Health inspection·December 6, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm interdisciplinary care plan team will review each resident's advance directive status as documented in the resident's record at the time of the initial care plan conference and reconfirm that no changes in status are desired. The team will also conduct such reviews and reconfirmations at the time of every scheduled care plan conference. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 2 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to include urinary catheter use in R85's comprehensive care plan, have urinary catheter care orders, and maintain R85's dignity by not failing to provide a urinary catheter privacy bag for one (R85) out of a total sample of 46 residents. Findings include: R85's Face Sheet documents in part diagnoses of infection in the urine, presence of urogenital implants and attention to other artificial openings of urinary tract. It documents in part urinary catheter use. R85's Physician Order Report from 11/03/2024 - 12/03/2024 does not document in part urinary catheter care orders. R85's Care Plan does not contain a focus for urinary catheter use, goals, or interventions. On 12/03/2024 at 9:33 AM, R85's room was in front of the main entrance to the facility. R85's room door was open and R85 was lying in bed. Urinary catheter tubing and bag was in plain sight. On 12/05/2024 at 9:21 AM, V2 (Director of Nursing) stated R85 has had the urinary catheter for weeks. V2 stated the expectation when it comes to urinary catheters is for staff to provide a privacy bag to maintain dignity. Staff are to make sure the urinary catheter tubing and bag are clean and patent. If urine is not flowing correctly, staff are to notify the doctor. These interventions were not listed in R85's Physician Order Report or in R85's Care Plan. admission to the Facility policy, last revised 12/2006, documents in part: Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least: Routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan. Facility's 4/2015 Care Plans (Comprehensive) policy documents in part: An individualized Comprehensive Care Plan that includes measurable objectives and timestables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident. Each resident's Comprehensive Care Plan has been designed to: incorporate identified problem areas, incorporate risk factors associated with identified problems, build on the resident's strengths', reflect treatment goals and objectives in measurable outcomes, identify the professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status and/or functional levels, enhance the optimal functioning the resident by focusing on a rehabilitative program, as needed. Facility's Catheter Care, Urinary procedural policy (last revised 09/2005) documents in part: Review the resident's care plan to assess for any special needs of the resident. Under Equipment and Supplies, it did not include urinary privacy bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 3 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to transcribe hospital orders upon initial admission for one (R96) out of a total sample of 46 residents. Residents Affected - Few Findings include: R96's Face Sheet documents in part diagnoses of seizures, hypertensive heart disease, neuralgia and neuritis, alcohol dependence, insomnia, and mood disorder. On 12/03/2024 at 11:02 AM and during a follow-up interview at 12:38 PM, R96 stated when [R96] discharged from the hospital, the hospital staff instructed R96 to take Magnesium pills. R96 stated [R96] had a bottle of Magnesium pills but facility staff took it during admission. R96 asked staff about the Magnesium pills but they have not added it to R96's treatment. R96's Patient Discharge Instructions dated 11/01/2024 documents in part printed prescription for Magnesium Oxide 250 mg (milligrams) 2 tablets orally every day for 30 days. Reason for the prescription was for supplement. Surveyor reviewed R96's Progress Notes. V22's (Nurse) 11/01/2024 6:52 PM admission note for R96 documents in part: [V23 (Physician)] made aware of resident's admission and medication reconciliation done. Ordered to continue medications as received. R96's Physician Order Report from 11/03/2024 - 12/03/2024 did not include orders for Magnesium Oxide. On 12/05/2024 at 9:38 AM, V2 (Director of Nursing) stated that [V2] was not aware of R96's concerns relating to prescribed Magnesium Oxide. V2 stated [V2] will look into R96's medications. During a follow-up interview at 11:19 AM, V2 stated facility called R96's physician and received orders for blood work and Magnesium Oxide. R96's updated Physician Order Report documents in part a new order for Magnesium Oxide 400 mg one tablet orally once a day. admission to the Facility policy, last revised 12/2006, documents in part: Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least: . b. Medication orders, including (as necessary) a medical condition or problem associated with each medication. Facility's Medication Administration Policy effective 01/2020 documents in part: Drugs will be administered in accordance with orders of licensed medical practitioners in this State. Facility's Attachment J: Statement of Resident Rights policy documents in part on page 33: The right to request, refuse, and/or discontinue treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 4 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to a.) ensure the portable oxygen tank was on the correct setting, b.) ensure the oxygen tubing was stored to prevent contamination, and c.) ensure the oxygen tubing was labeled and dated when changed. This failure has the potential to affect 1 (R37) of 2 residents reviewed for oxygen therapy. Residents Affected - Few Findings Include: R37 has diagnosis not limited to Respiratory Failure, Unspecified with Hypoxia, Chronic Kidney Disease, Stage 4, Permanent Atrial Fibrillation, Pleural Effusion, Shortness of Breath, Unilateral Primary Osteoarthritis, Left Knee, and Hypertensive Heart Disease. R37 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderately impaired. Physician Order Report dated 11/03/24 - 12/03/24 document in part: Oxygen: Change tubing and