Inspection·March 8, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/07/24 at 9:44 AM, V3 (Director of Nursing, Registered Nurse) stated it is the responsibility of all the health care staff to pass out trays. V3 stated people sitting at the same table should receive their meals at the same time so the other resident is not waiting and watching the other people eating. On 03/07/24 at 12:33 PM, V18 (Registered Dietitian) stated via phone interview that hopefully residents sitting at the same table are receiving trays at the same time. V18 stated V18 thinks that it a dignity issue if someone sitting in front of you is eating and you are not eating. R134's diagnosis which includes but not limited to Unspecified Dementia, Dysphagia, Chronic Kidney Disease, Anemia, Malignant Neoplasm of Prostate. R134's Order Summary Report dated 03/06/24 documents in part General diet, pureed texture, regular/thin consistency related to dysphagia, oropharyngeal phase ordered 01/05/24. R134's MDS (Minimum Data Set) from 01/12/24 BIMS (Brief Interview for Mental Status) was 07 out of 15 indicating severe cognitive impairment. Facility provided policy titled, Meal Tray Service Policy dated 10/2017 which documents in part meal tray service to residents dining on the unit arrives in multiple carts at approximately the same time so meals can be served simultaneously as is possible. Facility provided document titled Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities which documents in part your facility must treat you with dignity and respect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 2 of 13 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 03/08/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to refer one (R44) resident with newly evident or possible serious mental disorder to the appropriate state-designated authority in a total sample of 31 residents reviewed. Findings include: On 03/07/2024 at 12:19PM, V2 (Associate Administrator) states the hospital is responsible for completing the Level 1 Pre-admission Screening and Resident Review (PASARR) prior to a resident's admission to the facility. V2 states the facility ensures the resident has a Level 1 PASARR prior to admission because this ensures the facility receives payment. V2 states without the Level 1 screening, the facility cannot receive payment. V2 states if a resident has a mental health diagnosis upon admission, then the resident should have a Level 2 PASARR screening. V2 states she was not aware that the facility was responsible for referring residents for a Level 2 screening if a resident develops a mental health diagnosis after being admitted to the facility. R44's Face sheet documents that R44 is an [AGE] year-old female admitted to the facility on [DATE] who has diagnoses not limited to: schizoaffective disorder (07/07/2023), dementia with anxiety, (07/07/2023), major depressive disorder (11/09/2021). Record reviewed documents that R44 has an initial Level 1 Pre-admission Screening and Resident Review/PASARR dated 09/27/2021. There is no documentation to show that R44 was screened for a Level 2 PASARR. On 03/07/2024 at 3:13PM, V2 (Associate Administrator) states the facility does not have a PASARR policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 3 of 13 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 03/08/2024 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 observation, interviews and records review, the facility failed to change oxygen tubing and humidifier bottle weekly according to facility policy and failed to obtain a physicians order to continuously administer oxygen to one (R42) resident of six reviewed for oxygen in a sample of 31. Residents Affected - Few Findings include: On 3/5/24 at approximately 11:50 AM, surveyor observed oxygen tubing/nasal cannula and humidifier bottle being used by R42. 2/22 (12 days prior to 3/5) was written on the humidifier bottle, there was no date on the nasal canula. On 3/5/24 at 12:00 PM, V16 (Registered Nurse) stated the oxygen tubing and humidifier bottle should be changed weekly. V16 stated it did not look like R42's oxygen tubing/nasal cannula and humidifier bottle had been changed within the week according to the date, 2/22, written on the bottle. V16 stated the tubing and bottle should be changed weekly for infection control. Since the nasal cannula is in the nose, if it is not changed appropriately, it is possible for the resident to breath in and catch something. On 3/7/24 at 11:36 AM, V3 (Director of Nursing) stated the nasal cannula tubing and humidifier bottle should be labeled with the date it was changed. The bottle and tubing should be changed once a week, every Wednesday. Nursing standard is to label both the tubing and bottle. They are labeled in order to monitor infection control for both the tubing and the bottle. The humidifier bottle observed on 3/5 that was labeled 2/22 means the tubing and bottle were changed on 2/22. The tubing and bottle were outdated and not changed when they should have been, weekly. There is potential risk to the resident for infection. On 3/7/24 at 11:47 AM, V2 (Associate Administrator) stated the 11PM-7AM, night shift, changes the oxygen humidifier bottle and tubing every Wednesday. On 3/8/24 at 10:10 AM, V3 (Director of Nursing) stated to place a resident on oxygen therapy there should be a diagnosis, symptoms, shortness of breath, clinical assessment, COPD (Chronic Obstructive Pulmonary Disease), Asthma, difficulty breathing. You need a doctor's order to administer oxygen. R42's order for oxygen therapy was placed 3/5/24 at 15:27 (the day surveyor entered facility and questioned staff about oxygen setup labeling and dating). I'm not seeing a discontinued order for oxygen therapy. Since I've been here, 1/12/24, R42 has been on oxygen, on a daily basis. If the resident is showing shortness of breath, then the nurse on duty should update the doctor and receive an order for oxygen therapy. There should be a physician order for continuous oxygen therapy. V3 stated the order for oxygen administration is in the paper chart. Nurses have been charting on electronic medical record for a year. They (facility) merged paper with electronic medical record September 2022. Nurses are currently using electronic medical record. R42 diagnoses include but are not limited to chronic obstructive pulmonary disease, asthma, iron deficiency anemia, type 2 diabetes mellitus, shortness of breath. R42 POS (Physician Order Summary) printed 3/7/2024 documents in part: Oxygen - change tubing, humidifier, cannula every night shift every Wed (Wednesday), order date 3/5/2024 (the day surveyor entered facility and questioned staff about oxygen setup labeling and dating). Oxygen at 1-2L/NC (liters/nasal cannula), order date 3/5/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 4 of 13 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 03/08/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R42 care plan dated 11/11/2022 documents in part: R42 is at risk for SOB (shortness of breath)/respiratory distress related to COPD (chronic obstructive pulmonary disease)/Asthma and history of pneumonia. Resident has an order for O2 see TAR/POS for current orders. Per care plan interventions include OXYGEN SETTINGS: O2 2-3l/min via nasal. R42 Physician's Order Sheet from paper chart, 6/16/22, documents O2 (oxygen) Saturday, check every shift, start 6/16/22. Facility Oxygen Therapy Policy, 6/2023, documents in part: Oxygen Therapy is used when there is evidence of respiratory distress. Oxygen is administered according to the doctors orders. Nasal tubing/mask and humidifier must be changed weekly or as needed. [NAME] date of the replacement on the humidifier bottle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 5 of 13 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 03/08/2024 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 - Few 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 review of records, facility failed to ensure expired medications are discarded from the medication cart for 2 (R57, R42) out of three residents reviewed for expired medications in a sample of 31. Findings include: On 03/05/24 at 12:32 PM surveyor checked through 3rd floor medication cart #1 and medication cart #2. On 3rd floor cart #2, surveyor observed R42's Flutcasone metered does inhaler with the dates, O: 1/21/2024, X: 3/3/2024. Surveyor asked V16 (Registered Nurse) was does O and X mean. V16 stated O mean opened and X mean expired. Surveyor asked for a copy for R42's metered dose medication label packet. After making a copy, surveyor observed V16 putting the medication back into the cart. Surveyor also observed R57's Anoro Ellipta Aerosol Powder opened but not dated on the packet. On 03/07/2024 at 11:30 AM, V2 (Director of Nursing) stated that once an inhalation medication is opened is should be dated. After Anoro Ellipta metered dose inhaler is opened, that medication is good for 6 weeks. V2 stated that medications are not effective after their expired date. V2 stated that medications should be discarded after expired date. Facility's Administration Procedure for All Medications policy (Undated) documents in part: Check expiration date on package/container before administering any medication. When opening a multidose container, place the date on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 6 of 13 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 03/08/2024 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 ensure food items were labeled, discard expired food items, label dry storage items with a delivery date to ensure first-in-first-out policy is followed and store scoops outside of food bins. These failures have the potential to affect all 142 residents receiving food prepared in the facility's kitchen. Findings include: On 03/05/24 at 9:32 AM, started initial kitchen tour with V4 (Dietary Aide) because V5 (Food Service Supervisor) was not in the building yet. V4 stated everything in the walk-in refrigerator should be labeled and dated with a prepared date and use by date. V4 stated prepared food items should be discarded after seven days. On 03/05/24 at 9:50 AM, V5 (Food Service Supervisor) arrived in the kitchen and stated all items in the refrigerator need to be labeled and dated so that the staff knows when to discard what has been prepared. Items need to be used within seven days with day one being the date the food was prepared. On 03/05/24 between 9:36 AM - 10:12 AM, observed the following items in the walk-in refrigerator the without labels or dates: 1.) One large pan of sliced bologna not labeled or dated. 