Health inspection·December 15, 2023

F 0550 R70's lunch tray, and they are still waiting for it to be delivered to the unit. Level of Harm - Minimal harm or potential for actual harm On 12/12/23 at 12:41 PM, R70 was provided with a lunch tray. R70 began to eat immediately. R17 had finished eating by this time. When R70 saw the surveyor R70 stated, I got a tray, finally! Residents Affected - Few On 12/12/23 at 12:50 PM, V16 (Agency Licensed Practical Nurse) stated V16 had to call down to the kitchen this morning for R70's breakfast tray, and had to call down at lunch to request a tray for R70, because R70's tray was missing from the meal carts. V16 stated R70 was readmitted from the hospital on Friday 12/08/23, and the kitchen must not have been notified about R70's readmission. On 12/12/23 at 1:05 PM, V10 (Food Service Manager) looked through the diet slips previously sent down by nursing. V10 stated V10 could not find a recent diet split for R70, which meant the kitchen was not notified R70 was readmitted to the facility. V10 stated if the nursing units do not notify the kitchen R70 was readmitted , then the kitchen would not know to send R70's meal trays. On 12/12/23 at 2:45 PM, V10 provided surveyor with a copy of a diet slip, which was sent down from the nursing unit for R70 notifying the kitchen R70 about R70's diet order and room number. The pink slip was titled Dietary Communication, and dated 12/12/23. On 12/13/23 at 3:54 PM, V14 (Registered Dietitian) stated, Staff should pass out meal trays to residents sitting at the same table at the same time so that residents who are together can eat at the same time. Eating is a social activity and can encourage residents to eat better, so the facility encourages residents to eat together at the same time. This creates a sense of community. V14 stated it was a mistake the way the trays were distributed, and R70 should have been served R70's meal at the same time as the other person R70 was sitting with. V14 stated it was not okay for R70 to have to wait so long to receive a meal and have to sit and watch the other resident eat their meal. On 12/14/23 at 10:12 AM, V2 (Director of Nursing) stated, When a resident is readmitted from the hospital, the nurse on duty is responsible for sending a diet slip down to the kitchen, because that lets the kitchen know the resident is back in the building, and what diet they should receive. For dignity, all residents sitting at the same table for meals should be served their meals at the same time, and one resident should not have to sit and watch everyone else eating their meals. On 12/14/23 at 10:19 AM, V1 (Administrator) stated the facility did not have a policy on meal tray distribution. V1 stated residents sitting at the same table should receive their meal trays at the same time, and a resident should not have to watch another person eat due to dignity issues. Facility provided document titled, Residents' Rights for People in Long-Term Care Facilities undated, which documents the facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 2 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 (R60) resident reviewed for accommodation of needs in a sample of 19. Residents Affected - Few Findings Include: R60 has diagnoses not limited to Extended Spectrum Beta Lactamase (ESBL) Resistance, Major Depressive Disorder, Insomnia, Hallucinations, Dementia in other Diseases Classified Elsewhere, Mild, with other Behavioral Disturbance, Acute on Chronic Diastolic (Congestive) Heart Failure, Essential (Primary) Hypertension, Chronic Kidney Disease, Stage 3, Anemia in Chronic Kidney Disease, Cognitive Communication Deficit, Lobar Pneumonia, and Acute Cough. R60's Care Plan documents: Intervention: Keep call light within reach when in bedroom or bathroom Date Initiated: 12/08/23. Focus: (R60) has an ADL (Activities of Daily Living) self-care deficits r/t (related/to) decline in ADL functions. Resident needs staff assistance to safely complete ADL task r/t cognitive impairment, confusions, poor balance, limited mobility and decrease activity endurance. Intervention: CALL LIGHT: Call light within easy reach and encourage (R60) to use call light for assistance with ADLs. R60 is at [high] risk for falls related to cognitive impairment, confusions, impaired balance during transitions, decrease activity endurance and hx (history) of fall. On 12/12/23 at 10:38 AM, R60's call light was observed hanging on the wall lamp to the left side of the head of R60 bed out of R60 reach. Surveyor asked R60 could she reach the call light. R60 stated, I can't reach that. On 12/12/23 at 11:24 AM, surveyor asked V22 (Agency Registered Nurse) to enter R60's room then asked the location of R60's call light. V22 proceeded to remove the call light from the wall lamp and stated, The call light should be attached to (R60). V22 then attached the call light cord to R60 left upper side rail and placed the call button on R60 left side stating, I will put it right here where (R60) can get it. On 12/14/23 at 9:28 AM, V2 (Director of Nursing) stated, My expectation is that the call light is answered promptly and for all staff to see what the resident needs. The call light should be located within reach or clipped where the resident can reach it. If the call light is not within reach there is a potential that if a resident need something, we are not able to know what they need. If a resident is a fall risk and the call light is not in reach depending on what they need it would be a risk of them doing it on their own. This would put them at risk for falling. Policy: Titled Call Light Policy revised 07/27/23 documents: It is the policy of this facility to ensure that there is prompt response to the resident's call for assistance. Procedures: 1. Facility shall answer call lights in a timely manner. 