Inspection·October 18, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few want to move. [V7] said they will do something with [R2]. On 10/2/25 at 11:55 AM, I went down the hall to put my empty lunch tray on the cart. When I passed by [R2's] room, he was sitting on his wheelchair by the door. [R2] laughed at me and called me a white boy. I said you're still an as***le and I kept going. [R2] followed me out of his room. I saw him [R2] following me so I went to the office by the exit door in the lobby. There were two women in the office. I think they are the head of nursing. I told them what was going on that I'm being chased by [R2] and threatening to kill me. One of them asked me if I wanted to change rooms. I said no. I said I'm not the one creating trouble. This is happening on a daily basis. I did not get their names because there's a lot of things going on in my head. They did not say a word. They just told me to go back to my room. They were the nursing managers. I was emotionally distraught. I did not know what to do. On the same day at 2:30 PM, [V10 (Social Service Director)] the head of social services came to my room. I explained what happened to [V10]. I told her [V10] that [R2] was chasing me threatening to kill me. [V10] wanted me to change rooms. I told her [V10] I should not have to change my room. [V10] asked me if I felt safe on this floor, and I said absolutely not. [V10] asked me if I would feel safe if [R2] is placed on the other floor. I said I would feel safe then. If [R2] was transferred to a different floor, I would feel safe even at night when I'm sleeping. They still have not moved [R2]. On 10/16/25 at 5:00 PM, [R2] was outside. I was coming out of the van from my doctor's appointment. I saw him [R2] and followed me holding his phone up to my face and laughing. [R2] called me an ugly-fa**ot-tr*ny. No one heard or witnessed the incident. [R2] does not threaten me when anybody is around.On 10/17/25 at 11:04 AM, Surveyor observed R2 outside wheeling himself in a wheelchair. Surveyor made an introduction and asked if [R2] can be interviewed. R2 stated, No. I don't have time for that. I'm waiting for my bus to go for an appointment. Surveyor asked if [R2] is familiar with [R1]. R2 stated, I don't know who that is. I don't know what you're talking about. I got to go. You better be careful young lady. R2 ended the conversation.On 10/17/25 at 10:52 AM, V6 (Receptionist) stated that the abuse coordinator is V2 (Director of Nursing). V6 stated that two or three weeks ago morning time, R1 reported to V6 that R2 was saying all types of crazy things to R1. V6 said R1 did not say exactly what was said. V6 stated that he reported R1's complaints to V1 (Administrator). V6 stated that R2 is still residing on the first floor and would always hang out at the first floor lobby every day. V6 stated that he hears R2 say bad words to other residents but not specially towards R1. V6 stated he never heard R2 threatens anybody. On 10/17/25 at 11:12 AM, V7 (Psychiatric Rehabilitation Services Aide/PRSA) stated that R1 and R2 can move independently with their wheelchairs. V7 said that on end of September, I was asked to do a wellbeing check with R1. I went to her [R1] room. [R1] said that [R2] had said a couple of words to [R1]. [R1] said [R2] called her a white boy and mumbled something. [R1] told me that [R2] threatened to kill [R1] if she says something to him [R2]. I asked her [R1] what was her feelings. [R1] said she was uncomfortable in the room and she did not sleep well at that time when I asked her. [R1] said she felt unsafe. I told her [R1] that I would tell the corporate people to address her concerns. I reported it to [(V4 (Nursing Consultant)] right after I talked to [R1]. [V4] told me she would address it and that I make sure [R1] is okay. [V4] said she would take care of it. [R2] was not moved to a different floor. I did not talk to [R2]. I asked [R1] if she wanted to move but she said no. I'm not sure who talked to [R2]. I am not sure if it was investigated. The administrator [V1] does that. I never witnessed any negative interaction between [R1] and [R2]. That was the first time I heard they were having a disagreement.On 10/17/25 at 11:46 AM, V10 (Social Service Director) stated that if it's verbal allegation of abuse and if it's threatening, the aggressor will be sent out for psychiatric evaluation. V10 stated, Any types of abuse allegation even if it's unwitnessed, we (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 notify the abuse coordinator. Abuse coordinator will report to the State Agency right away no more than 2 hours. Initial investigation should be conducted right away and thorough and complete investigation should be done. Final investigation is sent to the State within 5 business days. It's important to conduct a complete and thorough investigation of any abuse allegation to make sure all the residents in the facility are safe. To prevent a resident from getting harmed. V10 stated that she has not witnessed any negative interactions between R1 and R2. V10 stated that R2 is verbally aggressive towards staff and residents. R2 curses staff and residents. Calling them names. V10 stated, It was reported to me on a Monday in September. It was the end of the month. I received the call from [V7] stating that [R1] reported that [R2] was threating to kill [R1]. It was reported to me that [R2] was calling [R1] white boy, fa**ot, and tr*ny. I reported it to the person in charge who was the acting administrator at that time. I reported it to [V4]. I also reported it to [V11 (Assistant Director of Nursing)] because [V2 (Director of Nursing)] was not available and [V1] was off sick. [V1's] been on medical leave. I reported it to the next person in charge. I could not get a hold of [V2] she was in some type of meeting, so I verbally reported it to [V11]. And then I notified everybody on the group chat. When [V1] is not here, [V4] or [V2] would be the abuse coordinator. I talked to [R2] that same day and he admitted it. [R2] said that he told [R1] that he was going to punch [R1] because [R1] called [R2] an as***le. [R2] admitted that he threatened to kill her [R1]. I let management know. I told them. They did not send [R2] out and they did not separate [R2] from [R1]. I talked to [R1] she told me that she does not feel safe. [R1] told me she was scared and that she does not feel safe. I reported it to [V4]. I also brought it up in the morning meeting the next day. [R1] and [R2] are both alert and oriented. On 10/17/25 at 12:08 PM, V2 (Director of Nursing) stated that she is the abuse coordinator if V1 (Administrator) is on vacation or on leave. V2 stated that V1 has been out on leave for 2 and a half weeks now. V2 stated, If there is a resident to resident abuse, we make sure we separate the residents and we make sure that they are safe. We have 2 hours from the time of incident to do initial investigation and reporting to IDPH [Illinois Department of Public Health]. Initial investigation is important to get accurate statements. To determine if it's abuse and to determine what's the next step. These applies to any type of abuse allegation. [V1] had an all staff abuse in-service before she went on leave. The types of abuse are mental, verbal, sexual, misappropriation of funds, neglect, seclusion. Physical abuse is when resident strikes another resident or staff strikes another resident. Threatening to kill somebody would be a verbal abuse. It could be mental abuse depending on the reaction and how the resident feels. My office is by the exit door in the lobby. The only interactions I've seen between [R1] and [R2] were friendly. They were friends joking around with each other. I've never had a conversation with [R1] about an abuse allegation. She's [R1] never brought any complaints. On September 29 around noon, [V13 (Licensed Practical Nurse)] told me that [R1] stated [R2] was going to kill [R1]. I let [V1] know. I called her [V1]. I told [V1] what the situation was. [V1] directed me what to do. We had [V10] talk to [R1] and [R2]. I spoke to [R2] and he denied the allegation. [R2] said that [R1] said something to him. I asked both [R1 and R2] parties if they were okay. They said they were okay. They denied that they feel threatened, and they were fine. They did not want to move rooms or floor. We do an investigation if we determine if it's abuse and if we determine its abuse, then we report it to IDPH. It was not reported to IDPH because it was not determined as abuse. Police were not called. It was not proven as abuse. They both said that they were fine, and they both said that they were not in fear. V2 said that R1's allegation against R2 was not investigated or reported to IDPH because it was not determined as abuse. Surveyor asked V2 to provide documentation of the complete investigation of R1's abuse allegations, but facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 did not provide. 