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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145885 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 145885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at the Boulevard 5905 West Washington 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)