Health inspection·June 5, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few history of substance abuse? She answered yes and in response to the to the question which one? Regarding substance use she answered, all of them. R12's Nurse Practitioner Progress note dated [DATE] documents she is a [AGE] year-old woman admitted to the facility on [DATE], with chronic diagnoses of Drug Use Disorders and Depression. R12's Preadmission Screening and Resident Review dated [DATE] documents she has been to the Behavioral Health/Substance Abuse Treatment Center for cocaine detox and rehab. R12's progress note dated [DATE] created by V21 (Licensed Clinical Social Worker) documents resident has a history of alcoholism and drug addiction (marijuana and cocaine). On [DATE] at 1:36 PM V18 (Licensed Practical Nurse/LPN) confirmed she responded to R13's room on [DATE] when R13 informed her that something was wrong with R12. When V18 arrived at the room, she observed R12 was unresponsive, laying across R13's bed and V23 (Certified Nursing Assistant/CNA) helped get R12 to the floor. V18 stated she performed a sternum rub on R12, R12 still had a pulse and was slowly trying to open her eyes but she still wasn't responding as normal. V18 stated R12's oxygen levels were dropping so we applied oxygen and once she placed the non-rebreather mask on R12 she had already grabbed Narcan (Opioid Antagonist) just in case. V18 stated she had just talked to R12 at 8:30 or 9 o'clock PM and she wasn't in that condition. V18 stated R12's eyes were rolling into the back of her head and R13 said he thought she had something. V18 stated R12's oxygen level was at like 82%. V18 said she used Narcan because one of the residents said they saw R12 coming out of another resident's room, and she doesn't visit everyone. The only room she ever sees R12 in is her room or in the resident's room she calls her boyfriend. V18 stated when the first Narcan dose was administered R12 slowly came back but not right away. Then when she gave R12 the second dose, her eyes opened, and she came back to us. V18 stated she still had oxygen on R12. By that time the paramedics arrived, and the police came, and they asked R12 in the presence of the paramedics did she take anything or have anything, and she said no it wasn't a pill. V18 stated R12 was asked if it was it a powdery substance that she took and she told the paramedics yes and began throwing up. V18 stated R12 gave the police the name of the resident's room she was in. V18 stated she went with the police to that resident, and he denied having anything. V18 stated the resident was R8 and the police advised they could not search his room because it was illegal. When asked by the surveyor if she or anyone else had R8 tested for drugs V18 stated that on the day of the incident she called V2 (Director of Nursing) and was told the social worker will follow up with R8 in the morning. When asked by the surveyor if any of the administrative or management staff followed up with her and asked any questions about the incident V18 stated on the day of the incident she called and spoke with V2 and called V1 (Administrator) who advised her to notify V24 (Nurse Consultant) and she then notified V24. When asked again by the surveyor if any of the administrative or management staff followed up with her and asked her any questions about the incident V18 stated all three managers did check on her and V23 about their well-being soon after the incident because it was a traumatic experience that she had never been through. V18 stated they gave her the next day off. V18 stated R13 is always in his room, and she has never seen him go out of the facility. V18 stated on that night that R8 was in his room the majority of the night. V18 stated this incident happened at approximately 9:40 PM. V18 stated she had not observed any abnormal behaviors from R8, R12, or R13 that night prior to the incident. V18 stated she is unaware if any drug testing was done on R8. V18 stated V25 (Registered Nurse) was also working during the incident and assisted her. R12's progress note dated [DATE] at 9:42PM created by V18 (LPN) documents she was visiting with a friend in his room, peer came to desk to get nurse stating, She's not responding to me. Writer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 2 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few entered peers room noticed a change of condition with patient not responding appropriately. Vital Signs noted oxygen at 82%. Writer applied oxygen at 5L via non-rebreather mask. Oxygen saturation increased to 92%. Narcan (Opioid Antagonist) administered twice, 911 called. Fellow co-workers assisted with patients care. At 9:50 PM it was documented that 911 paramedics arrived at facility to assess patient's status and scenario. 911 took over CPR (Cardiopulmonary Resuscitation). At 10:00 PM a late entry documented R12 discharged to the hospital on [DATE] at 9:42 PM; Reason for transfer: Patient not responding appropriately at her normal. At 10:10 PM it was documented patient being transported to the Hospital emergency room for further evaluation. R12's progress note dated [DATE] created by V31 (LPN) documents resident admitted to the Hospital with diagnosis of Overdose and Pneumonia. On [DATE] at 10:04 AM R13 stated on the day when R12 was sent to the hospital when he reported to V18 (LPN) that something was wrong with R12. R12 was sprawled out on the floor in his room and when she was revived there were multiple people standing around her and he asked her if someone gave her something. R13 stated R12 initially said she couldn't remember but then he pressed her further she finally admitted she got it from R8. R13 stated he went down to R8's room and asked him if he gave R12 anything and he denied it, however R13 stated he saw the bag in R8's hand. R13 stated he saw a dope bag in R8's hand with some of the substance in it and he was nodding off in his wheelchair. R13 stated he sometimes sees R8 nodding off in a way the indicates he may have used drugs. When asked by the surveyor if V1 (Administrator), V32 (Assistant Administrator), V2 (Director of Nursing) or V19 (Assistant Director of Nursing) came and