Inspection·January 17, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm reside in the facility under SSA and will be given back payment since there was an increase in monthly allowance from $30 to $60. She said there was only 1 corporate person giving trust funds for 7 facilities and was running behind, so an increase from 30$ to 60$ was not implemented yet. The company has already hired 2 more staff to help distribute trust funds / monthly allowance, and all residents eligible to get $60 will be given a back payment as it is their right to receive the correct amount. Residents Affected - Some MDS (Minimum Data Set) dated 10/9/24 showed R33's cognition was intact. R33's RFMS (resident fund management service) statement dated 1/15/25 showed in part: Allowance = $60.00. Resident advance cash of $30.00 was given every month from January 2024 to January 2025. The facility's RFMS transaction report dated 1/16/25 showed 16 residents under SSA. Provider notice issued 1/25/24 documented in part: This notice informs nursing Facilities (NF) that effective January 1, 2024, provides for the increase in the personal needs allowance (PNA) from $30 per month to $60 per month for nursing home residents who reside in a nursing facility licensed under the Nursing Home Care Act and who are determined to be eligible for Medical Assistance. The facility's Trust Fund Policy, dated 1/2024, documents in part that residents have a right to manage their own funds or to have the facility manage their funds. The patient allowance for residents who receive Social Security benefits or other pension benefits will be $60.00 per month. Facility's resident's rights policy (undated) documented in part: No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the constitution of the state of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of this community. Illinois Long-Term care Ombudsman Program Residents' Rights for people in long term care facilities dated 11/18 documented in part: Your rights regarding your money. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 2 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow its policy and procedure to ensure advance directives are included in residents' comprehensive care plans and updated as indicated for three (R32, R47, R63) out of 12 residents reviewed for advance directives in a final sample of 48 residents. Findings include: R47 was admitted to the facility on [DATE], and diagnosis included but was not limited to Parkinson's Disease and Neurocognitive Disorder with Lewy Bodies. R47 MDS dated 12/2024 documents in part, resident is rarely/never understood. R47's Physician Orders dated [DATE] documents in part Do Not Resuscitate (DNR) ordered [DATE]. R47's POLST (Practitioner Order for Life-Sustaining Treatment) Form dated [DATE] documents, in part, no CPR: Do Not Attempt Resuscitation (DNAR). R47's Advance Directives/Code Status care plan dated [DATE] documents in part, I wish for my code status to be FULL CODE. I am my own decision maker and have no POLST form on file at this time. On [DATE] at 8:55 AM, V10 (Social Service Director) reviewed R47's EHR (Electronic Health Record) and stated R47 has a physician order dated [DATE] for DNR and a POLST Form dated [DATE] for DNR. V10 stated that R47's advance directives care plan says full code, and that is a mistake. V10 stated that R47's care plan should have been updated to be DNR. V10 stated that the resident's wishes in the care plan should match the physician's orders and that the resident's care plans should be updated to reflect the resident's wishes. V10 stated it is important for the advance directive care plan to be updated so the nurses and the rest of the team know the code status of the resident and the plan of care in case of an emergency. R63 was admitted to the facility on [DATE], and the diagnosis included but was not limited to Age-Related Osteoporosis, Glaucoma, and Chronic Pain. R63's Physician Orders dated [DATE] documents in part, full code ordered [DATE]. On [DATE] at 02:54 PM, the surveyor reviewed R63's care plans. R63 has no care plan for advance directives in R63's EHR. On [DATE] at 8:59 AM, V10 (Social Service Director) reviewed R63's EHR and stated R63 is full code. V10 stated R63 does not have a care plan for advance directives but R63 should have one. Facility provided policy titled Advance Directives dated [DATE], which documents in part advance directive (s) shall be included in the resident's care plan and will be reviewed quarterly and updated, as needed. The facility provided policy titled Comprehensive Care Plan dated [DATE], which documents in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 3 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0578 1.) Level of Harm - Minimal harm or potential for actual harm Purpose to develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Residents Affected - Few 2.) Any services that would otherwise be required but are not provided due to the resident's exercise of rights, including the right to refuse treatment. 3.) The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. The findings include: R32's face sheet documented admission date on [DATE] with diagnoses not limited to Hemiplegia following cerebral infarct affecting right dominant side; Malignant neoplasm of prostate; Chronic systolic (congestive) heart failure; Essential (primary) hypertension; Type 2 diabetes mellitus without complications. On [DATE] At 8:48 am Surveyor interviewed V10 (SSD / Social Service Director) and said Advance directives include code status of the resident, to see what they would like or their wishes for medical care. She said code status is very important so staff will be able to know how to proceed when there is an emergency. V10 stated there should be a Care plan for advance directives so nurses know how to care for the resident during emergency whether to do CPR (Cardiopulmonary Resuscitation) for Full Code and or DNR (Do Not Resuscitate). She said Code status should have an order either full code or DNR. Surveyor reviewed R32's EHR (Electronic Health Record) with V10, no care plan found for advance directives. On [DATE] at 12:56pm Surveyor interviewed V18 (DON / Director of Nursing) and said resident should have Advance directives / code status and should be care plan so staff can carry out the resident's wishes for medical care whether to proceed with full CPR or DNR during emergency situation. MDS (Minimum Data Set) dated [DATE] showed R32's cognition was intact. R32's physician order dated [DATE] showed order not limited to: Advance Directives - Full code. R32's care plan reviewed and found no care plan for advance directives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 4 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 01/15/25 at 09:44 AM R25 stated I have complained of the water being warm for at least the pass 2 weeks. I don't know if there is something wrong with the boiler. I have not taken a shower because the water is too cold. I can't do anything for myself and have not had a bed bath. On 01/15/25 at 09:51 AM V4 (Registered Nurse) stated sometimes the residents make the complaint about the water being cold and we try to run the water long enough so that it will warm up. If they want it warmer, we use the microwave so it will be to the residents liking. We have a temperature thing in this room. V4 left the nurse station searching for the device that the water temperature is checked with then returned to the nurse station and stated we normally feel the water and ask the resident is it okay. They will confirm yah or [NAME]. I have not heard any further complaints outside of running or microwaving the water. On 01/14/25 at 01:05 PM R57 stated there have been no hot water for about 3 weeks. Half of the time it is cold, and they will warm the water up. I take a shower at least once a week, twice if possible. I have received 3 showers in the last 3 weeks. Having to bathe in cold water, that makes me feel terrible. I get a bed bath twice a week. Based on observation, interviews, and record reviews the facility failed to maintain a safe, comfortable home like environment [A] failed to maintain hot water temperatures for six [R24, R25, R52, R57, R58, R73] resident's rooms and the third-floor shower room, [B] failed to maintain a safe smoking patio environment related to not removing snow and ice for six [R25, R38, R52, R53, R73, R74] residents outside smoking reviewed in a sample of 18 residents. Findings include, On 1/14/25 at 9:40 AM R24 stated, In my bedroom the water does not get warm enough for two weeks. I'am tired of going to the first floor to take a shower. When I just want to give my self a bed bath, the nurse assistant warms up my water in the microwave. Sometime