Health inspection·January 31, 2025

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attacking other residents or staff in the facility. V7 stated was called by the nurse that R1 was in the facility intoxicated. V7 stated it was the facility that decided to give her and IVD notice. V2 (Director of Nursing) she sated on 1/29/25 at 2:00pm stated they had a care plan meeting with R1 about what she wanted which was to get a job and get approved for social security. V2 stated R1 did agree to go to substance abuse treatment program but she reneged. V2 stated that nurse informed her that R1 was sent to the hospital for being intoxicated. V1 (Social Worker Director) he stated on 1/29/25 at 1:10pm the plan was for R1 to go to a SMHRF (specialized mental health rehab facility) but she refused. V1 stated R1 met the criteria for SMHRF but she declined. V1 stated the plan was to convince R1 to go to SMHRF to better to meet her psychological and substance abuse. V1 stated while in the facility R1 had not displayed any suicidal or homicidal ideations. V1 stated she did not want to go to group so was getting 1:1 therapy. V1 stated he explained to R1 that if she did not comply with going to substance and mental health therapy that the facility would have to start the involuntary discharge process. V5 (Licensed Practical Nurse) stated on 1/29/25 at 9:45am she has taken care of R1 for about a year and never received report or seen R1 attacking other residents or staff. V5 stated it was late afternoon near the end of the shift when R1 came back to the facility intoxicated and was stumbling while walking. V5 stated she helped R1 into bed then contacted the Nurse Practitioner and administrator that R1 was in the facility intoxicated. V5 stated they received order to send R1 out for an evaluation. V5 stated she gave report to oncoming nurse as to what had transpired. V6 (Licensed Practical Nurse) stated on 1/29/25 at 10:20am he had been working at the facility for a few months. V6 stated he was never told that R1 had attacked any resident or staff at the facility. V6 stated he came to work on 12/25/24 for the pm shift and got report that R1 was going to hospital to be evaluated for intoxication. On 1/30/25 at 10:15 amV8 (Administrator) stated her reason for giving R1 the IVD (involuntary discharge) was because she refused go to the outpatient substance abuse program and she was not following some of the facility rules. V8 stated she believed that the facility could no longer meet R1's needs. V8 stated this was her first time ever filling out an involuntary transfer and discharge notice and checked off the wrong box that R1 was endangered to the individuals in the facility. V8 stated she should have checked off the box on the IVD form that R1's welfare and needs could not be met in this facility. V8 stated she was not familiar with the IVD process, time frames or of the residents right to appeal the IVD. V8 stated will educate herself going forward on how to fill out the IVD form correctly and allow the IVD process to play out according to the State and Federal Guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review facility failed to give a resident an involuntary discharge notice 30 days prior to the resident's discharge. This applies to one resident (R1) out of three residents reviewed for transfers and discharges. Finding Include: R1 progress note dated 12/25/2024 08:43 PM reads: Ambulance arrived to facility. Resident became aggressive yelling and screaming that she does not have to leave because she got drunk while on pass. Resident stated she will call state and that she has the right to drink when she is not at facility. Resident left facility on stretcher to Hospital. R1's emergency room note dated 12/25/24 reads: patient arrived by ambulance from nursing home with petition. Per Emergency Medical Support staff said she was aggressive earlier. On arrival patient is cooperative and calm. She is upset admission to psych unit. Diagnosis Depression and Intoxication R1 progress note dated 12/31/2024 03:58 PM reads: Writer talks to resident psychiatrist and the psych NP of resident behaviors at this facility. Resident has been non-compliance to go to an alcohol program for her addiction. Resident was given an immediate discharge and was explained the process. Resident received the original IVD with a stamped envelope with the address for appeal on the envelope to be mail to IDPH. Residents inform the marketer to inform the facility that she will have someone to pick up her belongings. Writer email DPH, and the ombudsman resident IVD. R1's Notice of involuntary transfer or discharge and opportunity for hearing for nursing home residents sheet dated 12/31/24 reads regardless of whether the facility's proposed action is under federal regulations or state law, you have the right to appeal the decision to transfer or