Inspection·February 23, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure the call light was within reach for 6 (R99, R159, R163, R178, R255, R256) residents reviewed for accommodation of needs in a sample of 36. Residents Affected - Some Findings Include: 1.) R255 has diagnosis not limited to Aphasia Following Cerebral Infarction, Obstructive Sleep Apnea, Psoriasis, Type 2 Diabetes Mellitus, Local Infection of the Skin and Subcutaneous Tissue, Lack of Coordination and Gastrostomy. Care Plan document in part: Focus: R255 is at risk for falls related to Current medication use, Poor safety awareness, Unsteady gait. Date Initiated: 11/02/23. Intervention: Keep call light within reach when in bedroom or bathroom Date Initiated: 11/02/23. Focus: is at risk for falls related to unsteady gait Date Initiated: 11/03/23. Intervention: Ensure that I will be able to use the call light. If the light is difficult to press, consider giving me a foam pad call light or other adaptive call lights Date Initiated: 11/03/23. On 02/20/24 at 10:40 AM R255 door was observed to be closed. Upon surveyor knocking on R255 door before entering staff that was sitting at the nurse station verbalized R255 does not talk. When surveyor entered the room R255 was observed lying near the edge of the bed. R255 call light was observed behind a chair and the bedside table out of reach. One floor mat was observed to the left side of the bed. On 02/20/24 at 2:36 PM Surveyor entered R255 room with V11 (Registered Nurse). Surveyor asked V11 the location of R255 call light. V11 responded R255 does not know how to use the call light. We need to check on him and make rounds. My eyes are on R255 all the time. When asked was the door closed before we entered the room V11 responded, R255 does not like the door open. R255 call light is behind the chair. V11 retrieved the call light from behind the chair and bedside table then clipped it to R255 pillow. 2.) R163 has diagnosis not limited to Mild Persistent Asthma, Alcohol Abuse with Intoxication, Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, Bipolar Disorder, Current Episode Manic Severe with Psychotic Features, Dysphagia, Oropharyngeal Phase, Epilepsy, Secondary Hypertension, Metabolic Encephalopathy, Atherosclerotic Heart Disease, Personal History of COVID-19. Care Plan document in part: Focus: R163 requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) Date Initiated: 07/26/22. Interventions: Keep call lights within reach when in bedroom or bathroom. Focus: Resident is at risk for falls related to: (Poor co-ordination and fall history), Poor safety awareness, Unsteady gait, Disease process. Interventions: Keep call light within reach when in bedroom or bathroom. On 02/20/24 at 10:43 AM R163 was observed lying in bed on a low air loss mattress. R163 call light was observed on the floor between R163 and his roommate's bed. On 02/20/24 at 02:39 the surveyor entered R163 room with V11 (Registered Nurse). When asked where the call light is located V11 responded, R163 is sometimes confused and in and out. V11 picked up the call light from the floor then clamped it to R163 pillow. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 2 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3.) R99 has diagnosis not limited to Acquired Absence of other Left Toe(S), Acquired Absence of Left Leg Below Knee, Acute Osteomyelitis, Left Ankle and Foot, Type 2 Diabetes Mellitus with other Skin Complications, Personal History of COVID-19. On 02/10/24 at 10:45 R99 was observed lying in bed asleep with the call light on the floor between R99 and his roommate's bed. On 02/10/24 at 02:41 AM the surveyor entered R99 room with V11 (Registered Nurse). R99 was asked by the surveyor can he reach his call light. R99 located the bed remote control, let down the head of the bed, reached over his head then pulled the call light. R99 then let the head of the bed back into the semi-Fowlers position. R99 was asked by the surveyor if there was an occasion that he could not reach or located the bed remote control would he be able to reach the call light. R99 gestured no. V11 placed the frayed string to the call light on R99 bed then stated, I called maintenance. 4.) R256 has diagnosis not limited to Proteus (Mirabilis) (Morganii) as the cause of Diseases Classified Elsewhere, Gram-Negative Sepsis, Obstructive and Reflux Uropathy, Dietary Folate Deficiency Anemia, Secondary Thrombocytopenia, Personal History of Transient Ischemic Attack (Tia), And Cerebral Infarction, Disorders of Brain, Cerebral Palsy, Infection, and Inflammatory Reaction due to Indwelling Urethral Catheter. Care Plan document in part: Focus: Resident is at risk for falls related to: [Specify: Current medication use, Poor safety awareness, Unsteady gait, Disease process. Interventions: Ensure that I will be able to use the call light. If the light is difficult to press, consider giving me a foam pad call light or other adaptive call lights Date Initiated: 02/14/24. On 02/20/24 at 10:59 AM was observed lying in bed with the call light on the floor near the right side of the bed. The bed was in the low position with floor mats in use. On 02/20/24 at 2:44 PM the surveyor entered R256 room with V11 (Registered Nurse). V11 stated R256 is alert and oriented x1. The call light is hooked around the right-side rail and is on the floor. V11 unwrapped the call light and clamped it to R256 pillow. 5.) R178 has diagnosis not limited to Aphasia Following Cerebral Infarction, Gastro-Esophageal Reflux Disease, Diabetes Mellitus Due to Underlying Condition with Hyperglycemia, Secondary Hypertension, Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Recurrent Depressive Disorder. Care plan document in part: Focus: R178 an ADL (Activities of Daily Living) Self Care Performance Deficit and Impaired Mobility r/t (related to) poor coordination Date Initiated: 04/21/23. Intervention: CALL LIGHT R178 call light placed within accessible reach. Focus: R178 at high] risk for falls related to Unsteady gait. Date Initiated: 04/21/23. Interventions: Ensure that I will be able to use the call light. If the light is difficult to press, consider giving me a foam pad call light or other adaptive call lights. On 02/20/24 at 10:47 AM surveyor observed R178 call light on floor between R178 and his roommate's bed. When asked if he could reach the call light R178 responded, No, I call on the phone. 6.) R159 has diagnosis not limited to Hepatic Encephalopathy, Chronic Kidney Disease, Diabetes Mellitus, Alcoholic Cirrhosis of Liver with Ascites, Pancytopenia, Severe Protein-Calorie Malnutrition, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 3 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Cocaine Abuse, Hypertensive Chronic Kidney Disease, Anemia In Chronic Kidney Disease, Hyperkalemia, Esophageal Varices, Gastrointestinal Hemorrhage, Nicotine Dependence, Cigarettes, Acidosis, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Obstructive and Reflux Uropathy, Acute Appendicitis with Generalized Peritonitis, Acute Kidney Failure. Care Plan document in part: Focus: R159 requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) Date Initiated: 12/07/23. Interventions: Keep call lights within reach when in bedroom or bathroom. On 02/20/24 at 10:49 AM R159 was observed in bed on a low air loss mattress. R159 call light was observed on the floor behind the head of the bed out of R159 reach. On 02/20/24 at 02:45 PM the surveyor entered R159 room with V10 (Registered Nurse). When asked where is R159 call light V10 responded The call light is stuck under the bed wheel. I will call maintenance. On 02/22/24 at 09:23 AM V3 (Director of Nursing/Infection Preventionist) stated Positioning of the call light should be close to the resident. If the call light is not close to the resident the resident will not get help when they need help and there is a possible increased risk of a fall. If a resident