Inspection·December 4, 2024

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some groin and buttock, DX (Diagnosis) Dermatitis. Triamcinolone Acetonide 0.5% ointment apply small amount topically to affected areas (groin, perineal) twice daily as needed for rashes. R148's care plan documents in part, Focus: Altered thought process related to dx (diagnosis) of Dementia. Focus: Cognitive Loss/Disorientations/Impaired Judgment. The resident demonstrates cognitive impairment related to a diagnosis of dementia. Symptoms are manifested by impaired decision making, poor logic and poor agility to understand cause and effect. Facility's policy (undated) and titled, Self-Administration of Medication documents in part, Policy: Self-administered medications will be encouraged f it is desired by the resident, safe for the resident and other resident of the facility. Ordered by the attending physician . Facility's policy (undated) and titled, Medication Administration documents in part, Policy: 5. The medication is to remain in the container until administration time. Facility job description titled License Practical Nurse documents in part, Essential Duties and Responsibilities: Carry out medical providers orders according to the order and in accordance with local, state, federal, and facility policies and procedures. Facility job description titled Registered Nurse documents in part, Essential Duties and Responsibilities: Carry out medical providers orders according to the order and in accordance with local, state, federal, and facility policies and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 2 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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** Based on interview and record review the facility failed to refer one resident (R126) for rescreening to the state agency for Preadmission Screening and Resident Review (PASRR). This deficient practice affected one resident (R126) in a total sample size of 57 residents. Residents Affected - Few Findings include: R126's admission date to the facility is 10/11/24. R126's PASRR (Preadmission Screening and Resident Review) level 1 outcome dated 08/29/24 documents in part, No level II required - No SMI (serious mental illness). R126's diagnoses on 10/11/24 include but are not limited to bipolar disorder current episode manic without psychotic features, schizophrenia, essential hypertension. R126's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score 14 which indicates R126's cognition is intact. On 12/03/24 at 11:19am V10 (Assistant Administrator/AA) stated that level 2 PASRR's are done when the resident has a mental diagnosis. V10 stated that a diagnosis of schizophrenia and bipolar should be included on the level 1 PASRR which would trigger for a level 2 PASRR to be done. V10 stated that PASRR's are done to make sure that residents are placed in the appropriate facilities and that it is a requirement to do the PASRR. V10 stated that if the serious mental illness diagnosis is not on the PASRR from the hospital then the facility should redo the level 1 PASRR immediately and include the diagnoses. Facility's policy dated 12/2023 titled Pre-admission Screening and Resident Review documents in part, In accordance with Federal and State of Illinois regulatory standards and recommended practices, this organization requires each resident to be screened for Level 1 prior to or shortly thereafter admission. The facility will expect Maximus to properly complete Level 2 if a PASRR condition (SMI) exists .Policy: It is the policy of this facility to: 1. Comply with Federal, State and appointed screening agency in standards addressing the PASRR assessment/screening process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 3 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure that medications were signed out when administered for four residents (R8, R43, R81, and R97). This failure affected four residents in the sample of 57 residents. Residents Affected - Some Findings include: On 12/02/24 at 8:58 am, Surveyor requested to observe medication pass on the first floor Team 2 cart with V18 (Licensed Practical Nurse, LPN) and V18 stated that V18 completed the 9:00 am medication pass. Surveyor and V18 reviewed R8, R43, R81, and R97's Medication Administration Record (MAR) and observed R8, R43, R81 and R97's medications not signed out for the 9:00 am medication pass. V18 stated, I (V18) gave them, but I (V18) did not get a chance to sign them out. I (V18) was going to sign them in a few minutes. R8's MAR presented by the facility on 12/02/24 shows the following medications for R8's were not signed after being administered by V18 for the 9:00 am medication pass on 12/02/24: Anastrozole 1 mg tablet by mouth Aspirin Enteric Coated (EC) 81 mg tablet by mouth Daily Vite tablet by mouth Docusate Sodium 100 mg capsule by mouth Vitamin D 1000IU (units) tablet by mouth Oyster Shell 500 with Vitamin