Inspection·April 4, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide an appropriate call light and accessibility to a call light for one resident who was identified with self-care deficits. This affected one of three residents (R22) reviewed for call light accessibility. Residents Affected - Few Findings Include: R22 has a diagnosis of Quadriplegia. Minimal Data Set section C (cognitive pattern) dated 3/20/25 documents: a score of fifteen which indicates R22 is cognitively intact. Section GG (functional abilities) documents: impairment on both sides for upper and lower extremities. Dependent on staff. Care plan initiated 9/29/2020 documents: R22 has activities of daily living self-care performance deficit related contractures bilateral upper/lower extremities, Quadriplegia. On 4/1/25 at 12:02pm, R22 who was assessed to be alert and oriented to person, place and time, was observed in bed with the call light string hanging from the wall onto the night stand. R22 could not reach the call light/string. R22 said, he was quadriplegic. R22 said, he cannot use the call string. R22 said, he has to wait until see staff pass by his room, yell and ask for assistance. R22 said, some days he has to wait a long time until he see staff to get help with activities of daily living. R22 did not have any other devices in his room to call for staff assistance. On 4/2/25 at 12:03pm, V2 (Director of Nursing/DON) said, the call light should be within R22's reach. R22 said, he can't pull the call light string even if it was within reach. Concern form dated 4/2/35 documents: R22 did not have a call light he could access. Resolution: maintenance installed an accessible call light. Call light policy dated 6/2013 documents: If a call light is not functional, give the resident another means to call for assistance (i.e bell). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 2 of 7 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 04/04/2025 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 Based on observation, interview and record review, the facility failed to provide incontinence care at least every two hours. This affected one of three residents (R5) reviewed for incontinence care. Residents Affected - Few Finding Including: R5 has a diagnosis of Hemiplegia. Minimal data set section G (functional abilities) dated 1/10/25 documents: Toileting hygiene: dependent. Section H (bladder and Bowel) documents: Urinary Continence: R5 was always incontinent. Care plan initiated 4/2/22 documents: R5 is incontinent of bladder and bowel function related to impaired mobility, weakness and other co-morbidities secondary to diagnosis of: hemiplegia, affecting left non-dominant side. Goal: staff will assist with toileting throughout the day. On 4/1/25 at 1:09pm, R5 was observed sitting in his wheelchair with wet soiled pants in his peri-area/between his legs. R17 (R5's roommate) who was assessed to be alert and oriented to person, place and time said, R5 was provide incontinence care around 9:30am this morning. A clock displaying the correct time was observed on the wall in the middle of R5/R17's bed area. R5 said, he was changed in the morning but was unable to report the time due not paying attention to the clock during incontinence care. R5 said, V12 (Certified Nursing Assistant/CNA) was his CNA and she provided his care. On 4/1/25 at 1:15pm, V12 (CNA) said, she provided incontinence care for R5 at 10:00am. V12 said, she will provide incontinence care for R5 again at 2:00pm. V12 was observed monitoring residents in the dining room. V12 said, she had to stay in the dining room until she was relieved. V12 said, sometimes R5 needs to be changed before 2pm. On 4/1/25 at 1:56pm, R5 was still observed sitting in his wheelchair, with the same wet pants on. R5 was wet in his peri-area/ between his legs with an irregular dry line on the outer portion of the wet spot on R5's pants. Incontinence Care policy dated 9/14 documents: Incontinent resident will be checked periodically every two hours and provided perineal and genital care after each episode. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 3 of 7 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 04/04/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician orders by not applying splint or braces for three residents (R5, R11 and R19) out of three residents reviewed for restoratives services. Findings include: 1. R19 was admitted to the facility on [DATE] with a diagnosis of hemiplegia affecting the left side. R19's brief interview for mental status score dated 3/5/25 documents a score of 15/15 which indicates cognitively intact. R19's physician order dated 6/10/24 documents: apply splint/brace to left upper extremities for 4-6 hours as tolerated. May remove during ADL care. R19's care plan dated 6/4/19 documents: R19 requires the use of splint to left hand/left knee related to diagnosis of hemiplegia/hemiparesis, contraction to left hand/left knee following Cerebral Vascular Accident, (CVA) affecting left dominant side. Interventions include: Splint to be on for at least 4-6 hours daily as tolerated. May remove when up to wheelchair per request. Help apply Splint to help maintain and/or improve current ROM status and prevent any further deterioration unless disease process causes unavoidable deterioration. On 4/1/25 at 12:00PM, R19 who was alert and oriented at time of interview said he doesn't know anything about a splint to his left hand. R19's left arm was contracted in a bent position with his hand towards his chest. His fingers were bent into a ball. R19 said he has limited mobility to his hand. No splint observed to his left hand. On 4/2/25 at 1:30PM, R19 was observed in bed. R19 said he had not had any splint on his left hand today and unsure where it was. On 4/2/25 at 1:34PM, V13 (Restorative Nurse) and V9 (Restorative Aide) said R19 did not have his splint on today because he was in bed. Both staff said that if the resident is in bed they do not wear splints. On 4/2/35 at 1:46PM, V9 (Restorative Aide) said she was unable to place splint or braces on the residents on 4/1/25 because she was doing weights for all the residents. V9 said she or V13 are the only staff that will apply the splints or braces. V9 confirmed that R19 splint was not applied on 4/1/25 or 4/2/25. Facility restorative policy undated documents: It is the policy [NAME] nursing and rehabilitation center to develop a restorative nursing program to serve as a guide in establishing individualized restorative care to assist each resident in achieving the highest level of self- care and independence. