Inspection·December 19, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Face sheet, dated December 2024, shows R77, a [AGE] year-old female resident with diagnoses that includes bipolar disorder, psychoses, Alzheimer's disease, arteriosclerotic heart disease, dementia, osteoarthritis, and right wrist drop. R77 was admitted to the facility on [DATE]. MDS (Minimum Data Set), dated October 24,2024 shows R77's cognition was severely impaired and required extensive to substantial assistance from staff for personal hygiene/grooming. R77's care plan dated October 24,2024 showed R77 was dependent on staff for assistance with ADLs. Residents Affected - Some On December 16,2024 at 11:00 A.M., R77 was in the dining room on the third floor designated Memory Unit. R77 was attending recreational activity. R77 was observed with long chin hair approximately 2 inch long. R77 was also had long, jagged fingernails with black substance under the nails. During this time, V21 (Memory Care Coordinator) was present and said that the residents in the designated Memory Care Unit were low functioning residents and their cognition were severely impaired. At 12:30 P.M., R77 was still in the same dining room, eating her lunch. R77's hygiene and grooming were remained the same with long soiled nails and long chin hair. V20 (RN/Registered Nurse) was present during this observation. On December 17,2024 at 12:20 P.M., R77 was in the memory unit dining groom eating her lunch. R77's hygiene and grooming were not maintained, with long soiled jagged nails, and an unkempt chin hair. V20 (RN/Registered Nurse) was again present during this observation and was R77's assigned nurse. 10. Face sheet, dated December 2024, shows R80, a [AGE] year-old female resident with diagnoses that includes type 2 diabetes mellitus, dementia, heart disease, chronic kidney disease, bipolar disorder and major depressive disorder. R80 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R80's cognition was moderately impaired, and she required substantial/maximum assistance from staff for ADLs including hygiene and grooming. The care plan dated December 3,2024 shows that R80 was dependent on staff for assistance with ADLs. The POS (Physician Order Sheet) for the month of December 2024 shows Special Instructions: **Extensive assistance - one+ person physical. On December 16, at 10:50 A.M., R80 was in the dining room on the third floor designated Memory Unit. R80 was attending recreational activity. R80 was observed with long chin hair approximately 2 inch long. R80 was also had long, jagged fingernails. V20, the assigned nurse for R80 said that R80 was a total care for all ADLs. On December 17,2024 at 1:04 P.M., R80 was in the dining room on the third floor designated Memory Unit. R80 was eating her lunch. R80's personal hygiene remained unkempt, with long jagged fingernails, black substance under nail bed and chin hair that was unbecoming for a female resident. V20, was present during this observation. 11. The Face Sheet for the month of December 2024 show that R106, a [AGE] year-old female resident with diagnoses that includes dementia, Alzheimer's disease, major depressive and anxiety disorder. R106 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R106's cognition was severely impaired and required maximum/dependent on staff for assistance with ADLs. The care plan dated March 19, 2024 showed R106 be aided with ADLs. On December 16, at 1:34 P.M., R106 was in the dining room on the third floor designated Memory Unit. R106 was eating her lunch. R106 was observed with long chin hair approximately 2 inch long. R106 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 2 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was also had long, jagged fingernails V20, the assigned nurse for R106 said R106 was a total care for all ADLs. On December 17,2024 at 1:10 P.M., R106 was in the dining room on the third floor designated Memory Unit. R106 was eating her lunch. R106's personal hygiene remained unkempt, with long jagged fingernails, black substance under nail beds and chin hair that was unbecoming for a female resident. V20, was present during this observation. 12. The Face Sheet for the month of December 2024 shows that R115, an [AGE] year-old female resident with diagnoses that includes Alzheimer's disease, schizophrenia and hypothyroidism. R115 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R115's cognition was severely impaired and required maximum/dependent on staff for assistance with ADLs. The care plan dated November 22, 2024 showed R115 be aided with ADLs. The POS for the month of December 2024 Special Instructions: POS *Extensive assistance - one+ person physical assist* On December 16,2024 at 12:30 P.M., R115 was in the dining room on the third floor designated Memory Unit. R115 was eating her lunch. R115 was observed with long chin hair approximately 2 inch long. R115 was also observe with long, jagged fingernails V20, the assigned nurse for R115 had said that R115 was a total care for all ADLs. On December 17,2024 at 1:15 P.M. R115 was in the dining room on the third floor designated Memory Unit. R115 was eating her lunch. R115's personal hygiene remained unkempt, with long jagged fingernails, black substance under the nails and chin hair that was unbecoming for a female resident. V20, was present during this observation. 