting in minor injury to R1 and R2. Findings include: R1 is a [AGE] year old female with a diagnosis including Diabetes 2, Anxiety Disorder, Heart Disease and Pyoderma Gangrenosum. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview for Mental Status) score of 15/15. R2 is a [AGE] year old female with a diagnosis including Diabetes 2, Chronic Respiratory Failure, Peripheral Vascular Disease and Congestive Heart Failure. R2 was first admitted to the facility on [DATE]. R2 has a BIMS (Brief Interview for Mental Status) score of 15/15. Facility Resident Abuse Investigation dated 2/21/25 shows R1 made contact with R2. Staff intervened and separated R1 and R2. Body assessment completed with no pain noted from both parties. R1 and R2 placed on increased monitoring and transferred out of facility for a psych evaluation. Family and MD notification made. R1 and R2 declined police involvement. Both parties feel safe in the facility. On 3/19/25 at 12:30PM R1 stated, Yes R2 and I were roommates. We were playing cards. I wanted the door left open and she didn't. We started arguing and we both made contact with each other. R2 scratched my forearm, and she got a small mark under her eye when I struck her in the face. The nurses came in right away and separated us. They assessed us and sent us both to the hospital for psych evaluations. We did not go to the hospital for any injuries. I was not afraid of her after it happened. I am not afraid now. We are good friends again and we play cards. They put us in different rooms. They also asked us if we wanted to file police reports and we both declined. I am safe here and the staff take good care of us. R1 progress note dated 2/22/25 shows R1 returned back from hospital in stable condition. Head to toe assessment completed with a superficial scratch to right arm, no active bleeding noted, no pain or swelling noted, area cleansed with NSS, and bacitracin ointment applied, resident expresses she feels safe at the facility. Resident denies emotional/mental distress at this time. Vitals wnl. Resident oriented to room [ROOM NUMBER] and remains on frequent monitoring. On 3/19/24 at 1PM R2 stated, I was roommates with R1. We were playing cards and we got into an argument over the doors to the room being closed. We had contact with each other. I got a very small mark under my eye when R1 hit my face. The staff quickly came in and separated us. We were both sent to the hospital with no injury. They sent us for a psych eval. We were both put in different rooms. The police didn't have to be involved. I never felt unsafe. We are friends now and I wish we were roommates again. We have not had any other issues and we still play cards. R2 progress note dated 2/22/25 shows R2 returned back from the hospital in stable condition. Head to Toe assessment completed with discoloration noted to the left eye. No swelling noted. No vision concerns. Slight redness under the left clavicle area. Denies pain. States that she feels safe in the facility. R2 expressed no mental distress at this time. MD updated and made aware of the residents return. Frequent monitoring remains implemented. 145654 Page 3 of 4 145654 03/25/2025 Landmark of Lincoln Park Rehabilitation and Nursin 735 West Diversey Chicago, IL 60614

F 0600 Level of Harm - Minimal harm or potential for actual harm On 3/24/25 at 10:16AM V4 (LPN) stated, I was charting and heard commotion coming from R1 and R2's room. I ran down and it was a physical altercation between R1 and R2. R1 was striking R2. I immediately separated R1 and R2. I called a code purple which is a behavior code. Other staff came in and took over. It was the end of my shift, and I left after the incident. Both R1 and R2 were sent to the hospital for a psych evaluation. Residents Affected - Few Facility Policy Titled Abuse Prevention Program shows: Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. 145654 Page 4 of 4