Inspection·August 1, 2023

F 0573 Fax Transmission Sheet confirmed to be sent on 10/14/22 at 3:23PM to facility fax number. Level of Harm - Minimal harm or potential for actual harm Review of facility Medical Information policy (undated) reads: YOUR MEDICAL INFORMATION RIGHTS Residents Affected - Few Inspect and/or obtain a copy of your medical information. You have the right to inspect and/or obtain a copy of your medical information maintained in a designated record set. If we maintain your medical information electronically, you may obtain an electronic copy of the information or ask us to send it to a person or organization that you identify. To request to inspect and/or obtain a copy of your medical information, you must submit a written request to our Privacy Officer. If you request a copy (paper or electronic) of your medical information, we may charge you a reasonable, cost-based fee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 2 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 that incontinence care was provided for four (R2, R6, R7 and R12) of four residents reviewed for activities of daily living this failure has the potential to affect all 37 residents currently residing at the facility. Residents Affected - Some Findings include: 7/29/23 at 7:08AM, V5 (CNA) was observed telling V17 that R12 had to get ready to go to dialysis and that V5 was tied up with another resident and asked V17 to please help R12. V5 notified V17 that R12 needed one person assist because she is blind. V17 (LPN) agreed and then proceeded to R12's room to provide R12 assistance with ADL's (Activities of Daily Living). R12 asked V17 to please provide incontinence care because no one had changed her since yesterday. Surveyor observed that incontinence brief was soaked with urine and feces. Surveyor asked R12 if anyone had provided incontinence care to her overnight and R12 said, No, the last time I was changed was yesterday morning. All day yesterday no one changed me. 7/29/23 at 7:27AM Surveyor asked V1 (Administrator) why there were no CNA's in the building last night and why V4 (LPN) was the only staff on duty to care for all 37 residents. V1 said that she thought there were two CNA's scheduled to work last night; one CNA called and said she would be late but then never showed up and the other CNA apparently was not scheduled to work. V1 added that the former Director of Nursing had made the July schedule before resigning and that V1 would be responsible for making the August schedule and was planning to start working on it. V1 was asked if the facility ever uses a staffing agency and V1 responded that she had actually looked into yesterday (7/28/23) and showed surveyor a contract from a local staffing agency. V1 said that she filled out the contract yesterday because she thought she would need a nurse on duty but decided against it once she realized that V4 (LPN) was scheduled to work last night so it wasn't necessary to use agency staff. At 11:17AM, R7's mother went in to R7's room and came out immediately complaining and yelling in the hall about R7's condition. Surveyor asked permission to enter R7's room and R7's mother said, yes, look at my son. He is soaked and dirty. Someone better get in here right now and clean him up. R7's mother was visibly upset, using foul language and walked out of the room to get staff assistance. R7 was noted to be in bed, with incontinence brief visibly soiled and sheets soaked and stained. R7 has communication deficits and could not respond to questions. Surveyor noted V18 (CNA) in the hall and asked if she had provided any care for R7 today and V18 said, no, that's not my side; I think that side belongs to V5 (CNA) but she is in with another resident right now. On 7-29-2023 6:00am V4- (Licensed Practical Nurse) observed to be in R6's room telling the patient, I am the only one here, you will need to wait for the morning shift to come and they will help you with morning care. V4 came out of the room and said, I did not have any Certified Nurse Assistant working with me last night, I was by myself. I did the best I could to keep the patients safe and I was not able to change them all. I called V1 (administrator) to let her know. I know we need to make rounds at least every two hours and provide incontinence care, but I was not able to do it last night, I was alone for 37 residents. R6 is a [AGE] year-old female originally admitted on [DATE] with medical diagnosis that include hypertension, major depressive disorder and personal urinary tract infections. Minimum Data Set (MDS) dated [DATE] Brief Interview for Mental Status (BIMS) score of 9/15 (Impaired cognition). MDS dated : (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 3 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5-13-2023 reads: R6 needs extensive assistance of one-person physical help for transfers, walking, dressing, and toileting. At 6:10am, R6 said I am soak and wet, I need help, I do not want to get another urinary infection, I am soak and wet. Last night no one was available to change me, this happens frequently, that I am urinated for long periods of time, for the nurses to come and change the undergarments. I do not like to feel dirty; I was always a well-kept person. At 6:25am V5 (Certified nurse assistant) said, I am the morning Certified Nurse Assistant, I come to work early because I like to get things done and ready as early as possible. We are supposed to make rounds every two hours and as needed, no patent should be let wet for long period of time, they can develop bed sores. I am going to take care of R6. At 6:30am incontinence care observation done, V5 (C.N.A) assisted R6 from the bed to the wheelchair and transported the R6 to the toilet, R6 observed to be able to stand and pivot to the toilet. V5 removed the incontinent brief that appeared to be soiled, V5 said is very heavy and soaked. R6 said please clean me well I smelled like urine. After R6 was cleaned V5 went to make R6's bed and said, I had to wait for the mattress to be clean/ disinfected by housekeeping because the urine penetrated all the linen up to the mattress and has a strong smell of concentrated urine. At 7:00am V4 (licensed practical nurse) told V5 (C.N.A) to clean R2 as soon as possible. R2 is a [AGE] year-old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: nontraumatic intracerebral hemorrhage, anxiety and hemiplegia and hemiparesis. R2 is nonverbal but can follow simple commands answering by nodding his head yes or no. MDS dated [DATE] reads; BIMS unable to be complete. MDS; dated 6-14-2023 reads R2 needs extensive assistance of two staff members for bed mobility, transfers, toileting, and personal hygiene. At 7:20am V5 went in to R2's room to provide incontinence care. R2 observed to have a brown substance in his hands all over the linen and in the mattress. V5 said, I know I need another person with me to perform the care on R2 but I am they only one here, I am going to do it by myself. V5 explained to