mask weekly and prn (as needed) (Label). Start date 11/11/24. Oxygen: Nasal Cannula. Rate 3L/Min (Liters/Minute) Continuous. Every shift: Days, Evenings, Nights. Start date 11/11/24. Care Plan Problem start date 11/16/24 document in part: Problem: R37 has ineffective breathing pattern R/T (Related to) SOB (Shortness of Breath). R37 has a diagnosis of respiratory failure, pleural effusion, and SOB. R37 wears continuous O2. On 12/03/24 at 11:31 AM R37 was observed sitting in a wheelchair with oxygen at 2 liters per nasal cannula in use. R37 stated when I came back from the hospital, they put the oxygen on me. The oxygen tubing was observed undated with no label. Oxygen nasal cannula tubing was observed laying on the concentrator not in use and not in a storage bag. On 12/03/24 at 12:28 PM R37 was observed sitting in a wheelchair in the dining room with oxygen at 2 liters per nasal in use. V5 (Licensed Practical Nurse) stated the oxygen tubing is changed weekly, and we label the tubing with tape. I didn't get a chance to label this oxygen tubing. R37 is on 3 liters of oxygen. Surveyor asked V5 the oxygen setting on R37's portable oxygen tank. V5 stated it is on 3 liters now, it was on 2 liters, and I just changed it. When the oxygen tubing is not in use it goes in a bag. If it is not in a bag, it can get dirty. V5 was informed by the surveyor that R37's nasal cannula connected to the oxygen concentrator in R37's room is not in a bag. V5 stated I am going to throw it away and get another one. On 12/05/24 at 09:10 AM V2 (Director of Nursing) stated all oxygen equipment is changed every Sunday night into Monday morning. When the oxygen tubing is changed it is labeled and we apply the oxygen as ordered. We label the oxygen tubing and equipment with tape. The oxygen tubing is labeled and dated so that we will know when it is change and to make sure it is changed adequately. We apply the oxygen according to the doctor's order. The doctor order has a rate inside of the orders. If the oxygen is not on the correct setting there is a potential that the resident has difficulty breathing, shortness of breath and is not getting the amount of oxygen that should be delivered. When the oxygen is not in use the nasal cannula is put in a plastic bag to keep it clean. Oxygen tubing is changed it is signed off on the MAR (Medication Administration Record). On 12/05/24 at 11:18 AM V2 (Director of Nursing) stated we do not have a separate oxygen labeling policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 5 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0695 Policy: Level of Harm - Minimal harm or potential for actual harm Titled Oxygen Administration dated 03/04 document in part: The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the procedure: 5. Start the flow of oxygen as ordered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 6 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview, and record review the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours in a 24-hour period on Mondays, Wednesdays, Thursdays, Fridays and every other Saturday and Sunday during 3 of 3 months reviewed. This failure has the potential to affect all 105 residents residing in the facility. Findings include: During the facility tour 12/03/24 -12/05/24 there were no Registered Nurse assigned to provide care to the facility residents. The Third Quarter PBJ (Payroll Based Journal) indicate V19 (Nurse Manager/Registered Nurse) worked 07/06/24. 07/07/24, 07/20/24, 07/21/224, 08/01/24, 08/02/08/03/24. 08/04/24, 08/17/24. 08/18/24, 08/31/24, 09/01/24, 09/02/24, 09/28/24 and 09/29/24. V20 (Registered Nurse) worked 07/02/24, 07/09/24, 07/16/24, 07/23/24, 07/30/24, 08/06/24, 08/13/24, 08/20/24, 08/27/24, 09/3/24, 09/10/24, 09/17/24 and 09/24/24. There are no documented hours for V21 (Registered Nurse) during the third quarter (PBJ). On 12/03/24 at 09:48AM V1 (Administrator) stated there are no nursing staff waivers. On 12/05/24 at 09:10 AM V2 (Director of Nursing) stated I deal with staffing. We schedule 2 nurses per shift and at least 6 certified nurse assistants on days and evenings. On nights there are at least 4 certified nurse assistants. We do not staff according to the acuity or census. On 12/05/24 at 12:45 V2 (Director of Nursing) stated there is a Registered Nurse in the building every day. The Assistant Director of Nursing and I are both Registered Nurses, but we do not work the floor unless we are short staffed. I have Two Registered Nurses that work on the weekend, V21 (Registered Nurse) and V19 (Nurse Manager/Registered Nurse). On the weekend V19 (Nurse Manager/Registered Nurse) does not work the floor but V19 is in the building every other weekend. We have never had a Registered Nurse to work on the floor every day. I will work the floor if we are short, but I try not to. On 12/05/24 at 1:16 PM V1 (Administrator) stated there is a total of four Registered Nurses in the facility, V2 (Director of Nursing), V3 (Assistant Director of Nursing), V19 (Nurse Manager/Registered Nurse) and V20 (Registered Nurse). For the PBJ (Payroll Based Journal) there are 4 Registered Nurses. V19 (Nurse Manager/Registered Nurse) only works every other weekend as the nurse manager on the floor and is here for 8 hours. V20 (Registered Nurse) worked every Tuesday night shift for 8 hours. V3 (Assistant Director of Nursing) works one weekend and V19 (Nurse Manager/Registered Nurse) works the other weekend. The manager on duty on the weekend role is as needed wound nurse, manage all the other departments, give me a report and they do the reportable. If we are short that is when they are assigned to residents. On 12/05/24 at 01:34 PM V1 (Administrator) stated V21 (Registered Nurse) is a new hire and just works every other weekend. Document titled Facility Assessment Tool dated 12/23 -11/24 document in part: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 7 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as capabilities to provide services to the residents in the facility. 4. The facility assessment should serve as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources. Staff type: 4. 