asked him any questions about the incident after it happened R13 said no. R13 stated the next night after the incident V18 worked and she asked him if knew where R12 got the drugs from, and he told her R8. R13 stated V18 told him they would get R8 out of the facility. R13 stated the police came and didn't do anything and R8 is still here. R13 is a [AGE] year-old male with diagnosis not limited to history of Stroke, Dependence on Renal Dialysis, and End stage renal disease. R13 was admitted to the facility [DATE]. R12's progress note dated [DATE] documents resident is readmitted to the facility day 1 of 3. Resident transferred from Hospital related to overdose and pneumonia. On [DATE] at 12:21 PM, observed R12 in her room handling her belongings showing no signs of distress, illness, or injury. When asked by surveyor about her being hospitalized on [DATE] R12 confirmed she was hospitalized for an overdose. R12 stated she has a habit of roaming around and going in and out of rooms and on that day, she had been wandering in and out of rooms and when she arrived to R8's room she saw him snorting heroin. R12 asked if she could join him and she snorted heroin six times, then went to her boyfriend (R13's) room and passed out. R12 stated was told she was given CPR (Cardiopulmonary Resuscitation) because she was not responding. R12 stated she told them in the hospital she was suicidal. R12 stated while in the hospital, she was told she that she has a heart murmur and pneumonia and that if she has another incident she could end up in the ICU (Intensive Care Unit). R12's Community Survival Skills Assessments dated [DATE], [DATE], [DATE], and [DATE] documents that R12 does not appear to be capable of unsupervised outside pass privileges at this time. R12's current care plan does not include interventions for monitoring for drug seeking behaviors. The surveyor reviewed the facility's reportable investigations from May and [DATE]. There were no reports of an investigation of R12's overdose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 3 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] at 4:59 PM V27 (Family Member) stated peer pressure, and the environment are triggers for R12's drug use. V27 stated she doesn't know how but R12 will be in the company of not good people and monkey see monkey do with her. V27 does go out with R12, and she monitors her closely and R12 does not use drugs when she's with her. When R12 was in the hospital after her ordeal on [DATE] she received a phone call from the hospital physician that was treating R12, and he said they found her unresponsive. She doesn't know what kind of drug R12 does or how much or what she does. The hospital physician may have mentioned what kind of drug R12 used but V27 couldn't recall. V27 stated the hospital physician informed her that R12 overdosed. R12 was nonresponsive, the paramedics were called, and they had to detox her. No one from the facility contacted V27 to ask any questions about R12's overdose incident. V27 confirmed she found out from the hospital that R12 was there and doesn't recall receiving a phone call from the facility notifying her of R12 being admitted to the hospital. V27 stated she asked R12 how she was able to get drugs while in the facility and R12 sometimes can deflect and not answer questions directly but from what R12 told her it sounds like one of the residents in the facility was able to bring in the drug. V27 stated she is not sure what drug, but she thinks it was heroin. V27's greatest concern is that R12 was unresponsive, it could have been a matter of moments, and if she took just a little bit more of the drug or there was a delay in getting to her, she could have been lights out meaning passed away. V27 stated her concern is she could have lost R12 and if there's a way to prevent drugs from coming in, she would want that. V27 stated R12 said they had to do electric shocking to resuscitate her. V27 stated thankfully R12 didn't die but hopefully it doesn't happen to someone else or another resident's family. V27 stated R12's overdose caused her and V33 (Family Member) a lot of distress. V27 asked what if the nurse hadn't gotten to R12 at the time she did or if there was a minute delay? V27 stated every moment or second is imperative to life in that situation. 3.) On [DATE] at 11:09 AM R8 stated a few weeks ago he was threatened to be put out by V16 (Substance Abuse Coordinator/Psychosocial Rehabilitation Services Coordinator) because he had a verbal altercation with her about not letting him go out on pass. R8 stated V16 told him he was going to be put out. R8 is a [AGE] year-old male with diagnosis not limited to history of Recurrent Major Depressive Disorder, Bipolar Type Schizoaffective Disorder, Psychoactive Substance Abuse, COPD, Peripheral Vascular Disease, and Prostate Cancer who was admitted to the facility [DATE]. On [DATE] at 1:15 PM V17 (Receptionist) stated R8 had an outside pass and was going out regularly. When asked by surveyor was R8's outside pass privileges removed in the past few weeks, V17 stated R8's outside pass was revoked and she isn't sure why. V17 stated residents are supposed to sign in on a log at the front desk whenever they go in and out of the facility. V17 stated R12 never had an independent pass and always goes out of the facility with family or friends. On [DATE] at 1:23 PM V16 (Substance Abuse Coordinator) initially stated R8's outside pass privileges were revoked due to suspicious behaviors of hanging around other residents. V16 could not provide information on when these behaviors were reported. When asked by surveyor if suspicious behavior is documented, V16 stated it depends on if a resident's name keeps coming up or if she keeps hearing their name brought up involving behaviors. V16 stated she followed up on the report about R8's suspicious behavior of hanging around people by asking him what's going on and who he's been hanging around etc. and his response was nothing was going on. At the time of the survey R8's progress notes from [DATE] did not include any behavioral documentation concerning drug use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 4 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few