is cognitively unable to use the call light the call light should still be within reach. R255 can still pull the call light if they put the call light near R255. If a resident is nonverbal, it does not mean that they cannot use the call light. Policy: Titled Call Light Policy revised 07/27/23 document in part: 5. Be sure call lights are placed within reach of residents who are able to use it at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 4 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to refer four (R5, R48, R64, R175) residents with newly evident or possible serious mental disorder to the appropriate state-designated authority for review in a sample of 59 residents. Findings include: On 02/21/2024 at approximately 10:30AM, V12 (Social Services Director) states she does not deal with the Pre-admission Screening and Resident Review (PASARR) process and refers surveyor to V13 (Admissions Director) for further information. On 02/21/2024 at 11:01AM, V13 (Admissions Director) states he has been working at the facility for 9 months. V13 states he works with the facility's hospital liaison to get the DON/determination of needs screening and Level 1 screening because it is performed prior to being admitted to the facility. V13 states once he obtains the DON score, he is then able to go into the facility's PASARR screening system to go to obtain the Level 1 screening. V13 states once he obtains the Level 1 screening, V13 uploads it into the facility's electronic medical records system into the resident's chart. V13 states this process allows the facility to get paid and without the Level 1 screening, the facility cannot receive payment. V13 states all residents receive a Level 1 screening because it is done at the hospital before admission. V13 states he is unaware what the Level 1 or Level 2 screenings are indicative of and V13 states he is not responsible for referring residents to a Level 2 screening. V13 refers surveyor to V12 (Social Services Director) for further information. Surveyor states to V13 that V12 has already referred surveyor to V13 for more information regarding the PASARR screenings. V13 insists he is not responsible for the PASARR screenings. V13 states his only responsibility regarding the PASARR screenings is to make sure the screening has been completed prior to admission and uploaded into the resident's chart. On 02/21/2024 at 11:47AM, V12 (Social Services Director) states the only thing she knows about the PASARR screenings is that they should be completed at the hospital before a resident is admitted to the facility. V12 states if a Level 2 screening is required for a resident, then the resident is referred to V19 (Social Services Consultant). V12 states surveyor can also speak to V2 (Assistant Administrator) for more information related to the PASARR screenings. On 02/21/2024 at 11:51AM, V2 (Assistant Administrator) states the Level 1 PASSAR screening determines the level of needs a resident requires. V2 states he is unsure but believes the DON score ranges from 1-100 and V2 believes the higher the DON score, the greater the resident needs are. V2 states if a resident is identified to require a Level 2 PASARR then the facility will email V19 (Social Services Consultant) to make V19 aware and V19 follows up with the Level 2 PASARR screening process. V2 states there has never been a time when the facility had to refer a resident for a Level 2 PASARR screening. V2 states the facility has not been made aware that any of the residents need a Level 2 PASARR screening. V2 states he will find out further information and follow up with this surveyor. On 02/21/2024 at 12:08PM, V2 states a new company took over the PASARR screenings in May 2022. V2 states he did not find out more about the PASARR levels prior to the new company taking over the screening process. V2 states he did not educate himself more on the Level 2 screening process. V2 states he was not aware that the facility was responsible for referring residents for a Level 2 screening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 5 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some V2 states he was made aware of new information related to the PASARR screening process. V2 states if a resident has a mental health diagnosis upon admission, then the resident should have a Level 2 PASARR screening. V2 states if a resident develops a mental health diagnosis after being admitted to the facility, then the facility should refer the resident to receive a Level 2 PASARR screening. 1.) R5's Face sheet documents that R5 is a [AGE] year-old female admitted to the facility on [DATE] who has diagnoses not limited to: schizophrenia dated 11/01/2023 and bipolar disorder dated 10/01/2023. There is no documentation to show that R5 was screened for a Level 2 PASARR. 2.) R48's Face sheet documents that R48 is a [AGE] year-old male admitted to the facility on [DATE] who has diagnoses not limited to: schizophrenia dated 04/22/2022. There is no documentation to show that R48 was screened for a Level 2 PASARR. 3.) R64's Face sheet documents that R64 is a [AGE] year-old female admitted to the facility on [DATE] who has diagnoses not limited to: bipolar disorder dated 02/26/2020 and recurrent depressive disorder dated 02/22/2023. There is no documentation to show that R64 was screened for a Level 2 PASARR. 4.) R175's Face sheet documents that R175 is a [AGE] year-old male admitted to the facility on [DATE] who has diagnoses not limited to: schizoaffective disorder bipolar type dated 02/22/2023 and recurrent depressive disorder dated 02/22/2023. There is no documentation to show that R175 was screened for a Level 2 PASARR. Facility policy date 07/24/2023 titled PASSAR Screening of Residents with Mental Disorder or Intellectual Disability documents Policy: It is the policy to ensure that residents with Mental Disorder and those with Intellectual Disorder will receive PASSAR Screening within the timeframe allowed. Procedure: 1) The facility will not allow admission from the hospital without a preadmission screening which includes OBRA Screen 1 and OBRA Screen 2 (PASSAR screening), for those with Mental or Intellectual Disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 6 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R194's face sheet documents in part an admission date of 01/03/2024. It also documents in part medical diagnoses of bipolar disorder, recurrent depressive disorders, and generalized anxiety disorder present on admission. Residents Affected - Few R194's admission Minimum Data Set assessment dated [DATE] documents in part the listed medical diagnoses above and that R194 was on antipsychotic, antianxiety, and antidepressant medications. Facility provided a one-page copy of R194's state agency Interagency Certification of Screening Results dated 01/02/2024. It documents in part that nursing facility services are appropriate. Form did not indicate R194's diagnoses of mental illness. Surveyor requested the entirety of the OBRA-1 (Omnibus Budget Reconciliation Act) screening for R194. Facility did not provide this. On 02/22/2024 at 12:31 PM, V2 (Assistant Administrator) showed surveyor laptop screen. V2 stated the State Agency did not decide whether R194 needed a PASARR (Preadmission Screening and Resident Review) Level II evaluation. V2 stated it was pending in the system. V2 stated facility did not follow up with the State Agency regarding R194's Level II screening. Based on observations, interviews, and record reviews, the facility failed to follow their policies and procedures to consistently follow the Preadmission Screening and Annual Resident Review (PASARR) process for 2 (R68, R194) out of 22 residents with mental illness reviewed for a Level 2 PASARR Screening for MD and ID in a total sample of 36. Findings Include: 1.) R68's Minimum Data Set (MDS) dated [DATE] shows R68 is cognitively intact. According to the