Inspection·May 13, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported she arrived to the scene of the incident late and observed R1 sitting down on the ground with staff around and another staff member told her to stop following him then she and another staff got in the car; V8 (Certified Nursing Assistant) reported R1 left the facility against medical advice and was acting abnormal, she got in her car to see what was going on and saw R1 running backwards waving his middle fingers then trip over a rock, then staff told them to stop following the resident and she got back in her car with another staff member and returned to the facility. On 05/06/2025 at 1:52 PM R1 stated when he left the faciity on [DATE] he ran away from the facility between 4-5PM, the nurses were chasing him, he got halfway down the block, a lady nurse caught him, and he told her he had to sit down because he was winded. R1 stated he sat down and crossed his legs Indian style. R1 stated just before he ran away from the facility, he was in the hall just thinking and then walked through the double doors and left the facility. R1 stated he ran away because he was just upset with everything going on in the facility. R1 stated one of the female nursing staff wouldn't let him get his phone, R4 was holding onto his phone and using it because he owes him money for coffee etc . R1 stated they were yelling that he escaped like some kind of inmate or something. R1 stated after being slammed on the ground he heard nurses say V4 (Clinical Director) said let him go and let's go. On 05/06/2025 at 2:10 PM V9 (Psychosocial Rehabilitation Services Coordinator) stated on 05/05/2025 she was notified that R1 walked out of the facility. V9 stated V5 (Certified Nursing Assistant) and V7 (Certified Nursing Assistant) went out to get R1. On 05/06/2025 at 2:18 PM V4 (Clinical Director) stated V9 (Psychosocial Rehabilitation Services Coordinator) notified him by phone that R1 left the facility. V4 stated he advised that R1 is alert and oriented if he doesn't return and if he does return, he would need to be sent out for evaluation. On 05/06/2025 at 3:45 PM V7 (Certified Nursing Assistant) stated she responded when she heard a code called while in the facility, went down the street to where R1 was, saw R1 sitting on the ground, and saw V8 (Certified Nursing Assistant) and V11 (Housekeeping) were standing by him. V7 stated she observed a lot of cars stopped on both sides of the street where R1 and staff were located. V7 stated one of the other CNA's (Certified Nursing Assistants) called V4 (Clinical Director) who advised since R1 was so far away to let him go. V7 stated she and V5 (Certified Nursing Assistant) then left together in V5's car and returned to the facility. V7 stated V8 and V11 remained with R1 at this time. On 05/06/2025 at 3:53 PM V8 (Certified Nursing Assistant) stated before R1's elopement incident she was assigned to the wing he was located on and was about to go on break. V8 stated she was heading to her car in the parking when she saw R1 running across the parking lot. V8 stated she then called the facility phone and V5 (Certified Nursing Assistant) answered and had already called the elopement code. V8 stated she headed towards R1 and calmed him down and he sat down, then she observed V11 (Housekeeping) and V5 come outside during that time. V8 stated V11 attempted to catch R1 and he was still near the building in the grassy area and he was on the ground sitting there saying he didn't want to come back in and wanted to go to the hospital for psych. V8 stated V11 reached R1 before she did and R1 was waving his middle fingers on both hands at V11 and then tripped and fell. V8 stated while R1 was waving his hands V11 tried to grab R1 by the shirt however he only has one arm, and it was difficult to grab him so she reached out and caught him. V8 stated V11 couldn't catch R1, he was about to run out in the street, so she grabbed his shirt and R1 sat down. On 05/06/2025 at 4:17 PM V11 (Housekeeping) stated prior to R1's elopement incident he was in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 2 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dining room, heard a code, and by the time he arrived at the door R1 was already at the stop sign outside the building. V11 stated he ran after R1 and attempted to tap him on the shoulder and ask him sir can I bring you back to the facility, however R1 took off running. V11 stated maybe R1 ran because he didn't know who he was. V11 stated when R1 initially took off running, he caught up to R1 and asked him to return to the facility but was out of breath and R1 took off running again. V11 stated during the process of fleeing R1 rolled a couple of times and kept getting back up. V11 stated R1 took off running again and fell backwards right next to the street and cars were stopping out of concern. V11 stated R1 was 10-15 feet away from him when he fell and V8 pulled up and got out of the car and she kind of grabbed his arm to try and get him out of the street. V11 stated after that R1 was on the gravel by the apartments and by the time he walked up to V8, R1 was sitting down and cooperative and saying he didn't want to return to the facility. V11 stated a couple of other aides pulled up to the scene and were on the phone with V4 (Clinical Director) who told them just let R1 be. On 05/07/2025 at 4:02 PM V5 (Certified Nursing Assistant) stated prior to R1's elopement incident she was sitting at the front lobby looking down and looked up and asked R1 where he was going. V5 stated R1 responded he was going home and proceeded to walk out of the building. V5 stated she called a code W and V11 (Housekeeper) responded and went out to get R1. V5 stated she went out to assist along with other staff. V5 stated when she arrived R1 was on the ground and staff reported he tripped and was almost hit by a car. V5 stated when she arrived, she observed a long line of cars that seemed to be wanting to know what was going on. V5 stated R1 got up and fell again. V5 stated she spoke with a social services staff that sat in her place at the front desk during the incident and they informed her that V4 (Clinical Director) instructed them to just let R1 go, he had a right to leave and them trying to make him come back was against his rights. On 05/12/2025 at 2:26 PM V4 (Clinical Director) confirmed R1 was not an elopement risk and had made no request for outside pass privileges. V4 stated R1 had not been outside the facility independently since he never made the request. V4 stated R1 had not met the outside pass criteria because he hadn't attended any programming. V4 stated if R1 wished to leave for fresh air he could have inquired with staff or let someone know. V4 stated if residents attempt to leave the facility unauthorized, they try to encourage residents, go talk to them to find out what is the problem and how can we solve it. V4 stated R1 was calm and never exhibited the behavior of attempting to leave the facility without authorization before and it was appropriate for staff to run to catch up to him to assess his state of mind and show concern for his safety. V4 stated if when staff caught up to R1 he didn't want to engage they have to respect that. V4 stated if the resident is waving their hands in defiance when staff are attempting to get them to return to the facility after leaving unauthorized, we