Health 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 Page 1 of 2 146001 146001 03/27/2025 Aperion Care International 4815 South Western Ave Chicago, IL 60609

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few commotion in R3 and R4's room. V4 stated I went into R3 and R4's room. V4 stated both R3 and R4 stated they were fighting, I separated R3 and R4. V4 stated I brought R4 back to the nurse's station to provide first aid because R4 had a laceration over his right eye. V4 stated as I was talking with R4, R4 would not give me a direct answer as to what happened between him and R3. V4 stated all R4 stated to me was to ask R3 about the incident. V4 stated when I questioned R3 about the incident, R3 stated R4 was getting into his personal space, and he told R4 to back away from him but R4 would not back away. V4 stated R3 did not have any injuries. V4 stated both R3 and R4 went out to the hospital. V4 stated when R4 returned from the hospital he was moved to a room on the second floor. On 3/25/2025 at 3:17pm V5 (CNA/Certified Nursing Assistant) stated I am familiar with R3 and R4. V5 stated I did work on the first floor on 3/1/2025, R3 and R4 were not on my caseload. V5 stated I went off the floor for my lunch break, when I returned to the floor, I was told R3 and R4 had had a fight. V5 stated I noticed R4 had a cut above his eye. V5 stated I can't remember if R3 had any injuries. V5 stated both R3 and R4 went out to the hospital. On 3/26/2025 at 12:43pm V2 (DON/Director of Nursing) stated I am familiar with R3 and R4. V2 stated from what I heard, I was not a witness, R3 and R4 got into it. R3 did not want to eat the garlic bread R4 was offering to him. V2 stated R4 threw the garlic bread at R3. V2 stated R4 then started to roll himself in the wheelchair toward R3, and R4 hit R3 in the chest. V2 stated none of the staff witnessed the incident. V2 stated the nurse on duty, V4(RN/Registered Nurse), stated she had just left out of their room and heard the commotion when returning to the medication cart, went back into the room and separated R3 and R4. V2 stated after the incident both R3 and R4 went to the hospital due to behaviors. The facility's Abuse Prevention and Reporting-Illinois Policy dated 10-24-22, which documents in part, the 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. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. 146001 Page 2 of 2