R12's progress notes from [DATE] and the facility's resident reception log dated [DATE] do not document any record of R12 leaving the facility on that date. However, the resident reception log dated [DATE] does document that R8 left the faciity on [DATE] shortly after 9AM. On [DATE] at 1:47 PM V10 (Psychosocial Rehabilitation Services Director) stated when residents leave the facility independently it is documented in the resident log kept at the front desk. V10 stated if Narcan (Opioid Antagonist) is used on a resident, and it is effective or if they were hospitalized related to an overdose that should be communicated to the Director of Nursing and V16 (Substance Abuse Coordinator) because she is the substance abuse coordinator. V10 stated she is not aware of R12 engaging in any substance use while in the facility. On [DATE] at 2:44 PM when asked by the surveyor if there was an investigation regarding staff's documented report of R12 being hospitalized for an overdose, V2 (Director of Nursing) stated he doesn't have an investigation for R12's overdose incident because they said she overdosed but couldn't specify what it was. V2 stated that he did not see the paperwork from the hospital with any information on what substances were involved. V2 said you can talk to the patient and ask about the overdose, but you can't just accuse people based on allegations; and you have to be careful to accuse people. If an overdose is an admitting diagnosis for a resident this should be investigated. People overdose on a lot of stuff but most commonly drugs. The facility should follow up and ask for the toxicology result if there is a report of an overdose for a resident. V2 agreed it is standard practice to obtain hospital paperwork when residents return from the hospital. It is important to follow up on this situation to ensure the patient is safe and possibly remove the source to prevent reoccurrence. On [DATE] at 4:10 PM R8 stated he was drug tested within a day of a female resident reporting that he gave her some drugs. On [DATE] at 2:11 PM V2 (Director of Nursing) stated Narcan (Opioid Antagonist) is used when there is a suspected overdose. V2 stated Narcan will revive someone even if they don't have drugs in their system. V2 stated Narcan is also effective for Catatonia. V2 stated there are 9000 reasons that someone could become unresponsive and that the use of Narcan depends on the assessment of the patient and it's better to be safe than sorry. V2 stated that in his opinion; in order to suspect someone is under the influence of a substance you have to have the toxicology. If there were any investigations of any incidents they would be included with the reportable investigations, and he doesn't believe there were any reportable investigations for R12 in the month of May. The National Institute on Drug Abuse's Drug Facts page accessed [DATE] documents Narcan (Brand name for Naloxene) is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. Naloxene has no effect on someone who does not have opioids in their system. Examples of opioids include heroin. On [DATE] at 3:25 PM, when asked by the surveyor how the facility responds if a resident experiences an overdose while in the facility V26 (Medical Director) stated the facility performs random routine drug testing, they are more vigilant with vitals, and if there are any signs of intoxication, they will drug test them. V26 stated he heard some sort of rumor about residents bringing recreational drugs in the facility and selling it to other residents. V26 stated he met with the administrator last week and discussed this issue and as a result they planned to work on fixing the cameras and doing some undercover investigating to get to the bottom of this. When informed by the surveyor that she was inquiring about a specific resident who was documented as being hospitalized for an overdose incident that occurred while in the facility V26 stated he didn't hear about a specific resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 5 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few having an overdose otherwise they would have been kicked out of the building or it would have been investigated further. When asked by the surveyor if any report of a resident overdosing while in the facility should be investigated, V26 stated 100% this should have been investigated and that's common sense. V26 stated he doesn't know how drugs got in the facility in the first place, and he doesn't expect drugs to be inside the facility. Narcan is just a reversal agent and reverses an opioid overdose and won't do anything for an infection, or pneumonia, or sepsis. If the facility is not investigating an overdose incident that is unacceptable because the facility should be, and something should be done about it. When asked by the surveyor why would it be important to investigate such incidents V26 stated, the facility is a place of rehab, and they should try to prevent these incidences for the purpose of the safety of the residents and the staff. On [DATE] at 10:28 AM V1 (Administrator) stated she did participate in an unscheduled meeting with V26 (Medical Director) and V2 (Director of Nursing) a week ago because they wanted to discuss workflow. V1 stated V26 provided suggestions on how to improve the workflow by asking them to prioritize a list on the residents he needs to see when he comes in. V1 stated V26 did not discuss anything during that meeting about residents bringing drugs in the facility. V1 stated she had not received any concerns about residents having drugs in the facility. V1 stated there's always a speculation about this because of the type of population of residents we have in the facility. On [DATE] at 12:26 PM and 4:07 PM the surveyor requested confirmation as to whether V25 (Registered Nurse) or any other nurse performed drug testing on R8 on [DATE]. On [DATE] at 4:40 PM V32 (Assistant Administrator) advised that V2 (Director of Nursing) would provide this information. As of the time of the survey exit [DATE] the facility had not provided this information. On [DATE] at 11:00 AM R8 stated the next day after R12 alleged he gave her drugs V2 (Director