should respect that because that could create a worse outcome. V4 stated when staff notified him of R1 leaving the facility unauthorized he advised they can't force him to return to the building. The facility's Managing Behavior Policy dated 10/01/2023 and received 05/12/2025 states: This policy is designed to provide guidance for managing challenging behaviors in residents while ensuring their dignity, safety, and well-being. Behavioral interventions aim to prevent and de-escalate situations without resorting to restraint. These guidelines help staff address the needs of the residents with mental health conditions or other behavioral challenges in a person-centered and respectful manner. De-Escalation Techniques: Staff will be trained in de-escalation methods including verbal redirection, distraction, and active listening, to prevent escalation of behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 3 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedures for behavior and substance abuse management by not adequately monitoring and communicating suspected or observed substance use in the facility; not conducting room searches per the facility's protocol of reported suspicion of substance abuse; not referring suspected substance abuse to law enforcement; and not identifying or implementing personalized care plan interventions for prevention of suicidal/self-harming behavior and substance use. This failure applied to two of two (R1, R4) residents reviewed for supervision and resulted in R1 and R4 testing positive for drug use while in the facility and R1 engaging in self-harming behavior. Findings include: 1. R1 is a [AGE] year-old male with a diagnosis history of Severe Bipolar Disorder with Psychotic Features, Generalized Anxiety Disorder, Hypertensive Heart Disease Without Heart Failure, Cannabis Use, and Nicotine Dependence who was admitted to the facility 04/11/2025. R1's admission Hospital Records dated 04/08/2025 document he was admitted for psychiatric evaluation 04/01/2025 due to suicidal ideations with plan to walk into traffic, burning himself with a lighter and was noted with a history of severe mental illness, previous suicide attempts and hospitalizations and cannabis use; he had 5 prior hospitalizations with the last one being at a Behavioral Health Facility in 2024; he shared that he began burning himself on Sunday because it provided relief of his symptoms; he has a history of three prior suicide attempts via overdosing and walking into traffic with the most recent attempt within the last year, a history of self-harm including burning and cutting; reported using cannabis daily and last cocaine use of 15 years ago; noted with poor insight, judgment, and impulse control; he has a substance abuse history of cannabis and reported last using cocaine 15 years ago. R1's PASRR I (Preadmission Screening and Resident Review) dated 04/08/2025 documents his current Mental Health Diagnoses include Recurrent Severe Major Depressive Disorder, Anxiety Disorder, Schizophrenia, and Cannabis Use; he exhibited self-injurious behavior within the past 30 days and reports depressive symptoms including hopelessness, helplessness, worthlessness, guilt, anhedonia (lack of pleasure or interest in doing things that used to be pleasurable), apathy, lack of motivation, lack of energy, concentration difficulties, anxiety symptoms within the past 30 days. R1's PASRR II (Preadmission Screening and Resident Review) dated 04/10/2025 documents he was admitted to the hospital on [DATE] for thoughts of ending his own life; his long term goal is placement where he is able to receive mental health support; a wellbeing assessment indicated he may have depressive symptoms; he has a history of psychiatric hospitalizations; he enjoys anything that has to do with nature and the outdoors, hiking and going for long walks and a good day is when the sun is shining; he may benefit from a plan to keep himself and others safe and he may benefit from psychotherapy to decrease mental health symptoms. R1's admission Hospital Records dated 04/11/2025 document a diagnoses history of Depressive Type Schizoaffective Disorder, Cannabis Use Disorder, Non-Suicidal Self Harm, and Thoughts of Self Harm. R1's admission Progress Notes dated 04/11/2025 documents he is a [AGE] year-old male with a history (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 4 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 of Marijuana and cigarette use. Level of Harm - Actual harm R1's admission progress note dated 04/22/2025 he has a history and current diagnosis of drug/alcohol abuse, and has a history of Suicidal Ideations with intent, as well as mental health diagnosis. He also has a history of non-suicidal self-harm. Staff will continue to monitor and encourage him to comply with recommended and prescribed treatments across all disciplines. Residents Affected - Few R1's Community Access assessment dated [DATE] documents he does not desire independent access to the community. R1's Substance Use History assessment dated [DATE] documents he has no history of using Cocaine. R1's Suicidal Risk assessment dated [DATE] documents he has no history of suicide attempts. R1's Current Care Plan (initiated 04/16/2025) documents he has chronic health conditions, challenges, and bipolar disorder with current episode severe and depressed with psychotic features and factors that will require monitoring; social services will provide support and case management services and referral will be made to psychotherapeutic service providers with interventions of conducting appropriate assessments to promote knowledge and interventions to address identified areas of interest and follow person-centered care models that afford him as much initiative, control, and self-determination as possible. R1's Current Care Plan (initiated 04/24/2025) documents he is at moderate risk for suicidal ideation due to the last suicidal ideation hospitalization being prior to admission to this facility with interventions including social services to provide one to one counseling as needed and will continue to assess his risk level quarterly. R1's current care plan does not include personalized interventions for suicidal ideations or attempts or self-harm; does not include a history of substance abuse or interventions for substance abuse; does not include activities or personalized interventions based on past interests and preferences; and does not include a daily routine. R1's progress note dated 05/04/2025 at 4:52 PM documents the PRSC (Psychosocial Rehabilitation Services Coordinator) found him with 4 other residents huddled in a room violating facility rules. Resident was counseled and placed on monitoring. No documentation of attempt to conduct a room search, notification to the physician of suspicious behavior, request for specimen collection, referral to law enforcement, nor his response to interventions were noted. R1's progress note dated 05/05/2025 at 6:22 PM documents he eloped from facility and ran down the road. Staff attempted to get him to return to facility, resident refused; at 06:27 PM Writer was notified by staff that he had aggressive behavior and verbalized he had thoughts of harming himself. Assistant Director of Nursing was notified, resident to be transferred the hospital for evaluation. R1's Hospital Record dated 05/05/2025 documents he attempted to run away