D 200 mg by mouth Quetiapine Fumarate 100 mg by mouth Vitamin C 500 mg tablet by mouth R43's MAR presented by the facility on 12/02/24 shows the following medications for R43's were not signed after being administered by V18 for the 9:00 am medication pass on 12/02/24: Amantadine 100 mg (milligram) tablet by mouth Carbidopa-Levodopa 25 -100 mg tablet by mouth Eliquis 5 mg tablet by mouth Entacapone 200 mg tablet by mouth Lamotrigine 25 mg tablet by mouth Levetiracetam 100 mg tablet by mouth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 4 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 0658 Potassium Chloride 10 % liquid by mouth Level of Harm - Minimal harm or potential for actual harm Tamsulosin 0.4 mg capsule by mouth Valproic Acid 250 mg/5ml (milliliter) by mouth Residents Affected - Some R81's MAR presented by the facility on 12/02/24 shows the following medications for R81's were not signed after being administered by V18 for the 9:00 am medication pass on 12/02/24: Citalopram 10 am tablet by mouth Quetiapine Fumarate 100 mg by mouth Quetiapine Fumarate 50 mg by mouth Tradjenta 5 mg tablet by mouth Vitamin D3 25 mcg tablet by mouth R97's MAR presented by the facility on 12/02/24 shows the following medications for R97's were not signed after being administered by V18 for the 9:00 am medication pass on 12/02/24: Aripiprazole 15 mg tablet by mouth Aspirin 81 mg tablet by mouth Bethanechol 25 mg tablet by mouth Brimonidine 0.2% eye drop ophthalmic Docusate Sodium 100 mg by mouth Famotidine 40 mg tablet by mouth Farxiga 10 mg tablet by mouth Flovent 110 mg inhaler by inhalation Gabapentin 300 mg capsule by mouth Hydroxyzine 25 mg capsule by mouth Polyethylene Glycol 3350 powder by mouth Potassium Chloride Extended Release (ER) 10 meq (milliequivalents) by mouth Dry Eye Relief eye drops ophthalmic solution Topiramate 25 mg by mouth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 5 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 0658 Vitamin D3 25 mcg (micrograms) by mouth Level of Harm - Minimal harm or potential for actual harm On 12/02/24 at 10:01 am, Surveyor asked V18 regarding the facility's policy for medication administration and V18 stated, Medications should be signed out when given. When V18 was asked regarding the importance of signing out medications when given V18 stated, If medications are not signed out when given they can be misconstrued as not given and another nurse can administer the medications again. Residents Affected - Some On 12/03/24 at 8:47 am, V2 (Director of Nursing, DON) was asked regarding the facility's policy for medication administration and V2 stated, Medication should be signed out immediately after the medication is given. If the nurse gives the medication and does not sign out medication the medication can be double dosed. The facility's undated policy titled Medication Administration documents, in part: Policy: 4. Nursing personnel administer and record all medications. The facility's undated document titled The Licensed Practical Nurse (LPN) documents, in part: Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times . Complete the required documentation and evaluation by the local, state, federal and facility policies. R8's Brief Interview for Mental Status (BIMS) dated 10/28/24 shows that R8 has a BIMS score of 15 which indicates that R8 is cognitively intact. R8's Face sheet shows that R8 has diagnosis which include but not limited to schizoaffective disorder, malignant neoplasm, metabolic syndrome, and hypothyroidism. R43's Brief Interview for Mental Status (BIMS) dated 10/20/24 shows that R43 has a BIMS score of 15 which indicates that R43 is cognitively intact. R43's Face sheet shows that R43 has diagnosis which include but not limited to schizoaffective disorder, Parkinson's, epilepsy, and hypothyroidism. R81's Brief Interview for Mental Status (BIMS) dated 10/21/24 shows that R81 has a BIMS score of 15 which indicates that R81 is cognitively intact. R81's Face sheet shows that R81 has diagnosis which include but not limited to paranoid schizophrenia, major depression, and generalized anxiety. R97's Brief Interview for Mental Status (BIMS) dated 10/08/24 shows that R97 has a BIMS score of 15 which indicates that R97 is cognitively intact. R97's Face sheet shows that R97 has diagnosis which include but not limited to Parkinson's disease without dyskinesia, major depressives disorder, chronic obstructive pulmonary disease, and schizoaffective disorder bipolar type. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 6 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Findings include: The (12/03/2024 email correspondence with V10 (Assistant Administrator documented that there were 56 residents on the second floor. On 12/01/24 at 11:09am on the second floor, there was a razor on R36's bed side table. This observation was pointed out to V5 (Maintenance Director). V5 stated there is a razor on his (R36) bedside table. On 12/01/24 at 11:15 AM, this observation was also pointed out to V6 (Director of Clinical Special Projects). V6 stated the resident is not allowed to have a razor in their room for safety. The razor should not be in here because the resident can use the razor to cut themselves and other residents. On 12/02/2024 at 9:40am, V2 (Director of Nursing) stated there should be no razor inside the resident's room because it is a safety issue for the resident, staff, and other residents. The resident may use the razor to cut themselves, other residents, or staff. R36's admission Record documented that R36's diagnoses (include but not limited to) schizoaffective disorder and type 2 diabetes mellitus. R36's (09/17/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for Daily Decision Making: 2 - Moderately impaired - decisions poor, cues/supervision required. The (undated) Hazard Policy: Proper Disposal of sharps documented, in part Purpose: To Establish procedures for the safe handling and disposal of sharps, including razors, needles, and other sharp objects to minimize risk of injury and ensure compliance with local, state, and federal regulations. Scope: this policy applies to all staff, residents, and visitors at the facility. Definitions. Sharps: items capable of puncturing or cutting skin, such as needles, scalpels, broken glass, and razors. Policy Statement: All sharps must be disposed of in accordance with established guidelines to ensure the safety if residents, staff, and visitors. Procedures: 2. Disposal of Razors and other sharps. Disposable Razors: After use, razors must be placed directly into an approved sharp container. Residents who are alert and oriented may use disposable razors under supervision or independently as appropriate. After use, they should return the razor to staff for proper disposal in a sharp container. Staff will verify that the razor is disposed of safely and according to policy. Based on observation, interview, and record review the facility failed to ensure that a resident (R120) smoke at a designated smoking area; and failed to ensure that environment was free from hazards (razors) for three residents (R36, R116 and R148). These failures have the potential to affect all 47 residents on the first floor, and all 56 residents on the second floor at the facility. Findings include: The (12/03/2024 email correspondence with V10 (Assistant Administrator documented that there were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 7 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 0689 47 residents on the first floor. Level of Harm - Minimal harm or potential for actual harm On 12/01/24 at 10:40 am, Surveyor observed R116 in R116's room holding 3 shaving razors in R116's right hand. R116 stated that R116 was given the 3 razors from staff 3 days ago to shave R116's head. R116 stated that R116 receives razors from staff to shave R116's head and face. When R116 was asked regarding where does R116 store the razors in R116's hand R116 stated in R116's room. Residents Affected - Some On 12/01/24 at 11:29 am, V12 (Licensed Practical Nurse, LPN) was asked regarding residents with razors and V12 stated that residents cannot have razors due to safety. V12 stated that a resident who does not know how to use the razor can get the razor, cut themselves and bleed. When V12 was asked regarding who monitors the residents that shave themselves and V12 stated that V12 was a agency nurse working at the facility and that V12 did not know. On 12/03/24 at 8:49 am, Surveyor questioned V2 (Director of Nursing DON) regarding residents with shaving razors and V2 stated that residents cannot have razors in their possession due to safety. When V2 was asked regarding who was responsible for monitoring the residents who shave themselves with razors and V2 stated that it is all the nursing staff responsibility to monitor residents who are able to shave themselves with a razor. R116's Brief Interview for Mental Status (BIMS) dated 10/29/24 shows that R116 has a BIMS score of 15 which indicates that R116 is cognitively intact. The facility's undated policy titled Hazard Policy: Proper Disposal of Sharps documents, in part: Purpose: To establish procedures for the safe handling and disposal of sharps, including razors, needles, and other sharp objects, to minimize risk of injury and ensure compliance with local, state, and federal regulations . Policy Statement: All sharps must be disposed of in accordance with established guidelines to ensure the safety f residents, staff, and visitors. Under no circumstances should sharps be discarded in regular trash or recycling bins. On 12/01/24 at 10:52 am, Surveyor observed R120 in R120's bathroom with a lighter and cigarette smoking a cigarette. When R120 saw this Surveyor at R120's bathroom door R120 immediately turned on the water from the bathroom sink in R120's bathroom and put the cigarette out in R120's bathroom