Health inspection·June 2, 2023

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. Based on interviews, and record reviews the facility failed to ensure or establish mechanisms for documenting and communicating to interdisciplinary team regarding code status. This failure has the potential to affect one (R99) of one resident reviewed for advance directive in a sample of 26. The findings include: R99 admission date was on 11/5/22 with diagnoses not limited to Alcoholic cirrhosis of liver without ascites; Venous insufficiency; Peripheral vascular disease; Essential hypertension; Type 2 diabetes mellitus; Iron deficiency anemia; Osteoarthritis; Gastro-esophageal reflux disease; Hyperlipidemia; Vitamin B deficiency; Dysphagia, oropharyngeal phase; Major depressive disorder; Insomnia. On 6/1/23 at 10:27 am V32 (Social Service Coordinator) was interviewed and stated she is working in the facility 3 times per week. V32 stated that there is a social worker consultant working remotely who is available anytime when there is any social service concerns or issues. V32 stated that she is responsible in completing resident's minimum data set (MDS) assessments and care plans including advance directive. V32 stated that she (V32) is also helping with discharge planning. R99 electronic health record (EHR) was reviewed with V32 and stated that R99 code status is DNR. V32 stated that R99 care plan documented R99 is full code. V32 stated that she (V32) was not aware that code status was changed. V32 stated it looks like the care plan was not updated; I will update the care plan right now. V32 stated that it is an issue if code status order is not consistent with resident's plan of care and potentially can create confusion to staff providing care. V32 stated care plan is reviewed quarterly or as much as I can. At 10:37 V3 (Director of Nursing - DON) was interviewed and stated that social service is responsible with residents' advance directives. V3 stated that residents' code status should be ordered and consistent in residents' health record to avoid confusion. V3 stated that code status should be reviewed periodically. Reviewed R99 order summary report has an order of DNR (Do not Resuscitate) with order date of 11/5/22. R99 care plan date initiated 9/1/22 documented in part: R99's currently FULL CODE post review of the POLST form and advance directives. Goal: Mr. Harrison's existing advance directives will be honored through the next review. Interventions: o Complete / update Advanced Directives document o The EMR chart will reflect the FULL CODE status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 2 of 12 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 145532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Plaza 1426 West Birchwood Chicago, IL 60626 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 FORM CMS-2567 (02/99) Previous Versions Obsolete R99 minimum data set (MDS) with assessment reference date (ARD) of 4/4/23 indicated that R99 has impaired cognition. R99 needed extensive assistance with bed mobility, dressing, eating. R99 required total assistance with transfer, toilet use and personal hygiene. R99 is always incontinent of bowel and bladder. Surveyor requested for advance directive policy and facility provided policy for uniform DNR order form dated 11/2012 was reviewed. Event ID: Facility ID: 145532 If continuation sheet Page 3 of 12 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 145532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Plaza 1426 West Birchwood Chicago, IL 60626 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 observations, interviews, and record reviews the facility failed to follow policy for oxygen therapy to ensure that oxygen nasal tubing and humidifier be changed weekly and when oxygen tubing is not in active use be stored in plastic bag. These failures have the potential to affect one (R118) of one resident reviewed for respiratory care in a sample of 26. Residents Affected - Few The findings include: R118 admission date was on 12/28/22 with diagnoses not limited to Malignant neoplasm of unspecified part of unspecified bronchus or lung; Chronic obstructive pulmonary disease; Unspecified asthma; Secondary malignant neoplasm of bone; Atherosclerotic heart disease; Cardiomyopathy; Chronic kidney disease, stage 3B; Hypertensive heart disease with heart failure; Chronic pulmonary embolism; Heart failure; Essential hypertension; Spinal stenosis, lumbar and cervical region; Alcohol abuse; Nicotine dependence. On 5/31/23 10:29 AM Observed R118 lying on bed, on moderate high back rest, alert and verbally responsive. Observed oxygen concentrator machine was going on at 2L/min. Observed oxygen nasal tubing on the floor. R118 stated that recently he (R118) has been using oxygen most of the time, but he (R118) was just taking a break from oxygen, and he (R118) removed the oxygen tubing. Observed oxygen tubing and humidifier bottle was dated 5/23/23. V19 (Registered Nurse) was requested in R118's room and stated that recently R118 has been