Health inspection·August 30, 2024

F 0921 Normal and Final Terminal Stopping Devices Level of Harm - Minimal harm or potential for actual harm Firefighters' Emergency Operation Standby or Emergency Power Operation Residents Affected - Many Power Operation of Door System Broken Rope, Tape, or Chain Switch E/E/PES Electrical Protective Devices All elevators need a working door restrictor is required. First cited on 4/5/2023. Under Safety Code for Elevators and Escalators, ASME (American Society of Mechanical Engineers) 17.1-2016/CSA B44-16 dated 01/17/2016 as revised, defines Egress restrictors, if used, that would prevent the free and continuous exiting of passengers, shall provide a signal to a device on the moving walk that shall cause the electric power to be removed from the moving walk driving-machine motor and brake when the exit restrictors begin to close. All elevators need to be clean cartops, puts divider beams and headers. All elevators working direction arrows and position indicators required. Elevator 3 working five service [NAME] and buzzer required. First cited on 4/5/2023. Elevator 3 check battery for EM cab lighting / alarm bell. First cited on 4/5/2023. Per city, Department of Buildings report dated 8/15/2024 facility has a total of five (5) violations. Inspection results: Failed (Reinspection) on all elevators. On 8/28/2024 at 1:19 PM, V11 (Maintenance Assistant Director) stated that the facility has 3 elevators. And elevator number 2 which has the post of out of order will not close half an inch. V11 then showed the picture on his cellphone showing the elevator door not completely close. Per V11 facility maintenance staff cannot fix the problem because it needs a license person to do the job. When asked about the restrictors of all elevators that was identified as a problem since 4/5/2023? V11 stated, I understand what you mean that it was a problem since 4/5/2023. But I really can't say. We just order it to our contractor. Sometimes, we are waiting for a part. Sometimes couple days sometimes couple months. I don't why it was not fix. V11 stated that door restrictor's function works for opening and closing the door. But he is not certain about the function of the restrictor. V11 stated that for a period of fifteen (15) years there were only three (3) incidents that a person was stuck inside the elevator. And it needs to be opened manually by a special key. V11 stated that City Inspector told him (V11) that elevators can be used but to send the report to their contractor. On 8/29/2024 at 9:37 AM, V10 (Maintenance Director) stated he did not schedule the testing for Category 1. Because Category 1 Test needs to be scheduled by the contractor and the city needs to be present during the testing. V10 was asked if facility needs to coordinate with contractor if they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 2 of 3 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 08/30/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many schedule Category 1 testing or at least call their contractor to ensure testing was done? V10 stated that contractors are in-charge in scheduling testing. Per V10, door restrictors help prevent door from opening when the elevator is between floor or not in a proper position. It needs the fire department to open the door. V10 said, If you are stuck in the inside of the elevator, they don't want you to open from the inside. V10 stated that restrictor was not working properly. With the restrictor it acts like a break for the door not to open when it is not in the proper place. And the city put it in to replace the whole thing. V10 stated, as to cleaning staff clean from time to time but facility does not have a fix schedule. V10 said, People throw garbage. Bulbs are burn out and contractor change the bulb as needed. Under TITLE 41: FIRE PROTECTION CHAPTER II: ELEVATOR SAFETY REVIEW BOARD PART 1000 ILLINOIS ELEVATOR SAFETY RULES SECTION 1000.140 CONVEYANCE INSPECTION b) Periodic Inspections and Tests 1) It shall be the responsibility of the owner of all new and existing conveyances located in any building or structure to have the conveyance inspected annually. [225 ILCS 312/120(a)] It shall be the responsibility of the owner to ensure that the inspections and tests are performed at the prescribed intervals. Facility provided a contract from contractor titled Upgrade Order Agreement dated 8/29/2024, it reads: Contractor proposes to furnish and install three (3) new mechanical door restrictors. One (1) for each elevator. And to test and return to service the elevators. Facility still needs to accept the said proposal agreement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 3 of 3