Inspection·January 28, 2026

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but R1 did not leave and so R2 hit R1 in the face. V2 stated that R2 was sent to the hospital for behavioral evaluation.On 1/26/2026 at 3:03 PM V14 (Registered Nurse/RN) stated, that V14 remembers the incident with R1 and R2 and was notified by other residents, (does not remember who) that R1 and R2 were having a brief altercation and that R2 hit R1. V14 stated, that R1 went to R2's room and confronted R2 about R4, because R2 went to R4 ‘s room earlier and pulled the covers off R4's bed while R4 was lying in the bed. V14 stated that R2 said that R2 was just joking and was playing with R4 and that the whole incident was a misunderstanding and was apologetic about hitting R1. V14 stated that when police came, the paperwork incident was not filled out because R1 did not want to press charges.On 1/26/2026 at 3:25 PM, V2(DON) stated, that police report was not filed because R1 did not want to press charges. On 1/27/2025 at 9:29 AM, R1 stated that, R4 told R1 about R2 coming to R4's room and flipped the covers on R4's bed and that R4 did not like that. R1 said that R1 came up to R2's room, between the doors, and told R2 to leave R4 alone. R1 said that R2 should not do that and R2 got mad and started yelling and punched R1 on the right side of face. R1 said that R1 and R2 were separated by the staff and then later R1 observed R2 being taken to the hospital. R1 said that R2 did not hit him hard, and R1 did not have any injury, just slight redness for few minutes. R1 said that the police came and talked with R1, but R1 did not want to press charges because R1 already saw R2 being sent out to the hospital.1/27/2026 at 1:12 PM V1 (Administrator) stated, that V14 (Registered Nurse/RN) notified V1 about R1 and R2's incident and that there was physical and verbal confrontation, with no injuries. V1 said that R1 went to R2's room to confront R2 about a friend (R4), because R2 went to R4's room before and flipped the bed covers off R4 and R1 went to tell R2 that it is not appropriate. V1 said that R2 got mad and agitated and hit R1. V1 said that R1 had no injury, R2 was sent out to hospital for behavioral monitoring and that police was called in, but the report was not filed due to R1 not wanting to press charges and R2 going to hospital.R1's Face Sheet showed in part R1 was admitted to facility on 7/26/2022 and R1's Diagnosis include but are not limited to Hypertensive heart disease, Bipolar disorder, Atherosclerotic heart disease, Iron deficiency, Hepatic failure, Substance abuse, Unsteadiness on feet, Muscle wasting and Atrophy, Abnormal posture, Cognitive communication deficit, Depression, Mental Disorder, Hyperlipidemia, Unspecified psychosis, Xerosis cutis, schizoaffective disorder, History of Syphilis, and Diverticulosis.R1's MDS (12/5/2025) Section C for Cognitive Patterns showed Brief Interview for Mental Status (BIMS) score of 13, which showed mild cognitive impairment.R1's Care Plan (12/5/2025) showed in part that R1 is at risk for abuse related to nursing home living and diagnoses of Schizoaffective Disorder and unspecified Psychosis and the short-term goal was for R1 to remain free of abuse/neglect.R1's Care Plan (12/21/2025) showed in part that R1 went to another resident's room and had verbal and physical altercation when refused to leave other resident's room.R1's Progress notes (12/21/2025 at 2:35PM) documented by V12 (Social Services Director) showed in part that R1 had a counseling session related to impulse control, Boundaries and Self - Awareness due to R1's going to other male resident's room and that male resident hit R1.R1's Progress notes (12/21/2025 2:49 PM) documented by V13 (RN) showed in part that R1 had altercation with another male resident and police was called.R1's Abuse Risk Review (12/4/2025) showed in part that R1 has serious mental illness and verbally threatening behavior and to continue current plan of care where R1 will be monitored for verbal and physical abuse.R1's Abuse Risk Review (12/21/2025) documented by V12 (Social Services Director) showed in part that R1 has serious mental illness, communication barriers, Impulse Control Issues, verbally threatening behavior, Minimization of circumstances, Low self-esteem/self-worth, Aggression/Combativeness and Exposure to Trauma.R2's Face Sheet showed in part R2's admission date on 4/30/2019 with a hospital stay from 12/21/2025 12/30/2025.R2's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146018 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Diagnosis include but not limited to Major Depressive disorder; Type 2 Diabetes Mellitus; Unsteadiness on feet; Schizophrenia; Bipolar Disorder; Hyperlipidemia; Auditory hallucinations; Gastro-esophageal reflux disease and Muscle wasting and atrophy.R2's Minimum Data Sheets (MDS) (1/6/2026), Section C for Cognitive Patterns showed Brief Interview for Mental Status (BIMS) score of 15, which showed intact cognition.R2's Physician Order Report (12/1/2025 -1/27/2026), showed in part and active new order for Divalproex 250mg oral tablets twice a day and Haloperidol decanoate 50mg/ml intramuscular injection on the 1st of the Month and discontinued order for Sertraline 50mg oral tablet.R2's Care plan (1/7/2026) showed in part that R2 has a history of Physical and verbal aggression related to Hallucinations, Schizophrenia and Major Depressive Disorder and that R2 should not have any incidents of physical and verbal aggression.R2's Progress Notes (12/21/2025 at 2:30 PM), documented by V12 (Social Services Director) showed in part that R2 had an altercation with R1 because R2 was playing with R4 and R1 got upset; R2 said that R2 was not serious but R1 did not think so and got upset.R2's Progress Notes (12/21/2025 at 2:31 PM), documented by V14 (Registered Nurse/RN), showed in part that R2 was accepted to hospital for admission and ambulance would come pick R2 up from the facility.R2's Progress Notes (12/21/2025 at 2:42 PM), documented by V14 (RN) showed in part that R2 had an altercation with another male resident, no injuries noted, police was called and V14 obtained an order to admit R2 to hospital for psych admission.R2's Abuse Risk Review (12/21/2025), showed in part R2 has serious mental illness, communication barriers, Impulse control issues, Verbally threatening behavior, Minimization of circumstances, low self-esteem, aggression/combativeness, and exposure to trauma.R2's Hospital records showed in part, that R2 was admitted (12/21/2025 at 10:45 PM) to acute care hospital for behavioral evaluation due to punching a resident in the face. Internal medicine history and physical document (Date of service on 12/22/2025) showed in part that R2's chief complaint was punching a resident in the face. Assessment and plan showed in part that R2 will be in-patient to psych to manage psychosis/aggression. Patient Visit Information sheet (received 12/30/2025 at 11:54 AM) showed in part, that R2 will be returning to facility on 12/30/2025 with orders for Divalproex 250mg oral tablets, twice a day (9AM and 9PM), and Haloperidol decanoate 50mg intramuscular injection monthly and that the Sertraline 25mg oral tablets to be discontinuedR4's Face Sheet showed in part that R4 was admitted to facility on 2/12/2024 and diagnosis include but not limited to Chronic Obstructive Pulmonary disease; Major depressive disorder with psychotic features; Cocaine abuse; Emphysema; Tobacco use and Personal history of other infectious and parasitic disease - Syphilis.R4's MDS (11/18/2025) Section C for Cognitive Patterns showed Brief Interview for Mental Status (BIMS) score of 15, which showed intact cognition. Event ID: Facility ID: 146018 If continuation sheet Page 3 of 3