Health inspection·June 26, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility CNA (Certified Nursing Assistant) job description documents, in part, DUTIES/RESPONSIBILITIES/FUNCTION: 30. Follow HIPPA (Health Insurance Portability and Accountability Act) confidentiality requirements. Assure each resident's privacy in all facets. Facility Residents Rights for people in long-term care Facilities, documents in part, Your rights to dignity and respect, your rights to privacy and confidentiality: you have a right to privacy and confidentiality . Your medical and personal care are private. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Event ID: Facility ID: 145482 If continuation sheet Page 2 of 11 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 145482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to rescreen a resident to determine if specialized services under the Preadmission Screening and Resident Review requirements are necessary. This failure affected 1 (R153) resident reviewed for PASRR screening in the total sample of 59 residents. Residents Affected - Few Findings include: R153's ([DATE]) Notice of PASRR (pre-admission screening and resident review) Level I Screen Outcome documented, in part PASRR Level Review Date: [DATE]. PASRR Level I Determination: Convalescence Categorical. Approval period: 60 days. Suspected or confirmed PASRR condition(s): Mental Health Disability. PASRR outcome explanation. Notice of criteria met for convalescence categorical-no PASRR Level 2 required. Your Level one screen shows you have evidence of serious mental illness. Further PASRR evaluation is not required because you meet criteria for a short term convalescence admission. This means you may stay for a limited number of days in a Medicaid certified nursing facility without further PASRR evaluation. If you or your care provider thinks you need to stay longer than the number of approved days listed on the notice of PASRR Level one screen outcome that came with this letter, a nursing facility staff member must submit a new Level one screen to M****** . This must be completed by or before the last approved date after your admission to the nursing facility. This Level I screen is good within 90 calendar days of the notice date listed on the notice of PASRR Level one screen outcome. After that time, any nursing facility you admit to must submit an updated Level 1 screening form to M****** . Outcome. Rationale: 60 day convalescent care approval- a 60 day or less stay in the NF (nursing facility) is authorized. Re-screening must occur by or before the 60 day if the individual is expected to remain in the nursing facility beyond the authorization time frame. On [DATE] at 10:47am, V26 (Psychiatric Rehabilitation Services Director) stated the purpose of pre-admission screening is to determine the need of the resident. In reference to the PASRR recommendation, V26 stated the expectation is to follow the recommendation stipulated in the PASRR. On [DATE] at 10:49am, this surveyor showed V26's R153 Notice of PASRR Level I Screen Outcome. V26 stated it means the person needs to be re assessed within 60 days from the date written in the M****** (PASRR). He (R153) is expected to be rescreened on 03/2023. I (V26) will check with admission Director (V20) if there's another PASRR for him (R153). On [DATE] at 11:34am, V26 stated we don't have PASRR for him (R153) after the 01/2023 screening. The only thing we (facility staff) have is the expired 1/2023 screening. On [DATE] at 2:20pm, V26 stated his (R153) rescreening is submitted today. It was not done within the 60 days per 01/2023 PASRR recommendation. R153's ([DATE]-[DATE]) Physician Order Report documented, in part Diagnoses: Bipolar disorder. R153's ([DATE]) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R153's mental status as cognitively intact. Section I. Active Diagnoses. Psychiatric/Mood Disorder. I5900. Bipolar Disorder. Section N - Medications. N0415. High risk drug classes: use and indication. A. Antipsychotic. N0450. Antipsychotic Medication Review. A. Did the resident received antipsychotic medications since admission/entry or reentry or the prior OBRA assessment? 