Inspection·December 13, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Once (R40) gets back, (R40) starts right back up. We're asleep and it wakes us up. Just listening to it all day and night is aggravating. R57's admission Record documents, in part, R57's diagnoses including but not limited to: polyosteoarthritis, chronic kidney disease, hypothyroidism, and hypertension. Residents Affected - Few R57's MDS, dated , 11/07/23, documents, in part, R57's BIMS score is 13, which indicates that R57 is cognitively intact. On 12/12/2023 at 11:19 am, surveyor asked how the facility is ensuring residents' rights of other residents for a quiet environment with R40's audible loud noises. V2 (Director of Nursing/DON) stated, We have made room changes for other residents. When asked who these other residents were, V2 stated, I cannot remember which residents those were. Surveyor asked if any residents have expressed concerns or grievances about R40's loud noises. V2 stated, I don't know if other residents filed grievances in regard to this matter. Surveyor asked if residents have the right to a calm, quiet environment. V2 stated, If you hear it all day and all night it's not a homelike environment. Facility document dated 9/19/23 and titled Concern/Response Form, documents, in part, that concerns were expressed regarding noises in R40's room. In R40's Progress Note, on 10/6/23 at 2:42 pm, V19 (Social Services Director, SSD) documents, in part, Writer received a concern from other residents on the floor (B-side) that they cannot sleep at night because resident is screaming during the night. In R40's Progress Note, on 11/3/23 at 8:20 am, V8 (Licensed Practical Nurse, LPN) documents, in part, (R40) nonverbal, screaming and yelling . disturbing other residents with loud screaming. In R40's Progress Note, on 11/14/23 at 12:11 pm, V19 (SSD) documents, in part, Writer received a concern from other residents on the floor (B-side) that they cannot sleep at night because resident is screaming during the night. Facility presented contract titled, Facility admission Contract, with a revised date of January 2022. This contract documents, in part, . No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the Constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of the Community, nor shall a resident forfeit any of the following rights: 1. The right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy, and choice and to be treated with consideration and respect; Facility document dated 8/20/2021 and title, Residents' Rights for People in Long-term Care Facilities, documents, in part, You have the right to .Your facility must provide services to keep your physical and mental health, and sense of satisfaction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 2 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/10/2023 at 11:36am, R198 was lying on a Low Air Loss (LAL) mattress. The setting of R198's LAL mattress observed at 230 pounds. Residents Affected - Few On 12/10/2023 at 12:30 pm, this surveyor inquired with R198 about R198's weight. R198 stated, I (R198) weigh about 120 pounds. R198's admission Record documents, in part, R198's diagnoses including but not limited to: hypertension, hyperparathyroidism, chronic kidney disease, Hemiplegia and Hemiparesis. R198's Minimum Data Set (MDS), dated [DATE], documents, in part, R198's Brief Interview for Mental Status (BIMS) score is 09, which indicates R198 is moderately cognitively intact. R198's (printed date: 12/12/2023) Monthly Weight Report documented, in part December 114.0 lbs (pounds). R198's Patient Risk Profile, dated 12/07/2023, documents a Braden score of 13 which shows R198 is at moderate risk for developing a pressure ulcer injury. R198's Care Plan, with initiated on 4/24/23 with last review completed on 11/6/23, documents, in part, a focus of (R198) is at risk for alteration in skin integrity and additional skin breakdown based on co-morbidities stroke, HTN (hypertension), CDK (chronic kidney disease) stage 5, ESRD (end stage renal disease), renal dialysis, HLD (hyperlipidemia), anemia, hyperparathyroidism, anemia, protein-calorie malnutrition, insomnia, hypertensive urgency, DM-II (type 2 diabetes mellitus) and sacroilitis with an intervention of Apply Special mattress on bed LAL (Low Air Loss Mattress) for preventative. R198's Order Summary Report documents, in part, an active order (dated 12/6/23) for Pressure relieving mattress. Based on observation, interview, and record review, the facility failed to have low air loss mattress at the correct weight settings for a resident with pressure ulcer who was at high risk for further pressure ulcers, and for another resident at risk for pressure ulcers. This failure affected two residents (R26 and R198) of two residents, reviewed for pressure ulcer prevention interventions, in a total sample of 50 residents. Findings include: 1. On 12/10/23 at 10:40am during observation of residents on the fourth floor, R26 was observed on a low-air-loss mattress (LALM) system with the machine weight setting