Inspection·July 31, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have a policy to ensure a resident is supervised and monitored to prevent resident from leaving the facility unauthorized or without staff knowledge. These failures affected one (25) of one resident reviewed for supervision to prevent an unauthorized exit from the facility. This failure resulted in R25 leaving the facility through a window unauthorized or unknowingly to facility staff. Findings include:R25's medical record notes R25 was admitted to this facility on 6/4/25 with diagnoses including but not limited to opioid abuse, cocaine abuse.R25's social service initial interview for substance abuse disorder, dated 6/9/25, notes R25's drug of choice is cocaine and alcohol.R25's admission BIMS (brief interview of mental status), dated 6/11/25, notes R25's BIMS score is 15 out of 15. R25 is cognitively intact.R25's community survival assessment, dated 6/11/25, notes R25 does not appear to be capable of unsupervised outside pass privileges at this time.R25's discharge planning review, dated 6/11/25, notes R25's discharge potential is fair. Barriers to discharge include R25 has had problems complying with his psychiatric treatment regimen (including taking medications as ordered, following up with mental health/psychiatric counseling and case management recommendations); and R25 has had problems complying with substance abuse treatment and after care (has returned to chemical dependence once out of a structured setting, diminished ability to avoid self-neglect). Discharge status nursing facility required to help R25 attain or maintain highest practical health status. Discharge plan - do not initiate discharge planning.R25's screening assessment for indicators of aggressive and/or harmful behaviors, dated 6/11/25, note R25 is at minimal risk.R25's POS (Physician Order Sheet) notes last order documented on 6/26/25.R25's MAR (Medication Administration Record), dated July 2025, notes the last time R25 received any medication was on 7/7/25 at 4:00 PM.R25's POC (Point of Care), dated 7/7/25, notes R25's last documented meal was at 8:42 AM.R25's medical records notes R25 had an appointment with an outside physician at an outpatient clinic on 7/8/25 at 8:15 AM.There is no documentation noted in R25's medical record noting V17 (Licensed Practical Nurse/LPN) tried to keep R25 in the facility so R25 could go to appointment scheduled on 7/8/25.On 7/22/25 at 10:50 AM, the surveyor entered the smoke room and observed wires broken on three windows. The surveyor was able to exit the smoke room and enter the smoking patio. There is a metal fence surrounding the patio and a pad lock on the gate. The fence is 7 feet 9 inches high.On 7/26/25 at 8:45 AM, this surveyor observed the main entry door to facility unlocked. The entry door to the nursing units from the main lobby is locked. Staff at the first-floor nurses' station and the receptionist at the main desk can remotely unlock this door by pressing a buzzer. Residents were observed not having access to open this secured door. Only staff, visitors, and residents with a community pass are allowed to enter and exit the facility.On 7/26/25 at 10:11 AM, V1 (Psychosocial Aide) stated that the smoke times at this facility are 9:00 AM - 10:00 AM, 1:00 PM - 2:00 PM, and 5:30 PM - 6:30 PM. V1 stated that the smoke room door is kept locked.On 7/26/25 at 1:10 PM, V5 (Director of Nursing/DON) stated that one resident attempted to exit the facility through the window in the smoke room. V5 stated that R25 broke the wires securing the window. V5 stated that he does not know where R25 is or what happened to R25. V5 stated that there is only one smoke room, and it is kept locked unless it is smoke time.On 7/26/25 at 1:10 PM, V7 (Maintenance Director) stated that he is on call 24/7 for the facility. V7 stated that residents breaking the wires that prevent the windows from opening more than five inches is a common occurrence at this facility. V7 stated that a resident broke the wires recently. V7 stated that when he came into work, he was informed by a staff member that the wires were broken on three windows in the smoke room. V7 stated that staff did not notify him that the wires were broken. V7 stated that he should have been Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 2 of 6 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 07/31/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notified immediately. V7 stated that staff locked the windows, but anyone can unlock and open window. V7 stated that he placed screws in the window frames to prevent