Health inspection·March 7, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R117's (01/16/2024) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15.,indicating R117's mental status as cognitively intact. Section GG. Functional Abilities and Goals. GG0130. Self-Care. I. personal hygiene: The ability to maintain personal hygiene, including shaving: 05 Set up or clean-up assistance. R117's (01/23/2024) Preadmission Screening and Resident Review documented, in part What did the evaluation identify as important for a provider to know about our symptoms, diagnosis(es), behaviors or other needs and history? Your medical record notes that you have a diagnosis of schizophrenia. When mental health symptoms are present your mood can go from one extreme to anther rapidly. You have a history of hearing things that others do not hear. R117's (07/24/2023) Care Plan documented, Problem: has a diagnosis and history of severe mental illness. Goal: use harm reduction strategies. On 03/04/24 at 10:53am, there were 3 razors on top of R117's TV stand. V12 (Restorative Aide) stated, He (R117) has 3 razors in his room. R117 stated, I use the razor every 7days. On 03/06/2024 at 10:50am, V1 (Administrator) stated residents who are able to use the razor should use it, and return the razor to the nurse after using it. On 03/06/2024 at 11:00am, V2 (Director of Nursing) stated residents are not supposed to keep razors in their room. When they are finished, they should return it to the nurse for safety reason. The (08/22) ADL Care - Shaving documented, Policy: Each resident shall receive nursing care and supervision based on individual needs. Each resident shall show evidence of good personal hygiene. ADL -care will be conducted in a private area for resident dignity. Procedure: A. To shave a resident, you will need the following: - Disposable razor; Basin of warm water; Clean wash cloth and towel; Shaving Cream; Gloves. B. 5. Change disposable razor as needed. Disposable razor must be disposed of in sharp container. 9. Dispose razor in sharp container. The (undated) hazardous Materials and Waste Management Plan Environment of Care Management documented, Purpose: The hazardous Material and Waste management plan is designed to establish and maintain a program to safely control hazardous materials and wastes. Goals and Objectives: 2. To minimize hazards to human health and/or environment from unplanned release of hazardous materials. Hazardous material and waste can be, but not limited to the following: b. razors. Sharp containers are kept in laundry, shower rooms, med rooms, and med cart to dispose of all razors. Based on observation, interview, and record review, the facility failed to provide an environment free from hazards. This failure has the potential to affect two residents (R79 and R117) and all 45 residents on the third-floor unit at the facility. 1. On 03/04/24 at 12:45 pm, surveyor and V7 (Licensed Practical Nurse, LPN) inspected the third-floor medication cart and observed a shaving razor hanging outside of the sharps container, not properly disposed of. V7 stated, I don't know who put that there. When V7 was asked regarded the shaving razor hanging from the sharps container, V7 stated, The sharps container is not full. It (referring to the razor) should be pushed all the way inside of the sharps container. When V7 was asked regarding the importance of properly disposing shaving razors, V7 stated, I or someone can cut themselves. On 03/6/24 at 11:03 am, V2 (Director of Nursing, DON) stated shaving razors should be properly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 2 of 12 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some discarded inside of the sharps containers. V2 explained shaving razors should not be visibly hanging out of the sharps containers and razors that are hanging from the sharps container and not properly disposed inside the sharps container, can fall out of the sharps container and someone can hurt themselves. The facility's policy, dated 07/22 and titled Sharp Objects Policy, documents: Policy: To assure that sharp objects are properly container, promoting a safe environment. Policy Specifications: . 