Health inspection·August 7, 2025

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to refer two residents (R14 and R17) to the appropriate state designated authority for PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination and failed to perform additional screening for one resident (R17) diagnosed with a new mental disorder. This deficient practice affected two residents (R14 and R17) in a total sample size of 77 residents.Findings include: Residents Affected - Few 1. R17’s Omnibus Budget reconciliation Act (OBRA) dated 12/4/20 documents in part, “Screening indicates nursing facility services are appropriate; based upon all information and data available R17 has no reasonable basis for suspecting Developmental delay or Mental illness diagnosis.” R17’s admission to facility was 12/7/2020 and readmission date to the facility was 8/7/2022. R17’s medical diagnosis includes but are not limited to Schizophrenia 1/4/2021, diabetes mellitus, epilepsy, chronic kidney disease, hypertension, gastro esophageal reflux disease. R17’s Physician order summary report dated 8/8/2023 documents in part that R17 takes Risperdal oral tablet 0.25mg by mouth at bedtime related to Schizophrenia. On 8/5/25 at 3:54pm, V31 admission Director stated the facility utilizes two major diagnoses to identify if a resident would need a PASARR 2 completed, and these two diagnoses that qualify a resident are major depressive disorder and Schizophrenia. V31 stated that normally a resident is sent from the hospital with PASARR 2 and that she is responsible for handling the process to have PASARR’s completed. V31 stated that in the morning meeting (intradisciplinary team present) or care plan conference meetings, residents are discussed who may have new diagnosis that needs to be reviewed for further assessments. V31 stated that if a resident received a new diagnosis of Schizophrenia, the referral for assessment should be sent to the designated agency so the resident can be assessed and reviewed for further evaluation. V31 stated that R17 does not currently have a PASARR 2 in chart. On 8/6/25 at 9:31am, V1 Administrator stated a resident should have a PASARR 2 when they have a new mental health diagnosis or if they were screened from hospital with a major mental health disorder. V1 stated that Schizophrenia is a major diagnosis that qualifies a resident to have a PASARR 2 completed. V1 stated that the purpose of resident with major mental health diagnosis being assessed is to give the facility an idea of the treatment plan and services that resident may need, and if the PASARR 2 was not completed, it is a possibility that treatment plan of R17 was not completed accurately. On 8/6/2025 at 11:45 am, V31 submitted a document titled “Notice of Preadmission Screening and Resident review (PASRR) Level Screen Outcome,” which documents, in part, that a PASRR Level 1 Determination: Refer for Level 2 Onsite; Mental health diagnosis: Schizophrenia, current; Outcome: reviewer documented R17 referred for level 2 screening; rationale: A PASRR level 2 evaluation must be conducted. That evaluation will occur as an onsite/face-to-face evaluation. Suspected or confirmed PASRR condition: Mental health disability. 2. R14’s admission Record documents, in part, diagnoses of chronic obstructive pulmonary disease, end stage renal disease, type 2 diabetes mellitus, heart failure, anemia, hyperlipidemia, dementia, delusional disorders, difficulty in walking, lack of coordination, hypertension, and cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 2 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 0645 communication deficit. Level of Harm - Minimal harm or potential for actual harm On 8/5/2025 after requesting for R14’s PASSAR (Pre-admission Screening and Annual Resident Review) screening(s), V1 (Administrator) presented this surveyor with R14’s one page document (2536) titled “Interagency Certification of Screening Results” certified by the Department on Aging and dated 10/17/2018 documents, in part, that this screening indicated nursing facility services are appropriate. Residents Affected - Few On 8/5/2025 at 12:56 PM, this surveyor requested from V1 for R14’s PASARR screening(s) due to R14’s “Interagency Certification of Screening Results” not indicating the physical and mental condition of R14 or the level of services that R14 requires to be provided by the facility. On 8/6/2025 at 10:56 AM, V1 (Administrator) stated that the facility performed an audit about one year ago for all residents, which included R14, who have been residing in the facility prior to the new state designated authority’s process for electronic submission for resident PASARR evaluation and referral screenings. V1 stated that V1 does not have further PASARR screenings, including a Level 1 for R14. On 8/6/2025 at 11:04 AM, V29 (Social Services Director) stated that R14's Interagency Certification of Screening Results is not the same as a PASARR Level 1 screening. V29 stated that the state designated authority will perform a separate assessment for the PASARR Level 1 screening to determine if there is suspicion for mental condition(s) that would require a more in-depth screening (Level 2) which tells the facility what mental programs or therapies that the resident should have in the facility. V29 stated that to my (V29's) knowledge, R14 does not have a PASARR Level 1 screening done. On 8/6/2025 at 12:23 PM, V29 provided this surveyor with a document, with R14’s name on it, and V29 stated that it was a screenshot from V29’s computer where V29 has logged into the electronic system for the state designated authority for PASARR evaluations and screenings. This document indicates a Level 1 Screen for R14 with a status of “Queued for Review” with no determination date and was started by V31. On 8/6/2025 at 12:30 PM, V31 (Admissions Director) stated that every current resident should have a PASARR Level 1. V31 stated that today (on 8/6/2025), V31 initiated for R14’s PASARR Level 1 screening via the state designated authority’s electronic submission process. V31 stated that since there is this new state designated authority’s electronic submission process that was implemented in 2022, V31 is “getting it together” to ensure that all residents have a PASARR Level 1 screening, which will then indicate if a resident should have additional screening for a Level 2. Facility’s policy dated 10/06/2023 titled PASARR, documents in part; It is the policy of this facility to conduct a preadmission screening and resident review (PASARR) prior to admitting a new resident. The screening will be obtained so that the facility can make appropriate decisions regarding care and placement; Responsibility: Admissions director, Administrator; Procedure: 1.Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid pre -admission screening and resident review program (PASARR).7.Should the resident require a PASARR update after admission the facility will contact the state agency to update the PASARR; the facility will document attempts to contact the agency and update the PASARR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 3 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Facility’s undated job description titled admission director, documents in part “ Essential duties and responsibilities: Admit, transfer, and discharge residents in accordance with established policies and procedures; Attach preadmission documentation to admission papers as appropriate; refer admission problems to proper authority, nursing service and social services; keep abreast of current Medicare/Medicaid regulations governing admission/ discharge requirements of health care facilities; Assist the MDS Coordinator in scheduling resident assessments; collect, assemble, and check admission papers, forward to appropriate departments. Event ID: Facility ID: 145977 If continuation sheet Page 4 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure that medications were signed out when administered for one residents (R143). This failure affected one out of 77 residents in the sample. Findings include:On 08/04/25 at 1:00 pm, R143 was observed with a PICC (Peripherally Inserted Central Catheter) to R143's right arm with medication infusing. R143 stated, I usually get my IV (Intravenous) medication around 9:00 am but I did not get it today. On 08/04/25 at 1:25 pm, V5 (Licensed Practical Nurse, LPN, Unit Manager) stated, I signed R143's IV medication out this morning but I did not give it. V5 explained that medications should be signed out when administered to avoid a medication error. R143's Medication Administration Record (MAR) presented by the facility on 8/04/25 shows R143 has orders for Vancomycin