discharge you. If you think you should not have to leave this facility, you may file a Request for a Hearing with the Illinois Department of Public Health within 10 days after receiving this notice. If the decision following the hearing is not in your favor, generally you will not be transferred or discharged prior to the expiration of 30 days following receipt of the original Notice of Transfer or Discharge. R1's hospital record dated 1/2/25 reads: patient scheduled for discharge by attending psychiatrist. Patient denied auditory hallucinations, denied suicidal/homicidal ideations. Patient has agreed to take medications given and follow treatment plan provided. Patient was resident at nursing home and plan was to return, until nursing home provided an involuntary discharge. Patient requested to go to nephews' home, now stated she cannot go to nephew. Patient offered alternative placement but refused. Per patient, she spoke to friend who is able to come pick her up today at 1pm. V3 (Director of Business Office) stated on 1/29/25 at 2:30pm she was instructed by the V8 (Administrator) to go to the hospital to give R1 IVD, (involuntary discharge) paper work. V3 stated when she arrived at the hospital she was escorted to R1's room by the hospital social worker. V3 stated she explained to R1 that she was receiving the IVD because on two different occasions she was intoxicated and displaying aggressive behavior. V3 stated the only forms she gave R1 was the IVD and did not explain to R1 that she had a right to appeal the process. V3 stated while at the hospital told the social worker who was in room with R1 and her, that the facility not allowing R1 to come back to the facility. V3 stated at that time R1 told her and the hospital social worker that her nephew might come and pick her up from the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/30/25 at 10:15 am V8 (Administrator) stated her reason for giving R1 the IVD (involuntary discharge) was because she refused go to the outpatient substance abuse program she was not following some of the facility rules. V8 stated she believed that the facility could no longer meet R1's needs. V8 stated she was not familiar with the IVD process, time frames or of the residents right to appeal the IVD. V8 stated will educate her herself going forward on how fill out the IVD form correctly and allow the IVD process to play out according to the State and Federal Guidelines. V1 (Social Worker Director) stated on 1/29/25 at 1:10pm the plan was for R1 to go to SMRF (specialized mental health rehab facility) but she refused. V1 stated R1 met the criteria for SMRF but she declined. V1 stated the plan was to convince R1 to go to a SMRF to meet her psychological and substance abuse. V1 stated he explained to R1 that if she did not comply with going to substance and mental therapy the facility would have to start the involuntary discharge process. Facility's transfer and discharge policy reads to assure resident transfers and discharges will be conducted in accordance with residents' rights , physician's orders, and in such a manner as to maintain continuity of care for the resident. Prior to any interfacility or involuntary, interfacility relocation, a relocation plan will be prepared to provide continuity of care. Relocation planning requirements do not apply to temporary relocations, i.e., hospitalizations where the resident will be readmitted . The resident , family , if known legal representative, and physician will be given timely notice in writing or the transfer and reasons thirty (30) days prior to relocation. A statement that the resident has the right to appeal the action to the State. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review facility failed to follow their bed hold policy for one resident (R3) out of three residents reviewed for discharges/transfer. This failure resulted in the facility not holding R1's bed for 10 days and subsequently R1 was discharged to the community instead of being allowed to return to the facility Findings Include: Facility's bed hold and readmission policy denotes it is the policy of this facility to readmit residents after hospitalization or temporary therapeutic leave when the resident requires services which can be provided by the facility. Residents, or their designated representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours. A specific bed may be held for ten (10) days recipients of Medicaid benefits in accordance with the State Plan unless the resident has indicated a desire not to return to this facility or physician has indicated the services provided by the facility are no longer appropriate. 