Inspection·June 24, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's Facesheet documented that R2's Diagnoses: (include but not limited to) hypertension, anxiety disorder, schizophrenia, and bipolar disorder. R2's (04/04/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating R2's mental status as moderately impaired. R2's (06/03/2025) progress note documented, in part a co-resident came to talk to him but he slapped him. Authored by: V4 (Licensed Practice Nurse). R2's (06/03/2025) progress note documented, in part Resident states that a co-peer approached him telling him to be quiet, resident became triggered and struck co-peer. Authored by: V11 (Psychiatric Rehabilitation Services Director). R2's (06/03/2025) Petition for Involuntary/Judicial admission documented, in part Resident presents as a threat to others at this time. Resident stood up from his wheelchair and struck another resident in the face. The (06/03/2025) Preliminary State Agency Incident Investigation Report documented, in part Person Completing The Form: (V1 - Administrator). We have received an allegation that may involve one of the following reportable offenses: (x) Physical Abuse. Name of person allegedly abused: (R1). On 06/03/2025 at approximately 9:45am, resident (R2) raise his hands and slapped resident (R1) on the left side of his face. The (06/06/2025) Final Incident Investigation Report documented, in part Name of Resident Abused or Neglected: (R1). Based on the known facts from medical record review and interviews, the following conclusions have been determined about the allegation: (X) Abuse IS (X) FOUNDED. Person Completing the Form: V1 (Administrator). 2. On 06/16/2025 at 11:36am, R3 stated, I don't remember who. Somebody was attacking me, somebody in the dining room. Somebody pushed me at the same time. No, I don't expect somebody to push me. I would like that not to happen again. I don't remember how. I was just sitting down. On 06/18/2025 at 10:22am, R4 stated, I was warming food and watching TV on the 3rd floor day room. He (R3) was seated on one of the chairs and he (R3) said something that threw me off. I (R4) told him to leave me alone and he kept talking. I told him (R3) if he wanted to fight me and then he looked at me smugly. I went to the other side of the room, and he went charging at me, swinging his hands. I tried pushing him towards the door and the door closed. I tried to avoid his punches and I pushed him. On 06/18/2025 at 1:12pm, V1 stated I was notified by the nurse (V9-Licensed Practice Nurse) there was altercation between them (R3 and R4). I asked if there was a contact; physical contact between the residents and he said 'yes'. There was a small pinpoint scratch on (R3). The same day I sent the initial reportable. At the end of the investigation, the result is the physical abuse between (R3) and (R4) did occur. (R4) said he was in the dining room, heating up his food in the microwave. (R3) walked in the dining room. He (R3) could not tell me what happened. (R4) said he pushed him because 'he just kept on bothering me.' R3's Facesheet documented that R3's Diagnoses: (include but not limited to) extrapyramidal and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146169 If continuation sheet Page 2 of 7 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 146169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fargo Health Care Center 1512 West Fargo Chicago, IL 60626 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 movement disorder, and schizophrenia. Level of Harm - Minimal harm or potential for actual harm R3's (05/17/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating R3's mental status as cognitively intact. Residents Affected - Few R3's (06/06/2025) progress note documented, in part resident stated he was pushed by a co resident without provocation and that he fell on his buttocks. Resident noted with a scratch at the back of his head with minimal bleeding. Authored by: V9 (Licensed Practice Nurse). R4's Facesheet documented that R4's Diagnoses: (include but not limited to) schizoaffective disorder, bipolar type, chronic pain, and restlessness and agitation. R4's (05/09/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R4's mental status as cognitively intact. R4's (06/11/2025) Progress note documented, in part Type: Correction. Resident stated he pushed the co resident. R4's (06/06/2025) Petition for Involuntary/Judicial admission documented, in part Resident noted to be physically aggressive to co-resident. Resident poses danger to other residents. The (06/05/2025) Preliminary State Agency Incident Investigation Report documented, in part Person Completing The Form: (V1 - Administrator). We have received an allegation that may involve one of the following reportable offenses: (x) Physical Abuse. Name of person allegedly abused: (R3). On 06/06/2025 at approximately 8:45pm, resident (R4) stated he became very agitated with (R3). (R4) punched (R3). (R3) lost his balance fell backward hitting the left side of his head sustaining a superficial cut to her left side of his head. The (06/10/2025) Final Incident Investigation Report documented, in part Name of Resident Abused or Neglected: (R3). (R4) became very agitated with (R3) when he got very close in his personal space. (R4) stated I (R4) pushed him away from my face. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the allegation: (X) Abuse IS (X) FOUNDED. Person Completing the Form: V1 (Administrator). 