10/17/25 at 12:37 PM, V11 (Assistant Director of Nursing) stated she's been working in the facility since September 15th. V11 stated that if there is abuse allegation the process should be immediately reported to the abuse coordinator which is the administrator [V1]. V11 stated V1 is out sick. V11 stated, Generally, they have someone in her [V1] seat as acting administrator at that time if not, then [V2]. If there is negative interactions, separating both parties away from each other to ensure safety. If there is potential harm, we have to investigate see if there is any witnesses and take statements. The investigation should be done immediately when it's reported. If there is allegation of abuse initial investigation and reporting are sent to IDPH within 24 hours. The types of abuse are verbal, physical, emotional, mental abuse, financial abuse, seclusion and neglect. An example of verbal abuse is name calling, verbal threats such threatening to kill somebody. Mental abuse could be insults, calling name or threatening. I did not receive any report from any resident about abuse allegation. I have never witnessed any resident being abused by another resident. V11 stated she is familiar with R1 and R2. V11 said, From the time I've been here, I have witnessed them being friends and talking with each other. They stopped talking to each other in the last couple of weeks, but nothing negative I have witnessed personally.On 10/17/25 at 1:47 PM, V12 (Licensed Practical Nurse) stated that she is familiar with R1 and R2. V12 stated, Every time, I work in the facility I see [R2] on the first floor. [R2's] room was one room down from [R1] then they moved him [R2] to the other side on October 10th. Still on the same floor. [R1] came out one day very flustered. I don't' remember the day. It was in the afternoon. I was at the nurses' station at that time. I heard [R1] said that [R2] said something to her. [V4] and [V2] came out and said what's going on. Because [R1] was flustered. I went down the hall and [V2] asked me if I see or hear anything. I said I did not witness anything. I don't remember if they asked [R1] why she was flustered. [R2] is very argumentative with staff and patients. [R1] never bothers anybody.On 10/17/25 at 2:04 PM, a phone interview was conducted with V13 (Licensed Practical Nurse). Surveyor asked about R1 and R2's abuse allegation on 9/29/25. V13 stated, It was end of September. I was on lunch when I came back [V14 (Certified Nursing Assistant)] told me that [R1] and [R2] had an argument. I interviewed [R1] because [R2] already left for dialysis. [R1] said that since she came back from her last episode of amnesia, [R2] has been mean to her [R1] calling her white boy. [R1] said he did not touch her. Nobody was hurt or touched. [R1] did not tell me that he threatened to kill her. [R1] said to me that [R2] threatened to punch her. After that I reported it to the Social Worker [V7]. I didn't notify their doctors. I am not aware if they call the police. I'm not sure when they moved [R2] to a different room. [R2] was still on the first floor.On 10/17/25 at 2:15 PM, V4 (Nursing Consultant) stated that V1 went on leave on September 30. As of October 1st, V4 came to the facility for support. V4 stated she was not in the facility when R1 and R2's September 29 incident happened. V4 stated, I was in Florida. I was not made aware at that time. I heard that [R1] and [R2] had an unwitnessed argument. Back and forth exchange of words. That [V7] talked to [R1]. [V7] reported the allegation to [V2] I think. [V2] reported it to [V1]. They did not deem it reportable because it was not one sided. They said [R1] lashed out as well verbally. I would consider it verbal abuse the calling names and threatening to kill someone. It could be mental abuse.On 10/17/25 at 3:07 PM, a phone interview was conducted with V14 (Certified Nursing Assistant). Surveyor asked about R1 and R2's incident that happened on 9/29/25. V14 stated, I don't quite remember what happened. I witnessed [R2] was in the hallway and [R1] was in her room. [R2] was in the hallway by her [R1] door talking loud to [R1]. I think I heard [R2] say he was going to beat [R1] up. I reported it to the nurse [V13] right away. I separated them. [R2] went back to his room and [R1] stayed in her room. [R2] was put on one-on-one supervision. I don't remember if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 they call the police. I don't remember anything else what happened next.On 10/17/25 at 4:25 PM, a phone interview was conducted with V15 (Physician/Medical Director). V15 stated that threatening to kill or beat up someone is a type of verbal abuse. V15 stated that all abuse allegations should be thoroughly investigated for the safety of the residents. V15 stated that the aggressor should be sent out for a psychiatric evaluation.On 10/17/25 at 5:32 PM, a phone interview was conducted with V16 (Nursing Supervisor) and stated that R2 was moved to a different room (still first floor) on 10/10/25 not on 9/29/25.On 10/18/25 at 10:10 AM, a phone interview was conducted with V1 (Administrator). V1 stated she was not made aware of R1's allegations against R2 until yesterday (10/17/25). V1 stated she's on medical leave started on 9/28/25. V1 stated that V2 or V4 covers for her during her leave of absence, and they will serve as the abuse coordinators. V2 is the point of contact. V1 stated nobody notified her about R1 and R2's incident that happened on 9/29/25. V1 stated she was not aware R1 and R2 was having continued disagreements. V1 stated, Knowing what I know and their [R1, R2] history in the past they have denied any wrongdoing. These residents have history of being verbally aggressive with each other and being inappropriate. To them this is how they talk to each other. [R1] and [R2] use profanity a lot but [R2] does it more. They do that to each other. I don't hear them threaten each other. We tell them it's not acceptable in the facility. We keep them apart. They are aggressive and inappropriate a lot. I don't think it's intentional or abusive to each other because that's how they talk. V1 stated that it is important to follow the facility's abuse policy and procedures to protect the residents. R1's clinical records show and admission date of 5/1/25 with included diagnoses but not limited to unspecified convulsion, major depressive disorder, and gender identity disorder. R1's Minimum Data Set (MDS) dated [DATE] shows a BIMS (Brief Interview for Mental Status) score of 13 which means R1 is cognitively intact. R1 uses a wheelchair and able to wheel herself with supervision. R1's progress notes dated 9/29/25 at 12:21 PM documented by V13 reads in part: Writer