5. Be sure call lights are placed within reach of residents who are able to use it at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 3 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to obtain a Physician's order with the code status for 2 (R14, R66) of 2 residents reviewed for Advance Directives in a sample of 19. Residents Affected - Few Findings Include: 1. R66 has diagnosis not limited to Acute on Chronic Systolic (Congestive) Heart Failure, Paroxysmal Atrial Fibrilelation, Acute Embolism and Thrombosis of Right Axillary Vein, Essential (Primary) Hypertension, Acute and Chronic Postprocedural Respiratory Failure, Personal History of Pneumonia, Cardiomyopathies, and Cognitive Communication Deficit. R66's Care Plan documents: Focus: (R66) Advance Directive Status (Code Status: Full Code) Pursuant to resident rights, personal choices, and the individual's desire to retain control and autonomy over his health care decisions, the individual (or representative) has been educated on Advance Health Care (including end of life care) options. Date Initiated: 11/25/23. Intervention: As indicated, document the code status on the Physician's Order Sheet (POS) in the EMR system Date Initiated: 11/25/23. Order Summary Report has no physician order or special instructions with the code status for R66. On 12/14/23 at 9:31 AM, V2 (Director of Nursing) stated, The code status for DNR (Do Not Resuscitate), Social Service review and if the resident is a DNR we would put it in the POS (Physician Order Sheet). The POLST (Physician Order for Life Sustaining Treatment) form is uploaded into their file. A full code is not really an order if they do not have a DNR, it would be in the Advanced Directive about the full code. If they are a DNR, it will be there under their code status, but if they do not have a DNR, they will be a full code. We also have a binder on the floor; a binder Social Service does update and a red bracelet to say they are a DNR. The code status will be under the special instructions. 2. R14's health record documented admission date of 9/7/23, with diagnoses not limited to Extended spectrum beta lactamase (esbl) resistance, Primary osteoarthritis left shoulder, Essential (primary) hypertension, Other specified nutritional anemias, Chronic fatigue, Respiratory failure, Chronic obstructive pulmonary disease, Bipolar disorder current episode manic severe with psychotic features, Personal history of covid-19, Pulmonary fibrosis, Unspecified protein-calorie malnutrition, Hydronephrosis with ureteral stricture, Other specified disorders of urethra, Peritoneal abscess, Encounter for attention to colostomy, Other chronic pain, Pressure ulcer of sacral region stage 4, Acquired absence of right leg above knee, Acquired absence of left leg above knee, Encounter for, attention to other artificial openings of urinary tract, Activated protein c resistance, Atherosclerotic heart disease of native coronary artery without angina pectori, Hyperlipidemia, Peripheral vascular disease, Acute cough, Chronic kidney disease, stage 3 unspecified, Hyperkalemia, and Anemia. On 12/13/23 at 10:41 AM, V23 (Social Service Director / SSD) stated, Code status needs an order if DNR or Full code and is care planned. If there is no order of code status in resident's electronic health record, it can cause confusion. Code status should be consistent to prevent confusion to staff. R14's POS (Physician Order Sheet) or order review report, dated 12/12/23, showed no active order of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 4 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 0578 code status. Level of Harm - Minimal harm or potential for actual harm R14's care plan, dated 11/15/21, documented in part: ADVANCE DIRECTIVE STATUS (CODE STATUS: DNR comfort focused). Care plan interventions included but not limited to document the code status on the POS in the EMR system. Residents Affected - Few R14's POLST (Practitioner Order for Life Sustaining Treatment) form, dated 12/16/22, showed DNR (do not resuscitate). Policy: Titled Advance Directives, revised 05/20/23, documentsm 4. An Advance Directive form (as provided by the healthcare Facility) shall be completed with resident and/or legal representative to verify treatment options as well as code status. 5. Appropriate information will be added to Physician Order Sheet (POS).: FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 5 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide physician ordered oral nutritional supplements. This failure affected 2 residents (R23, R34) of 6 residents reviewed for nutrition. Residents Affected - Few Findings include: On 12/12/23 during initial kitchen tour conducted between 9:15-9:56 AM, observed cases of Magic Cup supplement stored in the reach-in freezer. 1. R34's diagnosis includes but not limited to Unspecified Protein Calorie Malnutrition, Alzheimer's Disease, Major Depressive Disorder with Severe Psychotic Symptoms, Schizophrenia, and Unspecified Bipolar Disorder. R34's Order Review Report, dated 12/12/23, documents in part Magic Cup three times per day, ordered on 10/11/22. R34's MDS (Minimum Data Set) from 12/07/23 indicates BIMS (Brief Interview for Mental Status) was not conducted. R34 is rarely/never understood. R34's nutrition care plan, dated 12/05/23, documents R34 is at risk for compromised nutritional status related to diagnosis of Alzheimer's Disease and R34 has experienced weight loss. Interventions include but not limited to Magic Cup three times daily. R34's Dietary Evaluation Assessment completed by V14, dated 12/07/23, documents R34 is at nutritional risk and to continue with Magic Cup three times daily. R34's meal ticket from 12/12/23 document in part, Magic Cup 1 each at lunch. On 12/12/23 at 12:30 PM, observed R34 being fed lunch by V19 (Agency CNA). R34's meal ticket listed Magic Cup as item for R34 to receive at lunch. Magic Cup was not provided on R34's tray. On 12/12/23 at 12:35 PM, R34 consumed 100% pureed items on lunch tray. V19 stated R34 eats well and would have probably consumed the Magic Cup if it was provided on R34's lunch tray. V19 stated Magic Cup is put on the trays by the kitchen staff before they come up to the unit. On 12/12/23 at 3:25 PM, V14 stated R34 is having a gradual weight loss, and is receiving Magic Cup to provide more calories to try to prevent further weight loss. V14 stated R34 did not trigger for weight loss over 1 month 3 months or 6-month period, but R34's weight is a big problem because of the gradual weight loss. V14 stated if R34 does not receive the nutritional supplements as ordered, then there is the potential for R34 to lose more weight. 