Inspection·December 5, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update a resident's (R41) care plan to coincide with their requested advanced directive wishes for one out of a final sample of 23 residents.Findings include: On [DATE] at approximately 3:00 PM, V4 (Registered Nurse) stated R41 was DNR (Do Not Resuscitate). R41's IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life-Sustaining Treatment (POLST) form dated [DATE] documents in part that R41's wishes include NO CPR [cardiopulmonary resuscitation]: Do Not Attempt Resuscitation (DNAR) with selective treatment. R41's Face Sheet and Physician Orders read DNR. However, R41's Care Plan dated [DATE] documents in part that R41 is FULL CODE (attempt resuscitation). On [DATE] at 9:34 AM, V2 (Director of Nursing) stated that residents' care plans should be updated when there are any changes to residents' plan of care. Facility's Health Care Policies Manual ([DATE]), Section 3.1, documents in part that care is subject to related physician orders and the resident's advance directives. Facility's Comprehensive Person-Centered Care Planning Manual ([DATE]) documents in part: [Facility] shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan describes the following: Any services that would otherwise be required under the regulations but are not provided due to the resident's exercise of rights, including the right to refuse treatment. Policy also documents in part that the interdisciplinary team is to review and revise the comprehensive care plan after each assessment. Event ID: Facility ID: 145285 If continuation sheet Page 2 of 13 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 145285 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Pavilion 2625 West Touhy Avenue Chicago, IL 60645 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a new Preadmission Screening and Resident Review (PASRR) after a resident's (R101) PASRR Level II short-term approval ended for one out of a total sample of 23 residents. Findings include: R101's ‘Face Sheet' documents in part diagnoses of schizophrenia, bipolar disorder, and depressive episodes. R101's [DATE] ‘Notice of PASRR Level II Outcome' documents in part a determination of Short Term Approval without Specialized Services. The short-term approval ended on [DATE]. Surveyor requested for the updated PASRR. On [DATE] at 12:17 PM, V10 (Admissions Director) stated facility resubmitted R101 for assessment and was flagged again for requiring a PASRR Level II evaluation. V10 stated the protocol is if it is an expired Level II PASRR, facility must resubmit for screening. V10 provided R101's Notice of PASRR Level I Screen Outcome dated [DATE] (time of survey). No other PASRR submitted after [DATE] or prior to start of survey. Facility's Health Care Policies Manual ([DATE]), Section 2.10 documents in part: Preadmission screening for individuals with a mental disorder and individuals with intellectual disability. [Facility] shall not admit any new resident with Mental disorder unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, that, because of the physical and mental condition of the individual, the individual requires the level of services provided by [Facility]. Policy does not read procedures related to short-term approvals. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 3 of 13 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 145285 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Pavilion 2625 West Touhy Avenue Chicago, IL 60645 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 observation, interview, and record review, the facility failed to ensure a resident (R101) took their medication, failed to ensure medications remained in their original packaging, failed to keep their medication carts clean and sanitary, failed to discard expired medications, and failed to store a medication per manufacturer recommendation for three out of three medications carts reviewed for medication storage.Findings include: R101's ‘Face Sheet' documents in part diagnoses of mild cognitive impairment and disorientation. On 12/02/2025 at 10:11 AM, R101 was oriented to name and city but disoriented to time and situation. There was a small purple pill on top of R101's dresser near the bed. R101 did not know which medication it was and asked surveyor if R101 should take it. R101 asked for water and stated could take it now. Surveyor instructed R101 to hold and called for V4 (Registered Nurse). V4 stated V4 did not leave the medication at bedside and did not know which medication it was. V4 stated when nurses are administering medications, they are to make sure the residents (especially those with cognitive impairments like R101) swallow their medications. V4 grabbed the pill and compared it to those in R101's prescribed medication blister packs. V4 stated it could be Levothyroxine which was scheduled at 6:00 AM. V4 stated V4 was not completely sure and discarded the pill. On 12/03/2025 at 10:18 AM, surveyor reviewed the U-medication cart on the third floor with V11 (Licensed Practical Nurse/LPN). V11 stated the medication cart services 11 residents. In the second drawer of the cart, there were multiple loose pills not in their original packaging. For example, in the first slot there were two white capsules at the bottom of the drawer. The second slot had a yellow round pill, a blue round pill, blue oblong pill, and orange oblong pill at the bottom. The third slot had a yellow round pill, white