Inspection·March 6, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview and record review, the facility failed to conduct care plan conferences, allowing residents/their families exercise the right to participate in the development/implementation of their plan of care; failed to follow their comprehensive care planning policy. These failure affects 4 residents (R9, R58, R163, and R48). Findings include: Record review of R9's Minimum Data Set (dated 1/2/2025) documents in part a brief interview of mental status (BIMS) summary score of 12, indicating mild cognitive impairment. On 3/3/2025 at 10:27 AM, R9 stated wishes to discharge from the facility but did not know what R9's plan for discharge was within R9's care plan. R9 denied being asked to participate in the development of R9's plan of care, denied that R9's plan of care was reviewed with R9 and denied ever being invited to a care plan conference to discuss R9's plan of care. R9 affirmed that if there was a meeting about R9's plan of care, R9 would want to attend. Record review of Interdisciplinary Team Meeting (Care Plan Conference) (dated 6/18/2024) documents in part that a care plan was held. R9's family member, a social service staff member, a registered nurse, wound care nurse, and guest services attended the meeting. The document does not indicate that R9 was invited to the care plan meeting and does not indicate that a member of dietary services or a certified nursing assistant was in attendance. Other listed disciplines that were not in attendance include therapy, activities and business office. No other documentation of care plan conferences for R9 were provided during the survey. Record review of R58's Minimum Data Set (dated 12/19/2024) documents in part a brief interview of mental status (BIMS) summary score of 10, indicating moderate cognitive impairment. On 3/3/2025 at 10:37 AM, R58 was observed lying in bed and lethargic. When asked if R58's care plan was ever reviewed/developed with R58, R58 shook R58's head no. Record review of R163's Minimum Data Set (dated 12/13/2024) documents in part a brief interview of mental status (BIMS) summary score of 14, indicating R163 is cognitively intact. On 3/3/2025 at 11:23 AM, R163 was observed lying in bed. R163 denied ever having R163's plan of care reviewed with staff. R163 denied ever attending any care plan conferences. R163 affirmed that if there was a meeting about R163's plan of care, R163 would want to attend. Record review of R48's Minimum Data Set (dated 12/5/2024) documents in part a brief interview of mental status (BIMS) summary score of 13, indicating R48 is cognitively intact. On 3/3/2025 at 11:20 PM, R48 was observed lying in bed watching TV. R48 denied ever being invited to a care plan conference. R48 asked, What is that (care plan conference)? Are they supposed to be doing that? R48 denied ever being asked to participate in the development and implementation of R48's care plan. R48 affirmed that if there was a meeting about R48's plan of care, R48 would want to go. On 3/4/2025 at 10:41 AM, R58, R163, and R48's care plan meeting documentation was requested from V1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 2 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (Administrator) and V3 (Director of Nursing). No documentation of care plan meetings or participation in the development of the resident's plan of care was received for R58, R163 or R48 during the survey. On 3/5/2025 at 1:24 PM, V32 (Guest Relations) affirmed that V32 is responsible for setting up care plan meetings with families and the residents. V32 stated that care plan meetings are held quarterly for residents. Surveyor requested documentation of care plan conferences for R58, R163 or R48 and V32 affirmed that the facility did not have any documentation of the meetings. R9's care plan meeting documentation was reviewed with V32 and V3 (Director of Nursing) and V3 denied that the facility had any documentation that the R9 had a care plan meeting within the last quarter. V3 explained that around 1/13/2025, that facility identified that care plan conferences were not being completed according to the policy. V3 denied that the deficient practice was reported to the QAA committee for review. When asked how the facility corrected the deficient practice once it was identified, V32 responded, we started doing them correctly from that day (1/13/2025) forward. V32 and V3 denied any other corrective action was taken. No further documentation was produced in response to correct the facility's deficient practice. Record review of facility policy titled Comprehensive Care Plan (dated 11/17/17) documents in part, .The resident and/or resident representative shall be invited to the review the plan of care with the interdisciplinary team either in person, via telephone or video conference (if available) at least quarterly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 3 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide assistance with grooming. These failures affected 1 (R46) of 3 residents (R46, R73, R148,) reviewed for ADLs (activities of daily living) in a sample of 65. Residents Affected - Some Findings Include: On 3/3/2025 at 12:04 pm, R46's fingernails were long and contained brown matter under all 10 fingernails. R46 stated that she did not like her nails long and wanted her nails trimmed. R46's Face Sheet dated March 4, 2025, shows R46 was admitted to the facility admitted to the facility on [DATE] with multiple diagnosis including but not limited to Encephalopathy, Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and anxiety, Altered Mental Status, Long Term Use of Anticoagulants, Hyperlipidemia, Essential Hypertension, Anemia, Contusion of Left Wrist, Syncope and Collapse, and Unspecified Psychosis Not Due TO Substance Or Known Physiological Condition. R46's Minimum Data Set (MDS) dated [DATE], shows R46 has a Brief Interview for Mental Status score of 10 which means R46 has moderate cognitive impairment, requiring supervision or touching assistance with most ADLs. R46's Care Plan dated 9/24/24 shows R46 requires has an ADL Self-Care Performance Deficit related to dementia which requires assistance with R46 has an ADL Self Care Performance Deficit related to Dementia. Per (V1) Administrator, Facility's ADL Self Performance Deficit policy falls under the Facility's Restorative Policy because the ADL policy consists of many sections. The Facility's ADL policy documents the following: Purpose: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Includes, but is not limited to, programs in walking/mobility, dressing and grooming, eating and swallowing, transferring, bed mobility, communication, splint or brace assistance, amputation care and continence programs. A functional maintenance program may include range of motion provided during routine daily care such as dressing, grooming/hygiene, eating, transfers, and bathing, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 4 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to make prescribed anticonvulsant medication (Dilantin/ Phenytoin) available for one a resident (R444), who is diagnosed with seizure disorder, had subtherapeutic (low levels) of Dilantin in his blood according to lab-work, and missed a dose of his anticonvulsant medication; the facility failed to administer medication for one resident (R15) who has seizure disorder. Residents Affected - Few This failure has affected R444, who had two episodes of seizures within five minutes of each other and resulted in R15 having sub- therapeutic levels Dilantin medication in the blood. Findings include: R444 is a [AGE] year old with diagnosis including but not limited to: Conversion disorder with seizures or convulsions, personal history of transient ischemic attack, congestive heart failure, hypertensive heart and chronic kidney disease with heart failure. R444's BIMS (Brief Interview of Mental Status) score as of 2/25/25 is 15, which indicates cognitively intact. On 3/3/25 at 11:53 AM, R444 was observed in hallway and complained of not having his seizure medication on 3/1/25, which resulted in two seizures on 3/2/25 in the morning. R444 said, they (facility) ran out of my seizure medication and I went without a dose on that night (3/1/25). The next morning, I had the seizures. I can't go without my medication. I'm epileptic. On 3/4/2025 at 12:11 PM, Surveyor observed emergency medication supply in the first-floor medication room with V14 (LPN). At that time, V14 accessed the emergency medication supply computer and affirmed that six doses of Dilantin 100 MG were noted in the emergency medication supply. On 3/4/2025 at 12:11 PM, V14 stated if medications are not available, the nurses are to call the pharmacy to pull from the emergency supply. If emergency supply is not available, the nurse should tell the pharmacy to send the medication STAT (as soon as possible). On 3/4/2025 at 1:34 PM, V20 (Nurse Supervisor) said, If the therapeutic levels are low, I would advocate for increased dose or one time dose. The therapeutic levels are to keep a resident from having seizures or reduce