2. Place any sharp object such as needles, broken glass, etc. in a sharp container. The facility's undated policy titled Hazardous Material and Waste Management Plan Environment of Care Management Purpose: The Hazardous Material and Waste Management Plan is designed to establish and maintain a program to safely control hazardous materials and waste . Hazardous material and infectious waste is managed and disposed of following policies and procedures. Hazardous material and waste can be, but not limited to the following: . b. Sharps, razors, lancets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 3 of 12 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change. These failures has the potential to affect all 45 residents on the third-floor unit and all 45 residents on the fourth-floor unit at the facility. Findings include: On 03/04/24 at 1:10 pm, Controlled Substances Check form for the 3rd floor unit medication cart had missing signatures for the oncoming nurse on 03/02/24 11:00pm to 7:00am shift, and 03/03/24 outgoing nurse for the 7:00am to 3:00pm shift. V7, Licensed Practical Nurse/LPN stated, I don't know why it's not signed. That was not during my shift. When V7 was asked regarding the importance of the controlled substance check form, V7 stated to make sure the narcotics are all there. The facility's document, dated March 2024 and titled Controlled Substances Check Form Station 3rd floor, shows missing signatures for 03/02/24 11:00pm to 7:00am shift and 03/03/24 outgoing nurse for the 7:00am to 3:00pm shift. On 03/5/24 On at 11:12am, the Controlled Substances Check form for the 4th floor unit medication cart had missing signatures for 03/04/24 outgoing nurse for the 3:00pm to 11:00pm nurse. V15, LPN, stated the narcotics accountability sheet should be signed at the beginning of every shift. When V15 was asked the importance of the controlled substance check form V15 stated, To make sure the narcotics count is accurate. The facility's document, dated March 2024 and titled Controlled Substances Check Form Station 4th floor, shows missing signatures for 03/04/24 outgoing nurse for the 3:00pm to 11:00pm nurse. On 03/06/24 at 10:57 am, V2 (Director of Nursing, DON) stated all controlled medications should be counted by the incoming and outgoing nurses and signed after the count. V2 explained it the facility's policy for the incoming and outgoing nurses to count the medication narcotics on each medication cart to make sure the count is complete and accurate. V2 stated if the narcotics accountability count is off (not accurate), V2 should be immediately notified. V2 also stated signing the narcotics accountability sheet means the narcotics were counted and accounted for. The facility's policy, dated 10/25/2014 and titled Controlled Substance Storage, documents,Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures: E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses or one Qualified Medication Aide (QMA) in the states who have approved such staffing positions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 4 of 12 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were two medication errors out of 27 medication opportunities, resulting in a 7.41% medication error rate and affected two residents (R1, and R47) observed for medication pass. Residents Affected - Few Findings include: 1. R47's face sheet documents R47 has a diagnosis which include but are not limited to: schizophrenia, and unspecified psychosis not due to a substance or known physiological condition. R47's Physician Order Sheet (POS) order date 02/07/24 through 03/07/24 shows R47 has an order for Aripiprazole 5 mg (milligrams) ½ tablet (2.5 mg) orally by mouth every day. Diagnosis: Other schizophrenia. R47's Brief Interview for Mental Status (BIMS), dated 01/23/24, documents R47 with a score of 15, which indicates that R47 is cognitively intact. On 03/05/24 at 8:26 am, V16 (Licensed Practical Nurse, LPN) was observed on the second floor at the second-floor medication cart. V16 prepareed and counted 10 pills total that were administered to R47. V16 stated, Abilify (referring to Aripiprazole) is not here. I have to reorder it. Upon surveyor reconciling R47's medication for medications that were ordered for administration and medications that were observed as administered and documented by V16, the following medication error was identified: - Missed Medication: Aripiprazole 5 mg (milligrams) ½ tablet (2.5 mg) by mouth every day. Diagnosis: Other schizophrenia. R47's Medication Administration History documents Aripiprazole 5mg (milligrams) ½ tablet (2.5mg) orally by mouth every day was not administered on 03/05/24. R47's progress notes, dated 03/05/24, had no documentation of V16 notifying R47's physician of R47's missed dose of Aripiprazole 5 mg (milligrams) ½ tablet (2.5 mg) orally by mouth every day on 03/05/24. 