13. The Face Sheet for the month of December 2024 shows that R167, a [AGE] year-old female resident with diagnoses that includes multiple sclerosis, dementia, obstructive hydrocephalus, urinary tract infection, anxiety disorder, depression, psychosis and type 2 diabetes mellitus. R167 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R167's cognition was severely impaired and required maximum/dependent on staff for assistance with ADLs. The care plan dated November 8, 2024 showed R167 needed help with ADLs. The POS for the month of December 2024 Special Instructions: POS *Extensive assistance - one+ person physical assist* On December 16,2024 at 12:40 P.M. R167 was in the dining room on the third floor designated Memory Unit. R167 was eating her lunch. R167 was observed with long chin hair approximately 2 inch long. R167 was also observed with long, jagged fingernails V20, said R167 was a total care for all ADLs. On December 17,2024 at 12:42 P.M., R167 was in the dining room on the third floor designated Memory Unit. R167 was eating her lunch. R167 hygiene and grooming remained unkempt. R167 was touching her food with her bare hands and her fingernails were long, jagged and black substance under nail bed. On December 18, 2024, at 3:46 PM, V2 (Director of Nursing/DON) stated the facility's practice is to ensure that residents are well groomed. Hygiene is provided including nail, facial hair, and incontinence care. Ensure that residents are wearing appropriate, comfortable, and clean clothing. The facility's policies for ADLs were as follows: -Care of Fingernails/Toenails: dated October 2010 shows: Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 3 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some General Guidelines 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin -Shaving the Resident: dated October 2010: Purpose The purpose of this procedure is to promote cleanliness and to provide skin care. -Urinary Continence and Incontinence date March 2020: Policy Statement: The staff and practitioner will identify and manage individuals with urinary continence or incontinence. .6. The staff is to assist the resident with his or her toileting needs at least every 2 hours and as needed. Assistance may include but is not limited to checking and changing if incontinent or assisting the resident to the toilet as needed .9. If the individual requires assistance from more than one person to transfer to the toilet, the staff will address his or her mobility problems before attempting a toileting assistance trial. 10. Incontinence care should be individualized at night to maintain comfort and skin integrity and minimize sleep disruption. 11. Prompted voiding is not helpful at night (e.g., between the hours of 10 p.m. and 5 a.m.) and has been shown to disrupt sleep. 12. If the resident is incontinent, provide incontinent care or check and change the resident at least every 2 hours and PRN. 13. If the resident does not respond and does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their name, staff will use a check and change strategy. 14. A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. 3. Face sheet shows that R21 is 79 years-old who has multiple medical diagnoses which include dementia, lack of coordination, and need for assistance for personal care. MDS (Minimum Data Set) dated November 6, 2024, shows that R21 is totally dependent on staff for dressing, and grooming and hygiene. On December 16, 2024, at 10:54 AM, R21 was sitting in the dining room along with other residents. R21 was unkempt and disheveled. His clothes have flaky substances all over from his top down to his pants, he displayed overgrown fingernails with black/brown substances underneath, his nail beds have yellowish/brownish discoloration, hair was uncombed, unkept overgrown mustache and beards, and he had overgrown hairs in the ears and nostrils which was sticking out. R21's ADL (activities of daily living) care plan with revision date of March 25, 2024, showed R21 had an ADL self-care performance deficit related to diagnoses which include Vascular Dementia. The goal was to meet R21's ADL daily. This same care plan shows R21 is totally dependent on staff for dressing, and to check nail length, trim, and clean on bath day and as necessary, 4. Face sheet shows that R190 is 94 years-old who has medical diagnoses which include Alzheimer's disease. MDS October 18, 2024, shows R190 requires maximum assistance with grooming/hygiene. On December 17, 2024, at 4:45 PM, R190 was sitting in the dining room displaying facial hair and long fingernails which has chipped nail polish and black/brown substance underneath the nails. R190 touched her face and felt her long facial hair on the upper lip and chin, then she looked at her fingernails. R190 stated that she would like her facial hair shaven, and fingernails clipped. 5. R16's face sheet included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cerebral infarction due to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 4 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0677 unspecified occlusion or stenosis of unspecified cerebral artery, arthropathy. Level of Harm - Minimal harm or potential for actual harm R16's quarterly MDS dated [DATE] showed that R16 had impairment on both sides for range of motion on upper extremities and was dependent on staff for personal hygiene. Residents Affected - Some On December 16, 2024 at 10:52 AM, R16 was lying in bed sleeping and both of her arms appeared deformed with very dry skin. R16 had both hands with fingers formed into fists and therefore the finger nails were not visible. V8 CNA (Certified Nursing Assistant), who was in the vicinity, stated that R16 is dependent on staff for ADLs. On December 17, 2024 at 9:23 AM, R16 was lying in bed with arms tucked under the blankets and was unable to respond coherently to queries. V6 (Restorative CNA) who was in the room assisting R16's roommate was requested to remove the blanket from R16's arms. R16's fingers on both hands were curled into fists and on opening them by V6, it was noted that R16's right hand and left hand pinky and middle fingers had very long and hardened finger nails that were curled in. R16's care plan initiated on October 19, 2021 showed that R16 has an ADL self-care performance deficit related to weakness secondary to above stated diagnoses. The care plan intervention for personal hygiene included that the resident requires (extensive assistance) by (1) staff with personal hygiene. 