seizures. It indicates the effectiveness of a medication in the body. On 3/4/2025 at 1:34 PM, V20 (Nurse Supervisor) said that medication should be reordered once there are five tablets left on the dispensing card. This is to give them enough time to get the medication and not run out. We have an emergency medication dispenser that all nurses are aware of. Agency nurses have to get access to emergency medication from a staff nurse, but all nurses are able to get medication from the emergency box. On 3/6/25 at 11:01 AM, V45 (MD/Medical Doctor) said, The labs indicate the amount of medication that is in the blood. For the therapeutic range of Dilantin, as long as it is within 10-20 ug/ml (microgram per milliliter), the resident is at decreased risk for seizure. With a sub-therapeutic Dilantin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 5 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 and a missed dose, that could be the reason for a seizure. The dosage needed to be increased. Level of Harm - Actual harm Surveyor inquired about the adverse effects of continued low levels of Dilantin in the blood and a missed dose of Dilantin, V45 (MD) said that the resident could end up having more seizures. Residents Affected - Few On 3/6/25 at 11:01 AM, V45 (MD) said that a complication from seizures is possible aspiration which could result in death. On 3/6/25 at 3:10 PM, V44 (LPN/ Licensed Practical Nurse) said, R444 was out of his medication (Dilantin) on 3/1/25 and the pharmacy was out delivering R444's medication on that day. Surveyor inquired about the emergency medication dispenser, V44 (LPN) said that she (V44) does not have access to the emergency medication dispenser and don't believe that any nurse in the facility on 3/1/25 had access to the emergency medication dispenser. MAR (Medication Administration Record) for the period of 3/1/25- 3/31/25 documents, R444's anticonvulsant medication N/A (not available) per V44 (LPN). Progress note dated 3/2/25 documents, R444 experienced two mild seizures. The first one occurred approximately at 06:42 and it lasted for one minute. The second seizure occurred two minutes after the first lasting for one more minute. R444's Care plan dated 2/18/25 documents, R444 has seizure disorder; give medication as ordered. R444's Order Recap report documents, Dilantin Oral capsule; give two tablets by mouth two times a day for seizure activity starting 2/19/25 and ending 3/4/25. R444's Laboratory Report dated 2/19/25, documents Phenytoin (Dilantin) level as 2.4 L (Low) with a reference range of 10-20 ug/ml (microgram per milliliter). R444's progress note dated 2/21/25 documents, Phenytoin level 2.4. New order to repeat level in one week. R444's progress note dated 2/26/25 documents, Medical Doctor contacted regarding abnormal labs, no new orders given at this time. R444's Laboratory Report dated 2/27/25, documents Phenytoin (Dilantin) level as 3.8 L (Low) with a reference range of 10-20 ug/ml (microgram per milliliter). R444's Medication Administration Record for 3/2025 documents, Dilantin NA (Not Available) for R444 on 3/1/25 at 1800 (6:00 PM). R444's progress note dated 3/2/25 documents, R444 experienced two mild seizures. The first seizure occurred approximately at 6:42 AM and lasted for one minute. The second seizure occurred two minutes after the first and lasted for one minutes. Facility policy titled Medication Administration documents, medications are administered as prescribed in accordance with good nursing principles and practices; the facility has sufficient staff and medication distribution system to ensure safe administration of medications without unnecessary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 6 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 interruptions; if a medication with a current, active order cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/ emergency kit. Level of Harm - Actual harm Findings include: Residents Affected - Few On 3/3/25 at 12:47 PM R15 was observed lying in bed resting, R 15's dresser next to bedside was observed to have a bottle of Liquid suspension Phenytoin sitting on dresser with R15's name on it. R15 stated she was unaware who placed the Phenytoin on her dresser, and she thought she was no longer receiving Phenytoin medication. R15's face sheet dated March 4, 2025, shows R15 was admitted to the facility on [DATE] with multiple diagnoses including Convulsions, schizophrenia, hypertension, dementia, insomnia, glaucoma (left eye), rheumatoid arthritis, major depressive disorder, cognitive communication deficit . R15's MDS (Minimum Data Set) dated December 6, 2024, shows R15 has a score of 13 which means R15 is cognitively intact. R15's care plan dated July 30,2024 shows R15 has potential for injury from seizure activity. Intervention/Tasks: staff will administer [R15's] anti-seizure medication as ordered. R15's Physician Order Sheet with order dated for June 3,2024 that states Dilantin Oral Suspension 125 MG/ML (Phenytoin) give 5 ml by mouth two times a day for seizures. On 03/03/25 at 12:52 PM V 21 Licensed Practical Nurse (LPN ) stated that she is the nurse for R15 and that R15 is not allowed to self-administer her own medication because she does not have an order to self-administer medication. V21 stated there are a lot of resident's who wander on this unit and there is a high risk for a resident to wander into anymore and take the Phenytoin medication that was sitting on the dresser.V21 stated that R15 has an active order to receive Phenytoin suspension twice a day and that she did not administer Phenytoin suspension per physicians orders today because she was unable to locate the medication in the cart and was going to contact pharmacy. V21 was given the Phenytoin suspension bottle that was on top of R15's dresser by the surveyor and V21 confirmed the Phenytoin suspension medication was prescribed for R15. R15's Medication Administration Record dated for March 4,2025 displays that Phenytoin 5ml medication dose was not administered by V21 on March 3, 2025, documentation charted by V21 at 10:00 am states NA (Not Available). R15's Phenytoin (Dilantin) level results dated for (2/18/25 is 3.7L, 2/25/25 is 4.4L, 3/4/25 is less than 1.8L). Laboratory report dated 3/4/25 states Phenytoin( Dilantin) level therapeutic reference range is (10-20). V21 documented in Progress note dated for 3/3/25 at 14:55 pm Dilantin medication made available at facility.NP aware next dose to be giving at schedule time. V43 Nurse Practitioner (NP) documented a progress note dated 3/4/25 at 18:59pm that states Results viewed for 3/4/25 by V43.See PCC (Point Click Care) for new orders for extra Dilantin. Okay for nurse to clear results and confirm orders. R15's prescription sheet for Phenytoin(Dilantin) dated for 3/5/25 with V43 as prescriber states (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 7 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 - Actual harm Dilantin (Phenytoin) give 5ml by mouth one time only for low phenytoin level less than 1.7 until 3/4/25 23:59 pm, give extra 5mg tonight and **DAW** give 2.5ml by mouth two times a day for low phenytoin level less than 1.7 until 3/6/25 23;59pm, give an extra 2.5 ml with the already scheduled 5 ml at 10am and 5pm. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 8 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm On 3/03/2025 at 11:10 AM, R148 was observed lying in bed. Observed R148's low air loss mattress set to approximately 350 lbs. V33 (Wound Care Nurse, Licensed Practical nurse) observed R148's mattress and stated, That is not right. It is set to 350 pounds, which (R148) is clearly not. V33 checked paperwork on the wound care cart and stated, (R148)'s last weight was 128 pounds. It should be set to the proper weight. V33 affirmed that if the weight is not set correctly, it will not alleviate pressure as intended. Residents Affected - Some Record review of R148's electronic health record documents in part on 2/18/2025, R148 weighed 128 pounds (last current weight). Record review of R148's care plan documents in part that (R148) is at risk for alteration for skin integrity, and Interventions . Low air loss mattress in place with appropriate settings and functioning properly. Date initiated: 3/3/2025 Based on Observation, interview, and record review, the facility failed to ensure that residents' Low Air Loss Mattresses (LALM) for pressure ulcer prevention are set at the correct weight settings. This failure affected five residents (R38, R40, R113, R148, R170) out of nine residents reviewed for pressure ulcer prevention and treatment in a sample of 33 residents. Findings include: Facility presented a list of 33 residents on low air loss mattress with the corresponding weight taken on 3/3/2025. R40's Face sheet dated March 4, 2025, documents that R40 was admitted to facility on November 19,2024 with diagnosis including Pressure Ulcer of Sacral region Stage 4, Pressure Ulcer of Right Hip Stage 4, Non- Pressure Chronic Ulcer of Right Heel and Midfoot with Unspecified Severity, Pressure Ulcer of Head Stage 3. R40's MDS (Minimum Data