Inspection·April 23, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 04/17/2025 at 12:22PM during interview with V9 (Registered Nurse/RN), V9 stated that when she started her shift at around 2:00PM, she made her rounds and saw R1 sitting at the edge of his bed. V9 stated that at around 2:15PM, she saw R1 walking from his room going to the dining room. V9 stated that when she was passing medications at around 4:00PM, she did not see R1 in his room, so she went on passing medications to other residents. V9 stated that when she was done passing medications to residents in their rooms, she went to the dining room to see if R1 was there so she can give R1's medications, but R1 was not there. V9 stated that she went to other units and checked if R1 was there, but she did not find R1 on the other units. V9 stated that she activated Code Pink, and called the V2 (Director of Nursing), V16 (Assistant Director of Nursing), and V3 (Assistant Administrator). V9 stated that the V3 and V16 came in to help with the search but did not find R1. V9 stated that she cannot remember who the staff members were she asked at the time of the incident. On 04/17/2025 at 10:41AM during interview with V2 (Director of Nursing), V2 stated that she received a call from a nurse around 5PM on 04/14/2025 informing her that R1 was nowhere to be found in the building. V2 stated that she instructed her to check all rooms inside the facility, do a head count, and check the outside vicinity of the facility to make sure R1 was not in those areas. V2 stated that the nurse called a Code Pink (Elopement) so all staff will be searching the facility. V2 stated that V3 (Assistant Administrator) and V16 (Assistant Director of Nursing) were also informed, who came back to the facility to assist the staff. V2 stated that staff should be aware of the whereabouts of R1 since R1 needs supervision with ambulation. V2 stated that she was in the building at the time R1 walked out the dining room door, but she did not hear any door alarms going off. On 04/17/2025 at 11:50AM during interview with V3 (Assistant Administrator), V3 stated that she received a call from staff on 04/14/2025 at 6:41PM about R1 not being found anywhere in the facility and the vicinity. V3 stated that she lives 7 minutes away, so she came back in the building immediately to help staff search for R1. V3 stated that they searched everywhere and could not find R1. V3 stated that when she reviewed the camera, she saw that at around 2:30PM that day R1 walked to the dining room, just pushed the door, went out to the patio/courtyard, tried to open the gate but was not able to because it was locked, then went on to the left end of the patio/courtyard. V3 stated that it was the last time R1 was seen in the facility's vicinity. V3 stated that she was in the facility around the time R1 left and did not hear any door alarm going off. V3 stated that the door alarm is loud, and she could have not missed it if it went off. V3 stated that the door R1 went through was supposed to be locked and secured. V3 stated that if the door was locked and secured, the door's alarm should have gone off when R1 pushed it, but she did not hear anything at the time R1 went out of that door. V3 stated that between 1:30PM - 2:00PM is a smoking time for the residents. V3 stated that after the smoking time, the staff who supervised the smoking should make sure that all residents are inside the facility and the door is locked and secured. V3 stated that all staff should be checking the door periodically to make sure that it is locked and secured. V3 also stated that all staff should be aware of the whereabouts of their residents. V3 stated that she cannot remember if she saw any staff member present in the dining room when R1 walked through the door. On 04/18/2025 at 11:45AM during interview with V16 (Assistant Director of Nursing), V16 stated that she was working on 04/14/2025 between 7:45AM-4:20PM and denied hearing any door alarm go off and she has heard the door alarm go off before so she knows that wherever she's at, she would hear it. V16 stated that she got a call from V9 and V2 between 5:45PM-6:00PM informing her that R1 was nowhere to be found. V16 stated that she asked V9 if Code Pink was activated and if they looked inside and outside the facility, which they already did. V16 stated that she was back in the facility 15 minutes after she received the call. V16 stated that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 2 of 8 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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 - Immediate jeopardy to resident health or safety Residents Affected - Few looked around inside and outside the facility herself to make sure everything was covered already. V16 stated that V3 was in the building already, and V3 called the local police department. On 04/17/2025 at 10:30AM, R1 refused to be interviewed. At 12:53PM during interview with R1, R1 stated that he left the facility the other day and just came back yesterday to the facility. R1 stated that he went out through the front door and rode in a car with someone he didn't know. R1 stated that he was dropped