6. R42's face sheet included diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified dementia, unspecified severity, with other behavioral disturbance, dysphagia, oropharyngeal phase, anorexia, unspecified protein-calorie malnutrition. R42's quarterly MDS dated [DATE] showed that R42 was moderately impaired in cognition for decision making and dependent on staff for oral hygiene and personal hygiene. On December 16, 2024 at 10:30 AM, R42 was propped up in bed and did not respond to queries but only smiled. R42's upper teeth that were visible were coated with extensive debris. R42's CNA (V8) stated that she provides cup and water set up only to R42 to brush her teeth and that R42 does not brush her teeth properly. R42's thumb nail on left hand was very long (about 1/2 inch) with blackish substance underneath. R42's right hand was contracted and holding paper towels that were crumpled up. On request R42's right hand fingers were opened by V9 (LPN, Licensed Practical Nurse) and R42's middle finger nail on right hand was also very long with blackish substance underneath. V8 and V9 were notified that R42's nails need to be trimmed. On December 17, 2024 at 9:25 AM, R42 was propped up in bed. R42's teeth remained with extensive debris built up and R42's middle finger nail on right hand and thumb nail on left hand remained long with blackish substance underneath. V8 was notified again about the observations. R42's care plan revised March 12, 2024 included that R42 has ADL self care performance deficit related to weakness with interventions showing that R42 requires extensive assistance by one staff for personal hygiene and oral care. R42's care plan initiated June 7, 2021 also included to check mouth after meal for pocketed food and debris and report to nurse and to provide oral care to remove debris. 7. R134's face sheet included diagnoses of primary generalized (osteo)arthritis, adult failure to thrive, dorsalgia, gastro-esophageal reflux disease without esophagitis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 5 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0677 Level of Harm - Minimal harm or potential for actual harm R134's admission MDS dated [DATE] showed that R134 is moderately impaired in cognition and is dependent on staff for personal hygiene. On December 16, 2024 at 12:05 PM, R134 was seated in dining room for lunch meal and noted to have several very long chin hairs and stated that she would like it removed. Residents Affected - Some On December 16, 2024 at 1:57 PM, R134 was seated in common activity room on first floor and the long chin hairs remained on her chin. This was relayed to V2 (Director of Nursing) who stated that the CNAs are supposed to provide grooming assistance per request or as needed. R134's care plan initiated November 1, 2024 included that R134 has an ADL self-care performance deficit related to activity Intolerance. 8. R199's face sheet included diagnoses of cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery, difficulty in walking, not elsewhere classified, need for assistance with personal care, other reduced mobility. On December 16 2024 at 10:37 AM, R199 lying in bed with hair and beard overgrown, and finger nails very long with blackish substance underneath. R199 stated that that he returned to facility in October, 2024. R199 stated that he wanted his hair cut and beard and nails trimmed and did not know if the facility offers these services. R199 remarked My hair is usually not this long. My nails are longer than I have ever had. On December 17 2024 at 9:21 AM, R199 was lying in bed and his hair, beard and nails remained long and this was relayed to V9 (LPN) who stated that R199 needs assistance with ADL care. R199's care plan revised on October 1, 2024 included that R199 has ADL self-care performance deficit related to above listed diagnoses with a goal that ADL needs will be met on a daily basis until next review. Based on observation, interview, and record review, the facility failed to provide incontinence care, oral care, and grooming to residents who depend on the facility for care. The facility also failed to shave female and male resident's long facial hair and trim and clean resident's long fingernails. This applies to 13 of 13 residents (R16, R21, R42, R61, R77, R80, R106, R115, R134, R160, R167, R190, R199) reviewed for ADL (Activities of Daily Living) in the sample of 35. The findings include: 1. R160's face sheet showed him to be a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Dominant side, Dysphagia, Anxiety Disorder, Seizures, and Dementia with Moderate Agitation. R160's Minimum Data Set (MDS) section C dated November 12, 2024 showed R160 to be severely cognitively impaired. The same MDS section GG showed R160 to be dependent or require substantial/maximal assistance for self-care activities. On December 16, 2024 at 10:14 AM, R160 was lying in his room and his finger nails were long and there was a black substance under the nails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 6 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On December 17, 2024 at 1:49 PM, V4 (CNA) and V25 (CNA) came in to perform incontinence care for R160. R160's incontinence brief was visibly soiled from the front. When V4 opened R160's incontinence brief, it was heavily saturated with urine soiled from mid front and went all the way up his back. Under the brief there was a yellow pad that had a brown ring around the wetness on the pad. R160 had stool that was dry, pasty and stuck to resident's inter-gluteal cleft and buttocks, because of this, V4 had to use almost a full pack of large wipes to clean R160. The fitted sheet that was underneath the yellow pad, was also wet with brown tinged urine. When V4 removed the socks, there was a copious amount dead skin that fell onto R160's bed. R160's feet were extremely dry, scaly and flaky. R160's finger nails were still overgrown, with black substance under his nails. R160's skin care plan shows the following: Keep skin clean and dry. May apply lotion or moisturizer cream as part of daily skin care. 2. R61 Face Sheet documents a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Parkinson Disease, Encounter for Attention to Gastrostomy, Dysphagia, Congestive Heart Failure, and Dementia. Minimum Data Set (MDS) section C