from the nursing home today because he did not feel he was getting the help he needed there; he stated he was able to get a lighter into the facility and continue burning himself, and watched as other patients were able to smoke crack; he states he began smoking marijuana again while there; Urine drug screen was positive for both cannabinoids and cocaine; he did not admit to using cocaine but stated that others at the nursing home were smoking it; R1 expressed suicidal ideations and exhibited self-harming behavior; he has a history of marijuana use disorder; R1 reported he wanted to leave the facility this evening stating I was there for help and I do not get help.; R1 also reports persistent drugs in the facility, and he acknowledges that he smoked marijuana at the facility; R1 stated he is not receiving the help he needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 5 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 - Actual harm Residents Affected - Few R1's progress notes and medical records from admission [DATE] until he transferred to the hospital 05/05/2025 do not include any documented counseling or conversations regarding substance use. Psychiatric Progress Notes for R1 requested by surveyor 05/13/2025 were not provided during the survey. 2. R4 is a [AGE] year-old male with a diagnosis history of Hypertensive Heart Disease, Psychoactive Substance Use, Suicidal Ideations, Bipolar Disorder, and Unspecified Convulsions who was admitted to the facility 09/11/2024. R4's admission Hospital Records dated 09/05/2024 documents he tested positive for Cocaine and has a Past Psychiatric History of Depression, Bipolar Disorder and Polysubstance Use Disorder including a history of using Cocaine and Alcohol; urinary drug screening results were positive for Cocaine; he was brought in for psychiatric evaluation due to complaints of depression and suicidal ideation with a plan to jump from a bridge with a chief complaint of nobody to talk to, they just throw the pills,; Severity of Illness Criteria includes severe/incapacitating substance abuse. R4's Current Care Plan Initiated 09/18/2025 documents he is an adult living with chronic health conditions, challenges, and psychoactive substance abuse and bipolar disorder that require monitoring with interventions including Staff to conduct appropriate assessments to promote knowledge and understanding of my past and to be able to formulate person-centered treatment interventions to address identified areas of interest; Identify if there are behaviors or factors from my past that should be considered in formulating my treatment plan. R4's current care plan does not include personalized interventions to address identified behaviors or factors from his past including triggers of substance abuse; does not include diversions from substance use or goals to achieve sobriety; and does not include an established routine. R4's Community Access Observation assessment dated [DATE] documents he may not access the community independently related to safety factor. R4's Behavioral progress note dated 01/14/2025 at 05:59 PM documents during a random room check, it was observed that he had cigarettes in an opened pack and more cigarettes with rolling paraphernalia on his bed. He had denied having these items upon initial questioning and remained in his room while the room search was completed. R4's progress note dated 01/25/2025 at 10:57 AM documents: Purpose of visit: Psychiatry follow up and medication management HPI: Patient report overall he has been doing well and describes current mood as good however reports disturbed sleep but not related to depressive mood, psychosis or anxiety and was demanding Seroquel to help me sleep R4 was educated there is no indication for Seroquel to be prescribed and was re-educated on sleep hygiene, he verbalized understanding and agreed; at 01:20 PM notes document R4 was sleep during the entire shift. Writer went to the room several times to encourage resident to allow them to take his blood pressure, but resident continued to sleep. No notification to the physician of suspicious behavior, nor implementation of interventions or his response to interventions were noted. R4's Behavioral progress note dated 01/28/2025 07:00 PM documents social services entered his room to initially speak with his roommate but smelled smoke among entry. Social Services will continue to monitor the resident's behaviors. No response to interventions were noted. R4's Behavioral progress note dated 01/31/2025 10:41 PM documents residents were observed in the main hall acting a bit strange and unusual prompting a wing room search. R4 was not in his room or on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 6 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 - Actual harm Residents Affected - Few his wing; found in another resident's room on another wing and he appeared to have contraband cuffed in his hand. PRSC (Psychosocial Rehabilitation Services Coordinator) asked him to relinquish items and he refused only giving up the lighter that he had in his hand. The other items remained. PRSC asked resident to go to the nurses station to get his vitals checks as his pupils appeared dilated; at 12:09 AM [Recorded as Late Entry on 02/01/2025 at 01:01 AM] R4 was petitioned to the hospital per physician's orders for a Psychiatric evaluation. R4's Hospital Record dated 02/02/2025 documents he was admitted [DATE] and he was involuntarily petitioned to the emergency department from the local nursing home for psychiatric evaluation; per the nursing home report he was suspected of bringing in contraband to the nursing home and his toxicology screen was positive for cocaine. R4's Behavioral progress note 05/04/2025 at 04:51 PM [Recorded as Late Entry on 05/06/2025 at 03:49 PM] Documents PRSC (Psychosocial Rehabilitation Services Coordinator) found resident with 4 other residents huddled in a room violating facility rules. Resident was counseled and placed on monitoring. No documentation of attempt to conduct a room search, notification to the physician of suspicious behavior, request for specimen collection, referral to law enforcement, nor his response to interventions were noted. Behavior Report Form dated 05/04/2025 documents R1, R5, R6, and R7 were observed huddled in a room together smoking and exhibiting behaviors of violating rules; they will continue to be monitored for behavior. No documentation of attempt to conduct a room search, notification to the physician of suspicious behavior, referral to law enforcement, nor their response to interventions noted. R4's progress notes and medical records from 01/14/2025 until 05/13/2025 when the survey was concluded, did not include any documented counseling or conversations regarding substance use, nor participation in substance abuse groups. Handwritten social services progress notes for R4 requested by surveyor 05/12/2025 were not provided during the survey. On 05/06/2025 at 1:52 PM R1 stated his main issue with the facility is all the partying. On 05/06/2025 at 2:10 PM V9 (Psychosocial Rehabilitation Services Coordinator) stated on 05/04/2025 she observed R1, R4, R5, R6 and R7, and in a room smoking and she forgot to add R4's name on the behavioral report form. V9 stated she notified V4 (Clinical Director). V9 stated when doing room searches, they found marijuana gummies in a female resident's room