Health inspection·October 2, 2023

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/30/2023 at 3:00PM, V9 (Environmental Services Director) stated she has been working at the facility for 31 years. V9 stated the protocol when a resident is discharged to the hospital is the staff will first disinfect the room. If the admission department informs us that a resident will not be returning to the facility, then we are instructed to put the resident belongings in storage. I was made aware that R2 was not coming back to the facility by V10 (Admissions Director). V10 informed me of this information about 5-7 days after R2 was hospitalized . An inventory of R2's belongings was not made when R2 went out to the hospital. Once I was made aware, I went into R2's room with V13 (Laundry Aide) about 5-7 days after R2 went out to the hospital. There were other housekeeping staff assigned to clean R2's room when R2 was in the hospital. I asked them have they seen any of R2's belongings and they have not seen them either. V13 and I both went into R2's room together. V13 stated to me that she searched the laundry room for R2's belongings and did not find any belongings for R2. Myself and V13 searched R2's room for any other belongings, we checked everything inside of R2's room and even the drawers but we did not see any of R2's belongings. There was nothing. I do remember seeing R2 with some glasses, they were big glasses. When we started looking for R2's belongings. I checked the storage room and there was nothing. If there is nothing found in the resident's room, then there is nothing to be filled out. If there are items found in a resident's room, then we fill out an inventory form that documents the resident's name, the date, and the items found. Myself, V13, and V1 all searched the storage room in hopes of finding R2's belongings. The storage room is located on the first floor of the facility. The housekeeping staff has access to and shares one key to the storage room. The CNAs are responsible for obtaining an inventory list of all the resident's belongings upon admission and discharge. We also tell residents and their family to let us know if they bring in or purchase new items for the resident so that we can update the resident's inventory list. On 09/30/203 at 1:55 PM, V3 (Social Services Director) stated I gave R2 an envelope to put his money in before R2 was going out to the hospital so that R2 could take his money with him. R2 left the envelop at the facility when he went out to the hospital. I am not aware of any other missing belongings that R2 had, I only know about the money. On 09/30/203 at 2:29PM, V2 (Director of Nursing/DON) presented R2's resident belongings log dated 04/13/2023. R2's resident belonging log documents 1 pair of glasses and $8 in cash. On 10/01/2023 at 9:21 AM V10 (Admissions Director) stated I was made aware of R2's missing items by the nursing and housekeeping staff. I was informed that R2 had some money, books, and glasses, and some clothes. I observed R2's inventory list when R2 was discharged from the facility. I saw the items on the list that R2's family was inquiring about. I saw this inventory list probably less than a week after R2 was sent to the hospital. To my knowledge, the housekeeping staff packed up all of R2's belongings and it should be in the storage room. I did not see R2's items and belongings but I did see the actual inventory list. This list is kept in the resident's chart. I have seen this inventory list in R2's medical chart, it is in there. When a resident is not returning back to the facility, I always tell the housekeeping staff to search the resident's room. I instruct the housekeeping staff to pack the resident's belongings because I know that the family will need them. I was informed that V1 (Assistant Administrator) addressed the concerns with R2's missing money and R2's money was returned and dropped off to R2 by V3 (Social Services Director). On 10/01/2023 at approximately 2:15 PM, Surveyor requested an inventory list of R2's belongings upon discharge from V2 (Director of Nursing). R2's discharge inventory list was not provided to surveyor. There was no documentation presented during this survey to show that R2's belongings were inventoried after R2's discharge from the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 If continuation sheet Page 2 of 5 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0602 Level of Harm - Minimal harm or potential for actual harm On 10/01/2023 at 10:57 AM, V4 (Social Services Coordinator) stated I've been working here for four months. I spoke with V8 (R2's family member) when she called and V8 told me about R2's missing items. V8 asked about R2's money which was $49 dollars and other items missing but I can only remember V8 mentioning some pairs of glasses that were missing. I told V8 that I would inform V1 (Assistant Administrator). Residents Affected - Few On 10/01/2023 at 2:10 PM, V1 (Assistant Administrator) presents surveyor with a written concern/grievance form dated 09/20/2023 documenting a concern made by R2's family about R2's missing items. V1 stated she was currently in the process of awaiting a receipt from V8 (R2's family member) to attach to the form so she had the form in her possession. V1 stated she forgot to give the concern/grievance form to surveyor when the concern/grievance logs were requested and reviewed by surveyor on 09/30/2023. On 10/02/2023 at 2:19 PM, V16 (Ombudsman) stated she was informed of R2's missing belongings by V8 (R2's family member). V16 stated that V8 informed her that R2 was missing money, books, eyeglasses, and clothes. V16 stated she reached out to the facility to address V8's concerns but has not heard back from anyone at the facility. Facility policy dated 11/28/2017, titled Abuse and Neglect documents in part, It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. 