using oxygen due to his medical condition - lung cancer. V19 stated that R118 is under hospice care. V19 confirmed that oxygen tubing was on the floor. V19 stated she (V19) will discard the oxygen tubing on the floor as it is contaminated and will provide a new oxygen tubing. V19 stated that resident at times would remove his (R118) oxygen tubing when he (R118) wanted to smoke downstairs. V19 stated that oxygen tubing and humidifier bottle was dated 5/23/23. V19 stated that oxygen tubing and humidifier bottle should be changed weekly and as needed. V19 stated that she (V19) will replace oxygen tubing and humidifier bottle. On 6/1/23 at 10:37 am V3 (Director of Nursing - DON) was interviewed and stated she has been working in the facility for a month. V3 stated that oxygen therapy should be ordered by physician including the liter flow and method of oxygen administration. V3 stated that oxygen tubing and humidifier should be changed weekly and as needed. V3 stated that if oxygen is not in active use, oxygen tubing must be stored in a plastic bag to prevent contamination. V3 stated that it is a facility protocol not to use a contaminated oxygen tubing and humidifier bottle. Reviewed R118 order summary report dated 5/31/23 documented in part: Oxygen -Change Tubing, Humidifier, Cannula every night shift every Wednesday and as needed. Oxygen - Care every shift and as needed. Oxygen at 2L-4L per NC (nasal cannula) as needed for comfort, SOB (shortness of breath). R118 Minimum data set (MDS) with assessment reference date (ARD) of 5/14/23 documented that R118 is cognitively intact. R118 needed extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Facility's policy for oxygen therapy (undated) documented in part: 6. Nasal tubing and humidifier must be changed weekly or as needed. [NAME] date of replacement. 7. When tubing is not in active use, it is stored in plastic bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 4 of 12 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 145532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Plaza 1426 West Birchwood Chicago, IL 60626 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 observations, interviews, and record reviews the facility failed to a.) discard expired medications from medication cart for three (R72, R88, R112) residents and b.) ensure that medications are properly labeled for one (R133) resident. These failures have the potential to affect four (R72, R88, R112, R133) residents to facilitate consideration of precautions and safe administration of medications reviewed for medication storage and labeling in 2 of 4 medication carts inspected in a sample of 62 residents. The findings include: On 5/31/23 at 2:56 pm V20 (Registered Nurse - RN) stated that she has been working in the facility for 10 years. Surveyor inspected 1st floor medication cart with V20. Observed R72 Humalog insulin multi dose vial labeled with date opened 4/30/23; expired 5/28/23. Observed R88 Azelastine Nasal spray labeled with open date 3/30/23; expiration / discard date was not labeled. V20 stated nasal spray should be discarded in 30 days after opening. Observed R112 Glargine insulin pen labeled Expired date: 5/25/23, open date was not labeled. Observed R133 Glargine insulin pen with no label for open and expiration / discard date. Observed R133 Humalog insulin pen with no label for open date and expiration / discard date. V20 stated it was written but it was erased, V20 was unable to identify or read the open / discard date. All insulins with sticker label indicating discard in 28 days after opening. All medications were observed inside the medication cart. V20 stated that medications beyond discard date or expiration date should not be given to residents. V20 stated that she (V20) will discard all expired medications in the sharp container box. On 6/1/23 at 10:37am V3 (Director of Nursing - DON) was interviewed and stated she has been working in the facility for a month. V3 stated that medication should be labeled and stored properly. V3 stated that most of the insulins should be discarded in 28 days after opening. V3 stated that nasal spray medication should be labeled with open date and should be discarded after a month of opening the medication. V3 stated that she (V3) is not sure if there is a potential effect to resident if medication was given beyond discard date. V3 stated that it is a protocol of the facility not to give medications if outdated or beyond discard date. Surveyor requested facility policy for medication labeling and storage. Reviewed R72 health record and documented admission date of 9/11/21. R72 order summary report dated 6/1/23 documented in part: Humalog 100 units/vial Inject as per sliding scale: if 70 - 180 = 0 Unit; 181 - 200 = 2 Units; 201 - 250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units Above 400 = 12 units and call MD/NP (Medical Doctor/Nurse Practitioner), subcutaneously before meals related to Type 2 diabetes mellitus. R88 health record documented admission date of 10/4/22. R88 order summary report