Inspection·December 11, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm The facility's Certified Nursing Assistant Job Description dated 08/24/2018 documents, in part, The CNA safeguards the health, safety, and welfare of all guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 2 of 19 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 12/11/2024 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow physician's orders regarding hand restraints. This failure affected one resident (R25) in the facility viewed for restraints in a sample size of 66. Residents Affected - Few Findings include: R25's admission diagnoses include but not limited to Alzheimer's, bipolar, emphysema, anxiety, scoliosis and motor and sensory neuropathy. R25's Brief Interview of Mental Status (BIMS) score is blank. On 12/8/24 at 11:10 am, observed R25 in room lying in bed with hand mittens on the left and right hands. On 12/9/24 at 9:50 am, observed R25 lying in bed with a hand mitten on the left hand. On 12/10/24 at 9:56 am observed R25 lying in bed with hand mittens on the left and right hand. R25's Active Orders Summary Report as of (12/10/24) documents in part, may use hand mitten on right hand. On 12/10/24 at 10:00 am V33 (Restorative Aide) stated, I put the mittens on R25 today. I was told to put on both hands by the restorative director. She has the hand mittens for involuntary movement. On 12/10/24 at 10:34 am, Surveyor inquired to V34 (Restorative Director) how many mittens does R25 have on. V34 stated, R25 has 2 mittens on, and she is only supposed to have on 1. I did not tell the aide to only put on 1 mitten. She is supposed to only have a mitten on the right hand only. R25's (8/25/24) consent for the use of restrain/mitten documents in part, 4. Type of Restrained/Mitten used: a. right hand mitten. R25's (11/8/24) Care plan documents in part, Focus: may use mitten on right hand related to involuntary movement of the hand. R25's (11/2/24) restorative assessment documents in part, 1. Type of device being applied: h. hand or wrist restraint/mittens. Specify: right hand mitten. Facility's job description undated titled Restorative Nursing Aide documents in part, Essential Functions: 1. Provides restorative nursing services to guests as assigned or directed. Facility's job description dated 8/24/2018 titled Restorative Nurse Director documents in part, Ensure that the restorative nursing program complies with applicable laws, regulations, and national restorative nursing standards and requirements. 8. Provide supervision to the RNA (Restorative Nursing Aide) and all subordinate staff which includes checking their work to ascertain that assignments have been completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 3 of 19 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 12/11/2024 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 not layered with multiple linens. This failure affected 2 residents (R44 and R66) reviewed for pressure ulcer/injury prevention and treatment in a sample of 66 residents. Residents Affected - Few Findings include: 1.) R44's admission diagnoses include but not limited to congestive heart failure, dementia, depression, venous insufficiency, chronic obstructive pulmonary disease, and pulmonary nodule. R44's Brief Interview of Mental Status (BIMS) score is 3. R44 has severe cognitive impairment. On 12/8/24 at 10:37 am, R44 was lying on a low air loss mattress with multiple layers between R44 and the low air loss mattress. The layers observed under R44 consisted of a flat sheet, a flat sheet folded multiple times, an incontinent pad, and an incontinent brief. R44's (12/11/24) Active Order Summary report documented in part, Air loss mattress alternating pressure for preventive measures. R44's Risk Assessment Profile dated 7/3/24 documents in part, R44's Braden Scale Score is a 14, indicating R44 is moderate risk. R44's (12/6/24) care plan documents in part, Focus: assessed to be high risk for skin alteration due to Braden score of 14, decreased mobility, wheelchair bound, history of pressure injuries, incontinent of bowel and bladder. Interventions: Apply air loss mattress on bed for preventive measures. 