R2 what she was going to do and R2 nodded his head in agreement. Incontinent care observation done. V5 said, I did not realize R2 was in such a bad shape, he has feces all over, all the bed linen are soiled. I must change everything from his bed. On 7-29-2023 at 12:00pm V8 (former Director of Nursing) said, We do have a big problem with staffing. We do not use any agency. We do not always have a Registered Nurse in the building for a 24-hour period. V8 added that she asked the Administrator and the owner multiple times to please consider using agency staff but they refused every time and assisted that the staffing was sufficient, even though V8 did not agree that the staffing was adequate to meet resident needs. On 7-30-2023 at 2:30pm V1 (Administrator) said, the floor nurse needs to make sure to pass the medications that are ordered, assist the residents as needed, answer the call, the nurse can provide incontinence care to all the residents that need to be change. Part of nursing is to provide incontinence care. The staff needs to be made rounds at least every 2 hours, and as needed, no resident should be soiled for extended period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 4 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete V1 presented undated policy titled: Incontinent Management Program Guidelines, reads: the purpose is to: prevent skin problems such as pressure areas and excoriation, improve the morale of the resident and restore the resident's dignity. Per Form 672 Resident Census and Conditions of Residents dated 7/31/23, there are currently 27 out of 37 residents in the facility who are occasionally or frequently incontinent of bowel and bladder. Event ID: Facility ID: 146013 If continuation sheet Page 5 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow physician orders in the administration of tube feedings for four (R1, R2, R7, and R11) residents and failed to administer IV antibiotic medication as ordered for one (R1) resident out of four residents reviewed for physician orders. Residents Affected - Some Findings include: R1's most recent re-admission to the facility, after hospitalization, was on 4/17/23. R1 physician orders included: Nothing by Mouth (NPO) diet, NPO texture Start Date 4/17/23 Jevity 1.5 at 270 ml bolus QID Start Date 4/17/23 Jevity is therapeutic nutrition for tube feeding. Review of medication administration record for April 2023 include no documentation that Jevity feeding was provided on the following dates/times: 4/19/23 0800 and 1200 4/20/23 1200 4/26/23 0800 Nursing Progress Note written by V8 (Former Director of Nursing) written on 4/26/23 12:46 reads: Note Text: writer went into residents' room to give afternoon feeding and Iv medication. Noted that resident was holding g-tube in her hand, it was dislodged from G-tube site. Daughter was notified. Daughter gave me the number to the intervention radiologist (named); Dr was paged waiting on a return call. No other documentation provided in medical record to show reason for missed doses of Jevity. Review of R1's physician orders include the following: Order Date 4/17/23, Start Date 4/17/23 Cefazolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Sodium) Use 2 gram intravenously three times a day for bacterial infection until 05/09/2023 23:59 CBC/ CMP weekly faxed to (physician name and fax number provided) while on abx (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 6 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of R1's MAR (Medication Administration Record) documentation includes the following: Level of Harm - Minimal harm or potential for actual harm 4/17/23 2200, 4/18/23 0600, 1400, and 4/19/23 0600 indicate that medication was not given; marked code 9 which means 9=Other / See Nurse Notes Residents Affected - Some 4/18/23 2200, 4/19/23 1400, and 4/20/23 1400 are blank with no code documenting reason not given Review of nursing progress notes for R1 include the following documentation: 4/19/2023 00:05 Nursing Progress Note written by V19 (LPN) reads: Note Text: Writer reached out to pharmacy regarding IV tubing, DON notified, and also reached out to pharmacy regarding IV tubing, awaiting response from pharmacy. 4/28/2023 14:08 Nursing Progress Note written by V8 (Former Director of Nursing) reads: Note Text: 4/18/23@ 9:30 pm Writer was made aware by the pm nurse that the facility was out of IV tubing. Resident did not receive Iv medication for 10pm dose. The nurse stated that she was told by pharmacy that they would need a pre-authorization signed by facilityrepresentee to receive tubing. Called the pharmacy consultant to expedite delivery. Tubing was received on 4/19/23 am. Iv medication was started at 12pm. Tolerated medication well. [sic] Interview with V8 (Former Director of Nursing) 7/29/23 at 12:00PM, V8 stated that R1's antibiotics got called in by the nurse when we admitted (R1). We couldn't get it from the pharmacy, and we didn't have it in the lock box. I told the daughter we didn't have it. I had to call the pharmacy to get tubing and supplies but she was very irate. I had to place a call to our representative at the pharmacy and she rushed it right over. When we received it, we gave it. When it was documented is when it was given. R2 was also reviewed for physician orders and the following was noted: Enteral Feed Order four times a day 200 cc FWF Phone Active 06/26/2023 Jevity 1.5 Cal @ 55ml/hr start time (12pm) Off time (8am) Start Date 6/17/23 Review of medication administration record for July 2023 include no documentation that enteral feed order was not given per physician orders on the following dates/times: 7/5/23, 7/7/23, 7/10/23, and 7/24/23 - no 0800 or 1200 feedings were documented as given 7/17/23, 7/21/23, and 7/22/23 - no 1600 or 2000 feedings were documented as given Observation of R2 on 7/28/23 at 1:52PM noted that tube feeding was running at 55ml/hr with approximately 900ml remaining in bag; bag was dated 7/28 with no time. Observation of R2 on 7/29/23 at 6:31AM noted that tube feeding was running at 55ml/hr with approximately 700ml remaining in bag; bag was dated 7/28 with no time. 7/29/23 at 8:05AM, V4 (LPN) was asked if the tube feeding bag had been changed for R2 and also how (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 7 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some long the feeding had been running since there was still about 700ml in the bag. V4 responded that she was the only person in the building last night and didn't have time, she remembered just pouring some more of the feeding in the bag around 12 o'clock or 1AM last night. V4 was asked how they keep track of how long the resident's feeding has been running or how much they are getting, and she stated that she was the only one working and didn't have time for any of that. V4 was also asked why R11 had orders for tube feeding but there was no set up in the room, nor was he set up for feeding based on observation this morning and V4 said, he only gets a bolus, and