dated 6/1/23 documented in part: Azelastine SPR 0.1% 2 spray in each nostril two times a day for stuffy nose / nasal congestion. R112 health record documented admission date of 2/25/23. R112 order summary report dated 6/1/23 documented in part: Basaglar Kwik Pen Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously at bedtime related to Type 2 diabetes mellitus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 5 of 12 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 145532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Plaza 1426 West Birchwood Chicago, IL 60626 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 R133 health record documented admission date of 5/6/23. R133 order summary report dated 6/1/23 documented in part: Humalog Kwik Pen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 10 unit subcutaneously one time a day for DM (diabetes mellitus). Humalog Kwik Pen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 5 unit subcutaneously two times a day for DM (diabetes mellitus) give pre-lunch and predinner. Humalog Kwik Pen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 -70 = 0 If BS (blood sugar) less than 70, have a snack and recheck blood sugar again after 15 minutes; 71 -149 = 0; 150 - 199 = 1; 200 - 249 = 2; 250 - 299 = 3; 300 - 349 = 4; 350 - 400 = 5. If BS (blood sugar) 401 and above, call MD, subcutaneously three times a day for DM. Insulin Glargine Solution 100 UNIT/ML Inject 35 unit subcutaneously one time a day for diabetes. Facility's policy for storage of medications dated 11/2017 documented in part: 8. Medications must be labeled accordingly. On 6/2/23 at 10:16 am Surveyor followed up facility policy for medication labeling, V2 stated we don't have it, policy is not available. Facility was not able to provide medication labeling policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 6 of 12 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 145532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Plaza 1426 West Birchwood Chicago, IL 60626 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 - Few 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 follow policy for residents on aspiration precautions to ensure that prescribed type of liquid consistency must be followed. This failure has the potential to affect one (R99) of six residents reviewed for nutrition in a sample of 26. The findings include: R99 admission date was on 11/5/22 with diagnoses not limited to Alcoholic cirrhosis of liver without ascites; Venous insufficiency; Peripheral vascular disease; Essential hypertension; Type 2 diabetes mellitus; Iron deficiency anemia; Osteoarthritis; Gastro-esophageal reflux disease; Hyperlipidemia; Vitamin B deficiency; Dysphagia, oropharyngeal phase; Major depressive disorder; Insomnia. On 5/31/23 at 11:46 am V21 (Certified Nurse Assistant - CNA) was observed assisting R99 at lunch meal in R99's room. V21 placed a clothing protector to R99. Observed R99 head of bed was elevated. Observed lunch tray with pureed food consisting of pasta, green peas, mushroom soup, and dessert. Observed with thickened coffee and thickened water in a cup. Observed a carton of 2% milk not thickened in lunch tray. R99 meal ticket indicated pureed, nectar thick liquid. Observed R99 ate 100% of the food served. Observed R99 able to hold a cup. Observed R99 drank 100% of thickened water and coffee. Observed V21 poured 2% milk not thickened in the cup without thickener powder. Observed R99 with coughing episodes after drinking almost a cup of 2% milk not thickened. V21 stated that there were remaining thickened liquids in the cup so V21 decided not to add thickener powder in the cup with 2% milk. V21 poured the remaining 2% milk in the cup and stated that he (V21) will ask for a thickener powder to add in the milk. Observed V27 (Nursing Supervisor) assisted V21 with thickener powder added to milk in the cup. Observed R99 ate 100% of the food and drank 100% of fluids assisted by V21. On 6/01/23 at 10:37 am V3 (Director of Nursing - DON) was interviewed and stated she has been working in the facility for a month. V3 stated that resident's diet including food texture and liquid consistency should be ordered by physician and followed by staff. V3 stated that if CNA observed any coughing episodes during mealtime, feeding should be stopped, and CNA is expected to inform the nurse on duty. V3 stated that resident would be monitored, and physician would be notified accordingly. V3 stated that thickener powder mixed with any liquids will be automatically dissolved. V3 stated that any additional liquid poured should have a thickener powder added according to the liquid consistency ordered by physician. V3 stated that coughing could be observed or expected when staff is not following the correct liquid consistency as ordered. V3 stated that depending on how much liquid was taken by resident then potentially can lead to aspiration pneumonia that is why resident should be monitored and physician should be informed. At 11:07 am V33 (Speech Therapist - ST) was