Health inspection·January 12, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm R24's Order Summary Report, dated 01/10/24, documents in part Advanced Directives: Full Code ordered 10/04/16. On 01/10/24 at 09:54 AM, surveyor reviewed R24's care plans. R24 has no care plan for Advanced Directives in R24's EHR (Electronic Health Record). Residents Affected - Some 5. R40 admitted to the facility 08/24/22. and diagnoses included Parkinsonism, Type 2 Diabetes Mellitus, Dysphagia, Unspecified Psychosis, Peripheral Vascular Disease, Cognitive Communication Disorder, Schizoaffective Disorder, Chronic Lymphocytic Leukemia, Major Depressive Order, and Bipolar Disorder. R40 MDS, dated [DATE], BIMS score of 12/15, indicating moderately impaired cognitive function. R40's Order Summary Report, dated 01/10/25, documents in part Advanced Directives: Full Code, ordered 06/08/23. On 01/10/24 at 10:27 AM, surveyor reviewed R40's care plans. R40 has no care plan for advance directives in R40's EHR. On 01/11/24 at 10:46 AM, V28 (Social Service Director) reviewed R40's care plans in R40's EHR and stated, I'm not seeing one and He should have one. At 10:49 AM, V28 reviewed R24's care plans in R24's EHR, and stated R24 does not have an Advanced Directive care plan, and R24 should have one. V28 stated everyone should have an Advanced Directive care plan because it helps with the continuity of care. On 1/11/24 at 9:40 AM, V28 (Social Service Director) stated residents and family members are educated upon admission, quarterly, and as needed about code status related to Advanced Directives. V28 stated sometimes when residents are admitted they already have something in place for their Advance Directives. In this case, V28 reviews their code status to confirm with the resident or representative if that is what they still want. V28 stated some residents refuse to sign the POLST (Physician Orders for Life Sustaining Treatment) form, so V28 lets those residents know their code status will default to full code. V28 stated for those residents who can sign the POLST form, V28 encourages those residents to sign it whether they are full code or DNR (Do Not Resuscitate), but sometimes they refuse to do so. V28 stated all residents who wish to be DNR/DNI (Do Not Intubate) should have POLST forms. V28 stated the facility does not keep binders on the floors with resident's code status information, and all POLST forms should be uploaded in the resident's EHR (Electronic Health Record). V28 stated if a resident does not have a POLST form, then they are considered to be full code. V28 stated a resident's code status should be in the EHR dashboard under special instructions, it should be ordered by the physician, and it should be addressed in the care plan. V28 stated a resident's code status in those three locations should all match. V28 stated if a resident's code status is not the same in one of those locations, then there is a risk that if a resident was to code the staff would not be able to provide the right response. V28 stated all residents should have a separate care plan for Advanced Directives, and V28 is responsible for updating the Advanced Directives care plan quarterly, significant changes, annually and as needed. The facility's policy titled; Advanced Directive Life Sustaining Treatment and End of Life Care Policy and Procedure dated 6/2018 reads in part: POLICY AND PROCEDURE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 2 of 20 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 01/12/2024 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 0578 1. Upon admission: Level of Harm - Minimal harm or potential for actual harm A. An Advance Directive form (as provided by the healthcare facility) will be completed with resident and/or legal representative to verify treatment options as well as code status (full code vs. DNR using the POLST document). Appropriate information will be added to Physician Order Sheet (POS). Residents Affected - Some C. Discussion of Advance Directives and treatment options/refusals shall be addressed in appropriate chart documentation as well as care planned during the admission process. The facility's policy titled; Care Plans, Person-Centered dated 12/2016 reads in part: 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 2. On 1/10/24 at 11:10 AM, R8's electronic health records (EHR) showd an admission date of 9/30/2015, with diagnoses not limited to Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, and Dementia. R8's Minimum Data Set (MDS), dated [DATE], shows R8 is cognitively impaired. R8's face sheet and Physician Order Sheet (POS) with active orders as of 1/10/2024 show Advance Directives: Full Code. R8's comprehensive care plan with goal last revised on 1/13/2023, shows R8's wishes for Do Not Resuscitate (DNR) will be honored. 3. On 1/10/24 at 12:53 PM, R128's electronic health records were reviewed, and there was no code status found in R128's physician orders or dashboard. R128's EHR shows an admission date of 11/03/23 ,with listed diagnoses not limited to Dementia and Psychosis. R128's MDS dated [DATE] shows R128 is cognitively impaired. At 11:21 AM, V28, Social Service Director, stated R8's code status is Full code not DNR. V28 stated R8 has no POLST form. V28 stated R128 should have a physician order for R128's code status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 3 of 20 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 01/12/2024 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 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, interview, and record review, the facility failed to ensure the correct oxygen flow rate setting used per physician order. This failure applied to 1 resident (R12) out of 11 reviewed for oxygen therapy out of a total sample of 27. Residents Affected - Few Findings include: R12's diagnosis included but not limited to Chronic Obstructive Pulmonary Disease with Acute Exacerbation Morbid (Severe) Obesity, Chronic Respiratory Failure with Hypoxia, Lymphedema, Obstructive Sleep Apnea, Dependence on Supplemental Oxygen, Need For Assistance with Personal Care, and Chronic Diastolic (Congestive) Heart Failure. R12's Order Summary Report, dated 01/10/23, documents