Inspection·May 30, 2025

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 initiate a new Level I screen for residents with a known mental illness for four (R76, R110, R116, R152) residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 35 residents reviewed. Residents Affected - Some Findings include: R76's Facesheet documents that R76 was admitted to the facility on [DATE], with diagnoses not limited to: Schizoaffective disorder and bipolar disorder. R76's Interagency Certification of Screening Results dated [DATE], does not indicate if there is a reasonable basis for suspecting DD (Developmental Delay) or MI (mental illness). R76's Minimum Data Set (MDS) Section I dated [DATE], indicates active diagnoses of anxiety disorder and bipolar disorder. There is no documentation to show that R76 has a Level II PASARR screening. R110's Facesheet documents that R110 was admitted to the facility on [DATE], with diagnoses not limited to: Schizophrenia, major depressive disorder, manic episodes, and suicidal ideations. R110's Interagency Certification of Screening Results OBRA-I Initial Screen dated [DATE], indicates that R110 has no reasonable basis for suspecting DD (Developmental Delay) or MI (mental illness). There is no documentation to show that R110 has a Level II PASARR screening. R116's Facesheet documents that R116 was admitted to the facility on [DATE], with diagnoses not limited to: Schizoaffective disorder, delusional disorders, major depressive disorder. R116's Level II PASARR/Preadmission Screening and Resident Review screening dated [DATE], documents that R116 is excluded from a Level II PASARR because R116 has No diagnosis- no LOC. R152's Facesheet documents that R152 was admitted to the facility on [DATE], with a diagnosis of schizophrenia. R152's Level I PASARR/Preadmission Screening and Resident Review screening dated [DATE], documents that R152 does not require a Level II PASARR because R152 does not have a SMI/severe mental illness, ID/intellectual disability, or RC/related concern. On [DATE], at 9:37 AM, V21 (Social Services Director) states V22 (Admissions Director) is responsible for inputting residents' PASARR/Preadmission Screening and Resident Review information into the screening agency website. V21 states V22 is also responsible for ensuring that a resident's PASARR screening is accurate. V21 states he is responsible for inputting resident's information and referring residents for a new PASARR screening once it expires. V21 states to his understanding, residents who have been admitted to the facility prior to 2022, do not need a new PASARR screening in the new screening system. V21 states any resident admitted to the facility after 2022, should have a PASARR screening in the new screening system. V21 states the PASARR screenings should be completed at the hospital before a resident is admitted to the facility. V21 states he checks the screening agency system daily for expired PASARR screenings and there should not be any PASARR screenings that are outdated. V21 states if a resident experiences any psychiatric mental health issues while residing in the facility, then the nursing home is responsible for ensuring that the resident is still suitable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 2 of 17 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 05/30/2025 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 live in the nursing home setting. Level of Harm - Minimal harm or potential for actual harm On [DATE], at 11:14 AM, V22 (Admissions Director) states he has been working at the facility for 2 months and he is responsible for making sure PASARR screening are valid upon resident admission. V22 states a resident's PASARR screening is considered valid if all pertinent information is entered correctly. V22 states V21 (Social Services Director) is responsible for making sure the PASARR screenings are updated. V22 states a PASARR is a screening that needs to be done by the transferring facility prior to a resident being admitted to the facility. V22 states the transferring facility is usually the hospital or another nursing home. V22 states residents who have been admitted to the facility prior to [DATE] has been grand-fathered in and do not require a PASARR screening through the new screening system. Residents Affected - Some Facility policy dated 12/2023 titled Preadmission Screening and Residential Review (PASRR) documents in part, Policy: 1. Comply with Federal, State, and the appointed screening agency in standards addressing the PASARR assessment/screening process. 2. Request full and complete PASRR materials (Level 1 and 2) from each referral source prior to or soon following admission. 3. Review the PASRR documents to help assess/ascertain what type of problems, needs and issues need to be addressed to help the resident function at his/her maximum level of well-being. Procedure: 3. The hospital/screening agency/referral source may be contacted, as indicated and asked to provide any missing or incomplete documents. The screenings are now expected to be located in the screening agency's system and accessible by the facility. 