oval, and square pill outside their packaging. The fourth slot had a yellow round pill. V11 did not know what the medications were. V11 stated the night shift nurse is supposed to be cleaning the carts nightly. On 12/03/2025 at 10:53 AM, surveyor reviewed the 2 South medication cart with V12 (LPN). V12 stated the cart serviced 25 residents. In the second drawer, the first and third slots had white pills not in their original containers. In the third drawer, there were loose pills in the first and third slots. When reviewing the narcotic drawer and bin, there was a bottle of Lorazepam 2 MG (milligram) per ML (milliliter) 30 ML bottle for R104. The packaging read store at cold temperature - refrigerate at 36F to 46F. When asked how long the bottle has been in the drawer, V12 stated the bottle was there when shift started in the morning. V12 stated the bottle has been open since 11/19/2025 and was not sure how long it's been out of the refrigerator. V12 stated each nurse is responsible for keeping their medication carts clean, safe, and sanitary. On 12/03/2025 at 11:14 AM, surveyor reviewed the medication cart for rooms XXX with V13 (Registered Nurse). V13 stated the cart serviced 16 residents. In the third drawer of the cart, there was greater than 30 pills/capsules that were loose and not in their original packaging at the bottom and back of the drawer. There was also different colored powder residue collecting at the back of each of the drawer slots. When reviewing the individualized medication blister packs, there were multiple expired medications for R113. There were ten Hydroxyzine 50 MG blister packs with varying expiration dates of 2/23/2025, 3/26/2025, 5/30/2025, and 9/30/2025. R113 also had two blister packs of Sennoside/Docusate Sodium that expired in 4/09/2024, three blister packs of Gabapentin 400 MG that expired 8/02/2025, and a blister pack of Loperamide 2 MG that expired 10/09/2025. R11 also had a blister pack of Senokot-S that expired 9/25/2025. On 12/04/2025 at 9:42 AM, V2 (Director of Nursing) stated all nurses on all shifts should be checking and maintaining their medication carts. The night shift nurses are responsible for cleaning the carts, but the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 4 of 13 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 145285 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Pavilion 2625 West Touhy Avenue Chicago, IL 60645 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 FORM CMS-2567 (02/99) Previous Versions Obsolete facility also has a part-time nurse that is responsible for overseeing all medication carts weekly. Regarding the pill at R101's bedside, V2 stated nurses are not to leave medications at bedside. V2 stated when administering medications, nurses are to make sure the resident swallows them. Regarding R104's Lorazepam, V2 stated the nurses are to withdraw the ordered dose and place it back into the fridge for storage. Facility's Administering Medications policy (11/06/2019) documents in part: Medications shall be administered in a safe and timely manner, and as prescribed. Facility's Storage of Medications policy (10/28/2019) documents in part: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals shall be stored in the packaging, containers or other dispensing system in which they are received. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Event ID: Facility ID: 145285 If continuation sheet Page 5 of 13 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 145285 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Pavilion 2625 West Touhy Avenue Chicago, IL 60645 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food items were properly labeled and dated. These failures have the potential to affect all 110 residents receiving food prepared in the facility's kitchen. Findings include:On 12/02/25 at 9:18 AM, V3 (Kitchen Supervisor) stated all food items are labeled with a delivery date, a prepared or opened date and a use by date. V3 stated if the item is labeled by the manufacturer with a use by date printed on the product, then that is the date the kitchen follows and items need to be discarded or used by this date. V3 stated it is everyone's responsibility to label and date food items and it is important for all items to be labeled and dated with use by dates so the staff knows when food should be discarded. V3 said, we have to do this, so the residents do not get sick by eating expired foods. On 12/02/25 at 9:23 AM, the following items were found in the in reach-in refrigerator:1.) Opened package of orange colored cheese slices wrapped in plastic labeled with an open date of 11/30/25. The package was not labeled with a use by date. The cheese slices had printed on the product by the manufacturer best by date of 06/09/26. V3 stated these sliced cheese needs to be used by 06/09/26 because that is what is printed on the product, and that is why the staff did not need to label the package with a use by date once they opened the product because there was a use by date already on there. 