dated October 22, 2024 showed R61 to be severely cognitively impaired. The same MDS section GG showed R61 to be dependent or require substantial/maximal assistance for self-care activities. On December 16, 2024 at 10:47 AM, R61 was sitting in the dining room and has long facial hair above her upper lip and at the corners of her mouth. R61's finger nails were long with brown substance underneath the nails. On December 17, 2024 at 1:30 PM and 1:45 PM R61, was sitting in the dining room displaying curly facial hair on the upper lip and below her lower lip. R61 also had long fingernails with chipped nail polish and black brown substance underneath her nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 7 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and treat a resident with a contracture of the left hand and failed to apply a splint in accordance with physician orders. This applies to 2 of 6 residents (R117 and R160) reviewed for range of motion in the sample of 35. Findings include: 1. R160's face sheet showed him to be a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Dominant side, Dysphagia, Anxiety Disorder, Seizures, and Dementia with Moderate Agitation. R160's Minimum Data Set (MDS) section C dated November 12, 2024 showed R160 to be severely cognitively impaired. The same MDS section GG showed R160 to be dependent or require substantial/maximal assistance for self-care activities. On December 16, 2024 at 10:14 AM, R160's left hand was contracted closed,with fingers touching the palm, and no splint or positioning device was in his hand. On December 17, 2024 at 1:49 PM, while V4 (Certified Nursing Assistant/CNA) and V25 (CNA) were providing care and R160 left hand remained without a positioning device or splint. On December 17, 2024 at 3:00 PM, V22 (Restorative Nurse) stated that she was not aware that R160 had any contractures, but she would assess him and have occupational therapy assess him also. V22 stated that R160 does not wear any kind of splint. On December 18, 2024 at about 9:20 AM, V22 stated that her assessment showed that R160 could benefit from a splint. On December 18, 2024 at 11:30 AM, V26 (CNA) and V23 (Licensed Practical Nurse/LPN) attempted to open R160's left contracted hand and R160 screamed in pain. On December 18, 2024 at 12:49 PM, V27 (Occupational Therapist) stated that she assessed R160 this morning because the staff was concerned with changes to his left arm. V27 stated that R160's left hand 3rd and 4th fingers Interphalangeal (IP) joints were contracted. V27 stated she recommended that R160 have a resting hand splint and occupational therapy. V27 stated, the resting hand splint was the best option for R160 because it would leave his hand in a neutral position, will not cause him to clamp down, and will prevent more deterioration. R160's Occupational Therapy Evaluation & Plan of treatment dated December 18, 2024, showed the following: Assessment Summary: Clinical impression/Reason for Skilled Services: Patient currently presents for skilled Occupational Therapy with changes to the proximal interphalangeal (PIP) joint and the distal interphalangeal (DIP) joints of digits 3 and 4 on the left hand, as well as mild changes in the metacarpophalangeal (MP) Joints (The knuckles) of all left digits. Patient will benefit from skilled (OT) to address range of motion, hand pain/stiffness, and possible splinting needs. Recommend splinting trials and range of motion with skilled OT. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 8 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. R117 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis due to cerebral infarction affecting the right dominant side, chronic obstructive pulmonary disease, essential hypertension, and dysphagia. R117's physician order summary showed an order initiated on November 5, 2024, apply R hand splint ON 9 AM and OFF PM. Check for integrity. continue to re-direct and motivate resident to participate in PROM and splint application. Monitor for pain. R117 was observed on December 16, 2024, at 10:50 AM, lying in bed. R117 was not wearing a right hand splint. R117 was not able to answer questions and only responded by opening her eyes. On December 17, 2024, at 11:42 AM, R117 was observed sitting in the dining room in a reclining wheelchair, not wearing a splint on her right hand. V5 (LPN MDS Coordinator) observed R117, and stated at 11:52 AM, R117 was not wearing a splint on her right hand. At 12:12 PM, V7 (CNA ) stated she had gotten R117 dressed and transferred her to the reclining wheelchair around 9:00 AM that morning and forgot to put on R117's right hand splint. The Facility's policy titled Application of splints or braces , dated November 2015, showed Policy: Adaptive devices will be used as ordered by the physician to prevent deformities or further contractures or to maintain an alignment on a limb or extremity .2. The splints or braces shall be applied according to physician's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 9 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide safe transfer and feeding supervision to residents who required assistance for activities of daily living care. This applies to 3 of 4 residents (R24, R42, R58) reviewed for safety during ADL assistance in the sample of 35. The findings include: 1. Face sheet shows R58 is 84 years-old who has multiple diagnoses which include displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing, Parkinson's disease, unspecified fall, reduced mobility, needs for assistance with personal care. On December 17, 2024, at 4:35 PM, V18 (Certified Nursing Assistant/CNA) assisted R58 to the bathroom. V18 propelled R58 to the bathroom, R58 held onto the grab bar as she was standing up unsteadily while V18 supported her by holding on to the waistband of her pants. After R58 completed toileting, R58 stood up while V18 cleaned her perineum, and was assisted back to the wheelchair without use of a gait belt. R58's care plan with initiated date of May 2022 showed R58 has an ADL self-care performance