Health inspection·October 3, 2024

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete consent to receiving bupropion. V3 stated R103 should have been informed of the risks and benefits of the psychotropic medication. Facility policy titled, PSYCHOTROPIC MEDICATION PROGRAM (reviewed 10/23), documents in part, GENERAL: The purpose is to promote safe and effective use of psychotropic medications .The second purpose of this process is to ensure the resident is evaluated and the indication for the medication is documented within the medical record . Also, the resident and representative are aware of the potential side effects and the facility obtains informed consent for the use of the psychotropic medication . 9. If a new order for a psychotropic medication is obtained, the resident, residents representative or POA must be informed of the risks and benefits of the medication. The facility must obtain informed consent. If the family or resident's representative is not able to sign the consent at the time of the order, a verbal consent will be obtained by the nurse and documented on a psychotropic consent form until written consent can be obtained. This form will be part of the medical record . Event ID: Facility ID: 145864 If continuation sheet Page 2 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for 1 resident (R136) out of 77 residents reviewed for call lights. Residents Affected - Few Findings include: On 9/29/2024 at 11:53am observed R136 lying in the bed watching television, alert and oriented. Surveyor asked R136 Where is your call light pull string located? R136 stated, I don't know where my call light string is at, it's a little green string. On 9/29/2024 at 11:55am observed R136's call light string (a little green string with a clip attached on the end) hanging on top of the light fixture located above the head of R136's bed. On 9/29/2024 at 11:57am surveyor asked V4(LPN/Licensed Practical Nurse) to come into R136's room. V4 was asked, Where is R136's call light string? V4 stated the call light string is located on top of the light above R136's bed. V4 stated the call light is supposed to be within reach of the resident. On 9/29/2024 at 12:00pm surveyor observed V4(LPN/Licensed Practical Nurse) take the call light string from the top of the light fixture and clip the call light string to the right shoulder area of R136's gown. On 10/01/2024 at 11:16am V2(DON/Director of Nursing) stated the resident's call light should be in the room, within reach of the resident. V2 stated the purpose of the call light is so that the resident can signal the staff for help. R136's diagnosis includes, but are not limited to, cerebral infarction, unspecified, morbid (severe) obesity due to excess calories, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and paraplegia. R136 has a Brief Interview for Mental Status (BIMS) dated 09/05/2024 which documents that R136 has a BIMS score of 14, indicating R136's cognition is intact. The facility's policy titled Call Light Response dated 2/2017(revision date of 9?2022) documents, in part, 3. Ensure call light is within resident's reach at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 3 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. On 9/29/2024 at 11:00 surveyor observed a missing ceramic tile in the bathroom under the sink joining 2 rooms and R32's closet door missing the entire top half of the door. Residents Affected - Some On 9/29/2024 at 11:41am R224 stated there are mice in the bathroom and they may be coming out of the hole where the tile is missing under the sink. On 9/29/2024 at 11:42am R32 said, Yes we do have mice and he reported the broken door to the CNAs who said they would let the nurse know but the door has been broken for about a week now. On 9/30/2024 at 12:35pm surveyor reviewed facility's pest control binder and on 9/23/2024 it was documented that there was a dead rodent discovered on two mice trips. On 9/30/2024 at 2:38pm V4 (Maintenance Director) stated, No the tile should not be missing, and I see a hole where their tile is missing, and the grout is dry rotted. Absolutely it is possible that mice can come in through that hole. V4 stated that there is a hole in the south wall by R224's bed that a mouse could squeeze through it. On 9/30/2024 at 2:46pm V4 stated, off the top of his head he doesn't recall being notified about the missing tile or broken door in the TELS app for maintenance issues. V4 pulled up his reports for the last 2 months so that surveyor can see that he had not received anything. V4 stated staff will also write it in the work order book. ON 9/30/2024 at 2:48pm surveyor reviewed work order book for the third floor and did not find any work order for the missing tile or broken door. On 9/30/2024 at 2:55pm V12 (Licensed Practical Nurse) stated, no she (V12) was not made aware of R32's door being broken. Preventive