Inspection·January 9, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few replied, . I did the investigation with R1 and R2. It was that morning that they found R1 with discoloration on the left eye. R1 and R2 were in the room and was then separated. Physician was notified, R1 was sent out. V9 (Restorative Aide, RA) told me that she (R1) has a discoloration to the eye and when they were trying to remove her (R1) from the room, R2 became aggressive and attempted to hit her (R1). V6 (CNA) and V9 were there, they witnessed the incident. R2 did not hit R1. I don't know how she got the discoloration of the eye. When I interviewed R2 and asked if she hit her (R1), she (R2) said that she (R2) wants her (R1) out of her (R2) way and denied hitting her (R1). It is hard for us to say if she was hit by R2 or she (R1) bumped her head to something else. R1 is highly demented, and she wanders around. She (R1) is oblivious to where she is going. On 01/06/24 at 2:19 PM, V9 was interviewed regarding R1 and R2. V9 stated, That day, I was doing my rounds, I walked into R1's and R2's room, I saw dry blood on the floor. R1 was standing, I asked how she (R1) was doing, she turned around and I saw blood from her nose, mouth. The blood was already dry, and she had a black eye on the left eye. I took her (R1) hand, took her out to hallway, I saw V6. She (V6) came to me and asked her (V6) about what happened, she said she doesn't know. We asked other staff for help; they came in and I left. I called V1 and V2 (Director of Nursing). V6 was also interviewed on 01/06/25 at 11:20 AM regarding R1 and R2 incident on 12/12/24. V6 verbalized, That incident, it happened like around 6:30 AM, I came out from another resident's room. One of the RAs said that there was a discoloration to R1's left eye, like a black eye, and there was blood in her (R1) nose and mouth. That those were not on R1's face before. I removed R1 from the scene, called the nurse and the nurse went to assessed her. I saw R2, her (R1) roommate, with blood on her (R2) hand. I asked her (R2) and she said she hit her (R1) because she was in her (R2) space. She (R2) hit her (R1). I notified V1 and V2 and she (R1) was sent out to the hospital. R1 wanders from room to room. She will just stand there talking to herself, but not aggressive. She can be easily redirected. When she (R1) wanders or walk in the hallway, one of us will walk with her and turn her around and bring her back to the dining room. So she won't intrude other's space. R2 is a known offender, she curses all out, verbally aggressive to staff and residents. I have not seen her hit anybody, but she will yell what she will do to you. Her behavior had been reported. Each time she had episodes, we notify nurses. When she (R2) was admitted , she was in another room but had an altercation with R7, her roommate. I heard her (R2) yelling. I went to the room, and she (R2) said that she doesn't want anybody touching her (R2) stuff. So, she (R2) was moved to another room. A week or two later, R1 was moved to her (R2) room. Progress notes dated 10/27/24 recorded that R2 requested to be transferred to another room due to not getting along with peers. Surveyor attempted to ask R7 on 01/06/25 at 11:45 AM regarding incident with R2 but she (R7) did not respond to question. Instead, R7 responded that she had a fall and now she is fine and happy. R7 was confused. Per MDS dated [DATE], R7 has BIMS score of 6 (which means severe cognitive impairment) and has a diagnosis of Unspecified Cerebral Palsy and Cognitive Communication Deficit. On 01/06/25 at 1:58 PM, V8 (Licensed Practical Nurse, LPN) was asked regarding R1 and R2. V8 stated, That day, 12/12/24, I was working that morning. I ran to the floor, and I was asked to assess R1. I went to her (R1) room, she had a discoloration to her left eye. I called physician and supervisors and there was an order for me to send her (R1) out to the hospital. R1 was unable to tell me what happened. I wasn't sure where it came from. I know R2 was her roommate. I asked her (R2) and she said she didn't know. No one reported anything to me or witnessed anything. I was just told that she had the discoloration to her left eye. I am not sure where she got the discoloration to her left eye. V8 was also asked regarding R1 and R2 behaviors. V8 verbalized, R1 is alert, oriented to self; she has Dementia, she is very confused. She is unaware of her safety and unable to make her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145942 If continuation sheet Page 2 of 5 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 145942 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453 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 needs known. We like to keep her in the dining room because she does walk around. When she is in the hallway, staff walks with her. She can easily be redirected. When she is in the room, staff has to do frequent checks on her because she will get up and wanders around. She walks with her head down, she touches things. R1 and R2 were roommates. R2 is alert, oriented, able to verbalize needs; sometimes she could be a little verbally aggressive to me, and to staff. She does have a behavior of verbal aggression. It could be anything or people rummaging through her things. She had a room change last 10/27/24 because she assumed that her roommate, R7, was rummaging through her things. She was yelling to me and wanted a room change that time, that she does not want to be in that room. She curses when she is upset. Per R2's face sheet, she was admitted in the facility on 10/25/24 with diagnoses of Schizoaffective Disorder, Bipolar Type;Schizophrenia Unspecified; and Anxiety Disorder, Unspecified. MDS dated [DATE] recorded R2 has BIMS score of 15 which means no impairment in cognition. Progress notes dated 10/27/24 documented R2 requested room change due to not getting along with peers. Progress notes dated 11/15/24 also documented that R2 was using inappropriate words in the common area. CHIRP (Criminal History Information Response Process) dated 10/25/24 recorded R2 is an identified offender and had history of incarceration for criminal damage to property. On 01/06/25 at 2:35 PM, V10 (Social Services Director) was also asked regarding awareness on R1 and R2's behavior. V10 stated, R1 is confused. She was in my elopement list because she walks with confusion. R2 used to be a resident here. She had delusional behavior. I was not aware of any verbal aggression. She had a room change on 10/27/24 due to resident (R2) choice compatibility. There was no incident reported. She (R2) chose to be removed, or