windows from opening. V7 stated that each window opening measures 24 inches x 48 inches. V7 stated that when the wires are broken the window will completely open. V7 stated that a resident did exit the facility via the window but does not know resident's name. V7 stated that the smoke room door is locked when it is not a scheduled smoke time.On 7/26/25 at 2:40 PM, V2 (Psychiatric Rehabilitation Service Coordinator/PRSC) stated that she is the social worker for all residents on the second-floor nursing unit. V2 stated that she was not present in the facility when R25 left and is unaware what happened to R25. V2 stated that R25 may have gone AMA (against medical advice). V2 stated that when she came in R25 was gone. V2 denied asking any staff where R25 was. V2 stated that R25 did not request a community pass from her. V2 stated that the smoke room door is supposed to be locked at all times except during smoke times.On 7/28/25 at 10:15 AM, V11 (Nurse) stated that on 7/7/25, R25 was usual self, self-propelling in wheelchair throughout facility. V11 stated that she administered morning medications to R25. V11 stated that her shift ends at 3:00 PM and R25 was present in this facility at that time. V11 stated that she found out R25 eloped over the fence on the smoking patio when she came in to work the following Monday, 7/14/25. V11 stated that the protocol is to call a code pink (changed to code yellow), each nurse does a head count of his/her assigned residents, one nurse from each floor, social services, and activity aides are expected to go into the community and search for resident. V11 stated that V14 (Administrator) is notified. V11 stated that the police are notified if assistance is needed to locate the resident. V11 stated that staff are expected to call hospitals to see if resident admitted , notify physician, and notify resident's family. V11 stated that this is to be documented in the resident's record. V11 stated that the nurse assigned to that resident is expected to search for resident with the other staff members. On 7/28/25 at 10:31 AM, V6 (PRSC) stated that she was not present in facility when R25 left. V6 stated that the elopement protocol is to call a code yellow overhead, staff are to go out into the community and look for resident, perform a head count on residents, call V14 (Administrator). V6 stated that R25 telephoned V6 on 7/10/25 and informed V6 he wanted to return to this facility. When questioned what phone number R25 was calling from, V6 responded she did not know because facility does not have caller ID. V6 stated that V6 instructed R25 to inform the hospital social worker to contact facility to assist with R25's transfer back to facility. V6 was questioned why the telephone conversation with R25 was not documented in R25's medical record until 7/26/25 at 6:13 PM. V6 stated that she forgot about the phone call until this surveyor was present in the facility asking about elopement on 7/7-7/8.A late entry created on 7/26/25 at 6:13 PM in R25's medical record by V6 for 7/10/25 noting R25 called V6 verbalizing that he was in the hospital. V6 redirected R25 to verbalize to the social worker at the hospital that he would like to return back to the facility. R25 was receptive and stated okay. Will document as needed.On 7/28/25 at 10:55 AM, V13 (R25's emergency contact) stated that V13 knows R25 was at this facility and then left. V13 stated that she does not know where R25 is currently. V13 stated that it has been three weeks since V13 has heard from R25. V13 stated that R25 has a text app. R25 does not have a cellular phone. On 7/28/25 at 11:05 AM, V10 (Assistant Administrator) stated that V10 learned of R25's absence on 7/9/25. V10 stated that V14 (Administrator) would have been the one staff notified. V10 stated that code pink was changed to a code yellow a month or two ago. V10 stated that the protocol is the receptionist calls a code yellow 2 times, staff pull everyone in that is outside, staff get a census, conduct a head count; staff go into community and search for resident. V10 stated that she was not made aware if police were called. On 7/28/25 at 11:33 AM, V5 (DON) stated that R25 is alert and oriented x 4. V5 stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 3 of 6 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 07/31/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R25 left the faciity on an unauthorized pass, R25 left without permission. When questioned if this is known as an elopement, V5 stated no because he was alert and oriented x 4 and we knew he left. V5 stated that elopement refers to