Health inspection·May 23, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep three residents (R2, R3, R4) free from abuse for three of four residents reviewed for abuse. This failure resulted in R2 losing a dental implant and a tooth, R3 sustaining an upper lip laceration, and R4 complaining of headache after being kicked to the head. Findings include: 1. R1's Resident Face Sheet documents diagnoses of schizoaffective disorder, bipolar type; anxiety disorder; and bipolar disorder. R1's Care Plan documents R1 experiences delusions (8/22/2024). V12's (Psychiatric Rehabilitation Services Coordinator) progress note for R1, dated 1/16/2025 10:31 PM, documents R1 was involved in a physical altercation with co-peer. R1 displayed agitated and aggressive behavior with delusions. Facility's Incident Report Form, dated 1/21/2025, documents an incident between R1 and R2 that occurred on 1/16/2025 at 9:10 PM. During facility's investigation, R2 stated R1 came into R2's room and hit R2 in the face, causing an implant tooth to fall off. R2 stated R1 was deeply delusional. On 5/21/2025 at 11:21 AM, R1 stated, [R2] instigated the fight. R1 stated R2 entered R1's room first trying to look for R5. R1 was unclear as to what happened next, but stated getting angry and following R2 back to R2's room. R1 stated, Whatever compelled me to do it, I punched [R2] in the mouth, and I guess [R2's] tooth fell out. On 5/21/2025 at 11:52 AM and during a follow-up interview at 1:45 PM, R5 stated R5 was hanging out with R1 earlier in the evening in the lobby. R1 and R5 were sitting at a table near the elevator talking about religious, magical, and spiritual stuff. R2 was sitting at a nearby table and told R5 to come sit with R2 instead. R5 stated R1 felt emotional that day and was upset that R5 was spending more time with R2 instead of R1. R5 stated R1 got up and left to go upstairs. R2 and R5 then went to R2's room to hang out. R5 stated, That's when [R1] came into [R2's] room and said something like 'you don't pay kindness with evilness.' Then [R1] punched [R2] in the face. R5 stated R1 punched R2 with a closed fist. On 5/21/2025 at 2:09 PM, V4 (Certified Nurse Aide) stated V4 was sitting in a chair near the nurses station when R2 stated, [R1] punched me, and I lost my tooth. V4 stated R2 had a little blood near the mouth. V4 recalls providing R2 with paper towel for R2's bleeding mouth and helping R2 locate (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: 146198 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 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)