Health inspection·January 20, 2023

F 0600 An incident witness statement (1/8/23) by the activity aide documents in part: R80 pushed R108 on the hallway floor and she (R108) hit her (R108) head on the floor. Level of Harm - Actual harm Residents Affected - Few R80's care plan documents in part: R80 has the potential to be physically aggressive, such as attempting to hit others, making aggressive remarks, and gestures towards others when agitated. R80 reportedly involved in physical altercation with co-peer on 8/8/2020. R80 reportedly involved with co-peer on 3rd floor on 4/29/20. Facility's final incident report investigation (1/10/2023) documents in part: R80 displayed physical aggression towards R108. R108 was noted with swelling to top of head. Facility's Abuse Prevention Policy (10/2022) documents in part: The facility affirms the right of our residents to be free from abuse. This facility prohibits abuse. Abuse means any physical, mental, or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury with resulting due to physical harm, pain or mental anguish to a resident. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145806 If continuation sheet Page 2 of 9 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 145806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and records review, the facility failed to follow their policy and procedure to develop and implement a comprehensive person-centered care plan that includes measurable objectives with timeframes and interventions to address the resident's restorative programs for 5 (R50, R66, R70, R103, R104) out of 5 residents reviewed for restorative programs in a sample of 24. Findings include: On 1/17/23 at 11:01 AM, R66 was sitting on R66's rollator alert and able to verbalize needs. R66 stated that R66 has some weakness in R66's legs but still able to ambulate. R66 stated that R66 had history of stroke. At 11:05 AM, R103 was sleeping in bed and noted with both hands' contractures with no assistive device in place. At 11:34 AM, R70 was sitting in R70's wheelchair. R70 stated R70 uses a wheelchair for primary mode of locomotion and stated that R70 is not steady with walking. On 1/18/23 at 11:06 AM, R50 was sitting in R50's wheelchair and noted with limitations in range of motion to both legs. At 1:38 PM, during interview with V9 (Director of Restorative), V9 stated that R50 is on Assisted Range of Motion (AROM) restorative program scheduled at least once or twice daily. V9 stated that R66 has weakness on one side of R66's body. V9 stated R66 had a history of stroke and is on grooming and walking restorative programs. V9 stated that R103 has limitations in R103's upper extremities and is on bed mobility and dressing restorative programs. V9 stated that R103 is not using splints for R103's hands, but the goal is to assist R103 with bed mobility. V9 stated that R104 has weakness in R104's upper extremities and is on transfer restorative program for safety, and also on dressing restorative program. V9 stated that R70 has weakness in R70's lower extremities and uses a wheelchair. V9 stated that R70 is on walking and AROM restorative programs. V9 stated that restorative programs are documented under the resident's ADL (Activities of Daily Living) assessment. V9 stated that restorative programs are included as one of the ADL care plan interventions, but are not part of the care plan focus with measurable goals. V9 stated that the goals are documented in the ADL assessment but not in the care plan. On 1/19/23 at 11:48 AM, during interview with V11 (Care Plan Coordinator), V11 stated that the resident's comprehensive care plan should be initiated within 48 hours of admission and revised within 14 days of admission; then quarterly, annually, and with significant change. V11 stated that any acute change with the resident, the care plan should be initiated as soon as possible within 24 hours. V11 stated that the resident's comprehensive care plan should include the resident's diagnoses, changes in status, restorative programs, any services the resident is getting, treatments, social services, and activities. V11 stated that the care plan should be individualized and should include the needs of the resident, the problem, the goals, and the interventions to achieve those goals. V11 stated that the care plan will be able to address the needs of the residents and the purpose is to meet those needs. V11 further stated that if the care plan is not implemented or if it's incomplete, the resident's quality of care will be compromised, and the care being provided to the resident will not be as effective. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145806 If continuation sheet Page 3 of 9 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 145806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some At 12:09 PM, reviewed R50, R66, R70, R103, and R104's comprehensive care plans with V11 and no restorative programs with measurable goals, timeframes and interventions were found. V11 stated that the resident's restorative programs should be included as part of the focus in the care plan, not just part of the ADL interventions, and should include measurable goals with timeframes, and interventions. A record review of R66's clinical record shows an admission date of 11/13/20 with listed diagnoses not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. R66's Quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 1/01/23 shows R66 requires assistance with ADLs and has functional limitation in range of motion on one side of R66's lower extremity. R66's Restorative Assessment and Progress Note dated 1/1/23 indicates R66 will continue restorative programs for walking and grooming/personal hygiene. A review of R66's comprehensive care plan printed on 1/17/23 does not show individualized care areas addressing R66's restorative