the water is too hot, and the nurse assistant would have to go bath and forth to get the basin water temperature right. Its not just my room, I been hearing other residents say they don't have warm water either. On 1/14/25 at 10:00 AM, V14 [Certified Nurse Assistant] stated, The water in a few rooms has not been warm for about a week or more. I reported the cool water to V6 [Maintenance Director] and Administration. To have warm water for the residents, I warm up the water basin in the microwave. I test the water temperature by touching the water. The residents are taken down to the first floor for showers, but some residents refuse to go down to the first floor. On 1/14/25 at 12:10 PM, V17 [Certified Nurse Assistant] stated, The water has not been hot for a couple of weeks, but when I need warm water for the residents, I warm up the water in the microwave. I don't know what temperature the water should be at, but I put my finger in the water to see if the water is too hot before washing up the residents. The administration people are made aware the water is not warm. On 1/15/25 at 8:20 AM, R73 stated, The bathroom water is cold, its s been over a week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 5 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0584 On 1/15/25 at 2:30 PM, V6 [Maintenance Director] and surveyor obtain water temperatures in the following areas: Level of Harm - Minimal harm or potential for actual harm Residents' bathroom water temperature measured: Residents Affected - Some R24 [ 66 degrees Fahrenheit] [F]. R52 and R58 [63 degrees F]. R25 [72 degrees F]. R57 [72 degrees F]. R73 [65 degrees F]. Third floor shower room temperature measured 64 degrees F. On 1/16/25 at 1:00 PM, V6 [Maintenance Director] stated, The resident's areas such as their bathrooms and shower rooms the water temperature should be 110 degrees Fahrenheit. The whole facility is not affected. The first-floor shower rooms are 110 degrees F. The kitchen is 140 degrees F and laundry is 140 degrees F. The facility has two hot water tanks. One tank was rusted and went out on 1/7/25. The administrator and corporate was made aware the water tank need to be replaced. On 1/10/25 the water tank was ordered and will take up to two weeks for delivery. Once the tank is delivered, it will be installed with in 24-hours. For the rooms with cool water, the nursing staff can go to other areas for warm water. On 1/16/25 at 2:40 PM V1 [Administrator] stated, I was made aware the hot water tank was not working. Corporate was contacted and a new tank was ordered on 1/10/25, should be delivered with in two weeks. There is hot water in other parts of the facility and first floor. I was not aware the nursing staff was warming up basins of water in the microwave. I will provide an in-service and thermometers to all nursing staff to make sure the water is not too hot. Using microwave water could potentially cause burn injury to the resident. Also, all nursing staff will be in-serviced that the first-floor shower room is available for resident showers. On 1/14/25 at 1:35 PM, V1 [Administrator], V10 [Social Service Director], and surveyor observed six residents [R25, R38, R52, R53, R73, R74] and V23 [Assistant Director of Social Service] on the outside smoking. The smoking patio ground was covered with snow and ice. V23 was monitoring residents outside smoking. On 1/14/25 at 1:35 PM, V10 [Social Service Director] stated, I can see the smoking patio from the office window. The snow and ice need removing. I will call V6 [Maintenance Director] to come clear the smoking patio now. On 1/16/25 at 11:38 AM, V23 [Assistant Director of Social Service] stated, I was outside on the smoke patio monitoring the 1:30PM smoke break on 1/14/25. Earlier that morning it was snowing, but the snow had stopped. Typically, V6 [Maintenance Director] would have been contacted to remove the snow and ice to prevent an accident. I allowed the residents to go outside on the smoking patio because the snow and ice was not so bad. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 6 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/16/25 at 12 PM, V6 stated, On 1/14/25 it did snow in the morning. However, our annual survey started, and I was busy. I forgot to shovel the smoking patio. The social service department was able to shovel the smoking patio as well or they should not have allowed the residents outside on the smoking patio. On 1/16/24 at 12:15 PM, V1 [Administrator] stated, Protocol for snow and ice removal is the Maintenance Director [V6] wound monitor the snow and inclement weather reports and outside premises. V6 is responsible to remove the snow and salt the ground for any ice. The residents should not have been outside on the snow and ice. It snowed this morning [1/14/25], but by the 1:30PM smoke break, my expectation was the snow and ice should have been removed before the residents were allowed outside on the smoking patio. The snow and ice could have potentially caused a fall.' Policies documented in part: Water Temperature Policy date 4/2007. The hot water temperatures are maintained by regulating valves. Resident services 110 degrees Fahrenheit [F] Smoking Safety Policy dated 4/2010 Provide a safe and healthy living environment with respect for the health and well-being needs of each resident. The facility recognizes the potential harm that may result from careless, hazardous smoking and has implemented this policy to maintain a safe living environment. Fall Prevention policy dated 11/28/2012. To assure the safety of all residents in the facility. Identify risk factors, use and implement of professional standards of practice, and communication with staff members. Safety interventions will be implemented for each resident. Maintenance Policy Inspections verify that all equipment and furnishings are clan and free from safety hazards internal and external the building. Building inspections include Water temperatures. The findings included: R58's face sheet documented admission date on 6/23/23 with diagnoses not limited to Essential (primary) hypertension; Folate deficiency anemia; Rash and other nonspecific skin eruption. On 1/15/25 at 10:00 am Surveyor conducted resident council meeting attended by residents including R58 who is alert and oriented x 3, verbally responsive. R58 said about a week ago, facility have an ice-cold water that he needed to go to his daughter's house to take a shower. R58 said water in 3rd (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 7 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0584 floor shower room is warm and not comfortable for shower. Level of Harm - Minimal harm or potential for actual harm MDS (Minimum Data Set) dated 12/5/24 showed R58's cognition was intact. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 8 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards for a PICC (Peripherally Inserted Central Catheter) line for 1 (R130) of 3 (R17, R132) sampled residents related to the maintenance of intravenous access devices. Residents Affected - Few Findings Include: R130 has diagnosis not limited to Encounter for Other Orthopedic Aftercare; Primary Generalized (Osteo)Arthritis; Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, History of Falling, Hyperlipidemia, Hypothyroidism, Polycythemia Vera, Bipolar Disorder, Effusion, Right Knee, Pyogenic Arthritis, Klinefelter Syndrome, Spinal Stenosis, Testicular Hypofunction, Depression, Retention of Urine, Morbid (Severe) Obesity, Iron Deficiency Anemia and Muscle Spasm. R130's Care Plan document in part: Focus: Intravenous Therapy: Antibiotic therapy. Resident has a need for IV (Intravenous) antibiotic therapy ceftriaxone 2-gram solution due to osteomyelitis. IV site will remain free of signs and symptoms of infection. R130's Resident Medication Administration Record provided by facility on 01/14/25 document in part: PICC (Peripherally Inserted Central Catheter) line IV catheter-change catheter dressing site dressing, start date: 01/14/25 with blank entry on date of 01/14/25. Resident Medication Administration Record provided by facility on 01/16/25 document in part: PICC line dressing change dated 01/15/25. On 01/14/25 at 09:32 AM R130 was observed lying in bed with a right arm PICC line dressing dated 01/07/25. On 01/15/25 at 09:29 AM R130 was observed lying in bed with a single lumen PICC line to the right arm with dressing dated 01/07/25. R130 stated they said that they will be back in to change the dressing. I receive IV antibiotics every morning. On 01/15/25 at 10:00 AM V4 (Registered Nurse) stated the PICC line dressing is change every 7 days and I would assume it would be in the morning. It would be documented on R130's 11pm-7am TAR (Treatment Administration Record). On 01/16/25 at 09:13 AM V18 (Director of Nursing) stated the PICC line dressing are changed weekly or as needed. When the dressing is changed it is signed and dated. If the PICC line dressing is not changed as ordered there's a potential for infection control and the assessment of the site. The dressing is changed to see if there is any change in the PICC line length and the site to see if there are any signs of infection. If R130's PICC line was dated 01/7/25 it should be changed the 01/14/25. Policy: Titled PICC Line / Midline Dressing Change Policy dated 04/23 document in part: PICC line/Midline catheter dressings will be changed at specific intervals, or when needed, to prevent catheter related infections associated with contaminated, loosened, or soiled catheter-site dressings. Guidelines: 1. Change PICC/Midline catheter dressings 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. Documentation: The following information (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 9 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0694 should be recorded in the resident's medical record. a. Date and time dressing as changed. 