09/23/2024 06:10 PM PSYCHIATRIC PROGRESS NOTE reads History of Psychiatric Illness: The patient, a black female resident with history of MDD and Anxiety Disorder is being examined for follow up mental health and wellness evaluation, chart was reviewed, staff were interviewed, resting comfortably in her room, able to ambulate with steady gait, calm and cooperative, no complaints noted. She is originally admitted to the facility on [DATE], Hospital due to depression and alcohol intoxication. She is admitted to the facility for management of her medication and symptoms of her behavior. R1 progress note dated 12/25/2024 08:43 PM reads Ambulance arrived to facility. Resident became aggressive yelling and screaming that she does not have to leave because she got drunk while on pass. Resident stated she will call state and that she has the right to drink when she is not at facility. Resident left facility on stretcher to Hospital. R1's emergency room note dated 12/25/24 reads patient arrived by ambulance from nursing home with petition. Per Emergency Medical Support staff said she was aggressive earlier. On arrival patient is cooperative and calm. She is upset about admission to psych unit. Diagnosis Depression and Intoxication. R1's Notice of involuntary transfer or discharge and opportunity for hearing for nursing home residents sheet dated 12/31/24 reads regardless of whether the facility's proposed action is under federal regulations or state law, you have the right to appeal the decision to transfer or discharge you. If you think you should not have to leave this facility, you may file a Request for a Hearing with the Illinois Department of Public Health within 10 days after receiving this notice. If the decision following the hearing is not in your favor, generally you will not be transferred or discharged prior to the expiration of 30 days following receipt of the original Notice of Transfer or Discharge. R1's Hospital record dated 1/2/25 reads patient scheduled for discharge by attending psychiatrist. Patient denied auditory hallucinations, denied suicidal/homicidal ideations. Patient has agreed to take medications given and follow treatment plan provided. Patient was resident at nursing home and plan was to return, until nursing home provided an involuntary discharge. Patient requested to go to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nephews' home, now stated she cannot go to nephew. Patient offered alternative placement but refused. Per patient, she spoke to friend who is able to come pick her up today at 1pm. V6 (Licensed Practical Nurse) stated on 1/29/25 at 10:20am he has been working at the facility for a few months. V6 stated he was never told that R1 had attacked any resident or staff at the facility. V6 stated he came to work on 12/25/24 for the pm shift and got report that R1 was going to hospital to be evaluated for intoxication. V6 stated he went to R1's room and told her the ambulance was coming. V6 stated he told R1 that she would probably be coming back to the facility the next day. V3 (Director of Business Office) stated on 1/29/25 at 2:30pm she was instructed by the V8 (Administrator) to go to the hospital to give R1 IVD, (involuntary discharge) paper work. V3 stated when she arrived at the hospital she was escorted to R1's room by the hospital social worker. V3 stated explained to R1 that she was receiving the IVD because on two different occasions she was intoxicated and displaying aggressive behavior. V3 stated the only forms she gave R1 was the IVD and did not explain to R1 that she had a right to appeal the process. V3 stated while at the hospital she told the social worker who was in room with R1 and her that the facility not allowing R1 to come back to the facility. V3 stated at that time R1 told her and the hospital social worker that her nephew might come and pick her up from the hospital. On 1/30/25 at 10:15 amV8 (Administrator) stated her reason for giving R1 the IVD (involuntary discharge) was because she refused go to the outpatient substance abuse program and she was not following some of the facility rules. V8 stated she believed that the facility could no longer meet R1's needs. V8 stated was not familiar with the IVD process, time frames or of the residents right to appeal the IVD. V8 stated will educate her herself going forward on how fill out the IVD form correctly and allow the IVD process to play out according to the State and Federal Guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Based on interview and record review the facility failed to let one resident (R1) return out of three residents reviewed transfers and discharges. This failure resulted in R1 not returning to the facility after hospitalization and was subsequently discharged to the community. Finding Include: R1 progress note dated 12/25/2024 08:43 PM reads: Ambulance arrived to facility. Resident became aggressive yelling and screaming that she does not have to leave because she got drunk while on pass. Resident stated she will call state and that she has the right to drink when she is not at