2.) Opened 24-ounce glass jar of Gefilte Fish with a white sticker on the lid with the word pureed and open date 11/20/25 handwritten on the sticker. There was no use by date written on the sticker. V3 stated this item comes in shelf-stable but does not in pureed form and that it was pureed on 11/20/25 by the cook. V3 stated it is not labeled with a use by date because they follow the date printed on the product by the manufacturer. V3 pointed to the lid which had a best by date of January 2027 printed on it by the manufacturer. V3 stated that is how long the Gefilte Fish is good for (even after being opened) but that this product would be used up before then. On 12/03/25 at 9:35 AM, the following item was observed in cabinet where spices are stored:1.) Opened large plastic container of [NAME] Pepper labeled with delivery date 06/28/20, opened date 05/10/21. Printed on the container by manufacturer was best by date 03/11/22. On 12/03/25 at 9:42 AM, V3 (Kitchen Supervisor) stated the spice should have been thrown out because it has expired already. On 12/04/25 at 11:36 AM, V27 (Consultant Registered Dietitian) stated opened and prepared food items should be labeled with an open/prepared date and a use by date. V27 stated use by dates vary depending on what the item is, and the kitchen follows the policy on use by date recommendations. V27 stated it is important for items to be labeled with an open and use by date, so the staff is aware of when to discard the item to make sure the kitchen does not serve somebody something that has gone bad, so no one gets sick. V27 stated shelf stable items printed with a best by date on the item by the manufacturer means this item can be used up until the best by date assuming it is not opened before that date. V27 stated once the shelf stable item is opened it needs to be labeled with an opened and use by date and that the use by dates and storage guidelines should be followed per the kitchen policy/guidelines. V27 looked at the kitchen document titled Use by Date Recommendations and stated the cheese slices once opened are good for two weeks, not until 06/09/26. V27 stated if the Gefilte Fish had a best by date of January 2027 printed on the jar that means it is good until January 2027 if the product is not opened but that once the Gefilte Fish is opened it should be used within 5-7 days based on the kitchen guidelines. V27 stated Gefilte Fish would be considered as a higher acid product and therefore be good for 5-7 days after opening. V27 stated white pepper should have been discarded because it expired and /or they are no longer using it in the kitchen. V27 stated there are two residents in the facility who receive nothing by mouth (NPO). On 12/04/25, V1 (Administrator) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 6 of 13 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 145285 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Pavilion 2625 West Touhy Avenue Chicago, IL 60645 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete provided list of diet orders for all residents in the facility. The diet order list indicates there is two residents receiving nothing by mouth (NPO). Facility provided policy titled, Labeling ad Dating Foods Policy dated 10/04/2016 which documents in part, for dry storage room once opened these items are refrigerated and labeled with the date opened and with discard or use by date. Refer to the following chart for use by recommendations. Refrigerated items are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date. If opened, the cold food items is labeled with the date opened and the date by which to discard or use by. Refer to the following chart for the use by recommendations. Facility provided document titled, Use by Date Recommendations (undated) which lists different food items and documents in part, 1.) Canned good - high acid recommended maximum storage if opened 5-7 days, refrigerated.2.) American cheese (sliced) recommended maximum storage if opened 2 weeks refrigerated.3.) Ground spices recommended maximum storage if opened 2-3 years. Event ID: Facility ID: 145285 If continuation sheet Page 7 of 13 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 145285 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Pavilion 2625 West Touhy Avenue Chicago, IL 60645 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 observation, interview and record review the facility failed to keep the door closed and educate visitors on proper Personal Protective Equipment (PPE) to be used when entering a resident room on Contact/Droplet precautions for one (R121) resident, failed to don proper PPE when entering the room of one (R1) resident room with a diagnosis of COVID-19 and failed to ensure clean linen was covered on two second floor linen carts. These failures have the potential to affect 51 residents residing on the second floor. Finding Include: Residents Affected - Some 1. R121 was admitted to the facility on [DATE] with diagnosis not limited to Non-ST Elevation (NSTEMI) Myocardial Infarction Presence of Coronary Angioplasty Implant and Graft, Paroxysmal Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 Through Stage 4 Chronic, Acute Diastolic (Congestive) Heart Failure , Chronic Kidney Disease, Stage 3, Coronary Atherosclerosis due to Calcified Coronary Lesion, Atherosclerotic Heart Disease of Native Coronary Artery, Bradycardia, Dizziness and Giddiness, Methicillin Resistant Staphylococcus Aureus Infection, Streptococcal Infection, Specified Bacterial Agents as the Cause of Diseases Classified Elsewhere and Pain In Left Leg. R121's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 13 indicating intact cognitive response. R121's Physician Orders document in part: 11/21/25 Strict contact isolation precautions due to an active infection. Single room, resident alone and not cohorted with a roommate. Resident remains in the room at all times. All services done inside the room. 11/26/25 Vancomycin HCl (Hydrochloric Acid) in NaCl (Sodium Chloride) 1GM (Gram)/250ML (Milliliters)-0.9% Solution Dose: 1000MG/ (milligram) 250ML (intermittent) @ (at) 125 ml/hr. (Hour) every three days 0600 Through: 12/28/2025 For: Bacterial Infection MRSA (Methicillin-resistant Staphylococcus aureus) in nose. R121's Care Plan document in part: Problem: 11/21/25 (Infection/Prevention): Related To: MRSA (nares). Approach: 11/21/25 Nurses - Contact precautions. 