2.) R66's admission diagnoses include but limited to Parkinson disease, peripheral vascular disease, glaucoma, emphysema, embolism and thrombosis, cognitive impairment, diabetes, congestive heart failure, and hypertension. R66's Brief Interview of Mental Status (BIMS) score is 7. R66 has severe cognitive impairment. On 12/8/24 at 10:50 am, R66 was lying on a low air loss mattress with multiple layers between R66 and the low air loss mattress. The layers observed under R66 consisted of a flat sheet, an incontinent pad, and an incontinent brief. R66's (12/10/24) Active Order Summary Report documents in part, pressure relieving mattress. R66's Risk Assessment Profile dated 7/5/24 documents in part, R66's Braden Scale Score is a 15, indicating R66 is at risk. R66's (2/20/24) care plan documents in part, Focus: assessed to be high risk for pressure injury development due to his current Braden scale of 15 . On 12/8/24 at 10:45 am, V6 CNA (Certified Nursing Assistant) stated, An air mattress should only have a flat sheet and incontinent pad. It was nightshift and they know better than that. It defeats the purpose of the air mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 4 of 19 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 12/11/2024 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 Residents Affected - Few On 12/10/24 at 10:56 am, V2 (Director of Nursing) stated that the low air loss mattress should only have a sheet and an incontinent pad if the resident is incontinent. The purpose for the low air loss mattress is to relieve pressure and heal wounds. On 12/10/24 at 11:05 am, V8 (Wound Nurse) stated, layering for the air mattress should be a flat sheet and 1 incontinent pad or 1 incontinent brief, not both, one or the other. The purpose for the air loss mattress should be to alternate the pressure if they have wounds or if at risk for wounds. Residents who have already had wounds before and it is healed we still put them on a low air loss mattress. Having more than two layers defeats the purpose for the air mattress. The (undated) (Manufacturer Name) Pressure Low Air Loss Mattress Operation Manual documented in part, Instructions step 2. You may place a thin cotton sheet over the mattress top cover. Operation Instructions 5. Patients can directly lie on the mattress or cover with a sheet and tuck loosely to increase the comfort of the patient. Facility's (revised 1/24/24) titled Wound Care Guidelines documents in part, Overview of the Program: The goal of this care guidelines is to achieve compliance to regulatory requirements and provide evidence-based recommendations for the prevention and treatment of pressure injuries that can be used by the health professionals in the facility. Facility's Job description dated 8/24/18 and titled Licensed Practical Nurse, documents in part, Essential Functions: 12. Administer or supervise all treatments prescribed by physicians including but not limited to pressure ulcer care . Facility's Job description dated 8/24/18 and titled Registered Nurse, documents in part, Essential Functions: 12. Administer or supervise all treatments prescribed by physicians including but not limited to pressure ulcer care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 5 of 19 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 12/11/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review the facility failed to ensure one resident (R169) received equipment to assure that R169 maintains, and/or improves to the highest level of range of motion (ROM) and mobility. This failure affected one resident (R169). Findings include: R169 has a diagnosis of but not limited to Idiopathic Normal Pressure Hydrocephalus, Hypertension, Cognitive Communication Deficit, Bipolar Disorder, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side. R169 has a Brief Interview of Mental Status score of 15, cognitively intact. R169's Order Summary Report with active orders as of 12/09/2024 documents, in part, may use Left hand splint/carrot. On 12/08/2024 at 9:45am surveyor observed R169 without a hand splint or carrot (assistive device) in R169's left hand. On 12/08/2024 at 9:46am R169 stated that staff has never place a rolled-up hand towel or carrot in his left hand to prevent his fingers from further contracture. On 12/08/2024 at 10:00am surveyor observed V20 (Restorative Aide) walk into R169's room with a hand brace in her hand. V20 stated that she was trying to find his (R169) device for his contracted hand and she is responsible for applying the resident's devices to prevent further contraction. On 12/08/2024 at 10:01am surveyor observed V20 attempting to put the hand brace on R169's right hand, which was not contracted. Surveyor than observed V20 attempting to put the hand brace on R169's left hand. Surveyor observed R169's face grimace and R169 moan in pain. Surveyor asked R169 was he in pain and R169 stated yes. On 12/08/2024 at 10:02am V19 (Licensed Practical Nurses) handed V20 a carrot and said try this. On 12/08/2024 V20 stated that there is a list that tells us what device each resident is to have but she did not remember what R169 used. On 12/08/2024 at 10:02 surveyor observed V20 place the carrot in R169 left hand with no issues. On 12/08/2024 at 10:03am R169 stated this was the first time anyone has ever put a device in his left hand. On 12/08/2024 at 10:03am V20 stated we (restorative aides) are supposed to put on the resident's splints or hand devices. On 12/08/2024 at 10:07am V19 stated that restorative staff are supposed to put on the resident's devices such as hand splints and braces. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 6 of 19 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 12/11/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm On 12/10/2024 at 10:30am V34 (Restorative Director) stated she expects the restorative aides to apply resident's devices and that there is a list of the devices and who is supposed to have what devices. V34 stated restorative aides are trained on how to put on the devices and are required to do return demonstrations on how to apply them. Residents Affected - Few Undated facility list titled Residents on Splints documents R169: left hand Carrot. Care plan focus (ADL Self Care) with a date of 11/01/2024 documents performance and impaired mobility deficit related to left hand weakness on a carrots program. Undated policy titled Restorative Daily Functions documents, in part, check and apply Carrots and check all residents to make sure all appropriate devices are in place. Undated Splint Care/Program documents, in part, Assistance with Splints: Resident to corrective orthotics d/t (related to) non fixed contractures. Corrective orthotic will be on for a duration up to 6 hours every day and released during care time, mealtime and when in bed. Job description titled Restorative Nursing Aide documents, in part, The R.N.A provides restorative nursing services to assigned Guests in effort to help them reach their full ability to perform essential daily living tasks and assists Guest with medical assistance devices. Job description titled Restorative Nurse Director documents, in part, the Restorative Nurse implements and directs the facility's restorative nursing program with the goal of helping Guests reach and maintain their full mobility potential and provides supervision to R.N.A and all subordinate staff which includes checking their work to ascertain that assignments have been completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 7 of 19 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 12/11/2024 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 Based on observation, interview and record review, the facility failed to properly contain oxygen equipment (nebulizer mask) for one resident (R133). This failure affected one residents (R133) reviewed for oxygen equipment, in a total sample of 66 residents. Residents Affected - Few Findings include: R133's face sheet shows that R133 has a diagnosis which includes but not limited to atherosclerotic heart disease of native coronary artery with unstable angina pectoris, chronic obstructive pulmonary disease with acute exacerbation, venous insufficiency chronic peripheral and hypertensive heart disease with heart failure. R133's Brief Interview for Mental Status (BIMS) dated 10/10/24 documents that R133 has BIMS score of 15 which indicates that R133 is cognitively intact. On 12/08/24 at 10:53 am, R133 was observed in bed awake, alert, with R133's nebulizer mask uncontained in bed with R133. R133 stated that R133 uses R133's nebulizer mask daily for R133's nebulizer treatments. When R133 was asked how R133's nebulizer mask is stored when not in use R133 stated, I (R133) just keep it in bed with me. I don't have anywhere to store it. On 12/10/24 at 9:45 am, V2 (Director of Nursing, DON) was asked regarding the facility's policy for storing oxygen equipment such as a nebulizer mask when not in use and V2 stated that oxygen equipment should be stored in a plastic bag when not in use. When V2 was asked regarding the importance of storing oxygen equipment (nebulizer mask) when not and use and V2 stated, It's to prevent infection with a resident. V2 then explained that oxygen equipment such as nebulizer mask should be change weekly by the night shift nurse, labeling the date the mask was changed. R133's Physicians Order Sheet (POS) dated 5/31/2024 shows that R133 has orders for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 3 MG(milligram)/3 ML (milliliter) (Ipratropium-Albuterol) 1 inhalation inhale orally every 6 hours for SOB (shortness of breath). The facility's document dated 08/16/24 and titled Oxygen Storage documents, in part: Policy Statement: it is the policy of the facility to store oxygen safely and properly. On 12/10/24 at 12:46 pm, Surveyor requested a policy regarding how staff should store and contain oxygen equipment (nebulizer mask) when not in use and V3 (Assistant Administrator) stated that the facility does not have a policy that informs staff on how to store oxygen equipment such as a nebulizer mask when not in use. V3 also stated, I (V3) am not nursing. V2 (DON) would have to tell you how staff will know how to store the nebulizer mask. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 8 of 19 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 12/11/2024 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to post the current daily nursing staffing. This failure has the potential to affect all the 188 residents residing in the facility. Residents Affected - Many Findings include: On 12/08/24 at 8:55 am, Surveyor entered the facility at 8:55 am, and observed the daily staff posting displayed in a glass casing, on a wall, across from the receptionist desk dated 12/06/24. On 12/08/24 at 9:09 am, V37 (Licensed Practical Nurse) presented a facility census of 188 residents in the facility. On 12/08/24 at 9:50 am, V26 (Weekend Receptionist) stated, I (V26) am the weekend receptionist. I don't change that out (referring to the Daily Staff Posting). I believe the Monday through Friday receptionist changes it during the week. When V26 was asked regarding how often the daily staff posting should be updated and displayed, V26 stated, I (V26) don't know. They do it during the week. On 12/09/24 12:09 pm, V27 (Receptionist) was asked regarding the Daily Staff Posting for the facility and V27 stated, I'm not sure who post the daily staffing on weekends. I update the daily staffing in the computer Monday through Friday and change it in the glass casing. I update it every day manually and change the posting in the glass. When V27 was asked the importance of the Daily Staff Posting V26 stated, The purpose is to get a good look and total of the nursing hours for the day. On 12/10/24 at 12:45 pm, V3 (Assistant Administrator) was asked regarding the daily staff posting at the facility and V3 stated, I (V3) oversee that the receptionist at the facility is posting the daily staffing. It is my fault V26 is now aware of the daily staff posting. She (V26) use to work the evening shift at that facility and was never made aware of the daily staff posting. When V3 was asked regarding the importance of the Daily Staff Posting V3 stated, The purpose of the daily staff posting is to inform everyone of how many nursing staff are working for the day. I (V3) will be in-servicing V26. The facility's document dated 07/26/24 and titled Facility Assessment documents, in part: Purpose: This Facility Assessment will be used to inform decisions to ensure that there is enough staff with appropriate competencies and skill sets necessary to care for the residents' needs as identified through resident assessment and plan of care. Consider staff needs for each shift including weekends and adjust as necessary based on any changes to the residents' population. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 9 of 19 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 12/11/2024 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 their policy for storage and labeling of food. The facility also failed to ensure proper dishwashing machine sanitation temperatures to prevent the spread of food-borne illnesses. These failures have the potential to affect 186 residents who are receiving oral diets. Findings Includes: The Form CMS 671 The Long-Term Care Facility Application for Medicare and Medicaid dated 12/8/24 documents there are a total of 188 residents within the facility. Per V1 (Administrator), there are two residents that are not receiving oral diets from the kitchen. On 12/8/24 at 9:30 am, during the initial tour of the kitchen with V7 (Acting Dietary Supervisor/ADS), observed the following foods were found open in the walk-in freezer without preparation and expiration date labels: 1. 1 bag Garlic Toast 2. 1 bag Meatballs On 12/8/2024 at 9:35 am, observed the following foods in the walk-in refrigerator: 1. 1 Tuna Salad in a large silver container covered with saran wrap no preparation date and expiration date label. 2. 1 bag Cheese cubes no preparation date and expiration date label 3. 1 large silver container Raw Chicken no preparation date and expiration date label. 4. Greens and carrot vegetables with written preparation date 12/2/24 and written expiration date 12/7/2024. On 12/8/24 at 9:41 am, V7 (ADS), stated that the dietary staff are supposed to label all foods before it is stored in the refrigerator. On 12/9/2024 at 10:07 am, during rounds with V28 (Regional Director of Operations) in the pantry room, observed 2 bags of white bread with delivery dates of 11/7/24. Upon interview, V28 stated bread should be discarded after 14 days. On 12/10/24 at 12:00 pm, V22 (Food Service Director) stated that they must label and use foods within 7 days. On 12/08/24 at 10:50 AM, during observation of the dishwasher machine, V7 (Acting Dietary Service), stated that we do a temperature check by