Health inspection·May 19, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm 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 keep a resident free from staff to resident verbal abuse. Residents Affected - Few This affected 1 of 3 residents (R1) reviewed for verbal abuse. This failure resulted in R1 being yelled and cursed at by V2 (certified nurse aide) Findings Include: R1 is a [AGE] year-old with the following diagnosis: schizophrenia, schizoaffective disorder, and moderate intellectual disabilities. R1 admitted to the facility on [DATE] and discharged on 5/4/23. The Resident Abuse Investigation Form dated 5/2/23 documents V2 (Former CNA) was yelling at R1 stating 'Why are you throwing milk down the hall?' V3 (PRSC) heard V2 state, 'You don't throw fucking milk in here.' V3 immediately separated R1 from V2. V2 was asked to go to the lobby, and the incident was reported to V4 (DON) immediately. No injuries were noted to R1. R1 denied being yelled at. R1 denied V2 using profanity toward R1. V2 acknowledged yelling down the hallway, asking R1 why did R1 throw the milk however, V2 denied using profanity. V2 reported being frustrated that V2 was behind in morning tasks and felt overwhelmed with the back and forth. On 5/17/23 at 11:41AM, V2 stated, R1 was being aggressive and threw and open carton of milk in the hallway. I finished with another resident and approached R1. I went to ask R1 why R1 did that; to try to get an understanding. I did get upset and told R1 that R1 shouldn't do that again. We both cussed at each other. I said, If you do that again a resident would kick your ass. I don't recall saying the F-word. The only cuss word I said was ass to R1. They told me I was discharged for misconduct as far as behavior. Verbal abuse would be a degrading statement or an insensitive comment. After I walked away from R1, the DON asked me to come into her office. I told V4 what happened, and I said some things I shouldn't have said in the heat of the moment. On 5/17/23 at 12:38PM, V3 stated, I heard V2 yell out 'What are you throwing stuff for? V2 said, 'You don't throw fucking milk in here.' V2 voice was raised. I could hear V2 clear down the hall. I went and told the DON what happened. I did not hear R1 cussing at V2. V2 was the only one speaking when I was coming down the hall. This would be verbal because it is profanity and demoralizing. That is not how we show respect to each other ever. On 5/17/23 at 12:52PM, V4 stated, I was told that V2 had cussed at R1. I don't remember the exact words, but I believe it was over a carton of milk that was thrown. This would be verbal because it was words that were said to a resident that were not appropriate. Page 1 of 2 145947 145947 05/19/2023 Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/17/23 at 1:08PM, V1 (Administrator) stated, I was out of the building and the DON called me to tell me what happened. It sounded like verbal abuse to me from what I was told so I told V4 to send in any initial report. I talked with V3, and V3 heard V2 yell in the direction of R1 as he walked away, 'Why are you throwing fucking milk in here?' or something like that. V2 was let go not because it was abuse but because V2 was providing good customer service to the residents. No, staff should be talking like that in front of the residents. The Abuse/Neglect Screening dated 4/11/23 documents a score of 4, which indicates a moderate risk for abuse for R1. Indicators for abuse risk are history of substance abuse, psychiatric and/or present mental health diagnosis, diagnosis of depression and/or history of depressive illness, and history and presence of dysfunctional behavior. The Notice of Corrective Action Form dated 5/3/23 documents V2 was discharged from further employment at the facility, due to failing to follow rule number 12 on page 44 in the employee handbook. Rule 12 on page 44 is discourteous behavior to any resident or visitor. On 4/28/23, V2 displayed discourteous behavior toward R1, and due to the severity, V2 will be discharged . The policy titled, Abuse Prevention and Reporting - Illinois, dated 10/24/22 documents, Guidelines: This facility affirms the right of a residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility, therefore, prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Definitions: Abuse abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful inflection of injury, unreasonable, confinement, come in temptation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse may be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residence within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include but are not limited to harassing a resident; mocking, insulting, ridiculing; yelling, or hovering over a resident, with the intent, to intimidate; threatening residence, including, but not limited to, depriving a resident of care or withholding, a resident from contact with family and friends; and isolating, a resident from social interaction or activities. 145947 Page 2 of 2