HCL (hydrochloride) intravenous solution 1250 mg(milligram)/250 ml solution administered by V5 at 10:01 am, however at on 08/04/25 at 1:00 pm R143 stated that R143 did not receive any IV medications (Vancomycin HCL (hydrochloride) intravenous solution 1250 mg(milligram)/250 ml) at 10:01 am.R143's Medication Administration Audit Record (MAAR) presented by the facility on 8/04/25 Vancomycin HCL (hydrochloride) intravenous solution 1250 mg (milligram)/250 ml solution administered by V5 at 10:01 am, however on 08/04/25 at 1:00 pm, R143 stated that R143 had not receive Vancomycin HCL (hydrochloride) intravenous solution 1250 mg(milligram)/250 ml.On 8/05/25 at 9:09 am, V2 (Director of Nursing, DON) was asked regarding the facility's policy for medication administration and V2 stated, Medication should be signed out immediately after the medication is given to prevent a medication error. V2 explained that if a medication is not administered the nurse should not sign the medication on the MAR.R143's Face sheet shows that R143 has diagnosis which include but not limited to presence of heart assist device, other mechanical complication of other cardiac and vascular devices and implants subsequent encounter, and acute osteomyelitis. R143's Brief Interview for Mental Status (BIMS) dated 07/13/25 shows that R143 has a BIMS score of 15 which indicates that R143 is cognitively intact.R143 Physician Order Sheet (POS) shows active orders as of 08/04/25 with orders for Vancomycin HCL (hydrochloride) intravenous solution 1250 mg(milligram)/250 ml (milliliter) (Vancomycin HCL) use 1.25 gm (gram) intravenously every 48 hours related to OTHER cardiomyopathies. The facility's policy dated October 2023 and titled Medication Administration Policy documents, in part: Policy: To authorize licensed nursing personnel (RN, LPN) (Registered Nurse, Licensed Practical Nurse) and Qualified Medication Aides (QMA) to prepare ad administer drugs and biologicals. Policy Specifications: 1. Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates. 2. All licensed nurses assigned the responsibility of administering and recording of medications must meet the requirement of the state in which the facility operates . 20. Medications shall be recorded on the MAR promptly after each administration by the individual who administered the drug.The facility's undated document titled The Licensed Practical Nurse (LPN) documents, in part: Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times . Prepare and administer medications as ordered by the physician.The facility's undated document titled Registered Nurse (RN) documents, in part: Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 5 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 0658 ensure that the highest degree of quality care is maintained at all times . Prepare and administer medications as ordered by the physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 6 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 toenail care with trimming for a resident with lengthy and jagged toenails which affected one resident (R147) in the sample of 77 residents reviewed for activities of daily living. Findings include:On 8/4/2025 at 12:48 PM, R147 observed lying in bed with no shoes or socks on, and R147 observed with long (3/4 to 1 inch long) toenails with jagged edges. This surveyor communicating with R147 via R147's Polish communication board in room, and R147 saying that nails are long and wants them cut. On 8/5/2025 at 9:47 AM, R147 observed lying in bed with no shoes or socks on, and R147 observed with the same length (long) and jagged toenails. R147's left toes observed with 4 long and jagged toenails, and the left 2nd toe (next to big toe) with the discolored toenail growing more outwards instead of upwards towards tip of toe. R147's right toes observed with 4 long and jagged toenails besides the left 2nd toe (next to big toe) with the nail short and jagged. R147 remains saying that R147 wants them cut. On 8/5/2025 at 9:53 AM, this surveyor requested that V26 (Registered Nurse, RN) come view R147's toenails. V26 stated that R147 has some long and jagged toenails, and stated, They can be cut. V26 stated that toenails are offered to be cut every shift and when needed by the nursing staff, except if the resident is a diabetic, then there is a referral to the podiatrist. V26 stated that V26 doesn't believe that R147 is a diabetic but has to check R147's chart. On 8/5/2025 at 10:03 AM, V26 confirmed via R147 electronic health record (EHR) that R147 is not a diabetic. V26 stated that staff responsible for cutting R147's toenails since R147 is not a diabetic are the nurses and the CNAs (Certified Nursing Assistants). V26 stated that nail clippers are kept on the nursing units in the clean utility room. R147's admission Record documents, in part, diagnoses of delirium, dysphagia, unsteadiness on feet, lack of coordination, reduced mobility, cognitive communication deficit, and person injured in unspecified motor-vehicle accident, traffic, subsequent encounter.R147's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R14 has severe cognitive impairment. R147's Functional Abilities for Self-Care for personal hygiene, lower body dressing, putting on/taking off footwear and shower/bathe self are coded as 4 which indicates that supervision or touching assistance from staff may be provided throughout the activity or intermittently. R147's Care Plan, initiated 5/15/2025, documents, in part a focus that R147 has an ADL (Activities of Daily Living) Self Care Performance Deficit related to weakness with interventions to provide assistance with bathing/showering as necessary and to monitor, document, report to doctor, as needed, any changes, reasons for self-care deficit, expected course or declines in function. Facility document titled Foot Assessment Documentation and dated 8/4/2025 documents, in part, 12 residents' names which includes R147's name. In the column for Skin Issue? a notation of All Pts (patients) need toenails trimmed is documented with an arrow extending down all 12 residents names, including R147.On 8/6/2025 at 1:28 PM, V2 (Director of Nursing, DON) stated that CNAs are responsible for assessing residents' toenails during ADL care and that toenail checks are to be done every day. V2 stated that nursing staff, including V2, will then provide trimming of a residents' lengthy or jagged toenails. V2 stated that if a resident is diagnosed with diabetes, the facility refers the resident to the podiatrist for toenail trimming. V2 stated that R147 is not a diabetic resident.Facility policy titled Care of Fingernails/Toenails and dated April 2007 documents, in part, Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines: 1. Nail care includes daily cleaning and Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 7 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the toenails of diabetic residents or residents with circulatory impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 1. Nail Clippers; 2. Nail file or emery board; 3. Towel; 4. Orange sticks; 5. Line protector (disposable or plastic), as necessary; 6. Hand lotion (as permitted or prescribed); 8. Paper towels; and 8. Personal protective equipment . Documentation: The following information should be recorded in the resident's medical record, if applicable: 1. The date and time that nail care was given. 2. The name and title of the individual(s) who administered the nail care . 6. If the resident refused the treatment, the reason(s) why and the intervention taken. 