Set) dated February 21,2025, shows R40 has a score of 3 which means R40 is has severe cognitive impairment. R40's care plan dated August 2,2024 shows that R40 has a Pressure injury to left ear, sacrum, right hip, left hip and left thigh back, is at risk for delayed wound healing. Interventions/Tasks: Staff to ensure Low air loss mattress in place with appropriate settings and functioning properly. On 3/3/25 at time 12:37pm, R40 was observed in bed, low air loss mattress setting was observed by surveyor at around 80 pounds, the air loss mattress was located at foot of bed. V21 Licensed Practical Nurse was called to the room of R40 to observe the Low air loss mattress setting. On 3/3/25 at 12:40pm V21 stated the setting on air loss mattress is currently set between 40-50 pounds while R40 is lying in bed. V21 stated she would check her weight in the system and adjust low air loss mattress according to weight. On 3/04/25 at 1:26 PM V21 assessed the low air loss mattress for R40, V21 stated that setting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 9 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0686 Level of Harm - Minimal harm or potential for actual harm currently reads between 60-70 pounds, V21 stated V27 Registered Nurse (Wound care Coordinator) informed her on 3/3/25 to inform the staff not to touch the dial on low air loss mattress. R40's current weight in Point Click Care (PCC) weight system is 90.4 pounds dated 2/18/24. On 3/5/25 at 10:39 AM Interview with V27 Registered nurse (Wound care Coordinator) Residents Affected - Some V27 referenced the weights of the residents on low air loss mattresses from Air mattress list dated March 3,2025. V27 stated Low Air loss mattress settings are check daily by nursing staff. V27 stated R40's weight was taken on 3/3/25 and documented on 94 pounds, V27 stated the current setting on the low air loss mattress is 75 pounds. On 03/05/25 at 10:41 V27 reviewed the low air loss mattress settings for residents R38, R40, R113 and R170 with surveyor present. R38's Face sheet dated March 5, 2025, documents that R38 was admitted to facility on March 15,2024 with diagnosis including Dementia, chronic kidney disease, anemia, hypertension, heart failure, maxillary fracture. R38's care plan dated October 9,2024 shows R38 is at risk for further skin impairment and delayed wound healing. Interventions/Tasks: Staff to ensure Low air loss mattress in place with appropriate settings and functioning properly. R38's weight on air mattress list is 86.9 but the setting on the bed is zero, R38 was not in the bed at time of observation. V27 stated that the air mattress setting could be at or below the resident's weight even if patient is out of bed. R113's Face sheet dated March 5, 2025, documents that R113 was admitted to facility on November 27,2024 with diagnosis including Pressure Ulcer of Sacral region stage 2, pressure ulcer of right buttock, stage 2, adult failure to thrive, Alzheimer's disease, Parkinson's disease, anemia, chronic diastolic heart failure, severe protein calorie malnutrition, osteoarthritis. R113's care plan dated March 4,2025 shows R113 is at risk for alteration in skin integrity. Interventions/Tasks: Staff to ensure Low air loss mattress in place with appropriate settings and functioning properly. On 03/05/25 at 10:42 AM R113's weight on air mattress list was 106.7 the setting on the low air loss mattress at foot of the bed for R113 was 90 pounds, R113 was in the bed at time of observation. R170's Face sheet dated March 5, 2025, documents that R170 was admitted to facility on May 23,2024 with diagnosis including Dementia, Alzheimer, hypertension, hypothyroidism, anxiety. R170's physician order sheet dated October 25,2024 shows R170 has an order for Low Air Loss Mattress in use. Staff to check for proper functioning and settings. 03/05/25 10:44 AM R170's weight on air mattress list was 130.9, the setting on the low air loss mattress was 120 pounds, R170 was in the bed at time of observation. The Manufacturer guideline for air loss mattress on weight setting is described as follows: To (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 10 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0686 Level of Harm - Minimal harm or potential for actual harm increase or decrease airflow for a softer or firmer mattress setting the numbers denote suggested setting based on patient weight. V27 provided an In-Service sheet with Topic: Air Mattress/Heel Protectors dated 9/11/2024 description states: All Air mattresses are set to the patient's weight and the settings should not be changed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 11 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 3/4/25 at 10:15 AM, R85 complained that he stays in bed all day, and no staff has helped him with exercising his right leg and left arm for a while. R85 added that he(R85) understands that Restorative staff might not want to do exercise for his right arm because of the dressing on the right shoulder area, but that he(R85) wants the other leg and arm to be exercised so he will not get weaker and weaker by staying in bed. R85 explained that once when they (Restorative staff) came, he(R85) was getting ready to go for dialysis, and they (Restorative staff) never came back. R85 wants the restorative staff to come at a time different from his scheduled Dialysis time. R85 explained that he goes for Dialysis on Mondays, Wednesdays, and Fridays. On 3/4/25 at 2:20pm, V13(Restorative Director) stated that R85 was discharged from Therapy to Restorative Care about 2 weeks ago. V13 explained that she(V13) went to do restorative for R85 up to 3 times in the past 2 weeks. Inquired from V13 about the records of the restorative care she(V13) provided to R85 so far, V13 stated that she did not document it, but she follows the care plan and no records available. On 3/04/25 at 10:15 AM, R85 complained that he stays in bed all day, and no staff has helped him with exercising his right leg and left arm for a while. R85 added that he(R85) understands that Restorative staff might not want to do exercise for his right arm because of the dressing on the right shoulder area, but that he(R85) wants the other leg and arm to be exercised so he will not get weaker and weaker by staying in bed. R85 explained that once when they (Restorative staff) came, he(R85) was getting ready to go for dialysis, and they (Restorative staff) never came back. R85 wants the restorative staff to come at a time different from his scheduled Dialysis time. R85 explained that he goes for Dialysis on Mondays, Wednesdays, and Fridays. On 3/4/25 at 2:20pm, V13(Restorative Director) stated that R85 was discharged from Therapy to Restorative Care about 2 weeks ago. V13 explained that she(V13) went to do restorative for R85 up to 3 times in the past 2 weeks. Inquired from V13 about the records of the restorative care she(V13) provided to R85 so far, V13 stated that she did not document it, but she follows the care plan and no records available. R85's Physical Therapy Discharge Summary shows that R85 was discharged from therapy on 2/14/2025(almost 3 weeks ago). Care plan dated 7/16/24 states R85 would benefit from a PROM/AROM (Passive/Active Range of Motion) program due to the risk for developing contractures and would benefit from AROM (Active Range of Motion) program due to Weakness and Impaired Mobility. Facility's policy on Restorative Nursing Program dated 1/4/19 states in part: Each resident involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care. Documentation of the interventions and the resident's response will be completed with each implementation. Care plan dated 7/16/24 states R85 would benefit from a PROM/AROM (Passive/Active Range of Motion) program due to the risk for developing contractures and would benefit from AROM (Active Range of Motion) program due to Weakness and Impaired Mobility. Facility's policy on Restorative Nursing Program dated 1/4/19 states in part: Each resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 12 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0688 Level of Harm - Actual harm Residents Affected - Few involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care. Documentation of the interventions and the resident's response will be completed with each implementation. Based on interviews and record review, the facility failed to provide restorative services for four physically impaired residents: R445, R59, R88 and R85. This failure has affected four of four residents reviewed for restorative services and has resulted in R445 becoming visibly emotional while expressing her fear of deteriorating in bed. Findings include: R445 is a [AGE] year old with diagnosis including but not limited to: multiple sclerosis, secondary malignant neoplasm of brain, neuromuscular dysfunction of bladder and adult failure to thrive. R445's BIMS (Brief Interview of Mental Status) score is 15, which indicates cognitively intact. R59 is [AGE] year old with diagnosis including but not limited to: rheumatoid arthritis, functional quadriplegia, presence of unspecified artificial