Maintenance Plan dated 1/2019 documents, in part, 9. Repair all ceramic tiles. Including loose or missing grout. Repair/replace as needed. Undated Job description titled Maintenance Director documents, in part, repair facility/resident property as necessary and ensure that equipment, etc. are maintained to provide safe and comfortable environment. Based on observation, interview, and record review, the facility failed to ensure the residents' ceiling was not leaking, failed to ensure the closet door was not broken, and failed to ensure the residents' bathroom has no missing ceramic tiles in effort to provide a homelike environment. These failures affected 5 (R21, R32, R50, R85, and R224) residents reviewed for homelike environment in the total sample of 77 residents. Findings include: On 09/29/2024 at 11:45am, R21, R50, and R85's ceiling was leaking. There was a big trash can used as a catch bin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 4 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 09/29/24 at 11:46am, V8 (PRSC (Psychiatric Rehabilitation Services Coordinator) stated there is a leak coming from the ceiling and there is a garbage bin that is used as a catch basin. There are 3 residents living in this room (R21), (R50), and (R85). On 09/29/2024 at 11:48am, R85 stated, It has been like that since Friday. I (R85) don't know what to say. I (R85) don't expect my (R85) room to be with a leaking ceiling. On 09/29/24 at 11:50am, V5 (Maintenance Director) stated, I (V5) am not sure at this moment what is going on inside the room. My Assistant Maintenance (V10) put the garbage can to catch the water leak. On 10/01/2024 at 10:55am, inside R21, R50, and R85's room, the ceiling was covered with a plastic, secured with blue tape. On 10/01/2024 at 10:58am, V12 (Licensed Practice Nurse) stated there was a leak on the ceiling and they covered the ceiling with a plastic. Maintenance is supposed to fix the leak. On 10/01/2024 at 11:00am, V3 (Psych Nurse/LPN) stated we have system called TELS where we log repairs for the Maintenance Department. It is like an eMaintenance Log. This surveyor requested to print the electronic Maintenance Log. On 10/01/2024 at 11:08am, V3 presented this surveyor the eMaintenance Log and inquired if there was a work order for R21, R50, and R85's room. V3 stated there is nothing specific for R21, R50, and R85's room. On 10/01/2024 at 11:18am, V10 (Assistant Maintenance) stated, The ceiling in the room had a leak. I (V10) don't know where the leak was coming from. The CNA told me Sunday morning. I (V10) checked 4th floor to assess where the leak was coming from. Nothing was going on in 4th floor that would cause a leak to the room. Instead of busting the ceiling open, I (V10) put a garbage can to catch the water. On 10/01/2024 at 11:25am with V10 inside R21, R50, and R85's room, R85 stated, The leak started when they cleaned the vent on Friday. I (R85) don't know who these people are. On 10/01/2024 at 11:30am on the smoking area with V10, R21 stated, The ceiling in my room was leaking. I (R21) don't remember when it started leaking. On 10/01/2024 at 11:32am on the smoking area with V10, R50 stated, I (R50) think the leak started on Friday. I (R50) was not in the room when it happened, when I (R50) went up in my room, the ceiling was leaking. On 10/01/2024 at 10:12am, V2 (Director of Nursing) stated, It is not expected to have a leak on the ceiling. It is not providing a homelike environment if the ceiling is leaking. Things like that may happen but it should be fixed immediately. The staff are expected to notify the Maintenance Department, Administrator, and DON. I (V2) am not aware of the issue verbally or through a work order. If the leak was observed on Friday, the leak should be fixed already by Sunday. The leak should be fixed immediately or as soon as possible but not for days. R21's (07/23/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 5 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 0584 mental status) Summary Score: 15. Indicating R21's mental status as cognitively intact. Level of Harm - Minimal harm or potential for actual harm R50's (08/22/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R50's mental status as cognitively intact. Residents Affected - Some R85's (08/29/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R85's mental status as cognitively intact. The (03/2024 - 10/01/2024) Work Order was reviewed; no work order for R21, R50, and R85's room. Sink in room leaking dated 09/29/2024 was for another room. The (09/29/2024) Work Order 2577 was in the common area on another floor and not in R21, R50, and R85's room. The (undated) Nursing Home Residents' Rights documented, in part Residents of nursing homes have right that are guaranteed by the federal Nursing Home Reform Law. The Law requires nursing home to promote and protect the rights