Health inspection·December 6, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Facility policy dated 07/26/2024, titled Call Light Policy documents in part, Policy Statement: It is the policy of this facility to ensure that there is prompt response to the residents' call for assistance. 5. Be sure call lights are placed within reach of residents who are able to use it at all times. 2. R377's current face sheet documents R377 is a [AGE] year old individual with medical diagnoses that include but not limited to: cognitive communication deficit, muscle wasting and atrophy, not elsewhere classified, right/left shoulder, postprocedural cerebrovascular infarction following other surgery, disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cerebral infarction, unspecified. Brief Interview for Mental Status (BIMS) dated [DATE] is documented as 03/15, indicating R377 has severe cognitive impairment and R377's Functional Abilities document R377 requires Partial/moderate assistance with eating and oral hygiene, dependent on Toileting hygiene, Lower body dressing, Putting on/taking off footwear, Shower/bathe self, requires Substantial/maximal assistance with Upper body dressing, and supervision and touching assistance with Personal hygiene. R377 uses a wheelchair for mobility. 12/03/24, 2:58 PM, R377 was observed in her room and laying in bed and was observed trying to use her call light. R377, in a very faint voice and using one word at a time stated her call light does not work and she needs help with getting her phone charger which was entangled on the bed frame. R377 was observed trying to detangle the call light but was not able to. R377 stated her call light has not worked all day. R377 pressed the call light but it did not work. R377 stated she needed to charge her phone, but she could not. On 12/03/2024, at 3:02 PM, Surveyor asked V14 (Certified Nursing Assistant-CNA) to come to R377's room and check R377's call light to see if it was working. V14 pressed R377's call light and it did not turn on and stated R377's call light should be working so that R377 call reach staff when she has a need. V14 stated R377 can slide out of bed and fall trying to reach or detangle her phone charger if R377's call light is not working to reach staff. V14 stated if R377 fell out of bed, she can get injured. V14 stated staff should check every resident's call light to make sure its working and if it is not working, staff should notify maintenance to fix it so that residents can reach staff as needed. On 12/04/2024, at 10:51 AM, V2 (Director of Nursing-DON) stated that call lights in residents' rooms should be checked regularly to make sure they are working so that residents can reach staff when needed. V2 stated R377's call light should be working so that R377 can reach staff when needed. V2 further stated staff should round frequently to make sure call lights are working and if a call light is not working, staff should notify maintenance to repair the call light. Call Light policy dated 7/24/204 documents: -Nursing staff should check all call lights daily and report any defective call light to the administrator / maintenance immediately for repair. -If a call light is not functional, evaluate and provide another means in order for the resident to call for assistance (i.e bell) until the call light is fix. 3. 12/03/2024, 1:35 PM, R24's call light not within reach, noted on the floor next to R24's bed, nearest to the room door. When questioned R24 if she can reach for her call light, R24 states no. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 2 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/03/2024, 2:08 PM, V12 (Licensed Practical Nurse) states that R24's call light should be within reach and should not be on the floor. V12 placed R24's call light within R24's reach. V12 states that it is important for residents to have their call light within reach because they can call for help. 12/03/2024, 2:11 PM, V13 (Certified Nursing Assistant) states that she is the assigned nursing assistant for R24. V13 states that she didn't get a chance to check if R24's call light was within her reach because she started work at 2:00 PM and she has not done rounds yet. 12/05/24, 3:03 PM, V2 (Director of Nursing-DON) reports that R24 needs a lot of assistance. V2 states that R24 is alert and oriented and has a BIMS (Brief Interview for Mental Status) score of 14/15 which makes her cognitively intact. V2 reports that R24 can use the call light. Facility document dated 7/26/24 titled Call Light Policy documents in part it is the policy of this facility to ensure that there is prompt