assessed resident: resident stated he's been coming pass my room all the time calling me white boy, but I just brush it off, but today after I mumbled as***le he told me he would punch me in the face or kill me. Writer notified social services. The resident is being closely monitored and is being kept separated from each other. No physical harm was done.R1's progress notes dated 9/29/25 at 12:55 PM documented by V7 reads in part: ALLEDGED ALIGATION OF ABUSE BY PEER: DAY 1/3 CO-PEER MADE INAPPROPRIATE/THREATENING STAEMENTS TO HER [R1]: Writer met with the resident [R1] due to report that a co-peer made negative statements to her. She [R1] was asked what happened and stated that she was sitting by her room door and the other resident rolled by and he called her [R1] boy and when she responded back, he [R2] told her that if she said anything else to him that he would kill her [R1]. She [R1] stated that this is not the first time he said something to her. Writer asked her why she did not say anything to staff before now, and she said she just didn't. Writer encouraged her to make staff aware any time someone is making her feel uncomfortable due to negative statement or actions toward her She [R1] was asked if she feels safe and she stated that she did not. Writer informed her that the appropriate parties will be notified and will follow up on her concerns.R1's progress notes dated 10/2/25 at 1:29 PM documented by V7 reads in part: Writer followed up with resident [R1] regarding an incident that happened between her and her peer. Writer went to the residents' [R1] room, and she told resident that she continues to have problems with co-peer. Resident [R1] stated that he continues to make comments to her and to call her [NAME] Boy. Resident [R1] stated she is getting tired of the situation, and something has to be done. Writer informed her that she would talk to someone in Administration to make them aware of the continuing issues between her and her peer. Social services will continue to follow up.R2's clinical records show an admission date of 1/10/25 with included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 diagnoses but not limited to hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, acquired absence of left leg below knee, and acquired absence of right leg below knee. R2's MDS dated [DATE] shows a BIMS score of 15 which means R2 is cognitively intact. R2 uses a wheelchair and able to wheel himself with supervision. R2's comprehensive care plan dated 3/17/25 documents in part: R2 has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). [R2] displayed verbal aggression towards staff on 2/4/2025. On 4/6/25 resident exhibited verbally abusive behavior toward others. R2's progress notes dated 9/29/25 at 10:35 AM, documented by V10 documents in part: Resident [R2] stated that his peer called him an as***le and he stated that he will punch her in the face and kill her. R2's progress notes dated 10/10/25 at 3:17 PM documented by V7 revealed R2's room was changed but remained on the same floor as R1. The facility's Abuse Prevention Program policy and procedures (no date) documents in part: The facility will take steps to prevent potential abuse while the investigation is underway. Consumers who allegedly abused another consumer will be removed from the immediate area and a determination made as to contact, if any, with other consumers during the course of the investigation. The accused consumer's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other consumers and employees of the facility.The facility's Resident Rights Guideline (no date) documents in part: Our residents have certain rights and protections under Federal law that help ensure appropriate care and services are provided. The right to a safe, clean, and comfortable, and home-like environment that allows independence as possible. Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to send the initial and final reports of abuse allegations to Illinois Department of Public Health (IDPH) for two (R1, R2) out of four residents reviewed for abuse.Findings Include: On 10/17/25 at 9:39 AM, Surveyor observed R1 sitting by the side of her bed alert and oriented to time, place, and situation. R1 stated, There is one gentleman his name is [R2]. He [R2] lives on the same floor as me. He [R2] is two rooms down from my room. He [R2] is black. He [R2] has prosthetics on both legs. He [R2] uses his wheelchair and continues to pass by my room and harasses and threatens me almost every day. This started a month ago. I have everything written down. It started on 9/14/25 at 6:15 PM, I came back from the hospital. I was in the hospital for multiple seizures. When I came back from the hospital [R2] keeps calling me white boy and he [R2] tells me that I'm faking my amnesia. I learned his [R2] name from one of the staff. Every day he [R2] sees me on the hallway he would laugh and mock me. I told [V6 (Receptionist)] that I'm not comfortable around [R2] and that he keeps calling me names. [V6] said he would report it, but no one came to talk to me. On 9/29/25 before 10:30 AM, I was in my room and my door was wide open. [R2] passed by and stopped. [R2] was laughing. I mumbled as***le quietly. I said it to myself not to him [R2]. [R2] heard it and he said if he hears that again he would punch me in the face or kill me. I think the CNA [Certified Nursing Assistant] heard it but I don't know her name. Right after [R2] told me that I reported it [V6] and I asked who I should speak with about racial and sexual harassment. Because almost every day [R2] would call me fa**ot and white boy. The same day at 10:45 AM, [V7 (Psychiatric Rehabilitation Services Aide)] came to my room. [V7] is my social worker. I told [V7] about the racial, sexual, and violent harassment from [R2]. I told [V7] that [R2] laughs at me, that [R2] says he will kill me and that he would call me white boy, fa**ot, and tr*ny. It's a derogatory way of saying transgender. It's sexual harassment. I feel very upset, scared, and unsafe. Why I'm here. I can't sleep at night. [R2] is two doors down from my room. Sometimes staff are not around. At any point [R2] can easily come while I'm sleeping and stab me. They did not move [R2] from my floor. Every day I would see [R2] and he is always sitting in the front lobby. I feel unsafe. [R2] roams around the whole first floor by himself and he would always follow where I'm at. After [V7] left then one of the nurses came to my room so she can document. The nurse's name is [V13 Licensed Practical Nurse)]. [V13] came to my room at 11:10 AM. [V13] wanted to know what happened and I told her everything. The next day on 9/30/25 at 10:15 AM, [V7] came to visit me in my room. [V7] said they spoke with [R2] that they are going to do something. They did not tell me what they were going to do. [V7] asked me if I wanted to change my room. I told her [V7] that I like my room and I like the first floor and that I don't want to move. [V7] said they will do something with [R2]. On 10/2/25 at 11:55 AM, I went down the hall to put my empty lunch tray on the cart. When I passed by [R2's] room, he was sitting on his wheelchair by the door. [R2] laughed at me and called me a white boy. I said you're still an as***le and I kept going. [R2] followed me out of his room. I saw him [R2] following me so I went to the office by the exit door in the lobby. There were two women in the office. I think they are the head of nursing. I told them what was going on that I'm being chased by [R2] and threatening to kill me. One of them asked me if I wanted to change rooms. I said no. I said I'm not the one creating trouble. This is happening on a daily basis. I did not get their names because there's a lot of things going on in my head. They did not say a word. They just told me to go back to my room. They