off around 95th street or something like that. R1 stated that he left because he got tired of the facility. R1 was able to repeat the three words that he was told, stated it was April of 2025, unable to state the day of the week, and unable to recall the three words he was told to repeat earlier even with cue. On 04/17/2025 at 12:11PM during interview with V8 (Activity Aide), stated that she was working on 04/14/2025 between 10:00AM-5:00PM. V8 stated that she supervised the 1:30PM-2:00PM smoking time. V8 stated that R1 smoked at that time and went inside when smoking time was done. V8 stated that she was in the dining room between 2:00PM-3:00PM and did not hear any door alarm go off or see anyone go through the dining room door. V8 stated that after smoking time, all residents must go back inside the building, then Activity staff closes the door after all the residents are in. On 04/17/2025 at 12:04PM during interview with V7 (Activity Aide), V7 stated that she was working on 04/14/2025 between 8:00AM-4:00PM. V7 stated that she was not sure where she was between the hours of 2:00PM-2:45PM but she denied hearing any door alarm go off and seeing anyone go out to the patio/courtyard using the dining room door. V7 stated that during smoking times, Activity staff lets the residents out to the patio/courtyard, give them cigarettes and light it for them. V7 stated that after all the residents are done smoking or the smoking time is done, all residents are directed to go back inside the building then Activity staff closes the door. On 04/18/2025 at 9:59AM during interview with V15 (Certified Nursing Assistant/CNA), V15 stated that she was working on 04/14/2025 between 2:00PM-10:00PM on the unit where R1 is staying and has not heard any door alarm go off. V15 stated that she made her rounds during the start of her shift and attended to the immediate needs of the residents. V15 stated that at around 3:30PM, she went into the dining room because it's her turn to supervise residents in the dining room, and then Code Pink was called. V15 stated that she did not see R1 between 2:00PM until the Code Pink was called. On 04/17/2025 at 2:27PM during interview with V12 (CNA), V12 stated that she was working on 04/14/2025 between 2:00PM-10:00PM and has not heard any door alarm go off. On 04/17/2025 at 2:29PM during interview with V13 (CNA), V13 stated that she worked 04/14/2025 between 2:00PM-10:00PM and did not hear any door alarm go off. V13 stated that between 2:00PM-3:00PM, she was working in her unit which was in the South unit. On 04/18/2025 at 10:25AM, V6 (Maintenance Director) stated that activity staff are expected to make sure that the door is locked and engaged after each smoking times and ensuring that all the residents who smoked that time are inside the building. On 04/18/2025 at 11:53AM during interview with V17 (Restorative Nurse), V17 stated that R1 has a shuffling gait and needs supervision with ADLs. V17 stated that R1 needs supervision with his ADLs for safety and to ensure that he is completing the task. On 04/18/2025 at 9:37AM during interview with V14 (Nurse Practitioner), V14 stated that R1 fairly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 3 of 8 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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 - Immediate jeopardy to resident health or safety Residents Affected - Few new to the facility and came from assisted living. V14 stated that R1 is alert and oriented x 2, ambulatory with limp but steady. V14 stated that she is not sure if R1 is safe to be in the community. V14 stated that she usually performs safety assessments on new residents, but she did not perform safety assessment on R1 because R1 came in from assisted living and V14 assumed that R1 is only here for short-term rehab and will be back to assisted living. On 04/18/2025 at 12:46PM during interview with V18 (Marketer), V18 stated that she reached out to Executive Director of the assisted living on 04/15/2025 and asked if R1 happened to be there. V18 stated that the Executive Director told her that R1 was there the night before and thought that R1 was just visiting. V18 stated that she told the Executive Director to call her back if R1 happens to go back at the assisted living facility. V18 stated that the Executive Director reached back to her on 04/16/2025 between 2:00PM-4:00PM to inform her that R1 went back to the assisted living, and they called the police department. V18 stated that she talked to the police department and was told that they are taking R1 to the hospital. On 04/17/2025 at 2:17PM during interview with V11 (RN), V11 stated that R1 mentioned that he wanted to leave when he first got into the facility but V11 encouraged R1 to stay for the night. V11 stated that R1 came from an assisted living facility, and he did not receive any report about R1. On 04/18/2025 at 2:05PM, V11 stated that on 04/16/2025 he received R1 back from the hospital. V11 stated that the hospital nurse endorsed to him that R1 was brought in by police department because R1 was found in an apartment building lobby wandering. V11 stated that the hospital nurse told him that R1 told