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: 145415 If continuation sheet Page 10 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a resident with a tracheostomy had the required emergency equipment at the bedside for 1 (R17) resident reviewed for respiratory care in a sample of 48. Residents Affected - Few Findings Include: R17 has diagnosis not limited to Tracheostomy, Chronic Respiratory Failure, Gastrostomy, Dysphagia, Morbid Obesity, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Major Depressive Disorder, Anxiety Disorder, Hypertensive heart disease, Epilepsy, Shortness of Breath Type 2 Diabetes Mellitus and Primary (Essential) Hypertension. R17's Physician's Orders document in part: Tracheostomy tube changes every 3 months and prn (as needed). (Tracheostomy tube) 6 as needed. Change Inner Cannula (Tracheostomy tube) 6 once daily and prn. R17's Care Plan document in part: Focus: Tracheostomy: Resident with tracheostomy r/t (related/to) dx (diagnosis) of chronic respiratory failure. On 01/14/25 at 01:12 PM Enhanced Barrier Precaution signage was observed on R17's entrance door. Upon entering R17's room, a suction machine, suction catheters, ambu bag and oxygen concentrator was observed at the bedside. On 01/14/25 at 01:17 PM V4 (Registered Nurse) stated R17 has oxygen but really don't use it because he is pretty stable. Surveyor asked V4 the location of R17's emergency step-down trach (Tracheostomy). V4 stated R17 wears an emergency step down #6 (tracheostomy tube trach). V4 proceeded to look in the medication cart drawer then pulled out an inner cannula that was not compatible with the trach that R17 has in use. On 01/14/25 at 01:26 PM V4 (Registered Nurse) entered R17 room then looked at R17 trach and stated R17 has a (tracheostomy tube) XLT (Extra Length Tracheostomy) #6, and the step down should be a #5. V4 looked in the bedside cabinet, on the counter at the bedside and could not locate the emergency step-down trach. V4 exited R17 room and stated, I will have to look for the emergency step-down (tracheostomy tube) trach. On 01/14/25 at 01:32 PM V4 (Registered Nurse) went to a room then returned to the nurse station with a tracheostomy in a box and stated it was in the supply room. When asked, if R17's tracheostomy had dislodged what would she (V4) do. V4 responded, I would have to get the one on the crash cart. I can put this one in R17's room, it is a #6 (tracheostomy tube) XLT. On 01/16/24 at 09:20 V18 (Director of Nursing) stated the tracheostomy supplies at the bedside should be a tracheostomy cannula step down by the wall, that is priority. Suction equipment should always be at the bedside. We should have the trach in the supply room, trach care kit, ties, and dressing change. In case the tracheostomy gets dislodge there is a potential for the stoma closing. It is not good if the stoma closes because that provides an airway for the resident. If the tracheostomy gets dislodged that is bad and the airway could possibly close. The stoma can close. The emergency tracheostomy should be easily assessable at the head of the bed so you can easily grab it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 11 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0695 Policy: Level of Harm - Minimal harm or potential for actual harm Titled Tracheostomy Care revised 11/24 document in part: 2. Gather the necessary equipment; (c) Emergency tracheostomy tube replacement the same size or one size smaller (should be kept at the bedside). (g) Trach care kit. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 12 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 observation, interview, and record review the facility failed to a.) ensure the accurate shift change reconciliation accountability record for controlled substance and b.) ensure an accurate accountability for 2 controlled substances (Clonazepam/Tramadol) by resolving discrepancies in a timely manner. This deficient practice was identified for 1 of 3 medication carts used to store controlled narcotics. Findings Include: Document titled Shift Change Accountability Record for Controlled Substance document in part: 2nd Month-Year January 2025: nurse Initials were missing for 01/13/25 second shift, third shift and 01/14/25 first shift. R9's Control Drug Receipt/Record/Disposition Form: document Date received 07/19/24, Drug Name/Strength: Tramadol HCL Tab 50 mg (Milligrams), Directions: One tablet by mouth every 6 hours as needed for pain. Quantity Received: 30. Amount Left: 16. R9's Bingo Medication Card contain a total of 15 Tramadol HCL Tabs indicating one missing tablet. R59's Control Drug Receipt/Record/Disposition Form: document Date received 10/31/24, Drug Name/Strength: Clonazepam 0.5 mg Directions: Two tablets (1 mg) per g (gastric) - tube three times daily. Quantity Received: 60. Amount Left: 41. R59's Bingo Medication Card contains a total of 39 Clonazepam 0.5 mg indicating two missing tablets. On 01/14/25 at 12:02 PM the second-floor medication cart one was reviewed with V7 (Licensed Practical Nurse). V7 stated when we come in, we count and sign off on the Narcotic Accountability Sheet at the beginning and end of each shift. The narcotics are signed out once given. If there is a discrepancy, we inform the director of nursing. On 01/16/25 at 09:27 V18 (Director of Nursing) stated the purpose of the Shift Change Accountability Record for Controlled Substance is to ensure the narcotic count is completed at the beginning and the end of each shift. Two people should sign it and if it is not signed the narcotic count was not done. If there is a discrepancy the supervisor or director of nursing should be notified and an investigate is done to check for what's going on, check medication card and reprimand whoever was involved. If there are narcotics missing, there is a potential that someone is stealing medication, or the medication is not being giving. Policy: Titled Narcotic/Controlled Substance Counting Policy revised 09/24 document in part: To ensure controlled medications are counted and verified with (2) license nurses on each shift to verify the accuracy of narcotic log sheets. Procedure: 2. Obtain sign-in/sign-out-controlled log sheet and keys to the controlled storage compartment. 4. Have co-nurse assist in the count, if the co-nurse is not available, call the director of nursing. 9. Verbally state medication count to person with sign-out record. 10. Listen while co-nurse verifies the count. 