Health inspection·March 4, 2025

F 0600 minimally displaced left nasal bone fracture with adjacent soft tissue swelling. There is deviation of the nasal septum towards the left. Level of Harm - Actual harm Residents Affected - Few R1's Face Sheet documents, in part, diagnoses of paranoid schizophrenia, conduct disorder-aggressive behavior, unspecified psychosis, schizoaffective disorder (bipolar type), chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic mononeuropathy, anemia, epilepsy, hyperlipidemia, dysphagia, and hypertension. R1's MDS, dated [DATE], documents, in part, a Staff Assessment for Mental Status is documented, in part, of short-term memory problems, and R1's Cognitive Skills for Daily Decision Making as 2 which indicates moderately impaired - decisions poor; cues/supervision required. R1's Resident Census documents, in part, that R1 is on hospital leave as of 2/10/25 and was unable to be interviewed by this surveyor. On 2/26/25 at 10:46 am, R6 stated that that remembers the incident between R1 and R2 on 2/10/25 in the basement dining room. R6 stated, He (R1) hit her (R2). I (R6) was behind them. When asked who else was there in the basement dining room that day, R6 stated, Vending machine guy (V6, Vending Machine Driver/Stocker, Contract Vendor). R6 stated that R2 was sitting at the table in R2's wheelchair close to the vending machines, and that R1 was arguing with R2. R6 stated, He (R1) stands up and he (R1) hit her (R2). When asked if it was with a closed fists or open hand, R6 put up R6's closed hand in a fist to show this surveyor. R6 stated that no one else, facility staff or residents, were in the basement dining room on 2/10/25 when R1 hit R2. R6's Face Sheet documents, in part, diagnoses of hyperlipidemia, paranoid schizophrenia, asthma, and hypertension. R6's MDS, dated [DATE] and 11/13/24, document, in part, a BIMS score of 14 which indicates that R6 is cognitively intact. On 2/25/25 at 12:37 pm, V6 (Vending Machine Driver/Stocker, Contract Vendor) stated that V6 was restocking vending machine items in the facility on 2/10/25 in the basement dining room. When asked about the incident that occurred on 2/10/25 in basement dining room, V6 stated, A fight broke out. I (V6) don't pay much attention when I am stocking. I'm there to do my job. When asked if V6 heard or seen anything, V6 stated, A man (R1) was standing and throwing punches at a lady (R2). V6 stated, I (V6) heard and saw them arguing. When asked what argument was about, V6 stated, I saw they (R1 and R2) were pushing and trying to get into a box. When asked what box, V6 stated, I (V6) have a box (extra) that I put aside when I am restocking and use if for garbage. I will take it out when I am done. When asked did this extra box have food items in it, V6 stated, No, it was empty. V6 stated that his body was turned towards the vending machines (south wall) in the dining room, but the table that R2 was sitting at was right in front of the vending machines. V6 stated that V6 continued stocking and when V6 heard yelling, V6 turned around from stocking the vending machines and observed (R1) punching (R2). V6 stated that R1 was standing and that R2 was in the wheelchair. V6 stated, I knew that was trouble, so I ran out the door to call for help, and there was a lady (V5, Laundry Aide), by the elevator, who came in. When asked what did V6 tell V5, V6 stated, I told her (V5) what happened. The man (R1) was punching her (R2). On 2/24/25 at 3:04 pm, V5 (Laundry Aide) stated that on 2/10/25, V5 did not observed the incident with R1 and R2 in the basement dining room. V5 stated, I (V5) didn't see anything. I was at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 2 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 - Actual harm Residents Affected - Few elevator. In the basement to take stuff (clean laundry) upstairs. The vending machine man (V6) came out and asked for help. I ran in there (inside the basement dining room). I seen them. 2 residents (R1 and R2). They were separated already. (V6) said they (R1, R2) was fighting. I went to go get help. When asked what did V6 say to V5, V5 stated that V6 said, I need help. V5 stated that V6 saw V5 by the elevator in the basement hallway and that V6 ran into the last door (end of hallway) to dining room. When asked what did V5 see upon entering inside the basement dining room, V5 stated, There are residents. One man (R1) standing by the door (last door) and the lady (R2) in a wheelchair over by the table. I never saw a thing. I went to go get help. When asked was there anyone else in the basement dining room, V5 stated, It happened so fast. I (V5) just went back out to holler for help and he (V7, Maintenance Operations Director) came and got (R2). V5 stated that V7's office is in the basement and that V7 took over with the residents in the basement dining room. On 2/25/25 at 10:58 am, V7 (Maintenance Operations Director) stated that V7's office is in the basement on the east side of the building, and on 2/10/25, V5 alerted V7 that there was an altercation between a female and male resident in the basement dining room. V7 stated that V7 walked to the basement dining room and observed R2 wheeling out of the basement dining room with an injury to (R2's) face. When asked to elaborate, V7 stated that V7 saw a dark bruise under (R2's) eye and that R2 was not saying anything. V7 stated that V7 wheeled from the basement hallway into the elevator to bring R2 to V1's office on the main floor. V7 stated that V7 and V37 (Plant Operations Manager) then took elevator to R1 and R2's floor, where R1 was standing, and escorted R1 to R1's room. On 2/24/25 at 2:22 pm, V3 (Licensed Practical Nurse, LPN), stated that V3 has worked in the facility for about 6 years and is assigned to R1 and R2's floor. V3 stated that R1 and R2's floor has a combination of skilled care residents and residents with severe mental illness. When asked to tell this surveyor about R1, V3 stated, He's (R1) somebody that you cannot come close to, or he will knock you out. Doesn't matter who you are. He's not (V3 pauses) . how can I explain it. He's crazy. He don't have anything here (pointing to V3's head making a looping circle). He will knock anyone out. It doesn't matter who you are. He will fight you. He will throw food at you. V3 stated that V3 would come close to R1 when V3 would attempt to give R1 medications, and then R1 would swing at V3 where V3 would have to stand back and curse at V3. When asked where would R1 spend time, V3 stated that R1 walks around independently, is alert and oriented times 2 (person, place), and He (R1) would come from his room to the day room, then back to his room. Sometimes he would want to go to the other side, the other hallway. When asked why wouldn't V3 want R1 to walk down the other hallway, V3 stated, (R1) may smack at peers. They (other residents) may accidentally cross him or get to close to his face, and he will smack you. He will hit you. V3 stated that V3 has witnessed R1 pulls back with a closed fist and says, 'I will kick you're a**' to another staff member. V3 stated that R1 would eat in the dining room on R1's floor, but on 2/10/25, He (R1) went to basement. I (V3) didn't see him (leaving floor). You know (I am) busy with my head down. I would have stopped him. He would fight. You don't know who he would pick to hit. Don't get in his face. V3 stated that V3 couldn't remember the time on 2/10/25 when V3 was notified of R1 and R2's incident in the basement. V3 stated, They (staff) called me (V3) and said that he (R1) hit her (R2). I was like 'Oh now. When did he go down?' They (R1, R2) are in basement. He's not to go to the basement if someone isn't watching. (saff) should be going with him. V3 stated that V3 took the elevator downstairs to the basement and neither R1 or R2 are there. V3 stated that on the main floor, V3 observed R2 in R2's wheelchair receiving first aide care from V2 (Director of Nursing, DON) and V36 (Former Employee, Wound Care Nurse) under R2's left eye. V3 stated that upon V3's assessment of R2 