of each resident and stresses individual dignity and self-determination. Right to a Dignified Existence. A homelike environment. The (undated) Resident Rights: Accommodation of Needs and Preferences and homelike Environment Policy documented, in part Policy: It is the policy of the facility to identify and provide reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. The facility will provide a safe, clean, comfortable, and homelike environment. Objective. The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference. Procedure: 7. The resident's environment will be maintained in a homelike manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 6 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and record review the facility failed to refer two residents R34 and R103 to the appropriate state designated authority for a new Level I PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination after R34 was admitted to facility without Mental Diagnosis disclosure on the Level I PASARR and R103 diagnosed with a new mental disorder. This deficient practice affected two residents (R34 and R103) in a total sample size of 77 residents. Findings include: R34's PASSAR dated 06/28/24 documents in part, PASRR Level I Determination: No Level II Required - No SMI (Serious Mental Illness)/ID (Intellectual Disability)/RC (Related Condition). R34's admission date to the facility is 06/28/24. R34's medical diagnosis includes but are not limited to Schizoaffective Disorder, Bipolar Disorder, Brief Psychotic Disorder, Depression, Impulsiveness. Facility's policy titled PASARR dated 04/2020 documents in part, General: The PASARR screening with be provided to the facility prior to admission so that the facility can make appropriate decisions regarding care and placement .Process: 1. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable .7. Should the resident require a PASARR update after admission, the facility will contact the state agency to update the PASARR. On 10/01/24 at 12:11pm V40 (Assistant Administrator, AA) stated, PASRR guides us (facility) with resident centered care using the diagnosis. PASARR is required to make sure that we (facility) are able to meet the needs of the residents. I (V40) am familiar with R34. R34 has mental diagnosis' and only has a level 1 PASARR. Even if the PASRR is done at the hospital, we (facility) should follow up on the accuracy of it. R103's admission record documents in part a diagnosis of major depressive disorder, recurrent (onset date 5/9/2023) and anxiety disorder (onset date 5/3/2023). R103's order summary report documents in part, R103 has active orders for bupropion HCl Oral Tablet 150 MG (Bupropion HCl) (antidepressant Medication) Give 1 tablet by mouth one time a day related to anxiety and Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) (antidepressant medication) Give 37.5 mg by mouth one time a day for Anxiety. R103's Level I PASRR (Pre-admission Screening and Resident Review) dated 5/3/2023, documents in part, no mental health diagnosis is known or suspected for R103 and R103 does not take any mental health medications. On 10/1/2024 at 12:05 PM, V40 (Assistant Administrator) stated the social services director normally completes that PASRR assessments but the social services director is on vacation so V40 is covering. V40 affirmed V40 is familiar with the Illinois process and standards for PASRR completion. V40 reviewed R103's electronic health record and acknowledged R103 has a diagnosis of major depressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 7 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 0644 Level of Harm - Minimal harm or potential for actual harm disorder and anxiety disorder. V40 reviewed R103's last PASRR (5/3/2024) and affirmed the PASRR does not identify R103's mental health diagnoses or medication use. V40 stated R130's PASRR should accurately reflect R103's health status and a new PASRR should have been completed. V40 stated PASRR assessments are important because they identify services a resident might need that is diagnosed with mental illness. Residents Affected - Few Facility policy titled PASARR (effective date 4/2020), documents in part, . 7. Should the resident require a PASARR update after admissions, the facility will contact the state agency to update the PASARR . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 8 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 Based on interview and record review the facility failed to refer one resident (R178) to the state agency for Preadmission Screening and Resident Review (PASRR) for rescreening before R178's Short Term Approval without Specialized Services determination's expiration date. This deficient practice affected one resident (R178) in a total sample size of 77 residents. Residents Affected - Few Findings include: R178's PASRR dated 11/06/23 documents in part, PASRR Determination: Short Term Approval without Specialized Services .Date Short Term Approval Ends: February 4, 2020 .This determination allows you a limited number of days in a Medicaid-certified nursing facility .If you or your care provider thinks you need you stay after that date, a nursing facility staff member must submit a new Level I screen .The new Level I screen must be submitted no later than 10 days before the Date Short Term Approval Ends. R178's PASRR Level I rescreen dated 06/07/24. R178's medical diagnosis' include Schizoaffective Disorder Bipolar Type, Type 2 Diabetes Mellitus, Asthma, Unspecified Psychosis Not Due to A Substance or Known Physiological Condition, Depression. On 10/01/24 at 12:11pm V40 Assistant Administrator (AA) stated, R178 PASRR was not resubmitted timely, R178 was here 4 months without the proper plan of care. Facility's policy titled PASARR dated 4/2020 documents in part, Process: 7. Should the resident require a PASARR update after admissions, the facility will contact the state agency to update the PASARR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 9 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to ensure that wound care treatment was completed and documented in a timely manner for one resident (R87) in a total sample size of 77 reviewed for wound care. Residents Affected - Few Findings include: R87's admission diagnoses include but not limited to hypertension, cerebrovascular disease, and furuncle unspecified. R87's Brief Interview for Mental Status (BIMS) dated 07/29/24 shows R87 has a BIMS score of 14 which indicates that R87 is cognitively intact. On 9/29/24 at 11:10 am, R87 observed in room lying in bed with a soiled undated dressing noted to the left side of R87's neck. There was a dark color drainage noted on the dressing. R87 stated that the dressing had not been changed in about three days. On 9/30/24 at 2:55 pm, surveyor observed R87 in room with same soiled dressing noted on the left side of R87's neck. R87 stated the dressing had not been changed and is the same dressing from yesterday. Surveyor requested for V26 (Wound Care Nurse) to look at R87's dressing and inquired about R87's dressing change. V26 looked at R87's dressing and stated, R87 has a cyst that drains. The dressing needs to be changed I will change it now. Surveyor inquired to V26 when was the last time it was changed because it's not dated. V26 stated, I do not date my dressing changes, it's not in the policy and the staff can look in the computer to see when the dressing was changed. R87's (Active Orders as of 10/1/24) Order summary Report documented in part, cleanse open area on left shoulder with normal saline solution and cover with a dry dressing, Monday, Wednesday, Friday, and prn (as needed) until resolved . To promote wound healing. R87's TAR Treatment Administration Record documented in part, treatment administered on 9/25/24 (Wednesday), 9/27/24 (Friday) and 9/30/24 (Monday) all dates were signed that treatment was completed. R87's Medication and Treatment Administration Audit Report documented in part, Schedule Date 9/25/24 (Wednesday) for wound care shows administration time 9/30/24 at 3:01 pm, and documented time 9/30/24 at 3:01 pm. Wound Care treatment for 9/27/24 (Friday) shows administration time 9/30/24 at 3:01 pm, and documented time 9/30/24 at 3:01 pm. On 10/1/24 at 11:02 V2 Director of Nursing (DON) stated that wound care dressing should be changed according to the doctor's order and as needed. If a dressing is soiled it should be changed to prevent infections. On 10/1/24 at 1:00 pm, Surveyor inquired to V26 (Wound Care Nurse) why was the wound care treatment on 9/25/24 and 9/27/24 not documented until 9/30/24. V26 (Wound Care Nurse) stated, I (V26) usually document after I finish the treatment. I thought I had documented on those treatments. When I went in to document the treatment for Monday, I saw that I did not document on Wednesday and Friday. I should document at the time I do the treatments and dressing changes. R87's dressing needed to be change because it was soiled and due to be changed. Surveyor inquired to V26 what could happen when a soiled dressing is not change. V26 stated that it could cause an infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 10 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R87's (9/24/24) care plan documents in part, Focus: Has an abscess to left side of neck. Goal: area to left side of neck will remain stable/heal throughout next review. Interventions: Educate resident on the risks of infection and poor healing related to non-compliance. Facility's policy titled Dressing Application review date 9/2017, documents in part, General: Dressings are changed as ordered by the Physician or Nurse Practitioner and PRN (As Needed). Facility's job description titled (Wound Care Nurse) documents in part, Basic function: The primary purpose of Wound Care Nurse is to provide for the day-to-day care needs of the residents in a Skilled Nursing Facility Environment. Essential Duties: 18. Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in facility's policies and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 11 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 On 9/29/2024 at 12:11pm observed R6 with an oxygen concentrator machine located next to R6's bed, the oxygen tubing/nasal cannula attached to the oxygen concentrator machine was sitting on top of the machine, not contained in a plastic bag while not in use by the resident. Residents Affected - Few On 9/29/2024 at 12:36pm surveyor brought the observation to V4's (LPN/Licensed Practical Nurse) attention. V4 stated the oxygen tubing/nasal cannula should be contained in a plastic bag when not in use by the resident. V4 stated the reason for placing the oxygen tubing/nasal cannula in the bag is to keep it from all the debris. On 10/01/2024 at 12:36pm V2(DON/Director of Nursing) stated the oxygen tubing/nasal cannula should be contained when not in use by the resident to prevent contamination; it is an infection control issue. R6's face sheet indicates that R6 has diagnosis which includes but are not limited, chronic obstructive pulmonary disease with (acute) exacerbation, type 2 diabetes mellitus without complications, pressure ulcer of sacral region, stage 4, gastro-esophageal reflux disease without esophagitis, and conversion disorder with seizures or convulsions. R6's Brief Interview for Mental Status (BIMS) dated 07/29/2024 documents R6 has a BIMS score of 11, which indicates R6's cognition is moderately impaired. R6's Physician Order Sheet (POS) with active orders as of 9/30/2024 documents in part, oxygen 2L(liters) via NC (nasal cannula) for hypoxia every 6 hours as needed for Hypoxia. Based on observations, interviews, and record reviews, the facility failed to ensure nebulizer mask and oxygen tubing was contained. These failures affected 2 residents (R6 and R88) reviewed for respiratory care in the sample size of 77 residents. Findings include: R88's admission diagnoses include but not limited to chronic obstructive pulmonary disease, chronic congestive heart failure, pacemaker, and atrial fibrillation. R88's Brief Interview for Mental Status (BIMS) dated 7/29/24 shows R88 has a BIMS score of 05 which indicates that R88 has severe cognitive impairment. On 9/29/24 at 11:45 am, R88's nebulizer mask was on top of a plastic bin in R88's room not contained. On 9/30/24 at 2:40 pm, R88's nebulizer mask was on top of R88 bed side table not contained. On 9/30/24 at 2:43 pm, this observation was pointed out to V9 License Practical Nurse (LPN). V9 stated that the mask should be in bag because it could get contaminated if not in a bag. It is not proper practice to have a respiratory mask laying on a bin not covered when not being use. On 10/1/24 at 11:02 V2 Director of Nursing (DON) stated, The respiratory mask should be in a plastic bag to prevent dust and contamination. It is also an infection control issue as well. It is not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 12 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 proper practice to have the respiratory mask or tubing to not be in a plastic bag when not being used. Level of Harm - Minimal harm or potential for actual harm R88's (Active orders as of 9/30/24) Order summary Report documented, in part Measure and record oxygen saturation. It < (less than) 90% start oxygen at 2 liters/minute per mask an notify the physician . Residents Affected - Few R88's Care plan dated 2/12/24, documents in part, focus: respiratory has potential for difficulty in breathing related to COPD (Chronic Obstructive Pulmonary Disease) and CHF (Congestive Heart Failure) Interventions administer oxygen as ordered. Facility's job description titled Registered Nurse/Licensed Practical Nurse documents in part, Essential duties: 3. Administer prescribed medications and treatments according to policy and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 13 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 observations, interviews and record reviews, the facility failed to ensure administration of controlled medication was documented and failed to ensure the incoming and outgoing nurses signed the Shift Change Accountability Record for Controlled Substances Forms. These failures affected R43 and all residents taking controlled medications on the 3rd floor, 4th floor B-wing, and the 6th floor B-wing. Findings include: On 09/30/2024 at 10:45am during the reconciliation of controlled medications task with V13 (Registered Nurse), R43's Controlled Drug Receipt Record/Disposition form for Tramadol 50 mg dispensed on 9/25 at 9A has a missing signature. This was pointed out to V13. V13 stated the nurse who