Health inspection·May 9, 2025

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. Based on interview and record review the facility failed to keep two residents (R2 and R5) free from abuse of three reviewed for abuse in a total sample of nine residents. Residents Affected - Few Findings include: On 5/2/25 at 1:30 PM, R2 said R5 hit her in the head with an open milk carton and milk went everywhere. R2 said R5 and her popped each other. R2 was smoking a cigarette outside. R5 said R2 needs to do something with her hair and kept calling R2 big girl. R5 wouldn't leave R2 alone. R2 pushed R5's face, I muffed him. R5 threw an open milk carton in R2's face. R2 said there was no staff outside. V11 (Psychosocial Aide/Social Service Assistant) came outside after everything happened. R2 said R5 talks about her almost every day. R2 said they talk about her weight, hair, and how crazy she is. On 5/6/25 at 10:00 AM, V2 (Director of Nursing) stated the incident with R2 and R5 happened on the patio during smoking break. The police were not notified of the altercation between R2 and R5. R2 was sent out to the hospital. On 5/6/25 at 10:30 AM, R5 said the incident with R2 was during a smoke break. R5 and R2 were on the back patio. R5 said the staff was not outside with them. The staff was at the door on the inside of the building. R5 said R2 was asking everybody for a cigarette. R5 told R2 to stop asking for cigarettes. R2 was being annoying by asking the same people for cigarettes. R5 and R2 exchanged a couple words. R2 got up and hit R5 in the face. R5 hit R2 back in the face. Staff separated us and told us to stay apart, and only one of us should be on the patio to smoke at a time. We speak to each other now; everything is cool now. We apologized to each other. I feel safe. The police were not called. I did not go out to the hospital. They looked me over to see if I was injured. On 5/7/25, at 1:05 PM, V11 (Psychosocial Aide/Social Service Assistant) stated R2 and R5's altercation was during the early smoke time/break. I was outside monitoring. I heard verbal aggression between R2 and R5. They were calling each other B****. R5 said R2 was all up in his space. R2 said she can be wherever she wants. I separated them outside and monitored them. I did not observe physical aggression. R2 has good days and bad days. She has the tendency to invade people's space, but I don't think she means any harm. I have witnessed R2 being verbally aggressive to staff. R5 has no behaviors and is liked by the residents and staff. R2's face sheet list diagnoses that include but are not limited to schizophrenia, major depressive disorder. R2's BIMS (Brief Interview for Mental Status) is 15 indicating intact cognition. R2's Abuse Risk Review, 4/21/2025, indicates R2 has risk factor for aggression/combativeness. According to care plan, R2 displays disrespectful, combative, verbally aggressive behavior towards staff and peers Page 1 of 2 145970 145970 05/09/2025 Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649

F 0600 manifested by agitation and a pattern of situational and/or ineffective coping mechanisms. Level of Harm - Minimal harm or potential for actual harm R5's face sheet list diagnoses that include but are not limited to chronic obstructive pulmonary disease, end stage renal disease. R5's BIMS (Brief Interview for Mental Status) is 15 indicating intact cognition. R5's Abuse Risk Review, 4/21/2025, indicates R5 has risk factor for aggression/combativeness. According to care plan, R5 displays disrespectful, combative, verbally aggressive behavior towards staff and peers manifested by agitation and a pattern of situational and/or ineffective coping mechanisms. Residents Affected - Few Final Report Incident Description, dated 4/21/2025, documents in part: R1, now R5, reported that he and a co-resident R2, were involved in a physical altercation. R5 stated R2 became upset and hit him with an open hand. R5 stated he threw his carton of milk at R2. Based on the investigation, it was determined that R2 initiated the physical contact with R5. V11 (Psychosocial Aide/Social Service Assistant) witness statement reads in part: I observed R2 hit R5 and immediately intervened. Facility policy, Abuse Prevention and Reporting-Illinois, 10/24/22, documents in part: This facility affirms the right of our 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. 145970 Page 2 of 2