I gave it to him. Review of physician orders for R11 include: Nothing by Mouth (NPO) diet, NPO texture, NPO consistency Diet Active 6/15/2023 09:22 Enteral Feed Order every shift Give 350 ml every shift, free water flush ORDER START DATE 06/23/2023 Enteral Feed Order every 18 hours on at 6 am and off at 11:59p ORDER START DATE 06/16/2023 Review of medication administration record for July 2023 include no documentation that enteral feed order was not given per physician orders on the following dates/times: 7/5, 7/7, 7/10, 7/24 - day shift 7/17, 7/21, and 7/22 - evening shift 7/3 and 7/22 - night shift Review of medication administration record for July 2023 include no documentation that enteral feed order was not given per physician orders on the following dates/times: 7/2, 7/3, 7/4, 7/6, 7/7, 7/24, 7/27, 7/28 - not documented as given with code 9 (see nurses notes). Review of nurse progress notes does not include any documentation as to why tube feeding was not given. Multiple observations of R11 at various times on 7/28/23 and 7/29/23 noted that resident was not receiving tube feeding as ordered; there was no tube feeding set up in R11's room. V17 (LPN) was interviewed on 7/29/23 at 1:38PM and asked if R11 has been receiving his tube feedings per physician orders. V17 replied that this was her first day and she was not familiar with the resident but would check the electronic medical record and his orders. V17 proceeded to check orders with surveyor present and confirmed the order in the system. V17 stated that she would have to call the physician to confirm the orders because she wasn't sure what R11 should be receiving and was unclear as to how long the tube feeding should be running for based on how the order was written. V17 confirmed that up to this time she had not administered any tube feedings to R11. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 8 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm 7/31/23 at 3:55PM V1 (Administrator) was asked if she was aware of the order clarification V17 was going to get regarding R11's tube feeding and V1 said that she was not sure and would get back to surveyor. At 4:55PM V1 confirmed that she was not able to locate the tube feeding order for R11. R7 was reviewed for tube feedings and the following orders were included in current physician orders: Residents Affected - Some Nothing by Mouth (NPO) diet NPO texture, NPO consistency with Active date of 06/01/2023 Jevity 1.5) @(60) ML/HR Start Time: (12pm ) off Time: (8 am) Give Via G-tube. every shift for Dysphagia Active 06/01/2023 Review of medication administration record for July 2023 include no documentation that enteral feed order was not given per physician orders on the following dates/times: 7/5, 7/7, 7/10, 7/13, 7/24, and 7/28 - day shift 7/21, 7/22 - evening shift 7/14, 7/22 - night shift Review of nurse progress notes does not include any documentation as to why tube feeding was not given. Facility provided Physician Order policy (dated February 2017), which reads: Policy: Drugs will be administered only upon a clean, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders will be received only by licensed nurses or pharmacists and confirmed in writing by the physician. Electronic orders transmitted via NCPDP Script 10.6 will be accepted. Procedure: Elements of the Medication Order: 1. Medication orders specify the following: a. Name of medication b. Strength of medication, c. Dosage. d. Time or frequency of administration. e. Route of administration, if other than oral. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 9 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 f. Quantity or duration (length) of therapy. If not specified by prescriber on a new order, the duration is limited by automatic stop order policy. Level of Harm - Minimal harm or potential for actual harm g. Diagnosis or indication for Residents Affected - Some h. Medication Allergy. 1. Any dose or order that appears inappropriate considering the resident's age, condition, or diagnosis is verified with the attending physician. 2. PRN (as needed) orders also specify the condition for which they are being administered, c.g, as needed for pain, as needed for sleep Documentation of the Medication Order: 1. The physician's new orders may be received on the admission Physician's Order form, by telephone or handwritten on the Physician Order Sheet. All drug orders received via transfer sheet must be verified by the attending physician and transcribed onto the Physician Order Sheet. 2. Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet or the telephone order sheet if it is a verbal order, and the Medication Administration Record (MAR) or Treatment Administrative Record (TAR). 3. The following steps are initiated to complete documentation: a. Clarify the order b. Enter the orders on the medication order and fax the medication order to the provider pharmacy. c. Transcribed newly prescribed medications on the MAR or TAR. If a new order changes the dosage of a previously prescribed medication, discontinue precious entry by writing DC's and the date. 4. After completion, document each medication order noted on the physician's order form with date, time, and signature. Example Noted I:15 p.m., 3/28/16. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 10 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to follow their protocols and have interventions in place for one resident (R1) assessed at very high risk for skin breakdown and failed to document skin impairments upon admission. Residents Affected - Few Findings include: According to the Electronic Health Record (EHR) R1 is a [AGE] year-old female, was admitted on [DATE] and has a diagnosis that include and are not limited to: dementia, cardiomegaly, gastrostomy status and weakness. The Minimum Data Set (MDS) dated : 3-11-2023 showed R1's cognition is unable to be assessed/15, impaired cognition. MDS dated [DATE] reads: R1 needs extensive assistance of two staff members for bed mobility, transfers, and toileting. Extensive assistance of one person for: dressing, locomotion, eating and personal hygiene. On 7-28-2023 at 1:50pm V9 (R1's Family member) said, R1 was not getting the care she was supposed to, R1 developed a wound while she was at the facility, because she was not provided incontinence care or repositioning. I spoke with administration and told them; I was never informed that R1 had a wound until she was in the emergency room and they showed me the wound. According to R1's electronic medical records progress note dated: 2-15-2023 with small open area on the coccyx will refer to wound nurse. R1's Braden Scale for predicting pressure sore risk dated: 2-15-2023 results show a score of 6 very high risk. R1's note dated: 2-15-2023 skin assessment reads: site coccyx and right antecubital. No documentation of sizes and description of the area was able to be obtained. on 2-17-2023 skin assessment reads: other skin tear to left forearm, both entries do not describe the size or stage of the skin impairment. R1's care plan did not have any interventions for wound care management, no individualized care plan presented. On 7-28-2023 at 11:20am V3- (Licensed Practical Nurse) said R1 was here for a short period of time. We (referring to the nurses) do not do any wound assessments and rounds with the wound care doctor was the responsible of the former director of nursing (V8). On 7-29-2023 at 12:00pm V8 (former director of Nursing) said, I do remember R1, I know that R1's family member spoke to me regarding the wound that it was identified at the hospital and how unhappy the family member was with not knowing about the wound. I was responsible for measuring and rounding with the wound care doctor, I do not remember if R1 was seen by the wound care doctor. 