back in R2's room on 2/10/25, V3 stated, She (R2) was upset from being hit. She didn't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 3 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 - Actual harm Residents Affected - Few explain it to me. She just said he (R1) hit her. (R2) couldn't tell me what happened. I know that man (R1), and I asked her, 'Did you provoke him (R1)? You can't get in his face' And she (R2) said, 'He hit me.' That man (R1) is just like a time bomb. (R1's) very easy to provoke. When asked to tell me any further details about the 2/10/25 incident between R1 and R2, V3 stated, Since no one saw them (R1, R2), I (V3) don't know. I wasn't there. V3 stated that R2 is alert, oriented times two (person, place), propels R2's self in wheelchair and is a one person assist with bathing. V3 stated, She (R2) goes around every floor. The basement was like her house and can navigate by R2's self. When asked when R2 is frequently going down to the basement, who is monitoring R2, and V3 stated, Nobody. After that, they lock it (basement dining room). There is supposed to be someone there. When asked prior to this incident with R1/R2 on 2/10/25, was the dining room in basement open, and V3 stated, Yes it was always open. All day. But not now. Not since this second incident. She (R2) got beat up again by another man (R7). On 2/10/25 at 4:53 pm, V3 (LPN) documented, in part, in R2's Progress Notes, Received resident (R2) on first floor from administration. Informed of the altercation between (R2) and another resident (R1). Upon assessment, the resident was noted with a small skin tear under her left eye with minimal discoloration. First aid and pain medication administered. R2's Care Plan (Problem Start date of 4/15/2023) documents, in part, the problem of Category: Psychosocial Well-Being (Abuse/Neglect) Resident (R2) is at risk for abuse due to impaired cognition, communication, and verbal and physical aggression. (R2) was the target of aggression on 1/6/25, 2/10/25 with a goal of Resident will be free of abuse/neglect daily through next review. R1's Care Plan (Problem Start date of 11/20/2024) documents, in part, the problem of Category: Behavior Symptoms: (R1) has physically aggressive behavioral symptoms towards others (e.g. (for example), hitting, kicking, pushing, scratching, abusing others sexually). (R1) was sexually inappropriate with female staff 11/19/2024. (R1) on 2/5/25 exhibited verbally aggressive threatening behavior toward staff with a goal of (R1) will not harm others secondary to physically abusive behavior. R1's Approaches (Interventions) for this specific care plan for R1 includes: Offer one step verbal direction for tasks. Allow for extra time to process the information with approach start date of 11/20/24; When resident becomes physically abusive, keep distance between resident and others (e.g., staff, other residents, visitors with approach start date of 11/20/24; and When resident becomes physically abusive, move to a quiet, calm environment with approach start date of 11/20/24. On 2/25/25 at 9:57 am, V1 (Administrator) stated that V1 is the abuse coordinator for the facility and is responsible for monitoring residents for abuse, facility staff training, and coordinating the facility's abuse prohibition program. V1 stated that V1 has been educating facility staff for a few months and explaining to them that we are worried about our high traffic areas especially near the elevators and any common areas. When asked V1 how are the facility staff to prevent resident to resident abuse, V1 stated, Monitoring any pre abuse type thing. Resident may say to another resident, 'Hey move.' And staff will say, 'Let me help you.' As example of that, if 25 people are trying to get in one elevator. Listening for signs of people (residents) agitated or frustrated. What's the purpose of monitoring residents in communal areas, V1 stated, Make sure resident was safe. When asked how was V1 informed on 2/10/25 about R1/R2 incident, V1 stated that V1 remembers being in V1's office and that V7 brought R2 up to V1's office. V1 stated, I asked maintenance (V7), where is he (R1)? Make sure someone is monitoring (R1). V1 stated that this was around noon on 2/10/25. V1 stated that V2 (DON) was informed to come to assess R2 in R2's wheelchair where V2 rendered R2's first aide. V1 stated that V1 observed R2's face with a break in the skin under the left eye, and R2 saying, He (R1) hit me (R2). V1 stated, That's the only thing I am getting from her. He hit me. V1 stated that V1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 4 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 - Actual harm Residents Affected - Few called the police department and arrived in the facility after R1 and R2 had been transferred to separate hospitals. When asked how is the facility staff monitoring residents in the basement dining room, V1 stated, Managers watching and directing them (residents). The dining room didn't have someone in there (2/10/25). Now there is more (staff). We lock it to make open certain times. Why do you want staff supervising in the basement dining room when residents are there, V1 stated, Frankly, in the location that it occurred and no one in there to possibly see if it is escalating into something. Does 'something' mean resident being physical volatile, I would say that. This surveyor had made several requests with V1 on 2/24/25 the video camera footage from the basement dining room from 2/10/25 for R1 and R2's incident, and V1 confirmed during this interview with this surveyor that V1 can only go 10 days back to review the video footage. When asked for the detailed description of V1's viewing of the video camera footage review from 2/10/25 incident in the basement dining room, V1 stated, I saw that (R2) and (R1) were in there. There was another person (R6). The guy (V6) was doing the vending machine. He (V6) had boxes. It was a low profile box. (R2) rolled up and picked up the box. (R1) got up and got the box and looked in it. Maybe thinking it was chips. (R2) moved the box close to (R2). R2 was in wheelchair at the table that was right next to the vending machine. V1 stated, (R1) walked up to the box. (R2) lifted the box up by her head. (R1) walked away. (R2) put the box on the table. V1 stated, A few minutes later, he (R1) got up and said something to her (R2) first. Then he was hitting her. V1 stated that R1 was originally sitting in a regular chair near the basement dining room door on the south side of the room: walked up to R2's table to look in the box; R1 yelling something at R2; R1 then walked back to the chair near the door and waited 1 and a half minutes before walking back to R2 hitting R2 in the face. When asked how many times did R1 strike R2, V1 stated, A couple. When asked the conclusion of V1's abuse investigation for the incident on 2/10/25 between R1 and R2, V1 stated, Conclusion is that he (R1) hit her (R2) and injured her. He hit her. It's abuse. He mistreated her. When asked about an incident that occurred between R2 and R7 in the basement dining room on 1/6/25, V1 stated that R7 is no longer a resident in the facility and that the incident was witnessed by facility staff (V38, Activities Aide). V1 stated that both R2 and R7 were wheeling in their respective wheelchairs out of the basement dining room door with V38 in the room picking up activity's items from the tables when R7 began hitting R2 with R2's backpack. V1 stated that the State Agency investigated this facility reported incident on a prior survey and that physical abuse towards R2 from R7 was substantiated. V1 stated, (R2) is victim of abuse. Both times (1/6/25 and 2/10/25), yes. 2) On 3/3/25 at 9:29 am, V1 stated, Something happened over the weekend. (R2) got hit again. V1 stated that R8 walked by R2 in the hallway on their floor and just hit her (R2). V1 stated that R8 was sent out to the hospital, and R2 has been moved to a different floor. On 3/3/25 at 10:13 am, this surveyor re-interviewed R2 on R2's new floor. When asked about the incident with R8 on 3/1/25 on the floor, R2 stated, She (R8) hit me (R2). When asked where did R8 hit R2, R2 stated, Back of my head. R2 stated that R2 came out of R2's room in wheelchair and in hallway is where R8 hit R2 on 3/1/25. R2 stated that R2 feels safe in the facility and likes R2's new room and floor. On 3/3/25 at 10:42 am, when asked about the incident between R2 and R8 on 3/1/25, V29 (Certified Nursing Assistant, CNA) stated, Yes, I (V29) witnessed it. I was sitting in dining room. (R8) walked past her (R2) and hit her (R2). I said, Don't that. Why would you hit this woman (R2). She (R2) didn't do anything? And she (R8) ignored me. (V30, Agency Registered Nurse, RN) asked her (R8) too. (R8) said, 'It was an accident.' I (V29) said, 'No, you (R8) purposely hit her (R2).' (V30) asked (R8), 'Would you want someone to hit you? Then why did you hit her (R2)?' She (R8) said, 'It was an accident'. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 5 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 - Actual harm Residents Affected - Few On 3/3/25 at 10:17 am, V30 (Agency RN) stated that on 3/1/25 around 9:45 to 10:00 am, V30 was sitting at the nurse's station desk charting, and V29 (CNA) alerted V30 that R8 hit R2 in the back of the head. V30 stated that V30 did not observe it, but V29 did. V30 stated that V30 kept R2 and R8 separated, and R8 told V30, It was an accident. V30 assessed R2 with no injuries, and V30 transferred R8 out to the hospital for a psychiatric evaluation. V30 informed V1 and V37 (Plant Operations Manager) who was on duty. In R2's Progress Notes, dated 3/1/25 at 10:19 am, V30 (RN) documented, in part, While charting at Nurses station Writer (V30) was informed by Nurses aide (V29) that resident above (R2) was hit in back of head while sitting in wheelchair in the hallway. Both residents (R2, R8) separated. Writer and MOD (manager on duty, V37) asked Resident (R2) what happened? Resident (R2) unable to verbalize what happened. In R8's Progress Notes, dated 3/1/25 at 10:09 am, While charting at Nurses station Writer was informed by Nurses aide that resident above (R8) hit another resident (R2) in back of head while walking pass her in the hallway. Both residents separated. Writer and MOD (V37) asked Resident (R8) what happened? Resident (R8) stated It was a (an) accident. Writer and MOD spoke with Resident informing her that behavior is unacceptable, resident verbalized understanding. On 3/3/25 at 12:36 pm, V1 and this surveyor together viewed the video camera footage in V1's office from 3/1/25 of the camera view from R2 and R8's floor dining room on north side of building facing down the hallway towards south side of the building. On 3/1/25 at 9:46:19 am, V29 (CNA) is observed in the dining room sitting watching down the hallway, and R8 walks freely out of her room; walks down the hallway to the alcohol based hand sanitizer (ABHS) dispenser on the wall near the nurse's station; pumps it 22 times to get ABHS and then walks back into R8's room. On 3/1/25 at 9:47 am, R2 is observed wheeling out of her room in R2's wheelchair and is staying on the side of the hallway (east side) and wheels past R8's room. R8 next walks out of R8's room and with an open hand, R8 hits R2 on the back of R2's head while in the wheelchair with R2's head jerking forward. V29 points to R8 who continues walking towards the nurse's station. R8's Face Sheet documents, in part, diagnoses of fibromyalgia, personality disorder (unspecified), asthma, anxiety disorder, psychotic disorder with delusions due to known physiological condition, major depressive disorder, hypertension, venous insufficiency, constipation and obesity. R8's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates that R8 is cognitively intact. Facility policy (undated) titled Abuse Prevention Policy documents, in part, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents . This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents. Facility policy with a revision date of 10/2024 and titled Resident Rights Guideline documents, in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 6 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete part, . Guideline: Our residents have certain rights and protection under Federal law that help ensure appropriate care and services are provided . Our facility will treat each resident with respect and dignity and care for each resident in a manner an (and) in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality . Freedom from Abuse, Neglect, Misappropriation of Property and Exploitation: The right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, exploitation, and misappropriation of your property by anyone. Event ID: Facility ID: 145828 If continuation sheet Page 7 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 interview and record review, the facility failed to provide facility staff supervision of a resident (R1) in the basement dining room in a sample of 6 residents reviewed for improper nursing care. This failure resulted in R2, a wheelchair resident, being punched in the face two times by R1, an ambulatory resident with verbal and physical aggressive behaviors, causing R2 to sustain a facial skin tear, periorbital contusion and nasal fracture. Findings include: On 2/24/25 at 12:52 pm, R2 was observed in R2's room in R2's wheelchair propelling self in room. When asked about an incident with another resident that occurred in the facility on 2/10/25, R2 stated, He (R1) came up to me (R2) and hit me. R2 stated that R2 was downstairs in the cafeteria (dining room) in the basement in R2's wheelchair, and I (R2) was just sitting. He (R1) hit me. R2 stated, It broke my nose. I felt it (pain) all the way to the back of my neck. When asked did R1 hit R2 in the face with an open hand or a closed hand (fisted hand), and R2 showed this surveyor a fisted hand. This surveyor observed faded bruise under R2's left eye as R2 is pointing to the area where R1 punched R2. When asked how many times did R1 hit you in the face with fisted hand, R2 stated, Twice. R2 stated, I couldn't move. I couldn't do anything. R2 couldn't remember if there was another resident in the dining room at the time. When asked did R2 see any facility staff before R1 hit you on 2/10/25 in the basement dining room, R2 stated, No, I didn't see anyone. When asked does R2 feel safe in the facility, R2 stated, I am okay. R2 stated that R2 moves R2's self freely in the wheelchair on the floor and down to the basement. R2's Face Sheet documents, in part, diagnoses of Parkinson's disease without dyskinesia, schizophrenia, adult failure to thrive, asthma, heart failure, hypertension, anemia, muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, mild neurocognitive disorder due to known physiological condition without behavioral disturbance and major depressive disorder. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that R2 has a Brief Interview for Mental Status (BIMS) score of 8 which indicates that R2 has moderate cognitive impairment; no behavioral symptoms or indicators of psychosis (hallucinations or delusions); and R2 mobility device is a wheelchair. R2's Emergency Hospital Records, dated 2/10/25, documents, in part, that R2 was see in the hospital for: Victim of assault and battery, head injury and contusion of periorbital region. R2's hospital CT (Computerized Tomography) scan of the maxillofacial region (2/10/25 at 6:51 pm) results documents, in part, that R2's head injury with left orbit swelling has findings of: There is an acute minimally displaced left nasal bone fracture with adjacent soft tissue swelling. There is deviation of the nasal septum towards the left. R1's Face Sheet documents, in part, diagnoses of paranoid schizophrenia, conduct disorder-aggressive behavior, unspecified psychosis, schizoaffective disorder (bipolar type), chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic mononeuropathy, anemia, epilepsy, hyperlipidemia, dysphagia, and hypertension. R1's MDS, dated [DATE], documents, in part, a Staff Assessment for Mental Status is