programs with measurable objectives and timeframes, and interventions. A record review of R103's clinical record shows an admission date of 3/1/21 with listed diagnosis not limited to Parkinson's Disease. R103's Annual MDS with ARD of 10/21/22 shows R103 requires assistance with ADLs and has functional limitations in range of motion on one side of R103's upper and lower extremities. R103's Restorative Assessment and Progress Note dated 10/21/22 indicates R103 will continue restorative programs for bed mobility and dressing. A review of R103's comprehensive care plan printed on 1/17/23 does not show individualized care areas addressing R103's restorative programs with measurable objectives and timeframes, and interventions. A record review of R104's clinical record shows an admission date of 8/18/20 with listed diagnosis not limited to Cerebrovascular Disease. R104's Quarterly MDS with ARD 11/03/22 shows R104 requires assistance with ADLs and has functional limitations in range of motion on both upper extremities. R104's Restorative Assessment and Progress Note dated 11/1/22 indicates R104 will continue restorative programs for ambulation/wheelchair mobility and dressing. A review of R104's comprehensive care plan printed on 1/17/23 does not show individualized care areas addressing R104's restorative programs with measurable objectives and timeframes, and interventions. A record review of R70's clinical record shows an admission date of 2/19/20 with listed diagnosis not limited to Chronic Obstructive Pulmonary Disease. R70's Annual MDS with ARD of 10/14/22 shows R70 requires assistance with ADLs and has unsteadiness with walking. R70's Restorative Assessment and Progress Note dated 10/9/22 indicates R70 will continue restorative programs for ambulation and AROM. A review of R70's comprehensive care plan printed on 1/17/23 does not show individualized care areas addressing R70's restorative programs with measurable objectives and timeframes, and interventions. A record review of R50's clinical record shows an admission date of 1/19/22 with listed diagnosis not limited to Cerebral Palsy. R50's Annual MDS with ARD of 12/14/22 shows R50 requires assistance with ADLs and has unsteadiness when walking and transferring. R50's Restorative Assessment and Progress Note dated 12/14/22 indicates R50 will continue restorative programs for AROM and dressing. A review of R50's comprehensive care plan printed on 1/18/23 does not show individualized care areas addressing R50's restorative programs with measurable objectives and timeframes, and interventions. The facility's Resident Mobility and Range of Motion policy (with revision date of 7/2017) reads in part, 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145806 If continuation sheet Page 4 of 9 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 145806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. The facility's Care Plans, Comprehensive Person-Centered policy (with revision date of 12/2016) reads in part, Policy: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Procedures: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145806 If continuation sheet Page 5 of 9 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 145806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645 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 follow its policy to: (a) ensure medications used in the facility are stored in locked compartments that had the potential to affect 57 residents residing on the second floor; (b) ensure that medications are stored in the packaging in which they are received; (c) maintain medication storage in a clean, safe, and sanitary manner; and (d) ensure that resident medications are stored separately for 3 residents (R33, R109, R79). The facility also failed to ensure that all medications are properly labeled for 2 residents (R100, R62) from 2 of 4 medication carts and 1 of 2 medication room inspected for medication storage and labeling. Findings include: On [DATE] at 10:02 am 2nd floor medication room inspected with V3 (Registered Nurse). Medication room observed unlocked. V3 stated that the medication room is usually locked. Medication room was observed with several cabinets, compartments with no locks and 2 black refrigerators. Surveyor observed house stock medications/over the counter medications such aspirin, vitamin C, multivitamins, vitamin D, etc. kept in one of the cabinets with no lock. At 10:25 am Surveyor inspected the first medication cart on the second floor with V4 (Licensed Practical Nurse). Surveyor observed the following: 1. R100's albuterol multi dose inhaler observed was used but with no open date labeled in the packaging or in the inhaler. 2. R62's albuterol multi dose Inhaler observed was used but with no open date labeled in the packaging or in the inhaler. V4 stated V4 was not sure why there was no open date for these inhalers. 3. R33's humalog insulin vial was not kept in the bag. 4. R109's lispro insulin vial was not kept in the bag. 5. R79's detemir insulin vial was not kept in bag. 6. Observed 3 insulin vials were kept together with no individualized packaging. V4 stated these insulin vials have an individualized bag when received from pharmacy and should be kept separately in each bag. On [DATE] at 2:48pm during interview V2 (Director of Nursing) stated the medication room should be locked at all times. V2 stated the medication room key is kept by the nurse on duty. V2 stated if the medication room is not locked anybody can have access and get something, especially there are medications stored in the medication room. V2 stated that multi dose inhalers for residents should be labeled and have an open date and discard date. V2 stated the discard date for multi dose inhalers should be 30 days. V2 stated that the potential effect of multi dose inhalers with no open date