at 100 pounds. On 12/10/23 at 11:50am, and at 1:40pm, R26's LALM was still at a weight setting of 100 pounds. At this time, R26 was asked if she (R26) requested staff to change the LALM weight settings at any time. R26 stated I don't know what they do with the machine, and I just want my wound to heal. R26's weight records show that R26 weighs 172 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 3 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 0686 Level of Harm - Minimal harm or potential for actual harm On 12/11/23 at 11:55am, V14 (Wound Care Nurse) was interviewed and requested to observe R26's LALM. V14 stated, (R26) is on air mattress because of pressure ulcers that has been there for almost a year, and is now healing, and the weight setting should always be at the patient's weight. I usually go round to check the air mattress settings for all the residents. I will remind the CNAs (Certified Nurse Assistants) to make sure they don't put the weight at the wrong setting. Residents Affected - Few R26's Pressure Ulcer Risk assessment dated [DATE] shows a score of 12 (high risk). R26's skin care plan dated 6/3/2020 states in part: (R26) is at high risk for skin impairment. Intervention states to check Air Mattress if functioning properly. R26's MDS (Minimum Data Status) section M dated 10/1/23 states that R26 should have a Pressure reducing device for bed and that R26 has unhealed pressure ulcer. R26's face sheet shows a diagnosis of Pressure Ulcer of Sacral Region Stage 4 dated 6/3/2020. V14 presented the Operations Manual for the Low Air Loss Mattress System for R26. This document states in #9: Turn the pressure adjust knob to set a comfortable pressure level using the weight scale as a guide. Facility's policy titled Skin Care Treatment Regimen with latest revision date 7/28/23 was reviewed. This policy states in #9: Residents with stage 3 or stage 4 pressure ulcer will be placed in specialized air mattresses like low air loss mattress . #b3 and #b4 both state that the Use of Pressure Relief Mattress is part of the treatment for stage 3 and stage 4 pressure ulcers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 4 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review the facility failed to ensure the G-tube feeding was labeled for one resident (R103). This has the potential to affect all residents receiving enteral feeding on the 2nd floor. Findings: R103 has a diagnosis of Sequelae of Cerebral Infarction, Chronic Respiratory Failure with Hypoxia, Metabolic Encephalopathy, Severe Protein-Calorie Malnutrition, Hypertension, Hemiplegia and Hemiparesis following Nontraumatic Intracerebral Hemorrhage, Dysphagia, Oropharyngeal Phase, Aphasia and Gastrostomy. R103's Order Summary Report with active orders as of 12/12/2023 documents Enteral Feed Order every shift Enteral Feeding: G-tube Nutren 2.0 at rate of 50ml for 21 hours to reach 1050ml. On 12/10/2023 at 10:50am surveyor observed R103's g-tube feeding running with no patient identifiers on the bag. On 12/10/2023 at about 11:00am V7 (LPN) stated, feedings are changed every 24 hours and should be labeled with the resident's name, rate, start and stop date and there is no label on R103 feeding or the information section is not completed. On 12/12/2023 at 11:45am surveyor observed R103's g-tube feeding with no patient identifiers on the bag. On 12/12/2023 at 11:47am V23 (LPN) stated, the night shift nurse hangs the feeding and should label the feeding with the name, date, time and rate when hanging the feeding. On 12/12/2023 at 8:46am V2 (DON) stated, g-tube feedings should include the resident's name, room number, rate of feeding and date and time of when the new feeding is hung. Policy titled Enteral Tube Feeding care with a revised date of 7/28/2023 documents, in part, check that Feeding bag is properly labeled to include: resident's name, Formula (If not a closed system) and rate of feeding administration, date and time feeding was started. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 5 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to label with date: the bag of intravenous (IV) fluids being infused, the IV site on the resident's left wrist, and the IV tubing, during administration of intravenous fluids to a resident. This failure affected one resident (R138), reviewed for IV fluids administration, in a total sample of 50 residents. Residents Affected - Few Findings include: On 12/10/23 at 10:50am during observation of residents on the fourth floor, R138 was observed awake in bed with IV(Intravenous) fluids, 1000mL IV Fluid Bag of 5% Dextrose in 0.45% Sodium Chloride infusing at 70 ml (milliliters) per hour. The IV bag was half infused but there was no date or label to show when it was hung up, no label or date on the left wrist IV site, and no label/date on the IV tubing. R138 told the surveyor that the IV was inserted 5 days ago. On 12/10/23 at 12:05pm, R138's IV fluid was running and there was no date on the IV bag, IV tubing and the IV site. On 12/10/23 at 11:20am, V18(Psychotropic Nurse) stated, I