4. As indicated, the screening material should be reviewed as a component of the assessment process and treatment, suggestions/recommendations should be identified and appropriately addressed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 3 of 17 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 05/30/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that medications were refilled and readily available for 2 residents (R60, R96) out of 8 residents reviewed for controlled substance medications in a sample of 35. The facility also failed to b.) keep an accurate count of all narcotic medications for two (R55, R118) residents, c.) ensure controlled substances were counted, and documented, at the beginning and end of each shift for 12 out of 237 shifts. These failures have the potential to affect 61 residents residing in the facility. Findings Include: R60's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Lymphedema, hypertensive heart disease without heart failure, chronic obstructive pulmonary disease, unspecified, Muscle wasting and atrophy, not elsewhere classified, unspecified site, abnormalities of gait and mobility. Minimum Data Set Section (MDS) section C (dated 03/24/2025) documents that R60 has an Interview for Mental Status (BIMS) score of 15, indicating that R60's cognition is intact. Care plan (dated 03/24/2025) documents that R60 has complaints of chronic pain. Care plan documents that R60 has a diagnosis of lymphedema and is at risk for circulatory complications, swelling, pain, cardiac distress and decreased mobility. R96's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Hemiplegia, unspecified affecting right dominant side, schizoaffective disorder, Bipolar disorder, Major depressive disorder, anxiety disorder. Minimum Data Set Section (MDS) section C (dated 03/19/2025) documents that R96 has an Interview for Mental Status (BIMS) score of 15, indicating that R96's cognition is intact. Care plan (dated 01/02/2025) documents that R96 is at risk for alteration in sleep patterns related to insomnia. On 05/27/2025, surveyor was conducting resident interviews during an annual licensure and recertification survey. At 1:22 PM, R60 stated, I am in a lot of pain. They did not give me my pain medication for a few days now because they ran out and did not reorder my pain medications. I take Tylenol with Codeine. The last time that they gave me my pain medication was two days ago. My pain is really bad. My pain is 10 out of 10. They said that they ran out of my medication because it was not ordered fast enough. They let my pain medication run out, and they did not re-order the pain medication before it ran out. They let my medications run out, and they are supposed to refill the medications before they run out. Now they want to give me regular Tylenol for my pain, but I told them that the regular Tylenol is not strong enough to manage my pain. I am in pain, and I am not comfortable without my Tylenol with Codeine. On 05/27/2025, at 1:38 PM, surveyor interviewed R96. R96 stated, I have a concern. They keep running out of my Lunesta sleeping medication. They continuously run out and they don't refill it before it runs out. I get the Lunesta at nighttime to aide me with sleep. Last night the nurse did not give (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 4 of 17 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 05/30/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it to me because she said they were out. I did not sleep the entire night without the Lunesta. This happened many times and I am so frustrated that they continue to run out of my sleeping medication. I am tired because without the Lunesta, I cannot sleep. On 05/27/2025, at 1:56 PM, surveyor inspected the 3rd floor nursing cart with V11 (licensed Practical Nurse) to determine if R60's Tylenol with Codeine pain medication and R96's Lunesta medication for sleep aide were stocked in the medication cart. Based on the inspection, surveyor observed that the two medications were not in the cart. V11 stated, I am the nurse for R60 and R96. R60's Tylenol with Codeine is not in the medication cart, because they ran out of the resident's pain medications. R60 told me that he is in pain and all I was able to give R60 is regular Tylenol. According to the controlled substance ledger, the last time that R60 got his Tylenol with Codeine was on 05/25/2025 at 9:00 PM. I faxed over the order for the pain medication to the pharmacy. Hopefully they will deliver it. R96's Lunesta medication is out of stock. R96 told me that last night she did not receive her scheduled Lunesta medications because the facility ran out. R96 told me that she did not sleep all night because she did not receive the Lunesta medications. They reordered the medication for R96. We are waiting for the pharmacy to bring it. On 05/28/2025, at 10:46 AM, V3 (director of nursing) stated, The expectation is that