1- yes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 3 of 11 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 145482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete R153's ([DATE]) State PASRR (pre-admission screening and resident review) documented, in part Reason for Screening. What is the purpose of this Level I screen. A previous PASRR short -term approval for nursing facility stay has expired (e.g. Convalescence.) Assessment Submitted by V26. The (Undated) Social Service Designee Job Description documented, in part Purpose Of Your Job Position. The primary purpose of your job position is to assist in planning, developing, organizing, implementing, evaluating, and directing our facilities social service programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. Administrative function. Participate in resident assessment. Event ID: Facility ID: 145482 If continuation sheet Page 4 of 11 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 145482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure food in the walk-in cooler/freezer was labeled with a date indicating when the item was placed into the walk-in cooler/freezer. This failure has the potential to affect all 174 residents in the facility who are receiving an oral diet. The findings include: On 6/23/2024 at 9:50am while inside the walk-in cooler, observed one 48-ounce package of chopped spinach not in a case and not labeled with the date it was placed in the walk-in cooler and one opened box (10 cans in the box) of non-diary whipped topping not labeled with a date it was placed in the walk-in cooler. On 6/25/2024 at 2:15pm V5 (Dietary Supervisor) stated the purpose of labeling/dating the food containers in the walk-in cooler and freezer is so that staff can monitor when to use the foods that are put into the walk-in cooler and freezer. V5 stated the staff has 30 days to keep the food items in the walk-in cooler and freezer once the food items have been dated with an in- date. V5 stated the cooks and dietary aids are responsible for labeling food items when the food items are placed in the walk-in cooler and freezer. V5 stated it is my expectation that the kitchen staff label food items when the food items are initially placed into the walk-in cooler and freezer. V8 stated if a food item is not labeled with a date it was placed into the walk-in cooler or freezer, the food item is at risk for expiring. V5 stated if a resident consumes expired food, the resident can get sick. V5 stated there are no residents in the facility who are NPO (nothing by mouth). Reviewed the Facility's Policy Labeling and Dating Foods (Date Marking) from the Health Technologies, Inc. Guideline & Procedure Manual, 2016 Edition which documents in part, Guideline: All foods stored will be properly labeled according to the following guidelines. Procedure 3. Date marking for freezer storage food items. Unopened cases of frozen food items will be dated with the date the item was received into the facility and will be stored using the first in-first out method of rotation. Frozen food packages removed from the case will be dated with the date the item was received into the facility and will be stored using the first in-first out method of rotation. Reviewed the facility's undated Dietary Aid Job Description which documents in part, Ensure that safe food handling procedures are being consistently maintained. Follow all dietary policies and procedures. This includes, but is not limited to, Proper sanitation procedures, proper food, and chemical storage procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 5 of 11 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 145482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to clean and correctly log refrigerator temperatures for one resident's (R135) personal refrigerator. Residents Affected - Few Findings include: On 06/23/2024 at 11:15am observed a black colored refrigerator in R135's room. Observed a temperature log affixed on the front of the refrigerator door. The temperature log was missing the documentation of a temperature reading for the following dates: 6/14/2024, 6/20/2024 and 6/21/2024. Observed a black substance on the thermometer located on the top shelf inside the refrigerator. The refrigerator contained two Styrofoam cups with drinks inside and a bottle of water. On 06/23/2024 at 12:15pm R135 stated the staff clean the refrigerator in my room once a month and the staff check the temperature in the refrigerator once a month. On 06/25/2024 at 10:29am R135 stated staff have not told me I need to clean my personal refrigerator. R135 stated I don't know what that black stuff is on the thermometer in the refrigerator. On 06/25/2024 at 10:43am V18(Housekeeper) stated I am responsible for cleaning the resident's personal refrigerator. V18 stated the housekeepers are responsible for taking the temperature in the resident's personal refrigerator and logging the temperature for the day. V18 stated I don't know what that black substance is on the thermometer in the resident's personal refrigerator. On 06/25/2024 at 12:06pm V19(Maintenance Director) stated the housekeeping staff are to check and log the temperature in the resident's personal refrigerator daily. V19 stated it is my expectation that the housekeeping staff check the temperature in the resident's personal refrigerator daily. V19 stated the housekeeping staff is to clean the resident's personal refrigerator