4.1 Identify the type of staff members, other health professionals, and medical practitioners that are needed to provide support and care for residents. Staffing plan: 4.2 Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staffing to meet the needs of the residents at any given time. 4.8 Develop and maintain a plan to maximize recruitment and retention of direct care staff. Synthesize and Use the Assessment Findings: 7. Review the findings of your assessment as a leadership team and discuss the following questions. The goal is to make decisions about needed resources, including direct care staff needs, as well as their capabilities to provides services to the residents in the facility. Staffing provided by the facility dated 09/01/24 - 12/06/24 only has a Registered Nurse assigned to the floor on Tuesdays, Saturday 09/14/24, Saturday 09/21/24, Saturday 09/28/24, Monday 10/07/24 and Sunday 11/24/24. Policy: Titled Staffing Policy undated document in part: It is the policy of this facility to provide an adequate umber of staff to successfully implement resident functions to meet resident needs. 1. The facility operates in compliance with applicable federal, state, and local laws, regulations and codes with accepted professional standards and principles that apply to professionals. 2. Adequate staffing ratios, by numbers and positions, required to meet the needs of the residents will be maintained. 4. Each Department Director shall assure a minimum staffing pattern is maintained. 6. A Registered Nurse will be scheduled seven days a week at least one continuous (8) eight-hour shift. 7. The Administer will be notified by the Department Directors whenever minimum staffing standards are not met and report appropriate interventions being initiated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 8 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews, and record reviews, the facility failed to have resident's medications readily available for administration, administer medications on time, and ensure accurate reconciliation of a resident's controlled medication for three residents (R43, R74, R78) observed during medication administration and during medication storage and labeling task. Findings include: R78's Face Sheet documents in part diagnoses of seizures, schizophrenia, bipolar disorder, insomnia, and delusional disorders. R78's Physician Order Report from 11/03/2024 - 12/03/2024 documents in part an order for Phenobarbital (Schedule IV controlled substance) 16.2 mg (milligram) tablets, take two tablets three times daily. On 12/03/2024 at 9:36 AM, surveyor reviewed Medication Cart B with V4 (Nurse). At 9:57 AM, V4 stated outgoing and oncoming nurse are supposed to count the controlled medications at the beginning of the shift. During review of the narcotic bin, surveyor and V4 reviewed R78's Controlled Drug Receipt/Record/Disposition Form for Phenobarbital 32.4 mg. Instruction was to take one tablet by mouth three times daily for seizures. The last written administration on the form documents in part a date of 11/22/2024. Facility administered one tablet and there should be one tablet remaining. V4 checked the narcotic bin and binder, there was no blister packet for R78's Phenobarbital 32.4 mg that had one remaining tablet. V4 did not know whether the form was wrong or whether the blister packet is missing. V4 reviewed R78's other controlled drug forms and Medication Administration Records. V4 could not explain the discrepancy. -R74's Face Sheet documents in part diagnoses of major depressive disorder, recurrent, severe with psychotic symptoms; schizophrenia; and bipolar disorder. R74's Physician Order Report from 11/04/2024 - 12/04/2024 documents in part an order for Sertraline tablet 50 mg (milligram) one tablet orally once a day at 9:00 AM. On 12/04/2024 at 9:21 AM, V4 (Nurse) prepared medications for R74. Facility uses individual blister packs along with house stock medications. At 9:26 AM, V4 stated [V4] did not have R74's Sertraline 50 mg tablets in the medication cart. V4 went to the facility medication storage room but R74's blister packet for Sertraline was not there. At 9:31 AM, V4 stated administration will order the medication STAT. R43's Face Sheet documents in part diagnosis of hypertensive heart disease (condition resulting from long-term high blood pressure). R43's Physician Order Report from 11/04/2024 - 12/04/2024 documents in part orders for Amlodipine 10 mg orally once a day at 9:00 AM and Metoprolol Succinate tablet extended release 24 hour 25 mg orally once a day at 9:00 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 9 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R43's Care Plan documents in part that R43 is at risk for complications related to cardiovascular status (start date 8/02/2022). Approaches include to administer prescribed medications as ordered (start date 8/02/2022). On 12/04/2024 at 9:38 AM, V4 (Nurse) prepared medications for R43. At 9:43 AM, V4 stated [V4] did not have R43's Amlodipine blister packet or R43's Metoprolol Succinate Extended-Release blister packet in the medication cart. At 9:47 AM, V4 went to the medication storage room to check if there were extras in their overstock pile but R43's Amlodipine and Metoprolol Succinate were not there. At 9:53 AM, V4 notified R43 that blood pressure pills were not available and would order then STAT (as soon as possible). At 10:42 AM, V4 informed surveyor that [V4] forgot that the facility had an electronic medication dispensing machine. V4 stated V4 and V16 (the other nurse working the floor) did not have access to it, but administration was getting their usernames and password from the pharmacy to get access into it. At 10:48 AM, V16 stated the pharmacy usually delivers twice during night shift. The first delivery is around 11:30 PM to 1:00 AM and the second delivery is around 4:00 AM. V6 stated pharmacy can also provide STAT medications during the day within the hour. At 11:00 AM, V4 stated facility retrieved Amlodipine 2.5 mg and Sertraline 25 mg from the electronic medication dispensing system but it did not have Metoprolol Succinate. V4 administered Amlodipine 10 mg to R43 at 11:09 AM (more than an hour after scheduled time). At 11:20 AM, V4 stated the facility called