deficit related to weakness and current medical condition which include radiculopathy of lumbar region, disorder of muscle, and Parkinson's disease. This same care plan shows R58 requires extensive assistance by two staffs to move between surfaces and as necessary. Use of gait belt by all staff whenever transferring. R58's fall assessment dated [DATE], showed R58 was at risk for fall. 2. Face sheet shows R24 is 92 years-old who had multiple medical diagnoses which include morbid obesity, Alzheimer's disease, abnormalities of gait and mobility, lack of coordination, and need for assistance with personal care. On December 18, 2024, at 10:23 AM, V17 (CNA) assisted R24 to the toilet. R24 was assisted to stand up and transfer from wheelchair to the toilet without a gait belt. After R24 used the toilet, she stood up and held on to the grab bar, while V17 provided peri-care, and was assisted back to the wheelchair without the use of gait belt. R24's active ADL care plan shows R24 has an ADL self-care performance deficit related to weakness and current medical condition including dementia, morbid obesity, and osteoarthritis. This same care plan shows R24 requires extensive assistance by two staffs to move between surfaces and the use of gait belt at all times especially during transfers and repositioning. R24's fall assessment October 15, 2024, shows R24 scored 13 which means she was at risk for fall. On December 18, 2024, at 4:10 PM, V2 (Director of Nursing/DON) stated the standard of practice for transferring resident who can stand up is for staff to apply gait belt to resident who requires assistance to ensure safety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 10 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Policy Statement Residents in the facility will be transferred safely from one location to another using the proper transfer technique. 3. R42's face sheet included diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified dementia, unspecified severity, with other behavioral disturbance, dysphagia, oropharyngeal phase, anorexia, unspecified protein-calorie malnutrition. R42's quarterly MDS (minimum data set) dated November 27, 2024 showed that R42 was moderately impaired in cognition. R42's diet order on Physician's order summary included mechanical soft texture, regular/thin consistency, no rice/beans, feeding assist alternate consistencies, small bites/sips, no straw. On December 16, 2024 at 12:34 PM, R42 was propped up in bed at around 45 degree angle and received a lunch tray set up on a bedside table. Set up for lunch meal was provided by V8 CNA (Certified Nursing Assistant) and V8 left the room. V8 stated that R42 is resistive to feeding assistance. R42 was observed attempting to eat some of the ground meat and dessert with her left hand that was unsteady. R42's right hand appeared contracted. R42's meal ticket showed mechanical soft diet, feeding assist, alternate consistencies, small bites/sips, and no straw. On December 17, 2024 at 11:11 AM, R42 was propped up in bed with bedside tray with disposable cup (4 oz/ounce) of water with a straw in the cup. V8 stated that she gave R42 the water and put the straw in the cup. On December 17, 2024 at 12:43 PM, R42 was propped up in bed at around 45 degree angle and was attempting to eat lunch that was placed in front of her on a bedside table. R42 also had the disposable cup (4 oz) of water with a straw in it. No staff was present in the room. R42's meal ticket showed mechanical soft diet, feeding assist alternate consistencies, small bites/sips, no straw. R42 was seen eating some of the bread and then sucked up all of the dessert directly from the bowl with her mouth. V10 (Licensed Practical Nurse) who was in the hallway was notified of the directions listed on the meal ticket. R42's care plan initiated June 7, 2021 included that R42 has a swallowing problem related to swallowing assessment results secondary to diagnoses of dysphagia. Interventions for the same included alternate small bites and sips. Use a teaspoon for eating. Do not use straws. On December 18, 2024 at 12:16 PM, V16 (Speech Language Pathologist) stated that she last saw R42 in March, 2022 and at the time of discharge she recommended mechanical soft /ground meat, thin liquids, small sips, small bites and to alternate consistencies during meals. V16 stated that she recommended direct supervision at meals for safety of intake and carryover of swallow strategies and also for encouragement of oral intake. V16 also added that direct supervision is beneficial as R42 has Dementia and needs cueing and has also has tremors related to Parkinson's. V16's discharge progress notes dated March 11, 2022 included as follows: Recommendations discussed with patient/staff include mechanical soft/thin diet with aspiration precautions (upright for meals, slow rate, small bites, alternating consistence's, tray set up, offer alternate food options. The same summary also included direct supervision during meals to encourage intake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 11 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 label and date medication to determine the expiration date once it was opened and failed to ensure narcotic medications were accounted for. This applies to 9 of 11 residents (R4, R11, R18, R36, R38, R89, R90, R134, R136) reviewed for medication storage and labeling in the sample of 35. The findings include: On December 18, 2024, inspections of 6 of the facility's 11 medication carts and 2 of their 3 medication rooms were conducted with each of the assigned staff nurses (V10, V11, V24, V29, V31, V32). The following was observed: 1. On December 18, 2024, at 1:26 PM, there was a Basaglar Kwik Pen (insulin solution) in the 4th floor center 1 medication cart that was unlabeled, opened, and not dated. The pharmacy recommendation shows to discard this medication 28 days after it was opened. R4's Lorazepam (antianxiety) 1 milligram (mg) tablet card/container had a seal broken and taped over for number 30. In addition, there were three