3. On 06/16/2025 at 2:45pm, R5 stated she (R6) was a former roommate. She was in the washroom, and I told (R7) that (R6) is always in the washroom when I needed to be there. She took a long time washing her hair in the sink every morning. She'd be there a half hour. I also added it is not exactly her fault. Then we (R5 and R7) went out in the porch to smoke. Five minutes later, she (R6) stalked out to the porch where we were siting and made a vicious verbal assault; loud and nasty verbal assault; right on my face about 2 inches off my face. She (R6) said 'you could have been in the washroom when I am not there'. She started to walk away a little and she said to me 'I'll beat your mother f*****g a**.' It was totally unprovoked and unnecessary. I was not happy about her saying that to me. I did not expect another resident to verbally assault me. On 06/16/2025 at 2:21pm, R6 stated I have a problem with her cussing and screaming. You don't get to holler at me. After the second smoke, I went to brush my teeth and she said you're always going in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146169 If continuation sheet Page 3 of 7 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 146169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fargo Health Care Center 1512 West Fargo Chicago, IL 60626 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 the bathroom. Saturday morning, I was going out to smoke. I got the feeling on how she was screaming at me. I saw her and I told her I will beat your f*****g a** up. Stop hollering at me. I am not a child. I know I should have not said what I said. But I got tired of her hollering at me all the time. I just reacted. I know it was wrong to say what I said. I was angry. On 06/18/2025 at 1:09pm, V1 stated the outcome for (R5 and R6) is allegation of verbal abuse that it did occur. (R5) said that (R6) told her 'I'll beat your mother f*****g a**.' It Did occur. Neither one of them denied it. The (06/02/2025) Email correspondence between V1 (Administrator) and the State Agency documented, in part Sent: 06/02/2025 7:16pm. Subject: Preliminary Incident Investigation Report - (R5 and R6). The (06/02/2025) Preliminary State Agency Incident Investigation Report documented, in part Person Completing The Form: (V1 - Administrator). We have received an allegation that may involve one of the following reportable offenses: (x) Verbal or Mental Abuse. Name of person allegedly abused: (R5). On 06/02/2025 at approximately 5pm, (R5) approached (V1) and stated (R6) followed (R5) to the smoke patio to confront her (R5). (R6) got into (R5) face and stated I will beat the fuck out of you. The (06/06/2025) Final Incident Investigation Report documented, in part Name of Resident Abused or Neglected: (R5). (R6) got into (R5) face and stated I will beat the fuck out of you. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the allegation: (X) Abuse IS (X) FOUNDED. Person Completing the Form: V1 (Administrator). The (18 - Nov - 16) Abuse Prevention Program Facility Procedures documented, in part Abuse is defined as the willful infliction of injury, and reasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, As used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. V. Internal Reporting Requirements and Identification of Allegations. Employees are required to report any incident, allegation or suspicion of potential abuse they observe or hear about or suspect to the administrator immediately. The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. You must not be abused, neglected, or exploited by anyone financially, physically, verbally, mentally or sexually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146169 If continuation sheet Page 4 of 7 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 146169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fargo Health Care Center 1512 West Fargo Chicago, IL 60626 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure initial reportable for allegation of verbal abuse was reported within the mandated timeframe. This failure affected 1 (R5) resident reviewed for reporting of abuse in the total sample of 7 residents. Findings include: On 06/16/2025 at 2:45pm, R5 stated, She (R6) was a former roommate. She was in the washroom, and I told (R7) that (R6) is always in the washroom when I needed to be there. She took a long time washing her hair in the sink every morning. She'd be there a half hour. I also added it is not exactly her fault. Then we (R5 and R7) went out in the porch to smoke. Five minutes later, she (R6) stalked out to the porch where we were siting and made a vicious verbal assault; loud and nasty verbal assault; right on my face about 2 inches off my face. She (R6) said 'you could have been in the washroom when I am not there'. She started to walk away a little and she said to me 'I'll beat your mother f*****g a**.' It was totally unprovoked and unnecessary. I was not happy about her saying that to me. I did not expect another resident to verbally assault me. I told (V6 -Security Guard). I said to him (V6) what she (R6) told me, and he wrote it in their report. On 06/17/2025 at 9:42am, V6 (Security) stated, It was 2-3 weeks ago; I think it happened on a Saturday. I was sitting on my post; (R5) came up to me. She (R5) approached me. From her behavior she seemed worried and have anxiety that something could happen. She looked worried. Her expression, I cannot