2.) One large pan of sliced turkey or chicken not labeled or dated. 3.) A plastic container filled with unidentifiable substance which was not labeled or dated. The substance appeared old. V4 stated I don't know what that it. I wouldn't eat it. It looks like it's spoiled. I don't know how long it's been in there because there is no date on it. 4.) Large metal bowl filled with what appeared to be shredded mozzarella cheese not labeled or dated. V4 stated this item should be labeled and dated. I don't know how long it has been in here. 5.) Two plates of salad wrapped in between two plastic plates not labeled or dated. V4 stated the items should be labeled and dated so the staff knows if it can still be used or not. 6.) Metal container filled with cooked waxed beans, carrots and broccoli with no label or date. 7.) Metal container with cooked shredded chicken not labeled or dated. 8.) Metal sheet pan containing chicken covered in tomato sauce or BBQ sauce. V5 stated I don't know how long it's been in here since there is no date on it. 9.) Large container of what appeared to be beef stew. V5 stated this was made last night. V5 stated there is no label or date on it and who ever put it in here should have labeled and dated it. On 03/05/24 at 9:43 AM, observed a large container of pureed sweet potatoes labeled with prepared date of 02/24/24. The item was not labeled with a use by date. V4 stated items are good for seven (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 7 of 13 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 03/08/2024 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 days with day one being the preparation date. V4 stated V4 would not serve the pureed sweet potatoes to the residents because it has expired from its shelf life and should be thrown out. On 03/05/24 at 9:53 AM, V5 viewed the pureed sweet potatoes labeled with prepared date of 02/24/24 and stated the pureed sweet potatoes should have been discarded because it is over the seven-day period. Residents Affected - Many On 03/05/24 at 10:27 AM, during tour through dry storage area observed that none of the number ten cans were labeled with any delivery date. V5 stated V5 is in charge of receiving all the deliveries and storing them on the shelves. V5 stated V5 does not label any delivered items with a date. V5 stated when a new delivery of an item arrives V5 rotates the old items to the front and the newer items to the back to use first-in-first-out. V5 stated the cooks come into the dry storage room to pull items to use and V5 expects them to pull products toward the front to be used first. On 03/05/24 at 10:35 AM, observed line of number ten cans of red kidney beans on one storage rack and two number ten cans of red kidney beans on a separate storage rack away from the other red kidney bean cans. V5 stated the red kidney beans on this shelf (pointing to the line of cans) just came in so the other ones should be used first. Surveyor asked V5 how the cooks would know which can use if they are not labeled with a delivery date. V5 stated V5 would have to tell them which ones to use. On 03/05/24 at 10:40 AM, observed storage containers of bin foods. The following bins had product inside but were not dated: rice, matzo meal, black beans. On 03/05/24 at 10:44 AM, observed flour bin dated 04/27/23. V5 stated this is not the correct date and removed the label from the container. Surveyor asked V5 to open the lid and saw that there was a ceramic bowl stored inside the flour bin. V5 stated that the bowl being used as a scoop should not be stored inside the container. On 03/06/24, V5 provided list of residents and diet orders. Two residents receive nothing by mouth (NPO) per the report. On 03/07/24 at 9:13 AM, V3 (Director of Nursing, Registered Nurse) stated there are two residents at the facility who are NPO. Facility provided kitchen policy titled; Discarding of Food dated June 2022 which documents in part all prepared food items will be discarded within 7 days from day of preparation. Facility provided kitchen policy titled Food Labeling dated May 2019 which documents in part all cooked food items stored in the refrigerator should be labeled with the name of the food item, the date it was prepared and cooked food items should be discarded within 7 days. Facility provided kitchen policy titled Policy for Receiving and Storage of Food Items dated 7/2016 which documents in part once a food item (without a printed expiration date) is removed from the original box or packaging, the item is then to be labeled with the date of delivery. Newer items are to be stored underneath or behind older items to ensure a rotation of stock. Facility provided kitchen policy titled Storage of Dry Food undated which documents in part the purpose is to prevent foodborne illness and food items will be used from the inventory as first-in, first-out and scoops will not be stored in food bins. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 8 of 13 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 03/08/2024 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to date food items and discard expired food items in resident personal refrigerator for 1 (R118) resident reviewed in the sample of 7 for safe personal food storage. Residents Affected - Few Findings include: On 03/05/24 at 12:33 PM, observed personal refrigerator in R118's room. R118 gave surveyor permission to look inside R118's refrigerator. Surveyor observed an opened 16-ounce container of Creamy Caesar Dressing with 25% left in the bottle dated with best by date 08/16/23. R118 said, I just had some of that the other day and it was okay. Observed numerous packages of different types of cheese (American, Swiss) in various zip lock bags not dated or labeled. On 03/05/24 at 12:45 PM, V6 (Registered Nurse) stated food in resident's personal refrigerators should be dated by the Certified Nursing Assistant and thrown out after three days. V6 stated the expiration dates listed a food product is followed and any expired items are thrown out so that the resident does not get sick by consuming the expired item. On 03/05/24 at 12:50 PM, V6 observed in R118's personal refrigerator opened 16-ounce container of Creamy Caesar Dressing and stated it had expired and should be thrown out. V6 observed various packages of cheeses inside R118's personal refrigerator and stated the bags of cheese should each be dated because you cannot tell how long the item has been in there unless it is dated. On 03/07/24 at 9:13 AM, V3 (Director of Nursing, Registered Nurse) stated food items in resident personal refrigerators should be dated and the nurses would go by the labeled date to know when a food item needed to be thrown out. V3 stated if an item is not dated the staff would not know when to throw it out unless the resident is alert and orientated and could tell them. V3 stated the facility does not want residents to potentially get sick by eating an expired food item. R118's diagnosis which includes but not limited to Multiple Sclerosis, Spinal Stenosis, Anxiety Disorder. R118's Physician Orders dated 03/06/24 documents in part General diet, regular texture, regular/thin consistency ordered 06/07/23. R8's MDS (Minimum Data Set) from 12/06/23 BIMS (Brief Interview for Mental Status) was 15 out of 15 indicating intact cognition. Facility provided policy titled, Resident Personal Refrigerators dated 10/22 documents in part, 11-7 nursing staff will check refrigerators at least weekly for expired foods to be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 9 of 13 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 03/08/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 144 residents who reside in the facility. Residents Affected - Many Findings include: On 03/05/24 at 11:05 AM, during observation of the outside garbage dumpster with V5 (Food Service Supervisor) observed large dumpster with 2 of the 6 lids wide open with garbage bags bulging out of the opened lids. V5 stated the lids should always be closed to prevent garbage from blowing out and to prevent rodents from getting inside. V5 stated this is important because we don't want rodents near the building. V5 trying to close the lid of the dumpster but it would not fully close all the way because the dumpster was too full of garbage. On 03/06/24 at approximately 9:30 AM, three surveyors observed a dead rodent in the facility driveway close to the side of the building by the side entrance. On 03/06/24 at 12:58 PM, V14 (Housekeeping/Laundry Supervisor) stated V14 tells the housekeeping staff to close the lids to the dumpster because V14 does not want rats to get inside and/or garbage to fly out of the dumpster. On 03/06/24 at 1:02 PM, looking out the stairwell window in between the 2-3rd floor observed with V14 the back alley overlooking the facility dumpster in full view. Observed one of the dumpster lids wide open. V14 verbalized that the dumpster lid was open and stated, it should be closed. On 03/07/24 at 1:17 PM, V29 (General Manager of Pest Control Company) via phone interview stated the facility has a contract with the pest control company to provide preventative measurements for general invaders such as ants, roaches, mice related to the interior and rats and mice for the exterior area. V29 stated preventative measures the facility can do to keep pest control activity down is to make sure that when staff put garbage in the dumpster, they are not overfilling the dumpster and to make sure the lid of the dumpster is closed all the way. V29 stated that keeping the lid to the dumpster closed is important because the rats go to the path of least resistance. V29 stated if there is a dumpster with the lid closed, and another dumpster down the alley with the lid open then rats will go to the dumpster with the open lid. V29 stated dumpsters are the rodent's restaurant and that access to open dumpsters would continue to attract rodents to the area. On 03/06/24 at 4:10 PM, V1 (Administrator) stated the facility does not have a policy about garbage disposal or how to depose of garbage and refuse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 10 of 13 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 03/08/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and records review, the facility failed to maintain infection prevention protocols for one (R110) resident on contact precautions by not wearing proper personal protective equipment to render care. Residents Affected - Few Findings include: On 3/5/24 at 11:30 AM, V15 (Registered Nurse) stated R110 is on transmission-based precaution for ESBL (extended spectrum beta lactamase) urine. 