of Nursing) and V16 (Substance Abuse Coordinator) asked him if he gave R12 anything and he told them no. R8 stated he told them R12 asked him for an ice cream sandwich, and he didn't have one and she left. On [DATE] at 11:02 AM V31 (LPN) stated she didn't know much about R12's incident on [DATE] that involved her being hospitalized . V31 stated it happened after she left for the day. V31 stated the next morning she contacted the hospital and was informed that R12 was admitted for an overdose and pneumonia. V31 stated she did not attempt to perform drug testing on R8. When asked by the surveyor if V1 (Administrator), V32 (Assistant Administrator), V2 (Director of Nursing) or V19 (Assistant Director of Nursing) came and asked her any questions about the incident V31 said no. On [DATE] at 2:55 PM V16 (Substance Abuse Coordinator) stated she doesn't recall asking R8 on [DATE] about whether he had any drugs in the facility. When asked by the surveyor if she was involved in any investigation regarding R12 being hospitalized on [DATE], V16 stated she heard bits and pieces about it and spoke with R12 about coping skills and provided her with some which was documented but that's all. 4.) On [DATE] at 11:14 AM R14 stated he has heard about other residents using drugs and 3 or 4 months ago he heard about residents overdosing. R14 is a [AGE] year-old male with diagnosis not limited to history of Single Episode Major Depressive Disorder, Generalized Anxiety Disorder, Opioid Use, and Accidental Poisoning by Unspecified Narcotics who was admitted to the facility [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 6 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] at 12:35 PM V16 (Substance Abuse Coordinator) confirmed R12 was admitted with a substance abuse history and was referred to her. V16 stated she sometimes hears about R14 being under the suspicion of bringing drugs in the facility and supplying it. V16 stated approximately 3 months ago a resident who was discharging informed them that there is a resident who grabs drugs that you want and gave a description of a tall dark resident who fit R14's description. V16 stated she overheard this conversation while in the social services office when the resident was on the phone with one of the social-services staff, however she couldn't recall which staff were taking this phone call. V16 stated the resident said he would call back and give a name, but they never called back. V16 stated she is unsure of the resident's name because they were only in the facility for one or two days. V16 stated she doesn't believe she reported this to any of the management staff and they were just waiting on the resident to call back. When asked by the surveyor if there was anyone that should be notified if they received information about residents allegedly bringing in drugs V16 stated the abuse coordinator. When asked by the surveyor if she knows what triggered R12 to use drugs in the past V16 stated R12 just said if she's around certain people or gets involved at parties; and V16 believes that's what lead up to R12 using substances in the past. The facility's list of residents receiving treatment for substance abuse disorders printed [DATE] documents there are currently 52 residents in the facility with active substance abuse disorders receiving treatment including R8, R12, R13, and R14. The facility's Alcohol/Substance Use/Abuse Policy received [DATE] states: It is the policy of the nursing facility to provide a safe and healthy living environment. The use of drugs that are not prescribed by the physician are not allowed in this facility or on the facility campus. Illicit drugs may not be brought inside the facility. Documentation should include the resident's own admission of drug use. The facility's Incident/Accident Reports Policy received [DATE] states: The accident report is completed for all accidents where there is injury or the potential to result in injury. The purpose of the policy is To report, record, and investigate all accidents. To provide a process for monitoring of planned corrective actions to prevent or reduce the risk of reoccurrence of reported accidents. An accident is defined as any happening, unexpected, unintended event not consistent with the routine operation of the facility that can result in bodily injury other than abuse. An accident report will be completed for: All serious accidents of residents; All accidental unusual occurrences; All accidental situations requiring the emergency services of a hospital or police; All unexpected events that occur that cause actual or potential harm to a resident. An accident report is to be completed by a Licensed or Registered Nurse and is to include date and time of accident, full written statement and possible cause of incident, and notification of appropriate parties. The Administrator, Director of Nursing, Assistant Director of Nursing, or Nursing Supervisor must (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 7 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0689 Level of Harm - Immediate jeopardy to resident health or safety notify the following if a serious injury occurs: The Illinois Department of Public Health as soon as possible within 24 hours of the occurrence. Public Health is to be notified of incident resulting in emergency services provided by the police (911), accidents resulting in serious injury requiring hospitalization, or any accident which has or is likely to have a significant effect on health, safety, or welfare of a resident. Residents Affected - Few All accident reports are reviewed, signed, and investigated by: The Administrator and The Director of Nursing or the Assistant Director of Nursing. Results of investigations are analyzed, and findings discussed in safety meetings. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. On [DATE] the survey team verified by observation, interview, and record review, that the facility implemented the following to remove the immediacy. Removal Plan: The Chicago Ridge Nursing & Rehabilitation Center outlines its plan to prevent illicit drug use and possible drug overdose among residents. The facility has implemented various measures to monitor residents to ensure a safe environment. R12 currently resides in the facility and remains in stable condition. R12 has had no ill effects from the alleged deficient practice. Education was initiated on [DATE] by the DON, ADON, and Social Service Director and is ongoing. All facility staff have been in-service in person or via telephone. Staff who receive training via telephone will be required to attend in-person training before the start of their shift. Upon completion of the in-person in-service, the staff will sign the in-service sheet. The administrator and/or social service director will conduct weekly spot checks to ensure the facility staff are knowledgeable of the content. Any staff who were unable to attend the in-service due to a planned vacation or leave of absence will be in-serviced on their next workday before the start of their shift. The administrator, social service director, DON, or ADON will lead this in-service [DATE], ongoing. Upon hire new staff are educated by social service and sign the in-service sheet ongoing The Facility does not contract with agency staffing. Education includes: All staff ' s education will be ongoing. Monitoring and investigating includes the steps to determine how illicit drugs got into the facility, prevent illicit drugs from entering the facility, are alerted when an illicit drug enters the facility and prevention of resident ' s use of illicit drugs and possible drug overdose. Substance abuse and prevention is a process that attempts to prevent the onset/relapse of substance use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 8 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Staff ensure the safety of residents and monitor the residents by conducting random room searches, supervised visits, and searching the residents' belongings. Anyone who appears under suspicion of illicit drugs are placed under 1:1 supervision, notifications will be made to the administrator, DON, family, and MD. Narcan will be administered per the physician's orders. The facility staff is responsible to reasonably prevent the entry of contraband into the facility and removing it from any resident who has it on them, including calling the police if applicable. Upon admission/re-admission to the facility, the resident ' s packet and PASSR screen is reviewed by the social services director. The social service director has re-educated the social service department on the resident ' s diagnosis and discuss therapeutic programming and care plan development. The resident's SMI/substance abuse disorder assessment was initiated, and care plan interventions updated 6-4-2025 to allow staff to adequately supervise and provide care to reduce the risk of substance use/ overdose. Education is covered in annual competency for all facility staff. Education on signs and symptoms of substance abuse and reporting signs and symptoms to the charge nurse. Educated on confiscation of contraband and labeling non-contraband items. The police department will be called immediately if contraband or illicit drugs are discovered, suspicious packages are delivered, or visitors bring them in. Or if a visit or resident refuses to have their packages searched. Prevention of illegal substances in the facility: The facility has posted signage in the lobby on 6-3-2025 alerting staff, residents, and visitors to the facility's policy of searching for contraband. This information has been provided to each resident in writing 6-4-25 and ongoing. Mouth checks on residents will be performed on residents with a history of substance abuse and residents who receive scheduled control medications. This will be performed to ensure medications are being taken when administered. This will be performed by licensed nurses. 6-4-2025 (ongoing). Upon admission/re-admission, the receptionist or designee will obtain the resident ' s belongings to be searched and inventoried before items are taken to the unit. 06-3-2025 and ongoing. Residents who refuse to be searched will be placed on 1:1 supervision, notifications will be made to the family, local police, and the physician, and the resident will be petitioned to t[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 9 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policies and procedures for providing services and supports for chemical dependence and substance abuse by not offering substance abuse group programming to a resident who reported a history of substance abuse and not ensuring a resident with a diagnosis history of Psychoactive Substance Abuse Disorder received psychiatric, group, or behavioral health counseling and services for two (R7, R12) of three residents reviewed for behavioral health services. These failures resulted in R12 using illicit substances in the facility and requiring emergent transfer to local hospital for overdose. Residents Affected - Few Findings include: 1. R7 is a [AGE] year-old male with diagnosis not limited to a history of Schizophrenia, Depression, Suicidal Ideations, a History of Suicidal Behavior, Crohn's Disease, Blindness of Left Eye, and Encounter for Palliative Care. R7 was admitted to the facility [DATE]. On [DATE] at 10:48 AM observed R7 sitting in the hallway in his wheelchair. R7 stated the facility does have a substance abuse group however, he was told he is not allowed to attend the substance abuse group because in order to attend he had to have a substance abuse history when he was admitted to the facility. R7 stated he knows other residents are using drugs in the facility because he recognizes the abnormal behaviors from drug use. R7 stated he recognizes these behaviors because he used to be a drug addict. R7 stated when he sees this it does tempt him to abuse drugs. R7 stated he uses a substance abuse program app on his phone for drug counseling and showed the app to the surveyor. R7 stated it would be helpful if he was able to attend substance abuse counseling groups at the facility or receive some substance abuse counseling at the facility. R7's Current Care Plan initiated [DATE] documents he has a substance use disorder with interventions including involve him in individual counseling as appropriate and it does not include