response to the resident's call for assistance. Be sure call lights are placed within reach of residents who are able to use it at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 3 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to complete a resident's assessment and transmit data to the CMS (Centers for Medicaid and Medicare) system within 14 days after resident discharged from the facility for one (R151) resident reviewed in a sample of 35 residents. Residents Affected - Few Findings include: 12/05/24 at 3:39 PM, V34 (MDS/Clinical Coordinator) states that she is familiar with R151, when residents go to the hospital, MDS completes the discharge return anticipated assessment and plan needs to be completed per MDS guidelines. V34 states that she has to check R151's assessments. V34 states that when residents are admitted MDS completes an entry assessment. V34 states that if the resident gets sent out to the hospital an assessment must be completed within 14 days. With V34, R151's MDS assessment reviewed and V34 states that R151's discharge assessment was not completed. V34 states that R151's discharge assessment will be completed today. R151's MDS assessment documents in part Discharge complete by 08/5/2024- 122 days overdue. Facility document note dated title RAI OBRA- required assessment summary documents in part, discharge assessment return anticipated non-comprehensive MDS completion date + 14 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 4 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to refer one resident (R143) of seven residents reviewed with serious mental disorders for a Preadmission Screening and Resident Review (PASARR) level 11 assessment in a sample of 35. Findings include: R143 current face sheet documents R143 is a [AGE] year-old individual with medical diagnosis dated 4/11/2024 include but not limited to: schizoaffective disorder, unspecified, anxiety disorder, unspecified, depression, unspecified. Brief Interview for Mental Status (BIMS) dated 10/15/2024, does not document R143's BIMS. R143's Preadmission Screening and Resident Review (PASRR) 1 Screening dated 04/09/2024 documents R143 does not have suspected of known mental diagnosis. On 12/05/2024, at 1:02 PM, V2 (Director of Nursing-DON) said R143 has mental health diagnosis of schizoaffective disorder, depression, and anxiety and should have been evaluated for PASARR 11 so R143's behavior can be monitored as well as the medications he is taking for behavioral health. V2 further stated if PASARR 11 is not completed, there could be an Issue with not taking care of R143's mental issues as they might not be properly addressed. On 12/05/2024, at 2:42 PM, V1(Administrator) stated the facility relies on the hospitals to send the correct information of residents regarding PASARR 11 and the hospital documented R143 did not have any mental health diagnosis. V1 further stated the staff member in the facility's admission office is not a nurse, therefore he/she did not look at R143's diagnosis to determine R143 needed a PASARR 11 screening. V1 stated after surveyor notifying the facility R143 does not have a PASARR 11, she (V1) has reached out to the screening agency to screen R143. PASSAR Policy titled PASSAR Screening of Residents with Mental Disorders or Intellectual Disability, dated 8/16/2024 documents: -It's the facility policy to ensure that residents with Mental Disorder and those with Intellectual Disorder will receive PASSAR Screening within the timeframe allowed. 1. The facility will not allow admission from the hospital without a preadmission screening which includes OBRA Screen 1 and OBRA Screen 2 (PASSAR Screening) for those with mental or intellectual Disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 5 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure pressure ulcer preventative measures were accurately applied for three residents (R3, R26 and R49) in a sample of 35 residents reviewed for pressure ulcer. Residents Affected - Few Findings include: 12/4/24, at 12:24 PM, observed R49 low air loss mattress setting at approximately 310 LBS (pounds). 12/4/24, at 12:27 PM, observed R3 lying on a low air loss mattress. The mattress had a flat sheet on it and there was a fabric chuck/pad underneath R3 and R3 was wearing an adult brief. 12/3/24, at 1:15 PM, observed R26 low air loss mattress setting at 90 LBS. There was a fitted sheet on the mattress and a fabric chuck/pad underneath R26 and R26 was wearing an adult brief. 