were the nursing managers. I was emotionally distraught. I did not know what to do. On the same day at 2:30 PM, [V10 (Social Service Director)] the head of social services came to my room. I explained what (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few happened to [V10]. I told her [V10] that [R2] was chasing me threatening to kill me. [V10] wanted me to change rooms. I told her [V10] I should not have to change my room. [V10] asked me if I felt safe on this floor, and I said absolutely not. [V10] asked me if I would feel safe if [R2] is placed on the other floor. I said I would feel safe then. If [R2] was transferred to a different floor, I would feel safe even at night when I'm sleeping. They still have not moved [R2]. On 10/16/25 at 5:00 PM, [R2] was outside. I was coming out of the van from my doctor's appointment. I saw him [R2] and followed me holding his phone up to my face and laughing. [R2] called me an ugly-fa**ot-tr*ny. No one heard or witnessed the incident. [R2] does not threaten me when anybody is around.On 10/17/25 at 11:04 AM, Surveyor observed R2 outside wheeling himself on a wheelchair. Surveyor made an introduction and asked if [R2] can be interviewed. R2 stated, No. I don't have time for that. I'm waiting for my bus to go for an appointment. Surveyor asked if [R2] is familiar with [R1]. R2 stated, I don't know who that is. I don't know what you're talking about. I got to go. You better be careful young lady. R2 ended the conversation.On 10/17/25 at 10:52 AM, V6 (Receptionist) and stated that the abuse coordinator is V2 (Director of Nursing). V6 stated that two or three weeks ago morning time, R1 reported to V6 that R2 was saying all types of crazy things to R1. V6 said R1 did not say exactly what were said. V6 stated that he reported R1's complaints to V1 (Administrator). V6 stated that R2 is still residing on the first floor and would always hang out at the first-floor lobby every day. V6 stated that he hears R2 say bad words to other residents but not specially towards R1. V6 stated he never heard R2 threatens anybody. On 10/17/25 at 11:12 AM, V7 (Psychiatric Rehabilitation Services Aide/PRSA) stated that R1 and R2 can move independently with their wheelchairs. V7 said that on the end of September, I was asked to do a wellbeing check with R1. I went to her [R1] room. [R1] said that [R2] had said a couple of words to [R1]. [R1] said [R2] called her a white boy and mumbled something. [R1] told me that [R2] threaten to kill [R1] if she says something to him [R2]. I asked her [R1] what was her feeling. [R1] said she was uncomfortable in the room and she did not sleep well at that time when I asked her. [R1] said she felt unsafe. I told her [R1] that I would tell the corporate people know to address her concerns. I reported it to [(V4 (Nursing Consultant)] right after I talked to [R1]. [V4] told me she would address it and that I make sure [R1] is okay. [V4] said she would take care of it. [R2] was not moved to a different floor. I did not talk to [R2]. I asked [R1] if she wanted to move but she said no. I'm not sure who talked to [R2]. I am not sure if it was investigated. The administrator [V1] does that. I never witnessed any negative interaction between [R1] and [R2]. That was the first time I heard they were having disagreement.On 10/17/25 at 11:46 AM, V10 (Social Service Director) stated that if it's verbal allegation of abuse and if it's threatening, the aggressor will be sent out for psychiatric evaluation. V10 stated, Any types of abuse allegation even if it's unwitnessed, we notify the abuse coordinator. Abuse coordinator will report to the State Agency right away no more than 2 hours. Initial investigation should be conducted right away and thorough and complete investigation should be done. Final investigation is sent to the State within 5 business days. It's important to conduct a complete and thorough investigation of any abuse allegation to make sure all the residents in the facility are safe. To prevent a resident from getting harmed. V10 stated that she has not witnessed any negative interactions between R1 and R2. V10 stated that R2 is verbally aggressive towards staff and residents. R2 curses staff and residents. Calling them names. V10 stated, It was reported to me on a Monday in September. It was the end of the month. I received the call from [V7] stating that [R1] reported that [R2] was threating to kill [R1]. It was reported to me that [R2] was calling [R1] white boy, fa**ot, and tr*ny. I reported it to the person in charge who was the acting administrator at that time. I reported it to [V4]. I also reported it to [V11 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Assistant Director of Nursing)] because [V2 (Director of Nursing)] was not available and [V1] was off sick. [V1's] been on medical leave. I reported it to the next person in charge. I could not get a hold of [V2] she was on some type of meeting, so I verbally reported it to [V11]. And then I notified everybody on the group chat. When [V1] is not here, [V4] or [V2] would be the abuse coordinator. I talked to [R2] that same day and he admitted it. [R2] said that he told [R1] that he was going to punch [R1] because [R1] called [R2] an as***le. [R2] admitted that he threatened to kill her [R1]. I let management know. I told them. They did not send [R2] out and they did not separate [R2] from [R1]. I talked to [R1] she told me that she does not feel safe. [R1] told me she was scared and that she does not feel safe. I reported it to [V4]. I also brought it up in the morning meeting the next day. [R1] and [R2] are both alert and oriented. On 10/17/25 at 12:08 PM, V2 (Director of Nursing) stated that she is the abuse coordinator if V1 (Administrator) is on vacation or on leave. V2 stated that V1 has been out on leave for 2 and a half weeks now. V2 stated, If there is a resident to resident abuse, we make sure we separate the residents and we make sure that they are safe. We have 2 hours from the time of incident to do initial investigation and reporting to IDPH [Illinois Department of Public Health]. Initial investigation is important to get accurate statements. To determine if it's abuse and to determine what's the next step. These applies to any type of abuse allegation. [V1] had an all staff abuse in-service before she went on leave. The types of abuse are mental, verbal, sexual, misappropriation of funds, neglect, seclusion. Physical abuse is when resident strikes another resident or staff strikes another resident. Threatening to kill somebody would be a verbal abuse. It could be mental abuse depending on the reaction and how the resident feels. My office is by the exit door in the lobby. The only interactions I've seen between [R1] and [R2] were friendly. They were friends joking around with each other. I've never had a conversation with [R1] about an abuse allegation. She's [R1] never brought any complaints. On September 29 around noon, [V13 (Licensed Practical Nurse)] told me that [R1] stated [R2] was going to kill [R1]. I let [V1] know. I called her [V1]. I told [V1] what the situation was. [V1] directed me what to do. We had [V10] talk to [R1] and [R2]. I spoke to [R2] and he denied the allegation. [R2] said that [R1] said something to him. I asked both [R1 and R2] parties if they were okay. They said they were okay. They denied that they feel threatened, and they were fine. They did not want to move rooms or floor. We do investigation if we determine if it's abuse and if we determine its abuse, then we report it to IDPH. It was not reported to IDPH because it was not determined as abuse. Police were not called. It was not proven as abuse. They both said that they were fine, and they both said that they were not in fear. V2 said that R1's allegation against R2 was not investigated or