R43's doctor and got a one-time order for Metoprolol Tartrate (not extended release) 25 mg for R43. V4 administered the Metoprolol Tartrate 25 mg to R43. At 11:18 AM, V4 administered Sertraline 50 mg to R74 (more than an hour after scheduled time). On 12/05/2024 at 9:43 AM, V2 (Director of Nursing) stated the pharmacy delivers every night. V2 stated the nurses are supposed to reorder residents' medications when they are down to less than three days' worth of supply. The nurses are to pull the tab on the blister packet and request a refill from the pharmacy. V2 stated the night shift nurse is responsible for receiving the medication deliveries and putting them away; however, each nurse is still responsible for checking their medication carts and making sure the residents' medication are there. Regarding controlled medications, V2 expects the nurses to sign out the medications as they give them. V2 could not explain the discrepancy with R78's Phenobarbital. Facility's undated Pharmaceutical Services Policy documents in part: It is the policy of this facility to provide pharmaceutical services including policies and procedures for safe and accurate drug therapy distribution, control and use. The facility maintains policies and procedures designed to ensure appropriate methods and procedures for the distribution, dispensing and administration of drugs and biologicals, in accordance with state and federal laws. Facility's 01/2020 Medication Administration Policy documents in part: Drugs will be administered in accordance with orders of licensed medical practitioners in this state. Medications shall be administered within one (1) hour of the medication schedule unless specifically ordered otherwise. Medications shall be recorded on the medication record promptly after each administration by the individual who had administered the drug. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 10 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Facility's undated Controlled Substance Policy documents in part: It is the policy of this facility to maintain individual records of receipt and distribution of all controlled drugs in sufficient detail to enable an accurate reconciliation. Controlled substance shall be securely stored and precautionary measures taken to prevent misuse. Each Schedule record shall be accurately maintained and include: Name resident, Name of prescriber, Drug name, Form of medication, Prescription number, Quantity received, Date sent/received, Strength and dose administered, Date and time of administration, Signature and title of person administering drug. Change of shift counts (audits) will be conducted by authorized nursing personnel to reconcile drug availability. Discrepancies between the record and the physical count, will be reported to the Director of Nursing and the Consultant Pharmacist. A Medication and Treatment Incident Report will be completed by the nurses discovering the discrepancy. Event ID: Facility ID: 146018 If continuation sheet Page 11 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: R96's Face Sheet documents in part an initial admission date of 11/01/2024. It documents in part diagnoses of unspecified psychosis, alcohol dependence, unspecified mood disorder, and insomnia. It also documents in part that R96 is responsible for self. On 12/03/2024 at 11:02 AM and during a follow-up interview at 12:38 PM, R96 stated [R96] did not want to take Aripiprazole (antipsychotic) and Lexapro (antidepressant). R96 stated the medications made [R96] loopy and see white dots. R96 stated facility did not have R96 sign consent for the medications. R96 stated V4 (Nurse) and V15 (Nurse) are aware that R96 does not want to take the medications but facility continues to have it ordered for R96. R96's Physician Order Report from 11/03/2024 - 12/03/2024 documents in part orders for Aripiprazole 10 mg (milligram) tablet orally daily (start date 11/01/2024) and Lexapro 10 mg tablet orally daily (start 11/01/2024). R96's Medications Flowsheets from November and December document in part that nursing staff documented administering Aripiprazole and Lexapro to R96. On 12/03/2024 at 2:41 PM, V4 stated R96 refuses to take Aripiprazole and Lexapro. V4 stated R96 refused them the last time V4 took care of R96 and refused them that morning. V4 stated R96 did not think [R96] needed them anymore. V4 stated administering the medications to R96 prior. When asked if R96 gave initial consent to be on the medications, V4 did not know. V4 stated facility did not have a psychotropic nurse and did not know who was responsible for obtaining psychotropic consents. During a telephone interview on 12/05/2024 at 11:12 AM, V15 (Nurse) stated there are days when R96 does not want to take medications. V15 was not sure whether R96 consented for Aripiprazole and Lexapro. On 12/04/2024 at around 1:38 PM, facility provided a copy of R96's Consent for Use of Psychotropic Medication for Aripiprazole and Lexapro. It was completed on 12/04/2024 12:44 PM (time of survey) by V3 (Assistant Director of Nursing/Psychotropic Nurse). On 12/04/2024 at 1:41 PM, R96 stated signing the document that day thinking it was a consent for a seizure medication. R96 stated informing V3 that R96 does not want to take Aripiprazole and Lexapro. V3 informed R96 that V3 will look into it prior to leaving with the consent. R96 maintained that R96 does not want to take Abilify and Lexapro. R96 stated facility did not obtain written consent for psychotropics upon admission. On 12/04/2024 at 1:48 PM, V3 stated [V3] was responsible for psychotropic medications. V3 stated initially talking to R96 about psychotropic medications around the time of admission. V3 stated [V3] did not get R96's written consent for psychotropics upon admission. When asked if facility is supposed to administer psychotropic medications prior to obtaining written consent, V3 stated technically no. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 12 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/05/2024 at 9:38 AM, V2 (Director of Nursing) stated [V2] was not aware that R96 did not want to take Aripiprazole and Lexapro. V2 stated that the expectation is for the admitting nurse to educate residents about the prescribed psychotropics and obtain the consent prior to administering them. During a follow-up interview at 11:19 AM, V2 stated R96 is own responsible party and makes own treatment decisions. Facility's Attachment J: Statement of Resident Rights policy documents in part on page 33: The right to request, refuse, and/or discontinue treatment. Facility's undated Psychotropic Medications Policy documents in part: This facility shall ensure that residents do not receive psychotropic drugs unless such therapy is necessary to treat a specific condition is diagnosed by the attending physician or psychiatric consultant. Attempts will be made to reduce or discontinue use of such medications whenever possible without compromising resident's health and safety, ability to function appropriately, or the safety of others. Based on interviews and record reviews, the facility failed to obtain written informed consent prior to prescribing and administering psychotropic medications for 3 residents (R15, R90 and R96) out of a total sample of 46 residents per facility's policy. Findings include: R15 is [AGE] years old, with primary medical diagnosis of COPD (Chronic Obstructive Pulmonary Disease), Schizophrenia disorder, bipolar type. Per R15's MAR (Medication Administration Record) resident has 3 psychotropic medications signed as given are as follows: Aripiprazole (antipsychotic) 10 MG signed as being administered daily, Depakote 250 MG (anticonvulsant) used for major depression signed as being administered 3 times a day, and Trazodone (antidepressant) 100 MG signed as being administered daily at night. R90 is [AGE] years old, with primary diagnosis of osteoarthritis on left knee, malignant neoplasm right breast, dementia, depressive episodes, and delirium. Per R90's MAR (Medication Administration Record) resident has 3 psychotropic medications signed as given are as follows: Aripiprazole (antipsychotic) 2 MG signed as being administered twice daily, Sertraline (antidepressant) 25 MG signed as being administered daily, and Trazodone (antidepressant) 100 MG signed as being administered daily at night. Per review of R15 and R90 psychotropic informed consent provided by V3 (Assistant Director of Nursing) it was noted that the date of completion was 12/04/2024 although both R15 and R90 were receiving psychotropic medication mentioned above prior to 12/04/2024. On 12/05/2024 at 11:39 AM, R90 was seen in her room and was asked if she was informed about medication side effects and benefits of any of her medicine she currently take. R90 stated that she does not know any side effects because nobody told her about her medicines. R90 was asked if she signed any consent document about her medication, specific to psych meds? R90 stated No I would not sign any psych medication consent form if I was given one. On 12/05/2024 at 11:51 AM R15 was asked if any of facility staff discussed to her about the medication she currently takes? R15 said that V8 (Social Service Director) came few minutes ago and told her that before she can leave for discharge, she needs to wait for all her medications. R15 was asked if she signed a consent for her psychotropic medication? R15 replied that yesterday a CNA (Certified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 13 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nursing Assistant) came to let her sign a consent form. And told her that she (R15) needs to sign the form in order to be discharge. And nobody explained the form to her. On 12/05/2024 at 12:01 PM V3 (Assistant Director of Nursing/Infection Control/Psychotropic Nurse) stated the informed consent was completed yesterday (12/04/2024) and talked to residents (R15 and R90) when they signed the form. V3 stated that informed consent should have been done before hand. V3 was informed that a resident stated that a Certified Nursing Assistant was the person who let her sign the informed consent form. V3 replied, I send other people to get them signed. V3 was also informed that R90 does not know about the side effect of her psychotropic medication when signing the form. Instead, R90 was informed that the form was for her discharged . V3 stated, Yes, I told R90 that in order to be discharged she needs to sign. V3 then stated, I can see the problem because R90 signed the consent because of her discharge not of knowing the side effects and benefit of prolonged use. Psychotropic Medication Policy dated 02/2014, reads: Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident's guardian, or other authorized representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 14 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews, the facility failed to discard medications not in their original packaging, label and date a used insulin pen, store unused insulin in the refrigerator, check medication fridge temperatures daily, store mediations in a clean fridge, and store refrigerated medications away from food. This has the potential to affect all 48 residents receiving medications from Medication Cart A and those residents on insulin. Findings include: On 12/03/2024 at 9:36 AM, surveyor reviewed facility's Medication Cart B with V4 (Nurse). V4 stated the cart contained medications for about 48 residents. On the first fourth slot in the first drawer, there was one loose, pink capsule not in its original packaging. On the first slot of the second drawer, there was a round, orange pill and an oval white pill not in their original packaging. In the fourth slot of the second drawer, there was a white oval pill not in its original packaging. In the second slot on the third drawer, there were five loose pills not in their original packaging (two circular, white pills in different size; one oval, white pill; one orange, circular pill; and one blue, circular pill). V4 did not know what the pills were. V4 stated the night nurses are supposed to be the ones cleaning the medications carts. In the insulin drawer, R72's Humalog Kwikpen did not have an open or discard date. R31's Basaglar Kwikpen did not have an open or discard date. Label documents in part to refrigerate if not opened. R31's Aspart Kwikpen did not have an open or discard date. Label