hip, contracture of muscle to right upper arm and left upper arm, contracture to muscle of right lower leg and left lower leg. R59's Care Plan documents, R59 has no cognitive impairment and/ or impaired thought process and functions at an independent level in decision making. R88 is [AGE] year old with diagnosis including but not limited to: Parkinsonism, depression, long term use of anticoagulants and essential hypertension. During investigation on 3/3/25 at 11:40 AM, R445 said that she sometimes get uncomfortable lying on her tailbone and that she is not repositioned correctly. Surveyor inquired about rehabilitation services such as therapy or restorative services. On 3/3/25 at 11:40 AM, R445 said I have not received any therapy or restorative services since being admitted to this facility about two weeks ago. I am capable of moving a little bit, but I feel like the more I lay here in bed, he more disabled I am becoming. I hate that I have to lay here and wait for help when I need to move. It becomes depressing. At that time, Surveyor noted R445 becoming tearful and emotional. Surveyor inquired about the facility's restorative program. On 3/3/25 at 11:59 AM, V13 (Restorative Director) said that upon admission to the facility, every resident is assessed by restorative and receives restorative services if they do not receive physical therapy, in order to maintain their current level of function and ROM (range of motion). V13 said, After a resident is assessed and it is determined that the resident would benefit from restorative services, the resident is then added to the restorative list (caseload). Their services should start no later than three to four days after their admission to the facility. It should not take two weeks for a resident to begin their restorative programs. Surveyor requested the restorative program schedule. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 13 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0688 On 3/3/25 at 11:59 AM, V13 (Restorative Director) said that there is no restorative schedule that the restorative team follows. Level of Harm - Actual harm Residents Affected - Few On 3/3/25 at 11:59 AM, V13 said that she (V13) was not sure why R445 was not added to the restorative list and that the list is usually updated twice per month. On 3/4/25 at 9:45 AM, V22 (Restorative Nurse) said, We are supposed to see everyone on the restorative list daily for 15 minutes per day. If the restorative techs aren't working the floors as CNAs (Certified Nurse Assistants) due to call offs, they work the restorative program. There is no restorative schedule of days and times that residents receive services. On 3/4/25 at 12:00 PM, V25 said The restorative caseload list includes residents on restorative programs and what programs they are on. A resident can be on Active ROM (A) or Passive ROM (P) exercises that are done with a restorative aide. The restorative list is a way to make sure no resident is overlooked. On 3/5/25 at 10:35 AM, V3 (DON/ Director of Nursing) said that the purpose of the restorative staff is to exercise with patients at risk for contractures and deterioration. The goal is to maintain range of motion (ROM), functioning and to prevent further contraction. On 3/5/25 at 10:43 AM, V28 (Restorative Aide) said that she (V28) is the only restorative aide for the first floor and that when there is downtime from doing resident's weights or working the floor as a CNA, then she (V28) will do restorative exercises with some of the residents on her list. Surveyor inquired about R445 and R88 restorative services. On 03/05/25 at 10:20 AM, V28 (Restorative Aide) said that she (V28) had not worked with R445 as of yet and does restorative exercises with R88 when she (V28) is able to. On 03/05/25 at 10:20 AM, V28 said that there was no restorative schedule that she (V28) is aware of and that she (V28) does whatever she can in the time that she has. On 03/05/25 at 11:25 AM, R59 said that her last time exercising with staff was about one week ago. On 03/05/25 at 11:25 AM, V29 (Restorative Aide) said that she (V29) had not performed PROM (Passive Range of Motion) exercises on R59 in about a week because R59 seemed to be in pain when she exercises. On 03/05/25 at 11:26 AM, R59 that she has pain in her limbs sometimes because she never moves them, but has never said that she didn't want to exercise due to pain. Surveyor inquired about the purpose of bedbound and immobile residents receiving restorative services when there is no therapy in place. On 3/6/25 at 11:05 AM, V45 (MD/Medical Doctor) said that restorative services is important to restore the resident's condition and prevent further contractures. R455's Section GG- Functional Abilities assessment dated [DATE] documents, R445 needs partial assistance from another person to complete upper and lower extremity (arms and legs) range of motion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 14 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0688 Level of Harm - Actual harm R445's Care Plan dated 2/21/25 documents, R445 would benefit from a PROM (Passive Range of Motion) program due to risk for developing contracture related to Multiple Sclerosis and general weakness; R445 will retain current ROM ability to the affected areas; Provide PROM exercises to the affected extremities as indicated. Residents Affected - Few Facility's document titled Restorative Caseload excludes R445 as a resident receiving restorative services. R59's Section GG- Functional Abilities assessment dated [DATE] documents, R59 needs partial assistance from another person to complete upper and lower extremity (arms and legs) range of motion. R59's Care Plan documents, R59 presents with a functional deficit in bed mobility related to contractures and rheumatoid arthritis; R59 would benefit from a PROM program due to contractures; provide PROM exercises to the affected extremities as indicated. Facility's document titled Restorative Caseload includes R59 as a resident to receive passive ROM (range of motion) exercises. R88's Section GG- Functional Abilities assessment dated [DATE] documents, R88 needs partial assistance from another person to complete upper and lower extremity (arms and legs) range of motion. R88's Care Plan documents, R59 presents with a functional deficit in bed mobility related to contractures and rheumatoid arthritis; R88 would benefit from a PROM program due to the risk of developing contractures/ actual contractures provide PROM exercises to the affected extremities as indicated. Facility's document titled Restorative Caseload includes R88 as a resident to receive passive ROM (range of motion) exercises. Facility policy titled Restorative Nursing Program documents, Purpose: to promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 15 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: Residents Affected - Few R544's diagnosis includes, but are not limited to, chronic obstructive pulmonary disease, unspecified, chronic respiratory failure with hypoxia, parkinsonism, unspecified, and essential (primary) hypertension. R544 has a Brief Interview for Mental Status (BIMS) dated 01/20/2025 which documents that R544 has a BIMS score of 15, indicating R544's cognition is intact. R544's Physician Order Summary Report dated 03/04/2025 documents, in part, Oxygen at 4 LPM (liters per minute) per nasal cannula continuously-monitor every shift. On 03/03/2025 at 11:39am observed R544 with oxygen concentrator machine, nasal cannula in nostrils, oxygen tubing was not dated with a date indicating when the tubing was changed. R544 stated staff change my oxygen tubing once a week and I haven't seen the staff place a label on the tubing. On 03/05/2025 at 11:05am V30(LPN/Licensed Practical Nurse) stated the oxygen tubing for those resident's requiring oxygen is changed weekly and as needed. V30 stated the nurse is responsible for changing the oxygen tubing. V30 stated the oxygen tubing and water canister should be dated with the date the change occurred. V30 stated the reason for changing the oxygen tubing and canister and dating the items is so that the resident does not have the canister and tubing for a longer than usual time and to prevent infection from occurring. On 03/05/2025 at 2:00pm V3(DON/Director of Nursing) stated the oxygen tubing is to be changed every Wednesday by the night shift nurse. V3 stated the oxygen tubing is not dated because the tubing does not have a place for the nurses to write the date. V3 stated a date is placed on the water canister when changed. V3 stated the oxygen tubing and water canister are changed to prevent bacteria and mold from growing. The facility's policy dated 12/1/2021 and titled Care and Cleaning of Respiratory Equipment documents in part, underneath Procedure: VII. Labeling A. All disposable respiratory equipment is labeled with date when placed in use. Based on observation, interviews and record review, the facility failed to provide continuous supplementary oxygen to one resident (R19); failed to provide the correct concentration of oxygen for R73; and failed to ensure that oxygen tubing for