daily. On 06/25/2024 reviewed the undated Housekeeping Aid job description which documents, in part, the primary purpose of this position is to: Provide housekeeping services to assure that a clean, orderly, and homelike environment is maintained in accordance with current federal, state, and local regulations. Clean all equipment and furniture as assigned. All other duties as assigned. On 6/25/2024 reviewed the facility's policy titled Use and Storage of Outside Foods in Resident's Room dated 10/01/2022 which documents in part, Refrigerator in Resident's room [ROOM NUMBER]. Check and monitor internal temperatures. R135's diagnosis includes but are not limited to, Multiple sclerosis, schizoaffective disorder, unspecified, Hemiplegia, unspecified affecting left nondominant side, Hereditary and idiopathic neuropathy, unspecified, Hyperlipidemia, unspecified, and Hereditary and idiopathic neuropathy, unspecified. R135's Brief Interview for Mental Status (BIMS) dated 04/23/2024 documents R135 has a BIMS score of 11 which indicates that R135's cognition is moderately impaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 6 of 11 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 145482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660 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 On 06/23/24 at 10:42 AM, there was an 'Enhanced Barrier Precaution' sign posted by R83's door. There was no PPE bin outside of the room. This observation was pointed out to V13 (Restorative Nurse/LPN) and V13 stated there is no PPE bin outside of his (R83) room. I (V13) think he (R83) is on extra barrier precaution due to his (R83) wound. This surveyor and V13 went inside R83's room to check for PPE bin. V13 stated there is no PPE bin inside his (R83) room. Residents Affected - Some On 06/23/24 at 10:52 AM, V4 (Director of Nursing) stated EBP (Enhanced Barrier Precautions) are for residents with g-tube, foley catheter, colostomy, and wounds. The purpose of placing residents on enhanced barrier precaution is for infection control; to prevent splashes of infection. The sign should be up and there should be a PPE bin outside the resident's room. On 06/23/2024 at 10: 53am, V4 went inside R83's room and stated I (V4) don't see a PPE bin inside the room and there is none outside the room too. R83's (04/18/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R83's mental status as cognitively intact. R83's Census documented that R83 was moved to a new room on 04/08/2024. R83's (05/24/2024-06/24/2024) Physician Order Report documented, in part Diagnoses: peripheral vascular disease. General: Start date: 05/30/2024 - Open Ended. Enhance Barrier Caution r/t (related to) wound. Treatment Flow sheet. General: Start date: 05/15/2024. End Date: 06/23/2024 (DC- discontinued Date) Description: Site: BKA (below knee amputation) cleanse wound with normal saline o wound cleanser. Pat periwound dry. Collagen and xeroform every 3 days and PRN (as needed) if loose/solid (soiled). General. Start Date: 06/23/2024. End Date: Open Ended. Description. Site: _ BKA cleanse wound with normal saline or wound cleanser. Pat peri wound dry. Foam (dressing) three times a week and PRN if loose /solid (soiled). The (06/19/2024) Resident Extra Barrier Precaution list included R83 (for wound). The (undated) Enhance Barrier Precautions policy documented, in part Policy. Enhanced Barrier Precautions is designed to reduce transmission of multi drug resistant Organism (MDRO) and extensive drug resistant Organism (XDRO) in nursing homes. It is the policy of this facility that Enhance Barrier Precautions, in addition to standard and contact precautions will be implemented during high contact resident care activities when caring for residents that have an increased risk for acquiring a multi drug resistant Organism such as a resident with wounds. Overview. The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of MDROs (multidrug resistant Organism) to employee's hands and clothing during cares beyond situations in which staff anticipate exposure to blood or body fluids. Pathogen-based approach will be used in the facility which will involve the use of gown and gloves during high contact activities for resident. A risk based approach will be used when residents have increased risk for acquiring MDRO or XDRO such as residents with wounds. Procedure 9. Personal protective equipment is required for all staff providing high contact resident care activities to include: viii. Wound care: any skin opening or requiring a dressing. R165's admission diagnoses include but not limited to malignant neoplasm of colon, colorectal cancer, malignant neoplasm of rectosigmoid, and diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 7 of 11 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 