approximately 6-7 months ago, however that resident is no longer in the facility, they have received reports of marijuana smoking a few months ago and those residents are no longer in the facility. On 05/06/2025 between 9AM - 4PM in separate interviews V12 (Anonymous staff) reported on 05/04/2025 they observed R1, R4, R5, R6, and R7 smoking and the smell was not of cigarettes or marijuana; V14 (Anonymous Staff) reported they occasionally smell marijuana when monitoring residents rooms. On 05/07/2025 at 9:27 AM R1 stated he saw so much partying going on at the facility the night of 05/04/2025 he had to get out of the facility. On 05/07/2025 at 12:05 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 7 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 - Actual harm Residents Affected - Few R4 stated he had been in the facility since September, and he sees residents high in the facility. R4 stated it's easy to get drugs or alcohol through the room windows. R4 stated he does not use outside pass privileges. R4 stated he feels the facility does not monitor residents behaviors adequately. On 05/07/2025 between 9AM - 4PM in separate interviews V13 (Anonymous Staff) reported that they have seen Marijuana paraphernalia on multiple units including where R4, R5, and R6's rooms are located and has smelled pipes burning, they have seen behaviors that indicate residents might be under the influence of substances such as red partially closed eyes, on Sunday 05/04/2025 they smelled a burning pipe in the facility, and multiple residents have used drugs in the facility; V15 (Anonymous Staff) reported they have smelled Marijuana in the halls; V16 (Anonymous Staff) reported they have smelled Marijuana in the halls and it's difficult to determine the source; V17 (Anonymous Staff) reported they have smelled marijuana in the facility and nurses have also reported smelling it, residents have also reported other residents drug use in the facility; V18 (Anonymous Staff) reported that they have observed a marijuana smell in the halls near residents rooms and in residents rooms and sometimes they report this to the nurse or social worker and sometimes they don't because when they do report it no one does anything about it. On 05/12/2025 at 2:26 PM V4 (Clinical Director) stated R1 had not met the outside pass criteria because he hadn't attended any programming. V4 stated if residents show signs suspicious of substance use, they will want to alert the physician, might do a specimen draw and follow whatever the physician recommends. V4 stated signs of drug use include unusual odors, glassy eyes, unsteady gait, flight of speech, a lot of anxiety, and sometimes delusions. V4 stated odors of marijuana or other illegal substances would be cause for alarm and rooms should be searched. V4 stated if residents have not been outside and test positive for illegal substances that does indicate they got it somehow while in the facility. V4 stated the facility monitors residents behaviors through clinical rounds in the building looking out for safety issues which includes room searches. V4 stated social services documents soft notes when there are observations of potential substance use or room searches due to protection of the residents rights. On 05/13/2025 at 11:23 AM V4 (Clinical Director) agreed it is the facility's responsibility to monitor drug use while in the facility even if visitors are bringing in drugs or paraphernalia. V4 stated if they do find contraband or signs of substance use, they inform the physician or follow any recommendations the physician may have. V4 stated behaviors are documented once they're observed. V4 stated on 05/03/2025 when R1 received snacks from his friend staff were present, they received the snacks for him because there were too many for his room and there were no concerning items found. V4 stated yes when asked by surveyor if residents showing signs of substance use should receive increased monitoring which he stated would include performing room checks with these individuals more regularly. V4 stated the response to this behavior includes trying not to look at them as being targeted. V4 stated the approach is always to be positive and try to get the resident to look at the times in which they're sober and try to express we're concerned about their safety and wellbeing and encourage sobriety. V4 stated if residents are found with contraband or show signs of drug use searches are commenced. V4 stated increased monitoring would consist of routine room checks likely on a daily basis which they encourage residents to be present for. V4 stated he wouldn't say it is normal for R4 to be found with contraband. V4 stated the rolling paper R4 was found with on 01/14/2025 was cigarette rolling paper. V4 stated R4 doesn't usually exhibit any unusual behaviors. V4 stated R4 doesn't go outside the facility, he has back spasms and doesn't normally like to venture out. V4 stated R4 had not had any visitors that he is aware of. V4 stated the concern with the cigarette rolling paper R4 was found with would be it is contraband and smoking material. V4 stated none of the residents are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 8 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 - Actual harm Residents Affected - Few permitted to use Marijuana, that the facility is a drug and alcohol-free facility, and use of marijuana is illegal in the facility. V4 stated yes when asked by surveyor if a resident has a history of self-harm do they require specialized services. V4 stated specialized services would include involving the resident in psychosocial groups, they would also receive one to one social services counseling, would see the psychiatrist on a regular basis, as well as receive required medications. V4 stated care planned interventions for residents with a history of self-harm would include monitoring for any mood changes, encouraging them to take advantage of any open-door policies they have, clinical rounds from social services staff to assess residents mood and behavior which is ongoing. V4 stated these interventions would also include talking to the residents, monitoring them, interacting, asking them about their state of mind and reminding them staff do care and are available to talk. V4 stated there may not be documentation of these interactions and attempts unless there's an intense episode because some interactions only require minor conversation and interaction. V4 stated to his knowledge R1 did not have a history of refusing psychosocial services. V4 stated we do complete psychosocial progress notes that are not necessarily documented in the electronic health record system. The facility did not provide documentation of law enforcement notification of potential drug use in the facility at any time during the course of the survey. The facility's Managing Behavior Policy dated 10/01/2023 and received 05/12/2025 states: This policy is designed to provide guidance for managing challenging behaviors in residents while ensuring their safety, and well-being. The facility is committed to providing a safe and therapeutic environment for all residents. Behavioral interventions will be individualized, evidence based, and focused on identifying and addressing the underlying causes of behaviors. Behavioral Care Plan Development: if a resident exhibits challenging behaviors, an individualized behavioral