interviewed via phone. V33 stated that she (V33) saw R99 over 6 months. R99 was discharged from speech therapy on 9/28/22 with diet recommendation of pureed, thin liquids. Surveyor informed V33 that current diet order for R99 is pureed, nectar thick liquid (NTL) as of 5/5/23 per R99's electronic health record (EHR). V33 stated that nurses can downgrade the diet as ordered by physician without speech therapy (ST) evaluation. V33 stated ST evaluation or treatment is needed for upgrading resident's diet. V33 stated that staff should follow the ordered liquid consistency. V33 stated that if R99 is on NTL then all liquids provided by staff should be thickened according to nectar consistency. V33 stated that depending on the resident and how much liquid was taken by resident could be a risk of aspiration if liquid consistency was not followed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 7 of 12 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 145532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Plaza 1426 West Birchwood Chicago, IL 60626 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 according to physician order. Level of Harm - Minimal harm or potential for actual harm Reviewed R99 order summary report with order date of 5/5/23 documented in part: General diet, Pureed texture, Nectar/Mildly Thick consistency. R99 with diagnosis of Dysphagia, oropharyngeal phase. Residents Affected - Few R99 care plan with revision date of 5/30/23 documented in part: Diet: pureed, NTL. Multiple supplements provided. Eats well at meals. Provide tray and spoon-fed R99 with strict aspiration precaution. R99 minimum data set (MDS) with assessment reference date (ARD) of 4/4/23 indicated that R99 has impaired cognition. R99 needed extensive assistance with bed mobility, dressing, eating. R99 required total assistance with transfer, toilet use and personal hygiene. R99 is always incontinent of bowel and bladder. Facility's policy for residents on aspiration precautions dated 12/2017 documented in part: 1. Prescribed type of diet and consistency of liquids must be followed. 6. Monitor for clinical signs of aspiration (coughing, elevated temperature, throat clearing). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 8 of 12 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 145532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Plaza 1426 West Birchwood Chicago, IL 60626 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide adaptive feeding equipment for 1 (R104) of 6 residents reviewed for adaptive equipment usage in a total sample of 130. Residents Affected - Few Findings include: On 05/30/23 at 11:39 AM, surveyor observed R104 feeding self in unit dining room with left hand, right hand was in a splint. R104 observed eating from a regular plate, not a divided plate, or a partition plate. There was no plate guard on the regular plate. Observed food spilling from R104's plate onto R104's tray. R104's meal ticket had Plate Guard written on it. On 05/31/23 at 11:53 AM, V23 (Occupational Therapist) stated R104 can feed self with left hand but does not have use of R104's right hand. V23 stated the nursing staff had referred R104 to V23 because they noticed R104 was having a harder time feeding himself. V23 stated R104 was observed to be having trouble getting enough food onto the spoon and keeping the food on the spoon during the feeding process. V23 stated a plate guard was recommended by V23 so that R104 could use the plate guard barrier to help R104 keep R104's food on the spoon when feeding himself and prevent the food from sliding off R104's plate when R104 was feeding himself. V23 stated that the recommendation for use of a plate guard was for R104 to receive a plate guard with every meal. On 05/31/23 at 12:10 PM, V5 (Food Service Supervisor) stated there is a list of residents who require adaptive feeding equipment such as plate guard or three compartment plate and that the specific adaptive equipment needed is put on by the kitchen staff during tray line. V5 stated if a resident requires use of adaptive equipment this would be written on the resident's meal ticket. V5 stated R104 name is on the adaptive feeding equipment list and that R104 uses a plate guard and partition plate during meals and the words plate guard are written on R104's meal ticket. R104 provided copy of R104's meal ticket and list of residents requiring adaptive feeding equipment. R104 was admitted to the facility on [DATE] with diagnosis which includes but not limited to: Cerebral Infarction due to Occlusion or Stenosis of Left Middle Cerebral Artery, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Dysphagia, Contracture of Right Hand and Right Elbow, Unspecified Dementia. R104's MDS (Minimum Data Set) dated 04/03/23 BIMS (Brief Interview for Mental Status) score is 00 indicating severe cognitive impairment. R104's restorative care plan dated 02/16/23 documents in part, R104 has decline in ability to feed self-due to decreased mobility with cognitive impairment and weakness and may use hi-sided