can be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145806 If continuation sheet Page 6 of 9 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 145806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645 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 administered in error. V2 further stated the facility doesn't want to give expired medication to residents. V2 stated that open insulin vials are kept in the cart and insulin vials or pens that were not open or were not used yet are kept in the fridge. V2 stated that insulin should have an individualized packaging from pharmacy and should be maintained. V2 stated that if insulin vials are not kept in the individualized packaging/bag, it could potentially be use on a different resident. Residents Affected - Some Review of R100's physician order sheet (POS) documented in part: ALBUTEROL HFA 90 MCG INH-VENT{18 GM} 2 puff inhale orally every 6 hours as needed for COPD related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED (J44.9). Review of R62's physician order sheet (POS) documented in part: Ventolin HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA) 2 puff inhale orally every 4 hours as needed for wheezing. Review of R33's physician order sheet (POS) documented in part: HumaLOG Solution 100 UNIT/ML (Insulin Lispro (Human) Inject 9 unit subcutaneously with meals for diabetes must be given with meals, hold for blood sugar <70, alert MD if blood sugar is <70 or >350. Review of R109's physician order sheet (POS) documented in part: Insulin Lispro Solution Inject 5 unit subcutaneously with meals for diabetes Review of R79's physician order sheet (POS) documented in part: Insulin Detemir Solution 100 UNIT/ML Inject 24 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9). Review facility's census printed on [DATE] indicated a total of 57 residents residing on the second floor. Facility Storage of medications policy (revised April, 2019) documented in part: 1. Drugs and biologicals used in the facility are stored in locked in locked compartments. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 10. Resident medications are stored separately from each other to prevent the possibility of mixing medications between residents. Facility Labeling of medications policy (revised April, 2019) documented in part: All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145806 If continuation sheet Page 7 of 9 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 145806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645 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 0882 Level of Harm - Potential for minimal harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to ensure that the designated Infection Preventionist, who is responsible for the facility's Infection Prevention and Control Program, has completed the specialized training in infection prevention and control. This failure has the potential to affect all 119 residents residing in the facility. Findings include: On 01/17/23 at approximately 10:30 AM, V1 (Administrator) stated that V7 (Infection Preventionist/LPN) is the infection preventionist and is a full-time employee who is responsible for overseeing the infection prevention and control program for the residents and staff at the facility. On 01/17/2022 at approximately 1:00pm, surveyor requested V7's infection preventionist training certificate. V7 stated, I don't have my infection prevention certificate with me, I have it at home and I cannot print it now because I am having trouble printing from my computer here at the facility. On 01/18/22 3:29 PM, V7 stated, I am an LPN and have been working here at the facility for 12 years. I have been the infection preventionist here at the facility since August 2022. V2 (Director of Nursing) was the previous infection preventionist but is no longer functioning as the infection preventionist since taking the role of DON around August 2022 last year. I completed the modules for the infection control training but didn't realize that there was a test that needed to be taken at the end. I completed the test for the infection control around 5pm yesterday on 01/17/2023. Surveyor requested infection prevention training module completion dates. V7 did not provide to them to surveyor. Review of V7's infection prevention training certificate titled Nursing Home Infection Preventionist Training Course documents that V7 completed training course on 01/17/2023. Facility census dated 01/17/2023 documents that 119 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145806 If continuation sheet Page 8 of 9 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 145806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to track and document the COVID-19 vaccination status of all staff providing care to residents at the facility. This failure has the potential to affect all 119 residing in the facility. Residents Affected - Many Findings include: On 01/19/2023 at 12:30 pm, V12 (Human Resources Coordinator) stated, I am responsible for obtaining the COVID status for contracted staff here at the facility. I do not have the COVID vaccination status for all of the contracted staff that work here at the facility. Since July 2022 last year, I was informed that we cannot ask the staff for their vaccination cards or status because it invades their privacy rights. For majority of the contracted staff working here, I am not aware of their COVID status and I do not have vaccination information for them. Being vaccinated for COVID is a condition of employment for nursing homes. Review of the facility's contracted staff list and contracted staff vaccination matrix shows that all contracted staffs' COVID status is not documented. Facility census dated 01/17/2023 documents that 119 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145806 If continuation sheet Page 9 of 9