Inspection·September 29, 2023

F 0677 Hygiene (bathing, dressing, grooming, and oral care); Level of Harm - Minimal harm or potential for actual harm 2. Mobility (transfer, bed mobility and ambulation, including walking); Residents Affected - Few 3. Elimination (toileting); FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 2 of 4 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 145659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford Care Center, The 7445 North Sheridan Road 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to provide an antiretroviral medication for a resident with Human Immunodeficiency Virus (HIV), and failed to notify the prescribing physician the medication was not available to the resident for one (R2) of ten residents reviewed for medications. Residents Affected - Few Findings include: R2's face sheet documents medical diagnosis of HIV disease. R2's physicians' order sheets document an order for Abacavir-Dolutegravir-Lamivud Tablet 600-50-300 MG (milligram) Give 1 tablet by mouth at bedtime for HIV infection. On 9/26/2023 at 11:32 AM, R2 was alert and oriented to person, place, and date. R2 stated R2 recently restarted the antiretroviral medication after R2's appointment with V18 (Infectious Disease Doctor) on 9/05/2023. R2 stated R2 was off the medication for a few months because the facility did not have it, and did not get it from the pharmacy. R2's September Medication Administration Records (MAR) document a charting code of 9 for 9/01/2023-9/03/2023 for R2's Abacavir-Dolutegravir-Lamivud. Per MAR Chart Codes, 9 indicates Other / See Progress Notes. Surveyor reviewed R2's MARs from April through September. Staff charted 9 for most of the dates for the antiretroviral medication. Progress notes, dated 9/02/2023 9:20 PM and 9/03/2023 9:58 PM, document Abacavir-Dolutegravir-Lamivud was not available. Multiple progress notes from May through September document it was not available. Progress note from 4/14/2023 documents it was not available. On 9/26/2023 at 11:38 AM, V4 (Nurse) stated R2 was not taking the antiretroviral medication for a few months. V4 stated medication was not refilled until 9/05/2023. V4 showed surveyor the printed label with the dispense date on R2's medication bottle; Dispensed 9/05/2023. On 9/27/2023 at 12:58 PM, V16 (Social Service Director) stated Illinois's AIDS (Acquired Immunodeficiency Syndrome) Assistance Program (ADAP) provides coverage for R2's antiretroviral mediation. V16 stated there was a lapse in coverage; therefore, the pharmacy did not refill the medication. V16 stated V16 did not know if V18 (Infectious Disease Doctor) or V19 (R2's Primary Physician) were aware the pharmacy did not fill the medication, or that R2 has not taken it for months. On 9/27/2023 at 1:24 PM, V17 (Nurse Practitioner) stated staff did not notify V17 that pharmacy did not refill R2's Abacavir-Dolutegravir-Lamivud from April until September. Staff did not notify V17 it was not available for a prolonged time. V17 stated R2 needs to take the antiretroviral medication because it will help increase R2's mortality. If R2 does not take the medication, then it increases R2's chances of getting AIDS and being in the end stage of HIV. V17 stated R2's life will be shortened if R2 does not take it. On 9/28/2023 at 1:51 PM, V18 stated the facility did not notify V18 that R2's Triumeq (brand name for Abacavir-Dolutegravir-Lamivud) was not available, and R2 was off the medication for months. V18 stated the medication's purpose is to have an undetectable viral load in the patient, maintain or raise a patient's CD4 count, and maintain health. V18 stated when V18's office conducted blood work on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 3 of 4 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 145659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford Care Center, The 7445 North Sheridan Road 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2 on 9/05/2023, R2's viral load was high, which was an indication that either R2 was not taking HIV medications, or that there was viral resistance. V18 stated R2's CD4 count on 9/05/2023 was also lower compared to R2's results from 4/13/2023. V18 stated if R2 is not taking the medication, R2 is at risk for the development of opportunistic infections. On 9/28/2023 at 2:01 PM, V2 (Director of Nursing) stated if a specialty medication such as R2's antiretroviral medication is not available, the nurse should call the doctor and get an order to see if there is any alternative. V2 stated staff did not notify V2 if this was done. Facility's Administering Medications policy, last revised 4/2019, documents in part: Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 4 of 4