12/02/25 Nurses - Droplet precautions Nurse Aide Droplet precautions. Goal: 11/21/25 to prevent the spread of infection. 11/21/25 Problem: (Infection/Prevention): R1 has Infection and receiving IV (intravenous) antibiotic Related to: dx (diagnosis) of Acute bacterial sinusitis, streptococcal bacteremia, sphenoid sinusitis, MRSA. R121's Hospital Record dated 11/21/25 document in part: Discharge Diagnoses: Sepsis Secondary to Step Anginous Bacteremia with Bilateral bacterial sinusitis, Bilateral bacterial sinusitis of sphenoid/ethmoid with MRSA and Strep anginous and mixed Gram-positive aerobes c/f (consider/rule out) skull base osteomyelitis. Infectious workup completed with BCX (blood Culture), CBC (complete Blood count), imaging. Found to have S. anginous in blood meeting criteria for sepsis. Taken for endoscopic sinus surgery. Found to have MRSA in OR (operating room) cultures with S. anginous. Started on Vancomycin and will need 6-week total course estimated end date 12/28/25. On 12/02/25 at 11:37 AM, observed R121's door posted with signage for Contact Precautions and Droplet Precautions. R121's door was wide open. Surveyor could see from R121's doorway that R121's was lying in bed. Supply of PPE outside R121's door included N-95 face mask, face shield, gowns, gloves. Surveyor knocked on the door, introduced self and asked if it would be okay to enter R121's room. R121's waved his hand and said, come in, come in. I cannot see you. I am blind. On 12/02/25 at 2:06 PM, observed R121's door wide open. Observed V21 (R121's Friend) inside R121's room talking to R121 within close proximity to each other. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 8 of 13 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 145285 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Pavilion 2625 West Touhy Avenue Chicago, IL 60645 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 - Some On 12/02/25 at 2:09 PM, V22 (Registered Nurse) observed R121's door wide opened and stated R121's door should be closed because he is on droplet/airborne precautions and that R121's visitor inside his room should be following the posted guidelines for wearing PPE (Personal Protective Equipment). On 12/02/25 at 2:13 PM, V21 (R121's Friend) stated she is R121's significant other and has visited him every day since he was admitted to the facility. V21 stated R121's door to his room is always wide open, never closed. V21 stated no one has said anything to her about wearing PPE. V21 stated those signs have only been up there for two days. V21 stated when the signs went up, she asked the staff if what he (R121) had was contagious and they said no to her. V21 does not remember the name of the staff who told her that, but she did ask because she was worried for herself. V21 stated the only staff wearing PPE when they go into R121's room are the therapist. V21 stated the nursing staff does not wear anything when they go in and out of R121's room. V21 said, they look just the way they do now walking in the hallway. V21 stated when staff go into R121's room to deliver his meals they also do not wear anything. On 12/02/25 at 2:21 PM, V2 (Director of Nursing) stated R121's family is non-compliant with wearing PPE and she thinks she provided education to V21 about wearing PPE but V21 does not follow the guidelines. V2 stated she does not remember if she documented that the education was done with V21 but if she did it would be documented in the progress notes section of R121's electronic health record (EHR). V2 stated R121 is on contact and droplet precautions due to having MRSA (Methicillin-Resistant Staphylococcus Aureus) in the nares and therefore R121's door should be closed to decrease the transmission through the air. V2 stated because the MRSA is in R121's nares if he sneezes it could be transferred through the air which is why his door should always be shut because it could pass to other residents. On 12/02/25 at 3:30 PM from the doorway surveyor observed R121 in bed with V21 (R121's Friend) sitting on R121's bed next to R121 with no PPE in use. Signage posted on the entry door of R121's room indicated Contact Precautions and Droplet Precautions. On 12/02/25 at 3:31 PM surveyor asked V21 (R121's Friend) to exit the room. Surveyor asked V21 was she aware and receive education that she (V21) should have a mask and a gown on while in R121's room. V21 said the staff never educated her about wearing the gown and a mask. They just put that sign on the door for Droplet Precautions yesterday. I have visited R121 every day since he has been here, and no one has told me that I need to wear a gown and mask until today. I have been coming here not knowing a thing. I found out that R121 has MRSA in the nares and now I may have it. I have a doctor appointment to see if I am infected. V21 then turn and asked R121 how many days have you been here. R121 responded, 12 days. V21 then reentered R121's room without putting on any PPE. On 12/02/25 at 3:35 PM