when we can't find a resident. V5 stated that V5 found out R25 was at a hospital in Chicago and has since been discharged . V5 does not know when R25 was admitted to the hospital, when R25 was discharged , or where R25 was discharged to.On 7/28/25 at 1:00 PM, V15 (Regional Consultant) stated that the police told social services today that R25 is not missing. The police officer called the hospital and learned R25 was discharged on 7/18/25 and did not want his family notified of his whereabouts. V15 stated that the police said R25 is not missing, and no report will be filed. V15 is unable to articulate a reason the police were not notified immediately on 7/8/25 when R25 exited the facility via the smoke room window. V15 stated that she spoke to R25 on 7/8/25 or 7/9/25 and R25 wanted to leave. When V15 was questioned what phone number she called to speak with R25, she responded the number on his face sheet. This surveyor informed V15 that there is no phone number listed for R25. V15 stated that the contact phone number had area code 312 on R25's face sheet. This surveyor informed V15 that there is no contact phone number with area code 312 on R25's face sheet. V15 stated to talk to social services.There is no documentation found in R25's medical record by V15 on 7/8/25 or 7/9/25.On 7/28/25 at 1:10 PM, V6 (PRSC) stated that she called the police regarding R25 missing. V6 stated that the police called the hospital and was informed that R25 left hospital on 7/18/25 and that R25 did not want his family to know. V6 stated that R25 hadn't expressed a desire for a community pass, to go AMA, or discharge home to her or anyone in social services. V6 stated that if a resident wants to leave AMA, V6 will discuss with V5 (DON) and/or family to set up proper discharge to ensure a safe discharge for the resident.On 7/28/25 at 3:55 PM, V17 (Licensed Practical Nurse/LPN) stated that V17 worked overnight 7/6-7/7/25. V17 stated that when he made his rounds at 6:00 AM or 7:00 AM, R25 stated that R25 wanted to smoke. V17 stated that he informed R25 that the smoke patio is locked. V17 stated that the smoke room has vending machines in it and this door is unlocked for residents to use. V17 stated that just prior to the end of his work shift he was called, and it was reported that R25 was trying to forcefully open windows in the smoke room. V17 stated that he went to the smoke room, R25 was agitated so V17 left R25 in there unsupervised. V17 stated that he worked 3:00 PM to 11:00 PM shift and 11:00 PM -7:00 AM shift 7/7-7/8/25. V17 stated that the last time V17 saw R25 was at 10:00 PM in his room speaking with friends. V17 is unable to articulate a reason he did not chart in R25's MAR (Medication Administration Record) after 4pm on 7/7/25. The MAR for night shift is blank. V17 stated that R25 is alert and oriented x 4.On 7/29/25 at 8:40 AM, V17 (LPN) stated that on 7/8/25 at 3:00 AM, R25 went down to the vending machine in the smoke room. V17 stated that he did not check to make sure R25 returned to his room. V17 stated that between 3:00 AM and 4:00 AM, there was a code paged overhead. V17 stated that he did a head count of residents but knew the code was for R25. V17 stated that he called V14 (Administrator) and was informed that she would arrange for search of resident. V17 stated that he did not go outside to search for R25 because he did not want to get shot. V17 stated that he did not inform V14 he would not go outside of building to search for R25. V17 stated that he did not call the police, R25's physician, or R25's family. When questioned about what the facility's protocol/policy is, V17 responded he did not know that he was just following instructions.Late entry created on 7/26/25 at 5:29 PM by V5 (DON) in R25's medical record entered for 7/10/25 at 11:30 AM. V5 noted V15 (Nurse Consultant) spoke with R25, second day of him being out on pass. R25 asked if the facility can pay for transportation and he was asked where he was and informed V15, that he was at the hospital and R25 was told the hospital will provide transportation for his return. R25 is currently at the hospital. Late entry created on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 4 of 6 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 07/31/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 7/26/25 at 5:53 PM by V5 (DON) in R25's medical record entered a second note for 7/10/25 at 11:50 AM. V5 noted R25 at the hospital, physician/nurse practitioner notified. Significant other called, no answer, message left on the voicemail. Late entry created on 7/28/25 at 10:20 AM by V5 (DON) in