when there are 3 or 4 pills left in the resident's bingo card, the nurses are supposed to reorder the medications. Nurses are not supposed to wait to the last minute to reorder resident's medications. All medications are supposed to be reordered before they run out. Controlled Substance Disposition Form indicated that that last time that R60 received Tylenol with Codeine 15mg for pain management was on 05/25/2025, at 9:00 PM. R60's Progress Note (dated 05/27/2025) documents, Resident complained of pain to the nurse and requested for his codeine. The medication was not available at this time. Doctor was notified immediately that we have tramadol in the convenient box. Doctor insisted we give Tylenol 1000mg PO and have pharmacy contact him for script. The order was noted and carried out. Pharmacist was called and medication will be delivered STAT (immediately). Resident was made aware. His emergency contact was notified. Resident was assessed for pain, complained of pain to the lower back rated 3/10. Tylenol 1000mg PO was given, well tolerated. Staff will continue to monitor. R60's Physician Order (dated 05/28/2025) documents: Acetaminophen-codeine - Schedule III tablet; 300-15 mg; amount: 1 tablet; oral Special Instructions: Give at 8:00 AM, 2:00 PM, 8:00 PM, as scheduled. R96's Physician Order (dated 11/06/2024) states: Lunesta (eszopiclone) - Schedule IV tablet; 1 mg; amount: 3 mg; oral tablet. Controlled Substance Prescriptions Policy (dated 10/25/2014) documents in part: Refill requests for CIII-CV, and partial fill quantity (CIIs) remains and medications are not automatically refilled by the pharmacy, refills are: Written on a medication order form or ordered by peeling the reorder tab from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy four (4) days in advance of need to assure an adequate supply is on hand. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 5 of 17 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 05/30/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm On 05/27/2025, at 10:25 AM, surveyor and V14 (Licensed Practical Nurse/LPN) located on the 5th floor of the facility performing a controlled substance count and record review. Surveyor observed the following: A medication bingo card labeled R118's name, Lorazepam 0.5mg. Surveyor observed there were 15 pills inside of the medication bingo card. R118's controlled drug receipt record documents a count of 16 pills. Residents Affected - Few A medication bingo card labeled R55's name, Lorazepam 1mg, surveyor observed there were 4 pills inside of the medication bingo card. R55's controlled drug receipt record documents a count of 5 pills. V14 states he administered the medications to R55 and R118 this morning and forgot to document that he administered them. On 05/27/2025, at approximately 11:00 AM, review of the Controlled Substances Check Form for the month of May 2025 for the third-floor medication cart indicated for 2 shifts in May 2025, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 05/13/25, 2nd shift (3:00 PM-11:00 PM) On 05/17/25, 2nd shift (3:00 PM-11:00 PM) On 05/27/2025, at approximately 11:00 AM, V16 (LPN/Wound Care Coordinator) states it is important to count and document all controlled substances to prevent drug diversions in the facility. V16 states if controlled substances are not documented, then it means that the control substances were not counted. On 05/27/2025, at approximately 11:20 AM, review of the Controlled Substances Check Form for the month of May 2025 for the second floor Cart B medication cart indicated for 4 shifts in May 2025, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 05/18/25, 3rd shift (11:00 PM-7:00 AM) On 05/19/25, 1st shift (7:00 AM-3:00 PM) On 05/23/25, 1st shift (7:00 AM-3:00 PM), 2nd shift (3:00 PM-11:00 PM) On 05/27/2025, at approximately 11:40 AM, review of the Controlled Substances Check Form for the month of May 2025 for the second floor Cart A medication cart indicated for 6 shifts in May 2025, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 05/01/25, 3rd shift (11:00 PM-7:00 AM) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 6 of 17 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 05/30/2025 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 0755 On 05/03/25, 3rd shift (11:00 PM-7:00 AM) Level of Harm - Minimal harm or potential for actual harm On 05/04/25, 1st shift (7:00 AM-3:00 PM) On 05/19/25, 2nd shift (3:00 PM-11:00 PM) Residents Affected - Few On 05/24/25, 3rd shift (11:00 PM-7:00 AM) On 05/25/25, 2nd shift (3:00 PM-11:00 PM) Facility policy dated 10/25/2014 titled Controlled Substance Storage documents in part, E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses. F4. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and Form: Controlled Substance Count Record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 7 of 17 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 05/30/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and records review, the facility failed to discontinue or get an order to continue as needed psychotropic medications and failed to get psychotropic consent from Power of Attorney (POA) for one (R52) resident of seven reviewed in a total sample of 35 Residents Affected - Few Findings include: R52's current face sheet documents R52 is a [AGE] year-old individual with medical diagnosis that include but not limited to Major depressive disorder, recurrent severe without psychotic features, Schizophrenia, unspecified, schizoaffective disorder, bipolar type, other psychotic disorder not due to a substance or known physiological condition, anxiety disorder, unspecified. Minimum Data Set (MDS) section C-Cognitive Patterns dates 05/14/2025, document R52's BIMS as 3/15, indicating R52 has severe cognitive impairment. R52's BIM scores dated 05/08/2025, 05/01/2025. BIMS dated 04/23/2025 is 3/15. On 05/27/25, 12:28 PM, R52 was observed sitting in the dining room with staff supervising him. R52 was observed with stacks of papers with pens. R52 stated he likes to write a lot. R52 was observed oriented to person/place and was confused about situation or time. R52 was not able to answer most of the questions that were asked. Review of R52's psychotropic consent forms document R52 consented for psychotropic medications on 05/08/2025: -Clonazepam - Schedule IV tablet; 1 mg; 1 tablet; oral Twice A Day As needed (PRN). -Zolpidem 5mg 1 tablet at bedtime -Olanzapine 10 Mg 1 Tablet PO(Oral) BID (two times day) Review of R52's psychotropic consent forms document R52 consented for psychotropic medications on 05/11/2025: -Lorazepam, 2mg/mL 1 mL Q6hrs PRN (As needed) Review of R52's face sheet and electronic Health Records document R52 has a POA for health. On 05/29/2025, V3 (Director of Nursing) stated although R52 has a BIMS score of 3/15 which means he is severely cognitively impaired, he can still sign for his psychotropic medications. The nurses document in progress notes that R52 is alert and oriented times two, which means R52 is alert and oriented to name and place. V3 stated he did not know if R52 can make decisions based on understanding. V3 stated the nurse on duty on 5/82025, notified R52's Power of Attorney (POA) that R52 was back in the facility, but there is not documentation that the POA was notified of R52's psychotropic medications. V3 stated if it's not documented it is not done. Reviewed of R52's progress notes dated 5/8/2025, document R52's POA was notified of R52's return to the facility but no documentation R52's POA was notified R52 was started on psychotropic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 8 of 17 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 05/30/2025 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 0757 medications and psychotropic consent was signed by R52. Level of Harm - Minimal harm or potential for actual harm V3 stated as needed (PRN) psychotropic medication orders are active for only 14 days and should be discontinued after the 14 days or an order for medication continuation should be given by the physician. Residents Affected - Few R52's Physician Order Sheet (POS) dated 5/11/2025 documents: Prescription Lorazepam - Schedule IV solution; 2 mg/mL; amt (Amount) 2 mg; injection Every 6 Hours -05/11/2025, Open Ended PRN Medications Prescription Lorazepam - Schedule IV tablet; 2 mg; : 1 Tab; oral Every 6 Hours -05/11/2025, Open Ended PRN Medications Policy titled MAC Rx Pharmacy Policies and Procedures Manual dated 10/25/2014, documents: -Effective 11/28/2017, CMS (Centers for Medicare & Medicaid Services) redefined the class definition of psychotropic medications to include the below listed drug classes. The PRN (as needed) psychotropic are time limited to a maximum day supply of 14-day duration for SNF (Skilled Nursing Facility). A continuation Psychotropic Medication Policy dated February 2014, documents: -Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident's guardian or other authorized representative. R52's Physician Order Sheet dated 05/08/2025, document: Prescription benztropine tablet; 1 mg; amt (amount) 1 tablet; oral. Twice A Day 9:00 AM, 5:00 PM. 05/08/2025, Open Ended Medications. Prescription Clonazepam - Schedule IV tablet; 1 mg; amt: 1 tablet; oral Twice A Day 9:00 AM, 5:00 PM. 05/08/2025, Open Ended Medications. Prescription Olanzapine tablet; 10 mg; amt: 1; oral Twice A Day 9:00 AM, 5:00 PM, 05/08/2025, Open Ended Medications Prescription Zolpidem - Schedule IV tablet; 5 mg; amt: 1; oral At Bedtime 9:00 PM, 05/08/2025, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 9 of 17 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 05/30/2025 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 0757 Open Ended Medications 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 10 of 17 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 05/30/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for one (R1) out of four residents reviewed for medication administration in a total sample of 35 residents reviewed, resulting in a 7.69% error rate. Residents