V5 (Registered Nurse) stated if R121 is on droplet precautions anyone that enters the room should wear a mask. I won't be able to answer any question about R121because that is not my resident. I saw V21 (R121's Friend) and I am not sure who she is. On 12/02/25 at 3:40 PM RN V22 (Registered Nurse) stated I think that I have taken care of R121 one time before today. V2 (Director of Nursing) was educating V21 (R121's Friend), not me. On 12/02/25 at 3:44 PM V2 (Director of Nursing) stated R121 came in with an order and I just talk to R121's son that said R121's isolation should be six weeks. We should do another culture. The Contact and Droplet Precaution signage has been on R121's door since he has been here. R121 has MRSA of the nares. V21 (R121's Friend) keep opening R121's door. I talked to V21 and told her you need a mask (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 9 of 13 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 145285 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Pavilion 2625 West Touhy Avenue Chicago, IL 60645 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 - Some and gown. I just went there, and she said no mask no gloves. The droplet precautions carry in the air and R121's door should be closed. I educated V21 multiple times. I teach them right away and the family is not complying. Surveyor asked V2 if she has documented the education for the use of PPE and keeping the door closed. V2 responded, I will check. On 12/03/25 at 9:40 AM V2 (Director of Nursing) stated the notes for PPE (Personal Protective Equipment) education for R121's family and visitors, I did not document at that time, I did a late entry. The second time that I saw V21 (R121's Friend) was yesterday. The other time that I saw V21 was in the hallway. R121's son was educated yesterday and on admission. R121's Progress Note dated 12/02/25 6:26 PM document in part: Late entry, upon admission resident's female friend in the room, education about isolation was done, the friend was very upset and screamed to question about the isolation and walked out of the room reluctantly because resident needed to be physically assessed, and the writer requested visitors to follow the isolation. Resident's son was educated for isolation and resident's granddaughter and daughter in law all were educated for the isolation and precaution. R121's Progress note dated 12/02/25 06:49PM document in part: Resident's female friend did not follow the isolation and ignored the door signs, the floor nurse reported to this writer. Spoke with the friend regarding the isolation and following the instruction to protect herself and others, she stated that she is not going to wear the gloves, and she is not going to wear the mask, after teaching. And later she walked out of the room with the gown on, followed this friend to insist her to follow the isolation requirement, this friend yelled at this writer and went to the room, removed her gown and sat next to the resident and stated that she cannot tolerate the gown, she is not going to wear it. Educated this friend about keeping the door closed, this friend was very upset and kept coming out of the room and kept the door open, this writer went to several times to close the door, and this visitor opened the door after. 2. R1's Progress note dated 12/03/25 3:53 AM document in part: Infection/ABT (Antibiotic) MRSA Nares, Streptococcus anginous bacteremia. Isolation: Contact Precaution. R1 was readmitted to the facility on [DATE] with diagnosis not limited to Heart Failure, Adult Failure to Thrive, COVID-19, Diabetes Mellitus, Muscle Weakness, Acute Kidney Failure, Paraplegia, Vascular Dementia, Secondary Malignant Neoplasm of Bone, Lymphedema, Hypo-Osmolality and Hyponatremia, Secondary Malignant, Secondary Hypertension, Synovial Cyst of Popliteal Space [Baker], Right Knee, Adjustment Disorder with Depressed Mood, Acute on Chronic Right Heart Failure, Unilateral Inguinal Hernia, Severe Protein-Calorie Malnutrition, History of Falling, Anemia in other Chronic Diseases, Acute Kidney Failure, Neuromuscular Dysfunction of Bladder and Wedge Compression Fracture of Third Lumbar Vertebra. R1's Physician Orders document in part: 12/01/25 strict contact & droplet isolation precautions due to an active infection. Single room, resident alone and not cohorted with a roommate. Resident remains in the room at all times. All services done inside the room. Three times a day AM, PM, NOC last date: 12/05/25. R1's Care Plan document in part: 12/02/25 Problem: (Infection/Prevention): Related to: MRSA nares, Respiratory infection (COVID). Approach: 12/02/25 Nurses - Droplet precautions Contact precautions. Droplet precautions Contact precautions. Nurses - Airborne precautions Nurse Aide - Airborne precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 10 of 13 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 145285 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Pavilion 2625 West Touhy Avenue Chicago, IL 60645 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 On 12/02/25 at 03:19 PM R1's entry door was observed with signage indicating contact/ droplet precautions with the door closed. On 12/03/25 at 9:49 AM two linen carts were observed in the hallway on the second floor with the flaps open exposing the clean linen. Residents Affected - Some On 12/03/25 at 10:20 AM R1's call light was activated. V25 (Certified Nurse Assistant) was observed with a standard surgical face mask in place. V25 