water cannister or tumblers stored inside this medication cart. V29 stated that all three belonged to her. 2. On December 18, 2024, at 1:35 PM, the narcotic medications on the 4th floor East medication cart were counted with V10. R136's Lorazepam 0.5 mg tablet showed there were 16 tablets in the bingo card/container. However, it was documented on the narcotic log/sheet that there were 17 tablets remaining. R36's Hydrocodone/APAP (pain medication) 5-325 mg showed 14 tablets, but the documented narcotic sheet showed 15 tablets. R38's Alprazolam (antianxiety) 0.5 mg tablets showed 18 tablets, the documented narcotic sheet showed 20 tablets remaining. R89's Lorazepam 1 mg tablet, showed 10 tablets, the documented narcotic sheet showed 11 tablets remaining. R134's Hydrocodone/APAP 10-325 mg showed 13 tablets, the documented narcotic sheet showed 14 tablets remaining. R18's Hydrocodone/APAP 5-325 mg showed 7 tablets, the documented narcotic sheet showed 8 tablets remaining. On December 18, 2024, at 1:59 PM V28 (Assistant Director of Nursing/ADON) stated the moment the staff administer the narcotic medication to the resident, the staff must sign it out on the narcotic sheet to have accurate count and ensure that it was given. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 12 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 3. On December 18, 2024, at 2:08 PM, the 3rd floor medication room was inspected with V30 (Nurse). R90's Ozempic 2mg/3 ml was stored in the refrigerator, it was opened and not dated. The pharmacy recommendation shows to discard this medication 56 days after it was opened. 4. On December 18, 2024, at 2:24 PM, the narcotic medications on the 2nd floor [NAME] medication cart were counted with V31. R11's Hydrocodone/APAP 5-325 mg showed 18 tablets, but narcotic sheet/log shows 19 tablets remaining. 5. December 18, 2024, at 2:45 PM, the 2nd floor East medication cart as checked with V11. There was a vial of Insulin Lispro that was unlabeled, opened and not dated. The pharmacy recommendation shows to discard this medication 28 days after it was opened. On December 18, 2024, at 3:40 PM, V2 (Director of Nursing/DON) stated that it is the facility's practice to document on the narcotic sheet/log to ensure accuracy of dispensing and administration of the narcotic medication. V2 added, that it is also the facility's practice to ensure all medications mentioned above are labeled and stored to ensure that potency and expiration date of the medications are monitored. V2 also stated Staff's personal belongings should not be stored in the medication cart. The facility's policy and procedure for Storage of Medication dated March 2020, shows: Policy Statement: The facility shall store all drugs and biologicals safely, securely, and orderly. 6. Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use and shall be stored separately from regular medications. Medications that are in bottles, vials, and pens should be dated when opened and discarded according to the manufacturer's guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 13 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observations, interview and record review, the facility failed to provide double protein portion as ordered by the physician. Residents Affected - Few This applies to 2 of 2 residents (R95 and R168) observed for dining in the sample of 35. The findings include: 1. On December 17, 2024 at 12:05 PM, during tray line service on the 4th floor, V12 (Dietary Aide) was platting the food and V13 (Dietary Manager) was checking meal trays. R168's meal ticket showed regular consistency, double protein and he received one serving portion (2 oz (ounces) with #16 scoop) of mechanical soft polish sausage and V13 was notified of the same. R168's diet order on POS (Physician Order Summary) showed LCS (Low Concentrated Sweets) diet, Regular texture, Regular/Thin consistency, double protein at lunch. R168's care plan initiated March 6, 2024 included that R168 requires a therapeutic diet and interventions included to provide ordered therapeutic diet. 2. On December 17, 2024 at 12:22 PM, R95 received one serving portion (2 oz with #16 scoop) of mechanical soft polish sausage. The facility diet order listing showed double protein at lunch for R95. When V13 was asked, why R95 only received one portion, V13 stated that the meal ticket only shows one portion of the same. V13 was notified at a later time that the diet order on POS shows double protein at lunch, and V13 responded that he will update the meal ticket. R95's diet order on POS showed LCS diet, Mechanical Soft texture, Regular/Thin consistency, double protein at lunch. R95's care plan revised January 22, 2024, included that R95 has nutritional problem or potential nutritional problem of weight changes related to disease process of Depression, Bipolar disorder, Dementia, Anxiety disorder. Intervention included to serve diet as ordered. On December 18, 2024 at 12:41 PM, V15 (Dietitian) stated that she recommended double protein for R168 related to his request for the same as a food preference. V15 added that R95 was recommended double protein for lunch as he has had a history of weight loss. Diet spreadsheet for lunch (week 4 Tuesday) included kielbasa [polish sausage] (1 portion=2 oz/ounce protein). The same spreadsheet also included portion serving size of 2 oz protein +1 oz broth of ground kielbasa for mechanical soft diet. Facility serving scoop equivalent chart showed that #16=2 oz portion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 14 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 2. On December 17, 2024, at 9:30 AM V11 (Nurse) prepared and administered medications to R144. There was a sign outside R144's bedroom which showed Contact Precaution. V11 went in and out of R144's bedroom twice, first to administer the intravenous antibiotic medication and then to administer all the oral medications to R144. V11 only used a pair of gloves, however she did not use an isolation gown. When asked about what contact precaution R144 has, V11 was