oxygen at two liters per minute via nasal canula continuously every shift ordered 06/03/23. R12's MDS (Minimum Data Set), dated 12/05/23, indicates intact cognition with BIMS (Brief Interview for Mental Status) 15/15. On 01/09/24 at 1:42 PM, R12 was sitting up in bed with oxygen infusing via nasal canula. R12 stated R12's oxygen runs all the time. Oxygen concentrator was located behind R12 off to the corner, out of R12's reach. Oxygen concentrator was set at four liters per minute. R12 denied asking the nurse to increase R12's oxygen rate. On 01/09/24 at 1:51 PM, V19 (Licensed Practical Nurse) observed R12's oxygen concentrator and said, It is set at four liters. On 01/09/24 at 1:54 PM, V19 stated, (R12's) order is for two liters per minute, so that it what it should be set at, not four liters per minute. V19 stated R12 might have been the one to change it. On 01/10/24 at 8:41 AM, the oxygen concentrator was behind R12 in the corner, out of R12's reach. R12 said, I don't touch that because I cannot reach it and The nurse sets that up for me. R12 stated if R12 felt R12 was not getting enough oxygen, R12 would call for the nurse. On 01/10/24 at 11:18 AM, V2 (Director of Nursing) stated V2 went to see R12 around 5:00 PM on 01/09/24, and R12's oxygen concentrator was set at two liters per minute. V2 stated R12 had no shortness of breath at that time and appeared comfortable. V2 stated V2 checked R12's oxygen saturation and it was 95% at that time. V2 stated R12 cannot reach the oxygen concentrator, and it is possible the rate was changed by mistake when it was being cleaned, or when a Certified Nursing Assistant was providing care. V2 stated the nurse checks the oxygen concentrator at the start of their shift, and periodically throughout their shift. V2 stated when oxygen saturation levels are checked, the nurses check the oxygen tubing, water level in the humidifier, and the oxygen flow rate. V2 stated the nurses should follow the physician orders for oxygen flow rate unless there is an emergency. V2 stated yesterday when surveyor observed R12, R12's oxygen flow rate order was two liters per minute, not four liters per minute. Facility policy titled, Oxygen Administration dated October 2010 documents in part purpose is to provide guidelines for safe oxygen administration, and oxygen therapy is administered according to physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 4 of 20 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 01/12/2024 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 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 follow their policies and procedures to ensure a resident received their medications according to the physician's order for 1 (R118) out of 6 residents reviewed for pharmaceutical services in a sample of 27. Findings Include: R118 ' s Minimum Data Set (MDS), dated [DATE], shows R118 is cognitively intact. R118's Physician Order Sheet (POS) with active orders as of 01/09/24 shows an order for sennoside 8.6 MG, to give 1 tab 2 times a day. R118's clinical records had no documentation showing R118 is safe to administer R118 ' s own medications. A review of R118's clinical records do not show a self-administration of medication assessment was completed. On 01/09/24 at 12:44 PM, surveyor and V12 (Registered Nurse) entered R118 ' s room, and observed 24 small, hard brown pills in the top lid of R118's water pitcher at R118 ' s bedside. R118 stated the pills are Senna, and R118 does not take them anymore because R118 goes to the bathroom on his own. R118 stated, They give me my medication in a cup. I take out that Senna pill and put it on my side table. R118 stated R118 did not take R118's Senna today and has not taken Senna for a long time, about 6 months. R118 stated R118 told a nurse about it, but R118 does not remember the name of the nurse, or when R118 told the nurse. V12 stated R118 routinely takes R118's medication, and it is surprising to V12 to see the pills there. V12 stated R118 never told V12 that R118 does not want to take the Senna. V12 stated V12 watches R118 take R118's medication at every medication pass. V12 acknowledged the medication as Geri-Kot tablets 8.6 MG (Sennosides). On 01/10/24 at 10:04 AM, V3 (Assistant Director of Nursing/ADON) stated nurses should be observing the Five Rights of medication administration, and mouth check to ensure the residents swallow their medications as prescribed. V3 (ADON) agreed other resident could have access to medication kept at bedside. The facility's policy for Self-Administration of medications, dated 12/2016, reads: As part of their overall evaluation, the staff and practitioner will assess each resident ' s mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. The facility's policy for Administering Medications, dated 04/2019, reads: Medications are administered in accordance with prescriber orders. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the IDT Care Planning Team has determined that they have the decision-making capacity to do so safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 5 of 20 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 01/12/2024 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 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 observation, interview, and record review, the facility failed to ensure cooking equipment was properly sanitized per manufacturer guidelines, failed to conduct hand washing in between handling dirty and clean plate ware/equipment, and failed to follow facility procedure for hand washing for appropriate length of time. These failures have the potential to affect all 132 residents receiving food prepared in the facility's kitchen. Findings include: On 01/10/24 at 10:41 AM, V25 (Dietary Cook) took the dirty blender, used for pureed food preparation, and put it into the dishwasher. At 10:42 AM, V25 pulled out a clean blender from the dishwasher. Hand hygiene was not done in between handing the dirty and clean blender. On 01/10/24 at 10:43 AM, V25 brought the same blender to the three-compartment sink and washed, rinsed, and dipped the blender into the sanitizing sink for 2-3 seconds, and then gave the blender to V24 (Dietary Cook). V25 did not perform any