reported to IDPH because it was not determined as abuse. Surveyor asked V2 to provide documentation of the complete investigation of R1's abuse allegations, but facility did not provide. On 10/17/25 at 2:04 PM, a phone interview was conducted with V13 (Licensed Practical Nurse). Surveyor asked about R1 and R2's abuse allegation on 9/29/25. V13 stated, It was end of September. I was on lunch when I came back [V14 (Certified Nursing Assistant)] told me that [R1] and [R2] had an argument. I interviewed [R1] because [R2] already left for dialysis. [R1] said that since she came back from her last episode of amnesia, [R2] has being mean to her [R1] calling her white boy. [R1] said he did not touch her. Nobody was hurt or touch. [R1] did not tell me that he threatened to kill her. [R1] said to me that [R2] threatened to punch her. After that I reported it to the Social Worker [V7]. I didn't notify their doctors. I am not aware if they call the police. I'm not sure when they moved [R2] to a different room. [R2] was still on the first floor.On 10/17/25 at 2:15 PM, V4 (Nursing Consultant) stated that V1 went on leave on September 30. As of October 1st, V4 came to the facility for support. V4 stated she was not in the facility when R1 and R2's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few September 29 incident happened. V4 stated, I was in Florida. I was not made aware at that time. I heard that [R1] and [R2] had an unwitnessed argument. Back and forth exchange of words. That [V7] talked to [R1]. [V7] reported the allegation to [V2] I think. [V2] reported it to [V1]. They did not deem it reportable because it was not one sided. They said [R1] lashed out as well verbally. I would consider it verbal abuse the calling names and threatening to kill someone. It could be mental abuse.On 10/17/25 at 3:07 PM, a phone interview was conducted with V14 (Certified Nursing Assistant). Surveyor asked about R1 and R2's incident that happened on 9/29/25. V14 stated, I don't quite remember what happened. I witnessed [R2] was in the hallway and [R1] was in her room. [R2] was in the hallway by her [R1] door talking loud to [R1]. I think I heard [R2] said he was going to beat [R1] up. I reported it to the nurse [V13] right away. I separated them. [R2] went back to his room and [R1] stayed in her room. [R2] was put on one-on-one supervision. I don't remember if they call the police. I don't remember anything else what happened next.On 10/18/25 at 10:10 AM, a phone interview was conducted with V1 (Administrator). V1 stated she was not made aware of R1's allegations against R2 until yesterday (10/17/25). V1 stated she's on medical leave started on 9/28/25. V1 stated that V2 or V4 covers for her during her leave of absence, and they will serve as the abuse coordinators. V2 is the point of contact. V1 stated nobody notified her about R1 and R2's incident that happened on 9/29/25. V1 stated she was not aware R1 and R2 was having continued disagreements. V1 stated, Knowing what I know and their [R1, R2] history in the past they have denied any wrongdoing. These residents have history of being verbally aggressive with each other and being inappropriate. To them this is how they talk to each other. [R1] and [R2] use profanity a lot but [R2] does it more. They do that to each other. I don't hear them threatens each other. We tell them it's not acceptable in the facility. We keep them apart. They are aggressive and inappropriate a lot. I don't think it's intentional or abusive to each other because that's how they talk. V1 stated that it is important to follow the facility's abuse policy and procedures to protect the residents. R1's clinical records show and admission date of 5/1/25 with included diagnoses but not limited to unspecified convulsion, major depressive disorder, and gender identity disorder. R1's Minimum Data Set (MDS) dated [DATE] shows a BIMS (Brief Interview for Mental Status) score of 13 which means R1 is cognitively intact. R1 uses a wheelchair and able to wheel herself with supervision. R1's progress notes dated 9/29/25 at 12:21 PM documented by V13 reads in part: Writer assessed resident: resident stated he's been coming pass my room all the time calling me white boy, but I just brush it off, but today after I mumbled as***le he told me he would punch me in the face or kill me. Writer notified social services. The resident is being closely monitored and is being kept separated from each other. No physical harm was done.R1's progress notes dated 9/29/25 at 12:55 PM documented by V7 reads in part: ALLEDGED ALIGATION OF ABUSE BY PEER: DAY 1/3 CO-PEER MADE INAPPROPRIATE/THREATENING STAEMENTS TO HER [R1]: Writer met with the resident [R1] due to report that a co-peer made negative statements to her. She [R1] was asked what happened and stated that she was sitting by her room door and the other resident rolled by and he called her [R1] boy and when she responded back, he [R2] told her that if she said anything else to him that he would kill her [R1]. She [R1] stated that this is not the first time he said something to her. Writer asked her why she did not say anything to staff before now, and she said she just didn't. Writer encouraged her to make staff aware any time someone is making her feel uncomfortable due to negative statement or actions toward her She [R1] was asked if she feels safe and she stated that she did not. Writer informed her that the appropriate parties will be notified and will follow up on her concerns.R1's progress notes dated 10/2/25 at 1:29 PM documented by V7 reads in part: Writer followed up with resident [R1] regarding an incident that happen between her and her peer. Writer went to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents' [R1] room, and she told resident that she continues to have problems with co-peer. Resident [R1] stated that he continues to make comments to her and to call her [NAME] Boy. Resident [R1] stated she is getting tired of the situation, and something has to be done. Writer informed her that she would talk to someone in Administration to make them aware of the continuing issues between her and her peer. Social services will continue to follow up.R2's clinical records show an admission date of 1/10/25 with included diagnoses but not limited to hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, acquired absence of left leg below knee, and acquired absence of right leg below knee. R2's MDS dated [DATE] shows a BIMS score of 15 which means R2 is cognitively intact. R2 uses a wheelchair and able to wheel himself with supervision. R2's comprehensive care plan dated 3/17/25 documents in part: R2 has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). [R2] displayed verbal aggression towards staff on 2/4/2025. On 4/6/25 resident exhibited verbally abusive behavior toward others. R2's progress notes dated 9/29/25 at 10:35 AM, documented by V10 documents in part: Resident [R2] stated that his peer called him an as***le and he stated that he will punch her in the face and kill her. R2's progress notes dated 10/10/25 at 3:17 PM documented by V7 revealed R2's room was changed but remained on the same floor as R1. V4 provided a copy of the initial investigation and reporting sent to IDPH dated 10/17/25 at 1:37 PM. The facility's Abuse Prevention Program policy and procedures (no date) documents in part: All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of consumer property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of consumer property will result in an investigation. The investigator will report the conclusions of the investigation in writing to the Executive Director or designee within five working days of the reported incident. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of consumer property has been reported and is being investigated. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse and failed to prevent potential further abuse by failing to remove the alleged perpetrator (R2) from interacting with R1. These failures affected two (R1, R2) out of four residents reviewed for abuse. These failures resulted in R1 feeling unsafe and scared for her safety, was unable to sleep, and felt like no one was doing something to protect her. Findings Include: On 10/17/25 at 9:39 AM, Surveyor observed R1 sitting by the side of her bed alert and oriented to time, place, and situation. R1 stated, There is one gentleman his name is [R2]. He [R2] lives on the same floor as me. He [R2] is two rooms down from my room. He [R2] is black. He [R2] has prosthetics on both legs. He [R2] uses his wheelchair and continues to pass by my room and harasses and threatens me almost every day. This started a month ago. I have everything written down. It started on 9/14/25 at 6:15 PM, I came back from the hospital. I was in the hospital for multiple seizures. When I came back from the hospital [R2] keeps calling me white boy and he [R2] tells me that I'm faking my amnesia. I learned his [R2] name from one of the staff. Every day he [R2] sees me on the hallway he would laugh and mock me. I told [V6 (Receptionist)] that I'm not comfortable around [R2] and that he keeps calling me names. [V6] said he would report it, but no one came to talk to me. On 9/29/25 before 10:30 AM, I was in my room and my door was wide open. [R2] passed by and stopped. [R2] was laughing. I mumbled as***le quietly. I said it to myself not to him [R2]. [R2] heard it and he said if he hears that again he would punch me in the face or kill me. I think the CNA [Certified Nursing Assistant] heard it but I don't know her name. Right after [R2] told me that I reported it [V6] and I asked who I should speak with about racial and sexual harassment. Because almost every day [R2] would call me fa**ot and white boy. The same day at 10:45 AM, [V7 (Psychiatric Rehabilitation Services Aide)] came to my room. [V7] is my social worker. I told [V7] about the racial, sexual, and violent harassment from [R2]. I told [V7] that [R2] laughs at me, that [R2] says he will kill me and that he would call me white boy, fa**ot, and tr*ny. It's a derogatory way of saying transgender. It's sexual harassment. I feel very upset, scared, and unsafe. Why I'm here. I can't sleep at night. [R2] is two doors down from my room. Sometimes staff are not around. At any point [R2] can easily come while I'm sleeping and stab me. They did not move [R2] from my floor. Every day I would see [R2] and he is always sitting up the front lobby. I feel unsafe. [R2] roams around the whole first floor by himself and he would always follow where I'm at. After [V7] left then one of the nurses came to my room so she can document. The nurse's name is [V13 Licensed Practical Nurse)]. [V13] came to my room at 11:10 AM. [V13] wanted to know what happened and I told her everything. The next day on 9/30/25 at 10:15 AM, [V7] came to visit me in my room. [V7] said they spoke with [R2] that they are going to do something. They did not tell me what they were going to do. [V7] asked me if I wanted to change my room. I told her [V7] that I like my room and I like the first floor and that I don't want to move. [V7] said they will do something with [R2]. On 10/2/25 at 11:55 AM, I went down the hall to put my empty lunch tray on the cart. When I passed by [R2's] room, he was sitting on his wheelchair by the door. [R2] laughed at me and called me a white boy. I said you're still an as***le and I kept going. [R2] followed me out of his room. I saw him [R2] following me so I went to the office by the exit door in the lobby. There were two women in the office. I think they are the head of nursing. I told them what was going on that I'm being chased by [R2] and threatening to kill me. One of them asked me if I wanted to change rooms. I said no. I said I'm not the one creating trouble. This is happening on a daily basis. I did not get their names because there's a lot of things going on in my head. They did not say a word. They just told me to go back to my room. They were the nursing managers. I was Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 0610 Level of Harm - Actual harm Residents Affected - Few emotionally distraught. I did not know what to do. On the same day at 2:30 PM, [V10 (Social Service Director)] the head of social services came to my room. I explained what happened to [V10]. I told her [V10] that [R2] was chasing me threatening to kill me. [V10] wanted me to change rooms. I told her [V10] I should not have to change my room. [V10] asked me if I felt safe on this floor, and I said absolutely not. [V10] asked me if I would feel safe if [R2] is placed on the other floor. I said I would feel safe then. If [R2] was transferred to a different floor, I would feel safe even at night when I'm sleeping. They still have not moved [R2]. On 10/16/25 at 5:00 PM, [R2] was outside. I was coming out of the van from my doctor's appointment. I saw him [R2] and followed me holding his phone up to my face and laughing. [R2] called me an ugly-fa**ot-tr*ny. No one heard or witnessed the incident. [R2] does not threaten me when anybody is around.On 10/17/25 at 11:04 AM, Surveyor observed R2 outside wheeling himself on a wheelchair. Surveyor made an introduction and asked if [R2] can be interviewed. R2 stated, No. I don't have time for that. I'm waiting for my bus to go for an appointment. Surveyor asked if [R2] is familiar with [R1]. R2 stated, I don't know who that is. I don't know what you're talking about. I got to go. You better be careful young lady. R2 ended the conversation.On 10/17/25 at 10:52 AM, V6 (Receptionist) and stated that the abuse coordinator is V2 (Director of Nursing). V6 stated that two or three weeks ago morning time, R1 reported to V6 that R2 was saying all types of crazy things to R1. V6 said R1 did not say exactly what were said. V6 stated that he reported R1's complaints to V1 (Administrator). V6 stated that R2 is still residing on the first floor and would always hang out at the first-floor lobby every day. V6 stated that he hears R2 say bad words to other residents but not specially towards R1. V6 stated he never heard R2 threatens anybody. On 10/17/25 at 11:12 AM, V7 (Psychiatric Rehabilitation Services Aide/PRSA) stated that R1 and R2 can move independently with their wheelchairs. V7 said that on end of September, I was asked to do a wellbeing check with R1. I went to her [R1] room. [R1] said that [R2] had said a couple of words to [R1]. [R1] said [R2] called her a white boy and mumbled something. [R1] told me that [R2] threaten to kill [R1] if she says something to him [R2]. I asked her [R1] what was her feeling. [R1] said she was uncomfortable in the room and she did not sleep well at that time when I asked her. [R1] said she felt unsafe. I told her [R1] that I would tell the corporate people know to address her concerns. I reported it to [(V4 (Nursing Consultant)] right after I talked to [R1]. [V4] told me she would address it and that I make sure [R1] is okay. [V4] said she would take care of it. [R2] was not moved to a different floor. I did not talk to [R2]. I asked [R1] if she wanted to move but she said no. I'm not sure who talked to [R2]. I am not sure if it was investigated. The administrator [V1] does that. I never witnessed any negative interaction between [R1] and [R2]. That was the first time I heard they were having disagreement.On 10/17/25 at 11:46 AM, V10 (Social Service Director) stated that if it's verbal allegation of abuse and if it's threatening, the aggressor will be sent out for psychiatric evaluation. V10 stated, Any types of abuse allegation even if it's unwitnessed, we notify the abuse coordinator. Abuse coordinator will report