2. R1's face sheet documents R1 has diagnoses which include but are not limited to: Vitamin B 12 deficiency, Squamous cell carcinoma of skin and Bilateral primary osteoarthritis of the knee. R1's POS, dated 02/07/24 through 03/07/24, shows R1 has an order for Cyanocobalamin (vitamin B-12) tablet; 100 mcg (micrograms) 1 tablet orally every day. R1's Brief Interview for Mental Status (BIMS), dated 02/29/24, documents R1 with a score of 15 which indicates that R1 is cognitively intact. On 03/05/24 at 8:43 am, V16 (Licensed Practical Nurse, LPN) was observed on the second floor at the second-floor medication cart. V16 prepareed and counted 12 pills total that were administered to R1. V16 stated, I have to reorder the Vitamin B12 (cyanocobalamin). Upon surveyor reconciling R1's medication for medications that were order for administration and medications that were observed as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 5 of 12 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 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 0759 administered and documented by V16, the following medication error was identified: Level of Harm - Minimal harm or potential for actual harm - Missed Medication: Cyanocobalamin (vitamin B-12) tablet; 100 mcg (micrograms) 1 tablet orally every day. Residents Affected - Few R1's Medication Administration history documents Cyanocobalamin (vitamin B-12) tablet; 100 mcg (micrograms) 1 tablet orally every day was not administered. R1's progress notes, dated 03/05/24, had no documentation of V16 notifying R1's physician of R1's missed dose of Cyanocobalamin (vitamin B-12) tablet; 100 mcg (micrograms) 1 tablet orally every day on 03/05/24. On 03/06/24 at 10:50 am, V2 (Director of Nursing, DON) stated the Medication Administration history shows if a medication was administered. V2 stated if a medication is not administered the Medication Administration history will have the reason the medication was not administered and the nurse on duty should notify the residents physician of the missed medication and follow through the with the physicians orders regarding the missed medication. On 03/06/23 at 10:51 am, V2 (Director of Nursing, DON) stated medications should be given per the physicians orders. V2 also stated the importance of medication administration is to ensure the residents are receiving their medications as ordered by the physician. V2 explained the residents physician should be notified of the residents missed medication so the residents physician knows the resident missed a dose of medication and to ensure the resident is not in any harm. V2 also explained if a resident missed a dose of a psychotropic medication, the resident can have behaviors and decompensate. The facility's document, dated July 2022, and titled Medication Administration Policy documents, Policy Specifications: 1. Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates . 19. Medications not received and /or from a pharmacy and/or administered within twenty-four (24) hours from the ordered time to be administered will be considered a medication incident. The attending physician shall be notified, and a facility designated from initiated. The Facility's job description document titled Charge Staff Nurse documents, Position Purpose: Provide direct nursing care to the residents, and to supervise nursing activities performed by nursing assistants. Purpose of Position: . Charting and Documentation: 11. Perform routine charting duties as required and in accordance with our established Charting and Documentation Policies and Procedures . Drug Administration Functions: 1. Prepare and administer medications as ordered by the physician . 6. Ensure that an adequate supply of floor stock medications, supplies, and equipment are on hand to meet the nursing needs of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 6 of 12 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 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 label and dispose of food items after the use by date. These failures have the potential to affect all 134 residents receiving oral nutrition at the facility. Findings Include: On 3/4/24 at 9:34 am, observed in the dry storage room, a bin of rice labeled with a use by date of 3/1/24; a bin of oats labeled with a use by date of 3/1/24; and a bin of grits labeled with a use by date of 1/16/24. All labels observed for an open date was blank. V17, Dietary Manager, stated the date on the label is when the items was put into the bin. The surveyor inquired to V17, how does V17 know when the items were put into the bin when the date on the label is blank and the use by dates is 3/1/24 for the rice and oats and use by date for the grits is dated 1/16/24? V17 stated, I don't know why the staff labeled the bins like that, it's not right. Surveyor inquired how should the label be filled out. V17 stated, The entire label should be filled out. On 3/5/24 at 2:45 pm, observed in the dry storage room, the rice bin, the oats bin, and the grits bin not labeled. V17 stated, The label was not correct with the use by dates, so