hand hygiene in between taking the blender from the dishwasher area to the three-compartment sink. On 01/10/24 at 10:49 AM, V25 was at the three-compartment sink washing a metal container. V25 rinsed and then submerged the metal container into the sanitizing solution for 2-3 seconds, and then placed the metal container in the tray line for use. On 01/10/24 at 11:04 AM, V27 (Dietary Aide/Pot Washer) was at three-compartment sink washing cooking equipment. V27 was leaving the cooking equipment in the sanitizing solution for 7-10 seconds before taking the items out to air dry. At 11:06 AM, V27 stated when washing items, they need to stay in the sanitation sink for at least 20 seconds. On 01/10/24 at 11:08 AM, V5 read from the sanitation solution bottle that items need to be submerged for 60 seconds to sanitize the item. V5 stated anything not washed and sanitized correctly has the potential to cause a food borne illness and make residents sick. On 01/10/24 at 10:56 AM, V26 (Dietary Aide) went to the handwashing sink and turned on water and soaped up hands for 3-5 seconds, before rinsing off the soap. Total process took 10-15 seconds. On 01/10/24 at 10:56 AM, surveyor asked V5 if V26 had washed V26's hands correctly, and V5 stated, No, (V26) did not wash his hands for long enough. On 01/10/24 at 10:56 AM, V5 called V26 back to the handwashing sink, and asked V26 to wash V26's hands again. V26 turned on the water, put soap into his hands, and agitated hands for 3-5 seconds before rinsing soap off hands. At 10:57 AM, V5 told V26 he is not washing V26's hands for long enough, and then V5 demonstrated to V26 how to wash hands correctly. On 01/10/24 at 10:58 AM, V5 said the entire process of washing hands should take 45 seconds, and V26 did not wash his hands for long enough. V5 stated if staff hands are not cleaned properly, they can have bacteria on them and that could potentially lead to food borne illness and residents could get sick. V5 also stated staff hands should be washed in between handling and placing dirty items into the dishwasher and removing the clean items from the dishwasher for the same reasons. V5 stated V25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 6 of 20 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 01/12/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many should have washed V25's hands after putting the dirty blender into the dish machine and before removing the cleaned blender from the dish machine. On 01/11//23 at 9:30 AM, V5 provided surveyor with a list of residents and their diet orders. V5 stated there are 4 residents who receive nothing by mouth (NPO). V5 also provide chemical manufacturer's reference sheet for sanitizer used in the kitchen and policies on handwashing and three-compartment sink. Kitchen policy titled Handwashing, dated 2021, documents, Food and nutrition employees will practice safe food handling to prevent foodborne illness, and food and nutrition services employees will thoroughly wash their hands and at the following times: after touching anything unsanitary (dirty dishes) and after handling soiled equipment and utensils. Facility policy titled Handwashing/Hand Hygiene, dated August 2019, documents, This facility considers hand hygiene the primary means to prevent the spread of infections and rub hands together vigorously for at least 15 seconds. Kitchen policy titled Manual Sanitizing in Three-Compartment Sink, dated 2021, documents, After washing and rinsing, utensils and equipment are sanitized in the third sink by immersion in chemical sanitizing solution used according to manufacturer's instructions. Chemical manufacturer reference sheet for sanitizer, dated 09/23, documents to allow solution to remain in equipment for at least 60 seconds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 7 of 20 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 01/12/2024 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 0880 Provide and implement an infection prevention and control program. 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 1 (R2) resident on TBP (Transmission Based Precaution) have proper signage indicating contact precautions and instructions on the use of specific PPE (Personal Protective Equipment) posted outside of R'2 room; failed to implement written EBP (Enhance Barrier Precaution) policy and procedures for 4 (R3, R57, R61, R113) residents; failed to ensure that staff was safely handling linens by not properly bagging soiled linens to prevent the spread of infection; and failed to review IPCP (Infection Prevention and Control Program) policy at least annually. Residents Affected - Many These failures can potentially affect 136 residents residing in the facility, as of census dated 1/9/24. The findings include: 1. R2's health record showed original admission date of 8/26/20, with diagnoses not limited to Encounter for surgical aftercare following surgery on the genitourinary system, Pneumonia, Gastrointestinal hemorrhage, Bacteremia, Severe sepsis without septic shock, Infection and inflammatory reaction due to indwelling urethral catheter, Chronic gastric ulcer without hemorrhage or perforation, Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, Aphasia following cerebral infarction, Dysphasia following nontraumatic intracerebral hemorrhage, Dysphagia following cerebral infarction, Gastro-esophageal reflux disease without esophagitis, Right hydronephrosis, Iron deficiency anemia, Obstructive and reflux uropathy, Encounter for attention to other artificial openings of urinary tract, Acquired absence of left leg above knee, Bipolar disorder, Schizophrenia, Hyperlipidemia, Thrombocytosis, Hypotension, Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, Candidiasis, Diaphragmatic hernia without obstruction or gangrene, Personal history of covid-19, Hypothyroidism, Essential (primary) hypertension, Atherosclerosis of native arteries of extremities with gangrene left leg, and Type 2 diabetes mellitus with other circulatory complications. R2'S POS (physician order sheet) with active order not limited to: Contact Isolation - ESBL Urine. R2's Care plan, dated 1/9/24, documented: The resident is readmitted with ABT for ESBL in urine. Placed