6. Financial/Misappropriation of property: financial abuse includes, but not limited to deliberate misplacement, misappropriation, exploitation or otherwise taking advantage of a resident's money or property temporarily or permanently. Must be reported includes theft of personal property, including but not limited to jewelry, computer, phone, and other valuable items such as eyeglasses and hearing aides. Facility policy dated 07/28/2023, titled Transfers and Discharges, documents in part, After transfer or discharge if it becomes clear the resident will not return to the facility, facility staff will pack the former resident's belongings within 24 hours . the former resident's belongings will be safely stored by the facility for no less than 30 days or no more than 60 days. Facility policy dated 07/28/2023, titled Personal Belongings List documents in part, It is the policy of the facility to protect the resident's belongings from being misplaced and from theft. In order to prevent this, the facility will ensure that the resident's belongings are tracked accurately. 5. All missing items alleged as missing by the resident or family member will be investigated thoroughly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 If continuation sheet Page 3 of 5 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report and investigate misappropriation of property for one (R2) of three residents reviewed for misappropriation of resident property. Residents Affected - Few Findings include: On 09/30/203 at 12:05 PM, V8 (R2's family member) stated that approximately at the end of August 2023, she informed V3 (Social Services Director) and V4 (Social Services Coordinator) of R2's missing money totaling $49 dollars and R2's missing belongings. V8 stated that she had been in contact with V3 and V3 told her that R2 did not have any belongings at the facility. V8 stated she had been in contact with V4 and V4 stated that he would follow up with V8 regarding R2's missing belongings. V8 stated it had been weeks since she heard anything so she contacted V1 (Assistant Administrator) and told V1 about R2's missing belongings. On 09/30/2023 at 3:35 PM, V1 (Assistant Administrator) stated she did not report allegations of theft to the state agency and was currently in the process of reporting to the state agency. V1 states she did not report this because the term theft was never mentioned to her by R2's family whom V1 has been speaking with. V1 stated she was made aware by V8 (R2's family member) of R2's missing money and belongings on 09/20/2023. V1 stated that based on surveyor's questions and inquiries of theft, she would file a report with the state agency, surveyor does not consult V1 on any actions to take. Facility reported incident reviewed for the past 3 months and does not document a report of theft or misappropriation of property for R2. Facility policy dated 11/28/2017, titled Abuse and Neglect documents in part, It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. V. Investigation: Investigate all allegations of abuse, neglect, exploitation, and misappropriation of property. Thorough documentation of the investigation. VII. All allegations and/or suspicions of abuse must be reported to the administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 If continuation sheet Page 4 of 5 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide their bed hold policy, upon discharge to hospital, for one (R2) of three resident reviewed. Findings include: R2's medical record (Face Sheet, MDS/Minimum Data Set, dated [DATE] documents R2 is a [AGE] year-old male who is cognitively intact with a BIMS/ Brief Interview for Mental Status score of 14/15. R2 has diagnoses not limited to: metabolic encephalopathy, dysphagia, schizoaffective disorders, major depressive disorder, atrial fibrillation, chronic kidney disease, and post-traumatic stress disorder. On 10/01/2023 at 9:21 AM V10 (admission Director) stated I sent out a bed hold notification to management and it's a template that I always follow when I send out the bed hold notifications. I send this template out via email every time a resident goes out to the hospital. I am not familiar with the bed hold policy but I do not send anything directly to the resident or their families, I only send it internally to V11 (Hospital Liaison) and the managers. The facility is required to hold a residents' bed for 10 days during hospitalization in order to accommodate the resident. On 10/01/2023 at 1:55 PM, V1 (Assistant Administrator) states that a bed hold notification was not provided to R2 or R2's family. There is no documentation to show that R2 or R2's family was made aware of the facility's bed hold policy. Facility's policy dated 07/27/2023, titled Bed Hold and Readmission documents in part 1. The facility must inform the resident or family member being transferred of the duration of bed hold in writing. Facility policy dated 07/28/2023, titled Transfers and Discharges, documents in part, The resident will then be given a bed reserve policy upon discharge to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 If continuation sheet Page 5 of 5