admission Record, R68 is [AGE] years old, R68 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder. There is no documentation to show that R68 was referred to the appropriate state-designated authority for Level 2 PASARR evaluation and determination. On 2/22/24 at 1:10 PM, the surveyor asked V2 (Assistant Administrator) for a Level 2 PASARR screening for R68. V2 provided the surveyor with a Level 1 PASARR screening dated 4/20/15 for R68. V2 was unable to provide a Level 2 PASARR screening for R68. V2 stated that V2 has no Level 2 PASARR for R68. The facility policy for PASARR Screening of Residents with Mental Disorder or Intellectual Disability dated 7/24/23 documented in part: The facility will not allow admission from the hospital without a preadmission screening which includes OBRA Screen 1 and OBRA Screen 2 (PASSAR Screening), for those with Mental or Intellectual Disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 7 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to follow care plan policy on person-centered care plan for a resident who has diagnosis for schizophrenia and bipolar disorder with psychotropic medication orders to 1 out of 36 residents (R405) for a total 36 residents reviewed for care plan. Findings include: R405 is [AGE] years old, initially admitted on [DATE] with diagnosis of schizophrenia and bipolar disorder. Per medication list of ordered by physician, R405 has the following psychotropic medications: -Sertraline Hydrochloride (antidepressant) 25 MG tablet with once daily order date 2/5/2024, -Fluphenazine Decanoate (antipsychotic) 25 MG per ML every 3 weeks with order date 2/16/2024, -Fluphenazine Hydrochloride (antipsychotic) 5 MG tablet once daily with order date 2/16/2024, -Haloperidol Lactate (antipsychotic) 2 MG per ML injection to be given for agitation with order date 2/16/2024, -Haloperidol (antipsychotic) 2 MG tablet to be given for agitation with order date 2/16/2024, -Trazodone Hydrochloride (antidepressant) 50 MG to be given once a day at bedtime for depression with order date 2/16/2024. On 02/20/2024 at 12:01 PM, R405 was seen alert and verbally able to express thoughts. R405 was seen a bit anxious during conversation. On 02/21/2024 at 02:58 PM, R405's full care plan was reviewed with V28 (Fall/Psychotropic Nurse). After review, V28 stated that because R405 has an order to take psychotropic medication, it should be care planned. On 02/22/2024 at 10:13 AM, With V35 (Minimum Data Set Coordinator) Upon looking at R405's full care plan and checking the date psychotropic medication was entered. V35 stated that psychotropic medication use of residents needs to be in the care plan in both interim and comprehensive care plans. V35 stated, All residents that are taking psychotropic medication needs to have care plan for psychotropic medication use. Full care plan of R405 does not include psychotropic medication use, dosage, and possible adverse effects until 2/21/2024 when it was entered. Care Plan policy dated 7/27/2023, reads: It is the policy of the facility to ensure that all care plans including baseline care plans are in conjunction with the federal regulations. Comprehensive care plan must be developed after the comprehensive assessment of the resident. After the comprehensive assessment (State-Federal required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 8 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0656 Minimum Data Set) is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days. R405 Minimum Data Set was completed on 2/16/2024. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 9 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to update a resident's (R162) comprehensive care plan and follow physician orders for one-to-one feeding for a dependent resident (R162) for 1 out of a total sample of 36 residents. Residents Affected - Few Findings include: V36's (Registered Dietician) progress note dated 01/30/2024 12:46 PM for R162 documents in part that R162 had significant weight loss. Recommendations included to continue meal set-up assistance to maximize oral intake at mealtimes. R162's physician orders document in part a new order on 02/19/2024 for one-to-one assist with feeding for every meal and as needed. R162's comprehensive care plan did not reflect this change. On 02/20/2024 at 12:53 PM, R162 was in the dining room eating lunch. R162 was confused and only oriented to self. R162 was pushing food around in meal tray and not focused on eating. V8 (Wound Care Nurse) went in and out of the dining room and cued R162 to eat. No staff sitting one-to-one assisting R162 with the meal. At 1:10 PM, R162 stated [R162] was done eating. R162's lunch tray was placed on top of the meal cart. R162 ate less than 50% of the lunch meal. On 02/21/2024 at 8:40 AM, R162 was in the hallway with breakfast tray. No staff sitting one-to-one assisting R162 with the meal. Staff, including V5 (Nurse), V14 (Regional Patient Service Coordinator), V15 (Certified Nursing Assistant/CNA), and V46 (CNA), walked past R162. At 8:43 AM, V14 stopped to cut up R162's food and provide cueing. V14 left at 8:46 AM. Staff did not provide one-to-one feeding assistance until 8:50 AM when V15 grabbed a stool and sat with R162. On 02/22/2024 at 10:23 AM, V42 (Restorative Nurse) stated R162 was not able to feed self and needed staff assistance. V42 stated staff are to sit with R162, provide cues and feed R162 to encourage as much oral intake during meals. At 10:37 AM, V45 (Restorative Director) stated CNAs recently told V45 that R162 was not eating and would just look at the food. V45 assessed R162 and informed R162's provider. Facility placed the order for one-to-one feeding assistance so that staff can sit with R162 to provide cues and assist with feeding. Facility's Restorative Nursing Program policy, last revised 07/28/2023, documents in part: Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. Services include eating. Nursing and restorative services shall be reflected in the resident's individualized care plan consistent to the completion of the resident comprehensive assessment. Facility's Care Plan policy last revised 07/27/2023, documents in part that the resident's person-centered care plan will be periodically reviewed and revised by a team of qualified person after each assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 10 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to have a person-centered care plan that included R74's hearing needs and ensure R74 received an assistive device to maintain hearing abilities for one out of a total sample of 36 residents. Residents Affected - Few Findings include: R74's face sheet documents in part an admission date of 08/29/2014. R74's Minimum Data Set assessment dated [DATE] documents in part that R74 is cognitively intact. On 02/20/2024 at 10:09 AM, R74 was alert and oriented to person, place, and time. R74's television was on a high volume which was heard from the hallway. R74 stated difficulty hearing and stated the left ear was worse than the right. R74 pointed to the right ear and instructed surveyor to speak to [R74's] right ear. R74 stated [R74] does not have hearing aids and cannot recall the last time an ear doctor evaluated [R74]. R74's physician orders from 06/19/2023 document in part that R74 may see an audiologist as needed. R74's comprehensive care plan did not include a focus for R74's hearing needs. On 02/20/2024 at 3:35 PM, V5 (Nurse) stated R74 does not have hearing aids and needs to see an audiologist because R74 is very hard of hearing. R74's Audiogram report dated 05/16/2022 from a nonprofit hearing healthcare organization document in part: Impression: Monaural (right) hearing aid candidate. On 02/21/2024 at 3:15 PM, R74 did not recall being told that R74 was a candidate for a hearing aid. R74 stated hearing is currently minimal and facility has not provided the hearing aid. At 3:33 PM, V5 stated