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 4 of 7 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 04/04/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. R11 was admitted to the facility on [DATE] with a diagnosis of hemiplegia following cerebral infarction affecting left side and aphasia. On 4/2/24 at 1:10PM, R11 who was alert and oriented a time of interview was able to communicate through typing on her phone. R11 said she has not had her left foot brace / orthotic for a long time a few months because it was too small. R11 was observed with brace or device to left foot. R11's foot observed turned inwards with limited mobility to joint. On 4/2/35 at 1:46PM, V9 (Restorative Aide) said R11 had a orthotic to left foot but it was not fitting right and she was waiting for anyone. V9 unsure how long R11 had been without it. On 4/3/25 at 3:30PM, V11 (Restorative Nurse) said she was not aware of R11 orthotic not being available or not fitting right until today. V11 said staff should let her know if there is a problem with device so they can get another one. R11's physician order dated 2/17/25 documents: left foot orthotic when out of bed and transfers every day. R11's care plan dated 6/5/19 documents left foot orthotics to be on 2-3 hours as tolerated. R11's restorative assessment dated [DATE] documents: left ankle severe loss/less than 50% of norm, resident currently using brace left foot orthotic. Facility restorative policy undated documents: It is the policy [NAME] nursing and rehabilitation center to develop a restorative nursing program to serve as a guide in establishing individualized restorative care to assist each resident in achieving the highest level of self- care and independence. 3. R5 had the diagnosis of Hemiplegia. Restorative Nursing assessment dated [DATE] documents: Soft foam/sponge on left hand. Physician order sheet dated 4/2025 document: Order clarification. Soft foam/sponge to be applied on L hand when up 4-6hrs and as tolerated to prevent from further contractures. May remove during ADL care and skin checks. Care plan initiated 5/25/2018 documents: R5 has a soft foam/sponge on the left hand secondary to the diagnosis of hemiplegia. On 4/1/25 at 1:09pm, R5 was observed without a sponge/form in his left contracted hand. R5 said, he was supposed to have form in his hand. On 4/2/25 at 1:46pm, V9 (Restorative Aide) said, R5 did not have his form in his hand yesterday. V9 said, did not have time to put the form in R5's hand due to her getting facility weights. Facility restorative policy undated documents: It is the policy [NAME] nursing and rehabilitation center to develop a restorative nursing program to serve as a guide in establishing individualized restorative care to assist each resident in achieving the highest level of self- care and independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 5 of 7 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 04/04/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow the Food Safety and Sanitation Policy by dietary staff using gloved hand to directly scoop a piece of cornbread after handling multiple food ladles, and dietary staff observed without beard covering for their exposed beards, and by not ensuring a bag of frozen peaches and open bottle of dried parsley was labeled with a made/open date and expiration date. This failure has the potential to affect all 48 residents in the facility on oral diets. Findings include: On 4-1-25 at 12:05 PM, surveyor observed V5 (Cook) plating lunch meals in the main dining room. Surveyor observed V5 wearing gloves and handling different food ladles, grabbing Styrofoam plates, and scooping cornbread with his gloved hand that touched multiple surfaces. V5 did not change his gloves or sanitize his hands when grabbing plates or cornbread. On 4-2-25 at 9:49 AM, V4 (Dietary Manger) said staff should change their gloves after touching multiple surfaces to prevent cross contamination. On 4-3-25 at 8:44 AM, V5 (Cook) said staff should change gloves when touching multiple surfaces to prevent cross contamination. Food Safety and Sanitation Policy dated 4-17 documents: The facility must- (2) Store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Cross contamination refers to the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels or utensils that are not cleaned after touching raw food and then touch ready-eat-foods. On 4-1-25 at 9:45 AM, surveyor was touring the kitchen and noted V5 (Cook) and V6 (Dietary Aide) with beards and no beard covers. On 4-2-25 at 9:49 AM, V4 (Dietary Manger) said beard guards are used to cover facial hair to prevent hair from going into the food. On 4-3-25 at 8:44 AM, V5 (Cook) said facial coverings are used to prevent contaminants from falling into the food. Food Safety and Sanitation Policy dated 4-17 documents: Hair restraints will be worn at all times. Beards should be well-trimmed and covered with an appropriate hair restraint. On 4-1-25 at 9:45 AM, surveyor and V4 (Dietary Manager) observed a bag of frozen peaches and container of dried parsley without a label including open and expiration date. V4 removed these items from the freezer and dried food storage. On 4-2-25 at 9:49 AM, V4 (Dietary Manager) said labels are used to ensure that staff know when to throw out old food. The label should include the use/open and expiration date. On 4-3-25 at 8:44 AM, V5 (Cook) said V5 said food label should include the open date and expiration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 6 of 7 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 04/04/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm date. V5 said all opened food items should be label once opened and the label determines how long the food is good for. Dating & Labeling Policy (no date) documents: Commercially processed food that has a use-by-date that is less than seven days from the date the container was opened, will be marked with that use-by-date. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146013 If continuation sheet Page 7 of 7