7-30-2023 at 2:30pm V1 (Administrator) said, if a patient is observed to have any skin impairment, the nurse needs to call the Medical Doctor to report the open area, obtain orders, call the family, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 11 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few developed the plan of care and document. We also have the wound doctor here weekly to assess all the wounds in house. I was not able to find any wound care notes, shower sheets in R1's file or in medical records. 7-29-23 at 10:40am V6 (Medical Doctor) said, I do remember R1, she was at the long-term care facility for a very short time, a few months only. I do not remember that R1 had a wound, My expectation is that if the nurse identifies a wound, I need to be contacted and the wound care doctor to see the patient and to implement the care needed. According to local hospital skin integrity care note dated 2-9-2023 and 2-10-2023 reads: treatment surface: specialty bed, positioning device: pillow in place, reposition at least every other hour, care given; peri care, skin care and skin protectant. V1 (Administrator) presented policy (dated 4-11), Prevention of Skin Breakdown, reads in part: is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers to implement preventive measures and to provide appropriate treatment modality. Inspect the skin every shift with care for signs and symptoms of breakdown. Establish and individualized turning and reposition schedule. Complete shower day worksheet and document findings. Place on a pressure reduction or pressure relief surface in bed and wheelchair. The care plan is to be evaluated and revised on response, outcomes and needs of the resident. Assessed the pressure ulcer for location, size (measure length, width, and depth). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 12 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to follow their policy for tube feedings by not administering tube feedings per physician orders; failed to document that physician was notified of missed feedings; failed to follow nutrition recommendations per nutrition assessments; and failed to document tube feeding intake and/or administration for two (R7 and R11) of four residents reviewed for tube feedings. Findings include: R7 and R11 were reviewed for feeding tube care during this survey. Review of physician orders for R11 include: Nothing by Mouth (NPO) diet, NPO texture, NPO consistency Diet Active 6/15/2023 09:22 Enteral Feed Order every shift Give 350 ml every shift, free water flush ORDER START DATE 06/23/2023 Enteral Feed Order every 18 hours on at 6 am and off at 11:59p (Jevity) ORDER START DATE 06/16/2023 Observations of R11 lying in bed in his room throughout the course of this survey and there was no feeding tube running nor any feeding tube set up in the room. Observations were made on 7/28/23 at 1:57PM, 7/29/23 at 6:42AM, 7:03AM, and 1:24PM. 7/29/23 at 8:05AM, V4 (LPN) was asked how they (nurses) keep track of how long the resident's feeding has been running or how much they are getting, and she stated that she was the only one working and didn't have time for any of that. V4 was also asked why R11 had orders for tube feeding but there was no set up in the room, nor was he set up for feeding based on observation this morning and V4 said, he only gets a bolus, and I gave it to him. Review of R11's medication administration record for July 2023 does not include documentation that enteral feed order (free water flush) given as ordered on the following dates/times: 7/5, 7/7, 7/10, 7/24 - day shift 7/17, 7/21, and 7/22 - evening shift 7/3 and 7/22 - night shift Review of R11's medication administration record for July 2023 does not include documentation that enteral feed order (Jevity) given as ordered on the following dates/times: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 13 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7/2, 7/3, 7/4, 7/6, 7/7, 7/24, 7/27, 7/28 - not documented as given with code 9 (see nurses notes). Review of nurse progress notes does not include any documentation as to why tube feeding was not given. V17 (LPN) was interviewed on 7/29/23 at 1:38PM and asked if R11 has been receiving his tube feedings per physician orders. V17 replied that this was her first day and she was not familiar with the resident but would check the electronic medical record and his orders. V17 proceeded to check orders with surveyor present and confirmed the order in the system. V17 stated that she would have to call the physician to confirm the orders because she wasn't sure what R11 should be receiving and was unclear as to how long the tube feeding should be running for based on how the order was written. V17 confirmed that up to this time she had not administered any tube feedings to R11. 7/31/23 at 3:55PM V1 (Administrator) was asked if she was aware of the order clarification V17 was going to get regarding R11's tube feeding and V1 said that she was not sure and would get back to surveyor. At 4:55PM V1 confirmed that she was not able to locate the tube feeding order for R11. R11's Nutrition Assessment - Enteral/Parenteral dated 7/7/23 reads: 1. Nutrition Diagnosis: Inadequate oral intake 2. Etiology (related to): decreased ability to orally consume sufficient energy 3. Symptoms (as evidenced by): the inability to maintain weight w/o use of enteral tube feeding 4. Plan: NUTRITION: TF/WT REVIEW WTS: 115.2/64in/BMI 19.8. Noted sig 9.6% wt gain x 1 mo. Res under hospice care, no wt goal at this time. DIET/TF: NPO. Jevity 1.5 @ 70mL/hr x 18 hrs to TV of 1260mL in 24 hrs. FWF 350mL TID. SKIN: no known areas of pressure REVIEW: Res under hospice care at this time r/t progression of disease. Res non verbal and TF is sole source of nutrition. No recent reports of vomiting or intolerance at this time. No reports of d/c. On 18 hour feed at this time as opposed to bolus. Res now with hx of wt gain, could be r/t switching from bolus to continuous and better tolerance. No edema reported. No new recommendations at this time. PLAN: Continue to follow with RD available for consult PRN. R7 was reviewed for tube feedings and the following orders were included in current