placing a strip in the high temperature dishwasher. At 10:54 am, V7 (ADS) performed a test cycle of the dishwasher by: 1. Placing a dish plate in a dishwashing tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 10 of 19 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 12/11/2024 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 2. Adhering a test strip to the dish plate Level of Harm - Minimal harm or potential for actual harm 3. Starting the dishwasher. Residents Affected - Many On 12/08/24 at 10:59 am, observed the test strip label remained white after completing the final dishwashing rinse. V7 (ADS) stated that the test strip should turn black indicating the sanitation temperature of 160 degrees Fahrenheit was met. Observed a second test performed with a test strip attached to a plate in a dish rack. This test also resulted in the test strip remaining white in color after the final dishwasher rinse cycle completion. Observed a third test performed using a dishwasher safe thermometer in a dish rack revealed a final rinse temperature result of 137.3 degrees Fahrenheit. V7 (ADS), stated that it looks like the temperature did not reach the desired temperature, so we are going to serve the residents meals on paper plates and notify a repairman. On 12/09/24 at 02:22 PM, V30 (Maintenance Director) stated that the dishwasher was serviced and cleaned by a provider and that the following service was performed: 1. Dishwasher and dishwasher pump was de-limed 2. The machine was cleaned with a heating element 3. The temperature was adjusted on the rinsing tank On 12/09/24 at 2:24 PM, V30 stated that the provider recommended to de-lime the dishwasher more often to prevent build up and failure to reach sanitizing temperature regulations. Facility policy statement named Food Storage: Cold with a revision date of October 2019 reads The Dining Services Director/Cook(s) ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Facility policy statement named Food Safety dated 7/5/2019, 5.1 Storage Standards and Procedures reads to: 1. Conduct daily visual walk-through inspections of all storage areas while the location is in operation. 2. Rotate all products in storage areas using the FIFO method so that older products are used first. 3. Discard out-of-date products. Facility policy statement named TCS & 7-Day Labeling and dated 2024 reads: For Non-TCS Foods without a Use By or Best By date, use a shelf-life of 30 days. The facility policy statement named Ware Washing dated October 2019 reads: The Dining Services Director ensures that all the dish machine water temperatures are maintained in accordance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 11 of 19 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 12/11/2024 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 manufacturer recommendations for high temperature or low temperature machines. Level of Harm - Minimal harm or potential for actual harm The facility policy statement named Equipment dated October 2019 reads: Residents Affected - Many 1. The Dining Services Director will ensure that all staff members are properly trained in the cleaning and maintenance of all equipment. 2. The Dining Services Director ensures that all food contact equipment is cleaned and sanitized after every use. 3. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or maintenance Director as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 12 of 19 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 12/11/2024 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm 3.) R135 has a diagnosis which includes but not limited to fusion of spine cervical region, encounter for screening for diabetes mellitus, anxiety disorder, other asthma, alcohol abuse and essential hypertension. Residents Affected - Few R135 Brief Interview for Mental Status (BIMS) dated 11/04/24 documents that R135 has BIMS score of 15 which indicates that R135 is cognitively intact. On 12/08/24 at 10:32 am, Surveyor observed R135's personal room refrigerator with a refrigerator temperature log sheet for December with missing refrigerator temperature logs for December 1, 2024 and December 4, 2024. R135 stated that R135 cleans R135's refrigerator as needed. When R135 was asked how often staff at the facility checks R135's personal refrigerator in R135's room R135 stated that the staff at the facility documents on R135's refrigerator temperature log sheet whenever staff at the facility checks R135's refrigerator. On 12/10/24 at 9:47 am, V2 (Director of Nursing) stated that the housekeeping staff at the facility monitors the residents personal refrigerators daily. V2 explained that the nursing staff at the facility do not monitor the resident's personal refrigerators. V2 also explained that Management at the