Inspection·June 8, 2025

F 0600 -Battery; Aggravated: OTHER Dangerous. Level of Harm - Actual harm Form titled Physical Aggression dated 5/22/2025, documents: Residents Affected - Few R1 had an altercation with R2 in the hallway. R1 struck R2 in the face and R2 was noted with open area to left eyebrow. Social Service Note dated 5/22/2025, 4:27 PM, documents R1 was involved in an altercation with R2. R2 displayed increased agitation toward staff. R2 was difficult to re-direct and non-receptive to counseling as she continued to be aggressive and being disruptive on the unit. On 06/07/2025, at 10:39 AM, V6(Certified Nursing Assistant-CNA) was observed sitting in the dining room at a corner adjacent to the nursing station looking through his phone. V6 stated he was supervising residents in the dining room for safety and further stated he can see the residents in front of him. He has turn to see the residents sitting behind him. V6 stated he should be sitting at a place where he can see all residents for resident safety and prevent resident altercations. V6 stated residents are not supposed to fight or have altercations because it can be a form of abuse. On 06/07/2025, at 10:42 AM, V7 (Licensed Practical Nurse-LPN) stated she was R2's nurse on 5/22/2025, when R1 struck R2 on the face outside the door leading to the dining room. She was not on the unit when it happened. V7 stated when she got back to the nursing station, she found V1 (Administrator) and V2 (Director of Nursing) at the nursing station, after being notified of the altercation. V7 further stated she went to R2's room and found the wound nurse cleaning and treating R2's wound in the face, which was bleeding. V7 stated residents are not allowed to hit each other because that's a form of abuse. R1 was sent out to a local hospital for psychiatric evaluation and did not come back to the facility. On 06/07/2025, at 10:24 AM, V5 (Certified Nursing Assistant-CNA) was observed sitting in the dining room at a corner adjacent to the nursing station looking through her phone. Some residents were observed sitting behind V5 playing music. On 06/07/2025, at 10:59 AM, V5 (Certified Nursing Assistant-CNA) stated when the surveyor observed her earlier, sitting in the dining room on her phone, she (V5) was completing her charting on her cell phone and supervising residents for safety in the dining room. V5 stated at the position she was sitting at; she would have to turn to see residents sitting behind her. She should have sat at a position where she could see all the residents in the dining room. V5 stated she worked on 5/22/2025, when R1 was physically aggressive towards R2. R1 was coming out of the dining room and R2 was going into the dining room. V5 stated R1 started becoming aggressive towards R2, swearing at R2, and took something from her wheelchair. R1 hit R2 on the face. V5 stated blood shot out of R2's face and blood went everywhere on R2's face and the floor. V5 stated at that time, all staff ran towards the dining room to see what was happening and separate R1 and R2. V5 stated residents hitting each other is not allowed and it is a form of abuse. On 06/07/2025, at 11:07 AM, V8 (Wound Care Nurse-LPN) V5 and surveyor observed R2 in her room. V8 described R2's scar on the left side of her face as: midline, left eyebrow, 4 centimeters long, width 0.5 centimeters, closed not draining, dark brownish scab on the scar. V8 touched R2's scar. R2 stated she felt pain of 5/10 with 10 being the most pain and the pain was regular in description. On 06/07/2025, at 11:26 AM, V4(Social Services Director) stated on 5/22/2025, there was a physical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145914 If continuation sheet Page 2 of 4 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 145914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpoint Nursing & Rehab Center 1010 West 95th Street Chicago, IL 60643 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 altercation between R1 and R2. R 1 was the aggressor hitting R2 on the left side of the face with an empty glass perfume bottle, causing R2 to bleed. V4 stated staff separated the residents and attended to R2. V4 stated a glass bottle can be used as a weapon and any form of physical altercation is abuse. Therefore, residents should be monitored for safety, so they don't hit each other. V4 stated R1 has a lot of behavioral issues such as aggression, disrespect, being inappropriate, yelling, and attention seeking behaviors. But R2 does not have these behaviors. V4 stated when residents are in the dining room or in common areas, staff should supervise residents for safety. On 06/07/2025, at 2:04 PM, V9 (Licensed Practical Nurse-LPN) via phone stated on 5/22/2025, at approximately lunch time, she was notified that R2 has a laceration on the face. V9 came to the unit and found R2 in her room sitting on in her wheelchair with a