her room be changed. During interview also with V1 on 01/06/25 at 12:23 PM, she was asked regarding R1, R2 and room change. V1 stated, We do room changes when we see residents not getting along with each other and they requested it; and for safety like for fall risk residents by placing them close to nurses' station. Residents who are known for aggression will be removed and put them in a private room by themselves with no room mates. There was no behavior of R2 being aggressive to staff and other residents, but she is resistive to care. If she has a known behavior of aggression to other residents, I will not pair her with a roommate. If a resident is not getting along with anybody, we are not going to pair them up. I am not aware that she (R2) has an aggressive behavior towards staff and residents. Screening Assessment for Indicators of Aggressive and/ or Harmful Behavior dated 12/26/24 documented that R1 appears to be at low risk for indicators of aggressive and/ or harmful behavior currently. Trauma Screening dated 12/04/24 documented R1 appears to be at minimal symptomology for trauma based off this assessment. On 01/07/25 at 2:18 PM, V2 was asked regarding abuse assessment and care planning. V2 replied, I am involved in care planning of residents. We do care planning upon admission. The IDT (interdisciplinary team) will come together and will develop care plan based from problems identified from previous facility. After 72 hours, we meet again and we see where we at, care plans are developed with interventions. If any behavior or fall or any incident occurs, we meet again and develop the care plan. We develop care plan on admission. The care plan is based on the problems upon admission. We don't do care plans for abuse. If there is no abuse, we don't do care plan for abuse. If there is an incident of abuse, it should be care planned. For R1, she has dementia, she is not vulnerable to be abused, so there is no abuse care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145942 If continuation sheet Page 3 of 5 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 145942 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453 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 Further review of R1's medical records showed that there was no abuse care plan, and abuse assessment even after 12/12/24 abuse report. Level of Harm - Actual harm Residents Affected - Few R1's care plan dated 12/04/24 regarding disoriented to place and time, recorded in part but not limited to the following: Intervention - Provide reassurance to help the resident feel safe and secure On 01/07/25 at 12:58 PM, V12 (Physician) was asked regarding R1. V12 verbalized, She wanders around, very confused. Yes, I was notified regarding altercation between her and the other resident. I think its because one of them is getting in another's space. I was notified regarding the discoloration to her left eye, bleeding to nose and mouth, she was sent out for evaluation. I was not sure of what happened. She (R1) is demented and always looking around and roommate didn't like it. Residents should not get injuries and needs to be protected while in the facility. Facility's policy titled Abuse Prevention Program, dated 3/1/21 documented in part but not limited to the following: Policy It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a third party. [NAME] Screen-Train-Report-Identify-Investigate-Protect-Prevent Procedure VII. Prevention The facility desires to prevent abuse, neglect, exploitation, misappropriation, and a crime against a resident by establishing a resident-sensitive and resident-secure environment. This will be accomplished by a comprehensive Quality Assurance Performance Improvement approach. As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis. Facility's policy titled, Abuse and Crime Reporting dated 01/2019 stated in part but not limited to the following: Policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145942 If continuation sheet Page 4 of 5 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 145942 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453 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 This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals. Facility's policy titled IDT Care Planning Policy and Procedure (Person-Centered Plan of Care), dated 6/2020 documented in part but not limited to the following: Each resident will have a comprehensive assessment completed that will assist the development of an individualized (Person-Centered) plan of care that will include goals and interventions aimed to improve or maintain the residents highest level of function, prevent decline, decrease risk of complications of medical condition, medications and diagnosis, decrease risk of injury or to promote comfort at end of life. The resident has the right to unless adjudged to be incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment changes in care and treatment. The facility must have evidence that the resident and/ or responsible party was afforded the opportunity to participate in care planning. It is the policy of the facility to assist residents to participate (Example: helping residents, families, surrogates or representatives understand the assessment and care planning process; when feasible, holding care plan meetings at the time of day when the resident is functioning best, planning enough time for information exchanges and decision making and encouraging residents to attend). 1.Each resident will have a comprehensive assessment completed by the Interdisciplinary team upon admission, quarterly and with significant changes and an individualized care plan will be developed and updated as needed with quarterly assessments, re-admissions, and changes in conditions. 6. New Admissions/Readmissions will have baseline care plans initiated by nursing with actual and potential problems identified and the comprehensive care plan will continue to be developed with the completion of the MDS Assessment process within the RAI (Resident Assessment Instrument) rules and regulations. New residents will be added to the Calendar within 72 hours of admission and resident/family/responsible party will be notified of the upcoming meeting. 7. Residents care plans will be reviewed and updated as needed with re-admissions, quarterly re-assessments, annually and with changes in conditions (Example: revisions may be made to the problem statement, goals and interventions). New care plans will be initiated with new significant problem area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145942 If continuation sheet Page 5 of 5