care plan will be developed. This plan will be based on the resident's history, preferences, and identified triggers and will include specific interventions aimed at reducing the behavior. Personalized Activities: The resident will be offered therapeutic activities tailored to their preferences. Routine and Familiarity: Establishing consistent daily routines and using familiar caregivers can help reduce behaviors triggered by anxiety or confusion. Documentation and Reporting: Behavioral Incidents: All behavioral incidents, interventions used, and the resident's response will be documented in the residents medical record. The facility's Substance Use History Policy dated 04/08/2024 and received 05/12/2025 states: The purpose of the policy is To create an environment as free of accidents and hazards as possible for residents with history of substance abuse. When substance use is suspected, (in the facility) which could lead to overdose, facility staff should implement care plan interventions, which includes notification of the resident's physician or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 9 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 provider. Level of Harm - Actual harm If the facility determines through observation that a resident may have access to illegal substances that they have brought into the facility or secured from an outside source, these cases may warrant a referral to local law enforcement. Residents Affected - Few Care Planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the resident's health and/or safety. Residents with SUD (Substance Use Disorder) may try to continue using substances during their stay in the nursing home. Facility staff will assess the resident for the risk for substance use in the facility and have knowledge of signs and symptoms of possible substance that include, but are not limited to: Odors; Changes in residents behaviors including Unexplained Drowsiness. The facility's Residents Possession and Use of Illegal Substance Policy dated 04/08/2024 and received 05/12/2025 states: The possession and use of illegal substances by residents will not be tolerated. Facility staff will have knowledge of signs, symptoms, and triggers of possible illegal substance use, which includes but is not limited to: Changes in resident behavior; Increased, unexplained drowsiness. If the facility determines through observation that a resident may have access to illegal substances that they brought into the facility or secured from an outside source, the facility will not act as an arm of law enforcement. In accordance with state laws, a referral will be made to local law enforcement. To protect the health and safety of residents the facility will provide additional monitoring and supervision. The facility's Policy on Contraband Materials, Inspection of Rooms and Use of Recording Devices Policy received 05/12/2025 states: This organization reserves the right to conduct inspections if there is reason to suspect/believe that a resident has contraband items/materials in his/her possession. These items include, but are not limited to illicit (street or over the counter) drugs. In situations where illegal activity appears to have taken place appropriate authorities will be notified. Again, safety and security are of the utmost concern. The facility may choose, at its discretion, to involve drug sniffing dogs if residents are suspected to be trafficking drugs inside the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 10 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedures for behavior and substance use management by not ensuring residents with a significant history of self-harm, suicidal behavior, and substance use received therapeutic mental health or substance abuse counseling or services; not establishing personalized care planned interventions for these behaviors based on identified causes of behaviors, preferences and individual interests; and not performing timely assessment of substance abuse history to apply knowledge and understanding of past and development of person-centered treatment interventions. This failure applies to two of two residents (R1 and R4) reviewed for behavioral health services. Residents Affected - Few Findings include: 1. R1 is a [AGE] year-old male with a diagnosis history of Severe Bipolar Disorder with Psychotic Features, Generalized Anxiety Disorder, Hypertensive Heart Disease (04/11/2025) Without Heart Failure, Cannabis Use, and Nicotine Dependence who was admitted to the facility 04/11/2025. R1's admission Hospital Records dated 04/08/2025 document he was admitted for psychiatric evaluation 04/01/2025 due to suicidal ideations with plan to walk into traffic, burning himself with a lighter and was noted with a history of severe mental illness, previous suicide attempts and hospitalizations and cannabis use; he present to the emergency department on 04/01/2025 for suicidal ideations and self-harming behavior of burning himself with a lighter on Sunday; he shared that he began burning himself on Sunday because it provided relief of his symptoms; he reported depressive symptoms including hopelessness, helplessness, worthlessness, guilt, and anhedonia (ability to experience pleasure or enjoyment from activities that would normally be pleasurable), apathy, no motivation, no energy, concentration difficulties, anxiety symptoms including excessive worrying, difficulty relaxing, racing thoughts, and intermittent panic and a history of self-harm including burning and cutting; he had 5 prior hospitalizations with the last one being at a Behavioral Health Facility in 2024; he has a history of three prior suicide attempts via overdosing and walking into traffic with the most recent attempt within the last year and a history of self-harm including burning and cutting; he has a substance abuse history of using cannabis and reported using cannabis daily and reported last using cocaine 15 years ago; he was noted with poor insight, judgment, and impulse control; he was noted to express feeling he received significant benefit from being hospitalized and receiving treatment and wanted to remain hospitalized for the full duration of his acute series ECT (Electroconvulsive Therapy), was anxious about discharging too soon due to fear of decompensating and resuming intrusive thoughts and was worried he may self-harm again if he left treatment too soon; Education and Therapeutic Programming recommendations included Participation in psychotherapeutic groups, individual counseling and encouragement to participate in groups; R1 expressed he normally attends groups and was noted to attend groups; R1 expressed he felt he had significant benefit from being hospitalized and receiving treatment. R1's PASRR I (Preadmission Screening and Resident Review) dated 04/08/2025 documents his current Mental Health Diagnoses include Recurrent Severe Major Depressive Disorder, Anxiety Disorder, Schizophrenia, and Cannabis Use; he exhibited self-injurious behavior within the past 30 days and reports depressive symptoms including hopelessness, helplessness, worthlessness, guilt, anhedonia (lack of pleasure or interest in doing things that used to be pleasurable), apathy, lack of motivation, lack of energy, concentration difficulties, anxiety symptoms within the past 30 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 11 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 - Minimal harm or potential for actual harm Residents Affected - Few R1's PASRR II (Preadmission Screening and Resident Review) dated 04/10/2025 documents he was admitted to the hospital on [DATE] for thoughts of ending his own life; his long term goal is placement where he is able to receive mental health support; a wellbeing assessment indicated he may have depressive symptoms; he has a history of psychiatric hospitalizations; he enjoys anything that has to do with nature and the outdoors, hiking and going for long walks and a good day is when the sun is shining; he may benefit from a plan to keep himself and others safe and he may benefit from psychotherapy to decrease mental health symptoms. R1's admission Hospital Records dated 04/11/2025 document a diagnoses history of Depressive Type Schizoaffective Disorder, Cannabis Use Disorder, Non-Suicidal Self Harm, and Thoughts of Self Harm; Discharge Instructions including Electroconvulsive Therapy and a referral to Human Resource Development Institute with details regarding programming/services of the Division for Addiction and Mental Health Treatment. R1's admission Progress Notes dated 04/11/2025 documents he is a [AGE] year-old male from local Hospital Patient with a diagnosis of Bipolar, schizophrenia and Vitamin D insufficiency. On examination patient is partially cooperative, with poor concentration and focus. Patient denies feeling depressed at this time but seems somewhat irritable and guarded. Patient currently denies any suicidal or homicidal ideations but appears to be impulsive. Resident has a habit of cutting himself for gratification. Resident has history of Marijuana and cigarette usage. R1's admission Minimal Data Set assessment dated [DATE] documents an active diagnosis of Non-Suicidal Self Harm, and Other Symptoms and Signs Involving Emotional State. R1's admission progress note dated 04/22/2025 documents he is a [AGE] year-old Caucasian male, admitted on [DATE] with admitting diagnoses of Bipolar disorder, current episode depressed, severe, with psychotic features, Vitamin D deficiency, Other symptoms and signs involving emotional state, Generalized anxiety disorder, Nicotine dependence, cigarettes, Cannabis use, Non suicidal self-harm and other medical diagnosis; he was admitted from the Hospital where he was seen for a psych evaluation due to Suicidal Ideations and Non suicidal self-harm; He also scored an 11/27 on the PHQ-9 (Patient Health Questionnaire) indicating moderate depression; Signs and symptoms of mood distress may be manifested by staying in room for long periods of time and lack of conversing with staff/fellow residents; he has a history and current diagnosis of drug/alcohol abuse and has a history of Suicidal Ideations with intent, as well as mental health diagnosis; He also has a history of non-suicidal self-harm; Staff will continue to monitor and encourage R1 to comply with recommended and prescribed treatments across all disciplines. R1's Substance Use History assessment dated [DATE] documents he has no history of using Cocaine. R1's Suicidal Risk assessment dated [DATE] documents he has no history of suicide attempts. R1's Current Care Plan (initiated 04/16/2025) documents he has chronic health conditions, challenges, and bipolar disorder with current episode severe and depressed with psychotic features and factors that will require monitoring; social services will provide support and case management services and referral will be made to psychotherapeutic service providers with interventions of conducting appropriate assessments to promote knowledge and interventions to address identified areas of interest and follow person-centered care models that afford him as much initiative, control, and self-determination as possible. R1's Current Care Plan (initiated 04/24/2025) documents he is at moderate risk for suicidal ideation due to the last suicidal ideation hospitalization being prior to admission to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 12 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 - Minimal harm or potential for actual harm this facility with interventions including social services to provide one to one counseling as needed and will continue to assess his risk level quarterly. R1's current care plan does not include personalized interventions for suicidal ideations or attempts or self-harm based on underlying causes of behaviors; does not include a history of substance abuse or interventions for substance abuse; does not include activities or personalized interventions based on past interests and preferences; and does not include a daily routine. Residents Affected - Few R1's Current Physician Order History did not include orders for referral to the Human Resource Development Institute or any other substance abuse programming. R1's Behavioral Progress Note dated 05/04/2025 at 4:52 PM documents PRSC (Psychosocial Rehabilitation Services Coordinator) found him with 4 other residents huddled in a room violating facility rules. R1's Behavioral Progress Note dated 05/05/2025 at 06:22 PM documents he eloped from facility and ran down the road. Staff attempted to get him to return to facility, resident refused; at 06:27 PM writer was notified by staff that he had aggressive behavior and verbalized he had thoughts of harming himself. Referred to counselor, redirected and no further aggressive behavior noted. Assistant Director of Nursing was notified, and he was to be transferred to the hospital for evaluation; at 07:00 PM R1 was petitioned out for psych evaluations due to Suicidal Ideations. R1's Hospital Record dated 05/05/2025 documents he was admitted last month for treatment of schizoaffective disorder/depression/ and suicidal ideation which included at least 4 separate ECT (Electroconvulsive Treatments) which seem to be helping; he attempted to run away from the nursing home today because he did not feel he was getting the help he needed there; he stated he was able to get a lighter into the facility and continue burning himself, and watched as other patients were able to smoke crack and verbally abuse him; he states he began smoking marijuana again while there; Urine drug screen was positive for both cannabinoids and cocaine; he did not admit to using cocaine but stated that others at the nursing home were smoking it; Clinical Impression included, self -harm, cocaine abuse, depression, and essential hypertension; R1 arrived via EMS (Emergency Medical Service) from the nursing facility and per EMS he tried to elope from the facility with suicidal ideations; Per petition completed by the nursing facility R1 expressed suicidal ideations and exhibited self-harming behavior; he has a history of marijuana use disorder; R1 reported he wanted to leave the facility this evening stating I was there for help, and I do not get help.; Type of Treatment Recommendation included Mental Health with Reasons for Level of Treatment including R1 having ineffective coping skills, inability to maintain stability without sessions, support; therapeutic contact required to achieve/maintain treatment goals, and requiring application of recovery skills in a structured therapeutic environment. Initial Abuse Investigation report dated 05/07/2025 documents a nurse notified V2 (Director of Nursing) that R1 had aggressive behavior and verbalized having thoughts of harming himself, and he was