documented, in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 8 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 part, of short-term memory problems, and R1's Cognitive Skills for Daily Decision Making as 2 which indicates moderately impaired - decisions poor; cues/supervision required. Level of Harm - Actual harm Residents Affected - Few R1's Resident Census documents, in part, that R1 is on hospital leave as of 2/10/25 and was unable to be interviewed by this surveyor. On 2/26/25 at 10:46 am, R6 stated that that remembers the incident between R1 and R2 on 2/10/25 in the basement dining room. R6 stated, He (R1) hit her (R2). I (R6) was behind them. When asked who else was there in the basement dining room that day, R6 stated, Vending machine guy (V6, Vending Machine Driver/Stocker, Contract Vendor). R6 stated that R2 was sitting at the table in R2's wheelchair close to the vending machines, and that R1 is arguing with R2. R6 stated, He (R1) stands up and he (R1) hit her (R2). When asked if it was with a closed fists or open hand, R6 put up R6's closed hand in a fist to show this surveyor. R6 stated that no one else, facility staff or residents, were in the basement dining room on 2/10/25 when R1 hit R2. R6's Face Sheet documents, in part, diagnoses of hyperlipidemia, paranoid schizophrenia, asthma, and hypertension. R6's MDS, dated [DATE] and 11/13/24, document, in part, a BIMS score of 14 which indicates that R6 is cognitively intact. On 2/25/25 at 12:37 pm, V6 (Vending Machine Driver/Stocker, Contract Vendor) stated that V6 was restocking vending machine items in the facility on 2/10/25 in the basement dining room. When asked about the incident that occurred on 2/10/25 in basement dining room, V6 stated, A fight broke out. I (V6) don't pay much attention when I am stocking. I'm there to do my job. When asked if V6 hear or see anything, V6 stated, A man (R1) was standing and throwing punches at a lady (R2). V6 stated, I (V6) heard and saw them arguing. When asked what argument was about, V6 stated, I saw they (R1 and R2) were pushing and trying to get into a box. When asked what box, V6 stated, I (V6) have a box (extra) that I put aside when I am restocking and use if for garbage. I will take it out when I am done. When asked did this extra box have food items in it, V6 stated, No, it was empty. V6 stated that his body was turned towards the vending machines (south wall) in the dining room, but the table that R2 was sitting at was right in front of the vending machines. V6 stated that V6 continued stocking and when V6 heard yelling, V6 turned around from stocking the vending machines and observed (R1) punching (R2). V6 stated that R1 was standing and that R2 was in the wheelchair. V6 stated, I knew that was trouble, so I ran out the door to call for help, and there was a lady (V5, Laundry Aide), by the elevator, who came in. When asked what did V6 tell V5, V6 stated, I told her (V5) what happened. The man (R1) was punching her (R2). On 2/24/25 at 3:04 pm, V5 (Laundry Aide) stated that on 2/10/25, V5 did not observed the incident with R1 and R2 in the basement dining room. V5 stated, I (V5) didn't see anything. I was at the elevator. In the basement to take stuff (clean laundry) upstairs. The vending machine man (V6) came out and asked for help. I ran in there (inside the basement dining room). I see them. 2 residents (R1 and R2). They were separate already. (V6) said they (R1, R2) was fighting. I went to go get help. When asked what did V6 say to V5, V5 stated that V6 said, I need help. V5 stated that V6 saw V5 by the elevator in the basement hallway and that V6 ran into the last door (end of hallway) to dining room. When asked what did V5 see upon entering inside the basement dining room, V5 stated, There are residents. One man (R1) standing by the door (last door) and the lady (R2) in a wheelchair over by the table. I never saw a thing. I went to go get help. When asked was there anyone else in the basement dining room, V5 stated, It happened so fast. I (V5) just went back out to holler for help and he (V7, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 9 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 Maintenance Operations Director) came and got (R2). V5 stated that V7's office is in the basement and that V7 took over with the residents in the basement dining room. Level of Harm - Actual harm Residents Affected - Few On 2/25/25 at 10:58 am, V7 (Maintenance Operations Director) stated that V7's office is in the basement on the east side of the building, and on 2/10/25, V5 alerted V7 that there was an altercation between a female and male resident in the basement dining room. V7 stated that V7 walked to the basement dining room and observes R2 wheeling out of the basement dining room with an injury to (R2's) face. When asked to elaborate, V7 stated that V7 sees a dark bruise under (R2's) eye and that R2 was not saying anything. V7 stated that V7 wheeled from the basement hallway into the elevator to bring R2 to V1's office on the main floor. V7 stated that V7 and V37 (Plant Operations Manager) then took elevator to R1 and R2's floor, where R1 was standing, and escorted R1 to R1's room. On 2/24/25 at 2:22 pm, V3 (Licensed Practical Nurse, LPN), stated that V3 has worked in the facility for about 6 years and is assigned to R1 and R2's floor. V3 stated that R1 and R2's floor has a combination of skilled care residents and residents with severe mental illness. When asked to tell this surveyor about R1, V3 stated, He's (R1) somebody that you cannot come close to, or he will knock you out. Doesn't matter who you are. He's not (V3 pauses) . how can I explain it. He's crazy. He don't have anything here (pointing to V3's head making a looping circle). He will knock anyone out. It doesn't matter who you are. He will fight you. He will throw food at you. V3 stated that R1 would come close to R1 when V3 would attempt to give R1 medications, and then R1 would swing at V3 where V3 would have to stand back and curse at V3. When asked where would R1 spend time, V3 stated that R1 walks around independently, is alert and oriented times 2 (person, place), and He (R1) would come from his room to the day room. Then back to his room. Sometimes he would want to go to other side, the other hallway. When asked why wouldn't V3 want R1 to walk down the other hallway, V3 stated, (R1) may smack at peers. They (other residents) may accidentally cross him or get to close to his face, and he will smack you. He will hit you. V3 stated that V3 has witnessed R1 pulls back with a closed fist and says, 'I will kick you're a**' to another staff member. V3 stated that R1 would eat in the dining room on R1's floor, but on 2/10/25, He (R1) went to basement. I (V3) didn't see him (leaving floor). You know (I am) busy with my head down. I would have stopped him. He would fight. You don't know who he would pick to hit. Don't get in his face. V3 stated that V3 couldn't remember the time on 2/10/25 when V3 was notified of R1 and R2's incident in the basement. V3 stated, They (staff) called me (V3) and said that he (R1) hit her (R2). I was like 'Oh now. When did he go down?' They (R1, R2) are in basement. He's not to go to the basement if not someone watching. Someone (staff) should be going with him. V3 stated that V3 took the elevator downstairs to the basement and neither R1 or R2 are there. V3 stated that on the main floor, V3 observed R2 in R2's wheelchair receiving first aide care from V2 (Director of Nursing, DON) and V36 (Former Employee, Wound Care Nurse) under R2's left eye. V3 stated that upon V3's assessment of R2 back in R2's room on 2/10/25, V3 stated, She (R2) was upset from being hit. She didn't explain it to me. She just said he (R1) hit her. (R2) couldn't tell me what happened. I know that man (R1), and I asked her, 'Did you provoke him (R1)? You can't get in his face' And she (R2) said, 'He hit me.' That man (R1) is just like a time bomb. (R1's) very easy to provoke. When asked to tell me any further details about the 2/10/25 incident between R1 and R2, V3 