R25's medical record entered a third note for 7/11/25 at 12:15 PM. V5 noted hospital called to inquire about R25's status and was informed R25 is discharged .R25's medical record notes facility staff were informed on 7/10/25 that R25 was in the hospital. There is no documentation found in R25's medical record noting the whereabouts of R25 from 7/8/25 about 4:00 AM until 7/10/25.On 7/31/25 at 2:10 PM, V14 (Administrator) stated that R25 left facility on an unauthorized pass. V14 stated that V17 (LPN) notified her in the middle of the night informing her that R25 left facility. V14 stated that V17 informed her that he contacted R25's physician and family, he looked outside in the community for R25 and attempted to re-direct R25 back into the facility. V14 was informed V17 denied notifying physician, family member, or looking for R25. V14 was informed that in interview with V17, V17 stated that V14 was going to arrange for the search of R25. V14 stated the staff present in the facility are expected to search community for resident. V14 stated how are you going to wait to search for a resident for 3-4 hours.The facility's supervision and safety policy dated 03/2025 notes resident supervision is a core component to resident safety.This facility's discharge against medical advice (AMA) policy, revised 07/2024, notes it is the policy of this facility to provide medical and psychosocial care to residents of the facility. The staff shall provide appropriate attention and make a reasonable effort to prevent a resident from leaving AMA. Call the physician and administrator to notify them of the pending AMA discharge. Assess the resident's competence to make the AMA decision (vital signs, mental status). Explain and document a discussion of the reasons to remain in the facility and all potential serious risks associated with leaving. Explain and document efforts to persuade the resident to remain in the facility. Explain and document ongoing concern for the resident and his/her well-being. Use all available resources to prevent a resident from leaving AMA. Negotiate and compromise with the resident. Assess what is bothering/upsetting the individual and attempt to find an equitable solution (perhaps he/she can enjoy a cigarette on the patio). Event ID: Facility ID: 145639 If continuation sheet Page 5 of 6 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 07/31/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to ensure that all elevators were working in the facility. This affects 4 residents (R1, R2, R9, and R24) that require services/care in the facility. Findings Include: On 7/26/25 during the survey tour one of the two elevators in the facility was observed not working. The elevator, to the left (front facing), was observed with a number one in the display box, the number did not change when the call button was pressed. On 7/26/25 at 1:37pm V7 (Maintenance staff) said the elevator company repaired the elevator yesterday 7/25/25. He was notified last night that the elevator went out again. V7 said the elevators breaking down has been an ongoing issue at the facility. V7 denied knowing what the elevator service company mention as the problem for the continue breakdown of the elevator. V7 said it is his opinion that the entire elevator system should be replaced because it is an old facility. Facility service record denotes service was performed on an elevator on 7/25/25, documentation shows car 2. V7 failed to identify which of the two elevators was serviced (car 1 or car 2). There is a certificate in the elevator right side (front facing showing that the elevator is car 2). R1 said it takes a long time for the elevator to arrive because there only one working. R2 said it takes a long time for the elevator to arrive because there only one working. R9 said it takes a long time for the elevator to arrive because there only one working. R24 said it takes a long time for the elevator to arrive because there only one working. On 7/26/25 the facility census report shows 191 residents reside in the facility. On 7/28/25 at 11:05am V5 (Director of Nursing) said the facility use the elevators for transporting the lunch tray to the different floors, resident/staff and visitors use the elevators for going between floors. V5 stated the laundry staff, and housekeeping staff utilized the elevators. Providers also use the elevator when visiting the residents. The facility policy for building maintenance does not denote information / protocol for the facility elevators. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145639 If continuation sheet Page 6 of 6