we took the labels off. On 3/6/24 at 2:00 pm, V28, Dietary Aide, stated, When putting a label on items, the whole label should be full out with the name of the item, date opened, date to use by, and your initials. On 3/6/24 at 2:03 pm, V29, Dietary Aide, stated, Open items should be labeled with the name of the item, date when it was opened, and a use by date. On 3/6/24 at 2:05 pm, V30, Dietary Aide, stated the entire label should be filled out. The label is important to know when the items are expired. Facility policy (undated) and titled, Labeling and Dating Foods documents, Policy: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received the date opened and the date by which the items should be discarded. Procedure: Dry Storeroom; Package or containerized bulk food may be removed from the original package and stored in an ingredient bin labeled with the common name of the food, the date the item was opened and the date by which the item should be discarded or used by. Facility Job description titled, Food Service Supervisor, documents, Food Service Functions: 2. Procure and store food supplies. 6. Assure proper storage and handling of food and supplies. Facility Job description titled, Dietary Aide documents, The primary purpose of the position is to provide assistance in all dietary function as directed or instructed and in accordance with established dietary policies and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 7 of 12 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to perform appropriate hand hygiene during dining, failed to appropriately sanitize dining tables between residents on the Main Dining room during dining, and failed to bag linens prior to sending the linens to the laundry area via the chute in an effort to prevent the spread of infectious microorganism. These failures have the potential to affect all the residents at the facility. Residents Affected - Many Findings include: 1. The (undated) Facility Meal times documented lunch meal times at the Main Dining room were at 12:00pm and 12:30pm. On 03/04/2024 at 12:30pm, during the dining observation on 1st floor, some residents were leaving the dining area, and some residents were standing by waiting for available tables. V13 (Housekeeper), with gloved hands, was observed going to one of the tables, wiping the table with a green cloth with his left hand, while holding a yellow pack of disinfecting wipes with his right hand. V13 placed the used green cloth to his right hand, and took a piece of the disinfecting wipe from the pack with his left hand and wiped the table. A resident was observed occupying the table. V13 then proceeded to another table, wiped the table with the green cloth, while still holding the pack disinfecting wipes with his right hand. V13, again, placed the green cloth to his right hand, and took a piece of the disinfecting wipe from the pack with his left hand and wiped the table. This surveyor got the attention of V13, and inquired about expectation with wiping the dining tables. V13 stated, not understand English (sic). During this observation, V14 (Dietary Aide) was asking residents, who were just seated to eat, their food preference. V13 was wiping the table, again, with a green cloth with his left hand, and still holding a yellow pack of disinfecting wipes with his right hand. V13 placed the green cloth to his right hand and took a piece of the disinfecting wipe from the pack with his left hand and wiped the table. V13 proceeded to another table, wiped the table with the green cloth while still holding the disinfecting wipes with his right hand. V13 placed again the green cloth to his right hand, and took a piece of the disinfecting wipe from the pack with his left hand and wiped the table. V14 stated, (V13) did not change his gloves and he did not rinse the towel he used to clean the tables. He is not supposed to do that. On 03/05/24 11:18 am, V2 (Director of Nursing) stated, He (V13) is supposed to remove his gloves because he already used the gloves to wipe the dirty table, and (V13) should don new gloves before going to the next table. If the staff has a sani bucket, staff is supposed to rinse the cloth towel. The purpose of changing gloves and rinsing the cloth towel is to prevent cross contamination. On 03/05/2024 at 11:43am, V13 was at the laundry area. V10 (Environmental Services Director) translated for this surveyor and inquired about how V13 wiped the tables on the 1st floor main dining room during lunch time on 03/04/2024. V13 stated, I wiped the tables with a rag and disinfected with (disinfectant) wipes. I did not change my gloves and I did not rinse the rag in the sanitation bucket. On 03/05/2024 at 11:45am, V10 stated, Each time he (V13) cleans a table, he is supposed to wipe the table with a rag that was in a solution of bleach and (brand name) soap, placed the dirty rag in a bucket, changed his gloves, and disinfect the table with (brand name) disinfecting wipes to prevent cross contamination. The (07/22) Facility General Housekeeping Procedures documented, in part Purpose: To ensure a safe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 8 of 12 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and clean environment. Procedure: 2. Main level dining room tables should be cleaned and sanitized before and after meals and as needed. 