7. The signature and title of the person recording the data.Facility job description (undated) titled Certified Nursing Assistant documents, in part, Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and Responsibilities: . Provide assistance in personal hygiene . Adhere to professional standards, company policies and procedures. Facility job description (undated) titled Licensed Practical Nurse (LPN) documents, in part, Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistants . Performs other duties as assigned.Facility job description (undated) titled Registered Nurse (RN) documents, in part, Summary: The RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistants . Performs other duties as assigned. Event ID: Facility ID: 145977 If continuation sheet Page 8 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 ensure ADL's (Activities of Daily Living) were completed for two residents (R202, R204) to allow the residents to maintain their dignity. This failure affected 2 residents out of a sample of 77.Findings include: Findings include: Residents Affected - Few R202 has a diagnosis of but not limited to Syncope and Collapse, Muscle Weakness, Lack of Coordination, Need for Assistance with Personal Care, Weakness and Hypertension. R202's Brief Interview of Mental Status score is 6 which indicates severe cognitive impairment. R202 Minimum Data Set section GG-Functional Abilities documents, in part, 02 (Substantial/maximal assistance) and Personal hygiene: the ability to maintain personal hygiene, including shaving. R202's Care plan focus for ADL's dated 08/06/2025 documents, in part, R202 has an ADL Self Care Performance Deficit related to muscle weakness and Personal Hygiene: R202 requires total staff assist with shaving facial hair. On 8/04/2025 at 11:28am, surveyor observed R202 with medium length gray hair extending from R202's chin. On 8/04/2025 at 11:30am, R202 stated she knows they (chin hairs) are there but can't cut them and no one has asked her if she (R202) wants them cut. R202 stated she wants them (chin hairs) cut off. On 8/04/2025 at 11:35am, V4 (Certified Nursing Assistant-CNA) stated with every shower or bed bath we offer to shave facial hair to all residents. On 8/06/2025 at 11:18am, V35 (Licensed Practical Nurse) stated facial hair shaving is offered to residents as soon as we see facial hair and it's a dignity issue. On 8/06/2025 at 11:22am, V34 (CNA) stated we offer to shave all residents when showers are given or when stumble is seen and if the resident allows us (CNA's) to shave the facial hair. On 8/06/2025 at 3:15pm, V2 (Director of Nursing) stated all residents are shaved as needed and when showers are given including female residents. Shaving the Resident Procedure with a revised date of March 2004 documents, in part, the purpose of this procedure is to promote cleanliness and to provide skin care. Activities of Daily Living (ADL) with an effective date of 2/2023 documents, in part, Purpose: based on a comprehensive assessment of the resident and consistent with the resident's needs and choices, our facility provides necessary care and services to ensure that a resident's abilities in activities of daily living (ADL) do not diminish unless the circumstances of the individual's clinical condition demonstrates that such decline was unavoidable. Job description titled Certified Nursing Assistant documents, in part, the Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents and provide assistance in personal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 9 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 hygiene by giving shaves. Level of Harm - Minimal harm or potential for actual harm R204’s diagnoses include but are not limited to acute osteomyelitis, lack of coordination, muscle wasting and atrophy. Residents Affected - Few R204’s Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 14, indicating that R204’s cognition is intact. On 08/04/25 at 10:26am R204 observed with a moderate amount of facial hair. On 08/04/25 at 10:26am R204 stated that he had been asking the staff to shave him. R204 stated that when he asks the staff to shave him, the staff tell him that they will get to it but haven’t got to it yet. On 08/04/25 at 10:37am V5 (Unit Manager) stated that she sends some of the residents down to be shaved by the wound care technician. V5 stated that staff know to look at the resident’s face and if the resident looks like they need to be shaved, then the staff should shave the resident. On 08/04/25 at 12:40pm V8 (Wound Care Technician) stated he cuts the resident’s hair and shave the resident’s whenever he is available, which is hardly ever. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 10 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 Based on observation, interview, and record review the facility failed to redistribute pressure by maintaining the air mattress pump at the correct weight setting to prevent pressure wounds. This failure has the potential to effect one resident (R7) in a sample of ----77.Findings Include: R7 was observed lying in bed on a low air mattress with an air mattress pump at the foot of the bed set on Firm which is one setting past 360lbs (pounds). On 8/4/2025 at 11:24 am, V17, RN (Registered Nurse/Agency) verified R7's air mattress pump was set past 360lbs (pounds) on firm. V17 stated she (V17) was not aware of the facilities protocol for the air mattress setting. V17 verified R7's current weight was 150.8lbs. On 8/4/2025 at 11:47 am, V8, WCT (Wound Care Technician) stated only a nurse, wound care coordinator, or the wound care tech can change the setting on a resident's air mattress pump. V8 stated an incorrect air mattress pump setting can cause a pressure ulcer wound to develop. On 8/6/2025 at 12:34 pm, V24 WCC (Wound Care Coordinator) stated R7's family requested R7 remain on a low air mattress for comfort measures since she was on one in the hospital; low air mattresses are used to promote wound healing; incorrect low air mattress settings can cause a decline in a wound; and a low air mattress is not needed for a resident who doesn't have a wound. R7's Face Sheet dated 8/6/2025 documents a diagnosis of but not limited to CEREBRAL INFARCTION, UNSPECIFIED, HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING RIGHT DOMINANT SIDE, ENCOUNTER FOR ATTENTION TO GASTROSTOMY, MILD NEUROCOGNITIVE DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITHOUT BEHAVIORAL DISTURBANCE, AND DYSPHAGIA FOLLOWING OTHER CEREBROVASCULAR DISEASE.R7's Physician Order Sheet dated 8/6/2025 documents no order for a low air mattress.R7's weight summary dated 8/4/2025 documents a weight of 150.8lbs (pounds) on 7/8/2025 at 10:44 AM.R7's Care Plan dated 7/28/2025 documents a focus for Risk for alteration in skin integrity R/T self-care deficits, impaired mobility and comorbidities and to pressure redistribution mattress, apply pressure redistribution cushion when up in chair/wheelchair, reposition/Shift weight at frequent intervals to resident's comfort, remind/Assist resident to reposition frequently.R7's Minimum Data Set Section GG dated 7/20/2025 documents in part, R7 is dependent eating, oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. On 8/6/2025 at 2:30 pm, V2, DON (Director of Nursing) stated the purpose of a low air mattress is to properly redistribute weight on a resident which ensures the resident doesn't have any skin breakdown; the low air mattress setting is determined by a residents weight; incorrect low air mattress weight setting can cause improper redistribution of pressure; and V2 is unsure if a physician's order is needed for a low air mattress. Facility Policy titled Low Air Mattress dated 7/2012 documents in part, to provide features of a mattress support system that provides a flow of air to assist in managing the heat and humidity (Microclimate) of the skin. Low air loss mattresses will be utilized for residents with Stage III, IV, and unstageable pressure ulcers of the trunk as well as residents with multiple Stage II pressure ulcers. Low Air Mattress Manufacturers User Manual REV3.6.5.17 documents in part, Static Control-Press to set the air mattress in static mode according to the weight of the patient and turn the pressure adjust knob to set a comfortable pressure level using the weight scale as a guide. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 11 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a resident's (R36) care planned fall precaution intervention by maintaining the bed height in the lowest position and failed to perform a resident's (R36) fall risk assessment quarterly which affected one resident (R36); and failed to secure a resident's (R131) oxygen tank in a holder which affected R131 and has the potential to affect all 29 residents residing on the 1st floor.Findings include: 1. R36’s admission Record documents, in part, diagnoses of type 2 diabetes mellitus, dementia, dysphasia, reduced mobility, need for assistance with personal care, mild cognitive impairment, hyperlipidemia, pseudobulbar affect, anemia, hypothyroidism, hypertension, lymphedema, and difficulty in walking. R36’s Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R36 has severe cognitive impairment. On 8/4/2025 at 11:38 AM, R36 observed lying in bed with the bed height level visibly high from the floor. This surveyor standing next to R36's bed and marking the top of R36’s bed mattress height at approximately 2 and 1/2 feet from the floor. On 8/4/2025 at 2:26 PM, R36 observed lying in bed with the same bed height level visibly high from the floor. R36’s bed controller for the height of bed is observed out of R36's reach hanging from the foot of the bed. On 8/5/2025 at 9:43 AM, R36 observed lying in bed with the bed height level visibly high from the floor. This surveyor asked V28 (CNA, Certified Nursing