12/4/24, at 1:27 PM, V31 (Registered Nurse) verified there was a fitted sheet on R26's low air loss mattress and a pad that is referred to as a chuck and R26 was wearing an undergarment/adult brief. V31 stated R26 has a low air loss mattress for wounds. The general purpose of the low air loss mattress is to prevent wounds and keep wounds from getting worse. V31 stated there can be a fitted or flat sheet on the mattress. There should be only one layer on the mattress. V31 verified there are three layers between the mattress and R26 and that is too many layers. 12/4/24, at 1:38 PM, V32 (Certified Nursing Assistant) stated there should be only one layer between the low air loss mattress and the resident. V32 verified there was a fitted sheet on R26's mattress that should not be there. It should be a flat sheet. V32 verified there was a fabric chuck that should not be there. V32 stated R26 can have on a brief. The brief is not considered a layer. V32 stated the purpose of the low air loss mattress is to prevent bed sores for incontinent patients on boney prominences. Too many layers may make the mattress less effective. 12/5/24, at 1:00 PM, observed R49's low air loss mattress setting. V8 (Licensed Practical Nurse) verified R49's low air loss mattress setting was at 310 LBS-318LBS. 12/5/24, at 12:15 PM, V23 (Wound Care Coordinator) stated we have our own air mattresses. The weight setting should be set at the patients approximate weight. The facility weighs the resident to obtain correct weight. Initially, supply staff sets up the mattress, adjusts the weight according to resident weight. On wound cares next round on patients with low air loss mattress, we check on the setting and functioning of the mattress. The wound techs/CNAs (Certified Nursing Assistants) round to check that the mattress is functioning, and the weight settings are correct. If the resident is incontinent, then we use an incontinent pad/chuck, flat or fitted sheet on the mattress, and the resident can be in an adult brief. That would be three layers. If the resident is not incontinent then we use underwear/pullup, chuck and a flat or fitted sheet on the mattress. That would be three layers. The purpose of the mattress is to relieve pressure. It's important as a preventative measure for pressure wounds. The three layers are not impeding the purpose of the mattress. 12/5/24, at 5:30 PM, V2 (Director of Nursing) stated the low air loss mattress settings should be according to the patient's weight. Generally, there is supposed to be only one layer on the mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 6 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few If the resident is incontinent, we can use a brief, chuck and a flat or fitted sheet, three layers. Purpose of the mattress is pressure ulcer prevention and aiding in pressure ulcer healing. If the low air loss mattress is not set correctly, it does not serve the purpose for proper intervention to aide in wound healing or prevention. Can have no more than three layers. According to R3's physician order summary provided by facility 12/5/24, R3 has active order LAL (low air loss) mattress, order date 12/20/2022. According to R26's physician order summary provided by facility 12/5/24, R26 has active order LAL mattress, order date 10/16/2024. According to R26 weights and vitals summary provided by facility 12/5/24, R26 weight on 11/6/24 was 148.4 LBS. According to R49 physician order summary provided by facility 12/5/24, R49 has active order LAL mattress, order date 10/25/2020. According to R49 weights and vitals summary provided by facility 12/5/24, R49 weight on 10/8/24 was 227 LBS. Proactive Medical Products Operation Manual, no date, reads in part: Installation Instructions Step 2 You may place a thin cotton sheet over the overlay top cover. Operating Instructions Step 5 Patients can directly lie on the overlay or cover with a sheet and tuck loosely to increase the comfort of the patient. Step 6 Determine the patient's weight and set the control knob to that weight setting on the control unit. [NAME] Medical Operating Instructions Manual, no date, reads in part: Operating Instructions 4. Once the mattress or overlay pad is inflated to its normal size, set mode key to STATIC therapy. Using the comfort control keys set the required patient weight position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 7 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews and records review, the facility failed to keep record of receipt and disposition of one controlled drug in sufficient detail to enable an accurate reconciliation in a medication cart that serves 23 residents on the 8th floor and failed to keep an account of all controlled drugs is maintained and accurate