Inspection·August 11, 2023

F 0550 At about 12:20 PM, most of the residents that eat independently completed their meals. Level of Harm - Minimal harm or potential for actual harm At 12:22 PM, R42 stated I want some food. V25 stated almost. V26 (Certified Nurse Aide) came over and told R42 [V26] will come over soon to feed R42. Residents Affected - Some At 12:27 PM, R42 stated you ready for me yet? V26 stated yeah, I'm going to get ready to feed you soon. At 12:28 PM, R42 stated loudly help! V26 stated [R42] I'm here. I promise. I'm going to get you food. At 12:31 PM, R42 stated Help, I'm waiting for some food here. V25 stated it's coming. At 12:32 PM, V26 placed R42's food on table next to R42. V26 started feeding R42 at 12:33 PM. 3) R78's comprehensive care plan contains a focus last revised on 4/14/2022 that documents in part R78 has an ADL (Activities of Daily Living) self-care performance deficit due to impaired mobility and strength. Intervention last revised on 8/07/2023 documents in part that R78 requires one-to-one assistance with eating. R78's physician orders documents in part an active order for one-to-one feeding assistance with meals. On 8/08/2023 at approximately 11:50 AM, V25 and staff started lunch services on the fourth-floor dining room. At about 12:20 PM, most of the residents that eat independently had completed their meals. V26 did not feed R78 until 12:45 PM. 4) R8's comprehensive care plan contains a focus initiated on 3/11/2022 that documents in part R8 has an ADL (Activities of Daily Living) self-care performance deficit. Intervention, last revised on 01/27/2021, documents in part that R8 requires one staff assistance with eating for one-to-one feeding assistance during meals. R8's POS documents in part an active order for one-to-one feeding assistance with meals. On 8/08/2023 at approximately 11:50 AM, V25 and staff started lunch services on the fourth-floor dining room. At about 12:20 PM, most of the residents that eat independently had completed their meals. At about 12:55 PM, V25 plated R8's meal (the last one plated) and cleaned up the steam table. At 12:58 PM, V26 started feeding R8. R8 was the last one eating in the dining room. Facility's Residents' Rights for People in Long-term Care Facilities pamphlet by State of Illinois Department on Aging documents in part Your facility must provide services to keep you physical and mental health, and sense of satisfaction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 2 of 11 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 145974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwood Crossing 6016 North Nina Avenue Chicago, IL 60631 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Facility's Mission statement documents in part: [Facility Name] enhances the independence and well-being of older adults. By; Maintaining a comfortable, secure, home-like, 'loving family' environment that promotes dignity and self-worth. Based on observation, interview and record review the facility failed to ensure dependent residents requiring 1:1 feeding were treated with respect and dignity by not being fed simultaneously with the other residents. These failures affected 4 residents (R8, R42, R78, R96) reviewed during dining observations in a total sample of 23 residents. Findings include: 1) R96 has diagnosis not limited to Subluxation of C1/C2 Cervical Vertebrae, Acute Kidney Failure, Generalized Anxiety Disorder, Dementia with Agitation, Psychotic Disorder with Delusions, Major Depressive Disorder, Insomnia, Vitamin D Deficiency, Dysphagia, Cognitive Communication Deficit, Need for Assistance with Personal Care and Psychosis. R96's Order Summary Report dated 08/09/23 documents in part: Regular diet, Pureed texture, Regular/thin consistency, 1:1 Feeding Assistance with meals. R96's Care Plan document in part: R96 is at nutritional risk. Intervention Provide diet as prescribed: Regular, puree texture, thin liquids, 1:1 feeding assistance for meals. R96 has an ADL (Activities of Daily Living) self-care performance deficit with intervention for eating stating R96 requires 1:1 staff assistance with eating. R96's MDS (Minimum Data Set) dated 08/03/23 indicates severely impaired cognition and total dependence required for eating. On 08/10/23 at 11:10 AM, V3 (Director of Nursing) stated a resident who requires 1:1 feeding assistance must be fed by a CNA (Certified Nursing Assistant) or a nurse. V3 stated the food should be fed to the residents when the food is served and when the resident is ready to be fed, not when it is convenient for staffing. V3 stated it is unacceptable for R96 to have to wait 1 1/2 hours before being fed. V3 stated it is a dignity concern to have R96 sit there and stare at other people eating and for R96 not to be fed. Facility provided document titled, Mission Statement undated, which documents in part (the facility) enhances the independence and well-being of older adults by maintaining a comfortable, secure, home-like, loving family environment that promotes dignity and self-worth. Facility provided document titled, ADL dated 09/09/17 which documents in part dependence on others for ADLs (Activities of Daily Living) assistance can lead to feelings of