145482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm On 6/23/24 at 10:38 am, R165 had an Enhance Barrier Precaution (EBP) sign on R165's door with a PPE (Protective Precaution Equipment) bin outside of R165's door with no gowns in the bin. R165's Physician Order Report documents in part, Enhance Barrier precaution r/t (related to) indwelling catheter. Residents Affected - Some R165's care plan documents in part, Problem: R165 is on enhance barrier precautions r/t indwelling catheter, colostomy . Approach: .Keep bin place outside of R165's door stocked with PPE. R24's admission diagnoses include but not limited to diabetes, mellitus, hypertension, benign prostatic hyperplasia, gastro-esophageal reflux disease, and urogenital implants. On 6/23/24 at 10:45 am, R24 had an Enhance Barrier Precaution sign on R24's door, with no PPE bin outside of R24's door. R24's Physician Order Report documents in part, Enhance Barrier precaution r/t (related to) indwelling catheter/ G-tube (Gastrostomy-tube). R24's care plan documents in part, Problem: R24 is on enhance barrier precautions r/t peg tube, stoma site. Approach: Wear gown and gloves for care of g-tube and feedings. On 6/25/24 at 10:00am, V4 DON (Director of Nursing) stated that the supply person should restock the PPE bins. The nurse and CNA (Certified Nursing Assistant should notify the supply person when supplies are needed. PPE supplies consist of gloves, mask, and gowns. They should be available for care at all times. On 6/25/24 AT 12:05 PM. V8 ADON (Assistant Director of Nursing) stated that every resident on EBP should have a bin that contains the gloves mask, gown. The nurse or CNA should notify the stock person when stock is needed. Every resident in an Enhance Barrier Precautions room should have supplies available when needed for care. The bin should be outside the resident's rooms. The facility EBP sign documents in part, Provider and Staff must wear gloves and gown for the following high contact Resident Care Activities .Device care or use: .urinary catheter, feeding tube . The facility CNA (Certified Nursing Assistant) job description documents, in part, DUTIES/RESPONSIBILITIES/FUNCTION: 14. Make sure that necessary supplies are available . The facility LPN (License Practical Nurse) job description documents, in part, DUTIES/RESPONSIBILITIES/FUNCTION: 11. Ensure that an adequate supply of floor stock .supplies and equipment is on hand to meet the nursing needs of the residents . Based on observation, interviews and records reviewed, the facility failed to ensure residents on enhanced barrier precautions (EBP) had EBP signs posted at their rooms, that staff were using Personal Protective Equipment (PPE) when providing care for residents and that the residents' PPE bins were available and stocked. These failures affected 4 (R24, R43, R83, R165) residents and has the potential to affect all 174 residents in the facility. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 8 of 11 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 145482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 06/23/2024 at 11:14 am, observed V12, Certified Nursing Assistant (CNA) with no gloves or gown on, adjusting R43's diaper, under pad and sheets. R43 observed with indwelling foley catheter. There was no Enhanced Barrier Precaution sign on the door of R43's room. The was no Personal Protective Equipment (PPE) bin outside R43's room. On 06/23/2024 at 11:20 am, V12 (CNA) stated Enhanced barrier isolation is pretty much when you gown and glove up. We use isolation when there is a sign on the door, or the nurses will let us know who to use isolation on. The resident R43, that I was just caring for is not on isolation. Normally we have in-services on infection control, or we would ask the nurse or treatment nurse. On 06/23/2024 at 11:27 am, V11 (Licensed Practical Nurse/LPN) stated, I am supposed to use EBP when hands on care to the resident is being done. We use EBP for everybody that has a sign on the door, for residents with wounds and foleys to protect them (residents) from us (staff). R43's room does not have a sign on the door. R43 should have an EBP sign on R43's door because he has a foley. On 06/23/2024 at 12:13 pm, V11 placed EBP sign to R43's door. R43's diagnosis includes but are not limited to Benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, presence of urogenital implants: indwelling urinary catheter. R43 has a pressure ulcer to left ear, last documented assessment 06/20/2024. Current wound care orders to left posterior ear, cleanse with normal saline pat dry and apply dry dressing 3 times a week and prn. R43's Care plan dated 05/01/2024, in part R43 is on enhance barrier precautions r/t indwelling catheter, wound. Place sign on door. Wear gown and glove for: dressing, grooming, bathing, showering, transfers, changing