on contact isolation per facility's protocol. MDS (Minimum Data Set), dated 12/18/2023, showed R2's cognition was severely impaired. R2 needed total assistance / dependent to staff with eating, oral and toileting hygiene, shower / bathe self, upper and lower body dressing. MDS showed R2 was incontinent of bowel and bladder. On 1/9/24 at 11:59 AM, V11 (Registered Nurse / RN) stated R2 is on Contact isolation for ESBL urine and is on IV (intravenous) antibiotic. At 12:07 PM, R2's room door signage showed Notice - all visitors must check in at nurse's station. No signage observed by R2's room entrance for the type of precaution, and there were no instructions of specific PPE to use when entering R2's room. 2. R3's health record showed admission date of 5/24/2022, with diagnoses not limited to Dysphagia following unspecified cerebrovascular disease, Chronic obstructive pulmonary disease, Type 2 diabetes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 8 of 20 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 01/12/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many mellitus with other circulatory complications, Other sequelae of other cerebrovascular disease, Unspecified dementia, Displaced intertrochanteric fracture of right femur, Personal history of covid-19, Anorexia, Age-related osteoporosis without current pathological fracture, Hyperlipidemia, Unspecified glaucoma, Essential (primary) hypertension, Schizophrenia, Non-pressure chronic ulcer of other part of left foot with unspecified severity, Encounter for attention to gastrostomy, Peripheral vascular disease, and Malignant neoplasm of unspecified part of unspecified bronchus or lung. R3's POS with active order of: Enteral Feed every shift Flush enteral tube with 20- 30 mLs water pre/post medication administration and 5-10 mLs water between each medication Crush and dilute solid medication with water. Enteral Feed two times a day - Jevity 1.5 at 90 cc/hr x 14 hours (ON at 4 PM- OFF at 6 AM). Enteral Feed every shift - Flush G-tube with 150 ml of water every shift. R3's Care plan, dated 7/15/23, documented: R3 requires tube feeding r/t (related to) dysphagia, anorexia/resisting eating, resist G-tube care/flushes. 3/08/23 from ER: New G-tube replacement MDS dated [DATE] showed R3's cognition was moderately impaired. R3 needed total assistance / dependent with eating, oral, personal and toileting hygiene, shower / bathe self, upper and lower body dressing. MDS showed R3 was incontinent of bowel and blader. MDS indicated R3 had feeding tube. At 2:09 PM, R3 was lying in bed, alert, and verbally responsive. G-tube in place. No signage was posted outside of R3's room for instruction on the use of specific PPE to wear when caring for the resident. No PPE supplies were available outside of R3's room entrance or nearby. On 1/10/24 at 10:48 AM, V15 (CNA) stated he is assigned to R3. R3 has G-tube and is incontinent of bowel and bladder. V15 stated he is wearing gloves and not wearing gown when providing high direct care activities like incontinence care to R3. V15 stated R3 requires total assistance with activities of daily living. 3. R57's health record showed original admission date of 5/24/2023, with diagnoses not limited to Other sequelae of cerebral infarction, Pressure ulcer of other site stage 3,Pressure ulcer of left ankle unstageable, Pressure ulcer of left heel stage 3, Local infection of the skin and subcutaneous tissue, Pressure ulcer of sacral region stage 3, Pressure ulcer of right heel unstageable, Other supraventricular tachycardia, Dysphagia, Essential (primary) hypertension, Anemia, Major depressive disorder, Dementia in other diseases classified elsewhere, Schizoaffective disorder depressive type, Anxiety disorder, Delusional disorders, Bilateral primary osteoarthritis of knee, Personal history of COVID-19, Bilateral inguinal hernia, and Hydrops of gallbladder. R57's POS with active order of: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 9 of 20 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 01/12/2024 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 0880 - Level of Harm - Minimal harm or potential for actual harm LEFT ANKLE WOUND: CLEAN WITH NSS AND APPLY HYDROGEL AND DERMABLUE AND COVER WITH GAUZE AND WRAP WITH KELIX every day shift for WOUND CARE AND as needed. Residents Affected - Many Care plan dated 12/30/23 documented in part: R57 has pressure injury of the left and right heel r/t impaired mobility. R57's MDS, dated [DATE] ,showed R57's cognition was severely impaired. R57 needed partial / moderate assistance with eating; Substantial / maximal assistance with oral hygiene and Total assistance / dependent with toileting and personal hygiene, shower/bathe self, upper and lower body dressing, and chair/bed transfer. MDS showed R57 was always incontinent of bowel and bladder. MDS indicated R57 had Stage III and Unstageable pressure ulcers. At 1:39 PM, R57 swas itting on the side of the bed, alert, and verbally responsive. R57 had a dressing on R57's left foot. No signage was posted outside of R57's room for instruction on the use of specific PPE to wear when caring for the resident. No PPE supplies available outside of R57's room or nearby. On 1/10/24 at 10:48 AM, V15 stated V15 is also assigned to R57. R57 has wound on left foot. V15 stated R57 requires total care with ADLS, uses total body lift machine for transfer. V15 stated R57 is incontinent of bowel and bladder. V15 stated V15 is wearing gloves and not wearing gown when providing incontinence care to R57. 