facility assigns the personal refrigerators to the residents and the housekeeping department to manage. On 12/10/24 at 9:58 am, V32 (Housekeeper Director) stated that V32 has been the housekeeping director for nine years at the facility. When V32 was asked regarding the personal refrigerators at the facility V32 stated that the housekeeping staff is responsible for monitoring the resident's personal refrigerators every day for refrigerator temperatures, expired food and for cleanliness. V32 also explained that each resident personal refrigerator should have a temperature log in the resident's room (usually on the resident's refrigerator) to document that the refrigerator was checked. V32 then explained that the resident's personal refrigerator temperature should be logged every day so that the residents do not get sick from a refrigerator that is not working or expired foods. On 12/10/24 at 12:45 pm, Surveyor requested a facility's policy for the staff's procedure to documents the monitoring of the resident's personal refrigerators checks and V3 (Assistant Administrator) stated, 'We don't have a policy for the temperature logs and corporate does not feel they should make one. On 12/10/24 at 2:00 pm, V3 (Assistant Administrator) presented a document titled Freezer Temperature Log for Non-24-Hour Operation and stated that staff should be recording the resident's personal refrigerator temperatures every day onto the Freezer Temperature Log for Non-24-Hour Operation log sheet. The facility's document dated December and titled Freezer Temperature Log For Non-24-Hour Operation shows that R135's personal refrigerator temperature log for December has missing temperature logs for December 1, 2024 and December 4, 2024. Based on observation, interview and record review, the facility failed to properly check and log a daily refrigerator temperature for three residents (R135, R145 and R113) with personal refrigerators. The facility also failed to provide a thermometer in one resident's refrigerator (R145) and failed to clean the personal refrigerator for one resident (R145). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 13 of 19 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 12/11/2024 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 0813 Findings include: Level of Harm - Minimal harm or potential for actual harm 1.) Residents Affected - Few On 12/08/2024 at 10:15 am observed a black personal refrigerator sitting on the floor next to R113's bed. Observed a temperature log on the front of R113's refrigerator door, the temperature log was for November (year not listed) and there was missing documentation for temperature readings on November 24th, 25th, 26th, 27th, 28th, and 29th. Upon R113 opening the refrigerator door, observed a carton containing 6 eggs and a clear locked box containing six insulin pens. R113 stated I have an order to keep my insulin pens in my refrigerator. R113 stated my refrigerator door has a lock on it and I check the temperature in my personal refrigerator every day. R113 stated I did leave the facility on November 24th, 2024, and did not return to the facility until December 3, 2024. R113 stated no staff checked the temperature in the refrigerator when I was out of the facility on pass. R113 stated the staff did not give me a new temperature log for December 2024, so I have not documented a refrigerator temperature since I returned to the facility. R113's Brief Interview for Mental Status (BIMS) dated 10/02/2024 Section C C0500 documents that R113 has a BIMS score of 15 which indicates that R113's cognition is intact. 2.) On 12/08/2024 at 10:55 am observed a black personal refrigerator sitting on a stand in R145's room. There was no temperature log observed posted near R145's personal refrigerator. Upon opening R145's refrigerator door, there was no thermometer observed inside the refrigerator. Observed a one-half pint (236ml) carton of 2% milk, a package of yellow cheese with a best by dated of 11/18/2024 and a container of potato salad. Observed two brown stains in the bottom shelf of the refrigerator and a loose and uncovered piece of lunch meat sitting on the door shelf of the refrigerator. On 12/08/2024 at 10:58 am R145 stated I do not let staff clean my refrigerator. I tell the staff I will clean the refrigerator. R145's Brief Interview for Mental Status (BIMS) dated 09/02/2024 Section C C0500 documents that R145 has a BIMS score of 15 which indicates that R145's cognition is intact. On 12/08/2024 at 11:00am V17 (Housekeeper) stated the residents are responsible for cleaning their personal refrigerators. On 12/10/2024 at 10:04am V32 (Housekeeping Director) stated the housekeeping staff is responsible for checking and logging the temperature in the resident's personal refrigerators