attending substance abuse groups. Substance Abuse Group Attendance Sheets from April - [DATE] did not include R7's signature in the attendance sheets for the substance abuse group meetings. On [DATE] at 1:59 PM V10 (Psychosocial Rehabilitation Services Director) stated V16 is the Substance Abuse Coordinator and conducts substance abuse groups 3-4x week. V10 stated V20 (Psychologist) also conducts Psychosocial programming every Tuesday and Thursday which includes three different groups on those days, and he also comes on Fridays. V10 stated V21 and V22 are Licensed Clinical Social Workers who see residents Monday - Friday and social services staff also meet with residents. V10 stated none of the current residents want to go to outside day programs and the few that do are in wheelchairs and those programs don't accept them. On [DATE] at 2:54 PM V16 (Substance abuse Coordinator) stated she conducts substance abuse classes twice weekly on Mondays and Wednesdays for two half hour sessions between 11AM - 12PM; Residents attend the substance abuse groups based on their hospital documentation upon admission, and she did not find any documentation of a history of substance abuse in R7's records. V16 stated she reviews all resident referrals and hospital packets on admission and if it specifies a substance use history she will complete an admission packet for the substance abuse department, offer the programming, and if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 10 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0745 Level of Harm - Actual harm Residents Affected - Few they decline, she has a one-to-one session with them on Tuesday. V16 stated she will encourage residents to come to the Groups during the one-to-one sessions. V16 stated approximately three months ago R7 mentioned to her he had a substance abuse background, and she told him she would have to review his admission packet and would get back to him. V16 stated when R7 returned from going in and out of the hospital for health issues he brought to her attention that he was enrolled in a substance abuse program online. V16 stated this was the second time he mentioned this, and she encouraged him to stay on the online program and advised it was really good. When asked by surveyor would a resident be invited to the substance abuse group program based on informing her of having a history of substance abuse or of her becoming aware of this information V16 stated she reviewed R7's admission packet and didn't find anything in his history and they must have this history in order to attend the group. On [DATE] at 1:47 PM V10 (Psychosocial Rehabilitation Services Director) stated R7 should not be restricted from attending the substance abuse groups based on a substance abuse history not being identified on admission. V10 stated V16 should initiate a care plan and document on his history of substance use. V10 stated residents with a substance abuse history should receive services to address whatever behaviors or issues they have. On [DATE] at 2:44 PM V2 (Director of Nursing) stated once a substance abuse history is identified for a resident, they should immediately be enrolled in the substance abuse group unless they decline. V2 stated this is important because you want to initiate the treatment protocols that are available to the patient. On [DATE] at 3:25 PM V26 (Medical Director) stated the facility wouldn't treat residents with a substance abuse history any differently than any other patient, all the residents have medical conditions and substance abuse is just another type of medical condition. When asked by the surveyor should the facility monitor or be aware of a resident's triggers for substance use for residents with a substance abuse history V26 stated the facility has psychiatry that sees the residents to make sure they don't have any symptoms or withdrawals. V26 stated assessing triggers and monitoring the residents desire for drug use is part of the psychiatry evaluation and residents with a substance use history are managed by a psychiatrist for their addiction problems. 2. R12 is a [AGE] year-old female with diagnosis not limited to history of Epilepsy, Restlessness and Agitation, Psychotic Disorders with Delusions, Paranoid Schizophrenia, Bipolar Disorder, Generalized Anxiety Disorder. Recurrent Major Depressive Disorder, Psychoactive Substance Abuse Disorder. R12 was admitted to the facility [DATE]. On [DATE] at 12:21 PM observed R12 in her room handling her belongings. When asked by surveyor about her being hospitalized for drugs on [DATE] R12 confirmed she was hospitalized for an overdose. R12 stated she has a habit of roaming around and going in and out of rooms and on that day, she had been wandering in and out of rooms and when she arrived to R8's room she saw him snorting heroin. R12 stated she asked if she could join him and she snorted heroin six times, then went back to her room then to her boyfriend R13's room and passed out. R12 stated she heard that she was given CPR (Cardiopulmonary Resuscitation) because she was not responding. R12 stated she was told while in the hospital if she has another incident she could end up in the ICU (Intensive Care Unit). R12's Hospital Record dated [DATE] documents she is a [AGE] year-old female with a past medical history of depression who presents to the emergency department from a Behavioral Health/Substance Abuse Treatment Organization for evaluation of a seizure sensation; she is at the Behavioral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 11 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0745 Health/Substance Abuse Treatment Organization for a history of drug, alcohol, and marijuana use; she reports last using cocaine 15 days ago. Level of Harm - Actual harm Residents Affected - Few R12's admission Contract includes a Social Services Quick Reference Interview form that documents she was admitted on [DATE], and in response to the question do you have a history of substance abuse? She answered yes and in response to the to the question which one? Regarding substance use she answered, all of them. R12's Nurse Practitioner Progress note dated [DATE] documents Chief Complaint is