one resident (R544) was dated. This failure has resulted in R19 having an oxygen saturation of 89% and has the potential to affect 30 Residents using oxygen in the facility. Findings include: R19 is [AGE] year old with diagnosis including but not limited to: Chronic obstructive pulmonary disease, malignant neoplasm of unspecified bronchus or lung, secondary malignant neoplasm of brain and chronic kidney disease. During investigation on 3/3/25 at 11:15 AM, R19 yelled out, I can't breathe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 16 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 At that time, Surveyor entered R19's room and noted a nasal cannula hanging from R19's ear but not placed into his nostril. Level of Harm - Actual harm Residents Affected - Few On 3/3/25 at 11:15 AM, Surveyor went to inform V11 (LPN/ Licensed Practical Nurse) that R19 needed help ASAP (as soon as possible). On 3/3/25 at 11:16 AM V11 (LPN) measured R19's oxygen saturation with an oxygen monitoring device and the device documented 89 % oxygen on room air (without supplementary oxygen). At that time, V11 reapplied R19's nasal cannula to his (R19's) nose and observed his oxygen level increase on the oxygen monitoring device. Surveyor asked how long R19's nasal cannula was misplaced. On 3/3/25 at 11:20 AM V11 (LPN) said that she (V11) was not sure how long R19's oxygen tubing was misplaced Surveyor asked what the purpose of a continuous oxygen order, V11 (LPN) said that continuous oxygen orders are ordered for people who are not able to get enough oxygen alone (without supplementary oxygen). On 3/3/25 at 11:25 AM, R19 said, My oxygen been off of my face for a while now. I tried to call for help cause it was hard for me to breathe. Surveyor inquired about possible adverse reactions to a resident having low oxygen levels below 90%. On 3/6/25 at 11:03 AM, V45 (MD/Medical Doctor) said that a resident with low oxygen and no supplementary oxygen could continue to desaturate (oxygen levels decline) and can possibly result in respiratory failure. R19's Order listing report documents the following active oxygen order: Oxygen at 3 LPM (Liters per minute) per nasal cannula/ mask continuously, monitor every shift. R19's Care Plan report documents, R19 has altered respiratory status/ difficulty breathing related to COPD (Chronic obstructive pulmonary disease); monitor for signs and symptoms of respiratory distress. Facility Oxygen list documents thirty residents with active oxygen orders in the facility. Facility policy titled Oxygen Delivery System documents, it is the policy of this facility that oxygen will be delivered to the resident based upon physician's orders. Facility policy titled Oxygen Therapy documents, to deliver oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. Indications for oxygen use via nasal cannula include: reverse the effects and symptoms of hypoxia; it is the policy of this facility that oxygen shall be used in a safe and effective manner in accordance with applicable rules and regulations and the standard of care; keep resident as comfortable as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 17 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 Findings include: Level of Harm - Actual harm R73's Face Sheet dated March 4, 2025 documents a diagnosis of including but not limited to Chronic Obstructive Pulmonary Disease, Long Term Use of Inhaled Steroids, Anemia, Unspecified Severe Protein-Calorie malnutrition, Bilateral Primary Osteoarthritis of Knee, Chronic Respiratory Failure with Hypoxia, Personal History of COVID-19, Repeated Falls. Residents Affected - Few R73's Physician Order Sheet documents an order for Oxygen at 2 Liters per minute dated 7/20/2023. On 03/03/25 at 11:24 AM, R73 had 2 oxygen concentrator machines one on both sides R73's of bed. One of the Oxygen concentrators had a mask attached without a date. R73's oxygen concentrator was set to deliver 4 Liters per minute. R73 had an oxygen tank sitting on the floor at the head of his bed without a holder. On 03/04/25 at 01:34pm, V2, Director of Nursing (DON) stated that the resident's oxygen concentrator is set between 3 and 4 liters. V2, DON stated that he is not sure what R 73's oxygen concentrator should be set on 2, 3, or 4 liters. V2, DON asked R73 if he adjusts his oxygen and R73 stated NO. Facility's Policy document named Oxygen Delivery System documents It is the policy of the facility that oxygen will be delivered to the resident based upon physician's orders. Facility's Policy document named Oxygen Therapy documents the following: PURPOSE: To deliver oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. Indications for oxygen use via nasal cannula include: -Reverse the effects and symptoms of hypoxia. Policy: It is the policy of this facility that oxygen shall be used in a safe and effective manner in accordance with applicable rules and regulation and the standard of care. Procedure: Keep resident as comfortable as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 18 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0758 Level of Harm - Actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview and record review, the failed to ensure residents are free from unnecessary psychotropic medication use; failed to ensure that gradual dose reductions were completed. This failure caused harm to R58, causing R58 to exhibit symptoms of sedation. On 3/3/2025 at 10:37 AM, R58 was observed in semi-Fowlers position resting in bed. Resident was difficult to arouse by voice and appeared lethargic. When being interviewed, R58's voice was unclear when speaking and was falling asleep mid conversation. Record review of R58's minimum data set (dated 12/19/2024) documents in part that R58 has clear speech, is able to make self understood, able to express ideas and wants; has a brief interview of mental status summary score of 10, indicating R58 has cognitive impairment; has no hallucinations, delusions, physical/verbal or other behaviors towards others, has not rejected care; does not have any serious mental illness (SMI). Record review of R58's admission record documents in part a diagnosis of unspecified dementia without behavioral disturbance. Record review of R58's care plan identifies that R58 displays socially inappropriate behaviors, attention seeking behaviors and maladaptive behaviors related to R58's diagnosis of dementia with symptom manifestation including agitation, combative behaviors, verbally aggressive behaviors, crawling on the floor, and falsely accusing others of wrong doing; identifies R58 utilizes psychotropic medications with a goal of .free of drug related complications including .cognitive/behavioral impairment with interventions including, monitoring for fatigue, pacing/wandering, disrobing, inappropriate response to verbal communication, aggression towards others, Et Cetera and document per facility protocol. The plan of care does not identify other non-pharmacological interventions that were ineffective prior to administration of the psychotropic medications. Non-pharmacological interventions initiated prior to psychotropic medication use were requested on 3/5/2025 from V3 (Director of Nursing) and not received by the end of the survey. No symptoms of psychosis or other serious mental illness were noted within the care plan. Record review of R58's physician orders documents in part that R58 has an active order (dated 9/17/2023) for QUEtiapine Fumarate (Seroquel) (Antipsychotic Medication) 25 mg tablet, give 0.5 tablet (total dose=12.5 mg) by mouth at bedtime for dementia with behavioral disturbance. Additionally, R58 has an active order for Sertraline 25 (Antidepressant Medication) mg tablet, give 1 tablet by mouth one time per day for hypersexuality. Record review of Black Box Warning attached to R58's physician order documents in part, .Warning: Increased mortality in elderly patients with dementia-related psychosis (,) Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis . Record review of R58's behavioral charting documents does not document any abnormal or targeted behaviors (as identified within the plan of care or related to psychiatric diagnosis) from 10/2025-3/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 19 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0758 Level of Harm - Actual harm Residents Affected - Few On 3/4/2025 at 1:42 PM, V20 affirmed that V20 oversees the psychotropic medication use within the facility. V20 reviewed R58's physician orders and diagnosis and affirmed that R58 is receiving QUEtiapine for dementia and Sertraline for hypersexuality. V20 denied ever witnessing any psychotic behavior by R58 or any behaviors. V20 reviewed the black box warning attached to R58's order and affirmed that R58 is at increased risk of death. V20 was unaware why the medications what target behaviors were being addressed by the medication. V20 affirmed that R58 has clear speech and is usually pretty alert. V20 affirmed that antipsychotic medication use can cause sedation. On 3/5/2025 at 10:50 AM, V34 (Nurse Practitioner) affirmed that V34 is the psychiatric provider for R58 