helped with putting in the IV and it's not up to 5 days; it was put in on the 8th (12/8/23). V18 was asked why the IV bag, tubing, and site should be labeled with the date. V18 stated, the IV should have a date so they will know when it should be changed. V18 added, I'm not sure when the IV bag was hanged up. I think it should be changed every 3 days. Also, V22 (LPN/Licensed Practical Nurse) stated I just looked in the resident's progress notes, and it shows that the IV fluids started on the 8th (12/8/23). R138's physician order sheets (POS) dated 12/8/23 states Dextrose-NaCl Intravenous Solution 5-0.45 %(percent); Use 70ml per hour intravenously every shift for Treatment for 2 days. On 12/11/23 at 11:55am, V2 (Director of Nursing) stated, the tubing is usually changed when the IV site is changed every 3 days. V2 explained, if there is no date on the site and tubing, they will not know when it should be changed. At this time, V2 presented the facility's policy titled Continuous Infusion dated 12-2014. This policy states in #3 states: Administration set should be changed every 96 hours or per facility policy. #26 states: Label medication/solution container and administration set with: (a)Date and time and nurses initials; (b) Nurse's initials. Another policy titled intravenous therapy with latest revision date 8/7/23 states in #2a: All peripheral IVs and dressing will be removed and IV reinserted on a different site every three days and PRN (as needed). The facility did not follow these policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 6 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that physician ordered oxygen therapy was provided to a resident which affected one resident (R21) in the sample of 50 residents when reviewed for oxygen therapy. Residents Affected - Few Findings include: On 12/11/23 at 10:20 am, R21 observed in bed with nasal cannula oxygen tubing noted on R21's face with the prongs outside of R21's nares above nose. R21's nasal cannula tubing observed disconnected from the humidifier bottle on the concentrator oxygen machine and laying on the floor next to R21's bed. R21's oxygen level is set at 2 liters per minute (L/min) on the oxygen concentrator machine. On 12/11/23 at 10:26 am, this surveyor requested V8 (Licensed Practical Nurse, LPN) to come see R21. This surveyor showed V8 that R21's oxygen is outside R21's nares on R21's face and is disconnected from the concentrator on the floor. V8 stated, sometimes, R21 will pull off the nasal cannula oxygen. V8 stated that the night nurse changes the oxygen tubing at 6:00 am and maybe the night nurse didn't connect it. V8 stated that R21's physician order for oxygen is at 2 L/min with consistent oxygen, and R21 recently had pneumonia and returned from the hospital with oxygen therapy. R21's admission Record, documents, in part, diagnoses of chronic diastolic (congestive) heart failure, pneumonia, sepsis, dementia, chronic respiratory failure with hypoxia and adult failure to thrive. R21's Minimum Data Set (MDS), dated [DATE], documents, in part, that R21 Brief Interview of Mental Status is not conducted with R21's Staff Assessment for Mental Staff indicates that R21 has short and long term memory deficits with R21's Cognitive Skills for Daily Decision Making scored as severely impaired. R21's Order Summary Report documents, in part, an active order, dated 12/4/23, of Oxygen therapy at 2 L/min via nasal cannula continuously. R21's Care Plan, dated 12/8/23, documents, in part, a focus of (R21) has oxygen therapy related to CHF (congestive heart failure) and pneumonia with an intervention of give continuous oxygen 2 L/min via NC (nasal cannula) as ordered by the physician. R21's Care Plan, dated 12/8/23, documents, in part, a focus of (R21) has pneumonia, RLL (right lower lobe) with an intervention of oxygen therapy as ordered - continuous oxygen at 2 L/min via nasal cannula. On 12/12/23 at 11:30 am, V2 (Director of Nursing, DON) stated, nurses must follow physician orders. V2 stated that an order for oxygen therapy is to keep oxygen saturations stable and to ease with (resident) breathing. When asked if there is an order placed for oxygen therapy, nurses should provide oxygen therapy, V2 stated, Yes, (they) follow the order. V2 confirmed that oxygen therapy can be used for resident with pneumonia or congestive heart failure (CHF). When asked how nasal cannula oxygen is delivered to a resident, V2 stated that the oxygen therapy flows in the tube into the resident's nostrils (via the nares prongs). V2 stated that nasal cannula tubing is connected to the oxygen tank or concentrator machine which provides the oxygen. When asked if a resident has a behavior of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 7 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 removing oxygen from nares, what must nurse do, and V2 stated, Staff have to frequently check the resident. When asked with a resident's disconnected nasal cannula oxygen tubing is in contact with the floor, how can this affect the resident, and