2. R23's diagnosis includes but not limited to Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Dysphasia, Unspecified Protein Calorie Malnutrition, Lack Of Coordination, Fracture Of Right Femur and Major Depressive Disorder. R23's Order Summary Report dated 12/12/23 documents in part Magic Cup three times a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 6 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R23's MDS (Minimum Data Set) from 12/08/23 BIMS (Brief Interview for Mental Status) was 07 out of 15, indicating severely impaired cognitive function. R23's nutrition care plan, dated 12/06/23, documents R23 nutritional status is compromised due to symptoms of depression with loss of appetite, cognitive communication deficit, weight loss contributed to inadequate PO intakes (changing appetite) and medical conditions/symptoms. Interventions include but not limited to provide dietary supplements as ordered including Magic Cup three times daily. R23's Dietary Evaluation Assessment completed by V14, dated 12/07/23, documents R23's BMI (Body Mass Index) is less than 23, R23 is at nutritional risk and to continue Magic Cup three times daily. R23's meal ticket from 12/12/23 documents in part, Magic Cup 1 each at lunch. On 12/12/23 at 12:40 PM, surveyor viewed R23's completed lunch tray. R23 consumed 100% all pureed items. There was no empty container of Magic Cup on R23's finished tray. On 12/12/23 at 12:41 PM, V18 (Restorative Aide) stated V18 fed R23, and R23 did not receive Magic Cup on R23's lunch tray. V18 stated the kitchen puts the Magic Cups on the trays. On 12/12/23 at 3:03 PM, V14 stated R23 is gradually losing weight, has a BMI (Body Mass Index) below recommended range for age, and is at moderate risk for malnutrition. V14 stated R23's is getting oral supplements because of R23's history of weight loss. V14 stated the oral supplements are used to increase R23's caloric intake. On 12/12/23 at 3:00 PM, V14 (Registered Dietitian) stated, If a resident has a physician order for a nutritional supplement like Magic Cup, the items will print on the resident's meal ticket and the kitchen would read the ticket and put the item on the tray before it reaches the nursing unit. Magic Cup supplements are not store on the nursing unit. Whatever is printed on the meal ticket should be given to the resident. Kitchen policy titled, Nourishments undated documents in part the Culinary Services Manager will assure that individuals receive the nourishments/supplements that have been ordered by the physician and designated staff delivers supplements to the nursing unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 7 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received the correct oxygen flow rate as ordered for 2 (R4, R66) of 2 residents reviewed for respiratory care in a sample of 19. Residents Affected - Few Findings Include: 1. R66 has diagnoses not limited to Acute on Chronic Systolic (Congestive) Heart Failure, Paroxysmal Atrial Fibrillation, Acute Embolism and Thrombosis of Right Axillary Vein, Essential (Primary) Hypertension, Acute and Chronic Postprocedural Respiratory Failure, Personal History of Pneumonia, Cardiomyopathies, and Cognitive Communication Deficit. Order Review Report, dated 12/12/23, documents: Oxygen 2L (Liters)/min (Minute) via nasal cannula to maintain Oxygen Saturation level equal or above 92% as needed for SOB (Shortness of Breath). R66's Care Plan documents Focus: R66 is at risk for alteration in respiratory functioning related to CHF (Congestive Heart Failure), Acute on Chronic respiratory failure, Hx (History) of pneumonia and Hx of R (Right) Hydropneumothorax s/p (status post) chest tube. Date Initiated: 11/16/23. Intervention: Administer oxygen (O2 (oxygen) @ 2L/min via NC (nasal cannula) to maintain O2 sat (saturation) equal or greater than 92%) and other medications and respiratory treatments as ordered Date Initiated: 11/16/23. On 12/12/23 at 10:46 AM, R66 was lying in bed with the oxygen nasal canula on the bed and not in use. The oxygen concentrator was observed with the setting of 4 liters. On 12/12/23 at 11:26 AM, V22 (Agency Registered Nurse) asked R66 did (R66) take off his oxygen? and R66 responded yes. V22 stated, (R66's) supposed to have oxygen on that he takes off. It is supposed to be set on 2 liters, and it is all the way on 4 liters. (R66) messes with the oxygen. V22 proceeded to obtain some gloves to reapply R66's nasal cannula and adjust R66's oxygen flow rate. On 12/12/13 at 11:49 AM, V22 (Agency Registered Nurse) stated, I put the nasal cannula back on (R66) and turned the oxygen concentrator to 2 liters. I don't know why (R66) takes the oxygen off. 2. R4's clinical records show R4 has a diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Dementia. R4's Minimum Data Set (MDS), dated [DATE], shows R4's cognition is severely impaired. R4's physician order sheet (POS) shows O2 @ 3 liters via NC as needed for SOB ordered on 12/2/23. R4's comprehensive care plan initiated on 12/2/23 shows R4 has oxygen therapy related to COPD and Congestive Heart Failure. One intervention reads, Give oxygen as ordered by the physician (O2 @ 3L/min via NC PRN for SOB). On 12/12/23 at 11:24 AM, R4 was resting in bed and was not interviewable. R4 was receiving oxygen set to 2 liters per minute (LPM) via nasal cannula. On 12/14/23 at 9:44 AM, V2 (Director of Nursing) stated, My expectation for the oxygen flow rate is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 8 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 Level of Harm - Minimal harm or potential for actual harm when the nurse makes rounds to check the oxygen order and check the flow rate when entering the resident room. If the residents are taking the oxygen off, the nurse should notify Social sServices, the doctor, or Nurse Practitioner to see if it is a behavior, or that they don't need it, if the oxygen saturation is above 92%. If the resident is receiving too much oxygen it depends on the diagnosis or need for oxygen it can affect the flow of oxygen to the body and the carbon dioxide. Residents Affected - Few Policy: Oxygen Therapy and Administration, revised 07/28/23, documents: Oxygen therapy shall be administered to patients as indicated and upon a physician's order. Purpose: To assure adequate oxygenation to all spontaneously breathing and ventilator dependent patients. Caution should be taken in patients with CO2 (Carbon Dioxide) retention where oxygen administration could depress the respiratory drive. Procedure: Confirm order from physician (this should include liter flow, FiO2 and delivery device). Physician Orders, revised 07/28/23, documents: It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (Plan of Care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 9 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in 2 of 2 medication carts reviewed. This affects 4 residents (R54, R3, R64, and R68) reviewed for medication storage. Findings Include: 1. R54 has diagnoses of Asthma and Essential (Primary) Hypertension. R54's Order Summary Report, dated 12/13/23, documents: Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally every 12 hours. R54's Care Plan documents: Focus: R54 has Asthma. Intervention: Give medications as ordered (Budesonide Inhaler). Monitor/document side effects and effectiveness. 