4. R61's health record showed admission date of 1/15/2015 with diagnoses not limited to Dysphagia following unspecified cerebrovascular disease, Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, Encounter for attention to gastrostomy, Aphasia following unspecified cerebrovascular disease, Type 2 diabetes mellitus without complications, Urinary tract infection, Unspecified protein-calorie malnutrition, Acute cystitis with hematuria, Hypokalemia, Calculus of kidney, Neuromuscular dysfunction of bladder, Covid-19, Retention of urine, Unspecified hemorrhoids, Gastrostomy malfunction, Gastro-esophageal reflux disease without esophagitis, Contracture right elbow, Contracture right wrist, Contracture right hand, Hypertensive heart disease with heart failure, Heart failure. R61's MDS, dated [DATE], showed R61's cognition was severely impaired. R61 needed total assistance / dependent with eating, oral, toileting and personal hygiene, shower/bathe self, upper and lower body dressing and chair/bed transfer. MDS showed R61 was always incontinent of bowel. R61 had feeding tube. On 1/9/23 at 11:59 AM, V11 stated R61 has G-tube. V11 stated she is only wearing gloves when administering G-tube feeding, flushing and medications through G-tube. V11 stated she is not wearing a gown, as R61 is not on any precaution. At 11:09 AM, V22 (RN) stated he is assigned to R61, who is receiving G-tube feeding continuously via machine pump and water flushing manual. V22 stated he is wearing gloves when administering medications per g-tube, administering g-tube feeding and G-tube flushing and not wearing gown. 5. R113's health record showed admission date of 12/13/2023, with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Encounter for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 10 of 20 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 01/12/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many attention to gastrostomy, Aphasia following cerebral infarction, Dysphagia following cerebral infarction, Aphasia, Dysphagia oropharyngeal phase, Atherosclerotic heart disease of native coronary artery without angina pectoris, Essential (primary) hypertension, Presence of coronary angioplasty implant and graft, Encounter for other orthopedic aftercare, Encounter for change or removal of surgical wound dressing, Chronic kidney disease, Cellulitis of right upper limb, Encephalopathy, Chronic systolic (congestive) heart failure, Anemia, Thrombocytopenia, and Epilepsy without status epilepticus. R113's POS with active order of: Enteral Feed every shift - Jevity 1.5 at 45 cc/hr continously, Off x 2 hours for provision of care. Enteral Feed every shift Flush enteral tube q 8 hours with 100cc Water. R113's Care plan, dated 12/18/23, documented: R113 has a swallowing problem r/t CVA. On tube feedings/NPO status. Jevity 1.5@45ml/cont.flush 100ml q8hrs.prostat awc 30ml BID for wound Healing. R113's MDS, dated [DATE], showed R113's cognition was severely impaired. R113 needed total assistance / dependent with eating, oral, toileting and personal hygiene, shower/bathe self, upper and lower body dressing, and chair/bed transfer. MDS showed R113 had feeding tube. On 1/9/24 at 11:52 AM, R113 was lying in bed, on moderate high back rest, alert and nonverbal. Observed with g-tube feeding infusing, Jevity 1.5 at 45ml/hr. No signage posted outside of R113's room for instruction on the use of specific PPE to wear when caring for the resident. No PPE supplies available outside of R113's room or nearby. At 2:55 PM, V17 (Certified Nursing Assistant / CNA) stated she is assigned to R113. R113 has G-tube and is incontinent of bowel and bladder. V17 stated she is wearing gloves when providing incontinence care with R113, and not wearing gown. V17tated R113 requires total assistance with ADL (activities of daily living). V12 (RN) stated she is assigned to R113. V12 stated R113 is receiving continuous G-tube feeding via pump and water flushing is administered via G-tube manually. V12 stated she is wearing gloves and not wearing gown when administering G-tube feeding and G-tube flushing. 6. On 1/11/24 at 10:20 AM, Surveyor checked laundry chute room with V6 (Maintenance and Laundry Supervisor) and observed plastic bin overloaded with soiled linens. Observed some soiled linens inside the bin were properly bagged, and some soiled linens were not in the bag and were scattered in the bin. Observed soiled white pillow cover / sheet on the floor. V6 stated staff should properly place dirty linens inside the bag before dropping into the laundry chute. At 10:34 AM Surveyor and V6 went to third floor and checked laundry chute. V29 (CNA) dropped a white linen, not in a bag, inside the laundry chute. V29 stated it was a wet flat sheet that was dropped inside the laundry chute. V29 stated normally she would put soiled linens inside the bag prior to dropping into the chute to prevent spread of infection or contamination. 2nd floor laundry chute (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 11 of 20 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 01/12/2024 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 0880 inspected with V6 and observed brown spots / particles present inside the laundry chute. Level of Harm - Minimal harm or potential for actual harm On 1/11/24 at 12:04 PM, V12, Registered Nurse/RN stated she has been working in the facility for 5 months, and had no concerns with staffing. V12 stated she received in services on a regular basis. V12 stated she was vaccinated with COVID 19, and has no concerns with Covid. Residents Affected - Many On 1/11/24 at 2:37 PM, V2 (Director of Nursing / DON) stated Enhance Barrier Precautions (EBP) are those residents with opening, stomas, IV access, wounds. G-tube feeding, catheter or indwelling devices. V2 stated proper PPE such as gown, gloves, should be worn by staff for high care activities for protection of resident and staff and to prevent transmission of infection. V2 stated the importance of room signage is to alert staff and visitor to take precautions and wear proper PPE to prevent or spread of infection. 7. The following IPCP policies were not reviewed at least annually: 1. [NAME] and bedding, soiled policy, revised October 2018, documented: Soiled laundry, bedding shall be handled, transported, and processed according to best practices for infection prevention and control. All used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriated processing. Laundry that is contaminated with blood or body substances is placed in leak-proof bags or containers. 2. Facility's enhance barrier protection (EBP), dated 7/22, documented: Facility will consider EBP for residents with any of the following: Wounds or indwelling medical devices, with history of MDRO and XDRO colonization status. Healthcare providers must don a gown and gloves prior to providing direct care and doff after leaving the room for high contact care activities including DIRECT ADL (activities of daily living) care dressing, bathing, providing hygiene, transferring, changing linens, changing briefs or assisting with toileting. Device care or use such as: feeding tube. Wound care and any skin opening requiring dressing. Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g. gown and gloves). Make PPE, including gown and gloves available. 3. Facility's transmission-based precautions, dated October 2018, documented: When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of precaution, instructions for use of PPE. 4. Facility's notices of transmission-based precautions, dated August 2019, documented: Contact precautions - a sign indicating Contact Precautions on the door of the resident's room. 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 12 of 20 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 01/12/2024 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 0880 Covid 19 vaccine / booster policy and procedures dated 6/22. Level of Harm - Minimal harm or potential for actual harm 6. Covid-19 testing, and response strategy policy dated 10/2022. Residents Affected - Many 7. Pneumococcal vaccine dated October 2019. 8. Influenza vaccine policy dated October 2019. 9. Antibiotic Stewardship policy dated December 2016. 10. Surveillance for infections policy dated September 2017. 11. Handwashing / Hand hygiene policy dated August 2019. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 13 of 20 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 01/12/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of available influenza vaccine for 3 (R3, R57, R113) residents; failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations for 4 (R19, R57, R61, R113) residents; failed to assess eligibility and offer pneumococcal vaccinations to 4 (R19, R57, R61 and R113) residents; and failed to update the facility's Pneumococcal and Influenza vaccine policy. Residents Affected - Some These failures have the potential to affect 5 (R3, R19, R57, R61 and R113) out of 6 residents reviewed for influenza and pneumonia vaccination. The findings include: 1. R3's health record showed admission date of 5/24/2022, with diagnoses not limited to Dysphagia following unspecified cerebrovascular disease, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus with other circulatory complications, Other sequelae of other cerebrovascular disease, Unspecified dementia, Displaced intertrochanteric fracture of right femur, Personal history of covid-19, Anorexia, Arthropathy, Age-related osteoporosis without current pathological fracture, Hyperlipidemia, Unspecified glaucoma, Essential (primary) hypertension, Schizophrenia, Non-pressure chronic ulcer of other part of left foot with unspecified severity, Encounter for attention to gastrostomy, Peripheral vascular disease, and Malignant neoplasm of unspecified part of unspecified bronchus or lung. R3's order summary report, dated 1/10/24, with active order of: May have annual flu vaccine unless contraindicated. R3's MDS (Minimum Data Set), dated 12/15/2023, showed R3's cognition was moderately impaired. MDS showed influenza vaccine was offered and declined. R3's immunization report, dated 1/11/24 ,showed refused Influenza vaccine. No record found in R3's EHR that education was provided, and no screening was done. V2, Director of Nursing, stated R3 had refused flu vaccine but no education provided, and no screening was found in R3's EHR. V2 stated, I don't know why it was missed. 2. R19's health record showed admission date of 9/16/2014, with diagnoses not limited to Chronic obstructive pulmonary disease, Unspecified asthma, Type 2 diabetes mellitus without complications, Hyperlipidemia, Allergy, Age-related nuclear cataract right eye, Cataract extraction status right eye, Essential (primary) hypertension, Chronic kidney disease, Hypothyroidism, Anemia, Benign prostatic hyperplasia without lower urinary tract symptoms, and Schizophrenia. R19's immunization report, dated 1/11/24, showed no record for pneumonia vaccine. No record was found in R19's EHR that education was provided, or screening was done for pneumonia vaccine. R19's order summary report, dated 1/11/24, with active order of: May administer pneumonia vaccine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 14 of 20 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 01/12/2024 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some V2 stated R19 had no pneumonia vaccine record. V2 stated no education or screening was found in R19's EHR (Electronic Health Record). 3. R57's health record showed original admission date of 5/24/2023, with diagnoses not limited to Other sequelae of cerebral infarction, Pressure ulcer of other site stage 3,Pressure ulcer of left ankle unstageable, Pressure ulcer of left heel stage 3, Local infection of the skin and subcutaneous tissue, Pressure ulcer of sacral region stage 3, Pressure ulcer of right heel unstageable, Other supraventricular tachycardia, Dysphagia, Essential (primary) hypertension, Anemia, Major depressive disorder, Dementia in other diseases classified elsewhere, Schizoaffective disorder depressive type, Anxiety disorder, Delusional disorders, Bilateral primary osteoarthritis of knee, Personal history of covid-19, Bilateral inguinal hernia, and Hydrops of gallbladder. R57's immunization report, dated 1/11/24, indicated R57 refused Influenza vaccine, and no record was found for pneumonia vaccine. No record was found in R57's EHR that education was provided, or screening was done. R57's MDS, dated [DATE], showed R57's cognition was severely impaired. MDS showed R57 offered and declined influenza vaccine, and Pneumococcal vaccine was not offered. V2 stated R57's EHR (electronic health record) showed no pneumonia vaccine record, and R57 refused flu vaccine. V2 stated no education or screening was found in R57's EHR. 4. R61's health record showed admission date of 1/15/2015 with diagnoses not limited to Dysphagia following unspecified cerebrovascular disease, Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, Encounter for attention to gastrostomy, Aphasia following unspecified cerebrovascular disease, Type 2 diabetes