helplessness, isolation, diminished self-worth, and loss of control over one's [NAME]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 3 of 11 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 145974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwood Crossing 6016 North Nina Avenue Chicago, IL 60631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure the call light was within reach for 1 (R65) of 23 residents reviewed for call lights on the total sample of 23. Residents Affected - Few Findings Include: R65 has diagnosis not limited to Metabolic Encephalopathy, Type 2 Diabetes Mellitus with Unspecified Complications, Acute Kidney Failure, Dementia, Muscle Weakness, Difficulty in Walking and Need for Assistance with Personal Care. Care Plan document in part: R65 is at risk for falls d/t (Due/to) impaired mobility, Gait/balance problems, Dementia, and incontinence. Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 08/08/23 at 11:20 AM R65 was lying in bed on a low air loss mattress. R65 call light was wrapped around and hanging from the left upper side rail touching the floor. When R65 was asked the location of her call light? R65 responded, I don't know where the call light is. On 08/08/23 at 11:22 AM V9 (Registered Nurse) entered R65's room. When asked the location of R65's call light, V9 approach R65 bed pointing to the floor. V9 stated (R65) rarely calls, and I don't know if (R65) would be able to reach the call light. The purpose of the call light is so the resident can call if they need something. The call light should be located within reach of the resident. On 08/08/23 at 11:43 AM V8 (Certified Nurse Assistant) stated I will take the blame for (R65) call light being out of reach. I changed the sheet on the bed because it had a hole in it, and I forgot to put the call light back in place. On 08/09/23 01:29 PM V3 (Director of Nursing) stated the call light needs to be answered promptly. The call light should be within the reach of the resident so they can put it on the moment that they need it, and so that the staff can meet the resident's needs. Facility Policy documents: Titled Call Light Education dated 07/21 document in part: The purpose of this procedure is to ensure timely responses to the resident's request and needs. General Guidelines: Educate resident on locations of call light. Staff are to ensure that the call light is plugged in and functioning at all times. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 4 of 11 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 145974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwood Crossing 6016 North Nina Avenue Chicago, IL 60631 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 Based on observation, interview, and record review, the facility failed to ensure an air mattress used for pressure reduction was on and operating while the resident was in bed, for one (R23) of four residents reviewed for wound prevention in a sample of 23. Residents Affected - Few Findings Include: R23 has diagnosis not limited to Fracture of Superior Rim of Right Pubis, Chronic Obstructive pulmonary Disease, Major Depressive Disorder and Dementia. Care Plan document in part R23 is at risk for pressure ulcer/skin breakdown d/t (Due/to) impaired mobility, right pelvic fracture, and incontinence. Intervention: Air mattress in place. Order Summary report dated 08/09/23 document in part: Air mattress. On 08/08/23 at 10:33 AM R23 was lying in bed asleep on a low air loss mattress the was not on and operating. R23 was sunken in the middle of the air mattress. On 08/08/23 at 10:38 AM V7 (Registered Nurse) entered R23's room. V7 was asked if R23's low air loss mattress was on and operating. V7 responded it was on when I came in here earlier. It may have gotten loose a little bit ago. V7 tuned on the low air loss mattress pump, bent over, and touched the edge of the mattress then said, the mattress is still firm, someone may have bumped it. On 08/09/23 at 01:29 PM V3 (Director of Nursing) stated my expectations are that the staff are supposed to check the low air loss mattress machine and make sure it is in good working condition. The low air loss mattress should be turned on, so it does what it supposed to do, relieve pressure, and prevent pressure ulcers. Facility Policy documents: Titled Low Air-Loss Mattress undated document in part: Purpose: To maintain skin integrity and to promote healing of existing pressure ulcers. The Air Loss Mattress: These mattresses are a great solution for patients that are bound to their beds or simply spend a lot of time in them. They will fend off skin sores and any other conditions that appear as a result of prolonged stay in one's bed. Low air loss mattresses are use for patients who may be in bed for long periods of time. A patient using a low air loss mattress will help prevent bed sores. Air loss mattresses take the pressure off of a patient's body. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 5 of 11 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 145974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwood Crossing 6016 North Nina Avenue Chicago, IL 60631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow their policy by not administering oxygen per physician's orders and not storing oxygen tubing in a protective plastic bag when not in use for 2 (R5, R98) residents reviewed for respiratory care out on a total sample of 23 residents. Residents Affected - Few Findings include: 1) R5's face sheet documents in part medical diagnoses of COPD (Chronic Obstructive Pulmonary Disease) and emphysema. R5's comprehensive care plan contains a focus for R5's diagnoses of COPD and emphysema. Intervention created 1/13/2023 documents in part to give oxygen therapy as ordered by the physician. R5's physicians' order sheets contain an active order dated 5/05/2023 that documents in part oxygen 2L (liters) continuously via nasal cannula every shift for shortness of breath. On 8/08/2023 at 10:43 AM, R5 was lying in bed and breathing with mouth open. Nasal cannula was on R5's face. The end of the tubing was on the floor at the head of the bed. Oxygen concentrator was turned to 4L and humidification bottle was bubbling; however, R5's nasal cannula was not connected to the humidification bottle or oxygen concentrator. Conducted follow-up observations at 11:09 AM, 11:40 AM, and 11:51 AM. R5's nasal cannula remained unplugged from the oxygen concentrator. During observations, R5 remained in bed, asleep, and with mouth open. At 12:06 PM, V6 (Nurse) was at R5's bedside. R5's nasal cannula remained unplugged from the oxygen concentrator. V6 stated [V6] was going to administer a nebulizer treatment for R5. V6 was concerned because R5's oxygen saturation was low at 89% (below normal) about 15 minutes ago. At 12:11 PM, V6 rechecked R5's oxygen saturation which was at 91% on room air (nasal cannula remained disconnected from the oxygen concentrator). V6 stated R5 is supposed to be on oxygen 2L continuously. V6 stated [V6] had to turn it up to 3-4L because R5's oxygen saturation was low. V6 checked the oxygen concentrator and the humidification bottle but failed to observe that the nasal cannula was not connected. At 12:15 PM, R5's oxygen saturation was 89%. V6 was shown that R5's nasal cannula was not connected. V6 re-inspected the nasal cannula and found the end of the tubing on the floor. V6 stated [V6] was not aware that it was disconnected and reconnected R5's nasal cannula. The Facility's policy documents: Oxygen Concentrators and Tubing policy, dated 8/04/23, documents in part: Oxygen will be administered as per physician's orders. 2) On 08/08/23 at 11:28 AM, observed R98 sitting in chair at bedside with oxygen concentrator behind R98, oxygen was not infusing. There was an empty plastic bag attached to the side of the oxygen concentrator. R98 stated I sleep at night with the oxygen. R98's nasal canula tubing dated 08/07/23 was wrapped around R98's bed rail with the end of the tubing laying on R98's sheets. R98 stated sometimes the Certified Nursing Assistant (CNA) puts the oxygen tubing in the plastic bag, sometimes they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 6 of 11 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 145974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwood Crossing 6016 North Nina Avenue Chicago, IL 60631 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 don't, it depends on who the CNA is that's assigned and today, the CNA must not have put it in the bag. Level of Harm - Minimal harm or potential for actual harm On 08/08/23 at 11:37 AM, V7 (Registered Nurse) observed the location of R98's oxygen tubing and stated the tubing should be in a plastic bag to keep it clean. Residents Affected - Few On 08/10/23 at 11:04 AM, V3 (Director of Nursing) stated oxygen tubing has to be stored in a plastic bag to prevent infection and to make sure that when the resident needs to use the tubing it is clean and ready to use. V3 stated it is the staff responsibility to put the oxygen tubing in the plastic storage bag. R98 has diagnosis not limited to Pneumonia, Acute Respiratory Failure with Hypoxia, Pulmonary Embolism without Acute Cor Pulmonale, Parkinson's Disease, Steele-[NAME]-[NAME], Intervertebral Disc Degeneration, Low Back Pain, Acute Embolism and Thrombosis, Anxiety Disorder, Insomnia, Obstructive Sleep Apnea, Repeated Falls, Muscle Weakness, Dysphagia, Unsteadiness on Feet, Reduced Mobility, Reduced Mobility, Need for Assistance with Personal Care. R98's Order Listing Report dated 08/10/23 documents in part oxygen 2-3 liters per minute nasal cannula to keep oxygen saturation above 92% every shift ordered 09/10/22. R98's Care Plan documents in part R98 has oxygen due to respiratory failure and R98 has altered respiratory status due to pulmonary embolism and respiratory failure. R98's MDS (Minimum Data Set) dated 08/11/23 indicates intact cognition. The Facility's policy titled, Oxygen Concentrators and Tubing dated 08/04/10 documents in part the oxygen tubing must be stored in a protective plastic bag by nursing personnel when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 7 of 11 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 145974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwood Crossing 6016 North Nina Avenue Chicago, IL 60631 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 food items were properly labeled, dated, and