slightly open wound over her left eyebrow, with minimal bleeding. V9 stated R2 did not complain of pain at time but R2 was upset because of the altercation with R1. V9 stated she assessed R2 and called V10 (Physician) who gave a one-time order to cleanse the wound with saline water, apply over the counter antibiotic bacitracin, then cover with strip strips (surgical cape). V9 stated she does not remember if she wrote the orders in R2's Physician Order Sheet (POS) and further stated she is supposed to write the orders to notify other nurses and doctors what has already been given for resident. V9 stated no other orders were given after that and she did not follow up on R2. On 06/07/2025, at 2:28 PM, V10 (Physician) via phone stated he was notified R2 has a lesion on her forehead and was not notified R2 had been hit by another resident. V10 stated V9 had evaluated R2 and informed V10 that the laceration was superficial. Therefore, it was not necessary to send R2 to the hospital. V10 stated he gave orders to V9 to clean the lesion with normal saline, put over the counter antibiotic, and cover with normal dressing. V10 stated nurses are supposed to write all physician orders in the Physician Order Sheet (POS) so the nursing team are aware of which treatments a resident has received for effectiveness. V10 stated residents in the facilities have arguments all the time and hit each other. R2 being hit by R1 is not considered abuse because the laceration R2 sustained was superficial and there was no hematoma of broken bones, but he does not expect residents to hit each other. On 6/7/2025, at 4:20 PM, V2 (Director of Nursing) stated she was informed that two residents on the second floor had an altercation, so she went to the unit to find out what was going on. V2 stated she saw V5 (Certified Nursing Assistant-CNA) with R2 in the hallway holding a gauze on R2's left side of the face, above the eyebrow. V5 informed V2 that R2 was bleeding after being hit by R1. V2 stated the staff told her R2 was sitting outside the dining room adjacent to the nursing station. R1 was coming out of the dining room and as she was passing by. R2 hit her on the face before staff could intervene. V2 stated V1(Administrator) told her R1 used a perfume glass bottle which was in a sock to hit R2 and that is physical assault. V2 stated her expectation is for staff to always monitor residents for safety and staff are not supposed to be on their phones while on the job or use their phones to access residents' medical records to chart. On 06/07/2025, at 5:00 PM, V1(Administrator) stated on 5/22/2025, during lunch time when a staff member (cannot remember who) called the front desk and stated something was wrong on the second floor. V2 ran to the second floor to find out what was going on. V1 stated she found other staff members already on the floor and was told R1 hit R2 with an empty perfume bottle that was in a sock, which R1 had been carrying around tucked under her thigh and wheelchair seat. V1 stated she and V4 brought R1 to V4's office to separate her from R2, as the nurses took care of R2. V1 stated she called the police right away. They came and interviewed R1, R2, and herself. Both residents' doctors were notified of the incident. R1 was sent to the hospital for further evaluation. R2 was treated at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145914 If continuation sheet Page 3 of 4 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 145914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpoint Nursing & Rehab Center 1010 West 95th Street Chicago, IL 60643 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 facility to stop her bleeding. V1 stated R1 attacked R2 which is a physical altercation, but V1 does not like calling it physical assault or abuse because calling it that is too harsh. V1 stated residents are not supposed to hit each other. V1 stated she spent some time with R2 that day and R2 told her she was scared. Residents Affected - Few Facility Reported Incident Report dated 5/28/2025, documents: -R1 was verbally aggressive to R1 and stuck R2 when attempting to go into the dining room. Facility Policy titled Standard Supervision and Monitoring, no date documents: Purpose: this guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes supervision and guidance to the residents is an essence part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs. Facility Policy Titled: Abuse Prevention Program Abuse And Crime dated 01/19, documents: -Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. -Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Physical Abuse: Hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. R1's care plan documents: R1 displays manipulative behavior which is disruptive, insensitive and/or disrespectful to staff and peers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145914 If continuation sheet Page 4 of 4