documents in part fridge/default. At 10:06 AM, V4 stated did not know if the insulin pens were used or not. After inspecting the solution in each pen, V4 stated that R31's Basaglar Kwikpen looked used because there was missing solution in the vial. V4 stated the other pens were full and seemed to be unopened. V3 stated not sure why the night nurse forgot to put the unused pens in the medication refrigerator. At 10:09 AM, surveyor reviewed the medication storage room near the B Wing with V4. There was a sign taped to the medication refrigerator noting there should only be medications in the refrigerator. No food is allowed in it. When surveyor opened the medication refrigerator, there were multiple dark, sticky streaks going down the refrigerator door. V4 did not know what the substance was. The freezer portion of the refrigerator had a thick layer of ice build-up. Underneath the ice build-up were multiple insulin pens. V4 did not know who was responsible for defrosting the refrigerator and how often it was done. Inside the refrigerator there was also a brown paper bag which contained a sandwich, two snack bars, and a beverage. V4 stated it was for R200. Staff keep the snack pack in the medication refrigerator because R200 goes to dialysis early in the morning. V4 stated there are no other accessible refrigerator to keep it separate from the medications. At 10:12 AM, V5 (Nurse) stated the night shift nurses are supposed to clean the medication refrigerator. V5 was not sure what day of the week they do it. V5 did not know what the sticky residue was inside the medication refrigerator. At 10:54 AM, V4 stated the night shift nurses are also supposed to check the temperature of the medication refrigerator daily. Reviewed facility's temperature logs for the medication refrigerator. Multiple missing entries from September, October, and November. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 15 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/05/2024 at 9:43 AM, V2 (Director of Nursing) stated the night shift nurses are responsible for receiving the pharmacy deliveries and putting them away; however, each nurse is still responsible for checking their medication carts. V2 stated the nurses should clean up after themselves after each shift and check for any loose pills. V2 stated loose pills should be discarded. V2 also stated that when insulin pens are unopened, they should be stored in the medication refrigerator. If insulin pens are opened and used, the nurse that opens it should write when they opened it and when it should be tossed. V2 stated the night shift is supposed to defrost the medication fridge; however, all nurses use the medication refrigerator daily and are responsible for cleaning it and making sure there is no food in it. Regarding R200's dialysis snack, V2 stated the facility does not have another refrigerator available to store snacks overnight. The other refrigerators in the facility are locked up at night and nurses do not have access to them. Facility's undated Pharmaceutical Services Policy documents in part: It is the policy of this facility to provide pharmaceutical services including policies and procedures for safe and accurate drug therapy distribution, control and use. The facility maintains policies and procedures designed to ensure appropriate methods and procedures for the distribution, dispensing and administration of drugs and biologicals, in accordance with state and federal laws. The facility shall maintain adequate equipment and supplies necessary to ensure proper storage, dispensing, distribution, and administration of drugs and biologicals. Facility's 10/25/2014 Storage of Medications policy documents in part: Medications and biologicals are stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medical medication disposal and reordered from the pharmacy if a current order exists. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator. Medications requiring refrigeration are kept in a refrigerator at temperatures between 2°C (36°F) and 8°C (46°F) with a thermometer to allow temperature monitoring. The facility should maintain a temperature log in the storage area to record temperatures at least once a day. Certain medications or package types, such as [Intravenous] solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 16 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of records the facility failed to follow handling of clothes inside a net-like bag by leaving on the floor exposed to unclean surfaces per their policy. These failures have the potential to affect 5 residents (R17, R10, R73, R22, and R100). Facility also failed to follow Water Management Program that have the potential to affect all 105 residents living in the facility in ensuring water supply in the facility are free from water borne diseases. Residents Affected - Many Findings include: On 12/03/2024 at 11:33 AM, a total of 3 rooms were seen with net-like (mesh) full of clothing laying on the floor. V11 (Certified Nursing Assistant) was informed, then identified as follows: Red bag is R17's clothing, blue and black bags is R10's clothing, and yellow bag is R73's clothing. V11 stated that bags that contains clothes need to be taken off the floor. V11 also said that the facility uses these net-like (mesh) bags to place resident's clothing to be laundered. V11 was asked if clothes that are placed inside these net-like (mesh) bags are left on the floor since the clothes inside are not protected or may be exposed to the floor? V11 replied that it should not be on floor. And it should have been placed in a bin. V11 then went to get a cylindrical dark blue colored bin in the hallway. Upon opening the lid, the bin was empty, V11 took some of the bags put it inside the bin. On 12/03/2024 at 11:53 AM, another room was seen with net-like (mesh) blue bag on the floor. V12 (Certified Nursing Assistant) stated that R22 owns the bag. V22 stated that it should not be left on the floor and should be placed inside the bin. On 12/03/2024 at 12:11 PM, another room was seen with net-like (mesh) bag on the floor. V13 (Certified Nursing Assistant) was informed and identified the clothes of R100. V13 stated that those bags are