V2 stated, The resident could develop an infection due to the open end of the oxygen tubing being in contact with the floor. Facility policy dated 7/28/23 and titled Oxygen Therapy and Administration, documents, in part, Oxygen therapy shall be administered to patients as indicated and upon a physician's order. Purpose: To assure adequate oxygenation to all spontaneously breathing and ventilator dependent patients . Procedure: Confirm order from physician . assemble equipment as needed. Use a humidifier for all patients requiring nasal cannula . Note: . b. 2. That the device is connected properly. Facility job description dated 12/1/19 and titled LPN Floor Nurse, documents, in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Licensed Practical Nurse (L.P.N.) plays a critical role in providing superior customer service and nursing care to all Guests. The L.P.N. provides supervision of staff and will safeguard the health, safety and welfare of all Guests/guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions: . 9. Responsible for all nursing care of assigned Guests while on duty. 10. Ensure that Guest care plans are being followed and assess each Guest's status in accord with their care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 8 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 observation, interview and record review, the facility failed to maintain an accurate account of controlled substance record for two residents (R28 and R42) reviewed for controlled substance in a sample of 50 residents. Findings include: On 12/10/23 at 11:37 am, V26 (Registered Nurse) review of 2nd floor team 2 medication cart. (room [ROOM NUMBER]-214, 216-229, excluding 211, 213 and 215). On 12/10/23 at 11:40 am, R28's controlled drug administration record documented, Hydrocodone-APAP 10/325 mg (Milligram) count of 27, observed 25 hydrocodone- APAP 10/325 mg on the medication bingo card. On 12/10/23 at 11:42 am, R42's controlled drug administration record documented Alprazolam 0.5 mg count of 24, observed 23 Alprazolam 0.5 mg on the medication bingo card. On 12/10/23 at 11:45 am, R42's controlled drug administration record documented Hydrocodone-APAP 5/325 mg count of 10, observed 9 Hydrocodone APAP 5/325 mg on the mediation bingo card. On 12/10/23 at 11:46 am, V26 (RN) stated, the night shift nurse took mediation out and did not sign it out. Surveyor inquired if a narcotic count was counted with the outgoing nurse and V26 (RN) stated, No, the nurse was already gone when I (V26) got to work. V26 (RN) stated, I (V26) counted with V7 (LPN) the other oncoming nurse. Surveyor inquired to V26 if the count was not correct doing the morning narcotic count? V26 stated, the night shift nurse must not have signed out the medications when they gave them. On 12/10/23 at 2:12 pm V2 Director of Nursing (DON) stated, narcotic count is counted shift to shift with the incoming nurse and the outgoing nurse. It could be two incoming nurses, as long as the cart is counted. The nurse is expected to sign out medications as soon as they take them out of the medication card. Facility job description undated and titled, RN Floor Nurse, documents in part, Essential Functions: 5. Administer medications within the scope of practice of the RN licensure. Maintain a current report of narcotics received and used. 6. Review daily the documentations of the dispensing of the controlled substances and narcotics. Ensure that drugs covered by controlled substances laws are verified by inventory. Facility Policy (revised 7/27/23) titled Controlled Medications Count, documents in part, Policy Statement: It is the policy of the facility to maintain an accurate count of scheduled II controlled medications. Procedure: 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled mediation sheet indicating the medication is taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 9 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 ensure that medications were secured in a locked medication and treatment cart which has the potential to affect 48 residents on the second floor and 52 residents on the third floor. Findings include: On 12/11/23 at 9:17 am, during the medication pass observation, V9 (Agency LPN) observed standing in front of medication cart A. V9 pulls out the medication cart keys out of V9's scrubs pocket, and a clear, plastic squeeze vial of nebulizer medication falls out of V9's pocket onto the floor. V9 then picked up the nebulizer medication vial (Ipratropium-Albuterol Solution 0.5-2.5 milligrams/3 milliliters) off the floor and placed it on top of medication cart A. V9 asked this surveyor where to show this surveyor the prepared medications, and this surveyor instructed V9 to perform V9's own process and that this surveyor will check the container that the medication is dispensed out of after V9 removes the medications. V9 next removes and prepares R69's medications from medication cart A except the Vitamin D 12 100 mg. V9 stated that V9 will go to the stock room down the hall at the nurse's station to find it. On 