for three (R61, R117, R429) in a sample of 35 reviewed. Findings include: 12/03/2024 at 10:20 AM, V5 (Registered Nurse) states that she is an agency nurse. After reviewing narcotics in the medication cart, there was one Hydromorphone 2mg (milligram) tablet in a three-tablet bingo card, appeared as if it was cut into this section, with no resident name and no controlled substance record form. V5 states that when she counted the narcotics with the previous nurse, V5 states that she was informed that it was an extra medication. V5 states that this medication should not be in the cart and unaccounted for. V5 states that there is no controlled substance record form to account for this medication (Hydromorphone 2mg one tablet). V5 states that she does not know if V2 (Director of Nursing) is aware. 12/5/24, 1:10 PM, V17 (Registered Nurse) states that she is from agency. V17 states, she picks up a lot of shifts for the facility. V17 states, that she just finished medication pass and she didn't sign the narcotic book. V17 states that it should be signed. V17 states that she was trying to finish giving other medications. Three residents' narcotic medications do not tally as to the records and the actual count of medicines: R 429's Hydrocodone record has 18, actual count of tablets has 17. R 429's Pregabalin record has 20, actual count of tablets has 19. R61's Pregabalin record has 13, actual count of tablets is 12. R117's Clonazepam record has 12, actual count of tablets is 10. V17 states that she gave R117 the medication twice today and has not signed it. V17 states that it is important to have the correct narcotic count so you don't give it again and can have proper count. V17 states that she knows that it is supposed to be accounted for in the narcotic records. V17 states that she just wanted to get her blood sugar monitoring done and then do her documentation. 12/05/2024, 3:15 PM, V2 (Director of Nursing) states that the narcotic medication (hydromorphone) 2mg that was unaccounted was used for one of the residents that didn't have their supply in yet. V2 states that all narcotics are supposed to be accounted for and documented on a controlled substance sheet. Facility document dated 7/26/2024, title Controlled Medications Count documents in part, it is the policy of the facility to maintain an accurate count of Scheduled II controlled medications. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 8 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 0755 the accompanying controlled medication sheet indicating the medication is taken. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 9 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for two (R89, R427) of six residents reviewed for medication administration resulting in a 6.67% error rate in a sample of 35 reviewed. Residents Affected - Few Findings include: 12/04/2024, 8:40 AM, observed V7 (Registered Nurse/RN) administer the following medication: V7 primed tubing, connected to machine, wiped lumen, no bubbles, connected to resident. V7 states it should run over 55 minutes. Surveyor observed pump set at 166ml/hr. Vancomycin 750mg/150ml. Label says infuse at 120ml/hr. nurse dated it with date and time. R427's current Physician Order Sheet document in part: Vancomycin HCI 750 MG/150ML Solution premixed vancomycin 750mg in 150ml water. Infuse intravenously at 120ml/hr (hour) over 75mins. Every other day for bone and joint infection until 12/31/24. 12/04/24, 9:57 AM, V7 (RN) states that nurses usually choose the intravenous (IV) medication dose in the pump, and the pump will set up the rate. V7 states that's the procedure. We put in the dose and the machine will give us the rate per hour. V7 states that she will notify V2 and call the pharmacy regarding R427's IV antibiotic medication. Surveyor questioned V7 if there is an option to change the rate on the IV pump. V7 responded I am not sure to be honest, I would have to check and get back to you. 12/04/2024, 1:16 PM, V15 (Medical Director) states that nursing staff talked to the pharmacist regarding the vancomycin administered at a faster rate. V15 states only need to watch out for local area, monitor site every shift. V15 states that R427's IV medication rate and order is still staying as is. V15 states that he looked at R427's IV site and did not observe any adverse reactions. V15 states that nursing should be following the orders including right rate. V15 states that the ordering dose was administered, V15 states but just went in a little faster. V15 states that pharmacy recommended only to monitor the site. V15 states that no level of harm occurred. 