daily. V32 stated the housekeeping staff is responsible for checking the expiration dates on foods in the resident's personal refrigerators and cleaning the refrigerator out. V32 stated the housekeeping staff keep track of the temperature in a resident's personal refrigerator by placing a temperature log on the refrigerator to document the daily temperature on. V32 stated if a resident consumes spoiled foods in their personal refrigerator, the resident can get sick. On 12/10/2024 at 10:21am V2 (Director of Nursing/Infection Preventionist) stated the housekeeping staff are responsible for checking the temperature daily in a resident's personal refrigerator. V2 stated each resident who has a personal refrigerator should have a thermometer inside the refrigerator. V2 stated if a resident consumes spoiled food because the temperature is not being checked in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 14 of 19 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 12/11/2024 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 0813 personal refrigerator, the resident can get sick. Level of Harm - Minimal harm or potential for actual harm On 12/10/2024 reviewed the facility's policy, with a revision date of 8/19/24, titled Refrigerator and Resident Appliance Maintenance Service which documents in part, Procedure 1. The maintenance department or facility designee is responsible for maintaining that resident appliance e.g. refrigerators are safe, clean, and operable at all times. a. Refrigerator in resident room. Residents Affected - Few Reviewed the facility's Housekeeper's Job Description which documents in part, the housekeeper is responsible for maintaining environmental and infection control standards by performing a variety of general cleaning tasks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 15 of 19 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 12/11/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to maintain a garbage dumpster lid in a closed position due to dumpster being overfilled with garbage forcing the dumpster lid to remain open providing an opportunity to attract rodents. This failure has the potential to effect 188 residents within the facility. Residents Affected - Many Findings Include: The Form CMS 671 The Long-Term Care Facility Application for Medicare and Medicaid dated 12/8/24 there are a total of 188 residents within the facility. On 12/8/2024 at 9:43 am, during rounds with V7 (Acting Dietary Supervisor), observed the garbage dumpster overflowing with garbage bags forcing the lids open on 2 of the three garbage cans. V7 stated that the garbage dumpster lid should be maintained in a closed position with the lid touching the garbage dumpster and that maintaining the garbage dumpster lid in a closed position will prevent attracting rodents. On 12/8/24 at 10:13 am, V3 (Assistant Administrator), stated that he thought the garbage lids were open because of the high winds and was informed the garbage dumpster was overflowing with garbage forcing the lid to remain open. On 12/9/24 at 9:04 am, surveyor observed one of the three outside garbage dumpster lids was observed overflowing with garbage bags forcing the lid to remain open. On 12/10/2024 at 10:21 am, surveyor observed one of the outside garbage dumpster lid was open due to the overflowing of garbage bags forcing the lids to remain in an open position. The facility policy statement named Dispose of Garbage and Refuse dated October 2019 reads: 1. The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 16 of 19 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 12/11/2024 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 Based on observation, interview, and record review, the facility failed to ensure an Enhanced Barrier Precaution (EBP) sign was posted for a resident on EBP in an effort to prevent the spread of multi-drug resistant organism at the facility. This failure affected 1 (R70) resident reviewed for infection control. Residents Affected - Few Findings include: The (12/07/2024) midnight census documented that there were 61 residents on the fourth floor. On 12/08/24 at 10:46 AM on the 4th floor, inquiring about the acuity of the floor. V4 (Registered Nurse) stated this is the dementia floor. (R70) has a g-tube (gastric feeding tube). On 12/08/24 at 11:02am, there was no EBP sign posted by R70's room/door. This was pointed out to V8 (Wound Care Coordinator/Registered Nurse). V8 stated she (R70) has a g-tube. She is on EBP. There is no EBP sign posted. The sign is supposed to be posted but I don't want to give you wrong information. I called the Infection Preventionist. On 12/08/24 at 11:08am, V2 (Director of Nursing/Infection Preventionist) brought an EBP sign and posted it by R70's door. V2 stated