and is the prescriber for the R58's psychotropic medications. V34 explained that R58 is taking QUEtiapine for dementia with behaviors and Sertraline for hypersexuality. V34 stated that QUEtiapine is the standard of care for dementia with behavioral disturbances. V34 described R58's behaviors related to dementia as aggressive and resistive to staff. They (the facility) have to give the medication so R58 allows them to care for (R58) so she doesn't refuse. (R58) is also very sexual in the past and has a history of sticking objects in her privates. Surveyor read the black box warning to V34 and V34 affirmed that it can place residents at risk for cardiac events. Surveyor asked what V34's rationale is for treating R58 with QUEtiapine when it is not approved for dementia, and V34 responded, We don't really have much to treat dementia. There is one medication Rexulti that has been approved for dementia related aggression. V34 stated that V34 did not prescribe Rexulti (approved medication) because it's too new. V34 affirmed that R58 does not have any hallucinations, delusions or other signs of psychosis and is R58 is utilizing these medications to treat aggressive and hypersexual behaviors. V34 was unaware of the last time R58 had any behaviors. V34 stated that the psychotropic medication can have sedative effects and that is why it is typically given at night. On 3/5/2025 at 11:43 AM, R58 was observed resting in bed with respirations even and unlabored in bed. Surveyor attempted to arouse resident via voice and was unsuccessful. R49 (R58's Roommate) observed surveyor trying to wake R58 and R49 stated, Good luck! (R58) is always like that, knocked out. They (the staff) always have a hard time waking her up. R58's Minimum Data Set (dated 12/23/2024) documents in part that R58 has a Brief Interview of Mental Status Score (BIMS) of 15, indicating that R58 is cognitively intact. On 3/5/2025 at 12:27 PM, V31 (Pharmacy Consultant) affirmed that V31 is a pharmacist and is the consultant pharmacist for the facility. V31 explained that dementia with behaviors is absolutely not an appropriate diagnosis that warrants Seroquel (QUEtiapine) use. Using Seroquel (QUEtiapine) for aggression caused by dementia or hypersexual behavior is not appropriate. V31 stated that V31 recommended the QUEtiapine and Sertraline to be discontinued 9/17/2024 but was denied by the provider. V31 affirmed that R58 is due for GDR requests this month. V31 stated QUEtiapine is known for being very sedative and can have other side effects like abnormal involuntary movements. Facility policy titled, Psychotropic Medication- Gradual Dose Reduction (dated 2/1/18) documents in part, .Purpose: To ensure that residents are not given psychotropic drugs unless drug therapy is necessary to treat a specific or suspected condition as per current standards of practice and are prescribed at the lowest therapeutic dose to treat such conditions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 20 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 - Few 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 store a bottle of lorazepam in accordance to manufacturer's instructions. This failure affects 1 resident (R32) in a sample of 65. Findings include: Record review of R32's physician orders documents in an order for Lorazepam 2mg/mL concentrate that was discontinued on 12/20/2024. On 3/4/2025 at 12:18 PM, observed V42 (Licensed Practical Nurse) withdraw R32's bottle of lorazepam from the team 1 medication cart narcotics drawer. On the bottle of the lorazepam, a sticker was observed indicating that the medication should be stored in the refrigerator. V42 observed the sticker and affirmed that the bottle of lorazepam should have been stored in the fridge. Record review of manufacturers' instructions for Lorazepam Oral Concentrate documents in part, .PROTECT FROM LIGHT STORE AT 2 (degrees) to 8 (degrees) C (Celsius) (36 (degrees) to 46 (degrees) F (Fahrenheit)) . Record review of facility policy titled, STORAGE OF MEDICATIONS (dated 5/1/2018) documents in part, Policy Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier . C. Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 (degrees Celsius) (36 degrees Fahrenheit) and 8 (degrees Celsius) (46 degrees Fahrenheit) . Controlled substances that require refrigeration are stored within a lock box within the refrigerator or locked refrigerator at or near the nurses' station or in a refrigerator within a locked medication room per IL Administrative Code Section 300.1640 d) Labeling and Storage of Medication . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 21 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 foods in the refrigerator and freezer were labeled with a date indicating when the item was placed into the refrigerator/freezer and labeled with a use by date. These failures have the potential to affect all 194 residents in the facility who are receiving an oral diet. The findings include: On 03/03/2025 at 9:35am Walk-in Freezer #1 observation accompanied by V4(Director of Food Service). Observed four boxes of wild berry magic cup desserts which contained 48(4 fluid oz) cups in each box, the four boxes were not dated with a date the item was stored in the freezer, nor dated with a use by date. On 03/03/2025 at 9:45am Walk-in refrigerator observation accompanied by V4. Observed a package of yellow pasteurized process American cheese slices, not dated with a date the cheese was placed into the refrigerator, nor dated with a use by date. On 03/05/2025 at 11:45am V4 (Director of Food Service) stated all kitchen staff are responsible for labeling food items placed into the freezers and refrigerators with a date indicating when it was placed into the freezer or refrigerator and a use by date. V4 stated that it is my expectation that all kitchen staff are following these food labeling practices. V4 stated the purpose of labeling the food containers in the freezers and the refrigerators is so staff can monitor what and when food are put into these areas and know when those food items should be removed from the areas. V4 stated if a food item is not labeled with a date or checked for a use by date the resident can get sick. Reviewed the facility's policy labeled Food Storage (Dry, Refrigerated, and Frozen), which lacks the facility's letterhead and documents in part, a. All food items will be labeled. The label must include the name of the food and the date by which it sold be sold, consumed, or discarded. Reviewed the facility's undated Food Service Director Job Description which documents in part, The primary purpose of the Food Service Director is to plan, organize, develop and direct the overall operation of the Food Service Department in accordance with current, federal, state, and local standards, guidelines, and regulations, and regulations governing our facility. Essential duties and responsibilities: supervise the receiving and storage of food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 22 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the personal refrigerator temperatures were monitored daily, failed to ensure expired food items were discarded, and failed to ensure personal refrigerator has temperature log form in an effort to prevent foodborne illnesses. These failures affected 5 (R7, R71, R77, R124, and R145) residents reviewed for personal refrigerator in a total sample of 65 residents. Residents Affected - Some Findings include: On 03/03/2025 at 12:09pm with V10 (Licensed Practice Nurse-LPN) inside R7's room. There was a personal refrigerator by R7's bedside. V10 was requested to check for the temperature log. V10 looked on the sides of R7's refrigerator and stated there is no temp log. There should be a log and we should be checking the refrigerator temperature every night. On 03/03/2025 at 11:50 AM with V7 (Certified Nursing Assistant). R71's personal refrigerator Fridge/Freezer log was from 12/2024. This surveyor requested V7 to check the food items inside R71's personal refrigerator. V7 opened the refrigerator and stated there are expired food items inside. She (R71) got Trix Banana Strawberry Bash with use by date: 12[DATE] and fruit cup use by date: 10/19/2024. On 03/03/2025 at 11:19 AM, there was a personal refrigerator inside R77's room. The last entry on the 12/2024 Fridge/Freezer log was on 12/18/2024. Inside the refrigerator were cartons of whole milk with best by dates 2/19/25 and 2/26/25. V8 (ADON) stated those are expired milk and the temperature log was from 12/2024. The housekeeping and maintenance departments are in charge of cleaning the refrigerator and monitoring the refrigerator temperature daily. The log is from December of 2024 meaning the temperature is not being checked. I do know that the administrator instructed the maintenance and housekeeping to monitor and log the temperature. If he (R77) ingested the milk he might get bacteria and the symptoms could be diarrhea and other foodborne illness. He could have GI (gastrointestinal) issue. The purpose of monitoring the temperature is if the temperature is too high, food items in the refrigerator