Inspection·February 7, 2025

F 0600 Minimum Data Set Section C (dated Dec. 12, 2024) documents that R2's Brief Interview for Mental Status (BIMS) score is 14, indicating that R2's cognition is intact. Level of Harm - Actual harm Residents Affected - Few Care plan (dated 01/14/2025) documents that R2 displays behavioral symptoms related to: Severe mental illness, poor and/or ineffective coping skills. These behavioral symptoms are manifested by verbal abuse/aggression, and disturbed sense of entitlement. On 02/06/2025, at 10:13 AM, V1 (administrator) stated, On 01/27/2025, it was reported to me that there was a loud commotion coming from R1 and R2's room. R1 and R2 were roommates at the time. V3 (registered nurse) went down the hallway to see what was going on. He explained to me that he saw R2 throw/push R1 from their bedroom into the hallway. V3 immediately intervened and escorted R1 to the nurse's station. V3 called the nursing supervisor and the nursing supervisor called me. We called the family; the physician and we called the police. The nursing supervisor went to speak to R2. R2 was informed that the police were called. R2 was notified that she would be petitioned and sent out to the hospital. R2 said that she refused to be sent to the hospital. R2 signed herself out against medical advice and left the facility. R1 said that R2 attacked R1 for no reason. V3 said that it appeared like R2 was going through some psychosis issues because R2 was acting bizarre and making weird statements that did not make sense. This could be the possible reason why she attacked R1. R1 had an abrasion under her eye. R1 said that R2 hit her, grabbed her and pushed her out of the room. R1 was kept safe away from R2. R1 was sent out to the hospital because she had an abrasion under her eye, and we were not sure if R2 hit R1 on the head. R1 is frail and R2 was of bigger frame, so that was an advantage over R1. On 02/06/2025, at 11:31 AM, during an interview with R1, surveyor observed an abrasion under R1's left eye, which appeared to be healing. R1 stated, On 01/27/2025, R2 was my roommate at the time. I was sitting on my bed, watching tv and doing puzzles. R2 said to me, B**** it's my room get out. Then R2 started attacking me. R2 started hitting me on my face and on my head and pulled my hair. R2 was beating me, and I fell to the floor. Then R2 grabbed me by my hair and called me names. R2 pulled me into the hallway by my hair. R2 went back into the room and slammed the door. The nurse came and asked me what happened. The nurse went into the room to talk to R2. The nurse gave me gauze to wipe my face and the nurse took me to the nursing station and called the social worker. My family, the physician and the police were notified. I was sent to the hospital because I was bleeding. I had a cut under my eye. I was examined in the hospital, and I received a tetanus shot just in case due to the scratches. R2 attacked me for absolutely no reason. I never provoked R2 in any way. R2 and I never had any issues in the past prior to the physical attack. I want to press charges against R2 but she left before the police came and now they cannot find her. On 02/06/2025, at 2:39 PM, V3 (registered nurse) stated, On 01/27/2025, R2 came and told me that she wanted to change rooms because she did not like her roommate. When I asked R2 what her issue was with her roommate, R2 said that she did not have to explain herself to me. I told her that social services handled room changes and since it was still relatively early, she can still talk to social services. R2 did not want to do that and said to me, What if I go in there and beat the woman up. I told her that she should not do that because then I would have to call the police. She left to go to her room, and she came back a short while later and called her mom. R2 started to complain to her mom that she was mad at her roommate and that she was going to do something to her roommate. R2 slammed the phone and went to her room and started knocking things down to the floor on her way to her room. I figured that she was going to do something to her roommate because R2 was upset. I got on the phone with social services to let them know that there is an incident possibly brewing and that the social worker needed to come up. In the middle of that phone call, I heard yelling and commotion in R1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145834 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 145834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Oasis, The 901 South Austin Blvd Chicago, IL 60644 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 - Actual harm Residents Affected - Few and R2's room. I went to the room, and I saw R2 tossing R1 out of the room. R2 tossed R1 into the hallway with a lot of force, holding R1 by her pants. I separated R1 and R2 by getting in between them. Social services came up also and I took R1 by the nursing station. I tended to R1's laceration under her left eye because it was bleeding. R2 left against medical advice from the facility before the police got there. R1 was sent to the hospital for evaluation for the laceration under her eye. R1's Progress Note (dated 01/27/2025) documents, While on the phone with social services at start of this incident. Writer heard yelling coming from the residents' room. Writer went to the room and saw R1's roommate holding her by her hair and back of her pants tossing her out into the hallway. Writer stood between the two residents to prevent further assault until social services arrived. Residents separated; vitals taken. R1 stated she did not hit her head. A small 1 centimeter laceration was noted under the left eye. Writer dressed the wound with gauze. There was minor bleeding. R1 was medicated with Tylenol for pain. R1's Progress Note (dated 01/28/2025) documents, Received report from nurse at community hospital. CT scan done, no fracture. Laceration treated. Awaiting to transport resident back to facility. R1's Progress Note (dated 01/28/2025) documents, Resident has a laceration to left eyebrow, resident will receive wound care. Physician notified; new orders carried out. R2's Progress Note (dated 01/27/2025) documents, R2 came to nursing station complaining that she wanted a new room because she did not like her roommate. Writer informed her that social services handled all room changes and she could consult with them as they had not left for the day. She got increasingly upset and wanted something done now. Writer asked the resident what the issue was. R2 stated I don't have to explain anything to you. Writer informed her again that social services can help her. She then stated; What if I just go beat her a**. Writer informed the resident that would be a bad idea because of the possibility of police involvement and expulsion from the facility. R2 came back to nursing station and called her mother telling her that she was going to attack her roommate. She began pushing items off the counter and knocking CNA's (Certiified Nursing Assistant) belongings on the floor on her way back to her room. Writer called social services to inform them of the situation and impending issue. While on the phone with social services, writer heard yelling and items falling coming from residents' room. Writer went to room and saw R2 holding her roommate by her hair and back of her pants tossing her out into the hallway. Writer stood between the two residents to prevent further assault until social services arrived. The residents were then separated. R2 was in the care of social services. R2 chose to sign out AMA (Against Medical Advice). Family stated to call her when R2 returns. Received police report number. Resident gone when Chicago Police Department & EMS Arrived. R1's emergency room Patient Discharge Summary (dated 01/28/2025) documents in part: Chief complaint/diagnosis: Assault. Discharge diagnoses: Acute head trauma/ Acute knee pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145834 If continuation sheet Page 3 of 3