stored and failed to store equipment in separate area from bulk food bins. This deficient practice has the potential to affect all 112 residents receiving food prepared in the facility's kitchen. Findings include: On 08/08/23 at 9:19 AM, during initial kitchen tour, V14 (Food Service Director) stated all opened food items need to be labeled and dated with a delivery date, an open date, and an expiration date. V14 stated labeling and dating food items are important, so the staff knows how and when to rotate them. On 08/08/23 at 9:23 AM, observed in the facility walk-in dairy refrigerator an opened 1-gallon container of Fat Free Skim Milk with sell by date of 08/03/23. The plastic milk carton was not labeled with a delivery or opened date. V14 stated the milk was expired and should be thrown out. On 08/08/23 at 9:28 AM, observed the following items in the walk-in fruit/vegetable/meat refrigerator: Opened 1 gallon container of Ranch Dressing dated with delivery date 12/16 and opened date 05/10/23. There was no expiration date printed on the container by the manufacturer. V14 stated this product is good for 30 days once it has been opened and will be thrown out since it is over 30 days. Opened 1 gallon container of Sweet Relish dated with delivery date 6/6. There was no opened or use by date labeled on the product. V14 stated there should be an opened and use by date labeled on this item otherwise the staff doesn't know when to discard it. Opened 1 gallon Teriyaki Sauce dated with delivery date 12/30. There was no opened or use by date. V14 stated there should be an opened and use by date labeled on this item otherwise the staff doesn't know when to stop using it. Opened 1 gallon container of Balsamic Vinaigrette dated with opened date 5/5. There was no manufacturer's expiration date printed on the container. V14 stated the product is good for 30 days after being opened and will be discarded today. Opened 1 gallon container of Mild Chunky Salsa dated with delivery date 03/28/23 and opened date of 5/ (specific day not documented). V14 stated the product is good for 30 days after being opened and will be rotated out of stock today. Opened 1 gallon container of Slaw Dressing dated with delivery date 6/23. There was no opened or use by date on the product. There was no manufacturer's expiration date printed on the container. V14 stated the product should have been labeled with an opened and use by date. On 08/08/23 at 9:56 AM, observed large bulk bins with flour, oats, and cornstarch in them. None of the bulk containers were labeled with an opened or use by date. V14 stated once the dry food items are opened and filled into the bulk bins the bulk containers should be labeled and dated. V14 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 8 of 11 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 145974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwood Crossing 6016 North Nina Avenue Chicago, IL 60631 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 I know they get rotated but without the dates you don't know. Level of Harm - Minimal harm or potential for actual harm On 08/08/23 at 9:57 AM, observed in the flour bulk container a small saucepan covered in flour and a square metal container in the cornstarch bulk bin. V14 stated the staff must be using those items to get the product out of the bin. V14 stated there should not be anything stored in the bulk containers to prevent risk of cross contamination. V14 stated if an employee did not change gloves or perform hand washing after using a piece of equipment to portion out the bulk food items and then placed those pieces of equipment back into the bulk containers this could cause a cross contamination concern. V14 stated V14 expectation is that the staff would use a scoop as a single use item and bring to the dish room when finished with it, not put it back into the bulk container. Residents Affected - Many On 08/08/23 at 10:57 AM, V14 provided requested information on diet lists, spreadsheets, and menu cycle. V15 (Registered Dietitian) stated there are 2 residents who receive nothing by mouth and therefore do not receive any trays from the kitchen. On 08/08/23 at 12:10 PM, during dining observations in the unit dining room observed numerous 8 ounce milk cartons in a large container of ice and Certified Nursing Assistants (CNAs) pulling milk cartons from the container and serving to residents as part of the meal service process. Observed 8-ounce carton of Fat Free Chocolate Milk date 08/07/23. V13 (Dietary Aide) serving the food stated, we wouldn't serve this because it's expired and normally we check the milk cartons for expiration dates. V17 (Resident Assistant) viewed the carton of milk dated 08/07/23 and stated, it should have been tossed yesterday. On 08/10/23 at 10:02 AM, V14 stated if there is no expiration date printed on a food container such as salad dressings or mayonnaise-based item than the kitchen would go by 30 days for use from the opened date. V14 stated if there is no open date or use by date the staff won't know when the item would expire and there would be no way to identify when it should be used by or disposed of. V14 stated this could potentially cause cross