2. R3 has diagnoses not limited to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Disorders of Electrolyte and Fluid Balance, and Urinary Tract Infection. R3's Order Review Report, dated 12/12/23, documents: Insulin Glargine Solution 100 UNIT/ML 25 unit subcutaneously at bedtime for diabetes. Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) 3 unit subcutaneously three times a day for Antidiabetics give medication with meals. R3's Care Plan documents R3 is at risk for fluctuating blood sugars due to diabetes mellitus. 3. R64 has diagnosis not limited to Type 1 Diabetes Mellitus, Essential (Primary) Hypertension, and Atherosclerotic Heart Disease of Native Coronary. R64's Physician Orders documents: NovoLog Flex Pen 100 UNIT/ML Solution pen-injector Inject 5 unit subcutaneously with meals. R64's Care Plan documents R64 is at risk for fluctuating blood sugars due to diabetes mellitus. 4. R68 has diagnoses not limited to Type 2 Diabetes Mellitus, Severe Protein-Calorie Malnutrition, and Pseudocyst of Pancreas. R68's Order Review Report, dated 12/12/23, documents: Insulin Glargine Solution Pen-injector 100 UNIT/ML (Milliliter) 25 unit subcutaneously at bedtime. R68's Care Plan documents R68 is at risk for fluctuating blood sugars due to diabetes mellitus. On 12/12/23 at 11:31 AM, the fourth-floor medication cart was reviewed with V22 (Agency Registered Nurse). R54's Symbicort (Budesonide-Formoterol Fumarate Inhalation Aerosol) 160-4.5 MCG/ACT (microgram/asthma count test) 2 puffs every 12 hours was observed in the medication cart drawer, with no open date. V22 stated, I have to blame myself because I gave the Symbicort this morning. R3's Insulin Glargine Solution 100 UNIT/ML (Milliliter) Lantus was observed in the red and clear plastic container (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 10 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 unopened. V22 (Agency Registered Nurse) stated, It doesn't look like it's been opened. They did not put any dates on them. R3's Humalog Injection Solution 100 UNIT/ML (milliliter) (Insulin Lispro) insulin vial was observed ,with an open date of 11/20/23 stored in the red and clear plastic container without a bag. A Lispro Kwik pen was observed unlabeled, undated, and stored in the red and clear plastic container with no bag. V22 (Agency Registered Nurse) stated, I can throw that away because it has no name. Residents Affected - Some On 12/12/23 at 11:44 AM, V22 (Agency Registered Nurse) stated, The insulin pen does not have any thing on it, and it don't (sic) say when they opened it or who it belongs to. The insulin vials and insulin pens being stored without a bag could cause cross contamination because it is open. R64's NovoLog flex pen was observed stored in the red and clear plastic container unopened in a bag labeled refrigerate. V22 (Agency Registered Nurse) took R64's Novolog flex pen and put it in the refrigerator. On 12/12/23 at 12:54 PM, the third-floor medication cart was reviewed with V4 (Licensed Practical Nurse). R68's Lantus insulin was observed unopened and stored in the blue plastic container in the third drawer of the medication cart. V4 stated, I think it was delivered today; I will put it in the refrigerator. On 12/14/23 at 9:50 AM, V2 (Director of Nursing) stated, My expectation when the insulin pen is open, to put the open date on the pen. There is a tag on the pen and the expiration date can be a 28-day depending on the type of insulin. The insulin pen can be kept in the medication cart once it is open, but if not opened, the insulin pen is refrigerated. If the insulin pen is not refrigerated and not open it would affect the effectiveness of the insulin. The insulin pen and insulin vial have their own bag. When stored in the plastic pencil case, the insulin pen and insulin vial should be in zip lock bags to avoid cross contamination. The inhaler has a gauge and we put a label when it was started. When done with the inhaler we toss them out. Policy: Medication Storage, Labeling, and Disposal, revised 08/24/23, documents: It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. Procedures: 1. Medications from pharmacy will be labeled by the pharmacy to include the name of the resident, route of administration, instruction, medication name (generic/brand), strength, and expiration date when applicable. 3. Medications will be stored safely under appropriate environmental controls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 11 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure a.) food items were properly stored per manufacturer guidelines, b.) expired foods were discarded, and c.) proper hand washing was done in between handling dirty and clean plate ware. These failures have the potential to affect all 77 residents receiving food prepared in the facility's kitchen. Findings include: On 12/12/23 at 9:15 AM, during initial kitchen tour, V10 (Food Service Manager) stated all food items in the refrigerator should be labeled with a delivery date, an open data, and an expiration date or use by date. V10 stated all items should be discarded after labeled use by date. On 12/12/23 at 9:20 AM, walk-in refrigerator had a container of opened package of French Toast labeled, with preparation date 12/08/23, and use by date 12/10/23. V10 stated this item would not be served to a resident because it is past its use by date. V10 stated I'll throw it out now. On 12/12/23 at 9:32 AM, V11 (Dietary Aide) was handling dirty plate ware, and placing dirty items into a dish rack before feeding the racks into the dish machine to be cleaned. At 9:33 AM, V11 walked to the other side of the dish machine, picked up mugs that had just come out of the clean side of the dish machine, and then placed the mugs back into the dishwasher racks. V11 did not wash V11's hands in between touching the dirty and clean items. At 9:34 AM, V11 walked back to the dirty side of the dish machine, began