can get bad and should be discarded. On 03/03/2025 at 12:19 PM, R124's personal refrigerator Fridge/Freezer log was from 12/2024. On 03/03/2025 at 12:23 PM, this observation was pointed out to V10. V10 checked the refrigerator and stated there are food inside the ref and the last entry on the Fridge/Freezer log was on 12/20/2024. On 03/03/2025 at 11:41 AM, inside R145's room with V8. R145's Fridge/Freezer log was from 12/2024. Inside the refrigerator, the thermometer registered at 60F. V8 stated the same problem. The date on the temp log is from December 2024. The temperature is registering at 60F, and it should be within 38F to 41F. It is out of range. If the temperature is higher than the range, the food will likely become spoiled. On 03/04/2025 at 12:47pm, (Infection Preventionist/LPN) stated the temperature of personal refrigerator in the resident's room should be checked daily and there should be a temperature log by the refrigerator. The department in charge of checking the temperature of the personal refrigerator is the Maintenance department. The purpose of checking the temperature of the personal refrigerator is to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 23 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ensure the refrigerated food is at a correct temperature, to ensure it is safe for consumption. The importance of the log is to track the temperature. The temperature of the refrigerator should be at 38F - 40F to keep food safe for consumption. R7's (01/31/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R7's mental status as cognitively intact. R71's (01/02/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R71's mental status as cognitively intact. R71's (12/2024) Fridge/Freezer Log last entry was on 12/18/24. R77's (02/26/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R77's mental status as cognitively intact. R77's (12/2024) Fridge/Freezer log last entry was on 12/22/24; with missing temperatures on 12/19/24, 12/20/24, and 12/21/24. R124's (02/04/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R124's mental status as cognitively intact. R124's (12/2024) Fridge/Freezer log last entry was on 12/20/24. R145's (12/26/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R145's mental status as cognitively intact. R145 [NAME] Burns (09/25/2024) Smoking Safety risk Observation documented, in part may independently be able to handle smoking materials. R145's (12/2024) Fridge/Freezer log last entry was on 12/19/24; with missing entry on 12/20/24 and 12/21/24. The 12/22/24 temp was entered as 50(F). The (undated) Refrigerators in Resident Rooms documented, in part Guideline: In keeping with the home-like environment for residents, some residents will request to have a refrigerator in the room. Resident and/or responsible party will agree to allow periodic safety checks by staff and allow staff to discard outdated food per safety guidelines. Procedure: 2. Each refrigerator shall have a temperature log with daily entry. The refrigerator temperature will be maintained at or below 41F. If the temperature is not maintained at 41F or below, the food will be discarded. 3. Housekeeper will enter the temperature once daily. Any temperatures not in range will be immediately reported to the Housekeeping Supervisor or Nursing Supervisor and Maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 24 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 outside trash dumpsters were not missing lids to cover the tops of the trash dumpsters. This failure has the potential to affect all 199 residents residing at the facility. Residents Affected - Many Findings include: The (3/03/2025) facility census was 199 residents. On 03/04/2025 at 10:04am V38 (Dietary Aide) escorted surveyor to the outside dumpsters located behind the facility. The facility has 2 green colored outside trash dumpsters. Each dumpster has a black plastic lid divided into three parts covering the top of the trash dumpster. Observed the first part of the black plastic lid missing on both trash dumpsters. On 3/4/2025 at 10:08am V38(Dietary Aide) stated the trash disposal company comes to empty the outside dumpsters two to three times a week. V38 stated the lids are required so that the trash will not fly out of the trash dumpsters and to prevent animals from getting into the trash dumpsters. V38 stated I do not know who is responsible for maintaining the outside trash dumpsters. On 03/04/2025 at 10:10am V4(Director of Food Service) stated the housekeeping department is responsible for maintaining the outside trash dumpsters. On 03/05/2025 at 11:53am V18(Director of Environmental Services) stated yes, my department is responsible for the outside trash dumpsters. V18 stated I see that the outside trash dumpsters have lids missing. V18 stated I let the disposal service know about the missing lids, but this was a while ago. V18 stated with missing lids on the trash dumpsters, the trash can blow onto the ground and liter the ground and pests can have access to the trash dumpsters. Review of the facility's undated policy titled Garbage and Rubbish Disposal documents in part, 8. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 25 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a clean linen cart was not stored inside the restroom of a resident on Enhanced Barrier Precautions (EBP) and failed to ensure the plastic bag used for containment of soiled linen were securely tied prior to conveyance via a chute. These failures affected 2 (R7 and R89) reviewed for infection control and have the potential to affect all the residents residing at the facility. Residents Affected - Many Findings include: #1 The (undated) Enhanced Barrier Precaution List include R89. On 03/04/2025 at 1:06pm, V26 (Infection Preventionist/LPN) stated residents on EBP are residents with indwelling cath, wound, trache, on dialysis, with colonized MDRO (multidrug-resistant organisms) and XDRO (extensively drug-resistant organisms). On 03/03/2025 at 11:25 AM, V8 (Assistant Director of Nursing) stated the orange sticker by the resident name identifier on the doorframe means the resident is on EBP (Enhanced Barrier Precautions). On 03/03/2025 at 12:03 PM, there was an EBP sign posted by R7 and R89's door and PPE bin by the door. R89's name identifier has an orange sticker next to it. R7's name with red star. [NAME] orange sticker. On 03/03/2025 at 12:06 PM, there was an uncovered clean linen cart inside R7's and R89's restroom with washclothes, fitted sheets, and adult diapers. On 03/03/2025 at 12:09pm, this observation was pointed out to V10 (Licensed Practice Nurse). V10 stated there is an uncovered clean cart inside the bathroom. The clean cart should not be inside the restroom of the resident because the cart and the linens become dirty at that point. On 03/03/2025 at 12:16 PM, V9 (Certified Nursing Assistant) stated I did not put the clean cart inside the restroom. Our policy is there should be no clean linen cart inside the residents' room or in the restroom for the safety of the residents and to prevent contamination. Putting the clean linen cart in the restroom contaminates the linens. I have my own cart out in the hallway. V9 and this surveyor went out of R7 and R89's room and showed this surveyor her cart. On top of the cart was a paper with V9 names. On 03/04/2025 at 12:54pm, V26 (Infection Preventionist/LPN) stated clean linen carts should be in the hallways, covered to prevent cross contamination. Once it enters the room of the resident, it is contaminated. Once a CNA goes to the contaminated cart and distributes the linens from that cart, other residents will be potentially affected, too. R7's (01/31/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R7's mental status as cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 26 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 - Many R89's admission Record documented that R89's diagnoses (include but not limited to) end stage renal disease and dependence on renal dialysis. Order summary: enhanced barrier precautions every shift for dialysis access. Order date: 07/09/24. R89's (01/03/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. indicating R89's mental status as moderately impaired. Section O. Special Treatment, Procedures, And Programs. J1. Dialysis. B. while a resident. R89's (01/16/2025) care plan documented, in part Enhanced Barrier Precaution: Resident requires EBP r/t (related to) dialysis access. Place soiled linens in bags. Bag linens and close bag tightly before taking to laundry. #2 On 03/04/2024 at 10:24am, while this surveyor was interviewing V18 (EVS Director) at the Laundry Department's soiled linen/chute area, a bag of soiled linen came down from the chute to the hamper that was used to catch bag of soiled linens from the chute. As the plastic bag landed on the hamper, a collection of soiled linen came out of the bag and landed on the floor. This was pointed out to V18 (EVS -environmental services Director) stated the plastic bag busted open when it went down the chute. This surveyor and V18 checked the plastic bags in the hamper and observed 