Affected - Few Findings Include: On 05/28/2025, at 9:22 AM, surveyor located on the 4th floor of the facility with V11 (Licensed Practical Nurse/LPN) during a medication administration pass. V11 administers Acetaminophen 500 mg: 2 tablets by mouth to R1. R1's medication administration record (MAR) dated 05/01/2025 - 05/28/2025 documents: Acetaminophen 325 mg- 2 tablets by mouth every 6 hours as needed. R1's medication administration record (MAR) dated 05/01/2025 - 05/28/2025 documents: Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg: 1 tablet by mouth twice a day scheduled at 9:00 AM and 5:00 PM. On 05/28/2025, at 9:22 AM, surveyor observes that this medication was not given to R1 during the 9:00 AM medication administration pass with V11 (LPN). V11 states she is finished administering all of R1's scheduled morning medications. On 05/28/2025, at 2:52 PM, V11 (LPN) states she did not administer R1's Bactrim medication during the morning medication pass while surveyor was present because she did not see the order in R1's MAR. V11 states she checked the facility's 24-hour communication report and saw that R1 was prescribed antibiotics. V11 states she then checked R1's MAR again and saw the Bactrim order on R1's MAR. V11 states she then administered R1's Bactrim medication to him at approximately 10:30 AM, after the surveyor had already left the 4th floor. V11 states she is aware that she should triple check the resident's MAR to check medications orders. V11 states it is important to read and re-check resident's MARs to prevent medication errors from occurring. Facility policy dated 10/25/2014, titled Medication Administration documents in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures: 4.) FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. b. Check #2: Prepare the dose- The dose is removed from the container and verified against the label and the MAR by reviewing the five rights. 5.) Prior to administration, the medication and dosage schedule on the on the resident's medication administration record (MAR) are compared with the medication label. 2) Medications are administered in accordance with written orders of the prescriber. 5) When PRN medications are administered, the following documentation is provided: a.) Date and time of administration, dose, route of administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 11 of 17 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 05/30/2025 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 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.) remove and discard expired medications that had been open in one of five medication carts reviewed, b.) remove and discard expired enteral feedings located in one of four medication storage rooms reviewed, and c.) ensure medications were locked and secured while unattended. These failures have the potential to affect 59 residents residing in the facility reviewed for medication labeling and storage. Findings Include: On 05/27/2025, at 11:07 AM, surveyor and V11 (Licensed Practical Nurse/LPN) located on the 3rd floor of the facility at the medication cart. Surveyor observes the following: one open house stock medication bottle labeled Meclizine 12. 5mg inside of the medication cart. Meclizine medication observed with an expiration date labeled 02/2025. V11 states the Meclizine medication should not be stored in the medication cart and should have been discarded once it expired on 02/2025. V11 states it is not safe to administer expired medications to residents and they could experience adverse reactions if given expired medications. On 05/27/2025, at 11:13 AM, surveyor located inside of the third-floor medication storage room with V11 (LPN). Surveyor observes the following: four house stock enteral feeding containers labeled Glucerna with Carbsteady 1.5 CAL 33.8 ounces with an expiration date labeled 04/01/2025. V11 states the enteral feeding containers should not be stored in the medication storage room for resident use and should have been discarded once it expired on 04/01/2025. V11 states residents receiving enteral feedings could potentially get sick if expired enteral feedings are administered to them. On 05/27/2025, at 11:16 AM, surveyor located on the second floor of the facility. Surveyor observes a medication cart (identified as Cart B) unlocked and unattended. V10 (Registered Nurse/RN) observed exiting a resident's room and locks the Cart B medication cart. On 05/27/2025, at 11:18 AM, V10 states she normally locks the medications cart when she leaves it unattended. V10 states she must have been rushing this time when she left the medication cart unlocked and unattended. V10 states that residents can potentially get access to the medications if the cart is left unlocked and unattended. V10 states then residents could potentially self-administer the medications and overdose or have an adverse reaction. Facility census dated 05/27/2025, documents a total of 30 residents resides on the third floor of the facility and 29 residents reside on the second floor of the facility. Facility document titled Residents on Tube Feeding lists a total of 4 residents residing in the facility who have gastronomy tubes for enteral feedings. Facility policy dated 10/25/2014, titled Storage of Medications documents in part, Procedures: B. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. Expiration Dating: H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 12 of 17 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 05/30/2025 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 0761 amount remaining. The medication will be destroyed in the usual manner. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 13 of 17 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 05/30/2025 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and records review, the facility failed to follow proper sanitation and food handling practices. This failure has the potential to affect all 178 residents receiving food from the kitchen. Residents Affected - Many Findings include: On 05/27/2025, at 9:39 AM, during tour of the kitchen with V4 (Dietary Manager), observed two silver baking pans wrapped with foil paper on top in the cooler, placed on top of a food cart. V4 stated inside the pans were meat loaf which was being thawed for next day's meal. Observed a pool of a white liquid spilled on top of one of the pans. V4 identified the liquid as milk. V4 stated the milk should not be spilt on the foil wrapping the meat loaf because it can drip inside the meat loaf. This could cause contamination and some residents could be allergic to milk. On one of the shelves in the cooler was observed two big cartoons, one containing cabbage and another containing oranges. Three cabbages were observed to be yellowing/brownish in color with brownish stuff dripping out. V4 stated the cabbages should have been thrown out because they were no longer good for resident consumption and can cause illnesses if cooked for residents. Observed the carton of oranges with some oranges having a grayish substance on them. The oranges were very squishy and broke open when V4 touched them. V4 stated the oranges were rotten and the grayish substance on the oranges was mold which can cause cross contamination and cause residents to become ill. V4 stated kitchen staff should be checking for spoiled food in the cooler and dispose of it to prevent cross contamination which can cause residents to become ill. The cooler temperature was observed at 51 degrees F. V4 stated the cooler temperature should be below 41 degrees F. In the freezer was a box of open waffles with no date when opened. V4 stated food should be labeled with date opened so that staff can know when the food is expired to prevent food borne illnesses. There were two black food carts, one the in cooler and one in the kitchen near a countertop were with whitish substances and black stains on the shelves of the carts. V4 stated the whitish substance was from spills from food and the carts were dirty. V4 further stated the staff who was responsible for cleaning all the food carts and checking the cooler for spoiled food quit over a week ago. V4 was trying to keep up with completing the staff who quit responsibilities and was not able to complete them all because he was also supervising the kitchen. V4 stated unsanitary or dirty food carts can contaminate residents' food and cause illnesses. On 05/27/2025, at 10:13 AM, V4 and surveyor observed V7 (dietary Aide) Rinsing dirty dishes and loading them into the dishwasher. V7 was observed walking over to the other side of the machine to take out the cleaned dishes. V7 did not wash her hands or wear gloves before touching the clean dishes. V4 stated V7 should wash her hands and/or wear gloves before touching the clean dishes and loading them on the clean rack. V4 stated R7 was contaminating the clean dishes by not following sanitary dish washing procedure and V7's actions can cause residents to become ill due to cross contamination. On 05/27/2025, at 11:35 AM, V6 (cook) was observed preparing puree and mechanical soft foods in the puree machine. V6 put cream style corn in the puree machine, pureed it and emptied it in a small baking pan. V6 walked over to the sink and rinsed the puree bowl. V6 came back and put the country style steak in the puree machine and pureed it. V6 stated as long as he was using the puree machine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 14 of 17 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 05/30/2025 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 constantly without stopping for more than five minutes. V6 stated he does not need to sanitize or wash it, rinsing is enough. V6 stated there is only one puree machine and this is how he has been pureeing the foods. Facility policy titled Blender, no date documents: Residents Affected - Many -Thoroughly wash unit and remove all food particles from blade. Check cleanliness of top of unit. -Rinse and Sanitize -Air dry Facility polity titled Storage of Refrigerated