Assistant) asked about R36’s elevated bed height from the floor, and V28 stated that R36 is care planned for the bed being high. On 8/6/2025 at 9:12 AM, R36 observed lying in bed still with the height level of bed visibly high from floor. This surveyor standing next to R36's bed and marking the top of R36’s bed mattress height at approximately 2 and 1/2 feet from the floor. R36’s bed controller for the height of bed is out of R36's reach hanging from the foot of the bed. R36 stated that the bed height goes up and down, but I (R36) can't do it and that the staff does it. On 8/5/2025 at 12:56 PM, this surveyor requested from V1 (Administrator) and V2 (Director of Nursing, DON) for R36’s two most recent fall risk assessments and current complete care plan. R147’s two most recent fall risk assessment provided are titled “Fall Risk Observation – V2” with dates of 1/24/2025 and 10/24/2024. R36’s “Fall Risk Observation – V2,” dated 10/24/2025 and 1/24/2025, document, in part, that R36 has intermittent confusion; requires use of assistive devices; confined to chair or wheelchair (unable to ambulate without assistance); needs assistance to and from, on and off toilet/commode for elimination and or with cares; uses antidepressants and antihypertensives; and has neuromuscular/functional, psychiatric or cognitive conditions. R36’s Care Plan dated 4/19/2019 documents, in part, a focus of R36 “at risk for fall related to co-morbidities” with an intervention of “bed in lowest position when lying in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 12 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bed (11/2/2021).” In review of R36’s current complete care plan (printed 8/5/2025), no interventions are noted for R36 being care planned for a high bed. On 8/6/2025 at 11:46 AM, V33 (Restorative Director, LPN, Licensed Practical Nurse) stated that V33 is responsible for the facility’s fall prevention program. V33 stated that one of the general fall prevention interventions for residents is to ensure that the bed is in lowest position. When asked the purpose of having the bed in the lowest position, V33 stated, “So, if they (residents) do happen to fall out of bed, there won’t be much damage. If resident were to have injury, it would reduce risk of major injury.” V33 stated that fall risk assessments are performed for all residents on admission, readmission, quarterly or when a resident has a fall incident. V33 stated that the quarterly fall risk assessments are performed because residents’ fall risk needs may change over time, and it helps to distinguish the level of fall risk by looking at predisposing factors such as cognition, needing assistance with toileting, types of medications, and any falls previous. V33 stated that performing these fall risk assessments every 3 months allows staff to identify and determine changes in the residents’ medical, mental or physical status. Facility policy titled “Falls Guideline” and dated August 2024 documents, in part, “Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and developed an organization-wide ownership for fall prevention to: To achieve each resident’s maximum potential of physical functioning. To prevent or reduce injuries related to fall. To enhance residents’ dignity and self-worth. To rehabilitate residents to their fullest potential of function. Falling is an unintentional change in position coming to rest on the ground floor or onto the next lower surface … The intent of this guideline is the (to) ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following processes: I. Identification of hazards and risks II. Evaluation III. Implementation IV. Monitoring V. Analysis. Responsible Party: IDT (Interdisciplinary Team). Fall Risk evaluation: A fall evaluation is used to identify individuals who have predicting factors for falls. This is evaluation is completed upon admission, quarterly, annually and with a significant change in condition. Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Preventable measures shall be taken to decrease the number of falls whenever possible. Purpose: 1. To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately. 2. To Achieve each resident’s maximum potential of physical functioning. 3. To Prevent or reduce injuries related to falls. 4. To enhance residents’ dignity and self-worth. 5. To rehabilitate residents to their fullest potential of function. 6. Individualize interventions for each resident. Evaluation May Include: residents with recent surgery or new admissions; psychotropic drug use; fall history; appropriate clothing and footwear; visual deficit; impaired mobility functional status; incontinence; change of environment; cognitive status; mood or behavior indicator; underlying illness and disease processes; sensory status; orthostatic hypotension … implement resident specific interventions/precautions.” Facility job description (undated) titled Certified Nursing Assistant documents, in part, Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and Responsibilities: . Adhere to professional standards, company policies and procedures. 2. On 08/04/25 V2 (Director of Nursing, DON) presented a facility census of 29 residents on the first-floor unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 13 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 0689 Level of Harm - Minimal harm or potential for actual harm On 08/04/25 at 11:52am, Surveyor observed 2 oxygen cylinder tanks in R131's room leaning up against the wall behind a chair and not in a holder. On 08/04/2025 at 11:53am, R131 stated those are empty oxygen tanks that the hospital loaned him on his last visit. Residents Affected - Some On 08/04/25 at 11:58am, surveyor brought this observation to V3 (Staffing Coordinator) attention. V3 stated oxygen tanks should not be free standing and should be in a holder and V3 proceeded to remove the oxygen tanks from the room with no holder. On 8/06/2025 at 11:18am V35 (Licensed Practical Nurse) stated empty oxygen tanks should be stored in the oxygen room with a tag on it and it should be in a holder. V35 stated storing a free standing oxygen tank could fall and be a big problem. On 8/06/2025 at 3:15pm V2 (Director of Nursing-DON) stated oxygen tanks are supposed to be stored in a holder and the purpose of storing them in a holder is to ensure the safety of all residents. Policy and Procedure for Portable Oxygen with an updated date of 5/21/2020 documents, in part, all E cylinders must be placed in carrier device before use and follow all safety precautions when using and storing E cylinder. All empty tanks go on a specific empty tank rack. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 14 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 - 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 contain oxygen equipment (nebulizer masks) per facility's policy. This failure affected four residents (R11, R47, R113, R143) reviewed for oxygen equipment, in a total sample size of 77 residents.Findings include: Residents Affected - Some R11’s medical diagnoses include but are not limited to chronic pulmonary embolism, essential hypertension, asthma with acute exacerbation. R113’s medical diagnoses include but are not limited to chronic obstructive pulmonary disease, pleural effusion, heart failure, chronic atrial fibrillation, shortness of breath. R113’s physician order dated 11/13/2023 documents in part, “change nebulizer administration device.” On 08/04/25 at 10:30am R11’s nebulizer face mask observed on R11’s nightstand not contained in a bag. On 08/04/25 at 10:33am R113’s nebulizer face mask observed on R113’s nightstand not contained in a bag. On 08/04/25 at 10:37am V5 (Unit Manager) stated that R11’s nebulizer face mask is not in a bag. V5 stated that R11’s face mask should be in a bag for infection control reasons. V5 stated that R113’s face mask is not contained and should also be in a bag. Facility’s undated policy titled “Oxygen Therapy and Devices” documents in part, “Purpose: Oxygen is a basic human need. Without it, we would not survive. The air that we [NAME] contains approximately 21% oxygen. For most people with healthy lungs, this is sufficient, but for some people with certain health conditions whose lung function is impaired the amount of oxygen that is obtained through normal breathing is not enough. Therefore, they require supplemental amounts to maintain normal body function…4). Simple Mask… f. Place in a labeled bag when not in use.” R47’s face sheet dated August 6,2025 documents in part, “R47’s initial admission date was 2/24/2022 and diagnosis listed: Benign neoplasm of meninges, seizures, migraines, diabetes mellitus, mild protein calorie malnutrition, major depressive disorder, essential hypertension, hypertensive heart disease, anemia, acute kidney failure, gastro esophageal reflux disease. R47’s Physician order summary report dated 8/4/2025 documents in part, that R47 is receiving medication for the treatment of pneumonia; “Azithromycin 500 milligram (mg) 1 tablet in the morning every day x 5 days for pneumonia dated 7/30/25 until 8/4/2025,Amoxicillin-Pot Clavulanate Oval tablet 875-125 mg give 1 tablet by mouth every 12 hours for pneumonia dated 7/30/25 until 8/5/2025”;Ipratroplum-Albuterol Solution 0.5-2.5 (3) mg/milliliters (ml), 3 ml inhale orally every 6 hours as needed for shortness of breath or wheezing via nebulizer”. R47’s Cognitive Patterns/brief interview for mental status dated May 5, 2025 documents in part, that “R47 has a score of 10 which means R47 has moderate cognitive impairment”. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 15 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R47’s care plan dated 8/5/2025 documents in part, “R47 has oxygen therapy/ nebulizer treatment orders as needed related to Pneumonia and respiratory illness; staff to administer nebulizer treatments per physician’s orders”. On 8/4/25 at 11:50am, R47’s was not in room her nebulizer machine was plugged into the wall socket and mask was sitting on bedside table not contained in any bag or covering over the device. On 8/4/25 at 11:51am, V17 Registered Nurse stated she was the nurse for R47 and that she wasn’t aware that the mask was not contained because she did not give her a treatment this morning. V17 said there are infection control concerns because the mask could become contaminated with dust or could possibly fall on the floor. V17 went to retrieve a plastic bag to cover the mask. On 8/4/2025 at 11:53am, V16 Licensed Practical Nurse/ Unit manager stated the mask for R47 should be contained in a plastic bag to decrease risk of contamination of the mask which could result in R47 becoming sick with respiratory issues, staff is aware that mask should be contained in plastic bag when not in use. On 8/4/25 at 11:56am R47 was observed in 2nd floor dining room watching television she was alert and responsive and reported that she does use oxygen and nebulizer treatments when she becomes short of breath at times and the nurses provide the treatments to her. R47 stated she is aware that she has pneumonia and is receiving antibiotic treatment that will be over in a few days. On 8/6/25 at 11:54am, V2 Director of Nursing stated nebulizer mask should be stored in plastic bag for infection control purposes, nebulizer mask should be contained and if nebulizer mask is not contained it could possibly result in infection to residents. R143’s Face sheet shows that R143 has diagnosis which include but not limited to chronic obstructive pulmonary disease, presence of heart assist device, other mechanical complication of other cardiac and vascular devices and implants subsequent encounter, heart failure, and primary pulmonary hypertension. R143’s Brief Interview for Mental Status (BIMS) dated 07/13/25 shows that R143 has a BIMS score of 15 which indicates that R143 is cognitively intact. R143 Physician Order Sheet (POS) shows active orders as of 08/04/25 with orders for Ipratropium Bromide inhalation solution 0.02% (Ipratropium Bromide) 2.5 inhalation inhale orally four times a day for shortness of breath/dyspnea related to heart failure, unspecified (150.9) Chronic obstructive pulmonary disease unpacified (j44.9). On 08/05/25 at 10:45 am, Surveyor observed R143’s nebulizer mask on top of R143’s Left Ventricular Assist Device (LVAD) not contained in a bag. R143 stated R143 uses R143’s nebulizer machine daily and sometimes R143’s nebulizer mask is placed in a bag and sometimes it is not. R143 could not recall the last time R143’s nebulizer mask was placed in a plastic bag when it was not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 16 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to lock the 3rd floor emergency crash cart and failed to double lock refrigerated controlled substances which affected R6, R8, R10 and R174 and has the potential to affect the 58 residents residing on the 3rd floor when reviewed for medication storage. Findings include:On [DATE] at 11:23 AM, this surveyor observed the 3rd floor emergency crash cart unlocked with the latch handle opened, and no facility staff observed in front of or near this cart. The 3rd floor emergency crash cart is observed in the 3rd floor hallway positioned outside the dining room doorway closest to the elevator.On [DATE] at 11:27 AM, this surveyor requested that V25 (Registered Nurse, RN/Nurse Supervisor) come over to the 3rd floor emergency crash cart, and upon arrival to this cart, V25 observed and stated that this cart is unlocked. When asked what contents were inside the 3rd floor emergency cart, V25 opened each one of the 4 drawers, showing this surveyor (while saying the name of each item aloud) all of the emergency medical items found which are listed on the 3rd floor emergency cart checklist (oxygen masks, tubing and airways; suction equipment; vital signs equipment; medical supplies; intravenous (IV) supplies; IV fluid bags; PPE (personal protective equipment); and general equipment). V25 stated that nurses, including V25, are responsible for locking the 3rd floor emergency crash cart to ensure that all emergency supplies are present, available, and not missing, if a resident has any medical emergency, like a code blue, on this floor. V25 stated that nurses perform daily checks with the emergency cart checklist to ensure that all supplies are in the cart, will fill out the check list and then will lock the emergency cart with a cable tie lock so the drawers cannot be opened. V25 stated that it's important that nurse monitor this cable tie lock on the 3rd floor emergency cart due to some of the floor's dementia residents walking by and thinking that it's a toy.Facility document titled 3rd Floor: Emergency Cart Check List dated for [DATE] documents, in part, the following items in the 4 drawers (indicated by check marks on dates [DATE] to [DATE]): adult oxygen mask, non-rebreather mask, adult nasal cannula, oxygen meter adapter, adult airway, flashlight, extra batteries, Yankauer suction tube, blood pressure cuff, stethoscope, oxygen sensor, suction catheter kits, 2 bottles of saline, band aids, alcohol wipes, tongue depressors, roll tape, primary IV tubing, extension sets, 1 liter Normal Saline bag, IV start kits, J loops, IV angiocaths, red bags, sharps container, PPE, gloves, and electrical cord. On [DATE] and [DATE], there are blank spots (no check marks) noted for the two entries of cart cleaned and locked and breakaway lock intact and in place.On [DATE] at 1:00 PM, V26 (RN) observed with keys on V26's person and requested to perform a check of V26's medication cart which V26 stated is the east medication cart. V26 used one of the keys on the ring to open the east medication cart. V26 and this surveyor viewed the controlled substances in this medication cart. V26 flagged 5 pink pharmacy sheets in the controlled substance folder to continue the controlled substance check in the 3rd floor medication room, since these 5 controlled substances are stored in the refrigerator in the locked medication room. V26 opened the medication door with a key from the key ring, and then V26 opened the refrigerator door by lifting up the latch from the top of the refrigerator where there is a key lock. V26 did not insert a key into the lock to open the latch. V26 opened the refrigerator and pulled out the 5 refrigerated controlled substances and sets them on top of the counter. V26 showed this surveyor each of R6's (2 Lorazepam elixir containers), R8's (1 Lorazepam elixir container), R10's (1 Lorazepam elixir container), and R174's (1 Lorazepam elixir container) for accurate controlled substance counts while verifying each amount on R6, R8, R10 and R174's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 17 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 - Some individual controlled substance records of 30 milliliters. V26 placed the 5 controlled substances (Lorazepam) back into the refrigerator, and this surveyor asked V26 about the refrigerator lock. V26 stated that V26 will lock it now. V26's tried to put each key into the refrigerator lock's hole to lock it with no success. V26 opened the medication room door and asked V27 (Licensed Practical Nurse, LPN) at the nurse's station for V27's keys. V27 observed handing V27's keys to V26, who then tried each one of these keys with no success. V27 next tried to insert V27's keys into the refrigerator lock to lock it with no success. V27 