to Establish care. This is a [AGE] year-old woman admitted to the facility on [DATE], with chronic diagnoses of Drug Use Disorders and Depression. R12's (PASRR) Preadmission Screening and Resident Review dated [DATE] documents she has been to a Behavioral Health/Substance Abuse Treatment Organization for cocaine detox and rehab. R12's Social Service Initial Interview for SMI (Severe Mental Illness) Substance Abuse Disorder dated [DATE] completed by V16 (Substance Abuse Coordinator) documents and answer of no in response to the question have you been in treatment for substance abuse? R12's progress note dated [DATE] documents V16 (Substance Abuse Coordinator) spoke with her about the Substance Abuse admission whereas she received the Addiction & Diagnosis contracts. She is strongly encouraged to participate in Substance Abuse groups which will result in a 1:1 if a group is missed. Substance Abuse Counselor will assist as needed. R12's drugs of choice are Alcohol, Marijuana, and Cocaine. R12's Current Care Plan initiated [DATE] documents her Comprehensive Assessment reveals a history of suspected Substance Abuse whereas the Resident is placed in the Substance Abuse Counseling group held on Mondays & Wednesday at 11 AM and alcoholics group which is held on Fridays at 11 AM. Her Drugs of choice are Alcohol, Marijuana, & Cocaine with interventions including emphasize treatment of causal factor and/or intervention designed to moderate/reduce symptoms (make treatment of compulsive behavior, Substance abuse, anger, and mental health issues available to the Resident, as indicated). R12 has a history of substance abuse/chemical dependency related to: Clinical depression and anger (substance abuse often indicates an attempt at self-medicating depression and disturbing thoughts), History of mental illness/severe mental illness, poorly developed ability to control impulses, and Allowing negative, inappropriate persons to influence his/her use of substances with interventions including: The physician may consider a referral to the psychiatrist. Provide leisure counseling to the resident to help him/her use free time in productive, not destructive ways. R12's Psychiatric Progress Note dated [DATE] documents the type of visit as acute and she was seen for a chief complaint of assessment after admission from other facility. History of present illness includes recently using crack cocaine which may have precipitated either a seizure or behavioral disinhibition. She reports a history of mixed substance abuse before coming to Chicago Ridge at the end of [DATE]. Diagnosis Assessment and Plan includes Alcohol dependence. R12's progress note dated [DATE] documents a referral packet was sent to V20 (Psychologist) for group therapy. R12 was denied for V20's services. R12 was referred to (another provider). R12's Psychiatric Progress Notes dated [DATE] do not include substance abuse counseling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 12 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0745 Level of Harm - Actual harm Residents Affected - Few R12's progress note dated [DATE] created by V21 (Licensed Clinical Social Worker) documents Reason for Referral as Comprehensive biopsychosocial assessment for initial psychiatric diagnostic evaluation as per referral by the Director of Social Services. Resident has a medical diagnoses history of Uncomplicated Other Psychoactive Substance Abuse. Resident has a history of alcoholism and drug addiction (marijuana and cocaine). Drug Use: Remote. R12's Psychiatric Progress Note dated [DATE] created by V29 (Addiction and Psychosocial Nurse Practitioner) documents the type of visit as addictions program follow up and she was seen for a chief complaint of assessment of current alcohol use. Substance use history includes her reporting a history of using heroin and cocaine for 1-2 years. Reports alcohol is a problem for her and refused to discuss her history with alcohol. Patient reports she would like to think about it regarding MAT (Medication-Assisted Treatment - a comprehensive approach to treating substance use disorders that combines medications with counseling and behavioral therapies). Per chart review patient was previously on an alcoholism medication although she can't recall this. Relapse prevention discussed. R12's Psychiatric Progress Notes dated [DATE] created by V28 (Psychiatric Nurse Practitioner) do not include substance abuse counseling. R12's progress note dated [DATE] documents resident is seen by the facility Psychiatrist once a month. R12's progress notes from April and [DATE] document she attended substance abuse group once on [DATE] and does not include any notes of one-to-one substance abuse counseling. R12's Psychiatric Progress Notes dated [DATE] created by V28 (Psychiatric Nurse Practitioner) do not include substance abuse counseling. R12's progress note dated [DATE] at 9:42PM created by V18 (Licensed Practical Nurse) documents she was visiting with a friend in his room, peer came to desk to get nurse stating, She's not responding to me. Writer entered peers room noticed a change of condition with patient not responding appropriately. Vital Signs noted oxygen at 82%. Writer applied oxygen at 5L via non-rebreather mask; Oxygen saturation increased to 92%. Narcan (Opioid Antagonist) administered twice, 911 called. Fellow co-workers assisted with patients care; at 9:50 PM it was documented that 911 paramedics here at facility to assess patient's status and scenario. 