to sort through dirty plat ware, placed dirty items into dish racks and then placed the racks into the dish machine to be cleaned. On 12/12/23 at 9:38 AM, V11 stated he went to the clean side of the dish machine to make sure the mugs were clean enough, and that he should have washed his hands in between touching the dirty items and the clean mugs. On 12/12/23 at 9:43 AM, observed opened 1-quart bottle of lemon juice 50% full, stored in the food prep area on metal storage rack, with other spices and condiments. The lemon juice bottle was labeled with an opened date of 12/08/23, and use by date of 12/12/23. The lemon juice bottle had printed on it Refrigerate After Opening. On 12/12/23 at 9:44 AM, V10 stated V10 did not know the lemon juice bottle had those manufacturer instructions to Refrigerate After Opening printed on the label, and that based on this label, the lemon juice should have been stored in the refrigerator. V10 stated, I'll throw this out right now. On 12/12/23 at 9:45 AM, observed opened 1-gallon Louisiana Hot Sauce 60% full, labeled with an open date of 10/31/23, and use by date of 11/30/23. At 9:46 AM, V10 stated the hot sauce should have been thrown out on or before the use by date 11/30/23, and the item should not be served to residents. On 12/13/23 at 12:04 PM, V10 stated food should be thrown out after the use by date, because it could potentially be a hazard to the resident by causing a food borne illness. V10 stated it is all kitchen staff's responsibility to check items daily, and any past use by date items should be discarded. V10 stated manufacturer storage guidelines should be followed. For example, the lemon juice should have been refrigerated not left out stored at room temperature. The lemon juice could potentially go bad if not refrigerated. V10 stated the purpose of running items in the dish machine is so they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 12 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many can be cleaned, washed, and sanitized. V10 stated the dish machine area is always staffed with two employees, so there is one staff to work on the dirty side, and another to work on the clean side. V10 said this is done to prevent cross contamination because if the person on the dirty side goes to the clean side and touches items that came out of the dishwasher, those items are no longer clean or sanitized. V10 stated this could cause cross contamination and is an infection control issue. V10 stated the exception would be if the staff washed their hands before touching the cleaned items. On 12/13/23 and 12/14/23, V1 (Administrator) provided policies on Food Receiving and Storage, Handwashing, Dishwashing Machine Use, and a form titled Expiration Dates. On 12/14/23 at 2:30 PM, V2 provided surveyor with a list of residents and their diet orders. V2 stated currently there are no residents who are NPO (Nothing by Mouth). Kitchen policy titled, Food Receiving and Storage, undated, documents foods shall be received and stored in a manner that complies with safe food handling practices. Kitchen form titled, Expiration Dates, undated, documents product that is in the original container and has a manufacturer expiration or use-by-date, follow that date, and foods that expire 3 days after opening and foods that expire 30 days after opening. Kitchen policy titled, Handwashing, undated, documents, staff will wash hands as frequently as needed throughout the day following proper hand washing procedures and when to wash hands including after handling soiled equipment or utensils. Kitchen policy titled, Dishwashing Machine Use, undated, documents, Culinary services staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 13 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 5. R60 has diagnoses not limited to Extended Spectrum Beta Lactamase (ESBL) Resistance, Major Depressive Disorder, Insomnia, Hallucinations, Dementia in other Diseases Classified Elsewhere, Mild, with other Behavioral Disturbance, Acute on Chronic Diastolic (Congestive) Heart Failure, Essential (Primary) Hypertension, Chronic Kidney Disease, Stage 3, Anemia in Chronic Kidney Disease, Cognitive Communication Deficit, Lobar Pneumonia, and Acute Cough. Residents Affected - Some R60's Order Review Report, dated 12/12/23, documents: Meropenem Intravenous Solution Reconstituted 1 GM (Gram) intravenously every 12 hours for ESBL urine for 10 Days -Start Date-12/11/23. Contact Isolation ESBL urine order date 12/09/23. R60's Care Plan documents: Focus: R60 is on antibiotic therapy for ESBL in Urine & Pneumonia (R lower lobe) Date Initiated: 12/09/23. Intervention: Focus: ISOLATION CONTACT PRECAUTIONS R60 is on contact isolation related to Positive ESBL in urine Date Initiated: 12/09/23. Interventions: Contact precautions include: [ Gloves, gown, mask, goggles, and biohazard supplies] Date Initiated: 12/09/23. Maintain contact isolation precaution in accordance with Centers for Disease Control (CDC) guidelines. Date Initiated: 12/09/23. R60's Progress note, dated 12/8/2023 at 06:44, documents: Health Status Note Text: Notified Dr. (doctor) of UA (urinalysis) culture results with new orders received noted and carried out. R60's Progress note, dated 12/12/23 at 12:06, documents in part: General Progress Note Text: IVABT (Intravenous Antibiotics) to start d/t (due/to) ESBL of urine. Laboratory Report, dated Specimen Collected 12/06/23, Final Report 12/09/23, Urine Culture Positive for ESBL. Lab Results Report, dated 12/09/23, document in part: Urine Culture. Positive for ESBL. On 12/12/23 at 10:24 AM, V22 (Agency Registered Nurse) stated (R60) is on Contact Isolation for ESBL of the urine. On 12/12/23 at 10:38 AM, upon entering R60 room, signage was posted on the entry door indicating Enhanced Barrier Precautions. The call light was observed hanging on the wall lamp to the left side of the head of R60's bed out of R60's reach. On 12/12/23 at 12:46 PM, V22 (Agency Registered Nurse) stated (R60) is on Contact Isolation for ESBL of the Urine. Somebody removed (R60's) sign. I don't know who removed the sign, but until the order is changed, the sign is supposed to be up there. V22 removed a contact isolation sign from a tray near the nurse station then placed it on R60 door, also leaving the enhanced barrier precaution sign on R60 door. On 12/14/23 9:54 AM, V2 (Director of Nursing) stated, If a resident is on contact isolation for ESBL of the urine, staff is expected to use PPE (Personal Protective Equipment). The signage should say contact isolation. If a resident is on a special isolation it surpasses the Enhanced Barrier Precaution, the Enhanced Barrier Precaution signage should be taken down. Policy: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 14 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Titled Infection Prevention and Control, revised 10/23/23, documents: The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility. 