3. Due to the Covid-19 virus, housekeepers will wipe down items such as tables more often with proper sanitizing cleaning agent. The (undated) Housekeeper Job Description documented, in part The primary purpose of the position is to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guideline and regulations governing our facility, and as may be directed by the Administrator, and/or the Director of Housekeeping, to assure that our facility is maintained in a clean, safe and comfortable manner. Duties and Responsibilities 5. Assure that established infection control and universal precautions practices are maintained when performing housekeeping procedures. The (undated) Hand Hygiene Policy Procedure documented, in part Purpose Effective hand hygiene reduces the incidence of healthcare-associated infections. Procedure: Indications for Handwashing: After contact with inanimate objects in the immediate vicinity of the patient. Gloves and Hand Hygiene. ear gloves when in contact with blood or other potentially infectious materials, and contaminated items will occur or could occur. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another resident. 2. On 03/05/2024 at 11:40am, V10, Environmental Services Director stated CNAs are expected to bag all linens prior to sending to the laundry area via chute to prevent cross contamination. On 03/05/2024 at 11:41am, V10 opened the 'chute' room. There were linens in the cart under the chute opening that were not bagged. V10 stated, These linens should be bagged to prevent cross contamination. The (03/07/2024) email correspondence with V10 documented, Subject: Residents' linens. It is expected to be bagged before going down the shoot (chute) to prevent cross contamination. The (08/2008) Laundry and Linen documented, Purpose: the purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. General Guidelines. 3. Consider all soiled linen to be potentially infectious. 9. When removing soiled linen from hampers, hold plastic bags from the bottom with the opening over the washer, and empty bags directly into the washer without handling the linens. 3. On 3/4/24 at 12:30 pm, multiple staff on the first floor in the dining room were serving residents lunch and not performing hand hygiene in between serving trays. On 3/4/24 at 12:45 pm, V18 (Activity Aide) was touching clipboard at the desk, patting the side of V18's leg, and getting silverware. V18 did not perform any hand hygiene before going back to the serving table to get more lunch trays for the residents. On 3/6/24 at 2:20 pm, V2, DON (Director of Nursing), stated staff should wash hands before the start of passing trays and in between passing trays. The purpose of handwashing is to prevent cross contamination with the residents. Facility policy, reviewed 7/22, titled Hand Hygiene Policy Procedure documents, B. Indications for Hand rubbing: After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 9 of 12 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 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 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide privacy with a ceiling suspended curtain (missing privacy curtain) for five residents (R2, R17, R26, R29 and R66). This failure affected 5 out 39 residents in the total sample. Residents Affected - Some Findings include: R17's Brief Interview for Mental Status (BIMS), dated 02/14/24, documents R17 has a BIMS score of 15, which indicates that R17 is cognitively intact. R17's Face sheet documents R17 has diagnoses that include but not limited to: schizoaffective disorder, bipolar, hypertensive heart disease, depression, and overweight. R26's Brief Interview for Mental Status (BIMS), dated 01/23/24, documents R26 has a BIMS score of 7 which indicates that R26 has some cognitive impairments. R26's Face sheet documents R26 has diagnoses that include but not limited to schizophrenia, chronic obstructive pulmonary disease, hypertensive heart disease without heart failure, depression, and peripheral vascular disease. R66's Brief Interview for Mental Status (BIMS), dated 02/19/24, documents