12/11/23 at 9:23 am, V9 locks medication cart A, and the nebulizer medication vial is still on top of medication cart A. V9 then holds onto R69's prepared medications (in 2 medicine cups) in V9's hand and walks to the nurse's station where V9 walked into the medication room. V9 comes out of the medication room saying that the stock medications are not in there. V9 then is approached by V13 (Registered Nurse, RN/Electronic Medical Record, EMR nurse) asking what V9 needs. V9 said that V9 needs the Vitamin D 12 100 mg. V13 then leaves off the floor via the elevator to retrieve the medications. V9 is waiting at nurse's station from 9:23 to 9:31 am, down the hallway from medication cart A with V9's back turned towards the cart A. On 12/11/23 at 9:31 am, V9 stated, it's taking a while for V13 to return, and this surveyor reiterated to V9 that V9 performs V9's own process during this medication pass observation. V9 stated, V9 will go to administer R69's medications and walked back to the unattended medication cart A with the nebulizer medication vial on top of the cart. V9 then enters R69's room and administered R69's medications to R69. On 12/11/23 at 9:36 am, V9 walks back to the unattended medication cart A. This surveyor points to the clear, plastic vial of Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml on top of the medication cart A and asks V9 what is this? V9 stated that it's an inhaler from a resident (R35) on the 4th floor. V9 stated that it was in V9's pocket because V9 pulled an extra one (dose) when V9 gave R35 the Ipratropium-Albuterol Solution 0.5-2.5 mg/3 ml this morning on the 4th floor. V9 stated that V9 worked a double shift from 11:00 pm to 7:00 am and moved to the 3rd floor for the day shift 7:00 am to 3:00 pm. On 12/12/23 at 11:30 am, when asked where nurses are expected to store resident medications, V2 (Director of Nursing, DON) stated, In the medication cart. Cart should be locked. When asked the purpose of securing resident medications, V2 stated that residents have no access (to medications) and for safety of other residents. When asked if medications are stored outside of the medication cart, like on top of the medication cart, is the medication secured, and V2 stated, No. V2 stated that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 10 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 resident medication is not secured outside the medication cart when the nurse leaves the area. When asked if the nurse walks down the hallway away from the medication cart, is this acceptable to leave a medication on top of the medication cart, and V2 stated, No, it's not acceptable. What is the possible effect of a resident who would have access or take the unsecured medication, V2 stated, It could cause harm if ingested with it not ordered for that individual resident. Residents Affected - Some R69's admission Record, documents, in part, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cervicogenic headache, aphasia, type 2 diabetes mellitus, major depressive disorder and hypertension. R69's Minimum Data Set (MDS) documents, in part, that R69 has a Brief Interview of Mental Status (BIMS) score of 14 indicating that R69 is cognitively intact. In R69's Progress Note, dated 12/11/23 at 9:45 am, V13 documents, in part, (R69) has order for Vitamin B12 100 mcg (microgram)/tab 1 tablet by mouth once a day; notified (V25, Nurse Practitioner, NP) that med is unavailable as house stock. R35's admission Record, documents, in part, diagnoses of chronic respiratory failure, Parkinson's disease, chronic viral hepatitis C, obstructive sleep apnea, chronic obstructive pulmonary disease, and personal history of COVID-19. R35's MDS documents, in part, that R35 has a BIMS score of 15 indicating that R35 is cognitively intact. R35's Order Summary Report, documents, in part, Ipratropium-Albuterol Solution 0.5-2.5 (3) mg (milligram)/3 ml (milliliter), 3 ml inhale orally four times a day for shortness of breath administer for 15 min with this order date of 7/4/22. R35's Medication Administration Record (MAR) for December 2023 documents, in part, that V9 administered R35's Ipratropium-Albuterol Solution 0.5-2.5 mg/ml inhaler on 12/11/23 at 0000 (midnight) and 0600 (6:00 am). Facility document, titled Daily Staffing for 12/10/23, documents, in part, that for the 11:00 pm to 7:00 am shift, V9 was working as the nurse on the 4th floor. Facility document, titled Midnight Census Report: 12/10/23 and provided to this surveyor on 12/11/23 by V1 (Administrator), documents, in part, that 52 residents reside on the third floor. Facility job description dated 12/1/19 and titled LPN Floor Nurse, documents, in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Licensed Practical Nurse (L.P.N.) plays a critical role in providing superior customer service and nursing care to all Guests. The L.P.N. provides supervision of staff and will safeguard the health, safety and welfare of all Guests/guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions: . 