taking care of R74 for many years and known R74 since admission. V5 stated [V5] does not recall R74 having hearing aids. V5 stated I told Social Services to make sure [R74] sees an audiologist because [R74] really needs to be seen. The TV is always on loud for [R74]. On 02/23/2024 at 1:20 PM, V51 (Patient Care Manager for the nonprofit hearing healthcare organization) stated they last evaluated R74 on 05/16/2022 and determined R74 qualified for a hearing aid. The organization sent multiple medical clearance requests to the facility for R74. V51 stated they sent a monthly notice to the facility to have R74's primary physician sign the medical clearance. V51 stated the most recent request was on 01/03/2024. Facility signed it and returned it on 01/05/2024. V51 stated due to the length of time passed since 05/16/2022, R74 will need a new evaluation and fitting for hearing aids. V51 stated R74 remains State-eligible to receive the hearing aids through the organization. V51's letter dated 02/22/2024 to the facility and V12 (Social Services Director) documents in part a last visit of 05/16/2022. Organization requested a medical clearance on 01/03/2024 and facility provided it on 01/05/2024. Organization will re-evaluate R74 on 03/04/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 11 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0685 Surveyor requested policies on hearing aid and audiology services from V4 (Regional Nurse Consultant) on 02/21/2024 at around 3:30 PM. V4 stated facility did not have policies related to audiology services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 12 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure the low air loss mattress was on the correct setting for 2 (R31, R163) of 2 residents reviewed for pressure ulcers in a sample of 36. Residents Affected - Few Findings include: 1.) R31 has diagnosis not limited to Fibromyalgia, Type 2 Diabetes Mellitus with Foot Ulcer, Radiculopathy, Lumbar Region, Gastro-Esophageal Reflux Disease, Secondary Hypertension, Human Immunodeficiency Virus [HIV] Disease, Chronic Osteomyelitis, Right Ankle and Foot, Bipolar Disorder, Chronic Kidney Disease, Stage 3, Abnormalities of Gait and Mobility. Treatment Administration Record document in part: Sacral-Coccyx wound: Cleanse with NSS gently pat dry apply Triple antibiotic ointment cover with dry dressing change QOD and PRN until healed. every day shift every other day -Start Date- 02/07/24. Care Plan document in part: R31 admitted with the following wounds, Left heel stage 3 pressure injury. Right heel stage 4 pressure injury. Right gluteal stage 3 pressure injury. Coccyx stage 2 pressure injury. R31 readmitted with the following wounds: Right heel stage 4 pressure injury Left heel stage 4 pressure injury. Sacral-Coccyx unstageable pressure injury. R31 is assessed to be at risk for further skin alteration based on her Braden score of 13, incontinent of bowel and bladder, bedbound, need assistance with ADLs (Activities of Daily Living) and current wounds status. Right gluteal wound healed 7/12/23. Right heel wound healed 12/20/23. Left heel wound healed 12/20/23. R31 weights dated 02/09/24 103.8 Lbs., 01/12/24 106.0 Lbs., 12/08/23 108.4 Lbs., 10/23/23 107.2 Lbs., 09/13/23 109.6 Lbs. On 02/20/24 at 12:24 PM R31 was observed sitting in bed on a low air loss mattress with a weight setting of 280 pounds eating lunch and being observed by the speech pathologist. On 02/20/24 at 02:46 PM Surveyor entered R31 room with V11 (Registered Nurse). R31 was observed lying in bed on a low air loss mattress. Surveyor asked V11 the settings on R31 low air loss mattress. V11 responded, it's 280. When asked if the low air loss mattress is set based on the resident's weight V11 responded, I don't know too much about that. On 02/22/24 at 9:03 AM V36 (Registered Dietitian) state R31 has a wound stage 4 sacral coccyx which has gone down in size. R31 is receiving (nutritional supplement) 3 times a day and the house supplement with protein to assist with wound healing. On 02/22/24 at 09:23 AM V3 (Director of Nursing/Infection Preventionist) stated for the low air loss mattress setting we notify maintenance to let them know that it is not at the right setting because they adjust the setting. Sometimes when staff change the low air loss mattress setting, they may not be able to put it on the right spot. The purpose of the low air loss mattress is for resident with pressure injuries to promote healing. If the weight setting is incorrect, it can affect the wound healing process if a resident has a wound. V31 has wounds but I can't remember where. 2.) R163 has diagnosis not limited to Mild Persistent Asthma, Alcohol Abuse with Intoxication, Adjustment Disorder With Mixed Disturbance of Emotions and Conduct, Bipolar Disorder, Current Episode (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 13 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0686 Level of Harm - Minimal harm or potential for actual harm Manic Severe with Psychotic Features, Dysphagia, Oropharyngeal Phase, Epilepsy, Secondary Hypertension, Metabolic Encephalopathy, Atherosclerotic Heart Disease, Personal History of Covid-19. R163 weights dated 02/09/24 162.8 Lbs. 01/12/224 168.8 Lbs., 12/27/23 174.4 Lbs., 11/30/23 162.0 Lbs., 09/12/23 158.2 Lbs. Residents Affected - Few On 02/20/24 at 10:43 AM R163 was observed lying in bed on a low air loss mattress. The low air loss mattress setting was on the line between 320 - 350 pounds. R163 stated I weigh about 150 pounds. On 02/20/24 at 02:39 the surveyor entered R163 room with V11 (Registered Nurse). Surveyor asked V11 R163 low air loss mattress setting. V11 responded between 320 - 350 pounds. Maintenance does the settings every week and when we need then we call. On 02/22/24 at 12:04 PM V8 (Wound Care Nurse/Registered Nurse) stated I have worked here for 10 years. R31 had 3 pressure ulcers, 2 healed, the left and right heels and the stage 4 sacral wound is closed. R31 is now receiving a dry dressing to the sacral area. R31 has a low air loss mattress to alternate pressure to the buttocks and assist in the wound healing. The low air loss mattress is set according to the resident's weight. It is not the exact weight because most of them are even number. R31 low air loss mattress should not be set at 280. If set on 280 the weight setting does not do anything to the bed. I set the low air loss mattress up according to the resident's weight. R163 had wounds and is at risk for having an alteration in the skin integrity. The weight setting of 320 - 350 is not the correct weight setting that R163 bed was on. R31 and R163 are at high risk for alteration in skin integrity that is why they are on the low air loss mattress. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 14 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observations, interviews, and record reviews, the facility failed to follow physician orders and assess for the removal of a urinary catheter for one (R101) out of a total sample of 36 residents. Residents Affected - Few Findings include: R101's face sheet documents an admission date of 01/29/2024. Listed medical diagnoses do not include urinary retention or bladder issues. On 02/20/2024 at 11:07 AM, R101 was alert and oriented to person, place, time, and situation. R101 stated admitted from the hospital with an indwelling catheter. R101 did not know why R101 continued to have it. R101 stated no bladder issues and no sacral pressure ulcers. R101 stated facility has not attempted to remove the urinary catheter. R101's physician orders contain an order dated 01/29/2024 that documents in part to discontinue indwelling catheter if without acceptable indication (pressure ulcers 3 and 4 at sacral areas, urinary retention secondary to certain diagnoses). R101's comprehensive care plan contained a focus created on 1/30/2024 for the indwelling urinary catheter but it did not list the