8. A sign will be provided outside the room for residents on transmission-based precautions indicating the type of the precaution (Contact, Droplet, or EBP (Enhanced Barrier Precautions)). 14. The transmission-based precaution for the resident is discontinued once the treatment is completed and the resident is no longer considered infected according to the Mc Greer's criteria. Precautions to Prevent Transmission of Infectious Agents and Transmission Based Precautions: 2. Contact Precaution - intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or environment. b. Use of Gown and gloves is necessary prior to room entry. Facility's infection prevention and control policy and procedures dated 10/23/23 documented: The facility has established a policy to identify, record, investigate, control, test and prevent infections in the facility. A sign will be provided outside the room for residents on transmission-based precaution (TBP) indicating the type of the precaution (Contact, Droplet, or EBP). Contact precaution - intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment. Use of gown and gloves is necessary prior to room entry. Face protection may be necessary if performing activity with risk of splashing or spraying. Droplet Precaution - intended to prevent transmission through close respiratory or mucous membrane contract with respiratory secretions. Eye protection, and mask should be worn for close contact with the resident. If there are infectious material that can be transmitted through contact, then gown and gloves should also be used. Facility's enhanced barrier precaution (EBP) policy and procedure dated 10/23/23 documented: The facility will use EBP to reduce transmission of multi-drug resistant organisms (MDRO) in the nursing home. EBP involves the use of gowns, gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as residents with wounds and / or indwelling medical devices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 15 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 EBP will be used for any resident in the facility: has indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of XDRO colonization status. Level of Harm - Minimal harm or potential for actual harm Facility's COVID 19 testing plan and response strategy policy dated 9/27/23 documented: Residents Affected - Some During outbreaks = N95 + face shield for staff in the affected area. N95: working in an area / unit with COVID 19 transmission. Staff to use N95 = face shield during care during outbreak in the affected unit. Based on observation, interview, and record review, the facility failed to follow their policy and procedures for infection prevention and control by: 1. Failed to ensure that proper PPE (Personal Protective Equipment) such as N95 mask is worn by staff during COVID outbreak in the affected area. 2. Failed to ensure that a sign will be provided outside the room for residents on transmission-based precautions indicating the type of the precaution for 5 residents (R9, R14, R60, R68, R274). 3. Failed to follow enhanced barrier precaution policy and procedures for resident (R68) with PICC (peripherally inserted central catheter) line. These failures affect 5 residents (R9, F14, R68, R274, and R60), and could potentially affect 23 residents residing on 3rd floor for facility's census, dated 12/12/23, reviewed for infection control. The findings include: 1. R9's health record documented admission, dated 3/9/2020, with diagnoses not limited to Covid-19, Spinal stenosis, lumbar region with neurogenic claudication, Mixed hyperlipidemia, Personal history of covid-19, Generalized anxiety disorder, Major depressive disorder, single episode, Chronic kidney disease stage 3b, Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Essential (primary) hypertension, Benign prostatic hyperplasia without lower urinary tract symptoms, Nontraumatic chronic subdural hemorrhage, Unspecified abnormalities of gait and mobility, Unspecified lack of coordination, Other lack of coordination. R9's care plan, dated 12/5/23, documented: R9 requires Droplet/Contact Precautions related to + COVID-19. Care plan interventions included but not limited to observe isolation precautions as clinically indicated. Use appropriate protective equipment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 16 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 R9's POS (physician order sheet) with active order not limited to: Isolation - Droplet/Contact COVID 19. Level of Harm - Minimal harm or potential for actual harm At 11:22 AM, Observed with 1:1 staff outside of R9's room, door closed. Observed door signage indicating Droplet Precautions. V4 (Licensed Practical Nurse/LPN) stated R274 is on contact/droplet precautions for COVID 19. Residents Affected - Some 2. R14's health record documented admission, dated 9/7/23, with diagnoses not limited to Extended spectrum beta lactamase (esbl) resistance, Primary osteoarthritis left shoulder, Essential (primary) hypertension, Other specified nutritional anemias, Chronic fatigue, Respiratory failure, Chronic obstructive pulmonary disease, Bipolar disorder current episode manic severe with psychotic features, Personal history of covid-19, Pulmonary fibrosis, Unspecified protein-calorie malnutrition, Hydronephrosis with ureteral stricture, Other specified disorders of urethra, Peritoneal abscess, Encounter for attention to colostomy, Other chronic pain, Pressure ulcer of sacral region stage 4, Acquired absence of right leg above knee, Acquired absence of left leg above knee, Encounter for, attention to other artificial openings of urinary tract, Activated protein c resistance, Atherosclerotic heart disease of native coronary artery without angina pectori, Hyperlipidemia, Peripheral vascular disease, Acute cough, Chronic kidney disease, stage 3 unspecified, Hyperkalemia, and Anemia. R14's care plan, dated 12/11/23, documented: requires droplet precautions related to influenza. Contact precautions related to ESBL in urine. Care plan interventions included but not limited to initiate proper precaution. Observe isolation precautions as clinically indicated (Droplet). Use appropriate protective equipment. Maintain contact isolation precautions in accordance with Centers for Disease Control (CDC) guidelines. R14's POS with active order not limited to Isolation- contact precaution, ESBL in urine. Droplet precaution for flu. At 11:20 AM, R14's room door was closed with signage indicating Enhanced Barrier Precautions (EBP). V4 (LPN) stated R14 is on contact/droplet precautions for ESBL in urine and Influenza. 