2 plastic bags, with soiled linens, not tied. These were pointed out to V18. V18 stated I don't know why the bags are not tied. The bags sometimes come down like that. On 03/05/2025 at 1:30pm, inside the soiled linen/chute room of the laundry department, there was a towel in the hamper that was not contained, and a plastic bag of soiled linen not tied. V41 (Laundry Aide) stated the soiled linen bag came from the chute that way and the towel is not contained in a plastic bag when it dropped in the hamper. On 03/05/2025 at 1:36pm, this observation was pointed out to V3 (Director of Nursing) stated the towel probably came out of the bag during transport through the chute and the tie on the plastic bag came undone. This surveyor inquired if the plastic bag was securely tied, can the towel come out of the plastic bag and the tie come undone. V3 stated I (V3) see what you are saying. I need to reeducate my staff about tying the plastic bag securely. On 03/04/2025 at 12:55pm, V26 stated once the care is done, the soiled linens should be placed inside of a plastic bag, tied, and dropped in the chute. The importance of putting it in a bag is to prevent carrying the soiled linens loosely and contaminate the providers clothes and other object that touched the linen. The staff are expected to tie the plastic bag because as it travels down the chute everything that is in the plastic bag should still be contained, and not burst open when it landed in the laundry area. The air in the laundry area could be contaminated. It has the potential to affect all the residents because we provide Iinens to all the residents. On 03/5/2025 at 11:50am, V3 (Director of Nursing) stated the soiled linen should be in a plastic bag, securely tied to prevent the spread of infection. The plastic bag should be tied so it can be transported via the chute securely. To prevent the spread of infection. So, the soiled linen is still contained when the staff dropped them in the chute. The (03/06/2025) email correspondence with V3 documented, in part Kindly state your staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 27 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 expectation before dropping soiled linen via chute. (V3 responded) Staffs expectations was (sic) to have the bag tied before dropping it off in the chute. My observation yesterday was the bag was tied, but probably did pop open during travel time from the floors to the laundry room. This is also not infection control problem or should be. We can in-service staffs and teach them on to use zip lock ties if needs be, but my observations were, it was tied and probably got loosed during travel time from the floor to the laundry. Residents Affected - Many The (03/06/2025) email correspondence with V3 documented, in part Kindly state your staff expectation before dropping soiled linen via chute. (V3 responded) In addition, laundry staffs are not waiting by the chute with their face or mouth open to the collection bin in the hope dirty linen would be coming down. Also, bags can break with impact or there may be spike in the chute that may be damaging the bags. I will recommend for cooperate (corporate) to change our vendors in the hope for more durable bags. The durability of the bag should be also questioned. The (11/28/12) Linen Handling Principles - Nursing documented, in part Purpose: To ensure proper handling of soiled and clean linen and personal laundry to prevent the spread of microorganism. Guidelines: 1. Clean linen shall be stored is such a manner to prevent contamination. Linen shall be maintained in the linen room or in enclosed or covered carts. 5. Soiled linen containers shall be constructed of impervious material, or the container shall be lined with a plastic bag of sufficient strength to prevent tears and splits. 6. Soiled linens shall not be placed directly on the floor. 7. Heavily soiled articles will be placed in a plastic bag, securely tied, in the resident room, the bag shall be taken to the soiled utility room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 28 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that residents' call lights are functional and in good working order. This failure has the potential to affect 4 residents, R32, R97, R645, and R646, reviewed for functioning call lights, in a total sample of 65 residents. Residents Affected - Some Findings include: On 3/03/25 11:50 AM, R32 was observed in bed and stated that no staff responded to his call light for the past few days, and he sometimes had to yell out if he sees someone in the hallway. The surveyor asked R32 to push the call button and the call light was not functional. V19(CNA/Certified Nurse Assistant) tried the call light, and the light still did not come on. V19 stated that she (V19) would notify Maintenance. On 3/03/25 11:58 AM, R645's and R646's bathroom call light was observed to be non-functional. V19(CNA) went into the bathroom and pulled the light and stated that it was not working. V11(LPN/Licensed Practical Nurse) was notified. The surveyor asked V11 about Maintenance logbook at the nursing station; V11 stated that they do not use a logbook and that she would call V15(Maintenance Director). On 3/03/25 12:20 PM, the call light situations were still the same. V15(Maintenance Director) was interviewed and stated that the staff are supposed to call Maintenance directly using a mobile communication system, and that he(V15) was not aware of the call light issues. Care Plans for all 3 residents state that all 3 residents should be encouraged to use call lights for assistance as dated below: R32 - 4/24/24 R645 - 3/5/25 R646 - 3/3/25. Facility's policy on call lights dated 11/28/2012 with latest revision date 2/2/2018 states in part: To respond to residents' requests and needs in a timely and courteous manner. Residents' call lights will be answered in a timely manner. #1: All Residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the residents at the bedside or other reasonable accessible location. #3: Bathroom call lights should be viewed as emergencies and immediate attention will be given. #5: Hand bells will be provided for alert dependent residents when positioned out of reach of permanent call light when needed. #6: Call bell system defects will be reported promptly to the maintenance department for servicing. Check room frequently until system is repaired. On 3/3/25 at 12: 20pm R97 stated he must yell out loudly towards the hallway if he needs staff assistance. R97 stated it's quicker than trying to ring the call light. R97 stated he must pull call light out of wall to have staff come and assist him, and when he pushes the call light button it doesn't work. R97 stated he must wrap the cord around his hand and pull it out the wall to have the call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 29 of 30 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some light turn on and ring. R97 stated he is visually impaired in left eye and sometimes unable to see where call light is located. Call light was observed on the floor, and was not in operative functioning status when button was pushed, light did not turn on. R97 was observed wrapping call light around his hand and pulling cord from wall and then call light turned on, that is when staff came to room. 3/3/25 at 12:29pm V 21 Licensed Practical Nurse (LPN) came to room of R97 to check the call light, V21 pushed the call light and stated the call light isn't ringing. V21 stated that R97 should not have to pull the call light out of the wall for the call light to ring, pulling the call light out of the wall could result in injury of a resident. V21 stated she would page maintenance to come and check the call light. 03/05/25 01:59 PM V15 Maintenance director, V15 stated that he could not recall if he was informed the call light for R97 was not functioning. V15 stated that he would have to check the maintenance log, maintenance log is where staff writes facility issues down that need to be repaired. V15 stated if the call light isn't working, he then checks to see what the issue is and then determines what needs to be fixed. V15 stated he would check the maintenance log and get back to the surveyor with an answer. On 3/5/25 at 2:19pm, V15 returned and stated on Monday 3/3/25 the call light concern was placed in the maintenance log. V15 stated someone was called out to repair the call light on 3/5/25 and stated call light system needs to be repaired because it is an old system. V15 stated he tested the call light with a new one call light device and discovered the system is faulty and malfunctioning. V15 stated we will work on it to get the call lights repaired. The Facility policy dated 2/2/2018 Titled Call Light documents in part : Purpose: To respond to residents' requests and needs in a timely and courteous manner. 1. All residents have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location . 6. Call bell system defects will be reported promptly to the Maintenance department for servicing. Check room frequently until system is repaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 30 of 30