Inspection·February 20, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 ensure the facility temperature in residents' rooms, common area hallways, and dining area on the 1st, 2nd, and 3rd floor meet the required temperature of 71-degree Fahrenheit to 80-degree Fahrenheit. This failure has the potential all the 120-resident residing in the facility. The facility aslo failed to ensure that residents sinks were functioning properly for two (R1 and R3) of five residents reviewed for physical environment. Finding include: 1. On 02/18/25 the following observation were made: Temperatures on the 3rd floor selected rooms and hallways did not meet the required 71 to 80-degree Fahrenheit. South hallway = 63.9 degrees Fahrenheit, room [ROOM NUMBER] =68.2 degrees Fahrenheit, room [ROOM NUMBER]=62.6 degrees Fahrenheit room [ROOM NUMBER]= 67.3 degrees Fahrenheit room [ROOM NUMBER]= 66.9 degrees Fahrenheit room [ROOM NUMBER]=57.2 degrees Fahrenheit room [ROOM NUMBER]= 64.8 degrees Fahrenheit Residents observed in the dining room wearing their winter coat. On 02/18/25 at 10:45am, to 11:00am on the 2nd floor census on the floor 41. Dining area = 64.8 degrees Fahrenheit, South hallway lower end 59.2=degrees Fahrenheit room [ROOM NUMBER]= 61.7 degrees Fahrenheit room [ROOM NUMBER]=66.9 degrees Fahrenheit room [ROOM NUMBER] = 66.6 degrees Fahrenheit room [ROOM NUMBER] = 61.8 degrees Fahrenheit North hallway = 64.8 degrees Fahrenheit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145829 If continuation sheet Page 2 of 5 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 145829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Place Nrsg & Rehab 3405 South Michigan Avenue Chicago, IL 60616 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 At 11:05am to 11:20am on the 1st floor with a residnet census of 36. Level of Harm - Minimal harm or potential for actual harm South hallway = 69.8 degrees Fahrenheit room [ROOM NUMBER] = 67.3 degrees Fahrenheit Residents Affected - Many North hallway = 70 degrees Fahrenheit room [ROOM NUMBER]= 67.5 degrees Fahrenheit. On the 3rd floor 11:10am, V3 (Lincensed Practical Nurse/LPN) stated that some of the residents complained but plastic covers were put over their windows about one and half months ago to block the cracks in the window. (R7) complained that the rooms are cold. V11 (Housekeeper) stated that it seems a little bit chilly especially on the lower end side of the hallway (North hallway). Between 11:11am to 11:18am, R8, R9 and R10 complained that the rooms are very cold day and night and there is no extra blanket provided. They stated that it is cold around here (facility) and most of the nighttime. R10 stated they (referring to the staff) don't have any blanket to give me (R10). At 11:24am V8 (Maintenance Director) stated that the normal temperatures in here (referring to the facility) should be between 75 to 80 degrees Fahrenheit. When the surveyor asked how often V8 checks the temperature in the facility that includes the residents' room and whether the reading of the temperatures is appropriate. V8 stated that I (V8) only check on the temperatures when it is cold or hot on severe whether days. In addition, V8 stated that the temperatures can be a little bit higher. The windows are not really sealed some of them have air coming in through the windows gap. Some of the tapes are off now in some rooms and needs to be put back on (referring to replacing the tape) I can see why some of the residents are saying is cold in their rooms. At 11:45am, R2 observed in the room covering the AC (Air Conditioning) with facility incontinent pad stating that it is cold in the room. R2 stated I am cold. When asked whether R2 notified any of the staff, R2 stated they (staff) don't do nothing for me. At 11:58am, R11 stated it is always cold in here (facility), the rooms are cold, the hallways are cold the dining room is cold. They know but don't do nothing. On 2/18/25 at 4:30pm, V8 was unable to present any temperature log for the month of December 2024 to February 2025. On 2/18/25 at 2:52pm V1 (Assistant Administrator) stated she was not aware that the facility temperatures are not meeting the required temperature of 71 to 80-degree Fahrenheit. V1 stated that V8 did not show the temperature logs to her and did not report that the temperature was still in sixties. V1 stated V8 said the windows in the rooms were taped but she (V1) did not physically check on the windows. On 02/19/25 at 9:35am, the facility presented a temperature log showing the facility temperature readings did not meet the required 71 to 80-degree Fahrenheit. When this was shown to V1, V1 stated V8 did not make her aware of the low temperature. V1 further stated that V14 (Administrator) is not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145829 If continuation sheet Page 3 of 5 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 145829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Place Nrsg & Rehab 3405 South Michigan Avenue Chicago, IL 60616 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many aware of this situation because V14 comes in and goes out. V1 explained that V14 would have discussed this with her (V1). V1 stated