indication for it. It also did not include interventions when to attempt to remove it. V50's (Nurse) admission summary progress note dated 1/29/2024 8:06 PM documents in part that R101 came to the facility with the urinary catheter. Did not list the indication for it. On 02/21/2024 at 12:32 PM, V8 (Wound Nurse) stated R101 admitted from the hospital with the urinary catheter. V8 stated per the hospital paperwork, R101 had the urinary catheter due to pressure ulcers to R101's sacrum and hips. However, when V8 conducted the admission skin assessment, R101 did not have any pressure ulcers or wounds. V8 did not know why R101 continued to have the urinary catheter. At 12:34 PM, V5 (Nurse) stated R101 admitted from the hospital with the urinary catheter but did not know the indication or reason for the continuing it. Reviewed R101's admission hospital records. Urinary catheter indication at the hospital was due to pressure ulcers and wounds. No other indication to continue the catheter once pressure ulcers or wounds healed. Facility's Indwelling Catheter policy, last revised 07/28/2023, documents in part: It is the facility's policy to ensure that no resident will have indwelling catheter, unless condition shows that there is a medical reason to justify the use of the indwelling catheter. Upon admission or readmission, each resident who came in with a catheter will be assessed to determine if there is a medical reason to support the use of the indwelling catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 15 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their oxygen therapy and administration policy to ensure adequate oxygenation to 1 (R19) of 3 oxygen dependent residents in the sample of 36. Residents Affected - Few Findings Include: R19's clinical record documents in part: R19 is a [AGE] year-old with the medical diagnosis of chronic obstructive pulmonary disease, asthma, metabolic encephalopathy, need for assistance with personal care, lack of coordination, abnormalities of gait and mobility, adult failure to thrive, adult failure to thrive, retention of urine, pleural effusion, myocardial infarction, fracture of nasal bones, subsequent encounter for fracture with routine healing, fall, subsequent encounter, secondary hypertension, chronic obstructive pulmonary disease, chronic kidney disease, stage 3a, retinopathy of prematurity, stage 2, unspecified eye, schizoaffective disorder, bipolar type, bipolar disorder, current episode mixed, moderate, major depressive disorder, spinal stenosis, schizophrenia, personal history of transient ischemic attack (TIA), and cerebral infarction, and fusion of spine cervical region. -R19's Minimum Data Set (MDS) dated [DATE], Brief Interview score [8] indicates R19 is cognitively impaired. R19's care plan dated 11/21/23 document in part: -R19 has chronic obstructive pulmonary disease with asthma. On 2/22/24 at 11:22 AM, surveyor and V23 observed R19 resting in bed. R19 oxygen nasal cannula was infusing near R19's left eye. R19 was exhibiting labored breathing. On 2/22/24 at 11:24 AM, V23 (Licensed Practical Nurse/LPN) stated, The hospice nurse recently left, she is at the nursing station. R19's oxygen tubing needs to be in his nasal passage, not near his left eye, this has caused R19 to have labored breathing. On 2/22/24 at 11:25 AM, Surveyor observed V23 obtain R19's oxygen saturation, it was ranging from 86% to 88% on room air, heart rate was 126 beats per minute. V23 placed oxygen tubing back into R19's nose. Surveyor and V23 observed R19's oxygen increase to 90% and heart rate remined at 126 beats per minute with 2liters of oxygen infusing, and R19 continued labored breathing. On 2/22/24 at 11:35 AM, V23 (LPN) stated, The hospice nurse wrote out an order that R19 may have oxygen 2 to 4 liters per nasal cannula, but I will place the order in the chart, before I will increase the oxygen. V23 then left out R19's room. On2/22/24 at 11:40 AM, surveyor went to the nurse's station, there was no hospice nurse at the station. On 2/22/24 at 11:56 AM, surveyor notified V3 (Director of Nursing) immediately of R19's oxygen saturation, heart rate, the placement of R19 oxygen tubing, and V23 would not increase R19's oxygen until she places in the order and left out R19's room. V3 stated, I will go now to help R19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 16 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/22/24 at 12:15 PM, V3 (Director of Nursing) stated, I made sure R19 oxygen was increased and in-serviced V23 related to oxygen therapy. The oxygen nasal cannula should be inside the nasal passage in order for the resident to received oxygen inside their body. If the oxygen nasal cannula is not placed properly inside the nasal passage, it could potentially cause their oxygen saturation to decrease and increase heat rate which could cause cardiac arrest. I know R19 was just today enrolled into hospice care, but the facility must still provide appropriate care for any hospice resident. Policy-Oxygen Therapy and Administration dated 7/28/24 -To assure adequate oxygenation to all spontaneously breathing dependent patients -Hypoxia- oxygen saturation levels of less than 92 % FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 17 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews, the facility failed to properly dispose of unused medications and expired medications during one observation of medication disposal and review of 2 of 4 medication carts. Findings include: On 02/20/2024 at 9:13 AM, V5 (Licensed Practical Nurse/LPN) prepared R152's medications. V5 took out two tablets of Tylenol 325 MG (milligram) and one tablet of Ascorbic Acid 500 MG and placed them in a medicine cup. R96 approached V5's medication cart. After speaking with R96, V5 stated [V5] will start medication preparation over again. V5 took the medicine cup and tossed the pills in the opening of the sharps' container. V5 did not close/push the lid leaving the pills sticking out and sitting on the lid. 2/20/24 at 9:29 AM, V5 stated there were two residents with dementia on the unit and a lot of residents that walk about independently. 2/20/24 at 9:33 AM, V5 walked away from the medication cart to the nurses' station. Medication cart was in front of room XXX. 2/20/24 at 9:37 AM, V5 was preparing medications for R101. At 9:40 AM, V5 donned personal protective equipment and went into the room at 9:44 AM to administer the medications. The medication cart was in the hallway with the three white pills sitting on the sharps' container lid. 2/20/24 at 9:47 AM, V5 stated nurses are to waste medications in the sharps' container. V5 stated (V5) was not aware that the pills were sitting on the lid. V5 pushed the lid to dispose the pills inside the container to secure them. On 02/20/2024 at 12:11 PM, surveyors reviewed facility's third-floor team one medication cart with V6 (LPN) and V7 (LPN). V6 stated the medication cart served about 35 residents on the unit. In the top drawer where the house stock medications were kept, there was an open container of Aspirin 325 MG. The expiration date on the bottle was 1/2024. Surveyor also found a medication blister pack for R18 of Hydroxyzine Hydrochloride 25 MG. The use by date was 12/02/2023. There were 16 tablets left in the blister pack. V7 stated R18 remains on the medication. R18's Medication Administration Records document in part that R18 currently receives Hydroxyzine Hydrochloride 25 MG three times a day for anxiety. 2/20/24 at 1:14 PM, surveyors reviewed the third-floor medication room with V7. Inside the medication refrigerator, there was a vial of Tuberculin in a cup on the top rack of the refrigerator door. The open date was 01/09/2024. The second written date was 02/07/2024. 