Health inspection·March 29, 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 ensure resident (R3) was free of abuse from (R2). This failure affected two of two (R2, R3) residents reviewed for abuse causing emotional distress. Findings include: According to the Electronic Health Record (EHR) R3 had diagnoses including osteoarthritis of knee, type 2 diabetes mellitus, morbid obesity, hyperlipidemia, sleep apnea, and long-term use of hypoglycemic agents. The Minimum Data Set (MDS) dated [DATE] showed R3's cognition was intact. On 3/28/2025 at 10:27 AM, R3 stated that sometime in the morning of February 26, 2025, while he was standing by the microwave in the dining room, R2 rolled in his wheelchair right past him so R3 started to move to the side to give way when R2 stated Don't move, it's not something I would have done to you Master. I was just reversing roles. R3 responded saying You mean, I'm supposed to be your slave? R3 stated that R2 alluded to him as a slave. R3 stated he was very upset and distraught about the incident so he went downstairs to the receptionist and was telling the receptionist what happened, and that the receptionist said that V2, Former Administrator, was not in the building yet but that she would inform him as soon as V2 arrives. On 3/28/2025 at 4:14 PM, V5, (Receptionist), confirmed that R3 had reported the incident to her on the same day. V5 stated that upon hearing R3's complaint, she immediately informed V2, (Former Administrator), when he arrived. V5 recalled that V2 assured her that he would speak with both R3 and R2 and address the issue. A progress note by V7, (Registered Nurse), dated 2/26/2025, indicated that R2 had been referred for an inpatient psychiatric evaluation due to escalating non-compliant behaviors and episodes of aggression. The note specifically mentioned that R2 had been vocalizing racial slurs and insults towards other residents, creating a significant safety concern. V7 also documented that R2 had verbalized self-harm and instigated altercations with other residents. The behavior was reported as alarming and required immediate assessment for inpatient psychiatric evaluation. On 3/28/2025 at 1:05 PM, V2, (Former Administrator), acknowledged that he had not been made aware of the allegations regarding R2's comments to R3. V2 stated that, had he known about the incident, it would have been treated as an abuse allegation, and an investigation would have been initiated immediately. However, no formal investigation or report regarding this specific incident was provided by the facility. (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 4 Event ID: 146058 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 146058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Evanston 1300 Oak Avenue Evanston, IL 60201 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)