Health inspection·August 5, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to immediately report an allegation of abuse and failed to protect one of two residents, (R1) reviewed for abuse. Findings include: Review of facility's abuse investigation (Investigation summary and conclusion) dated 6.16.2023 documents in part: On June 15. 2023, Dining Staff Member (V4-Server) made allegation that she saw CNA (V3-Certified Nursing Assistant) pinch the arm of resident (R1) in dining room last Saturday (6.10.2023). V4 who made the allegation did not report anything on day of the alleged incident but rather waited 5/several days, only expressing her concern, and reporting it when she saw resident rubbing his right arm. Employee believed that the alleged harm may still be happening given resident was rubbing his arm. At the time of interview, employee could not give details of her observation of the pinching except that it occurred after the resident slid off his chair and the pinching was done to his right arm. V3 (CNA) denied allegation and could not account for what could have been interpreted as pinching. On 8.5.2023 at 10:50 AM, V2 (DON-Director of Nursing) said, V4 (Server) did not report alleged incident until 7 days after alleged when she (V4) saw resident rubbing his upper arm. On 8.5.2023 at 1:18 PM, V1 (Executive Director) said V5 (Director of Pastoral Care and Mission Integration) texted her around 8:00 AM on 6.15.2023; I called him, got the basics. He said V4 (Server) reported that she observed V3 (CNA) pinch R1. V4 said it happened on Saturday. V4 (Server) reported it on 6.15.2023 because she saw R1 rubbing his arm and thought it was still happening (V3 still pinching R1). V4 (Server) told me that V3 (CNA) may have been punishing R1 because he kept sliding from his wheelchair. V4 (Server) stated she saw V4 (CNA) pinch him (R1). V1 (Executive Director) said any allegation or incident of abuse should be reported immediately to your supervisor. We interviewed V3 (CNA) in my office. V3 explained that it was Friday, not Saturday, that R1 was sliding on floor. She said she would never hurt a resident. I asked her if there was anything that could have been misconstrued as abuse, she said no. On 8.5.2023 at 1:56 PM, V5 (Director of Pastoral Care and Mission Integration) said, the server (V4) called me over and said, I know why he's (R1) rubbing his arm like that, the nurse (V3 CNA) from the overnight shift is pinching him. V4 (Server) reported to me on 6.15.2023 that incident had happened; she wasn't exactly clear when it did happen that day but probably within the last couple of days, I immediately reported to V1 (Executive Director), who asked me to ask a few more questions. V5 (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 3 Event ID: 146174 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 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)