stated, Since no one see them (R1, R2), I (V3) don't know. I wasn't there. V3 stated that R2 is alert, oriented times two (person, place), propels R2's self in wheelchair and is a one person assist with bathing. V3 stated, She (R2) go around every floor. The basement was like her house and can navigate by R2's self. When asked when R2 is frequently going down to the basement, who is monitoring R2, and V3 stated, Nobody. After that, they lock it (basement dining room). There is supposed to be someone there. When asked prior to this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 10 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 incident with R1/R2 on 2/10/25, was the dining room in basement open, and V3 stated, Yes it was always open. All day. But not now. Level of Harm - Actual harm Residents Affected - Few On 2/10/25 at 4:53 pm, V3 (LPN) documented, in part, in R2's Progress Notes, Received resident (R2) on first floor from administration. Informed of the altercation between (R2) and another resident (R1). Upon assessment, the resident was noted with a small skin tear under her left eye with minimal discoloration. First aid and pain medication administered. On 2/25/25 at 9:57 am, V1 (Administrator) stated that V1 has been educating facility staff for a few months and explaining to them that we are worried about our high traffic areas especially near the elevators and any common areas. When asked V1 how are the facility staff to prevent resident to resident abuse, V1 stated, Monitoring any pre abuse type thing. Resident may say to another resident, 'Hey move.' And staff will say, 'Let me help you.' As example of that, if 25 people are trying to get in one elevator. Listening for signs of people (residents) agitated or frustrated. What's the purpose of monitoring residents in communal areas, V1 stated, Make sure resident was safe. When asked how was V1 informed on 2/10/25 about R1/R2 incident, V1 stated that V1 remembers being in V1's office and that V7 brought R2 up to V1's office. V1 stated, I asked maintenance (V7), where is he (R1)? Make sure someone is monitoring (R1). V1 stated that this was around noon on 2/10/25. V1 stated that V2 (DON) was informed to come to assess R2 in R2's wheelchair where V2 rendered R2's first aide. V1 stated that V1 observed R2's face with a break in the skin under the left eye, and R2 saying, He (R1) hit me (R2). V1 stated, That's the only thing I am getting from her. He hit me. V1 stated that V1 called the police department and arrived in the facility after R1 and R2 had been transferred to separate hospitals. When asked how is the facility staff monitoring residents in the basement dining room, V1 stated, Managers watching and directing them (residents). The dining room didn't have someone in there (2/10/25). Now there is more (staff). We lock it to make open certain times. Why do you want staff supervising in the basement dining room when residents are there, V1 stated, Frankly, in the location that it occurred and no one in there to possibly see if it is escalating into something. Does 'something' mean resident being physical volatile, I would say that. This surveyor had made several requests with V1 on 2/24/25 the video camera footage from the basement dining room from 2/10/25 for R1 and R2's incident, and V1 confirmed during this interview with this surveyor that V1 can only go 10 days back to review the video footage. When asked for the detailed description of V1's viewing of the video camera footage review from 2/10/25 incident in the basement dining room, V1 stated, I saw that (R2) and (R1) were in there. There was another person (R6). The guy (V6) was doing the vending machine. He (V6) had boxes. It was a low profile box. (R2) rolled up and picked up the box. (R1) got up and got the box and looked in it. Maybe thinking it was chips. (R2) moved the box close to (R2). R2 was in wheelchair at the table that was right next to the vending machine. V1 stated, (R1) walked up to the box. (R2) lifted the box up by her head. (R1) walked away. (R2) put the box on the table. V1 stated, A few minutes later, he (R1) got up and said something to her (R2) first. Then he was hitting her. V1 stated that R1 was originally sitting in a regular chair near the basement dining room door on the south side of the room: walked up to R2's table to look in the box; R1 yelling something at R2; R1 then walked back to the chair near the door and waited 1 and a half minutes before walking back to R2 hitting R2 in the face. When asked how many times did R1 strike R2, V1 stated, A couple. When asked the conclusion of V1's abuse investigation for the incident on 2/10/25 between R1 and R2, V1 stated, Conclusion is that he (R1) hit her (R2) and injured her. He hit her. It's abuse. He mistreated her. R1's Care Plan (Problem Start date of 11/20/2024) documents, in part, the problem of Category: Behavior Symptoms: (R1) has physically aggressive behavioral symptoms towards others (e.g. (for example), hitting, kicking, pushing, scratching, abusing others sexually). (R1) was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 11 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 sexually inappropriate with female staff 11/19/2024. (R1) on 2/5/25 exhibited verbally aggressive threatening behavior toward staff with a goal of (R1) will not harm others secondary to physically abusive behavior. R1's Approaches (Interventions) for this specific care plan for R1 includes: Offer one step verbal direction for tasks. Allow for extra time to process the information with approach start date of 11/20/24; When resident becomes physically abusive, keep distance between resident and others (e.g., staff, other residents, visitors with approach start date of 11/20/24; and When resident becomes physically abusive, move to a quiet, calm environment with approach start date of 11/20/24. R1's Care Plan (Problem Start date of 11/20/2024) documents, in part, the problem of (R1) has verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) with a goal of (R1) will not threaten, scream at, or curse at other residents, visitors, and/or staff. R1's Approaches (Interventions) for this specific care plan for R1 includes: Maintain a calm environment and approach to the resident with approach start date of 11/20/24; Refocus conversation when resident becomes verbally abusive with approach start date of 11/20/24; and When resident becomes verbally abusive, STOP and try the task later. Do not force the resident to do the task with approach start date of 11/20/24. On 2/25/25 at 1:21 pm, V9 (Psychiatric Rehabilitation Services Assistant, PRSA) stated that V9 is familiar with R1 and has V9's office on R1's floor. V9 stated that V9 is responsible for documentation of resident behaviors, counseling residents and updating the resident care plans. V9 stated that R1 is oriented to self and people, but has confusion; is independent in walking; becomes verbally aggressive and needs frequent redirection. V9 stated that when R1 is going downstairs to activities in the basement, staff will be monitoring him. When asked why is facility staff to be monitoring R1 in the basement, V9 stated, Because of his (R1's) aggression. We don't want him to go somewhere where something can happen. When asked about how does V9 know about R1's recent behaviors, V9 stated that V9 will receive information about R1's behaviors from the IDT (interdisciplinary) meeting (morning meeting) and by observing R1's behaviors. V9 stated that V9 will update R1's care plan when a quarterly assessment is due or when there is a behavior. This surveyor then read R1's current social services care plan to V9, which included R1 being sexually inappropriate with staff. V9 stated, Huh, (R1)? I think that must have been an error or wrong resident. When reading R1's care plan about being physically aggressive, V9 stated, What? I saw him making verbal threats. I saw him agitated but not swing at anyone. V9 stated that on 2/5/25, R1 was agitated that day with verbal outbursts, not receptive to redirection, despite asking