Health inspection·June 20, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent and protect residents from resident-to-resident verbal abuse. This failure affects one (R6) resident out of four residents reviewed for abuse in a total sample of six. As a result of this failure, R3 verbally abused R6 on 06/14/25. Findings include: On 06/17/2025, at 11:10 AM, R3 stepped out of the restroom ambulating without an assistive device, in no apparent distress. R3 agreed to speak to the surveyor by his bed. R3 stated that this past Sunday he was coming out of the bathroom. His previous roommate R6, was yelling at one of the housekeepers. R3 was yelling, why don't you clean my bed? Why do you clean R3's only? R3 stated that when he heard this R3 told R6 they do clean yours too. The housekeeper lady said, yes [NAME] I do it for you. R3 stated that R6 got in R3's face and said, you know what, I'm tired of you too, you are always on the phone. R3 stated I told him I have family I speak to, I don't bother you sir. R6 tried to get in my face. R3 stated that he is usually very patient, but at that moment, R3 stated that he became stressed and tensed. R3 stated I have to tell you the truth, I told him I am going to f*ck you up. R3 stated that R6 sat down after that and R3 did not get physically aggressive towards R6. R3 stated that he denied R6 hurting R3 in any way. R3 stated that staff separated them and R3 remained downstairs. R3 stated the only thing that made me mad is that he (R6) can walk and do everything. I said I can hit him, and he can fight back. On 06/18/2025 at 10:49 AM V6 (Housekeeping) stated that she was working on Saturday June 14th when R6 was really mad saying they never do his bed just because he is Mexican and that all the black people don't mind him when he needs something. V6 stated that after that R6 started arguing bad with R3. V6 stated that R6 told R3 that he (R6) was tired of R3 getting calls at 5:00AM and R6 is trying to sleep. V6 stated that R3 started getting mad and started saying I am going to kick his a**. V6 stated that she did not witness the residents being physically violent. V6 stated that R3 is usually really calm, but when they get R3 mad, R3 can get really mad. V6 stated R6 fights with everyone, they keep switching him to different floors. V6 stated R6 really has a big mouth, one time he was fighting with a Mexican lady, calling her names. He (R6) is alert and sometimes he fights with the nurses, when they give him his meds (medications) late. On 06/18/2025 at 3:44 PM R6 preferred to speak in Spanish, stated that R6 has been in the facility since December 14 and stated it has been a year and almost 7 months. R6 stated that he feels safe in the facility. R6 stated that he has had some issues with some residents. R6 stated one wanted to hit me, but they didn't let him. And another one, they kept calling him on his phone at 5:00 AM, and I (R6) was trying to rest. R6 stated that he had let the night shift nurse know, she was African Page 1 of 2 146001 146001 06/20/2025 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 American. R6 stated that the nurse said that she was going to talk to him (R3) that day. R6 stated that he understands a little of English. R6 stated that he cannot remember the name of the nurse that he informed. R6 stated later that day R3 was going to hit me, I don't remember the time, when he was going to hit me, they separated us. R6 stated I am a very nervous person; I need to sleep. R6 stated that R3 speaks Spanish too and is Latino too. R6 stated I sat down, and I didn't go to his face. R6 stated that R3 was taken away and R6 stated I am fine with this room and roommate. R3's face sheet documents R3 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to seizures, unspecified cirrhosis of liver, essential (primary) hypertension, adjustment disorder with mixed anxiety and depressed mood. R3's MDS/Minimum Data Set, dated [DATE] documents that R3 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R3 has intact cognitive response. R3's behavior note dated 06/14/2025 at 9:30AM documents in part nurse on duty was summon to resident room and having a verbal altercation with his roommate. Upon entering the room both the residents were screaming and using foul language towards each other. R3's current care plan documents in part R3 is at risk for abuse/neglect possibly r/t (related to) adjustment disorder with mixed, anxiety and depressed mood which can lead to agitation as well as health and none health related complaints. Interventions document in part provide reassurance when negative feelings occur. R6's face sheet documents R6 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to other seizures, anxiety disorder, unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, insomnia, unspecified, major depressive disorder. R6's MDS/Minimum Data Set, dated [DATE] documents that R6 has a BIMS/Brief Interview for Mental Status score of 07/15, indicating that R6 has impaired cognitive response. R6's behavior note dated 06/14/2025 at 9:16 AM documents in part nurse on duty was summon to resident room because resident was being verbally aggressive with his roommate. Upon entering the room both the residents were screaming and using foul language towards each other. R6's current care plan documents in part R6 is at risk for abuse/neglect r/t: Major Depressive disorder. I will be cared for in a safe manner and verbalize to staff any incidences of abuse or neglect through review date. Ensure safety if feeling unsafe. Observe resident when in company of peers. Facility document dated 03/01/21, titled abuse prevention program documents in part abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limited to: yelling or hovering over a resident, with the intent to intimidate; threatening residents. 146001 Page 2 of 2