not sure of it. Residents Affected - Many 3. On December 17, 2024, at 4:35 PM, V18 assisted R58 to the bathroom. After R58 used the toilet, V18 wiped R58's perineum, then she pulled the incontinence brief and pants back in place, assisted R58 to transfer from toilet to wheelchair while wearing the same soiled gloves. V18 used one set of gloves all throughout the provision of care. 4. On December 18, 2024, 10:23 AM, V17 (CNA) assisted R24 to the toilet. R24 voided, afterwards V17 assisted R24 to stand up, provided peri-care, pulled the incontinence brief and pants back in place, and assisted R24 to sit down on the wheelchair while wearing same soiled gloves. V17 changed her gloves without performing hand hygiene and continued to assist R24. On December 18, 2024, at 4:02 PM, V2 (Director of Nursing/DON) stated it is the facility's practice to follow standard infection control process such as hand hygiene and donning of complete PPE (Personal Protective Equipment) which include glove and gown for resident on contact isolation. The staff should perform hand hygiene and change gloves in between tasks to prevent spread of infection. R144 is on contact precaution for MRSA (Methicillin-resistant Staphylococcus aureus) of the wound. Facility's Hand Washing/Hygiene Policy with revision date of November 2017 shows: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use and alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: f. Before moving from one contaminated body site to a clean body site during resident care. g. after contact with a resident's skin. j. After removing gloves. 8. The use of gloves does not replace handwashing/hygiene. Facility's Transmission Based Precautions dated June 21, 2023, shows: Contact Precautions: b. Wear a gown and gloves for all interactions with the patient or potentially contaminated areas in the patient's or resident's environment. Donning personal protective equipment (PPE) upon room entry and discarding it before exiting the patient room. Based on observation, interview, and record review, the facility failed to follow their Water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 15 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 Management Program, failed to follow their policy for PPE (Personal Protective Equipment) during care of a resident in contact isolation, and failed to follow their policy for hand hygiene and glove use during provisions of care. This applies to all 206 residents residing in the facility. Residents Affected - Many The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated December 16, 2024, by V1 (Administrator) showed there were 206 residents residing in the facility. On December 17, 2024, at 8:57 AM, V14 (Maintenance Director) said for the facility's Water Management Program for legionella, the facility receives a yearly water report from the village. V14 continued to say a monthly water quality test is performed with a TDS (Total Dissolved Solids) probe. V14 said sometimes while performing the monthly TDS test, he does a chemical test of the water but V14 does not document those test results. V14 said the facility submitted water samples for testing for legionella on December 4, 2024. V14 said the facility does not have documentation to show any legionella testing was performed prior to December 4, 2024. V14 said housekeeping flushes the water in resident rooms on a weekly basis. The instruction manual for the facility's TDS probe showed TDS is short for Total Dissolved Solids. TDS is not a measure of harmful substances or pollutants. It is simply a measure of all substances dissolved in water. Purified water has a TDS of 0 to 1 PPM (Parts Per Million). The ocean has a TDS of over 10,000 PPM. Neither water sources are harmful. TDS is a good tool for monitoring the general quality of a known source of water . 4. TDS and Tap Water: a high TDS of tap water usually indicated a high level of calcium and magnesium (hard water) and other salts. This water is probably corrosive to plumbing fixtures, pipes and appliances, the water may taste bad too. Due to high mineral content, a professional water treatment company will be able to advise you on specific actions to take to correct the situation. The United States Environmental Protection Agency sets the standards for drinking water in the United States. The maximum TDS in drinking water is 500 PPM . The manual does not show the TDS probe can test for chlorine levels. On December 17, 2024, at 2:46 PM, V1 said the facility's Water Management Program's attachment number three cannot be located. V1 continued to say V14 should be following the control measures that are listed in the facility's Water Management Program. The facility's Water Management Program dated 10/18 showed Policy: The facility will implement the Water Management Program to reduce the risk for Legionnaire's disease associated with the building water system and devices, reduce the growth and spread of Legionella bacteria in the facility to identify areas or devices in the facility where Legionella might grow or spread to people so that the facility can reduce that risk . Procedure: 1. The Water Management Program Team: a. The following but not limited to are the members of the Water Management Program Team: i. Owner of the building; ii. Building Manager/Director of Environmental Services; iii. Administrator; iv. Assistant Administrator; v. Medical Director; vi. Infectious Disease Specialist/Physician; vii. Director of Nursing; viii. Assistant Director of Nursing; ix. Interdisciplinary Team of the facility representative; x. Contractors/consultants; xi. State and local health officials; xii. Representative from the Governing Body. b. The following but not limited to are the duties of the Water management team: i. Oversee the program. ii. Identify control locations and control limits. iii. Communicate regularly about the program. iv. Monitor and document the performance of the program. v. Identify and take corrective action as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 16 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 - Many needed . 