R1 to come sit down in the dining room on the floor. V9 stated that R1 was pacing, going in and out of resident rooms, and trying to take residents' personal belongings. V9 stated that V9 tries to redirect R1 to a common area to watch him better. V9 stated that V9 tries not to agitate R1 by being to close to R1 but has to watch him to make sure he (R1) does not leave the floor without staff present. On 2/25/25 at 2:55 pm, V4 (Social Services Director, SSD) stated that R1 has displayed repeated verbally and physically aggressive behavior in the facility. V4 stated that facility staff are to be monitoring R1 when R1 is off of the floor because of (R1's) impulse behavior and it consistently happened. On 2/26/25 at 10:58 am, V2 (DON) stated that R1 is alert, ambulatory, can be combative and hostile with staff, aggressive with staff, can go in and out uninvited to other resident rooms and is hard to redirect. V2 stated that R1 did physically strike a staff member (V25, LPN). V2 stated that R1 likes food and likes coffee which helps with R1's redirection. This surveyor read to V2 a time-line from R1's Progress Notes from 10/28/24 (facility initial admission) to 2/10/25 (emergency discharge to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 12 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 hospital) with R1's behaviors documented, in part, of repeated verbal and physical aggression to staff; verbal aggression towards other residents; spitting at other residents; trying to steal food from residents in dining room; pacing; balling up fists with R1 threatening the lives of staff; screaming at other residents where staff needed to evacuate the floor dining room for safety; R1 throwing food trays in dining room; and R1 throwing items from the nurse's station and medication cart at the staff. This surveyor observed V2's face with eyes wide open, and V2 stating, I (V2) hadn't heard that. I wasn't aware of that. V2 stated, I absolutely was aware of his (R1's) behaviors towards staff. When asked about facility staff supervision for R1 in a communal place, like in the basement dining room, V2 stated, It's situational. If we see a behavior coming. Facility policy with revision date of 1/30/2025 and titled Safety and Supervision Guideline documents, in part, Purpose: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addressed risks for groups of residents . Resident-Oriented Approach to Safety: 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and the MDS. 3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents . Systems Approach to Safety: 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. Facility policy (undated) titled Abuse Prevention Policy documents, in part, . Procedures: . IV. Establishing a Resident Sensitive Environment: . Staff Supervision: Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 13 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise and review a resident's behavioral health care plan that has not been effective and develop individualized interventions which affected one resident (R1) out of three residents (R1, R2, R6) reviewed for quality of care. Findings include: On 2/24/25 at 12:52 pm, R2 observed in R2's room in R2's wheelchair propelling self in room. When asked about an incident with another resident that occurred in the facility on 2/10/25, R2 stated, He (R1) came up to me (R2) and hit me. R2 stated that R2 was downstairs in the cafeteria (dining room) in the basement in R2's wheelchair, and I (R2) was just sitting. He (R1) hit me. R2 stated, It broke my nose. I felt it (pain) all the way to the back of my neck. When asked did R1 hit R2 in the face with an open hand or a closed hand (fisted hand), and R2 showed this surveyor a fisted hand. This surveyor observed faded bruise under R2's left eye as R2 is pointing to the area where R1 punched R2. When asked how many times did R1 hit you in the face with fisted hand, R2 stated, Twice. R2 stated, I couldn't move. I couldn't do anything. R2 couldn't remember if there was another resident in the dining room at the time. When asked did R2 see any facility staff before R1 hit you on 2/10/25 in the basement dining room, R2 stated, No, I didn't see anyone. When asked does R2 feel safe in the facility, R2 stated, I am okay. R2 stated that R2 moves R2's self freely in the wheelchair on the floor and down to the basement. R2's Face Sheet documents, in part, diagnoses of Parkinson's disease without dyskinesia, schizophrenia, adult failure to thrive, asthma, heart failure, hypertension, anemia, muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, mild neurocognitive disorder due to known physiological condition without behavioral disturbance and major depressive disorder. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that R2 has a Brief Interview for Mental Status (BIMS) score of 8 which indicates that R2 has moderate cognitive impairment; no behavioral symptoms or indicators of psychosis (hallucinations or delusions); and R2 mobility device is a wheelchair. R2's Emergency Hospital Records, dated 2/10/25, documents, in part, that R2 was see in the hospital for: Victim of assault and battery, head injury and contusion of periorbital region. R2's hospital CT (Computerized Tomography) scan of the maxillofacial region (2/10/25 at 6:51 pm) results documents, in part, that R2's head injury with left orbit swelling has findings of: There is an acute minimally displaced left nasal bone fracture with adjacent soft tissue swelling. There is deviation of the nasal septum towards the left. R1's Face Sheet documents, in part, diagnoses of paranoid schizophrenia, conduct disorder-aggressive behavior, unspecified psychosis, schizoaffective disorder (bipolar type), chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic mononeuropathy, anemia, epilepsy, hyperlipidemia, dysphagia, and hypertension. R1's MDS, dated [DATE], documents, in part, a Staff Assessment for Mental Status is documented, in part, of short-term memory problems, and R1's Cognitive Skills for Daily Decision Making as 2 which indicates moderately impaired - decisions poor; cues/supervision required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 14 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's Resident Census documents, in part, that R1 is on hospital leave as of 2/10/25 and was unable to be interviewed by this surveyor. On 2/26/25 at 10:46 am, R6 stated that that remembers the incident between R1 and R2 on 2/10/25 in the basement dining room. R6 stated, He (R1) hit her (R2). I (R6) was behind them. When asked who else was there in the basement dining room that day, R6 stated, Vending machine guy (V6, Vending Machine Driver/Stocker, Contract Vendor). R6 stated that R2 was sitting at the table in R2's wheelchair close to the vending machines, and that R1 is arguing with R2. R6 stated, He (R1) stands up and he (R1) hit her (R2). When asked if it was with a closed fists or open hand, R6 put up R6's closed hand in a fist to show this surveyor. R6 stated that no one else, facility staff or residents, were in the basement dining room on 2/10/25 when R1 hit R2. R6's Face Sheet documents, in part, diagnoses of hyperlipidemia, paranoid schizophrenia, asthma, and hypertension. R6's MDS, dated [DATE] and 11/13/24, document, in part, a BIMS score of 14 which indicates that R6 is cognitively intact. On 2/24/25 at 2:22 pm, V3 (Licensed Practical Nurse, LPN), stated that V3 has worked in the facility for about 6 years and is assigned to R1 and R2's floor. V3 stated that R1 and R2's floor has a combination of skilled care residents and residents with severe mental illness. When asked to tell this surveyor about R1, V3 stated, He's (R1) somebody that you cannot come close to, or he will knock you out. Doesn't matter who you are. He's not (V3 pauses) . how can I explain it. He's crazy. He don't have anything here (pointing to V3's head making a looping circle). He will knock anyone out. It doesn't matter who you are. He will fight you. He will throw food at you. V3 stated that R1 would come close to R1 when