3. R68's health record documented admission date of 11/8/2023, with diagnoses not limited to Type 2 diabetes mellitus with hyperglycemia, Cervicalgia, Chronic viral hepatitis b without delta-agent, Hepatitis a without hepatic coma, Pneumonia due to klebsiella pneumoniae, Klebsiella pneumoniae [k. Pneumoniae] as the cause of diseases classified elsewhere, Other gram-negative sepsis, Other disorders of lung, Iron deficiency anemia secondary to blood loss (chronic), Acute pyelonephritis, Renal and perinephric abscess, Pseudocyst of pancreas, Other specified diseases of liver, Alcohol induced chronic pancreatitis, Alcohol dependence with other alcohol-induced disorder, Unspecified severe protein-calorie, Major depressive disorder, and Insomnia due to medical condition. R68's POS with active order not limited to change PICC line dressing weekly, measure external catheter. At 12:25 PM, R68 was sitting on the bed, alert, and oriented x 3, verbally responsive with PICC line single lumen on right upper arm. R68 stated he is getting IV (intravenous) antibiotic. R68 stated staff is not wearing gown when giving IV antibiotic or providing direct care. There was no EBP signage on R68's room. 4. R274's health record documented admission date of 11/29/2023, with diagnoses not limited to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 17 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Covid-19, Typical atrial flutter, Unspecified protein-calorie malnutrition, Repeated falls, Adult failure to thrive, Personal history of transient ischemic attack (tia) and cerebral infarction without residual deficits, Presence of other cardiac implants and grafts, Major depressive disorder, Atherosclerotic heart disease of native coronary artery without angina pectoris, Mixed hyperlipidemia, Essential (primary) hypertension, Benign prostatic hyperplasia without lower urinary tract symptoms, Malignant neoplasm of prostate, Hematuria, and Vascular dementia with other behavioral disturbance. R274's care plan, dated 12/8/23, documented: requires Droplet/Contact Precautions related to + COVID-19. Care plan interventions included but not limited to observe isolation precautions as clinically indicated. Use appropriate protective equipment. R274's POS with active order not limited to Isolation - Droplet/Contact Reason: COVID 19. On 12/12/23 at 10:44 AM, Observed with 1:1 staff outside R274's room, door closed, with signage indicating Droplet Precautions. V4 (Licensed Practical Nurse/LPN) stated R274 is on contact/droplet precautions for COVID 19. At 2:01 PM, V2 (Director of Nursing / DON) and V26 (Regional Nurse Consultant) were interviewed and stated IP (Infection Preventionist) Nurse is not available at this time. Both stated they oversee infection control program, and they have an outbreak for COVID. V2 stated COVID outbreak is defined as 1 or more positive COVID resident. V2 stated R9 and R274 both tested positive for COVID in the hospital, and were placed under contact/droplet precautions. Both residents have 1:1 staff for close monitoring due to behavioral issues. V2 stated staff is expected to wear proper PPE such N95 mask and face shield when on the 3rd floor due to COVID outbreak. V2 stated proper signage for transmission-based precautions with appropriate instructions for use of PPE should be in place. V2 stated criteria for EBP (Enhanced Barrier Precautions) are those residents with open areas / wounds, devices such as foley cath, G-tube, IVs, ostomies, dialysis patient, PICC or central line. V2 confirmed R68 has a PICC line and should be on placed on EBP. V2 stated staff should be wearing gown, gloves and mask when providing direct care to R68. The potential risk if staff is not wearing proper PPEs and does not follow TBP (transmission-based precautions) procedures could potentially cause cross contamination or spread of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 18 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: (1) provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal and Influenza vaccinations; (2) assess eligibility and offer Influenza vaccination to 2 (R9, R68) residents; and (3) assess eligibility and offer pneumococcal vaccinations to 4 (R9, R60, R68 and R274) residents. Residents Affected - Some These failures affect 4 (R9, R60, R68 and R274) of 5 residents reviewed for pneumococcal / influenza vaccinations. The findings include: 1. R9's health record documented admission date of 3/9/2020, with diagnoses not limited to Covid-19, Spinal stenosis, lumbar region with neurogenic claudication, Mixed hyperlipidemia, Personal history of covid-19, Generalized anxiety disorder, Major depressive disorder, single episode, Chronic kidney disease stage 3b, Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Essential (primary) hypertension, Benign prostatic hyperplasia without lower urinary tract symptoms, Nontraumatic chronic subdural hemorrhage, Unspecified abnormalities of gait and mobility, Unspecified lack of coordination, and Other lack of coordination. 2. R60's health record documented admission date of 9/30/2023 with diagnoses not limited to Aftercare following joint replacement surgery, Dysphagia, oropharyngeal phase, Other symptoms and signs involving the musculoskeletal system, Lobar pneumonia, Pleural effusion in other conditions classified elsewhere, Unspecified protein-calorie malnutrition, Cognitive communication deficit, Unspecified abnormalities of gait and mobility, Lack of coordination, Major depressive disorder, Insomnia, Hallucinations, Dementia in other diseases classified elsewhere, mild, with other behavioral disturbance, Fracture of unspecified part of neck of left femur, Presence of left artificial hip joint, Acute on chronic diastolic (congestive) heart failure, Essential (primary) hypertension, Mixed hyperlipidemia, Chronic kidney disease stage 3 unspecified, Anemia in chronic kidney disease, Gastro-esophageal reflux disease without esophagitis, Extended spectrum beta lactamase (esbl) resistance, and Acute cough. 