to the State Agency right away no more than 2 hours. Initial investigation should be conducted right away and thorough and complete investigation should be done. Final investigation is sent to the State within 5 business days. It's important to conduct a complete and thorough investigation of any abuse allegation to make sure all the residents in the facility are safe. To prevent a resident from getting harmed. V10 stated that she has not witnessed any negative interactions between R1 and R2. V10 stated that R2 is verbally aggressive towards staff and residents. R2 curses staff and residents. Calling them names. V10 stated, It was reported to me on a Monday in September. It was the end of the month. I received the call from [V7] stating that [R1] reported that [R2] was threating to kill [R1]. It was reported to me that [R2] was calling [R1] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 0610 Level of Harm - Actual harm Residents Affected - Few white boy, fa**ot, and tr*ny. I reported it to the person in charge who was the acting administrator at that time. I reported it to [V4]. I also reported it to [V11 (Assistant Director of Nursing)] because [V2 (Director of Nursing)] was not available and [V1] was off sick. [V1's] been on medical leave. I reported it to the next person in charge. I could not get a hold of [V2] she was on some type of meeting, so I verbally reported it to [V11]. And then I notified everybody on the group chat. When [V1] is not here, [V4] or [V2] would be the abuse coordinator. I talked to [R2] that same day and he admitted it. [R2] said that he told [R1] that he was going to punch [R1] because [R1] called [R2] an as***le. [R2] admitted that he threatened to kill her [R1]. I let management know. I told them. They did not send [R2] out and they did not separate [R2] from [R1]. I talked to [R1] she told me that she does not feel safe. [R1] told me she was scared and that she does not feel safe. I reported it to [V4]. I also brought it up in the morning meeting the next day. [R1] and [R2] are both alert and oriented. On 10/17/25 at 12:08 PM, V2 (Director of Nursing) stated that she is the abuse coordinator if V1 (Administrator) is on vacation or on leave. V2 stated that V1 has been out on leave for 2 and a half weeks now. V2 stated, If there is a resident to resident abuse, we make sure we separate the residents and we make sure that they are safe. We have 2 hours from the time of incident to do initial investigation and reporting to IDPH [Illinois Department of Public Health]. Initial investigation is important to get accurate statements. To determine if it's abuse and to determine what's the next step. These applies to any type of abuse allegation. [V1] had an all staff abuse in-service before she went on leave. The types of abuse are mental, verbal, sexual, misappropriation of funds, neglect, seclusion. Physical abuse is when resident strikes another resident or staff strikes another resident. Threatening to kill somebody would be a verbal abuse. It could be mental abuse depending on the reaction and how the resident feels. My office is by the exit door in the lobby. The only interactions I've seen between [R1] and [R2] were friendly. They were friends joking around with each other. I've never had a conversation with [R1] about an abuse allegation. She's [R1] never brought any complaints. On September 29 around noon, [V13 (Licensed Practical Nurse)] told me that [R1] stated [R2] was going to kill [R1]. I let [V1] know. I called her [V1]. I told [V1] what the situation was. [V1] directed me what to do. We had [V10] talk to [R1] and [R2]. I spoke to [R2] and he denied the allegation. [R2] said that [R1] said something to him. I asked both [R1 and R2] parties if they were okay. They said they were okay. They denied that they feel threatened, and they were fine. They did not want to move rooms or floor. We do investigation if we determine if it's abuse and if we determine its abuse, then we report it to IDPH. It was not reported to IDPH because it was not determined as abuse. Police were not called. It was not proven as abuse. They both said that they were fine, and they both said that they were not in fear. V2 said that R1's allegation against R2 was not investigated or reported to IDPH because it was not determined as abuse. Surveyor asked V2 to provide documentation of the complete investigation of R1's abuse allegations, but facility did not provide. 10/17/25 at 12:37 PM, V11 (Assistant Director of Nursing) stated she's been working in the facility since September 15th. V11 stated that if there is abuse allegation the process should be immediately reported to the abuse coordinator which is the administrator [V1]. V11 stated V1 is out sick. V11 stated, Generally, they have someone in her [V1] seat as acting administrator at that time if not, then [V2]. If there is negative interactions, separating both parties away from each other to ensure safety. If there is potential harm, we have to investigate see if there is any witnesses and take statements. The investigation should be done immediately when it's reported. If there is allegation of abuse initial investigation and reporting are sent to IDPH within 24 hours. The types of abuse are verbal, physical, emotional, mental abuse, financial abuse, seclusion and neglect. An example of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 0610 Level of Harm - Actual harm Residents Affected - Few verbal abuse is name calling, verbal threats such threatening to kill somebody. Mental abuse could be insults, calling name or threatening. I did not receive any report from any resident about abuse allegation. I have never witnessed any resident being abused by another resident. V11 stated she is familiar with R1 and R2. V11 said, From the time I've been here, I have witnessed them being friends and talking with each other. They stopped talking to each other in the last couple of weeks, but nothing negative I have witnessed personally.On 10/17/25 at 1:47 PM, V12 (Licensed Practical Nurse) stated that she is familiar with R1 and R2. V12 stated, Everytime, I work in the facility I see [R2] on the first floor. [R2's] room was one room down from [R1] then they move him [R2] on the other side on October 10th. Still on the same floor. [R1] came out one day very flustered. I don't' remember the day. It was in the afternoon. I was at the nurses' station at that time. I heard [R1] said that [R2] said something to her. [V4] and [V2] came out and said what's going on. Because [R1] was flustered. I went down the hall and [V2] asked me if I see or hear anything. I said I did not witness anything. I don't remember if they asked [R1] why she was flustered. [R2] is very argumentative with staff and patients. [R1] never bothers anybody.On 10/17/25 at 2:04 PM, a phone interview was conducted with V13 (Licensed Practical Nurse). Surveyor asked about R1 and R2's abuse allegation on 9/29/25. V13 stated, It was end of September. I was on lunch when I came back [V14 (Certified Nursing Assistant)] told me that [R1] and [R2] had an argument. I interviewed [R1] because [R2] already left for dialysis. [R1] said that since she came back from her last episode of amnesia, [R2] has being mean to her [R1] calling her white boy. [R1] said he did not touch her. Nobody was hurt or touch. [R1] did not tell me that he threatened to kill her. [R1] said to me that [R2] threatened to punch her. After that I reported it to the Social Worker [V7]. I didn't notify their doctors. I am not aware if they call the police. I'm not sure when they moved [R2] to a different room. [R2] was still on the first floor.On 10/17/25 at 2:15 PM, V4 (Nursing Consultant) stated that V1 went on leave on September 30. As of October 1st, V4 came to the facility for support. V4 stated she was not in the facility