gave the medication should signed (R43)'s form right after giving the medication to document the medication was given. On 09/29/24 at 11:37am during the Medication Storage and Labeling task with V6 (Licensed Practice Nurse) of the 3rd floor Medication Cart, there were missing signatures on 3rd floor Shift Change Accountability Record for Controlled Substances Form. This was pointed out to V6. V6 stated there are spaces in the sign in and out sheet. The incoming and outgoing nurses are supposed to sign after counting the controlled medications, so you know you handed over the correct count to the next nurse. On 09/29/2024 at 12:47pm during the Medication Storage and Labeling task with V3 (Psych Nurse/LPN) of the 6th floor B-wing medication cart, there were missing signatures on the 6th floor B-wing Shift Change Accountability Record for Controlled Substances Form. This was pointed out to V3. V3 stated there are couple of missing signatures on the sheet. The expectation is, when the outgoing and incoming nurses do the count, they are supposed to sign the accountability sheet for record keeping and tracking the reconciled medications properly. On 09/30/2024 at 10:23 am during the Medication Storage and Labeling task with V9 (Licensed Practice Nurse) of the 4th Floor B-wing medication cart, there was a missing signature on the 4th floor B-wing Shift Change Accountability Record for Controlled Substances Form. This observation was pointed out to V9 (Licensed Practice Nurse). V9 stated there is a missing signature on day 29. The outgoing nurse did not sign out. It is expected of the nurses to sign the Sheet after counting to document the count is correct. On 10/01/2024 at 10:17am, V2 (Director of Nursing) stated, I (V2) expect the staff to sign the Shift Change Accountability Record for Controlled Substances Form soon after the 2 nurses counted the controlled medications. The purpose of the accountability sheet is to ensure the controlled medications count is correct. To make sure the incoming nurse receive the correct count of the controlled medications from the outgoing nurse. On 10/01/2024 at 10:20am, V2 stated I (V2) expect the nurse to document administration of controlled medication right after the administration. The nurse is expected to sign, write how many was taken and how many medications are left in the cart. R43's (Active Order as of: 09/30/2024) Order Summary Report documented, in part Tramadol 25mg. give 25mg by mouth every 6 hours as needed for pain. Start Date: 05/20/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 14 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 R43's (received 5/29/2024) Controlled Drug Receipt/Record/Disposition Form for Tramadol 50mg 1/2 tab has a missing signature on 9/25, 9A(am). The (undated) List of Residents on Narcotics presented to this surveyor by V2 on 10/01/2024 at 12:48pm documented there were 4 residents on 3rd floor, 4 residents on the 4th floor, and 3 residents on the 6th floor. The (09/2024) 3rd floor Shift Change Accountability Record for Controlled Substance has missing signatures on Day: 18. Shift: 2nd. Nurses initial on; Day: 18. Shift: 3rd. Nurses initial Off; Day: 22. Shift: 1st. Nurses initial On and Off; Day: 22 Shift: 2nd. Nurses initial Off; Day: 23. Shift: 1st. Nurses initial on; Day: 23. Shift: 2nd. Nurses initial Off; Day: 24 Shift: 1st. Nurses initial on; Day: 24 Shift: 2nd. Nurses initial Off; Day: 25. Shift: 1st. Nurses initial on; and Day: 25. Shift: 2nd. Nurses initial Off. The (09/2024) 4Th Floor Shift Change Accountability Record for Controlled Substance on B-Wing has a missing signature on Day: 29. Shift: 2nd. Nurses initial Off. The (09/2024) 6th Shift Change Accountability Record for Controlled Substance on B-Wing has missing signatures on Day: 22. Shift: 3rd. Nurses initial on; Day: 23 Shift: 1st. Nurses initial Off; Day: 26. Shift: 1st. Nurses initial on; Day: 26 Shift: 2nd. Nurses initial on; Day: 26 Shift: 2nd. Nurses initial Off; Day: 26. Shift: 3rd. Nurses initial Off. The (1/2024) Controlled Substance policy and procedure documented, in part General: Medications classified by the FDA (Food and Drug Administrator) as controlled substances have high abuse potential and may be subject to special handling, storage, and record keeping. Policy: 10. Controlled Substances Count Sheet. c. Signature (which includes minimum of first initial, last name and title) of nurse who administered dose. 11. All schedule II controlled substances (and other schedules if facility policy so dictates) will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses. The two nurses will: d. Both nurses will sign the Shift/Shift Controlled Substance Count Sheet acknowledging that the actual count of the controlled substances and count sheet matches the quantity documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 15 