sink. This Surveyor brought this observation to V12 (Licensed Practical Nurse, LPN). Surveyor and V12 went back to R120's bathroom where R120 was still sitting and observed R120 still in R120's bathroom smoking another cigarette in R120's bathroom. R120 then immediately placed the cigarette under the running water in R120's bathroom sink, putting out the cigarette in R120's hand. When V12 was asked regarding residents smoking in the residents room V12 stated that residents cannot smoke in the resident due to the resident risking the safety of the other residents and the potential to start a fire. On 12/01/24 at 11:15 am, Surveyor asked V8 (Social Service Director) regarding residents smoking in the residents rooms and V8 stated that safe smokers are allowed to have smoking materials such as lighters and cigarettes in the residents room but the resident should not be smoking in the residents room even if the resident is assessed as a safe smoker. When V8 was asked regarding what could happen if a resident smokes in the residents room and V8 stated, There is a potential for a fire or the resident to burn themselves. When V8 was asked regarding who is responsible for monitoring the residents who smoke and V8 stated, It is all the staff responsibility. R120's face sheet shows that R120 has a diagnosis of schizoaffective disorder, hypothyroidism, and major depressive disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 8 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R120's Brief Interview for Mental Status (BIMS) dated 9/26/24 shows that R120 has a BIMS score of 15 which indicates that R120 is cognitively intact. R120's progress note dated 12/01/24 and authored by V8 documents in part: Per nursing report, R120 was smoking inside his (R120) room on 12/0124. Smoking materials were confiscated and staff-initiated cigar management as a consequence . R120 is unable to handle own smoking materials at this time. R120's Smoking Risk Review dated 12/01/24 documents, in part: 12. May not be capable of handling/carrying any smoking materials and requires supervision when smoking. The facility undated document titled Facility Smoking Safety Policy documents, in part: Policy Objective: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy. Guidelines 1. Smoking is only allowed in designated areas established by management. If indoor smoking is prohibited by state or local law the interior of the facility will remain smoke-free at all times. The designated area(s) will be outside in accordance with state/local standards. The organization has the right to enforce a policy prohibiting residents from keeping any smoking materials in his/her possession for health, safety, and security reasons . 3. Smokers will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. Residents requiring supervision shall receive this monitoring consistent with their assessment and plan of care. R120's care plan dated 12/01/24 documents, in part: Focus: Smoking management/noncompliance. The resident was smoking in a day room on 2/13/21. 11/8/21, 9/8/23 smoking in a washroom. 2/1/24 smoking in room. Date Initiated: 02/15/2021. Revision on: 12/01/2024. Intervention: 12/1/24 smoking materials were confiscated and staff-initiated cigar management as a consequence (resident is scheduled to d/c (discharge) from the facility on 12/6/24). SW (social worker) met with the resident 1:1 (one to one) to address the above. He (R120) is unable to handle own smoking materials at this time. Nursing staff and front desk staff were informed of the above. Patient is currently monitored for compliance. Date Initiated: 12/01/2024. Findings Include: R148's admission diagnoses include but not limited to osteoarthritis, atrial fibrillation, congestive heart failure, and dementia. R148's Brief Interview of Mental Status (BIMS) score is 11 which indicates R148 has moderate cognitive impairment. On 12/1/24 at 10:30 am, observed a razor in R148's room lying on the nightstand. R148 stated that he uses the razor to shave his head. On 12/3/24 at 12:20 pm, V14 RN (Registered Nurse) stated that R148 should not have a razor in his (R148) room. It is considered a contraband because it is a sharp. After the staff use the razor, they should dispose it for safety. On 12/3/24 1:10 pm, V2 DON (Director of Nursing) stated that razors should not be at a resident's bedside. Razors should be discarded in the sharp's container for safety because someone can get (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 9 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 0689 injured. Level of Harm - Minimal harm or potential for actual harm R148's care plan documents in part, Focus: Altered thought process related to dx (diagnosis) of Dementia. Focus: Cognitive Loss/Disorientations/Impaired Judgment. The resident demonstrates cognitive impairment related to a diagnosis of dementia. Symptoms are manifested by impaired decision making, poor logic and poor ability to understand cause and effect. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 10 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 label and date oxygen equipment (oxygen tubing and nebulizer mask per the facility's policy. These failures affected two residents (R54 and R126) reviewed for oxygen equipment, in a total sample of 57 residents. Residents Affected - Few Findings include: R54's diagnoses include but are not limited to heart failure, type 2 diabetes mellitus without complications, chronic kidney disease stage 3, essential hypertension, atrial fibrillation, acute respiratory failure, anxiety disorder, chronic obstructive pulmonary disease, morbid obesity. R54's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 8 which indicates R54's cognition is moderately impaired. R54's physician order dated 05/10/24 documents in part, change oxygen tubing and humidifier weekly or as needed. R54's care plan dated 03/04/23 documents in part, CHF: the resident has congestive heart failure .Give oxygen as ordered by the physician. R126's diagnoses include but are not limited to atrial fibrillation, chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, bipolar disorder current episode manic without psychotic features, schizophrenia, muscle weakness, acute kidney failure. R126's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score 14 which indicates R126's cognition is intact. R126's physician orders dated 10/31/24 documents in part, change nebulization cup and tubing weekly or as needed. On 12/01/24 at 10:28am observed R126's nebulizer mask sitting on nightstand undated. On 12/01/24 at 10:53am V17 (Licensed Practical Nurse/LPN) stated that there is no date on R126's nebulizer mask but it should have a date on it. V17 discarded nebulizer mask into trash can. On 12/01/24 at 11:10am observed R54 with nasal canula undated. On 12/01/24 at 11:11am V13 (LPN) stated that R54 has no date on nasal cannula tubing. V13 stated that oxygen tubing is changed weekly on Sundays by the night shift and that the tubing should have a date on it. On 12/03/24 at 09:42am V2 (Director of Nursing/DON) stated that oxygen tubing should be dated and changed weekly and/or as needed. V2 stated that oxygen tubing is dated to prevent infection from long term use. Facility's undated policy titled Oxygen Administration documents in part, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration .Steps in the procedure: 11. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 11 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 O2 (oxygen) equipment should be changed and dated weekly. 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: 145796 If continuation sheet Page 12 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 ensure the Daily Nursing Staffing was posted daily and failed to ensure the Daily Nursing Staffing was completed appropriately. These failures have the potential to affect all 159 residents residing at the facility. Residents Affected - Many Findings include: The (12/01/2024) Facility daily census was 159. On 12/01/2024 at 12:00pm by the reception area with V9 (Scheduler). This surveyor requested V9 to provide the Daily Staffing Posting for 12/01/2024. V9 looked around the reception area and stated it is not here. V9 inquired if this surveyor was looking for the Daily Staffing Schedule. This surveyor requested to see the Daily Staffing Schedule. On 12/01/24 at 12:05 PM by the first-floor nurse's station, V9 pulled a document from a clipboard and showed this surveyor the Daily Staffing Schedule for 12/01/2024. The form did not indicate the current number of residents and there were no hours for Registered Nurses, Licensed Practice Nurses and CNAs for each shift. This surveyor inquired for the total number of hours for registered nurse, licensed practice nurse and CNAs for each shift. V9 stated I have been here for 2 years, and nobody told me I need to put the total hours of the nurses and CNAs in the Daily Staffing Schedule. (V1 - Administrator) must have the document you are asking for. V9 also stated the Daily Staffing Schedule has a space for Total Census but it is not filled out. On 12/01/24 12:12 PM, V1 (Administrator), pointing to the Daily Staffing Schedule, stated the Daily Staffing Schedule is the Daily Staffing Posting. Nobody told us that we need to put the total number of nursing hours in the Daily Staffing Schedule. The hours (pointing to the shifts 7:00am - 3:30pm, 3:30pm - 12MN (midnight), and 12MN - 8:30am) are already written and that is already the nursing hours. On 12/02/2024 at 9:35am, V2 (Director of Nursing) stated the Daily Staffing Posting includes the total nursing hours on each shift and should be posted daily. That is the regulations. This surveyor requested V2 to show this surveyor the Daily Staffing posting. On 12/02/2024 at 9:37am, there was a Daily Staffing that was posted by the glass door between the reception area and the first-floor