stated that the refrigerator lock key is a silver key, and it's usually on the set of V26's key ring (with no silver key noted).On [DATE] at 1:21 PM, V25 (RN/Nurse Supervisor) stated that the refrigerator lock has been broken for a few days, and I (V25) am getting it fixed.R6's Individual Controlled Substance Record documents, in part, that Lorazepam (concentration of 2 mg/ml {milligrams/milliliter}) with a date received of [DATE] and has a quantity received of 30 ml. R6 also has another Individual Controlled Substance Record (with a #6 hand written on the top of the page) which documents, in part, that Lorazepam (concentration of 2 mg/ml) with a unclear date received (the month is not clearly written-not readable-followed by a forward slash and 22) and has a quantity received of 30 ml. No Lorazepam doses have been documented as given on either of R6's Individual Controlled Substance Record documents.R6's admission Record documents, in part, diagnoses of dementia, combined systolic (congestive) and diastolic heart failure, polyneuropathy, major depressive disorder, hypertension, acute embolism and thrombosis of vein, atherosclerotic heart disease, schizophrenia, and senile degeneration of brain.R8's Individual Controlled Substance Record documents, in part, that Lorazepam (concentration of 2 mg/ml) with no date received and has a quantity received of 30 ml. No Lorazepam doses have been documented as given.R8's admission Record documents, in part, diagnoses of dementia, hypertension, type 2 diabetes mellitus, atrial fibrillation, hyperlipidemia, dermatitis, acute embolism and thrombosis of unspecified deep veins of lower extremities, reduced mobility, unsteadiness on feet, and dysphagia.R10's Individual Controlled Substance Record documents, in part, that Lorazepam (concentration of 2 mg/ml) with no date received and has a quantity received of 30 ml. No Lorazepam doses have been documented as given.R10's admission Record documents, in part, diagnoses of dementia, adult failure to thrive, lack of coordination, unsteadiness on feet, malignant neoplasm of breast, hyperlipidemia, and hypertension.R174's Individual Controlled Substance Record documents, in part, that Lorazepam (concentration of 2 mg/ml) with a date received of [DATE] and has a quantity received of 30 ml. No Lorazepam doses have been documented as given.R174's admission Record documents, in part, diagnoses of dementia, Alzheimer's disease, personal history of transient ischemic attack (TIA), muscle wasting and atrophy, speech and language deficits following other cerebrovascular disease, primary open-angle glaucoma, blindness right eye category 3, peripheral vascular disease, lack of coordination, hypertension, bullous keratopathy, and pressure ulcer of left hip.On [DATE] at 1:28 PM, V2 (Director of Nursing, DON) stated that controlled substances are to be stored under double locks. V2 stated that if a controlled substance is refrigerated in the medication room, the nurse must lock the medication room door and lock the refrigerator lock for the double lock to be in place. V2 stated that the emergency crash cart is to be locked at all times when not in use.Facility resident roster titled Midnight Census Report and dated [DATE] documents, in part, that 58 residents reside on the 3rd floor.Facility policy (undated) titled Pharmaceutical Storage Policy documents, in part, Policy: it is the policy of this facility that drugs and biologicals shall be stored in a safe, sanitary and orderly manner at the proper temperatures. Policy Specification: To establish guidelines for the control and storage of drugs and biologicals. Responsibility: Consultant Pharmacist, Director of Nursing, Licensed Nurses, Qualified Medication Aide. Standards: . 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 18 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Medication and treatment cabinets or shall be locked at all times . 5. Only authorized personnel shall handle, distribute or administer drugs and biologicals . 8. Individually prescribed Schedule II drugs, shall be in separate containers under double lock and stored in a substantially constructed box, cabinet or mobile drug storage unit.Facility policy (undated) titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) documents, in part, Purpose: The purpose of his procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest. Preparation: . 3. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. Event ID: Facility ID: 145977 If continuation sheet Page 19 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 observation, interview, and record review the facility failed to follow infection control protocol by not displaying the correct isolation sign for two residents (R66 and R143); failed to ensure that Enhanced Barrier Precaution (EBP) sign was visibly posted for three residents (R209, R210 and R211) who require EBP; and failed to ensure staff perform hand hygiene during dining for three residents (R125, R130 and R190). Theses failures affected eight residents (R66, R125, R130, R143, R190, R209, R210, and R211) reviewed for infection control and has the potential to place all 198 residents at risk for the spread of infection.Findings include: Residents Affected - Many #1 On 08/04/2025 at 12:28pm on the 4th floor dining/activity room, V11 (Activity Aide) set up R11's food tray. After setting up R11’s food tray, V11 moved R11’s wheelchair closer to the table. On 08/04/2025 at 12:30pm, V11 took another food tray from the food cart without performing hand hygiene and set up the food tray in front of R190. After setting up the food in front of R190, this surveyor inquired about hand hygiene. V11 stated she is supposed to sanitize her hands before setting up her (R190) food tray but she forgot. On 08/05/2025 at 12:15pm, V22 (Infection Preventionist/LPN) stated the expectation is for the staff to wash their hands after contact with the resident’s wheelchair prior to serving another resident’s tray to prevent from passing on any type of contamination or germs. V22 added “We need to have clean hands when we serve food.” R11’s (Active Order as of: 08/05/2025) Order Summary Report documented R11’s Diagnoses: (include but not limited to) history of falling, hemiplegia and hemiparesis, and asthma with acute exacerbation. R11’s (06/26/2025) Minimum Data Set documented, in part “Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06.” Indicating R11’s mental status as severely impaired. Section GG0170. Q5. Does the resident use a wheelchair and/or scooter: 1- Yes.” R190’s (Active Order as of: 08/05/2025) Order Summary Report documented R190’s Diagnoses: (include but not limited to) epilepsy, muscle wasting and atrophy, and mild protein malnutrition. R190’s (06/11/2025) Minimum Data Set documented, in part “Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 07.” Indicating R190’s mental status as severely impaired. The (undated) Passing Meal Trays documented, in part “Policy: Nursing will be responsible for preparing residents for scheduled meal service. Policy Specifications: Dining Room Meal Service: Designated Staff will be responsible for distributing the beverages prior or during meal service. 3. Sanitize hands routinely.” (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 20 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 The (08/05/2025) email correspondence with V2 (Director of Nursing) documented, in part “Staff should utilize the hand sanitizer in dining room, after touching wheelchairs hands should be sanitized.” The (8/2024) Standard precautions Guidelines documented, in part “Standard Precautions are used for all patient care. They’re based on a risk assessment and make use of common sense practices and personal protective equipment used protect healthcare providers from infection and prevent the spread of infection from patient to patient. Implementation of standard precautions constitutes the primary strategy for preventing healthcare associated transmission of infectious agents among resident and healthcare personnel. Appropriate infection control measures should be used in each resident interaction. Standard Precautions include but not limited to hand hygiene. Equipment or items in resident environment likely to have been contaminated with infectious fluids or other potentially infectious matter must be handled in a manner so as to prevent transmission of infectious agents. Standard precautions are also intended to protect a residents by ensuring healthcare personnel do not carry infectious agents to residents on their hands or via equipment used during resident care.” The (undated) handwashing/Hand Hygiene Policy documented, in part “It is the policy of the