12/04/24 8:58 AM, V9 states that she works through agency, and she has worked in the facility before. Observed V9 (Licensed Practical Nurse) administer medication to R89: Vitamin D 1000 IU (UNIT) 1 tablet given. R89's current Physician Order Sheet document in part: Cholecalciferol Tablet 1000 UNIT Give 2 tablet by mouth 12/04/2024, 8:00 AM, one time a day for supplement. Facility document dated 8/16/2024, titled Medication Pass documents in part, it is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 10 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 follow proper sanitation and food storage practices as evidenced by a.) food not properly labeled, b.) food not properly stored, c.) equipment used for food preparation not properly sanitized, and d.) dishwasher temperatures not reaching at least 160 degrees Fahrenheit during the wash/rinse cycle. These deficient practices have the potential to affect all 183 residents receiving food prepared in the facility kitchen. Findings include: On 12/03/2024, at 10:15 AM, during initial kitchen tour with V21 (Dietary Manager), the following food items were found in the walk-in cooler: 1. 3 beverage dispensers and 2 beverage pitchers filled with red colored juice, no preparation date, expiration date, or use by date labeled on dispensers or pitchers. 2. 1 plastic container of individual margarine spreads with a use by date of 12/01/2024. 3. 1 opened box of semi-sweet chocolate chips, no expiration or use by date. 4. 1 opened package of hard-boiled eggs, no expiration or use by date. On 12/03/2024, at 10:29 AM, the following items were found in the walk-in freezer: 1. 1 opened box of striped pangasius fillet fish, no open date, no expiration date. 2. 1 opened box of bread, no open date, no expiration date. 3. 2 plates covered with aluminum foil, no preparation date, no expiration or use by date. On 12/03/2024, at 10:37 AM, the following items were found in the dry storage area: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 11 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 1 opened 25-pound bag of instant nonfat dry milk sitting on a shelf. Level of Harm - Minimal harm or potential for actual harm On 12/03/2024, at 10:40 AM, V21 states that the beverage dispensers and pitchers were filled with fruit punch juice. V21 states the fruit punch juice was prepared on 12/03/2024. V21 states that she was made aware that if beverages were prepared on the same day it was intended to be used, then it does not have to be labeled with a date. Surveyor inquires to V21 about how the preparation date is determined if there is no date labeled on the juice dispensers. V21 then observed searching the facility policies and later states that she is unable to find this verbiage pertaining to labeling the juice dispensers in the facility policy. V21 states the plastic container of individual margarine spreads were expired and should have discarded after seven days. V21 states the plastic container of individual margarine spreads should not be stored in the walk-in cooler for resident use. V21 states the opened 25-pound bag of instant nonfat dry milk should be stored in an airtight container. V21 states that all food items stored in the cooler and freezer should have an open and expiration date written on the packaging and always covered/wrapped. Residents Affected - Many On 12/03/2024, at 10:45 AM, during tour of the dish washing area with V21 (Dietary Manager), surveyor requested V21 to test the temperature of the cleaning cycle. V21 places a testing strip on a cup and put it inside the dishwasher and ran the cycle. As the dishwasher cycle ran, the wash temperature gauge was observed at 130 degrees Fahrenheit, and the rinse temperature gauge was observed at 138 degrees Fahrenheit. Once the dishwasher cycle completed, the testing strip remained white in color and did not turn black in color. V21 states if the dishwasher reaches the correct temperature, then the testing strip will turn black in color to indicate that the dishware has been sanitized properly. V21 states the final temperature should reach at least 160 degrees Fahrenheit. V21 then places another testing strip on a cup and ran the dishwasher cycle again, the second testing strip does not turn black and remain white color. V21 signs her name and dates both test strips that did not turn black and remained white in color. On 12/03/2024, at 11:08 AM, V21 tests the dishwasher temperature again and a third testing strip does not turn black, indicating the correct dishwasher temperatures were not reached. V21 states she will contact the dishwasher manufacturer company to