the hospital staff that R1 has been on the streets for 2 days before R1 went to the apartment building where he was found because R1 was cold. On 04/22/2025 at 11:00AM during interview with V1 (Administrator), V1 stated that he watched the surveillance video four times and noted that R1 was able to open the patio gate and exited the facility through the patio gate. Review of R1's Census Records indicated R1 was admitted initially on 04/07/2025. Review of R1's Physician Order Report dated 04/07/2025 indicated R1 was admitted on [DATE] with diagnoses of not limited to hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, and unspecified osteoarthritis, and an order to may go on therapeutic pass with medications and instructions with order date of 04/07/2025. Review of R1's Brief Interview for Mental Status (BIMS) dated 04/08/2025 indicated R1 scored 5 which indicates severe impairment. Review of R1's Community Access Observation dated 04/08/2025 indicated R1's has significant memory impairment which can be a barrier to safety in the community and was not able to verbalize understanding of the curfew and sign in/out process, so it was determined that R1 may not access the community independently related to cognitive functioning. Review of R1's Initial/Baseline Care Plan dated 04/07/2025 indicated R1 needs supervision with ambulation. Review of R1's Social Services admission Note dated 04/08/2025 indicated R1 was admitted from assisted living, has BIMS score of 5 and depression score of 10. Review of progress notes from 04/07/2025-04/17/2025 indicated V4 contact to R1's daughter and left a message on 04/08/2025. No other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 4 of 8 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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 documentation of attempt to reach out to R1's daughter was noted. Level of Harm - Immediate jeopardy to resident health or safety Review of R1's Nurse Practitioner Progress Note dated 04/11/2024 indicated R1 provided conflicting information about R1's living situation as R1 is stating that R1 both lives with his sister, and in assisted living. It also stated that R1's cognitive assessment reveals a BIM score of 5, and R1 has depression score of 10, suggesting cognitive impairment and significant depressive symptoms. Residents Affected - Few Review of R1's Cognition Loss/Dementia Care Plan created 04/08/2025 indicated problem start date of 04/08/2025, and R1 is an adult with impaired cognitive function and poor memory recall that may impact level of alertness, decision making task and responsibilities. It also indicated that according to Section C of the MDS (Minimum Data Set), R1 scored a 5 out of 15 in the BIMS assessment and R1 is severely impaired. Review of R1's Psychosocial Well-being Care Plan created 04/08/2025 indicated problem start date of 04/08/2025, and R1 requires the support, care and services of a long-term care facility and has been determined by community access assessment to be able to access the community with supervision. Review of R1's Nursing Progress Notes dated 04/14/2025 indicated V9 went to dining area during medication pass to administer R1 his medications but R1 was not there. It also indicated that V9 asked staff members that were in the dining room if they saw R1 and they said that they saw R1 walking along the patio. Review of R1's Nursing Progress Note dated 04/15/2025 indicated R1's daughter stated that R1 leaving the facility without notice is R1's behavior as R1 is used to coming and going as R1 pleased. Review of [NAME] Police Department Case Report with date and time of 04/14/2025 at 8:20PM indicated occurred incident type of Missing Person, event occurrence of 04/14/2025 at 2:30PM and R1 was reported missing. Review of [NAME] Police Department Case Supplemental Report with date and time of 04/16/2025 at 6:45PM indicated R1 was located by Chicago Police Department. Review of R1's Hospital Records indicated in nurse's progress notes dated 04/16/2025 that R1 was reported missing in [NAME], IL and was found in Chicago, IL. It also indicated that R1 arrived to the hospital at 7:07PM and was assessed for fall using [NAME] Fall Risk Assessment at 7:15PM with noted altered mental status. Review of undated, unlabeled document attached to R1's after visit summary from the hospital scanned to R1's electronic health record indicated R1 was found in the lobby of a building wandering and said he has been on the streets. Review of facility's policy entitled Elopement and Search Guideline (Code Pink) revised 09/04/2024 indicated the following: Purpose: To establish methods for protecting residents who are at risk for elopement and for conducting an organized search for a resident who cannot be located. Responsible Party: All staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 5 of 8 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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 1. All nursing personnel are responsible for: Level of Harm - Immediate jeopardy to resident health or safety a. Knowing the whereabouts of residents for which they are assigned. Residents Affected - Few