Health inspection·April 17, 2025

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 resident has the right to be free of abuse in 3 of 5 residents (R1, R2 and R4) included in the sample reviewed for abuse. Findings include: 1. R1 is a [AGE] year old female with a diagnosis including Paranoid Schizophrenia, Diabetes 1, and Traumatic Amputation of right lower leg. R1 has a BIMS (Brief Interview for Mental Status) score of 15/15. R2 was first admitted to the facility on [DATE]. R2 is care planned for including moderate to intense anger, conflicts, difficult behavior with other persons. R2 is a [AGE] year old female with a diagnosis including Schizoaffective Disorder, Violent Behavior, Suicidal Ideations, Fibromyalgia and metabolic encephalopathy. R2 was first admitted to the facility on [DATE]. R2 has a BIMS (Brief Interview Of Mental Status ) Score of 15/15. Facility abuse investigation report, dated 2/21/25, shows R1 reported to administration she and R2 engaged in a physical altercation while on the elevator. Both residents have different versions of what transpired to cause the altercation. R1 alleges R2 entered the elevator and pushed her wheelchair. R1 states she told R2 not to touch her chair and they began exchanging words. R2 struck her. R2 alleges when she entered the elevator, R1 was staring at her she yelled out of frustration, and R1 started swinging her arms. Staff present on the unit at the time of the incident report hearing raised voices between the residents immediately intervening, but unable to separate the residents before the physical altercation ensued. Both residents were assessed. R2 was observed with scratches on her chest and shoulder. R1 was observed with two scratches to her right cheek. Both residents were treated by the nurse on duty. They both denied being in pain and stated they were fine and felt safe in the facility. The residents physicians were made aware of this allegation. R2 was sent to the hospital per physician orders for evaluation; she remains out of the facility. R1 is receiving counseling and is being closely monitored. There have been no further incidents. The residents care plan has been reviewed and updated as appropriate. The clients needs are being met. All appropriate parties have been notified. Check all that were completed or in progress at the time of report submission. The allegation of abuse was substantiated by facility. On 4/7/25 at 9:50AM, R1 stated, Yes, I was on the elevator, and (R2) pushed me with her elbow and scratched my face. I pushed her back. I got a small scratch on my face. I didn't go to the hospital or anything; I was fine. I went to the administrator and reported it. They did investigation. I haven't had any issues since. I am safe. Page 1 of 3 145765 145765 04/17/2025 Park View Rehab Center 5888 North Ridge Chicago, IL 60660