V3 would attempt to give R1 medications, and then R1 would swing at V3 where V3 would have to stand back and curse at V3. When asked where would R1 spend time, V3 stated that R1 walks around independently, is alert and oriented times 2 (person, place), and He (R1) would come from his room to the day room. Then back to his room. Sometimes he would want to go to other side, the other hallway. When asked why wouldn't V3 want R1 to walk down the other hallway, V3 stated, (R1) may smack at peers. They (other residents) may accidentally cross him or get to close to his face, and he will smack you. He will hit you. V3 stated that V3 has witnessed R1 pulls back with a closed fist and says, 'I will kick you're a**' to another staff member. V3 stated that R1 would eat in the dining room on R1's floor, but on 2/10/25, He (R1) went to basement. I (V3) didn't see him (leaving floor). You know (I am) busy with my head down. I would have stopped him. He would fight. You don't know who he would pick to hit. Don't get in his face. V3 stated that V3 couldn't remember the time on 2/10/25 when V3 was notified of R1 and R2's incident in the basement. V3 stated, They (staff) called me (V3) and said that he (R1) hit her (R2). I was like 'Oh now. When did he go down?' They (R1, R2) are in basement. He's not to go to the basement if not someone watching. Someone (staff) should be going with him. V3 stated that V3 took the elevator downstairs to the basement and neither R1 or R2 are there. V3 stated that on the main floor, V3 observed R2 in R2's wheelchair receiving first aide care from V2 (Director of Nursing, DON) and V36 (Former Employee, Wound Care Nurse) under R2's left eye. V3 stated that upon V3's assessment of R2 back in R2's room on 2/10/25, V3 stated, She (R2) was upset from being hit. She didn't explain it to me. She just said he (R1) hit her. (R2) couldn't tell me what happened. I know that man (R1), and I asked her, 'Did you provoke him (R1)? You can't get in his face' And she (R2) said, 'He hit me.' That man (R1) is just like a time bomb. (R1's) very easy to provoke. When asked to tell me any further details about the 2/10/25 incident between R1 and R2, V3 stated, Since no one see them (R1, R2), I (V3) don't know. I wasn't there. V3 stated that R2 is alert, oriented times two (person, place), propels R2's self in wheelchair and is a one person assist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 15 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 0740 Level of Harm - Minimal harm or potential for actual harm with bathing. V3 stated, She (R2) go around every floor. The basement was like her house and can navigate by R2's self. When asked when R2 is frequently going down to the basement, who is monitoring R2, and V3 stated, Nobody. After that, they lock it (basement dining room). There is supposed to be someone there. When asked prior to this incident with R1/R2 on 2/10/25, was the dining room in basement open, and V3 stated, Yes it was always open. All day. But not now. Residents Affected - Few On 2/10/25 at 4:53 pm, V3 (LPN) documented, in part, in R2's Progress Notes, Received resident (R2) on first floor from administration. Informed of the altercation between (R2) and another resident (R1). Upon assessment, the resident was noted with a small skin tear under her left eye with minimal discoloration. First aid and pain medication administered. R1's Care Plan (Problem Start date of 11/20/2024) documents, in part, the problem of Category: Behavior Symptoms: (R1) has physically aggressive behavioral symptoms towards others (e.g. (for example), hitting, kicking, pushing, scratching, abusing others sexually). (R1) was sexually inappropriate with female staff 11/19/2024. (R1) on 2/5/25 exhibited verbally aggressive threatening behavior toward staff with a goal of (R1) will not harm others secondary to physically abusive behavior. R1's Approaches (Interventions) for this specific care plan for R1 includes: Offer one step verbal direction for tasks. Allow for extra time to process the information with approach start date of 11/20/24; When resident becomes physically abusive, keep distance between resident and others (e.g., staff, other residents, visitors with approach start date of 11/20/24; and When resident becomes physically abusive, move to a quiet, calm environment with approach start date of 11/20/24. R1's Care Plan (Problem Start date of 11/20/2024) documents, in part, the problem of (R1) has verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) with a goal of (R1) will not threaten, scream at, or curse at other residents, visitors, and/or staff. R1's Approaches (Interventions) for this specific care plan for R1 includes: Maintain a calm environment and approach to the resident with approach start date of 11/20/24; Refocus conversation when resident becomes verbally abusive with approach start date of 11/20/24; and When resident becomes verbally abusive, STOP and try the task later. Do not force the resident to do the task with approach start date of 11/20/24. On 2/25/25 at 1:21 pm, V9 (Psychiatric Rehabilitation Services Assistant, PRSA) stated that V9 is familiar with R1 and has V9's office on R1's floor. V9 stated that V9 is responsible for documentation of resident behaviors, counseling residents and updating the care plan. V9 stated that R1 is oriented to self and people, but has confusion; is independent in walking; becomes verbally aggressive and needs frequent redirection. V9 stated that when R1 is going downstairs to activities in the basement, staff will be monitoring him. When asked why is facility staff to be monitoring R1 in the basement, V9 stated, Because of his (R1's) aggression. We don't want him to go somewhere where something can happen. When asked about how does V9 know about R1's recent behaviors, V9 stated that V9 will receive information about R1's behaviors from the IDT (interdisciplinary) meeting (morning meeting) and by observing R1's behaviors. V9 stated that V9 will update R1's care plan when a quarterly assessment is due or when there is a behavior. This surveyor then read R1's current social services care plan to V9, which included R1 being sexually inappropriate with staff. V9 stated, Huh, (R1)? I think that must have been an error or wrong resident. When reading R1's care plan about being physically aggressive, V9 stated, What? I saw him making verbal threats. I saw him agitated but not swing at anyone. V9 stated that on 2/5/25, R1 was agitated that day with verbal outbursts, not receptive to redirection, despite asking R1 to come sit down in the dining room on the floor. V9 stated that R1 was pacing, going in and out of resident rooms, and trying to take residents' personal belongings. V9 stated that V9 tries to redirect R1 to a common area to watch him better. V9 stated that V9 tries not to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 16 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 0740 agitate R1 by being to close to R1 but has to watch him to make sure he does not leave the floor. Level of Harm - Minimal harm or potential for actual harm In R1's Progress Notes (2/5/24 at 4:26 pm), V9 documented, in part, that V9 observed R1 walking around the unit (the floor) all day exhibiting agitation and demanding behavior, going in and out of other residents' rooms, taking their belongings; R1 using profanity towards staff threatening them if R1 does not get his $25 dollars; and R1 was not easily redirected or receptive to guidance or redirection. Residents Affected - Few In R1's Progress Notes (2/6/25 at 12:10 pm and 2/7/25 at 12:20 pm), V9 documented, in part, that R1 continues to exhibit agitation and demanding behavior pounding on Social Services door; not receptive to redirection and becomes agitated when offered; makes threats telling staff what R1 will do to them; continues using profanity towards staff threatening to hurt them. On 2/25/25 at 2:55 pm, V4 (Social Services Director, SSD) stated that V4's general responsibilities include making sure that the social services team members (V9, PRSA, and