mellitus without complications, Calculus of kidney, Neuromuscular dysfunction of bladder, Covid-19, Retention of urine, Unspecified hemorrhoids, Gastrostomy malfunction, Gastro-esophageal reflux disease without esophagitis, Contracture right elbow, Contracture right wrist, Contracture right hand, Hypertensive heart disease with heart failure, Major depressive disorder, Anxiety disorder, Muscle wasting and atrophy, and Heart failure. R61's immunization report, dated 1/11/24, showed R61 refused Influenza vaccine. PPSV23 (Pneumococcal Polysaccharide Vaccine) was last given on 6/15/18. No record was found in R61's EHR that education was provided, or screening was done for flu and pneumonia vaccine. R61's order summary report, dated 1/11/24, with active order of: May administer pneumonia vaccine. V2 stated R61 received PPSV 23 (Pneumococcal Polysaccharide Vaccine) on 6/15/18. V2 previously stated pneumonia vaccine is given after 5 years, and R61 was due on 6/2023, but it was not given. V2 stated R61 is on the list to receive pneumonia vaccine. V2 stated no screening to assess eligibility to receive pneumonia vaccine was found in R61's EHR. 5. R113's health record showed admission date of 12/13/2023, with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Encounter for attention to gastrostomy, Aphasia following cerebral infarction, Dysphagia following cerebral infarction, Aphasia, Dysphagia oropharyngeal phase, Atherosclerotic heart disease of native coronary artery without angina pectoris, Essential (primary) hypertension, Presence of coronary angioplasty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 15 of 20 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 01/12/2024 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some implant and graft, Encounter for other orthopedic aftercare, Encounter for change or removal of surgical wound dressing, Chronic kidney disease, Cellulitis of right upper limb, Encephalopathy, Chronic systolic (congestive) heart failure, Anemia, Thrombocytopenia, and Epilepsy without status epilepticus. R113's immunization report showed no data found for influenza or pneumonia vaccine. No record was found in R113's EHR that education was provided, or screening was done for influenza or pneumonia vaccine. R113's order summary report, dated 1/10/24, with active order of: May administer pneumonia vaccine. May administer influenza vaccine yearly unless contraindicated. V2 stated R113 had no pneumonia or flu record. V2 stated no education or screening was found in R113's EHR. On 1/10/24 11:33AM, V2 (Director of Nursing/DON) stated Flu (influenza) vaccine is offered during flu season, offered upon admission together with Pneumo (Pneumonia) vaccine. V2 stated residents are screened if eligible to receive the vaccine. If resident / representative refused for vaccination (Pneumo / flu), monitor for flu like symptoms, provide education. V2 stated Pneumonia vaccine is offered and given to resident every after 5 years, unless resident had received Prevnar 20; that it is given one time. V2 stated the purpose of Flu and pneumonia vaccine is to build up immunity and prevent illness or complications. V2 stated education is important to inform resident or representative regarding the risk and benefits of the vaccines. Facility's Pneumococcal vaccine, dated October 2019, documented: Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission. Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. Facility's Influenza vaccine policy, dated October 2019, documented: Between October 1st to March 31st each year, the influenza vaccine shall be offered to residents unless the vaccine is medically contraindicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 16 of 20 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 01/12/2024 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 0883 - Level of Harm - Minimal harm or potential for actual harm Prior to vaccination, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's medical record. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 17 of 20 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 01/12/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review, the facility failed to assess eligibility and offer COVID-19 vaccination to 5 (R2, R3, R19, R57, and R113) residents; and failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of available Covid 19 vaccination for 5 (R2, R3, R19, R57, and R113) residents out 6 residents reviewed for COVID 19 immunization. The findings include: R2's health record showed admission date of 8/26/20, with diagnoses not limited to Encounter for urgical aftercare following surgery on the genitourinary system, Pneumonia, Gastrointestinal hemorrhage, Bacteremia, Severe sepsis without septic shock, Infection and inflammatory reaction due to indwelling urethral catheter, Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, Aphasia following cerebral infarction, Dysphasia following nontraumatic intracerebral hemorrhage, Dysphagia following cerebral infarction, Right hydronephrosis, Iron deficiency anemia, Obstructive and reflux uropathy, Encounter for attention to other artificial openings of urinary tract, Acquired absence of left leg above knee, Bipolar disorder, Schizophrenia, Hyperlipidemia, Thrombocytosis, Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, Candidiasis, Diaphragmatic hernia without obstruction or gangrene, Personal history of covid-19, Hypothyroidism, Essential (primary) hypertension, Atherosclerosis of native arteries of extremities with gangrene left leg, History of falling, Anxiety disorder, Dermatitis, Peripheral vascular disease, Anemia, Fatty (change of) liver, and type 2 diabetes mellitus with other circulatory complications. Reviewed R2's Covid 19 immunization record, and V1 stated last COVID vaccination was given on 1/7/22. V1 stated she is not sure if R2 was offered or educated with COVID 19 vaccine last year, 2023. V1 unable to find documentation in the tracker R2 was screen or educated with COVID 19 vaccine. V1 stated education is important so the resident / family / representative understand the risk and benefits of COVID-19 immunization. V1 stated COVIDvaccine is a preventive measure so to prevent major complications of the disease, especially for those residents with multiple comorbidities. R2's immunization report, dated 1/11/24, showed last COVID 19 immunization was on 1/7/22. No record was found in R2's EHR (Electronic Health Record) that education was provided, or screening was done. R2's order summary report, dated 1/10/24, with active order of: May have COVID 19 - primary series and boosters. 