the window gaps are supposed to have been fixed. V1 stated she was thinking it has been taken care of. V1 stated that V8 reports to V14 and V1. V1 acknowledge that this issue has never occurred. The facility policy on Loss of Heat During Cold Weather presented dated February documented that the policy is to establish guidelines to maintain a safe and comfortable environment in the event of the loss of heat. The facility shall be equipped with heating system that can maintain indoor temperatures between 75-degree Fahrenheit and 80-degree Fahrenheit. Facility Job Description for Maintenance Director documented in part that the primary purpose of this position is to maintain the orderly functioning of all equipment in the facility. Listed main duties includes but not limited to checking periodically and document the temperature in residents' rooms. Assure the proper maintenance 2 R1's medical record documents diagnoses including: hypertensive heart disease, dementia, schizophrenia, gastro-esophageal reflux, localized edema. The Minimum Data Set, dated [DATE] showed R1's cognition was intact with a score of 15 on the Brief Interview of Mental Status. On 2/18/25 at 11:18 am, R1 stated that my plumbing in the bathroom has not worked ever since the first week of January 2025. R1 stated she use to get my water from the bathroom sink but the sink no longer works, so R1 must go to community bathroom and get water from that sink. R1 also stated she has never requested that staff bring her water because she is independent, R1 prefers to get water by herself in her water bottle. R1 stated staff refused to allow her to retrieve water from community hydration station utilizing her plastic water bottle. That is why she gets water from community bathroom sink. R1 also stated her sink has an out of order sign with plastic wrapping on sink and there is no soap and water available in her room. R1 stated after she uses the toilet, she puts her own soap and water in a bottle, washes her hands over the garbage can, and then dries her hands with tissue paper. R1's sink was observed nonfunctional with plastic wrapping and out of order sign. There are no paper towels available in bathroom. 3. R3's medical record documents a diagnoses including: hemiplegia, dementia, hypertensive heart disease, type 2 diabetes mellitus, anemia, chronic kidney disease, benign prostate hyperplasia, syncope, chest pain, acquired absence of kidney. The Minimum Data Set, dated [DATE] showed R3's cognition was moderately intact with a score of 13 on the Brief Interview of Mental Status On 2/18/2025 at 11:46am, R3 stated his sink has been broken for a long time and staff sometimes brings him water. R3 stated after he uses the toilet he just puts soap on his hands and takes a paper towel and wipes his hands dry. He doesn't use water because the sink is not working. On 2/18/25 at 1:58pm,V8 (Maintenance Director) stated he was informed last week on Wednesday, February 12, 2025, that the sinks in R1 and R3's rooms were not working. V8 stated he attempted to repair the issue but was unsuccessful. That is when he called the plumber on February 12, 2025, but realized that the company went out of business. V8 stated on February 12, 2025, he reached out to another plumber and was given a date of February 19, 2025, at 9am for a plumber to come and assess the sink concern. V8 stated he has attempted to repair the sink issue again today by himself but was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145829 If continuation sheet Page 4 of 5 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 145829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Place Nrsg & Rehab 3405 South Michigan Avenue Chicago, IL 60616 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many unsuccessful. V8 stated the resident's with the clogged sinks that are not working could have moved to another room but nursing department handles the moves. On 2/18/25 at 3:10pm V1 (Assistant Administrator) stated bed management for residents depends on what the concern is with the resident at the time there is a need to change rooms. V1 stated that she was never made aware that the sinks for R1 and R3 were not operative and stated V8 Maintenance director never informed her that the sink were not operative. V1 stated V8 reports directly to her and is responsible for reporting concerns. Facility policy dated February 2014 Preventive Maintenance Policy to assure that all equipment included in the Preventative Maintenance program includes testing, maintenance and repair information at the established intervals. 1.The Maintenance Department checks for preventative maintenance program equipment work orders and evaluates/ repairs the malfunction described. 2.If equipment must be removed from the user area for more than a day, the maintenance Department will notify the respective department. 3.When maintenance is to be performed by an external vendor, the Maintenance Department contacts the vendor and instructs the vendor to pick up the equipment, to perform the maintenance detailed in the work order, and to document accordingly FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145829 If continuation sheet Page 5 of 5