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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. Based on observations, interviews and record reviews, the facility failed to follow Pharmacy recommendation for medication storage and failed to ensure the refrigerators were within the required temperature for proper storage of medications. These failures affected 2 (R84 and R100) residents and have the potential to affect all the residents on the 3rd and 6th floors. Findings include: On 09/29/2024 at 11:20 am during the Medication Storage and Labeling task with V6 (Licensed Practice Nurse), R84's Latanoprost eye drop was in a brown bag with sticker 'Refrigerate'. V6 checked if the bottle had been opened and stated the bottle was unopened. V6 stated the bag says 'refrigerate'. This medication should not be in the cart. It should be refrigerated to preserve the potency. On 09/29/2024 at 11:21am, R100's Latanoprost eye drop was in a brown bag. V6 checked if the bottle had been opened and stated the vial was unopened. On 09/29/2024 at 12:51pm during the 6th floor medication storage task with V4 (Licensed Practice Nurse), V4 opened the 6th floor medication room. This surveyor requested V4 to open the medication refrigerator and to check for the temperature registered on the thermometer. V4 checked the thermometer and stated temperature at 60F. There was an ice buildup on the small freezer inside of the 6th floor refrigerator. V4 stated the facility keep our unopened insulin in the refrigerator. On 09/30/2024 at 10:27 am during the Medication Storage Task with V11 (Licensed Practice Nurse) of the 4th Floor Medication Storage Room. This surveyor requested V11 to open the small refrigerator and to check the thermometer for the temperature. V11 stated the temperature is 48F. This surveyor requested to see the 4th floor refrigerator temperature log. The log documented temperature on 09/29 and 09/30 at 48F. V11 stated the facility keeps unopened insulin inside the refrigerator. The night shift checks the refrigerator daily to clean it and to check the temperature. On 10/01/2024 at 10:24am, V2 (Director of Nursing) stated, The refrigerator temperature should be within 36F to 46F. If above, staff are supposed to let maintenance know so it can be repaired. May be needing to adjust the setting. The purpose of keeping the medication storage within the required range is to keep the medications in a stable state; to keep the potency of drug in stable condition. There could be an ice buildup that is why it has to be checked to defrost the freezer. Temperature checking is daily to make sure the refrigerator in stable condition or functioning properly. On 10/01/2024 at 10:33am, V2 stated the instruction on the bag of Latanoprost from the Pharmacy to refrigerate the medication if not opened should be followed; the medication should be refrigerated for the same purpose. To follow the manufacturer's instruction which was passed on to the pharmacy for proper storage of medication. The medication will lose its potency. That is why it has to be refrigerated if not opened. R84's (Active Orders as of: 09/30/2024) Order Summary report documented, in part Diagnoses: (include but not limited to) essential hypertension. Latanoprost instill 1 drop in both eyes one time a day. Start Date: 07/10/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 16 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 R100's (Active Orders as of: 09/30/2024) Order Summary report documented, in part Diagnoses: (include but not limited to) Glaucoma. Latanoprost instill 1 drop in both eyes at bedtime. Start Date: 02/20/2024. The (2024) 4th Floor Refrigerator Temp Log documented that on Days 29 and 30 the temperature was at 48F. Residents Affected - Some The (undated) Facility provided Latanoprost Package insert documented, in part, Storage: Store unopened bottle under refrigeration at 36F to 46F. Once opened for use, it may be stored at room temperature up to 77F for 6 weeks. The (9/2022) Storage of Medications policy and procedure documented, in part, General: to provide the staff with guidance on the proper storage of medications. Storage of Medications: 9. Medications requiring refrigeration or temperature between 36F and 46F are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 17 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the dumpster lids were closed and free from overflowing trash. These failures have the potential to affect all 194 residents residing at the facility. Residents Affected - Many Findings include: The (9/29/2024) facility census was 194 residents. On 9/29/2024 at 9:34 AM, surveyor observed the singular metal lid open for the trash compactor and 2 lids for the dumpster open. Bags of garbage, boxes, and food waste products were observed inside the dumpster and compactor. Flying insects were observed flying in the vicinity of the open compactor