Health inspection·February 7, 2026

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Notice of Involuntary Transfer or Discharge and Opportunity for Hearing dated 9/29/2025; addressed to R1 and V4, R1's Legal Guardian; signed by the previous social services director who is not employed by the facility anymore. The form documents that the reason for this proposed transfer or discharge is the safety of individuals in this facility is endangered, 483.15 (c)(1)(i)(C). R1's electronic health records exclude any documentation from the physician regarding the reason for involuntary discharge and how the safety of individuals in this facility is endangered because of R1. It also excludes any behavior that endangers the safety of other residents in the facility.2. R4 was admitted to the facility on [DATE] and was discharged to the hospital on 1/27/2026 and was not allowed to return to the facility. R4 was petitioned for involuntary discharge and was also served a 30-day notice for involuntary transfer and discharge.Progress notes dated 1/27/2026 4:21 p.m. document: Staff observed R4 smoking in a non-designated area. When staff addressed the behavior, he became verbally aggressive and refuse(sic) to be redirected, he presents as a threat and harmful to self and others. This behavior may be influenced by symptoms associated with her diagnosis of paranoid schizophrenia, including impaired judgment and difficulty with impulse control. Due to concerns regarding a decline in his mental and physical status, nursing staff contacted his physician, who recommended further evaluation. R4 was subsequently petitioned, with IVD (Involuntary Transfer and Discharge) initiated and bed-hold policy notification completed. He was transported to the local hospital for further assessment and treatment.Review of R4's electronic health record affirms that R4 has been observed to be smoking in non-designated areas for smoking multiple times and has a behavior contract addressing this behavior. R4 also exhibits profanity towards staff and aggressive behaviors toward staff and peers.On 2/6/2026 at 11:45 a.m., V5, Social Services Director, stated R4 was presented with the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing, which V5 completed and signed, because the facility cannot accommodate the smoking times that R4 needs. R4 needs supervision when smoking because of mobility and safety and has violated the facility smoking policy at least three times during his stay. V5 stated she filled out the form and then gives it to the nursing department to notify the physician and hospital for necessary paperwork and documentation.On 2/6/2026 at 2:12 p.m. V1, Administrator, stated R4 is very non-compliant, is very bold, will tell you right in the face that he loves using marijuana and will not stop smoking. The reason he is being served the Involuntary Transfer and Discharge Notice is because R4 on multiple times has been caught smoking inside the facility and even engages other residents with him in his room to join him to smoke. V1 cannot provide physician documentation regarding reason for the proposed discharge of R4.Facility presented a document titled Notice of Involuntary Transfer or Discharge and Opportunity for Hearing dated 1/27/2026; addressed to R4 and R4's Representative; signed by V5, Social Services Director. The form documents that the reason for this proposed transfer or discharge is your welfare and needs cannot be met by the facility, as documented in your clinical record by your physician, 483.15 (c)(1)(i)(A). R4's electronic health records exclude any documentation from the physician regarding the reason for involuntary discharge, what services the facility was unable to provide to meet the needs of R4 and what the facility attempted to meet the R4's needs aside from the Smoking Behavior Contract. Event ID: Facility ID: 146169 If continuation sheet Page 2 of 4 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 02/07/2026 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement care plan for psychosocial and mental well being and failed to provide the necessary services for the behavioral health needs of a resident. This applies to one (R1) of 4 residents reviewed for behaviors. As a result, R1 harmed self requiring psychiatric hospitalization. Findings include: According to the Electronic Health Record (EHR) R1 had diagnoses including Other seizures; Bipolar disorder, current episode depressed, Gastro-esophageal reflux disease without esophagitis; Unspecified asthma, Major depressive disorder, single episode, Other chronic pain; Restlessness and agitation; Hypo-osmolality and hyponatremia; Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus; Pain in unspecified knee; Type 2 diabetes mellitus with other diabetic kidney complication; Cough, unspecified; and Tinea pedisR1 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE].The Minimum Data Set (MDS) dated [DATE] showed cognition was intact with a fifteen out of fifteen points requires on the Brief Interview for Mental Status (BIMS).A care plan on Mental and Psychosocial Well being showed R1 is in need of specialized rehabilitation, support, counseling and/or psychotherapeutic services secondary to mental illness diagnosis and a need to develop community integration skills. Care Plan goals include: The resident will engage in the following service(s): Mental health (i.e., psychotherapy, life skill training, substance abuse services). Intervention include: Obtain proper consent prior to making any referrals. Assist the resident in locating an appropriate treatment provider and making the initial appointment. Arrange transportation, as necessary. R1's records indicate that client centered therapy sessions were conducted on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No other therapy sessions were documented after the [DATE] session which documents in part: The therapist will continue meeting with the client for an individualized biweekly therapy for the next six months. On [DATE] at 11:45 a.m., V5, Social Service Director, facility has an outside provider that comes to the facility twice a week to conduct support group sessions and 1:1 sessions with the residents and another outside provider that provides Intensive Outpatient therapy that provides group therapy sessions outside of the facility to address their mental health needs. V5 stated she is not aware that R1 participates in either of these services and was not able to provide documentation that R1 had an ongoing structured group or individualized sessions to address her mental health needs. V5 also stated that the Social Services Department in the facility does not conduct any therapy group session or individualized sessions to address the mental health needs of the residents with behavioral and mental health needs of the residents in the facility. V5 confirmed that no other therapy sessions with R1 were conducted after [DATE] and confirmed that R1 did not participate in any psychosocial groups or 1:1 session for psychosocial well-being. Progress notes dated [DATE] 2:39 a.m. document R1 stated am depressed because my sister died (sic) and want to go to the hospital. R1 also stated that R1 cut herself with scissors and was observed with bleeding on R1's right wrist. R1 was sent to the hospital via 911 and returned the same day with stitches to her right wrist, was placed on 1:1 and was petitioned for involuntary discharge to another hospital for psychiatric evaluation. R1 was also issued an Involuntary Discharge and was not allowed to return to the facility. R1's Screening Assessment for Evaluating Self-Harm/Suicide dated [DATE] document under section Recommendation and Outcome (check the category corresponding with the resident's score): Expected to integreate (sic) with structure, direction and supportive counseling. Presents with a low to moderate risk for self-harmful behavior (score 6-10)Social Services policy with review date of 9/25 under Philosophy and Policy documents in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146169 If continuation sheet Page 3 of 4 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 02/07/2026 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 0740 Level of Harm - Minimal harm or potential for actual harm It is the philosophy of this organization to treat each resident as a unique individual with specific physical, psychological and spiritual needs. It is our policy to provide a competent variety of psychological programming and therapeutic recreation opportunities designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental and psycho-social well-being needs of each individual resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146169 If continuation sheet Page 4 of 4