3. The facility water systems: a. The Director of Environmental Services has to describe the facility's water system using a Flow Diagram and in a Text document. (Attachment number two). b. Once completed, identify areas where legionella could grow and spread. Decide where control measures should be applied and how to monitor them. Establish ways to intervene when control limits are not met. (Attachment number three). 4. Control measures and Corrective actions: .b. With the use of the diagram (Attachment number two), the facility identified and implemented a process in monitoring control measures. Control limit monitoring includes but not limited to checking water temperature weekly and PRN (Pro Re Nata/As Needed) and disinfectant levels weekly and PRN at different areas of the facility. c. The following but not limited to are the areas routinely checked: i. Quality of Water: On a weekly and PRN basis, the quality of the water will be measure throughout the system to ensure that changes that may lead to legionella growth (such as a drop in chlorine levels) are not occurring . v. Unoccupied room or unit closed to public use: if a room or floor will be unoccupied or closed to public use for a longer period of time which could be due to renovations, constructions or just plainly due to low census, this may cause a temporary hazardous condition because the water usage will decrease, which means stagnation is possible, therefore the following course of action should be implemented: a) Daily flushing of the sinks and fixtures with hot and cold water in several rooms including those at the end of the hall, which are farthest from the vertical pipe serving that floor (riser). b) Continued to monitor the water temperature and increase the frequency on monitoring the chlorine levels of the floor/unit/area that is closed from weekly to daily . On December 18, 2024, at 10:58 AM, V32 (Admissions Director) said a resident room on the second floor had been unoccupied since October 18, 2024. V32 continued to say she checked the facility's census from June 1, 2024, to present and the room next door had been unoccupied since before June 1, 2024. The facility does not have documentation to show daily flushing, water temperatures, or chlorine levels were monitored daily for the unoccupied rooms. The facility does not have documentation to show weekly water temperatures or weekly disinfectant levels were monitored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 17 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 follow their policy to offer residents the pneumococcal vaccine. Residents Affected - Few This applies to 3 of 5 residents (R63, R79, and R118) reviewed for immunization in the sample of 35. The findings include: 1. The EMR (Electronic Medical Record) showed R63 was admitted to the facility on [DATE], with multiple diagnoses including dementia, Alzheimer's disease, chronic bronchitis, chronic obstructive pulmonary disease, and hypertension. On December 17, 2024, at 2:26 PM, V3 (Infection Preventionist Nurse) said the facility offers the PCV20 (20-valent Pneumococcal Conjugate Vaccine) to eligible residents. V3 continued to say R63 had only received the PCV13 (13-valent Pneumococcal Conjugate Vaccine) and had not been offered the PCV20. V3 said R63 should had already been offered the vaccine. R63's Immunization Audit Report dated December 17, 2024, at 2:50 PM, showed R63 received the PCV13 on March 19, 2022. The report did not show R63 had been offered or refused another pneumococcal vaccine. As of December 17, 2024, at 2:50 PM, the facility does not have documentation to show R63 was offered an additional pneumococcal vaccine. 2. The EMR showed R79 was admitted to the facility on [DATE], with multiple diagnoses including chronic atrial fibrillation, chronic obstructive pulmonary disease, asthma, and hypertension. On December 17, 2024, at 2:26 PM, V3 said R79 received the PCV13 on March 29, 2022. V3 continued to say R79 had not been offered the PCV20. V3 said R79 should had already been offered the PCV20. R79's Immunization Audit Report dated December 17, 2024, at 2:56 PM, showed R79 received the PCV13 on March 29, 2022. The report did not show R79 had been offered or refused another pneumococcal vaccine. As of December 17, 2024, at 2:56 PM, the facility does not have documentation to show R79 was offered an additional pneumococcal vaccine. 3. The EMR showed R118 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, chronic kidney disease, and peripheral vascular disease. December 17, 2024, at 2:26 PM, V3 said R118 received two PCV13, one in 2018 and a second in 2019. V3 said R118 should had been offered the PCV20. R118's Immunization Audit Report dated December 17, 2024, at 2:54 PM, showed R118 received the PCV13 on October 12, 2019. The report did not show R118 had been offered or refused the PCV20. As of December 17, 2024, at 2:54 PM, the facility does not documentation to show R118 was offered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 18 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, IL 60634 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 0883 or refused the PCV20. Level of Harm - Minimal harm or potential for actual harm On December 17, 2024, at 2:26 PM, V3 said the facility follows CDC (Centers for Disease Control and Prevention) guidelines for pneumococcal vaccine timing. Residents Affected - Few The CDC's Pneumococcal Vaccine Timing for Adults dated October 2024, showed adults [AGE] years of age or older who have only received the PCV13 should receive the PCV20 after one year of receiving the PCV13. The facility's policy titled Pneumococcal Vaccine revised November 2017, showed Policy Statement: Residents in the facility will be offered a pneumococcal vaccine to air in preventing pneumococcal infections. Policy Interpretation and Implementation: .6. Administration of the pneumococcal vaccine or re-vaccinations will be made by current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 19 of 19