facility. Resident left facility on stretcher to Hospital. R1's emergency room note dated 12/25/24 reads: patient arrived by ambulance from nursing home with petition. Per Emergency Medical Support staff said she was aggressive earlier. On arrival patient is cooperative and calm. She is upset admission to psych unit. Diagnosis Depression and Intoxication. R1's Hospital record dated 1/2/25 reads: patient scheduled for discharge by attending psychiatrist. Patient denied auditory hallucinations, denied suicidal/homicidal ideations. Patient has agreed to take medications given and follow treatment plan provided. Patient was resident at nursing home and plan was to return, until nursing home provided an involuntary discharge. Patient requested to go to nephews' home, now stated she cannot go to nephew. Patient offered alternative placement but refused. Per patient, she spoke to friend who is able to come pick her up today at 1pm. V3 (Director of Business Office) she stated on 1/29/25 at 2:30pm was she instructed by V8 (Administrator) to go to the hospital to give R1 IVD, (involuntary discharge) paper work. V3 stated when she arrived at the hospital she was escorted to R1's room by the hospital social worker. V3 stated she explained to R1 that she was receiving the IVD because on two different occasions she was intoxicated and displaying aggressive behavior. V3 stated the only forms she gave R1 was the IVD and did not explain to R1 that she had a right to appeal the process. V3 stated while at the hospital, told the social worker who was in room with R1 and her that the facility was not allowing R1 to come back to the facility. V3 stated at that time R1 told her and the hospital social worker that her nephew might come and pick her up from the hospital. V5 (Licensed Practical Nurse) stated on 1/29/25 at 9:45am she has taken care of R1 for about a year and never received report or seen R1 attacking other residents or staff. V5 stated late afternoon near the end of the shift when R1 came back to the facility intoxicated and was stumbling while walking. V5 stated she helped R1 into bed then contacted the Nurse Practitioner and administrator that R1 was in the facility intoxicated. V5 stated they received order to petition R1 to the hospital for an evaluation. V5 stated she told the social worker and she wrote up the involuntary petition for admission. V5 stated she gave report to oncoming nurse as to what had transpired. V5 stated since it was the change of shift the oncoming nurse called the ambulance. V5 stated she was not told at that time that R1 was going to be involuntary discharged . V6 (Licensed Practical Nurse) stated on 1/29/25 at 10:20am he has been working at the facility for a few months. V6 stated he was never told that R1 had attacked any resident or staff at the facility. V6 stated he came to work on 12/25/24 for the pm shift and got report from that R1 was going to hospital to be evaluated for intoxication. V6 stated he went to R1's room and told her the ambulance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 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 0626 was coming. V6 stated he told R1 that she would probably be coming back to the facility the next day. Level of Harm - Minimal harm or potential for actual harm V2 (Director of Nursing) she stated on 1/29/25 at 2:00pm they had a care plan meeting with R1 about what she wanted which was to get a job and get approved for social security. V2 stated R1 did agree to go to substance abuse treatment program but she reneged. V2 stated that nurse informed her that R1 was sent to the hospital for being intoxicated. V2 stated it was never discussed with her that R1 would be involuntary discharged . Residents Affected - Few On 1/30/25 at 10:15 am V8 (Administrator) stated her reason for giving R1 the IVD (involuntary discharge) was because she refused go to the outpatient substance abuse program and she was not following some of the facility rules. V8 stated she believed that the facility could no longer meet R1's needs. V8 stated was not familiar with the IVD process, time frames or of the residents right to appeal the IVD. V8 stated will educate herself going forward on how fill out the IVD form correctly and allow the IVD process to play out according to the State and Federal Guidelines. Facility's resident rights admission contract statement policy denotes there may be instances when a Facility Resident leaves the facility for medical or therapeutic reasons. In such cases, Facility may be able to re-admit Resident to the same room and bed, but this not assured. If no bed is available at the times of Resident's hospital discharge because a bed was not held, Resident will be permitted to return to facility immediately upon first bed for the Resident's payor source becoming available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 8 of 8