3/5/24 at 12:50 PM, observed a sign reading Contact Precautions on R110's door. Observed V20 enter R110's room with no PPE (Personal Protective Equipment) gown on. On 3/5/24 at 1:00 PM, V20 (Certified Nursing Assistant) stated V20 repositioned and checked R110's adult brief. V20 stated of course V20 had to touch R110 to complete those tasks. V20 stated R110 is on precaution and V20 is supposed to put on gloves and gown to go into R110's room. V20 stated V20 did not put on a gown because V20 did not have contact with fluids. I just repositioned and checked R110's brief. V20 stated the purpose for PPE is to protect self from infection. Without wearing the proper PPE there is a chance/possibility to pass on infection to other residents. On 3/7/24 at 11:36 AM, V3 (Director of Nursing) stated if the yellow contact precaution sign is posted on the resident's door, then the resident is on contact precaution. Staff have to hand sanitize and wear their PPE (Personal Protective Equipment). For contact precaution, staff should wear gloves and gown when they go inside the room. If the staff person is not wearing the proper PPE and is in contact with the resident, then there is risk for infection to other residents that the staff person encounters. If the staff person repositioned the resident and checked the residents brief, then that is contact, and the staff person should have on a gown. For residents on contact precaution, we place a bin outside the room with appropriate PPE. We have an adequate amount of PPE in the building for staff. We can get PPE from [NAME] County. We have extra PPE supplies inside the medication room. Central supply replenishes PPE at the end of each shift and as needed. R110 diagnoses include but are not limited to extended spectrum beta lactamase (ESBL) resistance, acquired absence of left leg above knee, blindness right eye category 3, low vision left eye category 1, senile degeneration of brain. R110 Physician Order Summary, printed 3/7/2024, documents in part: Transmission-based precautions with appropriate PPE every shift, start date 2/22/2024. R110 care plan, provided by facility 3/7/24, not dated, documents in part: R110 readmitted with dx (diagnosis) of ESBL urine. Placed on contact isolation, all services and care rendered inside a private room, with intervention, maintain contact isolation precautions as ordered to prevent spread of infection. Facility Contact Precautions signage documents in part: Everyone must: Put on gown before room entry. Facility policy Isolation - Categories of Transmission-Based Precautions, 11/2017, documents in part: Contact Precautions - Wear a disposable gown upon entering the Contact Precautions room or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 11 of 13 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 03/08/2024 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 0880 cubicle, if contact with blood or bodily secretions is possible. 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: 145532 If continuation sheet Page 12 of 13 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 03/08/2024 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 19 resident's rooms out 86 rooms in the facility. This failure has the potential to affect 26 (R138, R16, R111, R41, R52, R130, R342, R86, R139, R12, R91, R72, R119, R114, R51, R44, R129, R127, R90, R88, R134, R61, R126, R109, R58, R24) residents in a sample of 144 residents. Findings include: On 03/05/24-03/08/24 during the facility tour on the first, second and third floors, observations were made of room sizes. On 3/6/2024 at 12:33pm, V1 (Administrator) said there are 19 rooms that do not measure 80 square feet per resident. V1 stated the furniture in those rooms is arranged to make sure there is space for the residents and some of the considerations the administrative team does is to consider the residents who will occupy these rooms to make sure they can be comfortable in these rooms because the bed sizes are smaller, and ambulatory status of the residents is considered. V1 stated no resident, or their family members have complained about the room size, and V1 submits a waiver every year. On 03/06/2024 at 1:14pm, V2 (Associate Administrator) stated no construction or modification has been made to the 19 rooms at this time, and the facility is an old building with no additional space to increase the rooms sizes. V2 further stated, the rooms are in different places within the building, therefore modification of those rooms is not possible. V2 stated administrative team always considers who to put in these rooms to make sure the residents are comfortable. V2 said for example, if one resident has a wheelchair in these rooms, then the other resident sharing the room cannot have a wheelchair but can have a walker. R88, R90, R127, R119, R114, R72 were interviewed. None of them voiced any concerns regarding their room sizes. All said they were happy with their rooms. Reviewed facility's room chart with 19 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 13 of 13