911 took over CPR (Cardiopulmonary Resuscitation); at 10:00 PM a late entry documented R12 discharged to: the hospital on [DATE] at 9:42 PM; Reason for transfer: Patient not responding appropriately at her normal; at 22:10 it was documented patient being transported to the Hospital emergency room for further evaluation. R12's progress note dated [DATE] created by V31 (Licensed Practical Nurse) documents resident admitted to the Hospital with diagnosis of Overdose and Pneumonia. R12's Physician Order History documents an order effective [DATE] for being able to be seen by a psychiatrist or psychologist. R12's Physician Order History does not include any previous orders for seeing the psychiatrist. R12's progress note dated [DATE] documents resident is readmitted to the facility day 1 of 3. Resident transferred from Hospital related to overdose and pneumonia. On [DATE] at 12:35 PM V16 (Substance Abuse Coordinator) confirmed R12 was admitted with a substance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 13 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0745 Level of Harm - Actual harm Residents Affected - Few abuse history and was referred to her. V16 stated R12 attends every group. V16 stated on admission she does ask residents what their current drug use is and if they have cravings. V16 stated she completes the substance abuse assessments yearly or whenever the residents get into trouble she revises them. When asked by the surveyor what are R12's triggers for drug use V16 stated she just told me she needed some coping skills. When asked by surveyor to specify what coping skills R12 needed V16 stated R12 was struggling with coping skills regarding sex, it's like difficult to explain, she needs something to keep her mind off things, so she gave her coping skills suggestions of meditation and finding inspirational speakers online. V16 stated R12 also received a paper with coping skills suggestions from V3 (Psychiatric Rehab Services Coordinator) her social worker. V16 stated residents receive coping skills guidelines through the documentation she provides during substance abuse groups. V16 stated every Tuesday she provides one to one substance abuse counseling for all the residents that don't attend the substance abuse groups which include for gambling, for alcoholics, and for narcotics and cocaine. V16 stated the residents are referred to groups based on their drug of choice. V16 stated R12's substance abuse care plan should include gambling and alcoholics and now she is interested in all three groups. On [DATE] at 11:09 AM V10 (Psychosocial Services Director) stated (provider name) is the program that V21 and V22 the LCSW's (Licensed Clinical Social Workers) work from. V10 stated V20 (Psychologist) provides psychosocial groups and one to one counseling. V10 stated R12 was denied V20's program due to insurance. On [DATE] at 11:23 AM V1 (Administrator) stated it's not part of their process to acquire any information from the substance abuse treatment center where R12 was being treated in just prior to her admission to the facility, however it's a good idea. On [DATE] at 12:10 PM V30 (Psychiatrist) stated R12 is seen once per month for schizophrenia by V28 (Psychiatric Nurse Practitioner) and seen once per month by the addiction provider V29 (Addiction and Psychiatric Nurse Practitioner). V30 stated V29 last saw R12 in March and believes this was the first time she saw her. V30 stated R12 has a history of alcohol use and was evaluated by V29 for this. V30 stated it looks like R12 also reported a history of cocaine for 1-2 years and said she would think about MAT (Medication Assisted Treatment). V30 stated he isn't sure if there was any discussion with R12 and V28 regarding using cocaine or heroin but there is no documentation of it in V28 notes. V30 stated R12 was seen by the psychiatric nurse practitioner once monthly and V29 was seeing her parallel to that. V30 stated he's not sure if R12 was in the hospital when V29 was rounding at the facility. V30 stated V29 comes to the facility approximately every two weeks and R12 would have been seen during those visits. V30 stated V29 was at the facility [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. V30 stated he did not find any notes from V29 for R12 other than on [DATE]. V30 stated R12 was on the list to be seen on 04/18 however there was no notation as to why she wasn't seen. V30 stated V28 is seeing R12 more for hallucinations, anxiety, and schizophrenia symptoms. On [DATE] at 2:23 PM V28 (Psychiatric Nurse Practitioner) stated the last time she saw R12 was [DATE] and she sees her monthly. V28 stated there has been no discussion about R12's use of cocaine or heroin during their meetings. V28 stated during her meetings with R12 she addresses her mental health and R12 is being seen by an addiction specialist as well. On [DATE] at 3:55 PM when asked by surveyor if during his meetings with R12 there is any discussion about her use of heroin or cocaine V21 (Licensed Clinical Social Worker) stated no, he lets V16 (Substance Abuse Coordinator) do that with R12 during her groups. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 14 of 15 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 145639 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415 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 0745 The facility's Chemical Dependency and Relapse Prevention Support Group Policy received [DATE] states: Level of Harm - Actual harm The purpose of the policy is To help the resident with a substance abuse diagnosis and/or history remain (clean) in the least restrictive setting. The group is an adjunct support in the patient's effort to decrease and eliminate the role and influence of chemical dependency in his/her life. Residents Affected - Few Referral Criteria: History/Diagnosis of substance abuse and some desire to achieve sobriety or remain sober. History of in-patient substance abuse treatment and need for aftercare. The facility's Alcohol/Substance Use/Abuse Policy received [DATE] states: It is the policy of the nursing facility to provide a safe and healthy living environment. The facility recognizes that persons requiring long-term care present with significant physical and mental health problems. The facility shall work with the individual to provide appropriate treatment referrals to enable the individual to work on abstinence, sobriety, personal improvement and reducing chances of recidivism. Appropriate interventions are strongly recommended to persons with substance abuse problems. Persons assessed with an active substance abuse problem are offered appropriate treatment and rehabilitative services. Follow-up interventions and treatment recommendations will be communicated to the resident and documented in the medical record. Outside treatment sources will be utilized as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 15 of 15