when R1 and R2's September 29 incident happened. V4 stated, I was in Florida. I was not made aware at that time. I heard that [R1] and [R2] had an unwitnessed argument. Back and forth exchange of words. That [V7] talked to [R1]. [V7] reported the allegation to [V2] I think. [V2] reported it to [V1]. They did not deem it reportable because it was not one sided. They said [R1] lashed out as well verbally. I would consider it verbal abuse the calling names and threatening to kill someone. It could be mental abuse.On 10/17/25 at 3:07 PM, a phone interview was conducted with V14 (Certified Nursing Assistant). Surveyor asked about R1 and R2's incident that happened on 9/29/25. V14 stated, I don't quite remember what happened. I witnessed [R2] was in the hallway and [R1] was in her room. [R2] was in the hallway by her [R1] door talking loud to [R1]. I think I heard [R2] said he was going to beat [R1] up. I reported it to the nurse [V13] right away. I separated them. [R2] went back to his room and [R1] stayed in her room. [R2] was put on one-on-one supervision. I don't remember if they call the police. I don't remember anything else what happened next.On 10/17/25 at 4:25 PM, a phone interview was conducted with V15 (Physician/Medical Director). V15 stated that threatening to kill or beat up someone is a type of verbal abuse. V15 stated that all abuse allegations should be thoroughly investigated for the safety of the residents. V15 stated that the aggressor should be sent out for a psychiatric evaluation.On 10/17/25 at 5:32 PM, a phone interview was conducted with V16 (Nursing Supervisor) and stated that R2 was moved to a different room (still first floor) on 10/10/25 not on 9/29/25. On 10/18/25 at 10:10 AM, a phone interview was conducted with V1 (Administrator). V1 stated she was not made aware of R1's allegations against R2 until yesterday (10/17/25). V1 stated she's on medical leave started on 9/28/25. V1 stated that V2 or V4 covers for her during her leave of absence, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 0610 Level of Harm - Actual harm Residents Affected - Few they will serve as the abuse coordinators. V2 is the point of contact. V1 stated nobody notified her about R1 and R2's incident that happened on 9/29/25. V1 stated she was not aware R1 and R2 was having continued disagreements. V1 stated, Knowing what I know and their [R1, R2] history in the past they have denied any wrongdoing. These residents have history of being verbally aggressive with each other and being inappropriate. To them this is how they talk to each other. [R1] and [R2] use profanity a lot but [R2] does it more. They do that to each other. I don't hear them threatens each other. We tell them it's not acceptable in the facility. We keep them apart. They are aggressive and inappropriate a lot. I don't think it's intentional or abusive to each other because that's how they talk. V1 stated that it is important to follow the facility's abuse policy and procedures to protect the residents. R1's clinical records show and admission date of 5/1/25 with included diagnoses but not limited to unspecified convulsion, major depressive disorder, and gender identity disorder. R1's Minimum Data Set (MDS) dated [DATE] shows a BIMS (Brief Interview for Mental Status) score of 13 which means R1 is cognitively intact. R1 uses a wheelchair and able to wheel herself with supervision. R1's progress notes dated 9/29/25 at 12:21 PM documented by V13 reads in part: Writer assessed resident: resident stated he's been coming pass my room all the time calling me white boy, but I just brush it off, but today after I mumbled as***le he told me he would punch me in the face or kill me. Writer notified social services. The resident is being closely monitored and is being kept separated from each other. No physical harm was done.R1's progress notes dated 9/29/25 at 12:55 PM documented by V7 reads in part: ALLEDGED ALIGATION OF ABUSE BY PEER: DAY 1/3 CO-PEER MADE INAPPROPRIATE/THREATENING STAEMENTS TO HER [R1]: Writer met with the resident [R1] due to report that a co-peer made negative statements to her. She [R1] was asked what happened and stated that she was sitting by her room door and the other resident rolled by and he called her [R1] boy and when she responded back, he [R2] told her that if she said anything else to him that he would kill her [R1]. She [R1] stated that this is not the first time he said something to her. Writer asked her why she did not say anything to staff before now, and she said she just didn't. Writer encouraged her to make staff aware any time someone is making her feel uncomfortable due to negative statement or actions toward her She [R1] was asked if she feels safe and she stated that she did not. Writer informed her that the appropriate parties will be notified and will follow up on her concerns.R1's progress notes dated 10/2/25 at 1:29 PM documented by V7 reads in part: Writer followed up with resident [R1] regarding an incident that happen between her and her peer. Writer went to the residents' [R1] room, and she told resident that she continues to have problems with co-peer. Resident [R1] stated that he continues to make comments to her and to call her [NAME] Boy. Resident [R1] stated she is getting tired of the situation, and something has to be done. Writer informed her that she would talk to someone in Administration to make them aware of the continuing issues between her and her peer. Social services will continue to follow up.R2's clinical records show an admission date of 1/10/25 with included diagnoses but not limited to hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, acquired absence of left leg below knee, and acquired absence of right leg below knee. R2's MDS dated [DATE] shows a BIMS score of 15 which means R2 is cognitively intact. R2 uses a wheelchair and able to wheel himself with supervision. R2's comprehensive care plan dated 3/17/25 documents in part: R2 has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). [R2] displayed verbal aggression towards staff on 2/4/2025. On 4/6/25 resident exhibited verbally abusive behavior toward others. R2's progress notes dated 9/29/25 at 10:35 AM, documented by V10 documents in part: Resident [R2] stated that his peer called him an as***le and he stated that he will punch her in the face and kill her. R2's progress notes dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145828 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 145828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2025 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 0610 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 10/10/25 at 3:17 PM documented by V7 revealed R2's room was changed but remained on the same floor as R1. V4 provided a copy of the initial investigation and reporting sent to IDPH dated 10/17/25 at 1:37 PM. The facility's Abuse Prevention Program policy and procedures (no date) documents in part: The facility will take steps to prevent potential abuse while the investigation is underway. Consumers who allegedly abused another consumer will be removed from the immediate area and a determination made as to contact, if any, with other consumers during the course of the investigation. The accused consumer's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other consumers and employees of the facility. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of consumer property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of consumer property will result in an investigation. The investigator will report the conclusions of the investigation in writing to the Executive Director or designee within five working days of the reported incident. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. Event ID: Facility ID: 145828 If continuation sheet Page 17 of 17