physician orders: Nothing by Mouth (NPO) diet NPO texture, NPO consistency with Active date of 06/01/2023 Jevity 1.5) @(60) ML/HR Start Time: (12pm ) off Time: (8 am) Give Via G-tube. every shift for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 14 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0693 Dysphagia Active 06/01/2023 Level of Harm - Minimal harm or potential for actual harm Observations of R7 lying in bed in his room throughout the course of this survey and the following was observed: Residents Affected - Some 7/29/23 at 6:29AM and at 7:01AM, feeding tube was connected but not running; bag was not labeled (no date, time, or name of the type of formula). At 11:17AM, R7's mother went in to R7's room and came out immediately complaining and yelling in the hall about R7's condition. Review of R7's MAR (medication administration record) for July 2023 does not include documentation that enteral feed order for Jevity was given per physician orders on the following dates/times: 7/5, 7/7, 7/10, 7/13, 7/24, and 7/28 - day shift 7/21, 7/22 - evening shift 7/14, 7/22 - night shift Review of nurse progress notes does not include any documentation as to why tube feedings were missed on dates indicated on the MAR. R7's Nutrition Assessment - Enteral/Parenteral dated 7/13/23 reads: 1. Nutrition Diagnosis: Inadequate oral intake 2. Etiology (related to): decreased ability to orally consume sufficient energy 3. Symptoms (as evidenced by): the inability to maintain weight w/o use of enteral tube feeding 4. Plan: NUTRITION: RD TF review PMH: quadriplegia, neuromuscular dysfunction, gastrostomy, MDD, anxiety WEIGHTS: 130.3#/67in/BMI 20.4. No sig wt changes noted. Res w/ slight insidious wt loss could be d/t previous hospitalization. DIET/TF: NPO. Jevity 1.5 @ 60mL/hr x 20 hrs to TV of 1200mL in 24 hrs. FWF 250mL q 6 hrs. SKIN: intact REVIEW: Resident reviewed for quarterly. Noted slight insidious wt loss. Wt loss likely r/t previous hospitalization UTI and fever, res likely hypermetabolic and burning excess kcals. No issues with TF toleration reported. Skin intact. No edema noted. No reports of n/v/d/c at this time. On meds PRN for constipation. No new recommendations at this time. Current TF regimen meets estimated needs along with med pass for additional fluid intake (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 15 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0693 PLAN/Monitoring: Continue to follow with RD available for consult PRN. Level of Harm - Minimal harm or potential for actual harm Facility provided policy titled, Tube Feeding (dated 5/2014), which reads: GENERAL: Residents Affected - Some Nasogastric, gastrostomy and jejunostomy tubes are used when an alternate method of nutrition is needed. RESPONSIBLE PARTY: RN, LPN POLICY: 1. Continuous tube feedings are based upon a 22 hour consumption period or other time frame tased on individual resident need per Registered Dietician assessment and delivered over a 24 hour period. There is no set hours for the tube feeding to be off. 2. Tube feedings are documented on the MAR and intake record. 3. Tube feedit gs are hang times are based on manufactures guidelines. 4. Feeding tube is flushed andelamped when not in use. 5. An order by the physician or nurse practitioner contains the type of formula and rate. 6. Documentation in the chart should support the use of a feeding tube. 7. Head of the bed should be elevated 30-45 degrees unless ordered differently by the physician. 8. The physician or nurse practitioner should be notified if tube feeding amount not infused as ordered. BOLUS FEEDING: 1. Ensure head of bed is 30-45 degrees. 2. Explain procedure, provide privacy, wash hands and done gloves. 3. Check tube placement by aspiration or air insertion. 4. Instill formula and run over appropriate time frame, monitoring resident for signs and sympfoms of aspiration. 5. Flush tube with amount of water ordered at end of tube feeding. 6. When feeding complete, disconnect and cover the end of the feeding set. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 16 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0693 7. Document feeding and alert physician or nurse practitioner of any issues or problems. Level of Harm - Minimal harm or potential for actual harm FEEDING PUMP: 1. Use feed in [sic] set for pump and assemble per manufacturer instructions. Residents Affected - Some 2. Turn on pump 3. Flush tube with water as ordered. 4. Check residual as ordered and alert physician if there is more than 100cc or other order. 5. Pump should be cleared at the end of each shift. 6. Document tube feeding delivered. 7. Alert physician or nurse practitioner of any issues or concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 17 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have sufficient nursing staff on duty to meet resident needs of providing assistance with ADLs (activities of daily living). This failure applied to four (R2, R6, R7, and R12) of four residents reviewed for ADLs and has the potential to affect all 37 residents currently in the facility. Findings include: Per Form 672 Resident Census and Conditions of Residents dated 7/31/23, there are currently 27 out of 37 residents in the facility who are occasionally or frequently incontinent of bowel and bladder. During initial rounds in the facility on 7/28/23 at 9:22AM, V2 (LPN) confirmed that she was the only nurse on duty and that there is currently no director of nursing. On 7-29-2023 6:00am V4- (Licensed Practical Nurse) observed to be in R6's room telling the patient, I am the only one here, you will need to wait for the morning shift to come and they will help you with morning care. V4 came out of the room and said, I did not have any Certified Nurse Assistant working with me last night, I was by myself. I did the best I could to keep the patients safe and I was not able to change them all. I called V1 (Administrator) to let her know. I know we need to make rounds at least every two hours and provide incontinence care, but I was not able to do it last night, I was alone for 37 residents. At 6:10am, R6 said I am soak and wet, I need help, I do not want to get another urinary infection, I am soak and wet. Last night no one was available to change me, this happens frequently, that I am urinated for long periods of time, for the nurses to come and change the undergarments. I do not like to feel dirty; I was always a well-kept person. At 6:25am V5 (Certified nurse assistant) said, I am the morning Certified Nurse Assistant, I come to work early because I like to get things done and ready as early as possible. We are supposed to make rounds every two hours and as needed, no patient should be left wet for long period of time, they can develop bed sores. I am going to take care of R6. V5 added that she comes in early when there are only two CNA's scheduled so that she can get prepared for the day because it is hard to do so when there are only two CNA's working for the day. After