nurse's station. The Daily Staffing did not indicate the RN hours, LPN hours and CNA hours for the evening shift and the night shift. This observation was pointed out to V2 (Director of Nursing). V2 stated the daily staffing is not completed appropriately; there is no total nursing hours for the evening shift and the night shift. The (undated) Facility Nursing Home Staffing Policy documented, in part Purpose: To ensure transparency and compliance with federal and state regulations by maintaining and posting accurate daily staffing information, including licensed nurses and Certified Nursing Assistants (CNAs) in the building. Policy Statement: the facility is committed to providing appropriate staffing to meet the needs of residents and will publicly post current staffing levels daily, in a visible and accessible location within the facility and required by applicable laws and regulations. Procedure: 2. Posting Requirements: Location: the staffing information will be posted at the main entrance or another highly visible area with the facility. Content: the posting will include: Date and shift (morning, afternoon, night). Number of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on duty. Number of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 13 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 Level of Harm - Potential for minimal harm Certified Nursing Assistants (CNAs) on duty. Total number of residents in the building. Format: the information will be presented in a clear, readable format and updated at the beginning of each shift. The (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) State Operations Manual documented, in part Residents Affected - Many §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 14 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to follow policy of reconciling controlled substances at the end of each shift. This failure has a potential to affect all 4 residents receiving controlled substances on the 1st floor. Findings include: Facility presented list of residents taking controlled medications on first floor which totaled 4 residents. On 12/1/24 at 11:40 am, during facility rounds with V12 Agency Licensed Practical Nurse(LPN) document called Controlled Substance Check Form did not have signatures of a narcotic shift to shift count for 12/1/2024. V12 stated she did not count narcotics with the night nurse at the start of her shift. 12/03/24 at 01:40 PM The Director Of Nursing (DON) V2 stated that the Nurses need to count narcotic medications between incoming and outgoing nurses at the end of each shift. V2 also stated if the nurses did not do the narcotic shift to shift count they will all be in trouble and they will have to investigate any discrepancies. Facility presented an undated policy titled Controlled Substances which documents: 1. Controlled medication are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. 2. Policies and Procedures for monitoring controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 15 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were stored at proper temperatures in two of three medication refrigerators reviewed for medication storage; failed to secure Schedule II controlled drugs and other controlled drugs subject to abuse in a separately locked compartment separate from non- controlled drugs; and failed to ensure medications including controlled drugs of two of two residents (R159 and R262) that expired are disposed timely. These failures have the potential to affect 47 residents residing on first floor and 56 residents residing on third floor of the facility. Findings include: The ([DATE] email correspondence with V10 (Assistant Administrator documented that there were 47 residents on the first floor and 56 residents on the 3rd floor. On 12-1-2024, at 11:10 AM, during rounds with V12, Licensed Practical Nurse (LPN) on the 1st floor medication refrigerator was noted with frost in freezer area of the refrigerator and temperature was 42 degrees Fahrenheit. V12 confirmed temperature to be 42 degrees Fahrenheit. On 12-1-2024, at 11:15 AM, V12 LPN stated this is her first first time working 1st floor because V12 work from an agency, and V12 wasn't for sure of the correct refrigerator temperature range. On 12-2-24 at 11:58 am during rounds with V7 LPN on the 3rd floor, medications refrigerator was observed with thick white frost in the freezer area of the refrigerator. V7 stated the refrigerator get defrosted weekly by the night nurse. Refrigerator temperature noted to be 42 degrees. V7 confirmed temperature to be 42 degrees Fahrenheit and stated that V7 will have this refrigerator defrosted today. On 12-02-24 12:58 PM, medication refrigerator on the 1st floor was noted to be at 48 degrees Fahrenheit. V18 (LPN) confirmed temperature to be 48 degrees Fahrenheit. On 12-02-24 at 12:26 PM. V2 DON stated the refrigerator freezer for medication get defrosted whenever necessary. Facility