2/20/24 at 3:38 PM, surveyors reviewed the third-floor overflow medication cart with V50 (Registered Nurse/RN). There was a single dose of Amoxicillin-Potassium Clavulanate 875 MG/125 MG tablet with a use by date of 06/10/2023. Additionally, there were two single dose tablets of Amoxicillin 250 MG with expiration date of 09/15/2022. V5 and V50 stated the night shift nurses are supposed to go over the medication carts and take out the expired or discontinued medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 18 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 02/22/2024 at 9:06 AM, V3 (Director of Nursing) stated staff clean the medication carts at nighttime and as needed. V3 stated it is all the nurses' responsibility to clean and dispose of medications that are expired. Facility's Medication Pass policy, last revised 07/28/2023, documents in part: All opened medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening except for Levemir insulin which can be discarded 42 days after opening and Xalatan eye drops which can be discarded six weeks after opening. Facility's Medication Storage, Labeling, and Disposal policy, last revised 08/24/2023, documents in part that house stock medications designed for multiple administration will automatically expire based on the expiration date based on the manufacturer's guidelines. Policy also documents in part: Medications will be secured in locked storage area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 19 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide food at a safe and appetizing temperature. This failure affects 202 residents receiving food in the facility. Residents Affected - Many Findings include: On 02/20/2024 at 11:40AM R81 was observed sitting on the bed in R81's room eating his lunch meal. R81 states sometimes hot foods are served cold, and the staff will have to reheat resident meals. On 02/21/2024 at approximately 9:30AM, V16 (Food Service Supervisor) informs surveyor that the spinach vegetable for lunch will be replaced with collard greens and all residents have been made aware. On 02/21/2024 at 12:50PM, V16 (Food Service Supervisor) states food temperatures are checked twice during meal preparation; first, when food comes out of the oven and second, when food is placed on the steam table right before plating. V16 states food temperatures were last taken at 11:00AM on the steam table and are as follows: Meat loaf- 186 degrees Fahrenheit Beef steak-195 degrees Fahrenheit Mashed potatoes- 197 degrees Fahrenheit Vegetables/collard greens- 200 degrees Fahrenheit On 02/21/2024 at 12:50PM, V16 (Food Service Supervisor) states food temperatures should be above 130 degrees Fahrenheit when it reaches the residents in time for them to eat. On 02/21/2024 at 1:08PM, the final food cart left the kitchen and arrived on the third floor at 1:10PM. On 02/21/2024 at 1:18PM, the final lunch tray was served to residents on the third floor of the facility. On 02/21/2024 at 1:19PM, with V16 present, the food items on the test tray were checked for temperature with a thermometer used by V16. Meat loaf was 112.3 degrees Fahrenheit, mashed potatoes were 145.1 degrees Fahrenheit, and Vegetables/collard greens were 127 degrees Fahrenheit. Facility's census dated 02/20/2024 documents a total of 204 residents residing in the facility. Facility document provided by facility on 02/20/2024 documents that a total of two residents residing in the facility who are NPO/nothing by mouth. Facility policy undated, titled Food Preparation and Service documents in part, The danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 20 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 follow proper sanitation and food storage practices. The facility failed to properly label food. The facility failed to properly store food. The facility also failed to adequately sanitize equipment used for food preparation. These deficient practices have the potential to affect all 202 residents receiving food prepared in the facility kitchen. Findings include: On 02/20/2024 at 9:11 AM during initial kitchen tour with V16 (Food Service Supervisor), the following food items were found in the walk-in cooler: 1. 3 boxes of blueberries with a receive date of 02/16/2024, 1 box of blueberries with a receive date of 02/13/2024, no expiration or use by date. 2. 1 box of oranges, no receive date, no expiration or use by date. 3. 1 box of spinach greens with receive date of 01/30/2024, no expiration or use by date. 4. 1 spray bottle with a pink colored liquid inside the spray bottle sitting on the second food storage shelf located in between the box of spinach greens and tomatoes. On 02/20/2024 at 9:18AM, V16 states the box of oranges should have been labeled with a receive date and he is not sure how that slipped through the cracks. V16 states the facility does not label the blueberries, oranges, or spinach greens with a use by date because the facility uses the produce until it deteriorates. V16 states it is at the discretion of V18 (Cook) and other kitchen staff who is preparing the food to decide if the produce is deteriorated or not. V16 states the pink colored liquid inside of the spray bottle found in the walk-in cooler is called (brand name cleaner). V16 states the (brand name cleaner) is a chemical used to clean surfaces. V16 states he is not sure who left the spray chemical inside of the walk-in cooler, but someone just mopped inside of the walk-in cooler and must have left it there. V16 states the (brand name cleaner) should not have been stored inside of the walk-in cooler. V16 states if the (brand name cleaner) chemical gets on the resident's food, then there is potential for the residents' food to get contaminated, and the residents could get sick. On 02/20/2024 at 9:35AM, V16 states the facility uses quaternary solution to sanitize dishes washed in the three-compartment sink. On 02/20/2024 at 9:41AM, V20 (Dietary Aide) observed testing the quaternary solution in the designated sanitize compartment of the three-compartment sink. V20 observed using test strips to test the quaternary solution. V20 observed immersing the test strip in the solution for approximately 5 seconds and test strips turns green in color. V20 places the test strip next to the test strip package to compare the colors. Surveyor observes that the test strip package has a label that obscures most of the ppm number readings. Surveyor observes that only the 50 ppm color shade is visible along with three more different color shades without ppm number readings. Surveyor asks V20 what is the correct ppm reading for the test strip he immersed in the quaternary solution? V20 states the test strip reading is 200 ppm. Surveyor asks V20 how can he be certain that the correct reading for the test strip (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 21 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 is 200ppm? V20 states he has it memorized and calculates it in his head because he does the task every day. V20 states he calculates the ppm based on the test strip color and never really rely on the ppm readings that are labeled on the test strip package. On 02/20/2024 at 9:54AM, V20 observed washing a pan in the three-compartment sink. V20 observed flipping the pan back and forth in the sanitize compartment for approximately 10 seconds. V20 states he submerged the pan in the sanitize compartment for about 5-10 seconds. On 02/202/2024 at 9:57AM, V16 (Food Service Supervisor) states the ppm reading for the test strip used by V20 (Dietary Aide) could not be determined due to the test strip package being covered by a label. V16 states if the ppm reading cannot correctly be determined then there is the potential for inadequate sanitation and cross contamination. Facility's census dated 02/20/2024 documents a total of 204 residents residing in the facility. Facility document provided by facility on 02/20/2024 documents that a total of two residents residing in the facility who are NPO/nothing by mouth. Facility policy, undated, titled Food Receiving and Storage documents in part, 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 14. Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in the storerooms for food or food preparation equipment and utensils. 15. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage. Facility policy, undated, titled Cleaning Guidelines three Compartment Sink documents in part, 1. c. Fill the sanitizing tank with 75 degrees Fahrenheit water, and 50ppm chlorine, 12.5ppm iodine or 195 ppm Quaternary solution. 2. Test that an adequate amount of sanitizer is present by using the appropriate test strip designed to test ppm of sanitizing agent used. Facility document dated 2021, titled Pot & Pan Cleaning & Sanitizing Procedures documents in part, 5. Sanitize- Submerge in sanitizer sink for 1-2 minutes. B. Dip paper for 10 seconds. C. Compare colors immediately with colors on the test strip package to determine ppm. D. Testing solutions should be between 200-400ppm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 22 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 a.) handle linen to prevent contamination, b.) ensure a resident on Droplet/Contact Precaution door was closed to prevent the spread of infection and c.) failed to handle and distribute food items in a sanitary manner. These failures have the potential to affect 204 residents residing in the facility. Residents Affected - Many Findings Include: 1.) On 02/20/24 at 09:24 AM surveyor asked during the entrance were there any positive COVID-19 cases in the facility. V1 (Administrator) responded that there was one resident and that (R29) is no longer on COVID precautions. R29 has diagnosis not limited to Alzheimer's Disease, Adult Failure to Thrive, Hypokalemia, Insomnia, Generalized Anxiety Disorder, Forms of Scoliosis, Lumbar Region, Bipolar Disorder, Elevated [NAME] Blood Cell Count, Hereditary Motor and Sensory Neuropathy, Lack of Coordination, Need for Assistance with Personal Care, Dysphagia, Oropharyngeal Phase, Abnormal Posture, Pneumonia, Unspecified Organism. Care Plan document in part: Focus: R29 has an active COVID-19 diagnosis Date Initiated: 02/12/24. Interventions: Close door of room at all times Date Initiated: 02/12/24. Place on strict, Droplet and Contact Isolation Date Initiated: 02/12/24. Focus: is on strict, droplet, contact isolation related to covid 19 Date Initiated: 02/12/24. Interventions: Maintain contact isolation precaution in accordance with Centers for Disease Control (CDC) guidelines. Date Initiated: 02/12/24. Progress note dated 02/09/24 23:40 document in part: Health Status Note Text: Noticed resident coughing and congestion heard upon cough. Progress note dated 02/12/24 08:00 document in part: General Progress Note Text: Lab results reveals that resident has pneumonia. Progress note dated 02/12/24 10:59 document in part: Social Service Note Text: Writer left a vm (Voice mail) to daughter to inform of mother's positive status of COVID-19. Daughter was informed that her mother will be on isolation for the next 10 days. Progress note dated 02/12/24 11:15 document in part: Notification (COVID) Notification: 1. Notification of Resident's Positive COVID 19 Test Result. Progress note dated 02/22/24 06:41 document in part: Infection Note Text: Resident completed 10 days of droplet/contact isolation precautions post COVID positive, isolation discontinued per protocol. On 02/21/24 at 09:17 AM V3 (Director of Nursing/Infection Preventionist) stated There is one (R29) resident on droplet/contact precautions. R29 tested positive for COVID on the 02/12/24 and today is R29 last day on contact/droplet isolation. R29 will be coming off droplet/contact precautions at the end of the day today because it is R29 10th day. R29 was having a cough and a little wheezing, the doctor ordered the RPR (Rapid Plasma [NAME]) and R29 tested positive for COVID. On 02/21/24 at 10:35 AM R29 door was observed open with signage on the door indicating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 23 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 droplet/contact precautions. Surveyor went to the nurse station and asked V32 (Registered Nurse) what type of Isolation was R29 on and informed V32 that R29 door was open. On 02/21/24 at 10:40 AM V32 (Registered Nurse) stated R29 is on droplet/contact precautions. The PPE (Personal Protective Equipment) that is worn is a gown, face shield, face mask (N95) and gloves. We close the door because it is air borne. I don't know who left the door open. V32 proceeded down the hallway and closed R29 door. On 02/21/24 at 10:46 AM V10 (Registered Nurse) stated There is one resident (R29) with COVID and R29 is on droplet/contact precautions. When a resident is on droplet precautions, they keep the door closed. 2.) On 02/22/24 at 09:57 AM the laundry room was reviewed with V39 (Housekeeping and Laundry Supervisor). Surveyor observed V40 (Laundry Aide) folding the bed linen sheets and pillowcases. While V40 was folding the bed linen sheets surveyor observed V40 allowing the bed linen sheets to touch the floor. Surveyor asked V39 to observe V40 folding the bed linen sheets and informed V39 that each bed linen sheet that is being folded by V40 touches the floor. Surveyor asked V39 if the bed linen sheets touch the floor while being folded are they now contaminated and should be rewashed. V39 responded yes. On 02/22/24 at 10:05 AM V40 (Laundry Aide) dropped a pillowcase on the floor, picked it up, folded the pillowcase then placed it in the pile of folded pillowcases on the folding table. Surveyor made V40 aware that when folding the bed linen sheets, it is touching the floor and asked if it is now contaminated. V40 responded, No, they are not contaminated, every day I clean the floor. Surveyor asked V40 did she fold the three piles of bed linen sheets that were observed on the folding table. V40 responded, yes, I have been here since 05:00 AM. On 02/22/24 at 10:27 AM V3 (Director of Nursing/Infection Preventionist) stated when folding linen, the linen should not touch the floor. If the line touches the floor, it is contaminated and should be put back in the washer. Facility census obtained from the facility roster dated 02/20/24. There are 204 residents in the facility. Policy: Titled Linen Handling by Laundry Staff revised 07/28/23 document in part: Policy Statement: It is the policy of this facility to wash linens and cloth to produce hygienically clean laundry. Procedures: 1. All laundry staff will be trained upon hire how to handle regular soiled linens and isolation linens and clothing properly, to avoid cross contamination. Titled Infection Prevention and Control revised 10/23/23 document in part: Policy Statement: the facility has established a policy to identify, record, investigate, control, test, and prevent infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for the identified infection. 31. The facility shall comply with infection control recommendations provided by (state agency) or certified local health department, including, but not limited to testing plans, infection control assessments, training or other measures designed to reduce incidence of infection. 