Health inspection·December 19, 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 document review the facility failed to ensure resident is free from verbal abuse. This failure affected 1 ( R1) of 4 ( R1,R2,R3 and R4) residents reviewed for abuse. Findings include: R1 is a [AGE] year old female with a diagnosis including epilepsy , anxiety disorder and chronic embolism and thrombosis. Resident is alert and oriented x 3, able to make all needs known to staff. Resident is a max assist with all adl cares. Incontinent of bowel of bladder. Uses a manual wheelchair for ambulation. R1 has a BIMS ( Brief Interview Of Mental Status) Score of 13/15. R1 was first admitted to the facility on [DATE]. R1 is care planned for abuse revised (12/3/24) . R1 is assessed as moderate risk for abuse. On 12/17/24, at 12:59 PM, R1 stated I had an incident in October where a CNA (Certified Nursing Assistant) started cursing at me because I asked her to help another resident who needed it. The CNA got mad at me and started yelling at me. I reported it. I haven't seen her since. On 12/17/24, at 1:10 PM, R1 stated there was another incident this month when a CNA told me that I stink and I have to take a shower. I did not like that at all. Her (CNA) and I were the only people in my room at the time. I reported it to the staff. They investigated and the CNA is gone. Per review of facility abuse investigations show the following two abuse investigations were conducted concerning R1. Both were substantiated. Facility abuse investigation incident dated 10/27/24 ( final) shows : Based on written statements from residents ( R1 ) and several statements residents and staff members. An investigation was conducted by the Administrator and the incident is noted to be found. One resident stated in his statement that he thought it was two staff members about to fight until he looked out his bedroom door and saw that it was a resident ( R1 ) and a staff person arguing , the staff person ( V3 CNA ) was really angry. This writer tried to contact V3 ( C N A ) ,she returned the call and stated that the resident asked her to push her to the elevator and she told the resident that she had to stay at the nurses station. V3 stated that that R1 got upset and started cursing her out. V3 denied cursing at the resident despite several statements from other residents who claimed that they witnessed the altercation. This writer has asked for a written statement , but V3 has yet to present one. V3 was terminated. R1 was again asked about her safety: do you feel safe here? R1 stated that , of course I feel safe , I don't have a problem with anybody here. R1 was instructed to Page 1 of 2 145885 145885 12/19/2024 Complete Care at the Boulevard 5905 West Washington Chicago, IL 60644

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few inform staff whenever a situation comes up that needs staff intervention. R1 stated she would do so. Physician notified of results of investigation and no new orders other than to monitor. R1 representatives notified of the results of outcome of this investigation. The care plan and assessment were updated as appropriate. On 12/17/24, at 1:32 PM, V4 (CNA) stated in the hallway when R1 stopped me and said V3 (CNA) was yelling at her and called he a crippled b**** and she was going to beat R1s a**. I immediately reported the alleged incident to V1 ( Administrator) . On 12/17/24, at 1:50 PM, R3 stated yes about a month ago I heard 2 people cursing and yelling loud. I didn't go to my door because it sounded like they were about to fight. On 12/17/24, at 1:58 PM, R4 stated R1 and a CNA were arguing in the hallway calling each other bad names. The CNA said she isn't doing s*** and continuing to yell at R1. They did not hit each other . I haven't seen the CNA since then . I feel safe here. Facility final abuse investigation dated 11/28/24 shows based on written statement from R1 . R1 and alleged victim and statements from other residents and staff. The allegation of abuse is substantiated. R1 stated she was quite offended when V5 (CNA) said to her that she stinks and needed to take a shower. R1 stated she thinks V5 was trying to make her feel bad because she was not doing anything to help herself go home to be with daughter. However , per V5 written statement and verbal interview , she stated she has known the resident for years and that she would not do anything to abuse her. Nonetheless , according to Abuse Prevention Program that meets C M S requirement, Appendix PP and Final Rule , 81 Fed . Reg 68688-68872- Verbal abuse is the use of oral , written , or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within hearing distance, regardless of an individuals age , ability to understand, or disability. It is not uncommon for staff to know residents personally, but, in a nursing home setting , All residents must be treated respectfully. While the staff member may not have willfully spoken , the resident stated that she felt horrible about what the staff member said to her. V5 was terminated. On 12/18/24, at 11:00 AM, V1 (Administrator/Abuse Prevention Coordinator) stated I investigate all allegations of abuse to the residents. We follow out abuse prevention policy. We have a no tolerance for any abuse to the residents by staff. I investigated both allegations of verbal abuse to R1 on 11/28/24 and 12/18/24. Both allegations were substantiated and the CNAs were terminated from employment. Facility policy titled Abuse Prevention Program 2-2017 includes statement the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. 145885 Page 2 of 2