presented undated policy with the title: Medical Refrigerator Management and Defrosting Protocol/Policy. Temperature Monitoring: Medical refrigerators should be monitored regularly (minimum of once per shift) to ensure they maintain the temperature range of 36-46-degree Fahrenheit; Temperature logs must be maintained, and any deviations outside of the acceptable range should be reported immediately. Defrosting Procedures: Frequency of Defrosting: Defrosting must be performed when ice accumulation reaches 1/2 inch (1.27cm) on the cooling coils; If the refrigerator's cooling performance decreases (e.g., temperature fluctuations, higher- than usual compressor running time)., defrosting should be carried out immediately, regardless of ice buildup, Defrosting should also be performed on a scheduled basis at least once every three months to prevent excessive buildup and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 16 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 12-1-2024, at 11:54 AM, observed the 1st floor medication refrigerator unlocked and easily accessible to all other residents and staff. The following controlled medications for R159 were inside the medication refrigerator: 1 bottle of 0.25 ml of Morphine Sulfate, Lorazepam 0.25ml- PRN - 1bottle- unopen and an unopened box symptom relief kit with R159 name on the label. V12 LPN stated that R159 already expired, and the controlled medications for expired residents are supposed to be given to V2, Director of Nursing (DON). V12 stated for the regular medications the nurses will return the medications to the pharmacy. On 12-1-2024, at 12:16 PM, the 3rd floor medication refrigerator was observed to be unlocked and accessible to other residents and staff. The following controlled medications for R262 were inside the medication refrigerator symptom kit which contained Ativan, hydromorphone. Facility presented undated policy with the title: Controlled Substances; Policy Interpretation and Implementation which documents: Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. Findings include: On [DATE] at 11:40 am, surveyor observed medication refrigerator on 1st floor was not locked and easily accessible to other staff and residents. Observed the following R159's controlled medications in unlocked refrigerator stored inside the bottom drawer not in a separate locked container: Morphine Sulfate 0.25 millimeter (ml) bottle, Lorazepam 0.25 millimeter (ml). An unopened Symptom Kit containing: Ativan and Hydromorphone. Interviewed V12 Licensed Practical Nurse (LPN) on [DATE] at 11:40 am, V12 LPN stated that she did not have the key to the unlocked refrigerator and did not want to lock the refrigerator to prevent inability to access the controlled medications if needed and further stated that confused patients could walk in the nursing station and access the refrigerator. Facility Controlled Medication Policy states Controlled substances are stored in the medication room in a locked container, separate from the containers for any non-controlled medications. Access to controlled medications remains locked at all times and access is recorded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 17 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 that medication that fell on the floor was not administered to a resident (R55). This failure affected one resident (R55) in the sample of 57 residents. Residents Affected - Few Findings include: On 12/01/24 at 12:34 pm, Surveyor observed V12 (Licensed Practical Nurse, LPN) administer medication to R55 during the first floor noon medication pass. Surveyor observed V12 drop R55's Divalproex Sodium DR (Delayed Release) 500 mg (Milligram)1 tablet on the floor next to R55's wheelchair, then pick up R55's Divalproex Sodium DR (Delayed Release) 500 mg (Milligram)1 tablet from the floor next to R55's wheelchair and then administer R55's Divalproex Sodium DR (Delayed Release) 500 mg (Milligram)1 tablet to R55 orally. On 12/01/23 at 12:52 pm, Surveyor asked V12 regarding administering medications that have falling on the floor to a resident and V12 stated that if a medication falls on the floor the nurse should discard the medication and give the resident another pill. When V12 was asked regarding the importance of discarding medications that fall onto the floor and V12 stated, I (V12) gave it to her (R55) because I (V12) did not want her (R55) to curse me out. If a medication is given to a resident that has fallen on the floor that can be infection control. It (referring to the medication) can have germs on it. On 12/03.24 at 8:48 am, Surveyor asked V2 (Director of Nursing, DON) regarding the facility's expectation for administering medications that have fallen onto the floor and V2 stated that If a nurse drop a residents medication on the floor the nurse should through the medication out due to infection control. V2 also stated that residents should not receive medications that have