3. R68's health record documented admission date of 11/8/2023, with diagnoses not limited to Type 2 diabetes mellitus with hyperglycemia, Cervicalgia, Chronic viral hepatitis b without delta-agent, Hepatitis a without hepatic coma, Pneumonia due to klebsiella pneumoniae, Klebsiella pneumoniae [k. Pneumoniae] as the cause of diseases classified elsewhere, Other gram-negative sepsis, Other disorders of lung, Iron deficiency anemia secondary to blood loss (chronic), Acute pyelonephritis, Renal and perinephric abscess, Pseudocyst of pancreas, Other specified diseases of liver, Alcohol induced chronic pancreatitis, Alcohol dependence with other alcohol-induced disorder, Unspecified severe protein-calorie, Major depressive disorder, and Insomnia due to medical condition. 4. R274's health record documented admission date of 11/29/2023, with diagnoses not limited to Covid-19, Typical atrial flutter, Unspecified protein-calorie malnutrition, Repeated falls, Adult failure to thrive, Personal history of transient ischemic attack (tia) and cerebral infarction without residual deficits, Presence of other cardiac implants and grafts, Major depressive disorder, Atherosclerotic heart disease of native coronary artery without angina pectoris, Mixed hyperlipidemia, Essential (primary) hypertension, Benign prostatic hyperplasia without lower urinary tract symptoms, Malignant neoplasm of prostate, Hematuria, and Vascular dementia with other behavioral disturbance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 19 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/13/23 at 2:21 PM, V2 (Director of Nursing / DON), V26 (Regional Nurse Consultant), and V5 (Registered Nurse / RN) were interviewed. V5 said she is helping V2 (DON) with the Infection Control Program about 1-2 times per week. V5 stated V2 is giving her Infection Control tasks with instructions, such as Antibiotic stewardship, handwashing, pneumonia, flu, COVID immunization. V5 stated she assesses, implements, and monitors on a regular basis. V5 stated she has IP (Infection Preventionist) certification, but she is not the IP nurse in the facility. V2 stated she and V26 are overseeing IPCP (infection prevention and control program). V5 stated, Upon admission, immunization record is checked including flu, pneumonia and COVID. If the resident is appropriate or eligible for vaccination, consent is obtained, education is provided, and documentation is done in resident's EHR. If the resident is eligible, obtain an order from MD/NP and give the vaccine to the resident. Consent is obtained whether resident/ representative agree to take the vaccine or decline vaccination. Consent, education, and documentation is important to show that vaccine was offered. CDC guidelines are followed for Pneumonia and influenza vaccination. Flu vaccine is seasonal, offered to all residents starting from September to March. On 12/14/23 at 10:41 AM, electronic immunization records and immunization consents were reviewed with V2 and V5 for the following residents: 1. R9 with no flu and pneumonia immunization record. No pneumonia and / or flu screening, education or consent found. Immunization record showed R9 refused for pneumonia vaccination and education was provided on 7/9/20. 2. R60 no pneumonia vaccination record. No pneumonia screening, consent or education found. 3. R68 no pneumonia and influenza vaccination record. No pneumonia and influenza screening, consent or education found. 4. R274's PPSV23 (Pneumococcal Polysaccharide Vaccine) was administered on 2/3/14. V2 and V5 stated flu and pneumonia vaccine is offered at least yearly. V2 stated if the resident refuses, then it will be offered and educated on yearly basis. V5 stated potential risk if flu or pneumonia vaccine was not offered, and education not provided, the resident could easily get infection and be more sick and could die due to complications. Facility's pneumococcal vaccination policy, dated 10/31/23, documented: It is the policy of the facility to offer and administer pneumococcal vaccinations to each resident who has not received immunization prior to or upon admission, unless otherwise contraindicated or the resident or responsible party has refused the vaccine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 20 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 0883 - Level of Harm - Minimal harm or potential for actual harm All residents and responsible parties will receive education about the risks and benefits of the pneumococcal vaccines. Residents Affected - Some Consent for vaccination is obtained. All adults age [AGE] years or older, and assess residents 19-[AGE] years old with certain underlying medical conditi8ons or other risk factors. For adults who require pneumococcal vaccination, if they have previously received PPSV23 but no PCV13, PCV15 or PCV20, one dose of PCV15 or PCV20 should be administered at least one year after PPSV23. All refusals will be documented. Facility's influenza vaccination policy, dated 2/8/23, documented: It is the policy of the facility to annually offer and administer vaccination against influenza to each resident unless otherwise contraindicated or the resident or responsible party has refused the vaccine. Influenza vaccination will be offered to residents seasonally when it becomes available, in preparation for flu season which is typically from October 1 to March 31. Any newly admitted residents during this period shall be offered the vaccination. All current residents shall be offered vaccination during flu season unless otherwise contraindicated or the resident or responsible party refuses. All refusals will be documented. Education of the risks and benefits of receiving vaccination will be provided to the resident and / or responsible party. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 21 of 22 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 145875 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lincoln Park 2732 North Hampden Court Chicago, IL 60614 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 0883 Consent for vaccination will be obtained. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145875 If continuation sheet Page 22 of 22