Inspection·March 27, 2025

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. Based on interview and record review, the facility failed to ensure that two residents (R3 and R4) were free from physical abuse. This failure affected two residents (R3 and R4) reviewed for abuse, resulting in R4 sustaining a laceration above the right eye. Findings include: R4's Brief Interview for Mental Status (BIMS) dated 2/24/2025 documents R4 has a BIMS score of 15, which indicates R4's cognition is intact. On 3/25/2025 at 12:23pm R4 observed sitting in wheelchair in his room watching television. R4 alert and oriented times three. On 3/25/2025 at 12:25pm R4 was interviewed regarding the incident that occurred with his roommate (R3) on 3/1/2025. R4 stated we (R3 and I) had a little altercation. R4 stated I really can't remember what happened. R4 stated I do remember the both of us had to go out to the hospital. R4 stated I had a little cut above my right eye. R4 stated I was moved from the room on the first floor to this room on the second floor. R4 stated I don't know if my roommate had any injuries. R4 stated I have not seen my old roommate since the incident happened. R3's Brief Interview for Mental Status (BIMS) dated 2/18/2025 documents R3 has a BIMS score of 15, which indicates R3's cognition is intact. On 3/26/2025 at 12:34pm R3 observed walking the first-floor hallway, back to his room. R3 alert and oriented times three. R3 stated I remember the incident that occurred between me and R4 on 3/1/2025. R3 stated (R4) was my roommate. R3 stated someone sent (R4) a pizza. R3 stated (R4) offered me some slices of the pizza. R3 stated I took the pizza. R3 stated then (R4) offered me some garlic bread and I refused the garlic bread. R3 stated (R4) said to me eat this garlic bread and threw a piece of garlic bread at me; but the garlic bread missed hitting me. R3 stated after that I looked at (R4) and said to (R4), what are you a girl, are you going to cry? R3 stated when I said that to (R4), (R4) started rolling his wheelchair towards me and started to swing his arms at me. R3 stated (R4) managed to hit me in the upper chest and clipped me on the right side of my chin. R3 stated I did hit (R4) back. R3 stated the nurse came into our room after the incident and did not see what happened between us. R3 stated I did go out to the hospital and stayed at the hospital for a few hours. R3 stated when I returned from the hospital, the staff had moved R4 to another room on the second floor. R3 stated I think R4 was having a bad day. On 3/25/2025 at 3:05pm V4 (RN/Registered Nurse) was interviewed and stated I am familiar with R3 and R4. V4 stated I was working on 3/1/2025 on the first floor. V4 stated I was passing medications at the time. V4 stated the other nurse I was working with came to me and stated she heard some (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: 146001 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 146001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care International 4815 South Western Ave Chicago, IL 60609 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)