V20, PRSC, Psychiatric Rehabilitation Service Coordinator) are following up with any resident behavior in the facility. V4 stated that when a resident displays a behavior, the staff look for what triggered the resident, identify that, remove the resident from the location and calmly talk to the residents. If that is not working, give the resident a few minutes then come back. V4 stated that when behaviors are increasing or escalating with redirection and a whenever needed (PRN) psychotropic medication is not effective, then a resident is sent out to the hospital for psychiatric evaluation. V4 stated that triggers for R1 were that R1 was impulsive. When asked how is the facility staff managing R1 with diagnoses of paranoid schizophrenia, conduct disorder of aggressive behavior and schizoaffective bipolar, V4 stated that R1 is rounded on by staff frequently and that when R1 would want to go to activities, the PRSA (V9) would escort R1 downstairs for close monitoring. When this surveyor reviewed with V4 the current social service care plan for R1 with the only approaches (interventions) on 11/20/24 for verbal and physical aggressive behaviors, V4 stated, There should have been more added in the approach. V4 stated that the staff must add different things (approaches) to see that we are trying all these interventions if they just are not working. V4 stated that when social services staff is following up with R1's behaviors, I would update the care plan. On 2/26/25 at 10:58 am, V2 (DON) stated that R1 is alert, ambulatory, can be combative and hostile with staff, aggressive with staff, can go in and out uninvited to other resident rooms and is hard to redirect. V2 stated that R1 did physically strike a staff member (V25, LPN). V2 stated that R1 likes food and likes coffee which helps with R1's redirection. V2 stated that R1 was being seen by V32 (Psychiatrist) and V33 (Psychiatry Nurse Practitioner, NP) and was sent out to the hospital multiple times since admission to facility via involuntary petitions for psychiatric evaluations. V2 stated that R1's psychotropic medications were changed with each re-hospitalization. V2 stated that V2 phoned V31 (R1's Family Member, Healthcare Power of Attorney) on 2/10/25 with all information about the emergency discharge to the hospital due to R1 striking another resident, R2, and the facility will not being able to accept R1 back to the facility. V2 stated that V31 requested to speak with V1, since V31 told V2 that this was above (V2's) head and V2 alerted V1 to this request. V2 stated that this decision for R1's emergency discharge on [DATE] was made by V1 and V32. This surveyor read to V2 a time-line from R1's Progress Notes from 10/28/24 (facility initial admission) to 2/10/25 (emergency discharge to hospital) with R1's behaviors documented, in part, of repeated verbal and physical aggression to staff; verbal aggression towards other residents; spitting at other residents; trying to steal food from residents in dining room; pacing; balling up fists with R1 threatening the lives of staff; screaming at other residents where staff needed to evacuate the floor dining room for safety; R1 throwing food trays in dining room; and R1 throwing items from the nurse's station and medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 17 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 0740 Level of Harm - Minimal harm or potential for actual harm cart at the staff. This surveyor observed V2's face with eyes open in aghast, and V2 stating, I (V2) hadn't heard that. I wasn't aware of that. V2 stated, I absolutely was aware of his (R1's) behaviors towards staff. When asked about facility staff supervision for R1 in a communal place, like in the basement dining room, V2 stated, It's situational. If we see a behavior coming. When asked does V2 update resident care plans, V2 stated, No, I (V2) don't do care plans. It's the MDS Coordinator. Residents Affected - Few On 3/4/25 at 3:02 pm, V35 (Former Employee, MDS Coordinator) stated that V35's last day of employment at the facility was 1/31/25. V35 stated that as a MDS Coordinator at the facility, V35 was responsible for reviewing documentation from the hospital, doing MDS assessments and completing and updating resident care plans. V35 stated that V35 and V26 (Remote/Float MDS Coordinator) did these responsibilities. V35 stated that V35 remembers R1 and did not complete R1's care plan or update R1's care plan. When asked if a resident, like R1, displays behaviors and is sent out to the hospital for evaluation, how is V35 able to find out what recent behaviors occurred to update the care plan, and V35 stated, The IDT team. When asked if V35 would be included in the IDT team, V35 stated, Yes. I did not update a care plan on (R1). On 2/27/25 at 12:25 pm, when asked does V26 complete or update a resident's care plan for this facility, V26 (Remote/Float MDS Coordinator, RN) stated, Not solely. It is an IDT team effort. Each department has their care plan they are responsible for. When asked does V26 update or add approaches/interventions when the existing approaches are not effective, V26 stated, Not particularly, no. I mostly do the care plan on admission. On 2/26/25 at 2:44 pm, V24 (Assistant DON/Psychotropic Nurse) stated that V24 is responsible for ensuring that resident psychotropic medication consents are completed for residents taking psychotropic medications. V24 stated that psychotropic medications are care planned for residents to show that medications have been tried and are effective with a goal to decrease agitation through the next review. When asked the purpose of care planning for differing psychotropic medications being used for behavioral health management, V24 stated, To show something else was implemented. V24 stated that with each of R1's re-hospitalizations for behavioral management, R1's psychotropic medications were changed or adjusted per hospital physician orders. R1's Complete Care Plan (all disciplines, 11 pages) provided to this surveyor on 2/24/25 was reviewed and does not contain a problem, goal or approach related to R1's psychotropic medication use from admission [DATE]) to discharge (2/10/25). Facility policy dated 10/1/2023 and titled Managing Behavior Guideline documents, in part, Purpose: This policy is designated 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 or punitive measures. These guidelines help staff address the needs of residents with dementia, cognitive impairments, mental health conditions, or other behavioral challenges in a person-centered and respectful manner. This 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 . Responsible Party: IDT (Interdisciplinary Team). Assessment: . Ongoing Monitoring: Staff will monitor and document residents' behaviors regularly to identify patterns, triggers, and effectiveness of interventions . Care planning: Behavioral Care Plan Development: If a resident exhibit 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 . Documentation and Report: . Review and Evaluation: The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 18 of 19 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenwood Vlge Nrsg and Rhb Ctr 4505 South Drexel Chicago, IL 60653 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interdisciplinary team will regularly review the effectiveness of behavioral interventions and revise the care plan as necessary. Facility policy dated August 2006 and titled Care Planning-Interdisciplinary Team documents, in part, Policy Statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Facility policy with revision date of 1/30/2025 and titled Safety and Supervision Guideline documents, in part, Purpose: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addressed risks for groups of residents . Resident-Oriented Approach to Safety: 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and the MDS. 3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents . Systems Approach to Safety: 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 If continuation sheet Page 19 of 19