R6 was cleaned V5 went to make R6's bed and said, I had to wait for the mattress to be clean/ disinfected by housekeeping because the urine penetrated all the linen up to the mattress and has a strong smell of concentrated urine. At 7:00am V4 (licensed practical nurse) told V5 (CNA) to clean R2 as soon as possible. R2 is a [AGE] year-old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: nontraumatic intracerebral hemorrhage, anxiety and hemiplegia and hemiparesis. R2 is nonverbal but can follow simple commands answering by nodding his head yes or no. MDS dated [DATE] reads; BIMS unable to be complete. MDS; dated 6-14-2023 reads R2 needs extensive assistance of two staff members for bed mobility, transfers, toileting, and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 18 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many At 7:20am V5 went in to R2's room to provide incontinence care. R2 observed to have a brown substance in his hands all over the linen and in the mattress. V5 said, I know I need another person with me to perform the care on R2, but I am they only one here, I am going to do it by myself. V5 explained to R2 what she was going to do and R2 nodded his head in agreement. Incontinent care observation done. V5 said, I did not realize R2 was in such a bad shape, he has feces all over, all the bed linen are soiled. I must change everything from his bed. 7/29/23 at 7:08AM, V5 (CNA) was observed telling V17 that R12 had to get ready to go to dialysis and that V5 was tied up with another resident and asked V17 to please help R12. V5 notified V17 that R12 needed one person assist because she is blind. V17 (LPN) agreed and then proceeded to R12's room to provide R12 assistance with ADL's (Activities of Daily Living). R12 asked V17 to please provide incontinence care because no one had changed her since yesterday. Surveyor observed that incontinence brief was soaked with urine and feces. Surveyor asked R12 if anyone had provided incontinence care to her overnight and R12 said, No, the last time I was changed was yesterday morning. All day yesterday no one changed me. At 11:17AM, R7's mother went in to R7's room and came out immediately complaining and yelling in the hall about R7's condition. Surveyor asked permission to enter R7's room and R7's mother said, yes, look at my son. He is soaked and dirty. Someone better get in here right now and clean him up. R7's mother was visibly upset, using foul language, and walked out of the room to get staff assistance. R7 was noted to be in bed, with incontinence brief visibly soiled and sheets soaked and stained. R7 has communication deficits and could not respond to questions. Surveyor noted V18 (CNA) in the hall and asked if she had provided any care for R7 today and V18 said, no, that's not my side; I think that side belongs to V5 (CNA), but she is in with another resident right now. 7/29/23 at 7:27AM Surveyor asked V1 (Administrator) why there were no CNA's in the building last night and why V4 (LPN) was the only staff on duty to care for all 37 residents. V1 said that she thought there were two CNA's scheduled to work last night; one CNA called and said she would be late but then never showed up and the other CNA apparently was not scheduled to work. V1 added that the former Director of Nursing had made the July schedule before resigning and that V1 would be responsible for making the August schedule and was planning to start working on it. V1 was asked if the facility ever uses a staffing agency and V1 responded that she had actually looked into yesterday (7/28/23) and showed surveyor a contract from a local staffing agency. V1 said that she filled out the contract yesterday because she thought she would need a nurse on duty but decided against it once she realized that V4 (LPN) was scheduled to work last night so it wasn't necessary to use agency staff. On 7-29-2023 at 12:00pm V8 (former Director of Nursing) said, We had constant problems with staffing because the administration and the owner refused to get agency. My last straw, why I left is because I was the only nurse on the floor. Even though the administrator is clinical she wouldn't help. I had to leave because I felt it was a dangerous situation. It was just me and one other staff that were RN's. I had to work almost every day to make sure that we had an RN in the building. Sometimes we would only have one nurse at night even though there are supposed to be two nurses in the building at night. Every shift I had some issue with staffing, at least 80% of the time. I went to the administrator and owner repeatedly and they would not open up the facility to get agency staff. I felt we needed two nurses during the most active times during the day and all times residents are active. One nurse at night is adequate because most residents are sleeping. I was told that one nurse was adequate enough for the whole building. I found CNA's to cover most of the time but there were events when I only had one CNA in the building. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 19 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0725 V1 provided policy and procedure titled, Direct Care Staffing (dated 9/8/2014), which reads: Level of Harm - Minimal harm or potential for actual harm Policy Residents Affected - Many The number of staff who provides direct care who is needed at any time in the facility shall be based on the needs of the residents and shall be determined by figuring the number of hours of direct care each resident needs on each shift of the say. [sic] The facility shall provide minimum care staff by determining the amount of direct staffing to meet the needs of the residents and meeting the minimum direct care staff ratios set forth in the Administrative Code 77. For the purpose of computing staff to resident ratios, direct staff shall Include registered nurse, licensed practical nurse, certified nursing assistants, rehabilitative and therapy aides, 50% of DON time, 30% of Social Service Director time and licensed physical, occupational, and speech therapists. Procedure To determine the numbers of direct care personnel needed to staff the facility, the following procedures shall be used: 1. The facility shall determine the number of residents needing skilled or intermediate care. 2. The number of residents in each category shall be multiplied by the overall hours of direct care needed each day for each category. 3. Adding the hours of direct care needed for the residents in each category will give that total hours of direct care needed by all residents of the facility. 4. Multiplying the total minimum hours of direct care needed by 25% will give the minimum amount of licensed nurse time that shall be provided during a 24-hour period. Multiplying the total minimum hours of direct care needed by 10% will give the minimum amount of registered nurse time that shall be provided during a 24-hour period. Registered nurses and licensed practical nurses employed by the facility in excess of the requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. 