3. Droplet Precaution - intended to prevent transmission through close respiratory or mucous membrane contact with respiratory secretions. Examples of infectious organisms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 24 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 requiring Droplet precaution includes COVID 19. Level of Harm - Minimal harm or potential for actual harm 3.) During observation of staff passing meal trays on 02/21/2024 at 1:14PM, V44 (Escort) observed located on the third floor of the facility passing resident lunch meal trays. V44 observed bending down to grab a resident's meal tray off the cart, in the process, a package of butter fell off the meal tray and onto the floor. V44 observed picking the butter package up off the floor and placing it back onto the meal tray. V44 then observed taking the tray inside R96's room. V44 did not discard the butter package. Upon exiting R96's room, surveyor inquires to V44 about V44 placing the butter back onto the meal tray. V44 denies placing the butter package back onto the meal tray after it fell onto the floor. Surveyor informs V44 that surveyor directly observed V44 placing the butter package back onto the resident's meal tray after it fell onto the floor. V44 continues to deny this. Surveyor observes a camera located above R144's room and brings this to V44's attention and V44 still continues to deny placing the butter package back onto the resident's meal tray after it fell onto the floor. Residents Affected - Many On 02/21/2024 at 1:23PM, V16 (Food Service Supervisor) states if a food item falls on the floor, the correct protocol to follow is to discard the food item and inform a direct supervisor of what happened so the food item can be replaced. V16 states cross contamination can happen if the food item is placed back onto the resident's meal tray. On 02/21/2024 at 1:26PM, surveyor located inside of V1's (Administrator) office and surveyor made V1 aware of what happened and requests to review footage for the camera located above room R144's room. V1 states he will inform the legal department and let surveyor know if it is okay to give the video footage to this surveyor. On 02/21/2024 at approximately 1:35PM, V43 (Vice President of Operations/VPO) states to surveyor he will try to get the video footage to surveyor as soon as possible. On 02/21/2024 at 2:21PM, surveyor receives a request from V43 to call V43 via telephone and is provided with V43's telephone number because V43 wanted to speak to this surveyor. On 02/21/2024 at 2:23PM, at V43's request, surveyor calls V43 at the telephone number provided. V43 states he is the VPO at the facility. VPO states to surveyor what you saw did happen. V43 states that V44 (Escort) became nervous and did not tell this surveyor the truth. V43 states he knows that this surveyor is telling the truth because the facility has had issues with V44 in the past. V43 states to surveyor what you're saying is correct. V43 (VPO) states that V44 (Escort) does not normally pass resident meal trays and V44 thought it was okay to place the butter back on the resident's meal tray since the butter was sealed but it was not okay to do that. V43 states that V44's behavior has gotten better and V44 has come a long way so the facility will not be firing V44. This surveyor informs V43 that firing V44 is never the intentions, but rather honesty during conduction of investigations during the survey process. V43 tells surveyor that V43 has a reputation for being transparent. V43 tells this surveyor to write whatever needs to be written and this surveyor can also write that V43 is made aware. Video footage requested from facility was not provided to surveyor. Facility policy, undated, titled Preventing Foodborne Illness Employee Hygiene and Sanitary Practices documents in part, 1. All employees who handle, prepare or serve food will be trained in the practices of safe food in handling and preventing foodborne illness. Employees will demonstrate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 25 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 knowledge and competency in these practices prior to working with food or serving food to residents. Employees must their hands: h. After engaging in other activities that contaminate the hands. Facility policy, undated, titled Food Preparation and Service documents in part, 22. Employees also will wash their hands after collecting soiled plates and food waste prior to handling food trays. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 26 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 offer and provide education to the residents or their Representatives for the Pneumococcal and Influenza Vaccine for 2 (R29, R255) of 5 residents reviewed for immunizations in a sample of 36. Residents Affected - Few Findings Include: 1.) R29 was admitted to the facility on [DATE]. R29 has no documentation of the pneumococcal of Influenza vaccination or education. Progress note dated 02/21/24 1:45pm document in part: General Progress Note Text: Spoke to R29 daughter to remind her about pending consents for flu, pneumococcal and COVID vaccines, she gave consent to have her mom get the flu vaccine but refused the pneumococcal. Resident schedule to get flu vaccine as consented by daughter. 2.) R255 was admitted to the facility on [DATE]. R255 has no documentation of the pneumococcal of Influenza vaccination or education. Progress note dated 02/21/24 1:45pm document in part: General Progress Note Text: Spoke to R255 wife (to remind her about pending consents for flu, pneumococcal, she gave consent for resident to get the flu and pneumococcal vaccines. R255 resident schedule to get flu and pneumococcal vaccine as consented by wife. On 02/21/24 at 09:17am V3 (Director of Nursing/Infection Preventionist) stated Staff and residents are being offered the Influenza, Pneumococcal and COVID vaccination. On 02/21/24 after V3 (Director of Nursing/Infection Preventionist) interview V3 Provided R29 Influenza Consents and Pneumococcal refusal dated 02/21/24 and R255 Influenza and Pneumococcal consent dated 02/21/24. V3 stated R29 family member refused the vaccinations at first and R255 initially said that he would think about the vaccinations. R255 went out for an appointment today and will receive the vaccinations when he (R255) returns. On 02/22/24 at 09:23 AM V3 (Director of Nursing/Infection Preventionist) stated Each year the influenza, pneumococcal and COVID vaccination is offered to the residents and staff. If they agreed to take the immunization, they sign a consent. If they refuse to take the vaccine, they still have to sign the consent as refusing and they are educated. R29 and R255 (family member) initially refuse the pneumococcal and influenza vaccination. We did not document the refusal at that time. We offer the vaccination; they sign a consent, and we give them the vaccination. If they refuse the vaccination, we educate them. Policy: Titled Influenza Vaccination revised 08/08/23 document in part: Policy Statement: It is the policy of the facility to annually offer and administer vaccination against and influenza to each resident/employee unless otherwise contraindicated or the resident/employee or responsible party has refused (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 27 of 28 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 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 the vaccine. 1. Influenza vaccination will be offered to residents seasonally when it becomes available, in preparation for flu season which is typically October 1 to March 31. 2. Residents who are admitted in the later part of the flu season (February and March) will be offered flu vaccine. 4. all current residents shall be offered vaccination during flu season unless otherwise medically contraindicated or the resident for responsible party refuses. All refusals will be documented. Residents Affected - Few Titled Pneumococcal Vaccination revised 12/12/23 document in part: Policy Statement: It is the policy of the facility to offer and administer pneumococcal vaccination to each resident as recommended by CDC's (Centers of Disease Control and Prevention) Advisory Committee on Immunization Practices unless otherwise Contraindicated or the resident or responsible party has refused the vaccine. 1. All residents and responsible parties will receive education about the risks and benefits of the pneumococcal vaccines. 6. All administration and refusals will be documented. Titled Influenza Management and Surveillance revised 08/07/23 document in part: Procedures: Prevention: a. Flu vaccinations will be done for residents per facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 28 of 28