facility to assure staff practice recognized handwashing/hand hygiene procedures as a primary means to prevent the spread of infections among residents. Policy Specifications: 4. When hands are not visibly soiled, employees may use an alcohol-based hand rub containing at least 60% alcohol in all of the following situations: n. during resident meal service: in between tray pass if contact with resident is made, hand hygiene should be used.” #2 On 08/04/2025 at 11:19am, R209 was seated on a chair. R209’s right foot was covered with [NAME] sheet, supported by a half cast, and wrapped with ace bandage. R209 stated he was on a car accident and the hospital put 2 screws in his right foot. This surveyor went outside the room, there was no EBP (enhanced barrier precaution) sign posted by R209’s door and no PPE bin available. On 08/04/2025 at 2:41pm with V5 (Unit Manager/LPN) by R209’s door. V5 stated there was no EBP sign posted by R209’s door and no PPE bin outside of the room. On 08/04/2025 at 2:47pm, V22 (Infection Preventionist/LPN) stated if a resident came in with surgical incision, the expectation is to place the resident on EBP (enhanced barrier precaution) to keep the wound from getting infected. There should be an EBP sign posted by his door and PPE bin available, so the staff is aware of what to wear when doing ADL (Activities of Daily Living) care. On 08/05/2025 at 3:23pm, there was an EBP sign posted by R209’s door and PPE bin across the room. V5 stated the EBP sign should have been posted and PPE bin available on 08/01/2025, the day he was admitted . On 08/06/2025 at 12:45pm, V2 (Director of Nursing) stated the resident has a surgical incision and should be placed on EBP. R209's admission Record documented R209's admission date was on 08/01/2025. R209’s (Active Order as of: 08/05/2025) Order Summary Report documented, in part (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 21 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 “Diagnoses: (include but not limited to) pathological fracture, hypertension, and Opioid abuse. Order Summary. Maintain Enhanced Barrier Precautions to prevent infection r/t (related to) surgical incision. Order Date: 08/05/2025.” Of note, order was placed 4 days after admission. R209’s (08/01/2025) Hospital External Transfer Report documented, in part “Diagnosis: Motor vehicle collision. Closed nondisplaced fracture of right calcaneus (heel bone). Surgery Performed: 7/26/2025 Right calcaneus ORIF (open reduction internal fixation). [NAME] (Active Wounds, Airways, Lines, Drains, Ostomies): Surgical/Procedure: Surgical Incision Posterior Right heel. Hospital course and therapy. Underwent ORIF right calcaneus.” R209 (08/05/2025) care plan documented, in part “requires Enhanced Barrier Precautions d/t surgical incision. Enhanced Barrier Precautions will reduce the spread of the infectious agent, minimize the transmission of the infection, and reduce the risk of colonization. Interventions: Follow facility's Infection Control and Enhanced Barrier Precautions policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen, disinfecting equipment, etc. Gown and glove use when performing high-contact resident contact activity. Have adequate PPE available. Practice good handwashing.” The (03/21/2024) Enhanced Barrier Precautions documented, in part “It is the practice of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of multidrug resistant organisms. Definitions: “Enhanced Barrier Precautions” refer to the use of gown and gloves for use during high contact resident care activities for resident known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices. Explanation and Compliance Guidelines: 1. Prompt Recognition of need: c. Clear signage will be posted on the door or wall outside of the resident room indicting the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities require the use of gown and gloves. 2. Initiation of Enhanced Barrier Precautions – b. implement Enhanced Barrier Precautions for resident with unhealed surgical wounds. 3. Implementation of Enhanced Barrier Precautions – a. make gowns and gloves available immediately outside of the resident’s room.” R66’s Face sheet shows R66 has diagnosis which include but not limited to infection and inflammatory reaction due to other internal prosthetic devices, implants, and grafts, presence of heart assist device, viral infection, and resistance to vancomycin. R143’s Face sheet shows R143 has diagnosis which include but not limited to presence of heart assist device, other mechanical complication of other cardiac and vascular devices and implants subsequent encounter, and acute osteomyelitis. R210’s Face sheet shows R210 has diagnosis which include but not limited to encounter for surgery aftercare following surgery on the digestive system. On 08/04/25 at 10:38 am, R66 and R143’s room door was observed with a sign stated, “Enhanced Barrier Precaution (EBP).” R66 and R143 were both observed with LVAD (left ventricular assistive device) next to R66 and R143’s bed side. R143 was observed with and IV (intravenous) pump next to R143’s bedside did not have any IV medication infusing into R143. R143 was observed with a PICC (Peripherally Inserted Central Catheter) to R143’s right arm. R143 stated R143 was receiving IV antibiotics for infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 22 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 On 08/04/25 at 10:49 am, R210’s room door was observed with Personal Protective Equipment (PPE) and without any visible signage posted (EBP or isolation sign). V13 (Registered Nurse, RN) stated, “He is on Enhanced Barrier Precaution (EBP) I took his sign down and threw it in the trash today because it was ripped and needed to be replaced. I just asked V22 (Infection Preventionist, Licensed Practical Nurse, LPN) to print another sign.” Surveyor and V13 then observed the trash can V13 stated she had thrown R210’s ripped EBP sign in and Surveyor and V13 did not observe any isolation signs ripped in the trash can(s) on the fourth-floor unit. V13 then stated she was going to get R210 a EBP sign for R210’s door. V13 explained residents should have the proper isolation signs on the residents door, so staff know what type of isolation the resident requires before entering the room. V13 then explained if residents don’t have the proper signage on the residents door it may cause a cross contamination. On 08/05/25 at 3:21 pm, Surveyor and V22 (Infection Preventionist, Licensed Practical Nurse, LPN) observed R66 and R143’s room with a sign on the door stated, “Enhanced Barrier Precaution” V22 stated R66 and R143 were on EBP precautions for having a LVAD (Left Ventricular Assist Device). When V22 was asked regarding R210 with no EBP sign on R210’s door, V22 stated, “R210 moved from the first floor to the fourth floor and his EBP sign did not go with him.” V22 explained every resident on isolation and EBP should have a sign visibly posted on the residents door regarding the residents isolation or EBP. V22 also explained residents on isolation and EBP should have an order for EBP on the residents Physician Order Sheet (POS) regarding the residents isolation or EBP type to prevent transmission of infection and so staff know what precautions to take with the residents during care. R66 Physician Order Sheet shows active orders as of 08/04/25 with orders for “Maintain contact/isolation for VRE/MDRO (vancomycin-resistant enterococci/ Multidrug-Resistant Organisms) of driveline site. However, surveyor and V22 observed R66’s room with EBP sign posted on R66’s door. R143 POS show active orders as of 08/04/25 with orders for “Maintain contact/isolation for MDRO (Multidrug-Resistant Organisms) Candida Auris of driveline site. However, surveyor and V22 observed R143’s room with EBP sign posted on R143’s door. R210 POS show active orders as of 08/06/25 with orders for Maintain enhanced barrier precautions to prevent infection r/t (related to) _ colostomy every shift. However, surveyor did not observe R210 with a EBP sign posted on R210’s door. The facility policy dated 01/20/2024 and titled “Enhanced Barrier Precautions” documents, in part: “Guideline: It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms … c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precaution, required personal protective equipment (PPE), and the high-contact resident care activities require the use of gown and gloves.” The facility policy dated 01/20/2024 and titled “Isolation Categories for Transmission-based Precautions” documents, in part: “Purpose: Identify appropriate transmission-based precautions … Policy Interpretation and Implementation: 2. Signage must be placed near entry to