foods dated 08/24 documents: - Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality -Refrigerated foods are stores at 41* or below. Facility polity titled Dishroom Sanitation, dated 08/24 documents: -Hands must be washed after handling dirty dishes before handling clean dishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 15 of 17 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 05/30/2025 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, facility failed to follow their policy to offer, educate and receive consent for influenza and pneumococcal vaccination for 1 (R66) out of 5 residents reviewed for immunizations, in a total sample of 35. Residents Affected - Few Findings include: On 05/28/2025, at 12:00 PM, R66 stated she doesn't remember the facility offering her influenza and pneumococcal vaccination. On 05/28/2025, surveyor reviewed R66's immunizations with V19 (Infection Preventionist). On 05/28/2025, at 12:37 PM, V19 stated that she cannot find R66's consent for influenza or pneumococcal vaccine. V19 stated she is pretty sure she offered it. V19 stated that R66 did not receive her influenza or pneumococcal vaccine, nor does she have education or consent. V19 stated that she does not know what happened and why R66 does not have her pneumococcal or influenza vaccine or was educated on the benefits of these vaccines. V19 stated that it is important for these residents to have their vaccination to protect them from influenza and pneumonia related infections. On 05/29/2025, at 2:05 PM, V3 (Director of Nursing) stated that upon admission, residents' immunizations are reviewed. V3 stated that if a resident did not receive the influenza or pneumococcal vaccination, we educate them the importance and benefits of the vaccine. V3 stated that then they can make an informed decision to give consent for the administration of the influenza or pneumococcal vaccine. V3 stated that we document every time we educate residents on the benefits of the immunization. If it is not documented, then it was not done. R66's immunization record documents in part: There was no influenza or pneumococcal vaccine offered in 2024. No pneumococcal or influenza vaccine administered. No documentation of education or consent for influenza or pneumococcal vaccination. Facility's Influenza and Pneumococcal Immunization Policy (undated) documents in part: Each resident or when appropriate resident representative, will be educated regarding the benefits and potential side effects of both influenza and pneumococcal immunizations and will be provided the opportunity to accept or refuse them. The facility will document both the education provided and the resident's decision in the resident's clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 16 of 17 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 05/30/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review, facility failed to follow their policy to offer, educate and receive consent for COVID-19 (corona virus) vaccination for 1 (R66) out of 5 residents reviewed for immunizations, in a total sample of 35. Findings include: On 05/28/2025, at 12:00 PM, R66 stated she doesn't remember the facility offering COVID-19 vaccination or educating her about it. On 05/28/2025, surveyor reviewed R66's immunizations with V19 (Infection Preventionist). On 05/28/2025, at 12:37 PM, V19 stated that she cannot find R66's consent for COVID-19 vaccine. V19 stated she is pretty sure she offered it. V19 stated that she is not sure if R66 received her COVID-19 vaccine nor does she have education documented. V19 stated that she does not know what happened and why R66 did not receive her COVID-19 vaccine. V19 stated that it is important for these residents to be educated and have their vaccination to protect them from COVID-19 infection. On 05/29/2025, at 2:05 PM, V3 (Director of Nursing) stated that upon admission, residents' immunizations are reviewed. V3 stated that if a resident did receive the COVID vaccination, we educate them the importance and benefits of the vaccine. V3 stated that then they can make an informed decision to give consent for the administration of the COVID-19 vaccine. V3 stated that we document every time we educate residents on the benefits of the immunization. If it is not documented, then it was not done. R66's immunization record documents in part: There was no COVID-19 vaccine offered nor administration history. No documentation of education or consent for COVID-19 vaccination. Facility's COVID-19 Immunization Policy (01/2021) documents in part: The facility shall notify all residents of the COVID-19 vaccination and shall provide or arrange for vaccination for all residents. The facility shall provide all residents with education about the benefits of COVID-19 vaccine and potential consequences of COVID-19 illness. The facility shall include documentation of each person either accepted the offer or declined the offer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145482 If continuation sheet Page 17 of 17