Review of Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument User's Manual Section C dated October 2024 indicated the following: 3. Residents are not permitted to leave the building alone unless a physician order is present. Health-related Quality of Life: - Most residents are able to attempt the Brief Interview for Mental Status (BIMS), a structured cognitive interview. - A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance. o Without an attempted structured cognitive interview, a resident might be mislabeled based on their appearance or assumed diagnosis. - The total score: o Decreases the chance of incorrect labeling of cognitive ability and improves detection of delirium. o Provides staff with a more reliable estimate of resident function and allows staff interactions with residents that are based on more accurate impressions about resident ability. Planning for Care - Awareness of possible impairment may be important for maintaining a safe environment and providing safe discharge planning. - The BIMS is a brief screener that aids in detecting cognitive impairment. - The BIMS total score is highly correlated with Mini-Mental State Exam (MMSE; Folstein, Folstein, & [NAME], 1975) scores. Scores from a carefully conducted BIMS assessment where residents can hear all questions and the resident is not delirious suggest the following distributions: o 13-15: cognitively intact o 8-12: moderately impaired o 0-7: severe impairment On 04/23/2025, the surveyor conducted an onsite review and verified that the facility implemented the following to remove the immediacy: 1. R1 exited the facility on 4-14-2025, code pink was code, physician was notified. Family was made (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 6 of 8 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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 aware. R1 returned to facility on 4-16-2025 with no injury. Level of Harm - Immediate jeopardy to resident health or safety 2. An investigation was conducted, and it was discovered that R1 left the facility out of the patio door and then through the gate. The gate was not secure due to a malfunction in the lock mechanism. This was repaired on 4-16-25. The patio door will be locked between smoking times. Residents Affected - Few 3. R1was put on 1:1 monitoring when he returned to the facility for off-shifts. R1 was reassessed, care plans updated. R1 was found to be cognitively intact with a bims of 13. We received an order from R1s physician for a wander guard, and it was placed on him. R1 was transferred to an assisted living on 4-18-25 per his request. Family notified, and agreed to the transfer. 4. Starting on 4-18-2025, All staff including staff on leave and on vacation were inserviced By DON or designee on Safety and Supervision of Cognitive Impaired Residents Policy (New Policy as of 4-18-2025) Policy outlines the supervision of cognitively impaired residents who are ambulatory and self-mobile in wheelchair. Staff will not work their shift without being in-serviced. Completion date: 4-21-2025. a. Staff completed posttest to evaluate understanding of in-service. 5. New residents who are cognitively impaired and are ambulatory or self-mobile in wheelchairs have been identified. a. These residents are listed in a binder at each nurses station. b. These residents are put on every 2-hour location monitoring. 6. Starting 4-18-2025, all staff including staff on leave and on vacation were inserviced by the DON or designee on facility's Elopement Policy. Completion date: 4-21-2025. 7. Starting on 4-18-2025, all staff including staff on leave and on vacation were inserviced by the DON or designee on ensuring all exit doors are alarmed. Completion date 4-21-2025. a. Staff will complete posttest to evaluate understanding of in-service. 8. Maintenance Director or designee will do AM checks to ensure exit doors are in good order, alarmed and functioning. The south nurse will do PM and night checks to ensure exit doors are in good order, alarmed and functioning. 9. Medical Director made aware of IJ on 4-19-2025 10. Administrator coordinator or designee will conduct QA studies: a. Starting on 4-21-25 A QA audit will be performed random twice weekly on a sample of 5 staff members to ensure staff is aware of the whereabouts of cognitive impaired residents. b. Starting on 4-18-25 A QA audit will be performed random twice weekly to ensure exit doors are alarmed. The QA will include random days and shifts twice weekly for 3 months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 7 of 8 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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 c. Starting on 4-19-25 A Mock Code Pink will be performed random weekly for 3 months. Level of Harm - Immediate jeopardy to resident health or safety d. QA audit results will be presented and reviewed at the facility monthly QA meetings for three months to ensure maintained compliance, and on an as needed basis thereafter as deemed necessary by the QA committee. Residents Affected - Few 11. An emergency QAPI was conducted on 4-21-2025 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 8 of 8