of linens and briefs, hygiene care, toileting. Wear gown and gloves for care of indwelling catheter. R43's active physician order dated 06/01/2024 include but not limited: Enhanced Barrier Precaution R/T wound and Foley. The facility's Infection Control Policy dated June 2020 in part 5. The facility provides personnel protective equipment (PPE) which refer to barriers used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. PPE used is based upon the nature of the interaction with the resident and/or the likely mode of transmission. During times when PPE is not sufficient in supply the facility will utilize CDC guidance for Optimizing PPE. Types of PPE include a. Glove, b. Gowns, c. Masks, d. Eye Protection Goggles and/or Face Shields. 9. Systems for monitoring resident care areas, such as urinary catheters, incontinence, wound care, skin care, infusion therapy, dialysis, mechanical ventilation and associated risks. The facility's Enhanced Barrier Precautions Policy dated 04/28/24, in part: 8. Post clear signage on the door/wall outside resident room. 9. Personal Protective equipment is required for all staff providing high-contact resident care activities to include: iv. Providing hygiene, v. changing linen, vi. Changing briefs or assisting with toileting. 19. Enhanced Barrier Precautions are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 9 of 11 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 145482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure a resident's adaptive equipment was functional. This failure affected 1 (R68) resident reviewed for adaptive equipment in the total sample of 59 residents. Residents Affected - Few Findings include: On 06/23/24 at 12:16pm, R68 was sitting on a wheelchair. R68 stated I (R68) have an issue with my (R68) wheelchair. The brakes are both broken. I (R68) got the wheelchair a couple of months ago. This surveyor requested R68 to engage the brakes; the brake on the right was not touching the rear wheel and the brake on the left was loose. The wheelchair moved while the brakes were engaged when R68 propelled the wheelchair. On 06/23/24 at 12:23 PM, this surveyor requested V8 (Assistant Director of Nursing) to check R68's wheelchair and R68 stated the wheelchair brakes are not tight; the one on the right is loose and the one on the left need's adjustment. We (facility) are going to provide a new wheelchair immediately. The purpose of the wheelchair brakes is to steady the wheelchair; for safety, to prevent falls. It is a concern. The restorative is responsible for checking the wheelchair every day; to make sure the wheelchairs are functional and safe to use. On 06/23/2024 at 12:43pm, V10 (CNA/Restorative Aide) stated I (V10) don't know how long she (R68) has been using the wheelchair. On 06/26/2024 at 9:55am, V4 (DON) stated the reason for maintaining the wheelchair, is for the safety of the resident because we (facility staff) don't want the resident to fall or cause any harm to the resident. If broken and not functioning, it may cause harm to the resident; they may fall. Or the resident might not use it and be limited and prevent them from moving around. R68's (05/24/2024-06/24/2024) Physician Order Report documented, in part Diagnoses: cervical disc degeneration and quadriplegia. R68's (05/01/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R68's mental status as cognitively intact. Section GG. GG0120. Mobility Devices: C. Wheelchair. GG0170. Does the resident use a wheelchair? 1- yes. R68's (11/03/2023) care plan documented, in part Problem: at risk for deterioration in bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit. Goal: will not deteriorate in ADL (activities of daily living). The (undated) Restorative Care Nurse Job Description document that, in part The primary purpose of your job position is to perform restorative nursing procedures that maximizes the resident's existing abilities emphasize independence instead of dependence and minimize the negative effects of this ability with an attitude of realistic optimism under the supervision of restorative nurse. Equipment and supply function. Provide necessary equipment for resident to perform required therapy or treatment. The (02/2014) EVALUATION CRITERIA FOR MEDICAL EQUIPMENT PROGRAM documented, in, part Policy Specifications: 1. All medical equipment used in the care of residence will be evaluated prior to use based (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 10 of 11 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 145482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660 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 0908 on functions and physical risk associated with maintenance requirement. 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: 145482 If continuation sheet Page 11 of 11