13. Sign name, time, and date of completed count. Procedure for errors in controlled substance count: 1. If the count is not correct and/or the narcotic log sheet from the previous shift was not signed, inform the director of nursing, or administrative nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 13 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a resident received the prescribed amount of insulin for 1 (R25) resident reviewed for significant medication error in a sample of 48. Residents Affected - Few Findings Include: R25 has diagnosis not limited to Paraplegia, Essential (Primary) Hypertension, Atrial Fibrillation, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Hyperlipidemia, Peripheral Vascular Disease, Polyneuropathy, Type 2 Diabetes Mellitus, Major Depressive Disorder, Pain in Right Knee, Pain in Left Knee, Foot Drop, Right Foot, Obstructive and Reflux Uropathy, Chronic Kidney Disease, Urethral Stricture, Retention of Urine, Hyperkalemia, Schizoaffective Disorder and Shortness of Breath. R25's Physician Order document in part: Basaglar Kwik Pen U-100 Insulin 100 unit/ml (milliliter) (3 ml) subcutaneous, inject 15 units by subcutaneous route Twice a day. Monitor Blood Sugar AC/HS (before meals/hour of sleep. R25's Care Plan document in part: Focus: Diabetes Mellitus: Resident has elevated blood glucose level secondary to diagnosis of NIDDM (Non-Insulin Dependent Diabetes Mellitus). Interventions: Monitor blood glucose level as ordered by MD (Medical Doctor). On 01/14/25 09:40 V4 (Registered Nurse) prepared R25's medication and placed a needle on the insulin Kwik pen then set the dial to 15 units without priming the needle. On 01/14/25 at 09:56 AM V4 (Registered Nurse) said I am going to check R25's blood glucose. The nurse may have missed the blood sugar. I think he (R25) should be fine because he has already eaten. V4 entered R25's room and administered the Basaglar insulin 15 units to R25's left lower abdomen. On 01/14/25 at 10:07 AM V4 (Registered Nurse) stated I figured since R25 had eaten, the blood glucose would not be accurate, and I felt it was safe to give 15 units of insulin as ordered. I should have primed the Kwik pen after putting on the needle. There is a potential R25 did not get the full dose of the insulin. On 01/16/24 at 09:36 AM V18 (Director of Nursing) stated the procedure when giving insulin is to check if it is for the resident, right dose medication, get the needle out, check to see what I am about to give, clean the top with an alcohol wipe, apply the sterile needle then prime the needle with two units, check dose and go to that dose. The nurse should explain what is being done, clean the site then administer the insulin. The purpose for priming the needle is not to give air and to give the exact dose. If priming the needle is not done the resident won't get the correct dose and air is injected into the residents' skin that is not needed. This would result in not giving the correct dose that the doctor ordered and that would be a medication error. Policy: Titled Medication Administration Policy updated 01/24 document in part: 17. Qualified nursing personnel shall perform monitoring (apical pulse, blood pressure, blood sugar test, etc.) prior to medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 14 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0760 administration. Medication may be withheld in conjunction with monitoring results. Level of Harm - Minimal harm or potential for actual harm Titled Insulin Administration Policy revised 07/02/24 document in part: To ensure proper administration of insulin. 1. Perform hand hygiene and apply clean gloves. Residents Affected - Few Title Flex Pen Insulin Administration reviewed 09/24 document in part: Flex Pen is used to administer manmade insulin to control high blood sugars on residents with diagnosis of Diabetes Mellitus. Procedure: 1) Wash Hands. 6) To avoid injecting air and ensure proper dosing, perform air shot before each injection. 7) Turn dose selector to 2 units, hold Flex Pen with needle pointing upwards, tap cartridge gently 2 times with finger a few times. Keep needle pointing upwards and press push button all the way in and see a drop of insulin appears at the end of the needle tip. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 15 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 a.) to ensure medications were securely stored during medication administration, b,) ensure expired medications were removed from 1 of 2 medication storage rooms and 1 of 3 medications carts and c.) ensure medication was labeled after opening for 1 of 3 medication carts reviewed for medication storage and labeling. Findings Include: On 01/14/25 at 09:25 AM V4 (Registered Nurse) prepared and administered medication standing at the medication cart to R38 in a medication cup and supplied R38 with a cup of water. During R38 medication preparation V4 wasted (Aspirin 325 mg (milligram)) orange pills in the top drawer of the medication cart. V4 put on gloves then placed the pills in a clear drinking cup (half full) and placed the cup on top of the medication cart. On 01/14/25 at 09:32 AM V4 (Registered Nurse) entered R130 and left the clear cup with the Aspirin on top of the medication cup unattended. On 01/14/25 09:40 V4 (Registered Nurse) entered R25's room leaving the clear cup with the Aspirin on top of the medication cart unattended. On 01/14/25 at 10:07 AM V4 (Registered Nurse) returned to the medication cart then placed the clear cup with the Aspirin 325 mg in the drawer of the medication cart. Surveyor asked was the clear cup of orange pills (Aspirin 325 mg) supposed to be left on top of the medication cart unattended. V4 responded I inadvertently left the pills in the cup on top of the medication cart. Someone could have taken the pills. On 01/14/25 at 11:44 AM the 2nd floor medication storage room was reviewed with V7 (Licensed Practical Nurse) One bottle of Liquid Pain Relief Acetaminophen 160 mg/5ml was observed in the cabinet with an expiration date of 12/24. V7 removed the medication from the medication storage room. On 01/14/25 at 11:49 AM the 2nd floor medication cart 1 was reviewed with V7 (Licensed Practical Nurse). One bottle of B complex was observed with an expiration date of 10/24 and One bottle of docusate sodium liquid 50mg/5ml with an expiration date of 10/24. On 01/14/25 at 12:51 PM the second-floor medication cart 2 was reviewed with V8 (Agency Licensed Practical Nurse) R1 Breztri aerosphere dispensed 12/27/24 was observed in the medication drawer with no open date. On 01/16/25 at 09:43 AM V18 (Director of Nursing) stated expired medications should be removed from the medication cart and medication room and properly disposed of. This should be done so you don't give a resident expired medication. When medications are opened it should be dated to know when to dispose of it. On 01/16/23 at 02:33 PM V2 (Interim Director of Nursing) stated medications should not be left on top of the medication carts because anyone can get them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 16 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 Policy: Level of Harm - Minimal harm or potential for actual harm Titled Medication Storage in the Facility effective date 07/18 document in part: medications and biologicals are stored safely, securely, and properly, following manufacturers recommendations for those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, four staff members lawfully authorized to administer medications. E. Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart designated area. Expiring Date: B. Drugs dispensed in the manufacturers original container will be labeled with the manufacturer's expiration date. E. When the original seal of a manufacturers container or vial is initially broken, the container or vial will be dated. 1) the nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best sticker to affix contain both a date opened and expiration' notation line). H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner. Residents Affected - Some Titled Medication Storage revised 07/02/24 document in part: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes, and needles. 3.2 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines: or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 17 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to follow standardized pureed recipe during food preparation. This failure has the potential to affect seven residents (R9, R10, R31, R35, R47, R56) receiving pureed diets prepared in the facility's kitchen based on list of residents receiving pureed diets dated 01/16/25 in a sample of 48. Findings Include: On 01/14/25 at 11:52 PM, during unit dining tours observed residents on regular diet consistencies receive roast turkey, egg noodles, mixed vegetables, fruit cup, and bread with margarine. Observed R9, R31, R35, R47, R56 who were on pureed diets receive pureed turkey, mashed potatoes, pureed vegetable, and pureed dessert. Pureed bread was not served. Pureed buttered noodles were not served. On 01/14/25 at 12:07 PM, observed lunch tray line in the kitchen still in progress with V12 (Cook) serving the food. V12 stated residents on regular diets and mechanical soft diets are receiving egg noodles and the pureed diets are receiving mashed potatoes in place of the egg noodles. On 1/14/25 at 12:08 PM, V11 (Dietary Manager) stated the residents on pureed diets get the same food as the residents on regular diet consistencies except in pureed form. On 01/14/25 at 12:09 PM, V12 stated V12 made mashed potatoes instead of pureeing the egg noodles. V12 stated V12 did not prepare pureed bread so the residents on pureed diets did not get it today. V12 stated, I just didn't do it. I didn't have time. On 01/15/25 at 7:30 AM, observed breakfast tray line in progress with V12 (Cook) serving