Inspection·July 18, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few another patient family that was leaving the unit. R1 was redirected and assisted back to the second floor. Spoke with nurse on duty and discussed elopement precautions and frequent rounding to be done to ensure R1 does not exit unit unless supervised by POA or staff due to being elopement risk with diagnosis of dementia, understanding voiced. Per nurse on duty the R1 did not leave the building and was easily redirected back to the unit. V11 request that families are made aware that staff should be notified of any residents attempting to leave the unit via elevator when they exit the facility. On 7/16/25 at 9:26am, V3 (complainant) said, she and V4 saw R1 on 95th street (7/4/25 @ 3pm) getting ready to cross the street. On 7/16/25 at 10:00pm, V4 (cna) said, he was off work. V4 said, he left the building around 3:15pm. V4 said, he saw R1 walking down 95th street. V4 said, he called out to R1, asked R1 what she was doing to which R1 replied taking a stroll. V4 said, he brought R1 back to the building, stop at V9's desk to inform her that R1 was found outside the building on 95th street. V4 said, he took R1 to V8 (nurse). V8 was the nurse on R1's unit. V8 did not know R1 left the building. V4's witness statement dated 7/17/25 documents: On July 4th, V4 saw R1 on 95th and walked R1 down the street back into the building. Let the front desk know and then took R1 back upstairs. On 7/16/25 at 10:58am, V8 (nurse) said, R1 attempted to exit the facility with R2's family. R1 went down the elevator. V4 (cna) brought R1 back to the unit. V8's statement documents: On 7/4/25 at 2:40pm, V8 was making the schedule for 3-11 shift when V9 called and asked if R1 was on the unit. V8 completed a head count with peer nurse. R1 was coming off the elevator with cna. On 7/16/25 at 11:02am, V5 (cna) said, she was sitting in the hallway at the end of R1's unit, because R1 got onto elevator, that requires a code, left the building and made it to 95th street. V4 brought R1 back into the building.On 7/16/25 at 11:19am, V9 (receptionist) said, R2's visitors V12-V13 (R2's visitors) signed out on the visitation log and proceeded to exit. V9 said, she saw someone walk pass really fast behind V12/V13. V9 said, she stood up, checked the computer because she was not sure if R2 was leaving with her family. V9 said, she recalled that only two (2) people came to visit R2 and three (3) people were leaving. V9 said, about one minute later, V4 (cna) brought R1 back into the facility. V9 said, R1 was a new admit. V9 said, she had never seen R1 before. V9 said, R1 left the building via the front lobby exit. V9 said, staff was standing in front of her desk but did not intervene. V9 said, V4 took R1 back to her unit on the second floor. V9 said, R1 exited after R2's family around 3:11pm on 7/4/25.V9's witness statement dated 7/16/25 documents: V9 observed a person walking past her behind two family members whom V9 did not recognize while at the front desk. V9 said, she checked the electronic computer system what R2 looked like. Two (V5-V6 certified nursing assistants/cna) knew who R1 was. V4 immediately walked R1 back in the building. As V5/V6 were standing at the front desk and said, that's R1 On 7/16/25 at 11:41am, V2 (don) said, she did not work on the 7/4/25. V2 said, she got some missed calls. V2 said, she got a call from V9 called to report R1 left out the building with R2's family.V2 said, she was informed that V4 brought R1 back in. V2 said, she was not aware R1 was on 95th street. Staff/certified nursing assistant (CAN) on R1's unit had to put in code for R1 to exit via the elevator. R1 was had yellow pass status which meant she need someone (family, staff or power of health care) to take R1 out of the building. On 7/16/25 at 12:51pm, V11 (nurse practitioner) said, she was not aware R1 left the building. V11 said, she was notified via message that, R1 was on the first floor. On 7/16/25 at 1:01pm, V1 (administrator) said, a true elopement is when a resident is found outside facility and staff doesn't know that they are missing, or when someone driving past and see one of the resident that no one knows is out of the building. V1 said, she has not have any true elopements. V1 said, residents that are high risk for elopement are residents who are exit seeking, mobile, with a diagnosis of Dementia, cognitively impairment residents, newly admitted or newly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145942 If continuation sheet Page 2 of 3 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 07/18/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete orientated to building. V1 said, R1 was not a true elopement. R1 was witnessed by staff leaving and redirected. V1 said, V9 reported seeing V12/V13 leaving but did not know R1 who left with R2 family. V1 said, the facility does not have a wander guard system. R1's unit has an elevator has a key pad to which the code must be entered to exit R1's floor. Nothing was written down, no new systems was implemented and she did not view cameras for R1 incident. V1 said, the cameras are for quality assurance purpose only. On 7/16/25 at 4:02pm, V12 (R2's visitor) said, he was with V13 when a female resident got on the elevator with him after staff entered the code. The code was enter three different time because the elevator did not come the first time. V12 was unable to identify which staff member entered the code. V12 said, a small, dark skin, thick staff member entered the code once and then another staff member entered the code a second/third time. V12 said, he was unable to determine if the staff member was a nurse or certified nursing assistant but they all had on scrubs. V12 said, he did not received any education from the facility about letting residents on the elevator. V12 said, he thought it was odd that a resident would be allowed on the elevator since staff had to enter a code for the elevator in order exit the second floor. V12 said, the sign out time on the visitation log was correct as far as he could remember. Visitation log dated 7/4/25 documents: V12 signed out at 3:11pm. On 6/17/25 at 9:17am, V4 (cna) said, R1 was found in the corner of 95th in front of the dental office. R1 had turned the corner off [NAME] and was walking east bound on 95th street. Google map documents: The dentist office was 450 feet away from the facility, mostly flat, with a two (2) minute estimate time of arrive (eta) by walking. R1 was returned to the facility less than ten minutes of leaving the facility by V4On 7/18/25 at 7:53am, V14 (R1's power of authority) said, R1 has a history of wandering. R1 would leave the house, go to located business and always find her way home. R1 was probably trying to find her way home when she left the building. V14 said, she wouldn't want R1 roaming the streets because she could have been hit by a car. V14 said, R1 said would have been extremely confused, fearful, agitated and scared wandering the streets in a neighborhood that was not familiar to R1. V14 said, she was scared for R1 during the interview to hear R1 was out of the building and found on the corner away from the facility. V14 said, R1 is mixed raced. V14 said, it is very concerning that R1 was out of the building with no identification or supervision. V14 said, if R1 was seen by united state immigration and customs enforcement R1 could have been detained. V14 said, she received a call from the facility at 9:30pm, informing her that R1 wanted to go home. V14 said, she was surprised by the call. The facility should have been able to address R1's needs. V14 said, she does not recall the nurse or the date she called. V14 said, she spoke to R1, along with other family member, R1 eventually forgot she wanted to leave prior to the end of the phone call. V14 said, she was not aware, R1 was out of the building. Elopement Policy no date document: It is the policy of this facility that all resident are provided adequate supervision to meet each resident's nursing and personal care needs. Resident at risk for elopement will be provide at least one of the following safety precautions, staff supervision of the facility exit either directly or by video camera. Procedure for the response to missing resident: The administrator/designee shall contact the resident's representative. Event ID: Facility ID: 145942 If continuation sheet Page 3 of 3