transferred to the Hospital for evaluation; V8 (Certified Nursing Assistant) reported R1 left the facility against medical advice and was acting abnormal. R1's progress notes and medical records from his admission [DATE] until he was transferred to the hospital 05/05/2025 did not include documentation of referral to a psychiatrist or psychotherapist, group therapy participation, or any substance abuse programming or whether he was offered or refused these services, nor attempts to provide activities based on identified preferences and interests and the facility could not provide any record of this information when requested 05/12/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 13 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 Psychiatric Progress Notes for R1 requested by surveyor 05/13/2025 was not provided during the survey. Level of Harm - Minimal harm or potential for actual harm 2. R4 is a [AGE] year-old male with a diagnosis history of Hypertensive Heart Disease, Psychoactive Substance Use, Suicidal Ideations, Bipolar Disorder, and Unspecified Convulsions who was admitted to the facility 09/11/2024. Residents Affected - Few R4's admission Hospital Records dated 09/05/2024 documents he tested positive for Cocaine and has a Past Psychiatric History of Depression, Bipolar Disorder and Polysubstance Use Disorder including a history of using Cocaine and Alcohol; he was brought in for psychiatric evaluation due to complaints of depression and suicidal ideation with a plan to jump from a bridge with a chief complaint of nobody to talk to, they just throw the pills,; Severity of Illness Criteria including suicidal, self-injurious threats, gestures or behaviors, and severe/incapacitating substance abuse; urinary drug screening results were positive for Cocaine. R4 PASRR Level I Screening Dated 09/05/2024 documents he has a history of cocaine use with last use within less than 7 days of the assessment. R4's PASRR Level II Screening Dated 09/08/2024 documents he has a diagnosis history of Bipolar Disorder; his mental health symptoms include hopelessness, increased worries, behaviors others find unpredictable, suicidal ideations, a history of using cocaine with last known use less than seven days of assessment, and alcohol; a behavior management plan could help the nursing home staff if you have thoughts of hurting yourself; One on one meetings with a psychiatrist or social worker can help you talk about and understand why you may feel depressed and anxious and will help you find ways to cope with your symptoms and group therapy led by a social worker will allow you to be around others who share similar experiences as you; it is important for staff to recognize the presence of depressive symptoms, increased anxiety, or changes in behaviors as early signs that he may need to be seen by his doctor or psychiatrist; services needed if returning to the community include Substance Use (Outpatient, Day Treatment, Detox, Residential, etc.); Substance use counseling can provide support and help him learn coping skills that eliminate the need for substance use. R4's Current Care Plan Initiated 09/18/2025 documents R4 is an adult living with chronic health conditions, challenges, and psychoactive substance abuse, and bipolar disorder that require monitoring. Social services will provide support and case management services and referral will be made to psychotherapeutic service providers as required to address areas of identified needs in order to maintain highest practicable level of stabilization with interventions initiated of connect him to psychosocial group programming so that he may acquire skills and address his psychopathology; and his social services advisors will meet with him to provide him with individual support to discuss and address needs and overall case management services; Refer him /connect him to mental health care through individual and/or psychosocial group programming as required; Staff to conduct appropriate assessments to promote knowledge and understanding of his past and to be able to formulate person-centered treatment interventions to address identified areas of interest; Identify if there are behaviors or factors from my past that should be considered in formulating my treatment plan. R4's current care plan does not include personalized interventions to address identified behaviors, underlying causes of substance use, or factors from his past including triggers of substance abuse; does not include diversions from substance use, goals for sobriety, or alternatives to any substance use; and does not include an established routine. R4's Behavioral Progress Note dated 01/14/2025 at 05:59 PM documents he had cigarettes in an opened (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 14 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 - Minimal harm or potential for actual harm Residents Affected - Few pack and more cigarettes with rolling paraphernalia on his bed. He had denied having these items upon initial questioning and remained in his room while the room search was completed. His smoking privileges will be suspended. No redirection, education or response to interventions were noted. R4's progress note dated 01/25/2025 at 10:57 AM documents: Purpose of visit: Psychiatry follow up and medication management: Patient reported overall he has been doing well and describes current mood as good however reports disturbed sleep but not related to depressive mood, psychosis or anxiety and was demanding Seroquel to help me sleep. R4 was educated there is no indication for Seroquel to be prescribed and was re-educated on sleep hygiene, he verbalized understanding and agreed; at 01:20 PM notes document R4 was sleep during the entire shift. Writer went to the room several times to encourage resident to allow them to take his blood pressure, but resident continued to sleep. R4's Behavioral Progress Note dated 01/28/2025 at 07:00 PM documents social services entered his room to initially speak with his roommate but smelled smoke among entry. Caseworker explained behavioral expectations while admitted to this facility to the resident and social services alerted the Clinical Director regarding this matter. Social services will continue to monitor the resident's behaviors. R4's Behavioral Progress Note dated 01/31/2025 10:41 PM documents residents were observed in the main hall acting a bit strange and unusual prompting a wing room search. R4 was not in his room or on his wing and was found in another resident's room on another wing. R4 appeared to have contraband cuffed in his hand. PRSC (Psychosocial Rehabilitation Services Coordinator) asked resident to relinquish items and he refused only giving up the lighter that he had in his hand. The other items remained. PRSC asked resident to go to the nurses station to get his vitals checks as his pupils appeared dilated; at 12:09 AM [Recorded as Late Entry on 02/01/2025 01:01 AM] it notes he was petitioned to the Hospital per physician's orders for a psychiatric evaluation. R4's Behavioral Progress Note dated 05/04/2025 at 04:51 PM [Recorded as Late Entry on 05/06/2025 03:49 PM] documents PRSC (Psychosocial Rehabilitation Services Coordinator) found resident with 4 other residents huddled in a room violating facility rules. Resident was counseled and placed on monitoring. R4's progress notes and medical records from 01/14/2025 