Health inspection·February 20, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one resident (R1) with a venous stasis ulcer received the necessary treatment and services to promote wound healing. This failure affected one resident (R1) out of four residents reviewed for wound care. Residents Affected - Few Findings include: R1's medical diagnoses include but are not limited to myositis, hypertensive heart disease with heart failure, nonrheumatic aortic stenosis, non-pressure chronic ulcer of unspecified part of left lower leg, muscle weakness, peripheral vascular disease. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 15, which indicates R1's cognition is intact. R1's care plan dated 11/13/24 documents in part, R1 at risk for pressure ulcer/skin breakdown due to impaired mobility and bilateral leg edema. Bilateral lower leg venous statis ulcers .Administer treatments as ordered and monitor for effectiveness. R1's physician orders dated with a start date of 12/14/24 documents in part, Left heel apply bordered foam dressing every day shift every Tuesday, Thursday, Saturday for DTI (Deep Tissue Injury) R1's physician orders dated with a start date of 01/21/25 documents in part, Left lateral lower leg wound, cleanse wound with saline, pat dry, apply Aquacel Ag, cover with gauze and abdominal pad and wrap with roll gauze and secure tape. Apply single tubugrip on left leg only per resident request .every day shift every Tuesday, Thursday, Saturday. R1's Treatment Administration Record shows no documentation for the completion of R1's left heel or left lateral lower leg wound care on Tuesday 01/21/25. R1's physician order dated with a start date of 12/07/24 documents in part, Left lateral lower leg wound cleanse wound with saline, pat dry, apply prisma and xeroform, cover with gauze and abdominal pad and wrap wit roll gauze and secure tape .every day shift every Tuesday, Thursday, Saturday. R1's Treatment Administration Record shows no documentation for the completion of R1 left lateral lower leg wound care on Tuesday 01/14/25. R1's physician order with a start date of 01/25/25 and discontinue date of 02/06/24 documents in part, left lateral lower leg wound cleanse wound with saline, pat dry, apply prisma cover with gauze and abdominal pad and wrap with roll gauze and secure tape .every day shift every Tuesday, Thursday, Saturday. R1's Treatment Administration Record shows no documentation for the completion of R1's left lateral lower leg wound care on Tuesday 01/28/25. On 02/19/25 at 11:36am, V6 (Registered Nurse/RN) stated that R1 went to the wound clinic every Thursday and the facility was responsible for changing R1's wound care dressings on Tuesdays and Saturdays. V6 stated that R1 had complained to her about not having his wound dressing changed on some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 2 of 5 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 02/20/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Tuesdays. V6 stated that she told R1 to remind the staff to change his wound bandage because he is alert and oriented. V6 stated that she put an order on R1's physician orders to make sure staff are changing R1's wound. V6 stated that she placed signage on R1's bedroom walls to remind staff to change R1's wounds. R1's physician order dated 02/06/25 documents in part, AM (morning) nurse to do wound dressing on the left lateral lower leg, foot doctor do not do the dressing on the leg every day shift every Tuesday, Saturday .FYI (for your information) resident goes to wound care clinic (WCC) on Thursday. On 02/20/25 V3 (Director of Nursing/DON) stated that if there is no documentation then it may not have been done. V3 stated the facility has a podiatrist that comes to the facility to see residents on Tuesdays. V3 stated that there was a mix up and the nurses thought that R1 was being seen by the podiatrist on Tuesdays, so the nurse was not changing the bandages of R1. V3 stated that if wounds dressings are not changed that the wounds could get worse. R1's left lateral lower leg wound measured 2.8 centimeters length by 1 centimeter width by 0.1 centimeter depth on 12/12/24. R1's wound for pre debridement and post debridement measured 5 centimeters length by 2 centimeters width by 0.2 centimeters depth on 2/6/25. Facility's job description for Registered nurse dated 04/2013 documents in part, Essential Duties and Responsibilities: .Perform treatments in a timely manner, using proper techniques. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 3 of 5 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 02/20/2025 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 properly log refrigerator and freezer temperatures in the facility kitchen; and failed to properly log the checking of the dating and labeling of food items and removal of expired items in the facility kitchen. These failures have the potential to affect all 104 residents receiving an oral diet in the facility. Findings include: On 02/19/25 at 12:06pm, with V4 (Director of Dietary Services), during observation of the facility's main walk-in freezer, walk-in refrigerators (coolers), and Ice Cream freezer, the following was observed: 1. The walk-in freezer's temperature log titled, Freezer/Refrigerator Temperatures, dated February 2025, documents, in part, -10 degrees Fahrenheit on 2/20/25 AM shift. This was observed on 2/19/25 which indicates the temperature of the walk-in freezer was documented for a future date. 2. The Ice Cream freezer's temperature log titled, Freezer/Refrigerator Temperatures (with the word Ice cream written at the top right corner of the document), dated February 2025, documents, in part, 5am 3.2 (degrees Fahrenheit) on 2/20/25 AM shift. This was observed on 2/19/25 which indicates the temperature of the Ice Cream freezer was documented for a future date. 3. The Refrigerator #1 (Cooler #1) temperature log titled, Freezer/Refrigerator Temperatures (with the words Cooler #1 written at the top right corner of the document), dated February 2025, documents, in part, 5am 37 (degrees Fahrenheit) on 2/20/25 AM shift. This was observed on 2/19/25 which indicates the temperature of Refrigerator #1 (Cooler #1) was documented for a future date. 4. Refrigerator #2 (Cooler #2) temperature log titled, Freezer/Refrigerator Temperatures (with the words Cooler #2 written at the top right corner of the document), dated February 2025, documents, in part, 5am 36 (degrees Fahrenheit) on 2/20/25 AM shift. This was observed on 2/19/25 which indicates the temperature of Refrigerator #2 (Cooler #2) was documented for a future date. 5. Facility document titled, (Facility Name) Dietary Audit Form: Dating and Labeling of Food Items and removal of expired items in the main kitchen, dated February 2025, documents, in part, that the ice cream freezer, produce, dairy, freezer, dry storage was checked for dating and labeling of food items as well as removal of expired items in the main kitchen on 2/20/25. This was observed on 2/19/25 which indicates the checking for dating and labeling of food items as well as removal of expired items in the main kitchen was done on a future date. On 02/19/25 at 12:10pm, when asked what the facility's expectations on documenting temperatures for the refrigerators and freezers in the kitchen; and documenting the checking of the dating and labeling of food items and removal of expired items in the facility kitchen, V4 (Director of Dietary Services) replied, I'm (V4) going to talk to this employee about this documentation. This should be done on am shift and pm shift. This is a mistake. It should not for the following day. When asked the purpose for properly documenting refrigerator and freezer temperatures and the checking for dating and labeling of food items, V4 replied, To make sure the coolers and freezers are working good so the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 4 of 5 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 02/20/2025 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 food doesn't go bad. If the food goes bad the residents can get sick. We (kitchen staff) actually checking the expirations on the food twice a day. Same thing. Expired food can cause the residents to get sick. I (V4) think she was just confused on the date. The facility's document, titled (Facility) Diet Type Report, dated 2/20/25, shows that the facility has 1 resident that does not have an oral diet. Facilities policy titled, Food Storage, dated 3/23, documents, in part, . Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination . A thermometer will be present in the storeroom and will be monitored on a regular basis . Refrigerators should maintain food temperatures at or below 41 ° F and freezer temperatures to keep food frozen solid . Temperatures for refrigerators should be between 35 to 39° F. Thermometers should be checked at least two times each day . Freezer temperatures should be checked at least two times each day . Facility's job description titled, Food Service Manager, revised date October 2013, documents, in part, . Manage all kitchen staff and front of the house operations to ensure the highest quality of customer service to residents . Ensures that all services and programs are in compliance with federal, state, and/or local regulations, laws and statues . Facility's job description titled, Dining Service Manager, revised date October 2013, documents, in part, . manage all kitchen staff and front of the house operations to ensure the highest quality of customer service to residents . Ensures that all services and programs are in compliance with federal, state, and/or local regulations, laws and statues . Facility's job description titled, Kitchen Supervisor, revised date October 2024, documents, in part, . manage all kitchen staff and front of the house operations to ensure the highest quality of customer service to residents . Ensures that all services and programs are in compliance with federal, state, and/or local regulations, laws and statues . Facility's job description titled, Dietary Aide, revised date March 2013, documents, in part, . To assist the Clinical Dietitian with food service to the skilled nursing patients, so that each receives the correct diet at the specified time . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145974 If continuation sheet Page 5 of 5