resident room when Transmission-based Precaution are necessary to indicate type of precaution and PPE (Personal Protective Equipment) needed.” (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 23 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 The facility undated document titled “Enhanced Barrier Precaution/Contact isolation shows R66, R143 and R210 is on Enhanced Barrier Precaution/Contact isolation. The facility undated document titled “Contact Isolation” does not show R66 and R143 receiving contact isolation. Residents Affected - Many On 8/5/25 at 12:42 pm, Surveyor conducted the laundry tour with V30 (Housekeeping Director) and observed the following: Upon entry of the laundry door, next to the folding table on the floor, 4 linen blankets. V30 stated. “I don’t know why these are on the floor.” Upon entry of the laundry door to the left underneath a table on the floor 2 flat linen sheets holding up a fan. V30 stated, “They are using the sheets to prop of the fan and get some air.” Next to the linen carts 3 bags of residents personal laundry on the floor. V30 stated, “These are clean. They were just washed. I know they shouldn’t be on the floor.” On 08/05/25 at 12:50 pm, V30 stated, “Nothing should be on the floor. is cross contamination.” The facility policy dated 11/01/2023 and titled “Laundry Services Policy” documents, in part: “Policy: It is the policy of this facility to provide and in-house laundry service for linens and resident personal laundry in a safe and sanitary manner … Policy Specifications: To ensure proper handling of soiled and clean linen and personal laundry to prevent spread of infection disease … 6. Resident personal laundry will be identified by sew-on labels or indelible ink, by the facility staff. Personal clothing and belongings shall be handled, stored, processed, and transported to ensure safe keeping and timely return to the resident in good condition. 7. The laundry staff shall store, process, and transport all linens and resident personal laundry in accordance with procedures which ensure safety and sanitary conditions to prevent the spread of infection … 13. The Laundry Department shall adhere to all infection control policies and procedure including those established for isolation.” The facility undated job description titled “Laundry Aide” documents, in part: “Summary: the primary purpose of this job position is to assist in providing exceptional cleaning services to our residents. The incumbent will work with all departments to ensure our residents are receiving the highest caliber of service during their stay. Essential Duties and Responsibilities: adhere strictly to rules regarding health safety and be aware of any company related practices.” R125’s medical diagnoses include but are not limited to chronic obstructive pulmonary disease, cognitive communication deficit, feeding difficulties, essential hypertension. R130’s medical diagnoses include but are not limited to pneumonia, Alzheimer’s disease, lack of coordination, weakness, schizoaffective disorder. R211’s medical diagnoses include but are not limited to pain in left foot, immunodeficiency, interstitial pulmonary disease, essential hypertension. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 24 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 R211’s care plan dated 07/25/25 documents in part, “R211 has an arterial/ischemic ulcer of the left toes 2-5 r/t (related to) peripheral arterial disease…R211 will be free form infection or complications related to arterial ulcer through review date.” R211’s physician order dated 07/28/25 documents in part, “Left foot: Cleanse with NS (normal saline), apply betadine and Abd pad, wrap with kerlix one time a day ever Monday, Wednesday, Friday for promote wound healing.” On 08/04/25 at 12:29pm V7 (Certified Nursing Assistant/CNA) observed pushing R130’s wheelchair to table. V7 then observed picking up a lunch tray and delivering lunch tray to R125. V7 did not perform hand hygiene between activities. V7 then observed adjusting R125’s body alignment then going back to lunch cart to continue passing tray without performing hand hygiene. On 08/04/25 at 12:31pm V7 (CNA) stated she should have performed hand hygiene between assisting residents. V7 stated everything she touches is considered contaminated. On 08/04/25 at 3:05pm, R211 observed with left foot bandage. No EBP (Enhanced Barrier Precaution) sign observed on R211 room door. On 08/04/25 at 3:06pm V14 (Licensed Practical Nurse/LPN) stated R211 has a wound. V14 stated there is no EBP posted for R211, and staff should be using PPE (personal protective equipment) when caring for R211. On 08/06/25 at 10:14am V22 (Infection Prevention Nurse/IP) stated residents with wounds should be placed on EBP and PPE should be worn when caring for these residents. Facility’s policy titled “Handwashing/Hand Hygiene Policy” dated 03/2020 documents in part, “Policy: It is the policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids…4. When hands are not visibly soiled, employees may use an alcohol-based hand rub (foam, gel, liquid) containing at least 60% alcohol in all of the following situations:…b. after direct contact with a resident but prior to direct contact with another resident…k. after contact with objects such as medical devices or equipment in the immediate vicinity of a resident may be potentially contaminated:…during resident meal service: in between tray pass if contact with resident is made hand hygiene should be used; when removing trays hand hygiene should be used before contact with fresh tray or with a resident.” Facility’s policy titled “Enhanced Barrier Precautions” with revision date 03/21/24 documents in part, “it is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms….Definitions: “Enhanced barrier precautions” refers to the use of gown and gloves for use during high-contact resident care activities for residents know to be colonized or infected with a MDRO (multi-drug resistant organism) as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices)…Explanation and Compliance Guidelines: 1. Prompt recognition of need:…c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities require the use of gown and gloves…2. Initiation of Enhanced Barrier (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 25 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 Precautions…b. Implement enhanced barrier precautions for residents with any of the following: i. Wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers).” Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 26 of 27 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based upon observation, interview and record review, the facility failed to empty the lint compartment and lint filter in an effort to provide safe environment to residents. This failure has the potential to affect all 198 residents in the facility. Findings include: On 08/05/25 at 12:42 pm, Surveyor and V30 (Housekeeping Director) toured the laundry area and observed dryer number 1 with the lint compartment that had a large amount of lint visible and not emptied. V30 stated the laundry staff is expected to check the lint traps and empty the lint every two hours. V30 stated the lint traps cleaning is signed off and logged by the staff every two hours. V30 stated that the lint traps should be cleaned every two hours to prevent a fire.On 08/05/25 at 12:45 pm, Surveyor and V30 observed the lint trap logbook with no staff signatures, not completed for 08/05/25.The facility document dated 11/01/2003 and titled Laundry Services Policy documents, in part: It is the policy of the facility to provide and in-house laundry services for linens and residents personal laundry in a safe and sanitary manner . Standards: Monthly quality assurance audits include inspection of the removal of lint and external dry ducts. Inspections are recorded and monitored by the Environmental Services Director . 18. Cleaning schedules for laundry equipment and area are in writing, posted for staff and adhere to. The facility document dated August 2025 and titled Lint Trap Cleaning Log shows no signatures for lint traps being checked on 08/05/25.The facility undated job description titled Laundry Aide documents, in part: Summary: the primary purpose of this job position is to assist in providing exceptional cleaning services to our residents. The incumbent will work with all departments to ensure that our residents are receiving the highest caliber of service during their stay. Essential Duties and Responsibilities: adhere strictly to rules regarding health safety and be aware of any company related practices. Event ID: Facility ID: 145977 If continuation sheet Page 27 of 27