18. Follow established safety precautions when performing tasks. On 12/10/23 Surveyor was presented with a census of 48 residents on the second-floor unit at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 11 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 On 12/12/23 at 10:54 am, Surveyor observed V14's (Registered Nurse, RN, Wound Care Coordinator) treatment cart on the south area of the second-floor unit hallway, unlocked and not in view of staff. Surveyor observed treatment medications noted in the unlocked treatment cart. Residents noted going back and forth in the second-floor hallway while V14 was inside of R37's room with R37's door closed. On 12/12/23 at 10:59 am, this observation was brought to V14 and V14 stated The cart (referring to V14's treatment cart) should be locked at all the time while I (V14) am in a residents room. V14 was asked regarding the importance of ensuring treatment medications are secure in locked treatment cart. V14 stated, Lots of medications that are dangerous for people are inside. Someone can eat them and have an allergic reaction or get harmed. On 12/12/23 at 11:28 am, V2 (Director of Nursing, DON) stated, the treatment cart should be locked at all times unless it is in the nurses view. When V2 was asked regarding the importance of the treatment cart locked when unattended and V2 stated that the treatment cart should be locked when not in use and out of view of the nurse for the safety of the residents. V2 explained if residents obtain medications from an unattended treatment cart the resident can get harmed from the medications if the medication is not prescribed to the resident. R37's Brief Interview for Mental Status (BIMS) dated 09/22/23 documents that R37 has a BIMS score of 15 which indicates that R37 is cognitively intact. R37's has a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, morbid (severe) obesity due to excess calories, opioid dependence in remission, and other adrenocortical insufficiency. The facility's policy dated 08/24/23 and titled Medication Storage, Labeling, and Disposal documents, in part: Policy Statement: It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. Procedures: .4. Medications will be secured in locked storage area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 12 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 properly log refrigerator temperatures for two residents (R 47 and R110); and failed to discard expired food from a resident (R110) refrigerator. These failures affected R47 and R110 in the sample of 50 residents. Residents Affected - Few Findings include: R47 has a diagnosis which includes but not limited to vitamin D deficiency, corticobasal degeneration, anemia, dysphagia oropharyngeal phase, acute respiratory failure with hypoxia, mixed hyperlipidemia, malignant neoplasm of prostate, anxiety, and spinal stenosis. R47's Brief Interview for Mental Status (BIMS) dated 09/30/23 documents that R47 has a BIMS score of 00 which indicates that R47 is cognitively impaired. During this interview R47 was able to answer questions appropriately. R110 has a diagnosis which includes but not limited to hypertensive heart disease without failure, seborrhea capitis, major depressive disorder single episode, generalized anxiety disorder, vitamin D deficiency, mixed hyperlipidemia, other insomnia not due to a substance or known physiological condition, obstructive sleep apnea, essential primary hypertension, gastro-esophageal reflux disease without esophagitis, alcoholic cirrhosis of liver without ascites, fatty (change of) liver, hypomagnesemia, alcohol abuse. R110's Brief Interview for Mental Status (BIMS) dated 09/12/23 documents that R92 has a BIMS score of 15 which indicates that R92 is cognitively intact. On 12/10/23 at 11:55 am, R110 was observed in bed awake and alert. R110's personal refrigerator was observed with an incomplete temperature log sheet dated Month: 11, and the last refrigerator temperature log recorded 11/08/23. Surveyor observed 1% low fat lactose free milk with an expiration date of 2022 in R110's personal refrigerator. R110 stated, R110 cleans and defrost R110's refrigerator himself at the facility. The facility's document dated year: 2023 (2023), month: 11 (November) and titled Resident Refrigerator Temperature Log and Weekly Cleaning documents, in part: R110's personal refrigerator last temperature log recorded on 11/08/23. On 12/10/23 at 12:13 pm, R47 was observed sitting in a wheelchair in the activity area of the second-floor unit with R47's private caregiver. Surveyor observed R47's personal refrigerator inside of R47's room with an incomplete temperature log sheet and the last recorded temperature log dated 12/03/23. R47 stated, R47 does not know when the last time R47's refrigerator was checked by staff. The facility's document dated year: 2023, month: Dec (December) and titled Resident Refrigerator Temperature Log and Weekly Cleaning documents, in part: R47's personal refrigerator last temperature log recorded on 12/03/23. On 12/11/23 at 2:37 pm, V21 (Environmental Service Director) stated, V21 