applied a gown, gloves and a face shield then entered R1's room. V25 then exited R1's room after removing the face mask, gown, face shield and gloves. Surveyor asked V25 was she aware that R1 was on isolation due to COVID-19 and what kind of mask should be worn. V25 responded yes, I should have put on the white mask for my own protection. The flaps on the linen carts should be closed. Maybe I left the flap open because I went to answer R1's call light. On 12/03/25 at 2:08 PM V14 (Infection Preventionist) stated R121 is on contact and droplet precautions isolation. The isolation entails before entering R121's room each person must implement PPE (Personal Protective Equipment) precautions, including putting on a mask, gloves, face shield and gown. The family members and visitors are supposed to wear the same PPE when entering R121's room. R121 was admitted to the facility on [DATE]. The isolation signage has been on R121's door since the day he was admitted . The education documentation was when the (V2) Director of Nursing noticed V21 (R121's Friend) did not have PPE on and V2 educated her (V21). I do not know if V21 had visited R121 prior to yesterday (12/02/25). PPE that should be worn for resident with COVID-19 are a gown, N95 mask, face shield and gloves. The purpose of wearing PPE is to prevent the spread of infection. The purpose for wearing the N95 mask is infections can spread. V14 (Infection Preventionist) stated R121 had MRSA of the Nares on admission, and they are placed on contact and droplet precaution. I do some care plans and MDS does them as well. Contact isolation was initiated on 11/21/25. The care plan should have indicated contact and droplet precautions immediately upon admission because contact and droplet precautions are for MRSA of the nares. I would have to check who updated the care plan. Signage titled Contact Precautions document in part: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Signage titled Droplet Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry or Remove face protection before room exit. On 12/04/25 at 11:01 AM V14 (Infection Preventionist) stated the flaps on the linen carts should always be closed. To prevent the spread of infection. The second-floor census was obtained from the Room/Bed List present to the surveyors on 12/02/25. Policies: Titled Infection Prevention and Control Program dated 05/10/20 document in part: The facilities infection prevention and control program shall include the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement and following accepted national standards. (2) Written standards, which include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 11 of 13 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 145285 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Pavilion 2625 West Touhy Avenue Chicago, IL 60645 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 - Some (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (4) A system for recording incidents identified under the facility's IPCP (Infection Control and Prevention Program) and the corrective actions taken by the facility. Titled Isolation – Categories of Transmission-Based Precautions dated 10/8/16 document in part: Policy Statement: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation 2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. 4. The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. Contact Precautions: 1. Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 3. The individual on contact precautions will be placed in a private room if possible. 4. Staff and visitors are instructed to wear gloves (clean, non-sterile) when entering the room. 5. Staff and visitors are instructed to wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions 1. Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). 2. Residents on droplet precautions will be placed in a private room if possible. 3. Masks will be worn when entering the room. 4. Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. Titled Linen dated 11/28/17 document in part: Personnel shall handle, store, process, and transport linens so as to prevent the spread of infection. 7. Clean linen shall be kept covered when on linen carts. Titled Contact Precautions dated 11/28/17 document in part: Contact precautions are intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident of environment and requires the use of appropriate PPE, including a gown and gloves before and upon entering the room. Prior to leaving the resident's room the PPE is removed, and hand hygiene is performed. Titled Droplet Precautions dated 11/28/17 document in part: The use of droplet precautions applies when respiratory droplets contain pathogens which can be spread to another susceptible individual. Respiratory pathogens can enter the body via the nasal mucosa, conjunctivae and less frequently the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 12 of 13 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 145285 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckingham Pavilion 2625 West Touhy Avenue Chicago, IL 60645 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 mouth. Appropriate facemasks should be used upon entry into a resident's room with respiratory droplet precautions. Based upon the pathogen or clinical syndrome, if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, glove and gown as well as goggles should be worn. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 13 of 13