usually left on the floor. On 12/04/2024 at 01:11 PM Per V3 (Assistant Director of Nursing / Infection Control Preventionist / Psychotropic Nurse) facility uses a net-like bag that is see through. Nursing staff on the floor has a collection bin that the bags with clothes that need to be laundered should be place inside, and it should not be left on the floor. On 12/05/2024 at 09:52 AM, V2 (Director of Nursing) stated that each wing has a different laundry day. Soiled clothes are collected by CNA and housekeeping, or laundry staff will bring clothes for washing to the laundry room. CNA are allowed to send it down for laundry. They should not leave it on the floor for the following shift because day shift does the linens and afternoon shift does the clothing. Both for the soiled and clean clothes should not leave it on the floor. Laundry and Bedding, Soiled policy dated 08/2008, reads: Soiled laundry and bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. On 12/03/2024 at 02:27 PM, V10 (Maintenance Director) was asked about water management program to prevent water borne disease like legionella. V10 stated that he noticed a kit in his office but does not know what the kit is all about. At V10's office, V10 showed the kit and stated that it arrived a month ago. V10 was asked again about water management program to prevent water borne disease? V10 stated that he does not have any documentation related to water check for prevention of water borne disease. V10 was asked if water temperature was being checked? V10 replied since he started 10 months (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 17 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many ago, he does not know that it needs to be checked. Requested to V10 any information at all that facility has on water management program or policies. V10 stated that he does not have any but will inform administration. On 12/04/2024 at 11:11 AM, V10 submitted Water Management Program Policy. Stated that water was not tested for Legionella last year, and after pointing out the policy requires risk assessment of water supply in the facility. V10 stated that he will address what is in the policy. On 12/05/2024 at 10:49 AM, V1 (Administrator) stated that the facility needs to have a kit to test the water once a year. And also need to do monthly testing of water temperature. Risk assessment was supposed to be done per Water Management Program. V10 is new to Long Term Care, he used to work in assisted living. And risk assessment was supposed to be completed last month. V1 said, that was supposed to be done by V10. Water Management Program dated 10/01/2017, reads: It is the policy of this facility to establish procedures to reduce risk of Legionella and other opportunistic pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophormonas, nontuberculous mycobacteria, and fungi) in the facility's water systems. The maintenance director will maintain documentation that describes the facility's water system. A risk assessment of water system components will be conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. CMS (Centers for Medicare and Medicaid Services) Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 07/06/2018, reads: Legionella Infections: The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains. o Facility Requirements to Prevent Legionella Infections: Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. o This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations. For skilled nursing facilities and nursing facilities: The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Expectations for Healthcare Facilities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 18 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0880 Level of Harm - Minimal harm or potential for actual harm CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Residents Affected - Many o Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. o Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit. Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. o Maintains compliance with other applicable Federal, State, and local requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 19 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on review of records and interviews the facility failed to educate 2 residents (R73 and R250) on influenza vaccination and 4 residents (R45, R73, R90 and R250) on pneumococcal immunization per their policy on documentation of influenza and pneumococcal immunization. These failures have the potential to affect 4 residents (R45, R73, R90 and R250) on informed decision on the risk and benefits of influenza and pneumococcal vaccinations in a sample of 46 residents. Residents Affected - Some Findings include: Per preventative health care of the sampled residents, it documents as follow: R45 has no record of pneumococcal vaccination. Informed consent form under for pneumococcal immunization reads that R45 request to received immunization on 9/11/2024 no record provided that R45 received immunization. R73 has no record of influenza and pneumococcal vaccination. Informed consent for influenza and pneumococcal vaccinations are both declined with reasons are left blank. R90 has no pneumococcal vaccination. Informed consent form under pneumococcal immunization reads that R90 request to received immunization on 9/11/2024 no record provided that R90 received immunization. R250 no vaccination on record and no informed consent. On 12/04/2024 at 01:11 PM with V3 (Assistant Director of Nursing / Infection Control Preventionist) stated, all resident's immunization should be documented under preventative health care and progress notes. Vaccinations including Covid-19, influenza and pneumococcal are located under preventative health care. V3 stated I need to make sure that I document all immunization under preventative health care. I know I failed to document. V3 stated that informed consent were provided to resident before immunization. And teaching is important for residents to know the risks and benefits of immunization. And that he (V3) will check for his notes on these residents (R45, R73, R90 and R250) that education was done. Before writer left, V3 stated I