2. R3's health record showed admission date of 5/24/2022 with diagnoses not limited to Dysphagia following unspecified cerebrovascular disease, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus with other circulatory complications, Unspecified dementia, Displaced intertrochanteric fracture of right femur, Personal history of covid-19, Anorexia, Arthropathy, Age-related osteoporosis without current pathological fracture, Essential (primary) hypertension, Schizophrenia, Non-pressure chronic ulcer of other part of left foot with unspecified severity, Encounter for attention to gastrostomy, Peripheral vascular disease, Malignant neoplasm of unspecified part of unspecified bronchus or lung, and Legal blindness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 18 of 20 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 01/12/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R3's immunization report, dated 1/11/24, showed last COVID 19 immunization was on 6/1/22. No record was found in R3's EHR that education was provided, or screening was done. 3. R19's health record showed admission date of 9/16/2014 with diagnoses not limited to Chronic obstructive pulmonary disease, Unspecified asthma, Type 2 diabetes mellitus without complications, Hyperlipidemia, Allergy, Age-related nuclear cataract right eye, Cataract extraction status right eye, Essential (primary) hypertension, Chronic kidney disease, Hypothyroidism, Anemia, Benign prostatic hyperplasia without lower urinary tract symptoms, and Schizophrenia. R19's immunization report, dated 1/11/24, showed COVID vaccine was given on 4/18/22. No record was found in R19's EHR that education was provided, or screening was done for COVID 19 vaccine. R19's order summary report, dated 1/11/24, with active order of: Administer COVID-19 vaccine. May have COVID 19 vaccine booster dose. 4. R57's health record showed admission date of 5/24/2023 with diagnoses not limited to Other sequelae of cerebral infarction, Pressure ulcer of other site stage 3,Pressure ulcer of left ankle unstageable, Pressure ulcer of left heel stage 3, Local infection of the skin and subcutaneous tissue, Pressure ulcer of sacral region stage 3, Pressure ulcer of right heel unstageable, Hyperlipidemia, Other supraventricular tachycardia, Dysphagia, Essential (primary) hypertension, Anemia, Major depressive disorder, Dementia in other diseases classified elsewhere, Schizoaffective disorder depressive type, Anxiety disorder, Delusional disorders, Bilateral primary osteoarthritis of knee, and Personal history of covid-19. R57's immunization report, dated 1/11/24, showed no record for COVID 19 vaccine. No record was found in R57's EHR that education was provided or screening was done. 5. R113's health record showed admission date of 12/13/2023 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Encounter for attention to gastrostomy, Aphasia following cerebral infarction, Dysphagia following cerebral infarction, Atherosclerotic heart disease of native coronary artery without angina pectoris, Essential (primary) hypertension, Presence of coronary angioplasty implant and graft, Chronic kidney disease, Cellulitis of right upper limb, Encephalopathy, Chronic systolic (congestive) heart failure, Anemia, and Epilepsy without status epilepticus. R113's immunization report showed no data found for COVID 19 vaccination. No record was found in R113's EHR that education was provided or screening was done for COVID 19 vaccine. On 1/10/24 at 11:33 AM, Resident's immunization record reviewed with V2 (Director of Nursing) and V2 stated V1 (Administrator) is tracking COVID 19 vaccination. At 2:13 PM, V1 (Administrator) stated she is tracking COVID 19 vaccination for staff and residents. V1 stated COVID-19 vaccination is offered continuously, and booster dose is given annually. COVID 19 vaccination is not mandatory, but it is always encouraged to both staff and residents. V1 stated if resident refused for COVID 19 vaccination, education should be provided by nursing staff. On 1/11/24 at 9:40 AM, V2 (Director of Nursing/DON) stated COVID vaccine is offered continuously, and booster is given once a year. V2 stated staff and residents are encouraged to receive COVID (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 19 of 20 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 01/12/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm vaccine once a year, but it is not mandatory. V2 stated if a resident refused the COVID-19 vaccine, education is provided and documented. V2 stated screening for COVID 19 immunization is important to make sure the resident is eligible to receive the vaccine, to know COVID history, and compromised resident. V2 stated education should be provided by staff and documented to know what to report to the nurses when vaccine is given and to educate the risk and benefits of the vaccine. Residents Affected - Some Facility's Covid 19 vaccine / booster policy and procedures, dated 6/22, documented: COVID-19 vaccine and boosters will be ordered to either pharmacy or local or state public health agency and administer to the staff or residents. COVID-19 vaccinations and boosters will be offered to residents (or their representative if they cannot make health care decisions) unless such immunization is medically contraindicated per CDC guidance, or the individual has already been immunized. All residents/ representatives will be educated on the COVID-19 vaccine and boosters they are offered. The facility will maintain documentation for all residents on COVID-19 vaccination and boosters. The information will be documented in their medical record. The information to be documented includes: The staff person, resident or representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145659 If continuation sheet Page 20 of 20