the food. Observed one large pan of oatmeal. Surveyor observed oatmeal to be thick and lumpy. V12 stated V12 does not puree the oatmeal and that residents on regular and pureed diet receive the same oatmeal because the oatmeal is soft enough to give to the pureed diets. On 01/15/25 at 7:49 AM, V11 (Dietary Manager) stated giving the same oatmeal to the residents on regular and pureed diets is okay because the oatmeal is real soft. V11 stated the oatmeal does not need to be pureed. On 01/16/25 at 9:33 AM, via phone interview V21 (Speech Language Pathologist) stated a resident could require a pureed diet for overt mastication difficulties which means the resident cannot break down the food properly and this could lead to choking and/or aspiration. V21 stated pureed foods should be a smooth consistency with no lumps or bumps. V21 stated oatmeal should be pureed after it is cooked to prevent lumps and bumps; it should have a flow to it and not be too thick or sticky. V21 stated as a preventative measure the oatmeal should be pureed to be safer for a resident on a pureed diet. V21 stated serving oatmeal which is too thick and/or has lumps in it could potentially lead to swallowing difficulties. On 01/16/25 at 11:13 AM, V19 (Consultant Registered Dietitian) stated the kitchen should be following the spreadsheets and serving all the items listed. V19 stated this is important to make sure the meals fall within the parameters of the diet for calories, and protein. V19 stated if items listed on the spreadsheets are not being provided over time there is the potential for weight loss. V19 stated the spreadsheets and recipes should also be followed to make sure the kitchen is providing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 18 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some correct texture and consistency for the diet order as generated by the physician. V19 stated if the food can be pureed safely, and the pureed item is palatable the pureed diets should be receiving the same foods as the residents on a regular diet consistency except in pureed form. V19 stated pureed diet consistencies should be smooth and free from chunks and hot oatmeal needs to be pureed because of the lumps. V19 stated the pureed diets should have received pureed egg noodles instead of mashed potatoes. V19 stated this is important for an eating enjoyment component in terms of offering greater variety of items to residents on pureed diets and from a dignity standpoint as residents on pureed diets have the right to be served the same meal as the regular diet consistencies. Facility provided copy of R9, R10, R31, R35, R47, R56's physician order sheets which document in part pureed diet texture as part of diet order. Facility provided copy of R9, R10, R31, R35, R47, R56's meal tickets which document in part, pureed diet texture and list pureed buttered noodles and pureed buttered white bread to be served on lunch - day 17 and pureed hot cereal to be served on breakfast - day 18. Facility provided copy of Diet Spreadsheet Tuesday day - 17 which documents in part for pureed to be served at lunch pureed buttered noodles, and pureed buttered white bread. Facility provided copy of recipes titled Pureed Buttered Noodles dated 2024, Pureed Buttered Dinner Roll dated 2025 and Pureed Hot Cereal dated 2024. Facility provided document titled, Pureed dated 2022 which documents in part hot oatmeal should be modified in a blender or food processor for pureed diets and pureed regular bread continue to be pureed as a separate menu item. Facility provided document titled, Cycle Menu dated 2018 which documents in part, the menu spreadsheets will be used in tray service. Facility provided document [NAME] dated 01/05 documents in part, duties, and responsibilities to include prepared food according to written menus and use standardized recipes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 19 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 Residents Affected - Some 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, interviews, and record reviews, the facility failed to provide fortified supplement as prescribed by the physician for six (R4, R10, R15, R23, R34, R55) residents reviewed in a total sample of 48. Finding include: On 01/15/25 at 7:30 AM, observed breakfast tray line in progress with V12 (Cook) serving the food. Observed one large pan of oatmeal. V12 stated V12 only prepared one type of hot cereal for the meal which was the oatmeal and that V12 had not prepared super cereal. V12 stated the oatmeal V12 prepared is like super cereal because V12 adds brown sugar, and cinnamon to it. V12 stated the oatmeal is prepared with water. On 01/15/25 at 7:47 AM, V11 (Dietary Manager) stated super cereal is a fortified food and is used for residents who need to gain weight. V11 stated super cereal is recommended by the Registered Dietitian and ordered by the resident's physician. V11 stated super cereal is listed on the resident's meal ticket to be served at breakfast daily. V11 stated super cereal is not the same as regular oatmeal and that there is a specific recipe for super cereal which the cook should be following. V11 stated the cook should have made super cereal today. On 01/16/25 at 11:13 AM, V19 (Consultant Registered Dietitian) stated fortified foods are used to add extra calories and protein to a resident's diet. V19 stated V19 may use super cereal as a nutrition intervention for an additional calorie source if a resident is losing weight. V19 stated if super cereal is ordered by the physician, then it should be made and provided to the resident. V19 stated if the resident had an order for super cereal but was not being provided with the super cereal then the planned and/or desired weight gain may not occur. Facility provided copy of R4, R10, R15, R23, R34, R55's breakfast meal tickets which list Super Cereal to be provided. Facility provided copy of R4, R10, R15, R23, R34, R55's Physician Orders which document in part, super cereal at breakfast. Facility provided recipe titled Super Cereal dated 2025 includes ingredients not limited but including non-fat dried milk, evaporated milk, margarine, brown sugar, granulated sugar. Facility provided recipe titled Choice of Hot or Cold Cereal dated 2024 includes ingredients not limited to water to prepare hot cereal and salt. Facility provided policy titled Fortified Foods dated 2017 which documents in part, fortified foods may be tried for clients who have difficulty meeting their nutritional needs with the regular food provided at mealtimes, fortified foods include items such as super cereal, and information on serving the fortified foods will be on the tray ticket. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 20 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 observations, interviews, and record reviews, the facility failed to a.) ensure food items were properly labeled and dated, b.) discard expired food based on use by guidelines and date, c.) sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 75 residents receiving food prepared in the facility's kitchen. Findings include: On 01/14/25 at 9:45 AM, during initial kitchen tour observed V11 (Cook) washing cooking equipment in the three-compartment sink. Observed V12 dipping the cooking equipment into the third sink containing sanitizing solution for less than 10 seconds and then putting the items on the side to air dry. On 01/14/25 at 9:48 AM, surveyor asked V12 to watch V11 washing various cooking equipment pieces and observed V11 dipping the cooking equipment quickly into the sanitizing solution and pulling them out to air dry. None of the items were submerged in the sanitizing liquid for more than 10 seconds. On 01/14/25 at 9:50 AM, V12 stated the cooking equipment must sit in the sanitizing solution for a full 60 seconds to sanitize the item. V12 stated the problem with the items not being fully sanitized is that all the bacteria on the item is not cleaned off which could potentially cause a food borne illness. On 01/14/25 at 9:45 AM, V12 (Dietary Manager) stated all food items should be labeled and dated with a prepared and use by date. V12 stated It is important to have both dates on each food item so the staff knows when to throw out the food and so they do not serve an expired item. V12 stated prepared/opened items use by date range between three to seven days depending on what the food item is. On 01/14/25 at 9:51 AM, observed the following items in the reach in coolers: 1.) Opened 2.5-pound package of deli ham wrapped in plastic wrap with no open or use by date. V12 stated the deli ham should be dated with an opened and use by date and the ham should be used within seven days of the package being opened. 