describe it, but I just can tell that she was worried. She said she was telling me in case something happened. And she told me her roommate (R6) was threatening her. She said 'I just want to let you know that she is threatening to kick me on my butt.' I called her (V1-Administrator) first; then I wrote, what she (R5) told me, in the Security Report. I informed the nurse on the first floor. I saw the nurse assessed (R5). The (05/31/2025) Daily Schedule documented that V7 (Licensed Practice Nurse) and V8 (Certified Nursing Assistant) were working on the first floor on first shift. On 06/17/2025 at 12:01pm, V7 stated I don't have any unusual event that happened on that day. He (V6) never approached me about (R5) in regard to allegation of verbal abuse. I don't have any knowledge of the allegation of abuse. Yes, 'I am going to beat the mother f****r a**' is a verbal abuse. On 06/17/2025 at 12:14pm, V8 confirmed she worked on 5/31/2025. V8 stated I don't remember unusual things that happened in the morning shift. Nobody reported to me there was an allegation of verbal abuse between them (R5 and R6). The (05/31/2025) Security Report Form documented, in part At 8:06am (R5) told me (V6) that her roommate (R6) told her I'm gonna beat your mother f*****g a**. (R5) told me that she (R6) made ferocious verbal assault towards her (R5). (R5) walked away while (R6) promised to beat her up. On 06/17/2025 at 12:28pm, V1 stated I got a call from (V6). He (V6) reported it to me with no urgency. I did not think he was reporting a verbal abuse. I did the reportable on 06/02/2025 when I got the information in real time. At this point, V1 was requested to read the security report dated 5/31/25. This surveyor also read the security report within earshot of V1 I'm gonna beat your mother f*****g a**. V1 stated that is verbal abuse. The initial reportable should have been reported on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146169 If continuation sheet Page 5 of 7 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 146169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fargo Health Care Center 1512 West Fargo Chicago, IL 60626 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 0609 5/31/2025. Level of Harm - Minimal harm or potential for actual harm R5's Face sheet documented that R5's Diagnoses: (include but not limited to) Type 2 Diabetes Mellitus, hypertension, and restlessness and agitation. Residents Affected - Few R5's (06/09/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R5's mental status as cognitively intact. R6's Face sheet documented that R6's Diagnoses: (include but not limited to) restlessness and agitation, bipolar disorder, and schizophrenia. R6's (05/03/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15 indicating R6's mental status as cognitively intact. R6's (06/02/2025) progress note documented, in part resident verbally threatened her roommate. R6's (06/02/2025) Petition for Involuntary/Judicial admission documented, in part resident presents as a threat to others at this time. Resident threatened to beat up her roommate stating I will beat your motherf*****g a** (while in their face and gesturing within close range). The (06/02/2025) Email correspondence between V1 (Administrator) and the State Agency documented, in part Sent: 06/02/2025 7:16pm. Subject: Preliminary Incident Investigation Report - (R5 and R6). The (06/02/2025) Preliminary State Agency Incident Investigation Report documented, in part Person Completing The Form: (V1 - Administrator). We have received an allegation that may involve one of the following reportable offenses: (x) Verbal or Mental Abuse. Name of person allegedly abused: (R5). On 06/02/2025 at approximately 5pm, (R5) approached (V1) and stated (R6) followed (R5) to the smoke patio to confront her (R5). (R6) got into (R5) face and stated I will beat the f**k out of you. The (06/06/2025) Final Incident Investigation Report documented, in part Name of Resident Abused or Neglected: (R5). (R6) got into (R5) face and stated I will beat the fuck out of you. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the allegation: (X) Abuse IS (X) FOUNDED. Person Completing the Form: V1 (Administrator). The (18 - Nov - 16) Abuse Prevention Program Facility Procedures documented, in part Abuse is defined as the willful infliction of injury, and reasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, As used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. V. Internal Reporting Requirements and Identification of Allegations. Employees are required to report any incident, allegation or suspicion of potential abuse they observe or hear about or suspect to the administrator immediately. External Reporting. 1. Initial Reporting of Allegations - When an allegation of abuse has occurred, the Department of Public Health regional Office shall be informed. Public Health shall be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146169 If continuation sheet Page 6 of 7 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 146169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fargo Health Care Center 1512 West Fargo Chicago, IL 60626 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 0609 informed that an occurrence of potential abuse has been reported and is being investigated. This report shall be made immediately not less than 24 hours. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146169 If continuation sheet Page 7 of 7