Health inspection·April 2, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few movie with other residents that had nudity and violence that R2 did not like and R1 was verbally aggressive towards me when I tried to unplug the television. On 3/31/2025 at 3:32 PM V5 (Activity Director) said, R1 and R2 sometimes call out names to each other. R1 will call R2 fat and R2 will call R1 fat. R1 uses Spanish words toward R2 that I do not understand. But both are redirectable and will stop. During smoking time, there is always someone supervising. On 3/29/2025 R1 got agitated and was calling R2 names and R2 was calling R1 names. R1 pushed the astray towards him and the Aide pushed back R2. Both residents always resolved their differences, and it is an ongoing issue that got worse on 3/29/2025. I had to notify V1(Administrator) and report verbal abuse. On 04/01/2025 at 11:00 AM V7 (Activity Aide) I was doing activities over the weekend on Saturday 3/29/2025 when R1 and R2 were smoking outside. R1 and R2 started calling each name. Both called each other fat. R2 scooted over towards R1 during the argument and R2 grabbed the ashtray and placed it in the middle between them. I called my supervisor and was notified of the name calling and R2 was very upset with the name calling. Both residents have called fat names to each other in the past but would stop after being redirected, but not this time. I separated them and pushed out R2. R1 and R2 never touched themselves or got physical at all, only calling out fat to each other. On 04/01/2025 at 2:35 PM V8 (Registered Nurse) said, R1 was very aggressive after R1 cornered the activity aide during activity, I called V1 and called the nursing practitioner and received orders to transfer R1 out to be evaluated. R1 and R2 usually say profanity to each other, but usually, I can redirect them. That did not happen this weekend. R1 is vocal when someone doesn't agree with him. R1 will belittle others. On 3/31/2025 at 4:00 PM V1(Administrative) said, V5 (Activity Director) reported to me that R1 was verbally abusive to R2 during the smoke outing on 3/29/2025 at 3:45 PM, R2 reported that R1 was yelling and aggressive. I gave directions to separate them and place R1 on one-to-one monitoring. On Sunday 3/30/2025 during the movie, R2 said felt uncomfortable with the movie that was showing and told V6 to intervene. R1 took the remote control and V6 unplugged the television. R1 got out of control and got to V6's face and said, You better watch out. I contacted the nurse and the nurse said that R1's behaviors were escalating and out of control. R1 was evoking fear in others staff and residents and is refusing psychiatric consultations. An involuntary petition was created and R1 went to the hospital in the morning. Transportation was here at 08:00-10:30 AM and R1 was refusing to go to the hospital. R1 started yelling in the community room and the nurse called 911. The police came in and R1 agreed to go to the hospital to be evaluated. On 04/01/2025 at 10:37 R5 said that on 3/29/2025 heard R1 and R2 yelling at each other names like, you are fat, and the other said you are fat too. I was working on my computer when I heard R1 and R2 arguing. On 04/01/2025 at 10:45 AM R3 said, R1 and R2 are an ongoing issue here and the staff try to keep them separated and away from each other. R1 intimidates staff and residents. R1 and R2 call each other inappropriate names. On 04/01/2025 at 10:50 AM R4 said, R1 and R2 call out names to each other all the time and on 3/30/2025, R1 picked a movie with the guys and R2 did not like the movie selection because of the violence and nudity and had a disagreement. R1 calls R2 fat and chicharron in Spanish fat pig and R2 calls R1 fat. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146058 If continuation sheet Page 2 of 3 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 04/02/2025 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 04/01/2025 at 3:45 PM V9 (Administrator Preceptor) and V1(Administrator) both verbalized that they would have expected the facility staff to have placed interventions in place to separate R1 and R2 during activity to prevent name calling or interaction. On 4/1/2025 at 2:02 PM, V1 provided Facility Policy Titled, Abuse Policy and Prevention Program (dated 10/2022), includes: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual ' s age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, and saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Event ID: Facility ID: 146058 If continuation sheet Page 3 of 3