5. Additional Direct Care Hours Equal to at least 75% of the Minimum Required. The remaining 75% of the minimum required direct care hours may be fulfilled by other staff identified above as long as it can be documented that they provided direct care. 6. The amount of time determined is expressed in hours. Dividing the total number of hours needed by the number of hours each person works per shift will give the number of persons needed to staff each shift. Calculations shall not include time for scheduled breaks or scheduled in-service training. The number of residents used to calculate staff ratios shall be based on the facility's midnight census. 7. Minimum staffing ratios will reflect the January 1, 2014 requirement. of 3.8 hours of nursing and personal care each day for a resident needing skilled care and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 20 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the services of a registered nurse in the building for at least 8 consecutive hours a day, 7 days a week and failed to have a designated registered nurse serving as a full-time director of nursing. This failure has the potential to affect all 37 residents currently in the facility. Findings include: Per Form 672 Resident Census and Conditions of Residents dated 7/31/23, there are currently 37 residents in the facility. During initial rounds in the facility on 7/28/23 at 9:22AM, V2 (LPN) confirmed that she was the only nurse on duty and that there is currently no DON (Director of Nursing). V2 added that she thought the DON just resigned. Interview with V1 (Administrator) on 7/28/23 at 12:40PM, V1 confirmed that the facility currently does not have a director of nursing. V1 said, She left yesterday. She was here about a week and a half. The one before that was here about a month. I have two RN's on staff, and they are going to be helping me fill in, in the meantime and I am in the process of hiring. The previous DON was V8 (Former DON), I believe she worked here about [DATE] - May 2023. I started February 2023. Up until today I have not had an issue with no RN coverage. I have not had a chance to look at the schedule. There are no RN's on duty today, those scheduled currently are both LPN's. V1 was asked to provide a facility assessment and stated that she was asked for that before but does not have one. At 6am on 7/29/23 and confirmed that there was no RN on duty. At this time, V4 (Licensed Practical Nurse) was observed to be the only nurse in the building and confirmed that she worked alone last night (night of 7/28/23) and that she is not an RN. V4 added that she just started working at the facility and was visibly upset that she was the only nurse on duty and stated that she does not like working under these conditions. Reviewed nursing schedule provided for June and July and identified concerns. V1 (Administrator) was asked to provide documentation of payroll for all registered nurses for the months of June and July. 7/29/23 at 1:15PM, V1 provided payroll documentation for RN staffing for June and July and stated, Our week starts on Sunday; if it's not listed on there, then they didn't work. Review of payroll information provided documented that there was no RN on duty in the facility on 6/23, 6/30, 7/7, 7/16 - 7/21, and 7/26 - 7/28, 2023. 7/29/23 at 7:27AM, V1 (Administrator) said that she had actually looked into contracting with a staffing agency yesterday (7/28/23) and showed a contract from a local staffing agency. V1 said that she filled out the contract yesterday because she thought she would need a nurse on duty but decided against it once she realized that V4 (LPN) was scheduled to work last night so it wasn't necessary to use agency staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 21 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0727 Level of Harm - Minimal harm or potential for actual harm On 7-29-2023 at 12:00pm V8 (former Director of Nursing) said, It was just me and one other staff that were RN's. I had to work almost every day to make sure that we had an RN in the building. Sometimes we would only have one nurse at night even though there are supposed to be two nurses in the building at night. V1 provided policy and procedure titled, Direct Care Staffing (dated 9/8/2014), which reads: Residents Affected - Many Policy The number of staff who provides direct care who is needed at any time in the facility shall be based on the needs of the residents and shall be determined by figuring the number of hours of direct care each resident needs on each shift of the say. [sic] The facility shall provide minimum care staff by determining the amount of direct staffing to meet the needs of the residents and meeting the minimum direct care staff ratios set forth in the Administrative Code 77. For the purpose of computing staff to resident ratios, direct staff shall Include registered nurse, licensed practical nurse, certified nursing assistants, rehabilitative and therapy aides, 50% of DON time, 30% of Social Service Director time and licensed physical, occupational, and speech therapists. Procedure To determine the numbers of direct care personnel needed to staff the facility, the following procedures shall be used: 1. The facility shall determine the number of residents needing skilled or intermediate care. 2. The number of residents in each category shall be multiplied by the overall hours of direct care needed each day for each category. 3. Adding the hours of direct care needed for the residents in each category will give that total hours of direct care needed by all residents of the facility. 4. Multiplying the total minimum hours of direct care needed by 25% will give the minimum amount of licensed nurse time that shall be provided during a 24-hour period. Multiplying the total minimum hours of direct care needed by 10% will give the minimum amount of registered nurse time that shall be provided during a 24-hour period. Registered nurses and licensed practical nurses employed by the facility in excess of the requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. 5. Additional Direct Care Hours Equal to at least 75% of the Minimum Required. The remaining 75% of the minimum required direct care hours may be fulfilled by other staff identified above as long as it can be documented that they provided direct care. 6. The amount of time determined is expressed in hours. Dividing the total number of hours needed by the number of hours each person works per shift will give the number of persons needed to staff each shift. Calculations shall not include time for scheduled breaks or scheduled in-service training. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 22 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0727 The number of residents used to calculate staff ratios shall be based on the facility's midnight census. Level of Harm - Minimal harm or potential for actual harm 7. Minimum staffing ratios will reflect the January 1, 2014 requirement. of 3.8 hours of nursing and personal care each day for a resident needing skilled care and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 23 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0774 Help the resident with transportation to and from laboratory services outside of the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to assist the resident in making transportation arrangements, resulting in the resident missing a post-operative follow up appointment for suture removal following a left leg above the knee amputation. This failure applied to one (R5) of one resident reviewed for transportation. Residents Affected - Few Findings include: On 7/28/23 at 1:30PM, V11 (R5's Family Member) was noted in the hallway asking the nurse on duty V2 (LPN) why the transportation had not been set up for R5's appointment that was scheduled for today at 2:15PM. V11 was visibly upset and irate and stated that she missed work because she was told to come in to accompany R5 to his appointment and now there is no way of getting him there. V11 then confirmed that she was called on July 19th and told that R5's follow up appointment was today to have his staples removed (after amputation) and that the prosthetic representative was going to meet them at the doctor's office to evaluate him as well. V11 added that she cannot take R5 to his appointment because he requires a stretcher and requires medical transport. V12 (R5's Family Member) was also present and showed her cell phone which had a voicemail dated 7/19/23. The message said that it was left by V10 (Restorative Nurse) and that she was calling to confirm that R5 was scheduled for an appointment on 7/28/23 at 2:15PM and in the message, V10 asked for family to please be at the facility by 1PM to accompany R5 to the appointment. V11 and V12 both stated that they were very upset and concerned that R5 was missing this appointment, especially since they missed work to accompany him, however that they will have the facility reschedule the appointment and the prosthetics representative agreed to come to the facility to evaluate R5 instead. R5's progress note include note written on 7/19/23 14:57 by V10 (Restorative Nurse) that reads: Follow up appointment for suture removal is July 28th @ 2:15pm (address listed) POA (V12 name / phone number) called, and message left to see if she will meet at the facility or escort him from this facility. Transportation is still required to be set at this time. No other documentation was found in medical record regarding appointment scheduling for R5. 7/28/23 at 1:39PM, surveyor asked V2 (LPN) if she knew if the transportation had been set up for R5 and V2 stated, I don't do that, nurses don't set up transportation. V2 stated that when she was informed this morning about R5's appointment, she did attempt to call multiple ambulance transport companies, but no one was available and that they required 24-hour notice. V2 added that normally the scheduler arranges the transportation since it requires 24-48 hours' notice but there is currently no scheduler. At 1:42PM, V1 (Administrator) confirmed that V10 (Restorative Nurse) does work at the facility and that she was just helping out with appointments. V1 said that medical records usually takes care of scheduling appointments but V10 was helping out since they didn't have a medical records person until last week. Facility provided Appointments and Transportation policy (undated), which reads: When a resident has an appointment outside of the facility, the staff will make the transportation arrangements, unless the responsible party chooses to make the arrangements themselves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 24 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0774 Level of Responsibility: Nursing Staff & Transport Coordinator Level of Harm - Minimal harm or potential for actual harm Procedure 1. Staff nurse ER designee will call the place of the appointment to verify the date, time, and location. Residents Affected - Few 2. Staff nurse or designee will then call the family to see if they will be providing transportation and accompanying the resident. 3. If the family is not making transportation arrangements, the staff nurse or designee will call the transportation company (Medicare, ambulance, etc ) to set up date and time of pick up. The pickup time should be at least one hour prior to the appointment. 4. If the family will not be accompanying the resident, the staff nurse or designee will inform the transport coordinator or designee that an escort is needed for the resident. 5. Prior to the appointment, the staff nurse or designee will gather the necessary paperwork to send with the resident to the appointment. This includes, but is not limited to a face sheet, POS, and progress note. 6. On the day of the appointment, the staff nurse or designee will ensure that the resident is clean and dressed appropriately for the weather. 7. All paperwork should be given to the family or driver for the appointment. 8. If the resident is unable to keep the appointment, it is the staff nurse's responsibility to cancel the appointment and reschedule it at the earliest time. 9. If the primary physician had arranged the appointment, the staff' nurse should alert them to the schedule change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 25 of 26 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 146013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302 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 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review the facility failed to conduct and document a facility-wide assessment to determine the necessary resources required to be able to provide residents with the necessary care and services to competently meet their needs. This failure has the potential to affect all 37 residents currently in the facility. Findings include: Per Form 672 Resident Census and Conditions of Residents dated 7/31/23, there are currently 37 residents in the facility. Interview with V1 (Administrator) on 7/28/23 at 12:40PM, V1 confirmed that the facility currently does not have a director of nursing. V1 said, She left yesterday. She was here about a week and a half. The one before that was here about a month. I have two RN's on staff, and they are going to be helping me fill in, in the meantime and I am in the process of hiring. Up until today I have not had an issue with no RN coverage. I have not had a chance to look at the schedule. There are no RN's on duty today, those scheduled currently are both LPN's. V1 was asked to provide a facility assessment and stated that she was asked for that before but does not have one. On 7/29/23 V1 was asked to provide any facility policy related to having a facility assessment tool and V1 confirmed on 7/29/23 at 4:16PM that she did not have any policy related to a facility assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 26 of 26