partition plate and plate guard to provide easy access to food. R104's Activities of Daily Living (ADL) care plan dated 01/03/23 documents in part R014 requires assist with ADLs related to weakness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture right hand and right elbow and may use hi-sided partition plate and plate guard to provide easy access to food. R104's meal ticket provided to the surveyor on 05/31/23 documents in part Plate Guard. Facility provided document titled, Special Eating Utensils dated 05/30/23 which documents in part R104's name, room number and device used as plate guard and partition plate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 9 of 12 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 145532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Plaza 1426 West Birchwood Chicago, IL 60626 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 0810 Level of Harm - Minimal harm or potential for actual harm Facility provided document titled, Supplemental Therapy Documentation dated 04/03/23 completed by V23, which documents in part R104 was referred to OT for adaptive equipment, upon assessment R104 showed inconsistency in ability in scooping food, and R104 to benefit from use of plate guard and partitioned plate to enable ease and efficiency with scooping, self-feeding. Residents Affected - Few Policy: Titled Adaptive Equipment Policy undated, documents in part, suggestive equipment if needed to include plate guard, divided plate and the procedure includes OT assessment and make recommendations and the program will be carried by the CNA on the floor or the rehab aide for every meal(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 10 of 12 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 145532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Plaza 1426 West Birchwood Chicago, IL 60626 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 follow their policy and procedure for food and supply storage to ensure foods in the main cooler were discarded after the expiration dates. This failure has the potential to affect 128 residents in the facility who are receiving oral diet. Findings Include: On 5/30/23 at 9:42 AM, during the initial kitchen tour with V5 (Food Service Supervisor), the following were found in the main cooler: cooked rice dated 5/22 with used by date of 5/28 and salmon patties with cooked date labeled as 5/22 with no used by date. V5 stated that these foods need to be discarded because they are passed the 7 days. V5 stated facility store leftover foods, prepared foods, dairies, vegetables, and meat in the main cooler. V5 stated that cooked foods are kept in main cooler for 7 days and then should be discarded. V5 stated that facility use the first in and first out method, which means that whatever is in first it should be used first. V5 stated that all expired foods and dairies are discarded and should not be served to the residents because they could get sick by eating expired foods especially the elderly. V5 further stated that residents could get food poisoning. Facility policy titled, FOOD STORAGE not dated reads in part: Prepared food should be labeled and stored in the refrigerator for use within 72 hours. The facility's roster documents 130 residents in the facility with 2 residents who are NPO (Nothing By Mouth). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 11 of 12 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 145532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Plaza 1426 West Birchwood Chicago, IL 60626 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observations, interview and record review, the facility failed to provide the required 80 square feet per bed for 20 resident's rooms out 196 rooms in the facility. This failure has the potential to affect 20 [R14, R18, R23, R24, R29, R58, R63, R66, R73, R93, R96, R98, R103, R105, R115, R123, R128, R130, R284, R285] residents in a sample of 62 residents. Findings include, On 5/30/23-6/2/23 during the facility tour on the first, second and third floors, observations were made of room sizes. On 5/30/23 at 10:10 AM, V2 [Assisted Administrator] stated, There are 19 rooms that do not measure 80 square feet per resident. Administration team always monitor the rooms to ensure there is space for each resident personal items and adaptive equipment. The 21 residents or family members have not complained about their room space. I submit a waiver every year. On 5/30/23 at 11:23 AM, V26 [Maintenance] stated, No construction or modification has been made to the 20 rooms at this time. This is an old building and there is no additional space to increase those rooms in size. R18, R285, R23, R63 was interviewed, no one voiced any concerns regarding the room size. All said they was happy with their rooms. Reviewed facility's room chart with 20 rooms listed including the medical equipment, furnishings, space for nursing activities, infection control issues and resident's satisfactory response FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 12 of 12