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/7/25 at 10:10AM, R2 stated, Yes, on the elevator; I bumped into (R1). She then pushed me back so I slapped her. I got scratches on me. The staff broke it up and they sent me to the hospital; I don't know why. Nothing happened at the hospital, and I was sent back. I have not had any issues since with (R1). I am safe here. On 4/7/25 at 12:46AM, V4 (Licensed Practical Nurse/LPN) stated, On the day of the incident, the elevator was going down, and the door opened. Both (R1) and (R2) were swinging arms and striking each other. I entered the elevator and stopped both of them. (R1) was removed from the elevator and (R2) continued going down on the elevator. The Administrator was notified. I assessed both residents who both had small scratches on them. (R1) was later moved from the 2nd floor to the 1st floor. There has been no further incidents between (R1) and (R2). On 4/7/25 at 11:40AM, V1 (Administrator/Abuse Prevention Coordinator) stated, There was an altercation between (R1) and (R2) . An investigation was initiated and the abuse prevention policy/protocol was followed. Both residents received scratches. Abuse to both (R1) and (R2) was substantiated. R1's 2/21/25 progress note states, Writer was told by staff that resident had physical altercation with a peer inside elevator, writer ask resident what happened she stated the peer was pushing her wheelchair she told her to stop, peer put her hand on her and she have to defend herself by fighting back, complete body assessment done found 2 scratches on resident right side face, Resident denies any pain and discomfort, no LOC (loss of consciousness), V/S (vital signs) T (temperature) 97.2, R (respirations) 20, P (pulse) 88, BP (blood pressure) 139/76, emergency contact on file state guardian (8xx-xxx-xxxx) called left massage on voicemail, doctor and psychiatrist made aware with order to send resident to hospital for evaluation, Resident insist she not going to hospital that she is fine, that she not in any distress, DON (Director of Nursing), administrator made aware, doctor and psychiatrist notified. Stated to document resident refused to go to hospital. Resident was instructed not to go to 2nd floor anymore, she verbalizes understanding. R2's 2/21/25 progress note states, Resident had a physical altercation in the elevator with peer. Resident and peer were noted swinging hands at each other in the elevator on the second floor. Staff separated both residents. Resident was transferred to the second floor. On assessment, resident is noted with scratches on the right upper back and right anterior upper arm. She is alert and oriented x3. Breathing is easy and non-labored. Pupils are equally round and reactive to light and accommodation. No change in LOC from baseline. Resident is able to move all extremities without pain. Cleanse with ns, pat dry and apply bacitracin oint. VS: bp=127/82, pr=73, res=18, temp=97.8, SPO2=97% RA. Notified resident's daughter . Notified Dr. and he ordered to send resident to hospital for Eval. Chicago police notified. Two policemen came to, identification (#) obtained report, simple battery as prescribed with case (#). 2. R4 is a [AGE] year old female with a diagnosis including Schizoaffective Disorder , Psychosis and Chronic Kidney Disease. R4 was first admitted to the facility on [DATE]. R4 has a BIMS (Brief Interview for Mental Status ) score of 14/15. R5 is a [AGE] year old female with a diagnosis including Schizoaffective Disorder BiPolar Type, Bipolar Disorder, Dementia and Psychosis. R5 was first admitted to the facility on [DATE]. R5 BIMS (Brief Interview for Mental Status) score is unscoreable. R5 is care planned for including behavioral symptoms related to Severe mental illness. Facility Abuse Prevention Investigation, dated 2/21/25, shows on 2/17/25, it was reported to 145765 Page 2 of 3 145765 04/17/2025 Park View Rehab Center 5888 North Ridge Chicago, IL 60660

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administration (R5) struck another resident (R4) without provocation. (R4) was interviewed by administration and reports she entered the dining room and sat at the table (R5) suddenly got up from her table and walked over to her swinging arms striking her in the head. Staff immediately intervened and separated the residents. Both residents were assessed by the nurse on duty there were no injuries, redness bruising, or swelling. Neither resident complained of pain. Nursing manager attempted to interview (R5), but she refused to answer any questions and became agitated with staff. The residents physicians were made aware of this allegation. (R5) was sent to the hospital per physician orders for evaluation she remains out of the facility. The residents care plan has been reviewed and updated as appropriate. The clients needs are being met. All appropriate parties have been notified. On 4/7/25 at 1:43PM, R4 stated, One day, I was in dining room when this crazy resident came at me with her arms flailing around. She hit me in the head lightly. It didn't hurt and it wasn't a big deal. The staff stopped it right away and it wasn't that big of a deal. They moved her to the third floor. I don't see her now. I am safe here in the facility. On 4/16/25 at 1:02PM, V5 (Housekeeping) stated, I was cleaning in hallway and when I went to look I saw (R4) get hit in the head. I yelled for the nurse and the CNA. We went to intervene. The CNA and Nurse separated both residents and put residents in their rooms. That is what I saw. I have been trained in abuse prevention. I attend regular inservices. On 4/16/25 at 12:20PM, V1 (Administrator/ Abuse Prevention Coordinator) stated, Abuse to (R4) by (R5) was substantiated. Facility Policy titled Abuse Prevention Policy states Residents have the right to be free from abuse, neglect, exploitation. misappropriation of property or mistreatment. 145765 Page 3 of 3