Inspection·May 19, 2023

F 0600 - Level of Harm - Minimal harm or potential for actual harm Per investigation report, R3 immediately swung at R1 with her right hand. Per V19's signed document, R1 pushed R3 into the corner and R8 who was present held R1's back. R5 ran out of the door. R8's signed document reads that he witnessed R3 slap R1 across the face. R8's cognition is intact with brief interview of mental status score dated 04/07/2023 of 15. On 05/17/2023 at 09:19 AM, V3 (Social Service Director) stated, Regarding R3 hitting R1, it was reported to me by V7 (Director of Nursing) and V19 (Front Desk Receptionist), it happened on a weekend. R8 was also present, and it was captured by camera. R3 was seen hitting R1 near this area (motioning on her chest and lower neck area). There was no provocation that happened before hand. R3 did not say anything that made her hit R1. Per progress notes dated 04/17/2023 by V3 it was documented that on 04/16/2023 R1 was suddenly hit by R3. And that video surveillance footage was reviewed and confirmed that R3 was primary aggressor. V10 (Registered Nurse) on his progress notes dated 04/16/2023 documents R3 swung at R1. Residents Affected - Few Investigation dated 04/12/2023 document that R4 slapped R3 on the side of the face. On 05/16/2023 at 01:25 PM R4 stated, R3 kept calling me her friend but we never been friends. I was engaged with R6, and we (R4 and R6) are planning to get married. R3 knew about the arrangement but kept taunting me saying, you got a good man, I wish I had him. One time, R3 kept telling me that our marriage was off. I told R3 to leave me alone but R3 kept telling me. I hit R3 on the face (slapping motion). My hands were open not close, I did not even hit R3 with my fist. Yes, I told few of the staffs about what R3 was doing. Even during election for resident council, R3 was telling other residents that I assaulted her. Yes, I was re-elected as council president. We (R4 and R6) got married and plan to be discharge in this facility. Am I in trouble? I know I did something wrong when I hit R3. At 03:10 PM, R6 said in Spanish using his phone with an app that translate Spanish into English, No I did not get married, and I am single. I do not entertain crazy people. R6's cognition is intact with brief interview for mental status dated 05/10/2023 of 13. On 05/16/2023 at 01:42 PM. R3 said, R4 is my friend, one day R4 pulled me over and told me that she is going to get married to R6. And I think that did not happened. Then when I saw R4, I remember R4 was wearing a robe, I told R4, sorry things did not work out. R4 then became furious and came at me. R4 said, I curse you! I curse you! I curse you! You are the devil! Then R4 assaulted me, hits me so hard (performing a slapping motion on the right side of her face.) R4 slapped me on my ear that I think it bled. At first, I want to retaliate to R4 because I knew taekwondo, but I stopped myself. You know what I will just get a pole and tip R4's wig. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral 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 0600 - Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Few On 05/17/2023 at 09:41 AM. V3 (Social Service Director) stated, Initially, R4 was connected with R6, and they kept their relationship private. R4 made known to R3, which initially R3 congratulated. R6 denied that they that he has relationship with R4. Because R3 kept telling R4 about her relationship with R6. R4 slapped R3 on her face. We knew about this situation and did counseling to R4. We trusted R4 that she would communicate to us right away but instead she (R4) slapped R3. V3 (Social Service Director) progress notes are as follows: Dated 04/11/2023, it was documented that negative comments and instigation between R3 and R4 happened on 04/10/2023. R3 was commenting/questioning R4's relationship with R6 verbal exchange was noted. And that nursing staff intervention happened due to the incident. Per nursing report: R4 was being targeted by another female resident (R3) on 04/10/2023 making negative comments. Dated 04/13/2023, it was documented that R3 and R4 had verbal and physical altercation on 04/12/2023. R4 was the aggressor. Dated 04/14/2023, it documents that R3 stated that her (R3's) ear was bleeding as a result of the R4 slapping R3 on 04/12/2023. V4 (Social Worker) progress notes are as follows: Dated 04/11/2023 that was strike out on 04/17/2023 after incident that R4 slapped R3 on the face. It was documented that nurse on duty (NOD) informed V4 that there was a heated argument between R3 and R4 regarding R6. And that heated argument between R3 and R4 could have turned physical. R4 reported that R3 is bullying her (R4) making R4 very angry and aggressive. V18 (Licensed Practical Nurse) progress notes dated 04/14/2023 documents that R3 reported that she had an ear bleeding. During V18 assessment not bleeding was found. V20 (Licensed Practical Nurse) progress notes dated 04/12/2023 documents, R3 went to Nurse's Station and said that R4 struck her in the lobby. R3 said, I said hello to R4 and R4 started screaming and smacked the side of my face. I just want her (R4) out of the building. Investigation dated 05/16/2023 R5 alleged that his roommate R7 pushed him R5 against the drawer. On 05/16/2023 at 12:20 PM, V13 was asked where is R5? V13 replies that R5 may have gone out on pass because R5 is allowed to go out on his own. At 03:20 PM, V4 (Social Worker) and R5 was seen inside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the same room where R7 was seen earlier. R5 was sitting on his wheelchair, R5 has amputation of both of his legs, smelling with alcohol, arguing with V4 verbally aggressive. V4 left and R5 said, I am not drunk! I took a drink a little bit, but I am not drunk. I am upset of my roommate, he (R7) hit me 6 months ago and also hit me today. I told V5 about it but she did not do anything. R5 does not respond to question when asked. And continue to be verbally aggressive. V5 was asked and denied that R5 told her R7 hit him. V4 then went to the Nurse's Station and informed V5 that R5 was having problem with breathing. R5 was left alone and was holding the rails on the wall from his wheelchair that made him fall on the floor. V6 (Registered Nurse) went to R5 and took vital signs. R5 was helped by V5 and V6 backed to his wheelchair. V5 said that R5 was intoxicated with alcohol drinks. V6 also said she can smell alcohol from R5. V6 said that since R5 goes out on pass he has access to buy alcoholic drinks. V4 (Social Worker) progress notes are as follows: Dated 04/28/2023 documents that R5 have ½ pint of alcohol and might be drunk. Dated 05/16/2023 documents that R5 told V4 that R7 pushed him against his drawer. On 05/17/2023 at 09:53 AM. V3 (Social Service Director) said, R5 had incident of alcohol intoxication, and this is the second one in one month. On May 13 R5's privilege was reinstated. But this problem is twice on one month. Yesterday, I spoke to R5 before you came. R5 admitted that he was taking alcohol. And asked me if I will suspend his out on pass privilege? I said yes then R5 became upset. R5 was involuntary discharge yesterday. R5 mentioned to me he does not want his roommate. On 05/17/2023 at 10:09 AM. V4 (Social Worker) said, Yes, R5 informed me between 10 to 11 AM about the incident with his roommate (R7). R5 said that they did not get along because his R7 can be aggressive. R5 said that R7 was physically aggressive towards him, pushing him towards the dresser. If it is true, pushing another person towards the drawer is abuse. V4 was asked why R5 and R7 was not separated and still on the same room after allegation of abuse? V4 said, I cannot say to that because I am not in-charge of changing rooms. I looked to my supervisor (V3) but was not able to find her. I did not tell the nurse or anyone because I was looking for my supervisor. R7 was also aggressive with V18 (Licensed Practical Nurse) that was when I knew who R7 was. I was asking staff trying to find R7, then I saw R7 at the Nurse's Station being aggressive to V18. I agree, not separating R5 from R7 will be a problem waiting to happen. On 05/18/2023 at 10:04 AM. V1 (Administrator) said, I understand that it is abuse when a person slaps another person, but you have to understand we did what is right. We reported it, we investigated it. We are trying out best. I agree if someone slaps me on the face, I will feel bad. As to R5 we should have separated him from R7. I guess we are just busy during that time. Abuse policy dated 05/16/2023 as reviewed, in part reads: Abuse is defined as the willful infliction of injury with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Resident who allegedly abused another resident will be removed from contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral 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 0600 Level of Harm - Minimal harm or potential for actual harm with other residents during course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 5 of 5