contamination and cause a resident to get sick. V14 stated the chocolate milk dated 08/07/23 being served on 08/08/23 should not have been delivered to the unit and it should have been identified down in the kitchen and discarded. The facility's policy, titled Food Storage & Labeling dated 10/14/28 documents in part, to ensure that food is properly stored and rotated so that food past its expiration date does not occur and discarded if necessary and each label must contain the following information: product name, use-by-date if applicable, date the product was prepared or opened and discard: throw out food that has passed its manufacturer's use-by or expiration date. The facility's policy, titled Maximum Storage Period of Dried Goods dated 9/22 documents in part opened sauces 6 months, relish 2 months, acidic vegetables (tomatoes) 7 days, salad dressings expiration date, mayonnaise expiration date. Kitchen policy titled 3.4 Storing: Food & Equipment undated, documents in part on page 46 label food bins, scoops may be used for flour, sugar, cereals and other grain products. Store scoops in a covered area next to the container and not in food the food container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 9 of 11 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 145974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwood Crossing 6016 North Nina Avenue Chicago, IL 60631 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 Based on observations, interviews and record review, the facility failed to ensure shared equipment was cleaned and decontaminated between each use for four [R28, R65, R81, R105] of seven residents reviewed for medication administration observation on the total sample of 23. Residents Affected - Some Findings included: On 8/8/23 at 9:37 AM, medication pass was observed with V9 [Registered Nurse]. There was a blood pressure machine on top on the medication cart. V9 placed the blood pressure machine on R105's lap and obtained R105's blood pressure on the right arm [114/53, pulse 64]. V9 did not clean the blood pressure machine before or after use. On 8/8/23 at 9:50 AM, V9 place the blood pressure machine on R81, and obtained R81's blood pressure [114/76, pulse 86]. V9 did not clean the blood pressure machine before or after use. On 8/8/23 at 10:06 AM, V9 placed the blood pressure machine on the dining room table and obtained R28's blood pressure [135/76 pulse 71]. V9 used a pulse oximeter finger device on R28's finger [97% oxygen and pulse 70]. V9 did not clean the blood pressure machine or pulse oximeter device before or after use. On 8/8/23 at 10:50 AM, V9 placed the blood pressure machine on R65's air loss mattress, and obtained R65's blood pressure [154/72, pulse 62]. V9 used the pulse oximeter finger device on R65's finger [99% oxygen and pulse 65]. V9 did not clean the blood pressure machine or pulse oximeter device before or after use. On 8/8/23 at 10:53 AM, V9 stated, I been working here at this facility for a year. However, I been a registered nurse for three years. I forgot to clean the blood pressure machine and the pulse oximeter before and after each resident use. I was focused on administering medications. I could have spread infection from one resident to another. I should have cleaned the blood pressure machine and pulse oximeter with a sanitizing wipe after each use to prevent the spread of infections. On 8/10/23 at V3 [Director of Nursing] stated, My expectation for shared blood pressure machines and pulse oximetry devices is for the nurses to clean and disinfect the shared resident devices before and after each resident use. If the nurse does not disinfect the shared devices, that could potentially spread infection from one resident to the next resident. V9 have been in-services in June 2023, and August 8, 2023. V9 knew the importance of cleaning the blood pressure machine and pulse oximetry device between each resident to prevent the possibility of spreading an infection. Facility forms document: (1)-In-Service Attendance, dated 8/8/23: Cleaning and disinfecting of reusable machine and equipment. Reinforced education about cleaning and disinfecting residents' usable equipment such as blood pressure cuff and machine. Nurse to clean and disinfect machine in between resident use. Nurse to observe infection control. (2)-In-Service Attendance, dated 6/12/23: blood pressure cuff, re-educated on cleaning and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 10 of 11 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 145974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norwood Crossing 6016 North Nina Avenue Chicago, IL 60631 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 disinfecting- use one minute kill time. Noted V9's name printed with signature. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Some Facility Policy's: Documents: Reusable blood pressure cuff and machine-cleaning and disinfection dated 5/2023 -To ensure infection control practice is observed with cleaning and disinfection of reusable blood pressure cuff and machine -Reusable blood pressure cuff, machine, tubing, will be clean using germicidal wipes FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 11 of 11