until 05/13/2025 when the survey was concluded, did not include any documented counseling or conversations regarding substance use, nor participation in substance abuse groups or outside therapeutic substance abuse programs. Handwritten social services progress notes for R4 requested by surveyor 05/12/2025 were not provided during the survey. R4's Substance Use assessment dated [DATE] documents he has a history of Cannabis use, Cocaine Use, and Alcohol Use; Substance Use Treatment he has participated in include Detox, Outpatient Counseling, and Inpatient Treatment; his most recent substance use treatment took place at an outside Treatment Center and he reported being able to speak on mental health issues and usage was very helpful; he currently participates in multiple psychosocial groups within the facility; he feels his substance use needs to be worked on. On 05/06/2025 at 1:52 PM R1 stated Just before he ran away from the facility, he was in the hall just thinking and then walked through the double doors and left the facility. R1 stated he ran away because was just upset with everything going on in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 15 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 - Minimal harm or potential for actual harm Residents Affected - Few On 05/07/2025 at 11:13 AM V8 (Certified Nursing Assistant) stated on the day R1 left the facility unauthorized 05/05/2025 he was screaming he wanted to kill himself and burning his hand with cigarettes. On 05/07/2025 at 12:05 PM R4 stated he had been in the facility since September, and he sees residents high in the facility. R4 stated it's easy to get drugs or alcohol through the room windows. R4 stated the facility just recently began offering substance abuse class. R4 stated the facility's favorite thing to do is send you to the hospital. On 05/12/2025 at 2:26 PM V4 (Clinical Director) stated residents have to be in compliance with medications, room care, diet, behavior, receive a community assessment, and attend some psychosocial groups to improve anxiety, communication skills, safety awareness, and symptom management to be eligible for outside pass privileges. V4 stated R1 had not met the outside pass criteria because he hadn't attended any programming. V4 stated he will check his notes on whether R1 was offered services and what his responses to those offers were. V4 stated interventions for residents with a substance abuse history include counseling/psychosocial programming, rounds, supervising them, encouraging them to set goals for sobriety, and identifying alternatives to any substance use. V4 stated social services has been doing a lot of one-on-one counseling and an alternative lifestyle choices program which is for substance abuse has been in effect for close to a month. V4 stated prior to this program the facility would refer residents to community partners programs that offer supportive counseling for substance abuse, however, they are scarce, and some have to be paid for. V4 stated one to one social services counseling is provided by the facility's PRSC's (Psychosocial Rehabilitation Services Coordinators). V4 stated the PRSC's are not licensed in substance abuse counseling. V4 stated at one point in time the facility did have licensed substance abuse counselors come in to provide services however this hasn't been available due to these resources being limited and due to some of them requiring payment. On 05/13/2025 at 11:23 AM V4 (Clinical Director) stated yes when asked by surveyor if a resident has a history of self-harm, they do require specialized services. V4 stated specialized services would include involving the resident in psychosocial groups, they would also receive one to one social services counseling, would see the psychiatrist on a regular basis, as well as receive required medications. V4 stated care planned interventions for residents with a history of self-harm would include monitoring for any mood changes, encouraging them to take advantage of any open-door policies they have, clinical rounds from social services staff to assess residents mood and behavior which is ongoing. V4 stated these interventions would also include talking to the residents, monitoring them, interacting, asking them about their state of mind and reminding them staff do care and are available to talk. V4 stated there may not be documentation of these interactions and attempts unless there's an intense episode because some interactions only require minor conversation and interaction. V4 stated to his knowledge R1 did not have a history of refusing psychosocial services. V4 stated we do complete psychosocial progress notes that are not necessarily documented in the electronic health record system. V4 stated R4 was offered emotional anxiety, management, and communications and the soft approach for sobriety groups as well. V4 stated R4 is participating in the new group for substance use that is nearly a month old. V4 stated the activities department assesses residents for past activities and hobbies and this would be included in their care plan. V4 stated this information would be pretty important to include in a residents care plan who has a history of self-harm and substance abuse. V4 stated if residents refuse psychosocial programs and one to one counseling other options include participation in resident counsel, games or activities would be offered, and they would make resources available for more choices in their interests. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 16 of 17 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 Managing Behavior Policy dated 10/01/2023 and received 05/12/2025 states: Level of Harm - Minimal harm or potential for actual harm This policy is designed to provide guidance for managing challenging behaviors in residents while ensuring their dignity, safety, and well-being. Residents Affected - Few The facility is committed to providing a safe and therapeutic environment for all residents. Behavioral interventions will be individualized, evidence based, and focused on identifying and addressing the underlying causes of behaviors. Behavioral Care Plan Development: if a resident exhibits challenging behaviors, an individualized behavioral care plan will be developed. This plan will be based on the resident's history, preferences, and identified triggers and will include specific interventions aimed at reducing the behavior. Personalized Activities: The resident will be offered therapeutic activities tailored to their preferences. Routine and Familiarity: Establishing consistent daily routines and using familiar caregivers can help reduce behaviors triggered by anxiety or confusion. Documentation and Reporting: Behavioral Incidents: All behavioral incidents, interventions used, and the resident's response will be documented in the residents medical record. The facility's Substance Use History Policy dated 04/08/2024 and received 05/12/2025 states: Care Planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the resident's health and/or safety. Provide substance use treatment services such as behavioral health services, MAT (Medication Assisted Treatment - a treatment approach for substance use disorders that combines medication with counseling and behavioral therapies), as well as working with the resident and the family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 17 of 17