Health inspection·October 20, 2023

F 0584 the top of the mattress. Level of Harm - Minimal harm or potential for actual harm On 10/20/23 at 3:00 PM in R19 and R20's room, the blinds on both windows were pulled all the way up, exposing the window and the room to the front of the building. R19 stated, They don't work. Surveyor attempted to close the blind covering the large window and was able to close it without difficulty. R19 stated, Oh, please leave it that way. Surveyor attempted to close the blind covering the smaller window, also facing the front of the building. The strings on this blind were broken and the blind was unable to be closed. Residents Affected - Some At 3:15 PM V7 (Maintenance) was asked to look at R1, R2 and R3's room/bathroom. V7 stated, I've been here since August of 2019. I didn't do this; this was before me. (Looking at the wall behind the toilet) V7 then stated that he was not aware of the issues in the bathroom and that nothing had been reported to him. V7 agreed that R2 and R3's bathroom should not look like that. On 10/20/23 at 3:30 PM (R5) asked to speak with Surveyor. R5 stated, The toilet seat is loose. I feel like I have been telling them that for two years and nothing gets done. Surveyor assessed toilet seat and found that it was loose and slid to the side when residents sit on it. R6 then asked to speak with Surveyor. R6 stated, The molding is coming off in the bathroom- there are bugs that come though there. Surveyor assessed the bathroom and found an area under the sink, in the front left corner of the bathroom, there was dark rubber baseboard (trim) pulled away from the wall and area behind it was covered in a thick, dark colored debris. On the other side of the room, between R21 and R22's beds, there was a large area (about the size of a microwave) on the wall under the window. The drywall was broken, sunken in (like something had been pushed into the wall) R5 stated It has been like that forever. On 10/20/23 at 3:50 PM V1 (Administrator) stated, This is an old building. We started working on it in 2020/2021-then we realized we had a big plumbing issue and then that issue got even bigger than we thought. We had areas of the building closed off for a long time. Everything took a long time to get finished. The owner came through about 2 weeks ago and did a walk through. So soon, they will be redoing the resident rooms from the Director of Nursing office to the end of the hall (will include R1, R2, and R3's room). We can still fix the little things, but we will be changing everything when those rooms are remodeled. The CNAs should let (V7) know when there are issues. Surveyor then walked with V1 to R1, R2, R3's room. V1 agreed that they could do some things to make the bathroom look nicer and it should not look like it does. R3 showed V1 that his mattress was sliding off the bed frame and V1 said it should be fixed right away. (R3's EMR-(Electronic Medical Record) shows that R3 has been in that room/ bed since 10/17/23.) On 10/20/23 at 1:50 PM V7 (Maintenance) stated, When things need to be fixed, residents can either tell me, or the reception desk has work orders and they can fill one out or they can tell their CNA and the CNA can call me. The Resident Council Minutes dated October 18, 2023, state, Maintenance: Two residents requested that the baseboard in their room be examined and possibly replaced to avoid ants and other insects entering. Several residents have requested new blinds in their rooms. The Resident Council Minutes dated 9/20/23 state, Maintenance: Two residents requested that the baseboard in their room be examined and possibly replaced to avoid ants and other insects entering. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145898 If continuation sheet Page 2 of 4 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 145898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Chicago Heights 120 West 26th Street South Chicago Height, IL 60411 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 The Resident Council Minutes dated 8/23/23 state, Maintenance: Three residents requested that the baseboard in their room be examined and possibly replaced to avoid ant and other insects entering. The facility Deep Clean Calendar for October 2023 shows that R1, R2 and R3's room was scheduled to be deep cleaned on 10/7/23. This same calendar shows that the facility Baseboards were scheduled to be cleaned on 10/11/23 and then weekly on Wednesdays throughout the month. Invoices provided by V1 show that the facility completed the remodel on 10 resident rooms and bathrooms on 5/3/2021. The proposal for an additional 10 rooms is dated 10/12/23 but does not show an actual date of construction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145898 If continuation sheet Page 3 of 4 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 145898 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Chicago Heights 120 West 26th Street South Chicago Height, IL 60411 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to maintain air conditioners in resident rooms by not cleaning the filters prior to them becoming caked with dust and debris. This failure applied to six of 22 residents (R1, R13, R14, R15, R16 and R17) reviewed for resident equipment in the sample of 22 residents. Residents Affected - Some Findings include: On 10/20/23 at 1:50 PM V7 (Maintenance) stated, The filters in the AC (Air conditioner) units are cleaned as needed. I don't have a schedule or anything for them. They are cleaned before the summer months and then if a resident notices the unit is not cooling like it should. (V7 was shown a picture of a dirty filter with caked on dust, lint and derris, from R1's room, provided to Surveyor prior to survey.) V7 stated, They should not look like that. On 10/20/23 at 2:25 PM V7 (Maintenance) and Surveyor toured the facility and randomly selected resident rooms to check the filters in the air conditioners. The filters in the air conditioners in R13 and R14's room; R15 and R16's room; and R17's room were very dirty and caked with dust and debris. (3 rooms) V7 stated, Moving forward- I will make that a monthly thing- it affects the coolness of the rooms. On 10/20/23 at 4:00 PM V1 (Administrator) stated, The rooms are deep cleaned like once a month and maybe we need to add that to the deep cleaning process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145898 If continuation sheet Page 4 of 4