2.) Opened package of sliced deli turkey wrapped in plastic wrap stored inside a box of labeled as bacon. The opened package of sliced deli turkey was not labeled with an open or use by date. V12 stated all items should be labeled and dated and if there is no date there is no way to know how long that item has been sitting there. 3.) Opened 5-pound package of sliced Swiss Cheese wrapped in plastic wrap with no open or use by date on it. 4.) Unopened 5-pound bag labeled as Grated Parmesan Cheese dated with a use by date of 04/11/25 with visible spots of green circles inside the bag of cheese. V12 stated, that's mold! 5.) Opened box of cucumbers dated with a delivery date of 01/02/24. Six out of 14 cucumbers inside the box had visible signs of deterioration including very soft spots, large circle spots of white/light green fuzzy material, and wrinkled areas. V12 stated, those look like they went bad and need to go into the garbage and those cucumber should not be moldy, soft, and bad like that. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 21 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 6.) Metal container labeled butterscotch pudding labeled with prepared date 01/09/25 and use by date 01/12/25. V12 stated this item was labeled incorrectly and should have been labeled with a use by date of 01/15/25. 7.) Opened half full 46-ounce container of Lemon-Flavored Water Nectar Consistency labeled with an opened date 12/28/24 and use by date 01/08/25. V12 stated once opened this item must be used within seven days. V12 stated V12 would not give this product to a resident because it is passed the seven days and therefore expired and needs to be thrown out. On 01/16/25 at 10:46 AM, V16 (Regional Culinary Specialist) stated the facility uses a quat (quaternary) sanitizer for their three-compartment sink to sanitize cooking equipment. V16 stated the items being washed need to be submerged in the solution for at least one minute to sanitize the item(s). V16 stated all items in the refrigerators should be labeled and dated with a prepared or opened date and a use by date to make sure the products are still in food condition for service and that expired items are not served to residents to prevent food borne illnesses. On 01/14/25, facility provided list of diet orders for all residents in the facility. The diet order list indicates there are three residents receiving nothing by mouth (NPO). Facility provided policy titled OnTray Dietary Policies and Procedures undated documents in part sanitize items in the 3rd sink and submerge items for at least 60 seconds and purpose is to ensure food safety. Facility provided policy titled Food Storage (Dry, Refrigerated, and Frozen) dated 2020 documents in part, all food items will be labeled, and the label must include the name of the food, the date by which it should be consumed, or discarded and discard food that has passed the expiration date. Facility provided policy titled OnTray Use By Guidelines undated which documents in part, pudding should be use by 3 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 22 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to a.) label/date food items in resident personal refrigerator, b.) discard undated and expired foods in resident personal refrigerators, c.) ensure resident refrigerators are in proper working order. This has the potential to effect one resident (R53) out of six residents reviewed for personal food storage in a total sample of 48. Residents Affected - Few Findings include: On 01/14/25 at 12:21 PM, R53 gave surveyor permission to look in R53's personal refrigerator at bedside. The inside of R53's refrigerator was warm, not cold, or cool. All items inside felt warm to the touch. Thermometer located inside R53's refrigerator read 58 degrees Fahrenheit (F). The temperature log on the outside of R53's refrigerator documented in part that on 01/14/25 the refrigerator temperature was 38 degrees F. Inside R53's refrigerator found the following items: 1.) Two unopened 2-ounce packages labeled Smoked Ham and printed on packaging use by September 25, 2024 by manufacturer. 2.) In freezer compartment of refrigerator found fully defrosted box labeled Beef Pot Pie. Cardboard packaging was completely wet, saturated with water. Not dated. 3.) Two unopened 7-ounce containers labeled as Strawberry Crème Parfait. Not dated. 4.) One unopened 8-ounce container labeled as [NAME] Pudding with Cinnamon. Not dated. On 01/14/25 at 12:35 PM, V14 (Certified Nursing Assistant) it is housekeeping's responsible to check the temperatures of the resident's refrigerators every day and the CNAs assist with cleaning out the resident's refrigerators and check the date of the food items before giving an item to the resident to make sure it has not expired. On 01/14/25 at 12:40 PM, V14 observed items inside R53's refrigerator and stated the deli ham had expired and should be thrown out. V14 stated the Beef Pot Pie should be frozen solid and there is no date on it so there is no way to know how long it has been in there. V14 felt the Strawberry Crème Parfait and [NAME] Pudding containers and stated they feel like they are at room temperature, and they should be cold. V14 stated, that refrigerator is hot in there and maintenance is needed and that is a serious concern. V14 stated it is important for the temperature of the refrigerator to be cold to keep the food fresh and safe for the residents to eat. On 01/14/25 at 1:21 PM, V6 (Maintenance Director) stated the housekeeping staff checks the temperatures of the resident's refrigerators daily and let V6 know if the temperatures are higher than 40 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 23 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few degrees F or below 30 degrees F. V6 stated V6 is responsible for making sure the resident's refrigerators are in working order and V6 rounds once a week to check to see if they are in working order. On 01/14/25 at 1:29 PM, V6 observed R53's refrigerator and stated the temperature is 60 degrees and it's pretty warm in there and none of the items inside are cold at all. V6 stated the risk to the resident if the refrigerator temperature is not at the right temperature being 40 degrees or less is the food could spoil and make them sick if they ate any of the food inside it. On 01/14/25 at 9:56 AM, V12 (Dietary Manager) stated the refrigerator temperatures should be 40 degrees F or below. On 01/16/25 at 11:35 AM, V19 (Consultant Registered Dietitian) all food items in resident personal refrigerators should be labeled and dated to prevent food borne illness and expired items should be discarded so they are not consumed by the resident. On 01/16/25 at 9:20 AM, V2 (Interim Director of Nursing) stated it is the CNAs responsibility to label and date food items in a resident's refrigerator, and to discard any expired items. V2 stated it is important that this is done because the food can spoil and if the resident was to eat any of those expired items they would get sick. R53's Refrigerator Log dated January 2025 documents in part, food refrigerator temperature to range 36-40 degrees F. Facility provided policy titled, Refrigerators (Resident) Policy for Maintaining and Cleaning undated, documents in part: 1.) The maintenance/housekeeping staff is responsible for ensuring that a resident's refrigerator is in proper working order. 2.) The CNA responsible for overseeing care for a resident with a refrigerator will check all contents for proper date of food items and check for cleanliness of the refrigerator on a weekly basis. 