am sure I have no documentation on the progress notes for education of vaccines. Requested to V3 all documentation related to vaccination. For those residents (R45 and R90) who requested to received pneumococcal vaccinations, no record that it was provided. For the resident (R73) who declined, reason was left blank. And R250 has no record at all related to immunization as to informed consent and preventative health care. Influenza and Pneumococcal Immunizations policy dated 11/2016, reads: To assure that each resident receives education regarding the benefits and potential side effects before being offered influenza and pneumococcal immunizations and securing their informed consent for administration of these immunizations. Each resident, or when appropriate their representative, will be educated regarding the benefits and potential side effects of both influenza and pneumococcal immunizations and will be provided the opportunity to accept or refuse them. The facility will document both the education provided and the resident's decision, or when appropriate that of the resident representative, to accept or refused the offered immunizations that will be maintained in the resident's clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 20 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on review of records and interviews the facility failed to educate 2 residents (R73 and R250) on Covid- 19 vaccination per their policy on documentation of Covid-19 immunization. These failures have the potential to affect 2 residents (R73, and R250) on informed decision on the risk and benefits of Covid-19 vaccinations in a sample of 46. Findings include: Per preventative health care of the sampled residents, it documents as follow: R73 has no record of Covid-19 vaccination for 2024. Informed consent was not provided. R250 no vaccination on record and no informed consent. On 12/04/2024 at 01:11 PM with V3 (Assistant Director of Nursing / Infection Control Preventionist) stated, all resident's immunization should be documented under preventative health care and progress notes. Vaccinations including Covid-19, influenza and pneumococcal are located under preventative health care. V3 stated I need to make sure that I document all immunization under preventative health care. I know I failed to document. V3 stated that informed consent were provided to resident before immunization. And teaching is important for residents to know the risks and benefits of immunization. And that he (V3) will check for his notes on these residents (R45, R73, R90 and R250) that education was done. Before writer left, V3 stated I am sure I have no documentation on the progress notes for education of vaccines. COVID - 19 Education and Vaccination for Resident Policy dated 03/2022, reads: The facility shall ensure that all residents are provided education and offered COVID - 19 vaccination including booster(s). The facility shall notify all residents of the COVID - 19 and shall provide or arrange for vaccination of all residents who need to avail themselves of the vaccination. The facility shall maintain a system to track the offer of vaccinations to residents. The system shall be documented that each person either accepted the offer or declined offer. Documentation shall be entered into Electronic Health Record under (preventative health care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 21 of 22 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 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Little Village Nrsg & Rhb Ctr 2320 South Lawndale Chicago, IL 60623 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of records the facility failed to ensure that resident room environment was in a safe condition for 1 (R73) out of 46 residents . Failure includes detached vinyl flooring and tiles located at entry door from the bed going to the restroom. Findings include: R73 is [AGE] years old with primary medical diagnosis of Parkinson's disease, schizoaffective disorder, bipolar type, difficulty in walking, lack of coordination, and dementia. On 12/05/2024 at 11:34 AM, R73 was seen sitting on the right side of the bed with walker. R73 stated she now uses the walker going to the toilet. In front of R73 about 4 to 5 feet was the door entrance to the restroom/toilet. Upon looking at the flooring of the entrance to the restroom and toilet, a thin vinyl that was detached around ¾ of the square remaining. When stepped by feet it easily slides on the floor. V11 (Certified Nursing Assistant) was informed. And upon seeing the flooring stated that it is a problem because R73 may slip and fall. And the area is where R73 pass often because it is the entrance to the toilet. V11 said to inform maintenance to correct the problem. V10 (Maintenance Director) came and stated that staff on the floor needs to inform maintenance by writing a ticket so that the problem can be fixed. On 12/05/2024 at 09:52 AM, V2 (Director of Nursing) stated that R73 graduated from wheelchair to walker. And the CNAs (Certified Nursing Assistants) on the floor are expected that if they see the situation (detached vinyl on the floor, similar to clutter) that put at risk for the resident they make a report to the maintenance and address the problem. On 12/05/2024 at 10:49 AM, V1 (Administrator) stated that this issue needs the cooperation of different departments. The CNAs (Certified Nursing Assistants) and the housekeeping should check on that issue. Housekeeping is sweeping the floor every time so they can see the tiles and the floor. When the staff see that issue, they need to write on the maintenance book for it to be addressed. If maintenance was informed, that should have been repaired. It is a cooperation of all departments that is hazard not only to resident but also to staff as well. Safety Policy not dated, reads: To ensure a safe living environment for each resident. Each resident shall be observed to identify potential risks and receive adequate supervision and assistance, including devices, to prevent accidents. Hazardous areas will be identified. All resident areas are easily visualized or observed by staff members. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 22 of 22