make them aware of the need for the dishwasher to be repaired. V21 states this is the only dishwasher in the facility. V21 states if the correct temperatures are not reached for the dishwasher, then dishware will not be sanitized properly, and residents could potentially get food poisoning. On 12/03/2024, at approximately 4:30 PM, V1 (Administrator) states the dishwasher manufacturer came to the facility today to service the dishwasher and the dishwasher is now working properly. On 12/03/2024, at 4:50 PM, with V1 present, V21 (Dietary Manager) tests the dishwasher temperature again. V21 places a testing strip on a plate and put it inside the dishwasher and ran the cycle. As the dishwasher cycle ran, the wash temperature gauge was observed at 110 degrees Fahrenheit, and the rinse temperature gauge was observed at 130 degrees Fahrenheit. Once the dishwasher cycle completed, the fourth testing strip remained white in color and did not turn black in color. V21 then places another testing strip on a plate and ran the dishwasher cycle again, the fifth testing strip does not turn black and remain white color. V1 states she will contact the dishwasher manufacturer company again to make them aware of the need for the dishwasher to be repaired. V1 states the facility will serve the residents' dinner on disposable dinnerware this evening. On 12/03/2024, at 10:54 AM, V19 (Cook), V21 (Dietary Manager), and surveyor located next to the three-compartment sink inside of the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 12 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 V19 observed washing a pan in the three-compartment sink. V19 observed submerging the pan in the sanitize sink for approximately 8 seconds. V19 states she submerged the pan in the sanitize sink for approximately 10 seconds. On 12/03/2024, at 11:07 AM, V19 states she should have submerged the pan in the sanitizing solution for 20 seconds. V19 states she does not have a reason for not submerging the pan in the sanitizing solution for the required time to sanitize the pan. Facility document dated 12/04/2024, titled Diet Type Report documents that a total of eight residents residing in the facility have a diet order for NPO/nothing by mouth and does not receive food prepared in the facility kitchen. Facility policy dated 10/2019, titled Food Storage- Dry Goods documents in part, 5. The Dining Service Director or designee ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed. Facility policy dated 10/2019, titled Food Storage: Cold documents in part, 5. The Dining Service Director/Cook(s) ensures that all food items are stored properly in covered containers, labeled, and dated and arranged in a manner to prevent cross contamination. Facility documents undated, titled TCS Foods & 7-Day Labeling documents in part, Temperature Control for Safety (TCS) foods can grow harmful bacteria if stored or labeled in correctly. TCS foods include items like meat, eggs, fish, dairy, rice, and cut or prepped fruits and vegetables. Labeling TCS foods we prepare helps us know when they were made and when they might spoil. We must label and use TCS foods within 7 days from preparation to stay safe. Facility documents undated, titled TCS Food Labeling Guide documents in part, TCS food labels must include these 4 things: 1. Item 2. Prep Date 3. Use by date 4. Your initials. Facility policy dated 10/2019 titled, Ware washing documents in part, 2. The Dining Services Director ensures that all the dish machine water temperatures are maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. Facility document titled Hi Temp Warewash Instructions documents in part that the dishwasher temperature gauge should be as follows: Prewash: 100- 130 degrees Fahrenheit Wash: 150-160 degrees Fahrenheit Power Rinse: 160-170 degrees Fahrenheit Final Rinse: 180-195 degrees Fahrenheit Dish washer testing strips documents when the indicator turns black, stated temperature has been achieved. The testing strip documents 160 degrees Fahrenheit as the stated temperature. Facility policy dated 05/18 titled, Operation of the Three Compartment Sink documents in part, 5. Completely submerge pots/pans in the sanitizing solution . items should be in contact with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 13 of 14 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 145336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610 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 sanitizing solution for 30 seconds or per manufacturers' recommendation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145336 If continuation sheet Page 14 of 14