our policy is, if a resident is on EBP, there should be a PPE bin and an EBP sign posted by the resident's door. Her (R70) EBP sign might have fallen, and nobody told me about it. The purpose of posting an EBP sign by the resident's door is to ensure staff know the proper PPE to wear when they do high contact care to residents. The purpose of wearing appropriate PPE is to prevent resident and staff from getting infection. It has the potential to affect other residents, too, if staff don't wear appropriate PPE. R70's (Active Order as of: 12/09/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) gastrostomy status. Enteral Feed: one time a day for Supplement (brand name of tube feeding) 1.5 at 45 ml/hr (18 hours total) via G-tube, or until 810 ml total volume infused. R70's (09/23/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C1000. Cognitive Skills for daily decision making: 3 - severely impaired. Section K. Swallowing/Nutritional Status. K0520. Nutritional Approaches. B. Feeding tube: 3. While a Resident. R70 (Target Date: 12/22/2024) care plan documented, in part is on Enhanced Barrier Precautions related to Gt-ube. Potential spread of infection will not occur until next review. Ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, feeding tube) that provide opportunities for transfer of MDROs to staff hands and clothing. The (undated) 4th floor Residents on enhanced Barrier Precautions documented that R70 was on the list related to G-tube with a start date of 4/3/23. The (7/26/24) Enhanced Barrier Precaution documented, in part Policy: The facility will use Enhanced Barrier Precautions (EBP) to reduce transmission of multi-drug resistant organism in the nursing homes. EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDRO's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 17 of 19 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 12/11/2024 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (multi drug resistant organism). Procedure: 1. EBP will be used for any resident in the facility: has indwelling medical devices (feeding tube) regardless of colonization status. 3. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of XDRO's (Extensively Drug Resistant Organism) to staff hands and clothing. Examples of high-contact care activities requiring gown and glove use among residents that trigger EPB use include: g) Device care or use: feeding tube. 7. An EBP sign should be posted on the doors of each resident on EBP. Event ID: Facility ID: 145670 If continuation sheet Page 18 of 19 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 12/11/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based upon observation, interview and record review, the facility failed to maintain an effective pest control program to ensure that the facility is free of roaches. This failure has the potential to affect all 188 residents in the facility. Residents Affected - Many Findings include: The 12/08/24 resident census was 188. On 12/08/2024 at 11:33am, R398 requested surveyor come to his room to observe the room bathroom. On 12/08/2024 at 11:35am upon arrival to R398's room, observed one large cockroach crawling on R398's toilet seat and 4 small cockroaches crawling on the floor in R398's room bathroom. On 12/08/2024 at 11:37am R398 stated I have seen roaches in my room before. I don't like that the facility has roaches. On 12/08/2024 at 11:40 am surveyor requested maintenance staff come to the second floor. On 12/08/2024 at 11:53am V18 (Maintenance Assistant) arrived at R398's room. V18 observed the roaches in R398's bathroom and stated, We are fighting the roaches. V18 stated pest control does come to the facility. On 12/08/2024 at 11:54am surveyor observed V18 stepping on the roaches, picking the roaches up from the floor with a paper towel, and placing the paper towel with roaches into the garbage can in R398's bathroom. On 12/10/2024 at 11:43am V30 (Maintenance Director) stated the last couple of weeks the facility has had a problem with roaches due to the weather changing. V30 stated the residents keep food on the floors and we try as much as possible to talk with the residents to keep food from off the floors to prevent pests from being in the facility. V30 stated the pest control was at the facility last Friday and I did call the pest control company and they are scheduled to come service the facility on Wednesday. V30's stated R398's room is on the list. V30 stated no resident wants roaches in their room, it is not a homelike environment. The pest control policy dated 8/16/24 documented, in part Policy: It is the facility's policy to ensure that there is an effective pest control process in the building. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145670 If continuation sheet Page 19 of 19