and dumpster. On 9/29/2024 at 9:41 AM, V19 (Regional Dietary Manager) stated the dumpster lids should be closed to prevent pests from entering the trash. V19 affirmed the trash compactor lid was broken and a work order had been completed. V19 stated the lid had been broken for about a month. V19 demonstrated the trash compactor lid was able to be shut/closed but did not latch. V19 affirmed the dumpster lids were not broken and should have been closed over the dumpster. Record review of work order dated 9/19/24 completed by V5 (Maintenance Director) documents in part dietary staff reported the trash compactor isn't latching properly. Maintenance staff called trash company for service. Record review of work order dated 9/30/24 completed by V5 documents in part the latch needs to be replaced on the garbage can (trash compactor) outside and asking for them to replace the current one we have. Call has been put out and they will be here 9/30/24. This work order was assigned the Critical priority. On 10/1/24 at 9:37 AM, surveyor observed the lid to the dumpsters open with trash and boxes preventing the lids from being closed. A large stone was observed on top of the trash compactor which adequately kept the lid to the compactor closed. V5 (Maintenance Director) stated the trash can lids should be closed at all times and staff should be putting garbage in the dumpster in a way so the lids can close properly. V5 arranged the garbage so the lids could close. V5 stated the garbage company came yesterday and stated they trash compactor couldn't be fixed and a new compactor was needed. V5 did not know when a new trash compactor would be delivered. V5 stated covering the dumpsters was important so pests do not get inside and so other objects from people in the community are not placed in the dumpsters. Facility provided policy titled, Dispose of Garbage and Refuse documents in part, .All garbage and refuse will be collected and disposed of in a safe and efficient manner . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 18 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Forest Edge 8001 South Western Avenue Chicago, IL 60620 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 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a residents had a privacy curtain which extended around the bed. This failure affected one resident (R62), out 77 residents in the total sample. Residents Affected - Few Findings include: R62's Face sheet documents R62 has a diagnosis which include but not limited to versus complete obstruction, prediabetes, alcohol abuse with alcohol- induced psychotic disorder, conversion disorder with seizures or convulsions, essential hypertension, and presence of cerebrospinal fluid drainage device. R62's Brief Mental Status Interview (BIMS) dated 09/23/24 documents R62 has a BIMS score of 15 which indicates R62 is cognitively intact. On 09/29/24 at 11:35 am, Surveyor observed R62's room without a privacy curtain. R62 stated, I (R62) have been at this facility for six months and I (R2) have never had a privacy curtain. I (R2) would like a privacy curtain for my (R62) privacy and especially when I (R62) am sleeping. On 09/29/24 at 11:38 am, Surveyor questioned V15 (Housekeeper) regarding R62's missing privacy curtain and V15 stated, I (V15) don't know where it is. There is some (referring to privacy curtains) in laundry, but we can't hang them up because there are no hooks to hang them (referring to privacy curtains) on. V15 then pointed to the privacy curtain track above R62'S bed to show surveyor there were no hooks on the privacy curtain track in R62's room. When V15 was asked regarding the importance of residents having a privacy curtain V15 stated, So the resident can have privacy from their roommate or when the resident is changing their clothes. On 09/30/24 at 2:30 pm, V36 (Account Manager, Housekeeping Supervisor) was asked regarding privacy curtains for residents and V36 stated the floor technicians at the facility are responsible for ensuring every resident has a privacy curtain and all residents should have a privacy curtain to provide privacy for the resident and the residents roommate. V36 stated privacy curtains help to keep the room separate from roommates sharing space. When V36 was asked regarding the importance of privacy curtains and V36 stated, So the residents privacy will not be invaded. The facility's document dated 10/2023 and titled, Residents Rights - Accommodation of needs and Preferences and Homelike Environment Policy documents, in part: General: the objective of accommodation of resident needs and preferences is to create an individualized, home like environment to maintain and or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the residents all needs and preference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145864 If continuation sheet Page 19 of 19