3.) If the CNA finds that the refrigerator has outdated food, the CNA will dispose of all outdated food and notify the resident. Facility provided policy titled, Food from Family, Visitors, Community dated 2020 documents in part, in order to prevent foodborne illness outbreaks, the facility staff will ensure proper handling, serving, and storage of any food items brought into the community and food stored for residents should be labeled and dated appropriately and discarded per safe food storage guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 24 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 78 residents. Residents Affected - Many Findings include: On 01/15/25 at 8:02 AM, during observation of the outside dumpster with V12 (Cook), one smaller dumpster close to the back door was overfilled with garbage bags with the lid opened. Observed a second larger dumpster in the corner of the parking lot propped open with empty cardboard boxes and the resident's personal refrigerator with some garbage bags inside towards the back of the dumpster. V12 stated that the smaller dumpster close to the back of the door was too full, and that was why the lid was not closed. V12 stated the larger dumpster is mostly empty, with room to put more garbage, but the lid is being kept open because someone did not push the old refrigerator and boxes all the way inside to allow the lid to close. V12 stated the lids should be closed because rats could get up in there. On 01/15/25 at 8:18 AM, V6 (Maintenance Director) observed the dumpsters outside with opened lids and stated the lids should not be open because rodents can get inside because they are attracted to the garbage inside. V6 stated the pest control company the facility uses has rat houses set up outside around the building. On 01/16/25 at 8:03 AM, observed small dumpster close to the back of the door with more garbage bags in it than seen on 01/15/25 and the lid of the dumpster was open. Facility policy titled, Dumpster/Waste Pick-Up Containment dated July 1, 2024 documents in part, the facility will ensure timely pick-up of garbage and proper containment of garbage to prevent pests and the maintenance director/designee must ensure the dumpster is covered at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 25 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 Findings include: Residents Affected - Many On 01/14/25 at 09:25 AM V4 (Registered Nurse) prepared and administered medication standing at the medication cart to R38 in a medication cup and supplied R38 with a cup of water. R38 took her medication then handed the medication and water cup to V4. V4 retrieved the medication and water cup and placed it in the medication cart garbage then began preparing R130's medication without performing hand hygiene. R130 has diagnosis not limited to Orthopedic Aftercare, Effusion Right Knee, Primary Generalized Osteoarthritis, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, History of Falling, Pyogenic Arthritis, Klinefelter Syndrome, Spinal Stenosis, Hyperlipidemia, Hypothyroidism, Polycythemia, Bipolar Disorder, Depression, Retention of Urine, Iron Deficiency Anemia and Muscle Spasm. R130's Physician's Orders document in part: Focus: Enhanced Barrier Precautions: Device IV (Intravenous access site. R130's Care Plan document in part: Focus: Enhanced Barrier Precautions: Resident has a device-Right arm PICC line, wound -right knee surgical site, small opening to great toe, Foley Catheter needing Enhanced Barrier Precautions as prevention. Goals: Staff will prevent the spread of infection. Interventions: Maintain Enhanced Barrier Precautions for High-Risk Contact. Maintain infection control practices through proper handwashing. 01/14/25 at 09:32 AM V4 (Registered Nurse) entered R130 room with Signage posted on the entry door indicating Enhance Barrier Precautions and administered R130 medications. At 09:38 AM V4 returned to the medication cart without performing hand hygiene. R25 has diagnosis not limited to Paraplegia, Essential (Primary) Hypertension, Atrial Fibrillation, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Hyperlipidemia, Peripheral Vascular Disease, Polyneuropathy, Type 2 Diabetes Mellitus, Major Depressive Disorder, Pain in Right Knee, Pain in Left Knee, Foot Drop, Right Foot, Obstructive and Reflux Uropathy, Chronic Kidney Disease, Urethral Stricture, Retention of Urine, Hyperkalemia, Schizoaffective Disorder and Shortness of Breath. R25's Physician Order document in part: Enhance Barrier Precautions: Klebsiella Pneumoniae. R25's Care Plan document in part: Focus: Enhanced Barrier Precautions. Goals: Staff will prevent the spread of infection. Interventions: Maintain Enhanced Barrier Precautions. Maintain infection control practices through proper handwashing. On 01/14/25 09:40 V4 (Registered Nurse) put on a pair of gloves then entered R25's room with Signage posted on the entry door indicating Enhance Barrier Precautions and administered R25's medications. V4 Administered the Basaglar insulin 15 units to R25's left lower abdomen. On 01/14/25 at 10:04 AM V4 (Registered Nurse) returned to the medication cart removed the gloves then put on another pair of gloves without performing hand hygiene. V4 reentered R25 room and proceeded to R25's roommate R7 bed, obtain the gastric tube syringe and water container, went to the bathroom to get water, returned to the bedside then flushed R7 gastric tube with 60 ml (milliliters) of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 26 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 water without putting on a gown. Level of Harm - Minimal harm or potential for actual harm On 01/14/25 at 10:07 AM V4 (Registered Nurse) returned to the medication cart and removed the gloves. V4 was made aware that she (V4) was not observed performing hand hygiene between residents. V4 stated There is a potential for the spread of infection. When flushing R7's gastric tube I should have worn a gown. Residents Affected - Many On 01/16/25 at 09:48 AM V18 (Director of Nursing) stated when passing medication at the start the nurse should wash their hands with soap and water. When going between residents use hand sanitizer so you won't spread infection from one resident to the other. Complete hand washing should have been done, the nurse should have put on a gown and gloves before going to do the gastric tube flush to prevent the spread of infections. Document Titled Enhanced Barrier Precautions document in part: Every Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Policy: Titled Enhanced Barrier Precautions dated 03/01/23 document in part: Enhance Barrier Precautions are indicated (when contact precautions does not otherwise apply). 3. Gloves and gowns must be worn for the following High-Contact Care Activities. Device care or use: central line, urinary catheter, feeding tube and tracheostomy. 4. Enhanced Barrier Precautions are indicated for all residents with any of the following: Wounds and/or indwelling medical devices (e.g., Central line, urinary catheter, feeding tube). 5. During High-Contact of these resident's care. Enhanced Barrier Precautions will be implemented. Titled Hand Hygiene Policy and Procedure undated document in part: Purpose: Effective hand hygiene reduces the incidence of healthcare-associated infections. All members of the healthcare team will comply with current Centers of Disease Control and Prevention (CDC) hand hygiene guidelines. Indications for handwashing and Hand rubbing: A. Indications for Handwashing: 3. Handwashing may also be used for routinely decontaminating hands in the following clinical situations: Before having direct contact with patients. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. After removing gloves. B. Indications for Hand rubbing: If hands are not visibly soiled, an alcohol-based hand rub may be used routinely decontaminating hands in the following clinical situations: Before having direct contact with patients. After contact with a patient's intact skin. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. After removing gloves. Based on observation, interview, and record review, the facility failed to ensure (a) hand hygiene was performed between each resident contact during medication administration; (b) proper PPE (Personal Protective Equipment) was worn during a High-Contact Resident Care Activity (gastric tube flush) for a resident on Enhanced Barrier Precautions; (c) proper handling and storing of linens; (d) ensure IPCP (Infection Prevention and Control Program) standard policies and procedures are reviewed at least annually. These failures could affect all 78 residents residing in the facility as of census dated 1/14/25. The findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 27 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 On 01/14/25, at 2:40 p.m., the Surveyor observed 7 uncovered bins with clean linens, washcloths, towels, gowns, bed sheets, fitted sheets, and pillowcases by the basement hallway exposed to the air. On 01/14/25, at 2:52 pm, V6 (Maintenance Director) stated that he has been working in the facility for 9 years and is also responsible for laundry services. V6 said the linens in the bins by the basement hallway were all clean and should be covered when not in use to avoid exposure to contaminants. He said clean linens are used for all residents in the facility, and if clean linens are not stored properly, there could be potential contamination. On 1/15/25, at 8:40 a.m., the Surveyor and survey team observed bins with clean linens uncovered by the basement hallway, exposed to contaminants. On 1/15/25 at 2:09 pm, the Surveyor interviewed V23 (Infection Preventionist / IP Nurse). She said she has been working in the facility for 18 years. She said clean linens should be stored or contained properly to prevent exposure to contaminants or potential contamination. On 1/16/25, at 9:45 a.m., the Surveyor toured the laundry room with