been dropped on the floor due to the medication containing germs. R55's Brief Interview for Mental Status (BIMS) dated 10/08/24 shows that R55 does not have a BIMS score indicated. However, during this survey, R55 was able to answer questions appropriately. R55's Physician Order Sheet (POS) shows that R55 has an order for Divalproex Sodium DR (Delayed Release) 500 mg (Milligram)1 tablet by mouth three times a day. The facility's undated document titled The Licensed Practical Nurse (LPN) documents, in part: Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times . Administer clinical care according to the standard of care and in accordance with local, state, federal and facility policies, and procedures. The facility's undated policy titled Infection Prevention and Control Program documents, in part: Purpose: To ensure the facility established and maintains an infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. Policy: The facility must establish an Infection Prevention and Control Program under which it 4. Infection Prevention and Control Program standards apply to all facility employees, contracted staff, consultants, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 18 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 volunteers . Program and Procedures: F. Preventing, identifying, report, investigating, and controlling infections and communicable diseases-based on the facility assessment. 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: 145796 If continuation sheet Page 19 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a comfortable environment to one resident (R162). This failure affected one resident in a total sample size of 57 residents. Findings include: On 12/01/24 at 10:58am, surveyor entered R162's room and felt cold from a decrease in temperature. On 12/01/24 at 11:00am, R162 stated that he that he had been complaining of the cold temperature in his room since Wednesday 11/27/24. On 12/01/24 at 11:11am, V13 (Licensed Practical Nurse/LPN) stated that R162's room is as cold as the weather outside. V13 stated that a room that is too cold is an immediate need. On 12/01/24 at 11:56am, V5 (Maintenance Director) stated that no one had informed him that R162's room was cold. V5 checked R126 room with hand thermometer. Hand thermometer showed temperature 61 degrees Fahrenheit. V5 stated that R126's room temperature should be at least 68 degrees Fahrenheit. V5 stated that R126's room is cold due to a crack in the window. On 12/02/24 at 09:11am, V5 used handheld thermometer to check R126's room temperature which registered at 68 degrees Fahrenheit. V5 stated that he placed tape over crack in the window to prevent the breeze from coming into the room. R162 has diagnoses of presence of right artificial hip joint, type 2 diabetes mellitus without complications, hyperlipidemia, muscle wasting and atrophy not elsewhere classified multiple sites, difficulty in walking, unilateral primary osteoarthritis right hip. R162's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, which indicates R162's cognition is intact. Facility's policy dated 10/2024 titled Cold Weather documents in part, Policy: For the safety and comfort of the residents, and staff the cold weather policy will be followed whenever extreme outdoor temperatures, power failure or heating plant malfunctions cause facility temperatures and humidity to rise beyond acceptable health and comfort levels .Procedure: Building manager will monitor the facility's main heating plant and individual room units to ensure that all are working at peak performance .When an uncomfortable building temperature is perceived by staff, resident or visitors, the building manager will take temperature readings at various locations of the building making sure to cover all residents and staff areas. Adjustments will be made to make all residents as comfortable as possibly .If temperatures of 65 degrees F (Fahrenheit) or lower are found readings will be taken every 2 hours. Temperatures will be documented on the Facility temperature form. The cold weather emergency plan will be followed to ensure the comfort and safety of all residents. Facility's policy dated 01/05/24 titled Policy on Resident Rights, Respect an Dignity documents in part, A resident has the right to receive services in a facility environment that is safe, clean, and comfortable with adequate space for all activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 20 of 21 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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 Facility's policy dated 04/2014 titled Quality of Life - Homelike Environment documents in part, Residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belongings to the extent possible .Policy Interpretation and Implementation .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include g. comfortable temperatures. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 21 of 21