manages the housekeeping services in the facility. V21 stated, the housekeeping department at the facility is responsible for cleaning the residents personal refrigerators and completing the personal refrigerator temperature logs at the facility. V21 explained, the residents personal refrigerator temperature log sheets are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 13 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few completed every day by the housekeeping staff. When V21 was asked regarding discarding expired foods from the residents personal refrigerators V21 stated, The nurses and the Certified Nursing Assistants, (CNA's) are responsible for removing expired food from the residents personal refrigerators. When V21 was asked regarding the purpose of ensuring that the residents personal refrigerator temperature logs are completed and that expired foods are removed from the residents personal refrigerators V21 stated, To ensure cleanliness and so that bacteria does not build up. Temperature logs are checked to make sure the refrigerators are in working order and so that food does not spoil. On 12/11/23 at 2:50 pm, V2 (Director of Nursing, DON) stated, the housekeeping department is responsible for cleaning the residents personal refrigerators, completing the residents personal refrigerator logs, and removing expired foods from the residents refrigerators. V2 stated, the nurses and CNA's are not responsible for removing expired foods from the residents personal refrigerators. On 12/12/23 at 10:11 am, V4 (Director of Maintenance) stated, all resident personal refrigerator checks are done by the housekeeping department at the facility. V4 explained that cleaning the residents personal refrigerators, completing the residents personal refrigerator logs, and removing expired foods from the residents refrigerators are done by the housekeeping department at the facility. On 12/12/23 at 3:05 pm, V1 (Administrator) was asked to provide the facility's policy regarding the residents personal refrigerator temperature logs and discarding of expired foods from the residents personal refrigerators. V1 (Administrator) stated, the facility does not have a policy for the logging of the residents personal refrigerator temperatures, or the discarding of expired foods from the residents refrigerators. The facility's policy dated 07/28/23 and titled Refrigerator and Resident Appliance Maintenance Service documents, in part: Procedure: 1. The maintenance department or facility designee is responsible for maintaining the resident appliance e.g., refrigerators are safe, clean and operable at all times. a. Refrigerator in resident room . e. ensure proper dating and disposition of outdated food items including food brought by family and residents from the outside. The facility's policy dated 07/28/23 and titled Food from the Outside Policy documents, in part: Policy: The facility will comply with sanitary food practices in storing, handling, and consumption of food brought by family and visitors from the outside of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 14 of 15 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 that the lids on the outside dumpsters were closed and maintained in a sanitary condition to prevent the harborage and feeding of rodents and pests. This failure has the potential to affect all 150 residents in the facility. Residents Affected - Many Findings include: On 12/10/23 at 11:30am after the entrance conference, the facility census was 150 as reported by V1 (Assistant Administrator). On 12/10/23 at 9.20am, two outside dumpsters were observed. Each dumpster had a lid attached. The larger 3 compartment dumpster had the middle lid flipped to the back of the dumpster, and the smaller dumpster also was left open. On 12/10/23 at 10:45am immediately after observation of the kitchen with V16 (Cook), the dumpsters were still in the same conditions. At this time, V16 was asked about why the dumpsters were left open. V16 stated that he believes that the housekeeping staff left the dumpsters open because housekeeping also dumps garbage there. On 12/11/23/at 10:50am, the smaller dumpster had the lid partially covering the dumpster, while the third compartment of the larger dumpster was left uncovered. On 12/11/23 at 11:45am, with V21(Environmental Services Director) was asked why the dumpsters were not closed. V21 stated, the dumpsters should be completely closed to prevent rodents from entering the dumpster and bringing out stuff from the dumpster. V21 added, We don't want those pests coming into the building. I will remind all the housekeeping staff to be sure to always close the dumpsters. Facility's policy titled Waste Management dated 7/14/23 states in part: It is the policy of this facility to maintain a clean environment for waste management. Areas around the dumpsters must be free of debris; cannot be overflowing with garbage; must have lids, and lids must be closed. The facility did not follow this policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 15 of 15