V6 and observed loose, soiled linens (towels and sheets) not properly bagged inside the chute container. The surveyor also observed a soiled towel not bagged inside the laundry room bin. V6 said staff should properly bag soiled linens/towels for infection control and to prevent contamination. On 1/16/25 at 11:05 a.m., V3 (IP Nurse) said that the policy and procedures provided to the Surveyor, including IPCP standards, are all current / updated. On 1/16/25, at 12:56 pm, the Surveyor interviewed V18 (DON / Director of Nursing). She said clean linens need to be covered to prevent potential contamination or exposure to contaminants. She said clean linens are used by all residents in the facility. V18 said soiled linens and residents' personal clothing should be bagged properly before being sent to the laundry chute for infection control to prevent contamination. The facility's census report dated 1/14/25 showed 78 active residents. The facility's laundry/linen policy and procedure dated 12/23 documented in part: All linen is handled, stored, transported, and processed in a manner that will prevent contamination and maintain a clean environment for patients, healthcare workers, and visitors. The nursing department assumes the direct and immediate responsibility for safely securing all clean and soiled linens. Linens soiled with body fluids shall be placed in a plastic bag before being sent to the laundry for processing. All soiled linens must be bagged in/near the room in which the procedure is being performed. Bags must be securely sealed before being removed from the room. Clean linen must be stored in the linen rooms on each unit. If the facility utilizes a linen chute, no loose items can be thrown down the linen chute and must be bagged per this policy. Facility's infection prevention and control program policy dated 11/2/23: The infection control program meets the guidelines of the US department of health and human services' centers for disease control and prevention, The occupational health and safety administration, local, state and federal rules. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 28 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 (1) provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations; (2) assess eligibility and offer pneumococcal vaccinations to five (R10, R11, R18, R25, R35) of eight residents reviewed for pneumococcal vaccinations in a sample of 48 residents. Residents Affected - Some The findings include: 1. R10's face sheet admission date on 12/31/08, age [AGE], with diagnoses not limited to -Alzheimer's disease and essential (primary) hypertension. R10's physician order dated 1/15/25 showed an order not limited to the pneumococcal vaccine unless contraindicated. MDS (Minimum Data Set) dated 1/2/25 showed R10's cognition was severely impaired. MDS showed that the Pneumococcal vaccine was not given and was not offered. R10's has no pneumococcal immunization record. No education or assessment eligibility for pneumococcal vaccination was found in R10's record. 2. R11's face sheet documented admission date on 1/3/23, age [AGE] with diagnoses not limited to Alzheimer's disease; Type 2 diabetes mellitus; -Chronic kidney disease, stage 3. R11's physician order dated 1/15/25 showed an order not limited to the pneumococcal vaccine unless contraindicated. MDS dated [DATE] showed R11's cognition was severely impaired, and the Pneumococcal vaccine was not given and was not offered. R11 has no pneumococcal immunization record. No education or assessment eligibility for pneumococcal vaccination was found in R11's record. 3. R18's face sheet documented admission date on 6/4/24, age [AGE] with diagnoses not limited to Dementia; Essential (primary) hypertension; Encephalopathy, unspecified. MDS dated [DATE] showed R18's cognition was severely impaired, and the Pneumococcal vaccine was not given and was not offered. R18's immunization record showed Pneumovax23 was given on 11/2/16. 4. R25's face sheet showed admission date on 11/9/21, age [AGE] with diagnoses not limited to Paraplegia; I10-Essential (primary) hypertension; Unspecified atrial fibrillation; Peripheral vascular disease, unspecified; Type 2 diabetes mellitus; chronic kidney disease, stage 3. MDS, dated [DATE], showed R25's cognition was intact. R25 has no pneumococcal immunization record. No education or assessment eligibility for pneumococcal vaccination was found in R25's record. 5. R35's face sheet documented admission date on 6/5/24, age [AGE], with diagnoses not limited to Malignant neoplasm of the prostate; Essential (primary) hypertension; -chronic kidney disease, stage 3. R35's physician order dated 1/15/25 showed an order not limited to the pneumococcal vaccine unless contraindicated. MDS dated [DATE] showed R35's cognition was severely impaired. R35's has no pneumococcal immunization record. No education or assessment eligibility for pneumococcal vaccination was found in R35's record. On 1/15/25 at 2:09 PM, the Surveyor interviewed V3 (Infection Preventionist / IP nurse), who stated she has been working in the facility for 18 years. She said they are following CDC (Centers for Disease Control) guidelines regarding Pneumococcal immunization. V3 said all eligible residents should receive Prevnar 20. She said assessments are done for pneumococcal vaccination to determine if they are eligible, provide education, and document in resident's health records. She said that those residents who are eligible to receive the Pneumococcal vaccine should be offered at least annually, document education, or refusal. The surveyor reviewed pneumococcal immunizations for the following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 29 of 30 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 145415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents with V3 (IP nurse) and said R25's pneumonia vaccine (pcv23) was given on 10/19/14. V3 said they are waiting for PCV20 vaccine. No education or assessment found in R25's record. V3 said R10, has no Pneumococcal immunization record. No education provided or assessment found in R10's record. V3 said R18 pneumo vaccine (PPSV23) was given on 11/02/16. No education or assessment found in R18's record. V3 said R35 has no record of the pneumonia vaccine. No assessment or education found in R35's record. V3 said R11 PPSV23 was given on 10/1/15. PCV13 was given on 10/31/19. No assessment or education found in R35's record. V3 said Pneumonia vaccine is given to residents for preventative measures to prevent possible severe complications. The pneumonia vaccine is not guaranteed to have 100% protection from pneumonia, but it could possibly or potentially prevent severe symptoms or complications from the disease. On 1/16/25 at 12:56 PM, the Surveyor interviewed V18 (DON / Director of Nursing) and said Pneumonia immunization is offered and encouraged to all residents. Assessment should be done to determine the eligibility for the vaccine; education should be provided and documented in the resident's record. V18 said the Pneumo vaccine is given to boost resident's immune systems related to pneumonia and is not 100% guaranteed protection but could prevent severe complications. She said facility is Following CDC guidelines regarding pneumococcal immunization. The facility's resident pneumococcal vaccination info showed: R25 PPSV23 was given on 8/19/15 with no education. R10 no pneumococcal vaccine record and no education. R18 PCV13 was given on 10/1/19, but no education was provided. R35 no pneumococcal vaccine record and no education. R11 PCV13 was given on 10/31/19, no education provided The facility's influenza and pneumococcal policy dated 4/21/22 was documented in part to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and pneumococcal pneumonia. The facility shall provide residents or legal representatives with pertinent information about the significant risks and benefits of vaccines. Each resident is offered a pneumococcal immunization per CDC recommendations. The resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of immunization and either received or did not receive the pneumococcal immunization due to medical contraindications or refusal. CDC's Pneumococcal Vaccination 2024 showed in part: age [AGE] Years or Older who have not previously received a dose of PCV13, PCV15 or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20. Previously received PCV 13: 1 dose PCV20 or 1 dose PPSV23. Previously received only PPSV23: 1 dose PCV15 or 1 dose PCV20. Administer PCV15 or PCV20 at least 1 year after the last PPSV23 dose. age [AGE]-64 years with certain underlying medical conditions or other risk factors who have not previously received a PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 30 of 30