R66 has a BIMS score of 14, which indicates that R66 is cognitively intact. R66's Face sheet documents R66 has a diagnosis that include but not limited to paranoid schizophrenia, anxiety disorder, depression, other insomnia, and disorder of the skin. On 03/04/24 at 10:35 am, R17's and R26's room was observed without a privacy curtain. R17 stated R17 likes to have a privacy curtain to pull closed for R17's privacy. R17 stated, It (referring to R17's privacy curtain) has been missing for a while. I think my roommate (R26), or someone took it down. R26 stated, They (referring to staff) took it down about a month ago. On 03/04/24 at 10:44 am, R66 was observed without a privacy curtain in R66's room. R66 stated R66 has not had a privacy curtain for a while. R66 stated R66 thinks the staff at the facility removed R66 privacy curtain from R66's room. On 03/05/24 at 8:20 am, surveyor observed R17's and R26's and R66's room still without a privacy curtain. On 03/04/2024 at 11:45am surveyor observed R29's and R2's room door open. R29 was observed from the open door changing her shirt and R29's upper body was naked and exposed. Surveyor observed no privacy curtains hanging from the ceiling for R29 and R2. On 03/04/2024 at 2:30pm. V6 (CNA/Certified Nursing Assistant) stated, The privacy curtains were here on Friday (3/1/2024). I did not work the weekend. The maintenance staff took the privacy curtains down over the weekend to wash. I will call someone to see where the privacy curtains are at. On 03/06/24 at 9:52 am, V10 (Environmental Service) stated the privacy curtains should be provided to each resident for the residents privacy. V10 stated when a residents privacy curtain is removed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 10 of 12 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 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 0914 Level of Harm - Minimal harm or potential for actual harm the privacy curtain should be cleaned and replaced by the laundry department. V10 explained the privacy curtain should be taken down early morning and returned to the resident the same day by 1:30 pm, from the laundry department. V10 stated V10 did not know why R17, R26, and R66 did not have a privacy curtain on 03/04/24. V10 stated V10 will make sure every resident has a privacy curtain, and when a residents privacy curtain is removed, the residents privacy curtain is put back in a timely matter. Residents Affected - Some On 03/06/2024 at 3:20pm V1(Administrator) stated the Maintenance Director is responsible for maintaining and hanging the privacy curtains in the resident's rooms. V1 stated the purpose of the privacy curtain is to maintain the resident's privacy during resident care. The facility's undated policy titled Residents Rights for People In Intermediate Care Facilities for the Developmentally Disabled document in part: Privacy: Your medical and personal care are private. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 11 of 12 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 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 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the handrails on the 3rd floor were firmly secured to the wall. This failure has the potential to affect all 45 residents on the third floor. Residents Affected - Some Findings include: The (03/04/2024) facility resident's census on the 3rd floor was 45. On 03/04/2024 at 11:48am on 3rd floor, the handrail located near the men's bathroom was not firmly secured to the wall. On 03/04/2024 at 11:49am on 3rd floor, the handrail located near the exit was not firmly secured to the wall. On 03/04/2024 at 11:53am, V11 (Assistant Maintenance Director) checked the handrail located near the 3rd floor's Men's bathroom and stated, It is not fixed to the wall. On 03/04/2024 at 11:55am, V11 checked the handrail located near the 3rd floor's exit door, and stated, It is not fixed to the wall. On 03/04/2024 at 12:11pm, V10 (Environmental Services Director) stated, The purpose of the handrail is to provide support to the residents, something for the resident to hold on to. The handrails are for residents who need support to prevent them from falling. On 03/04/2024 at 12:12pm, V10 checked the handrail located near the 3rd floor's Men's bathroom and stated, It is loose. It is not acceptable. It is dangerous for residents who use the handrail for support. They could fall if they use this handrail. On 03/04/2024 at 12:14pm, V10 checked the handrail located near the 3rd floor exit door and stated, The handrail is loose. It is not safe for residents to use this. The (7/2022) Facility Policy and Procedure Equipment/Maintenance Policy and Procedures documented, All Equipment utilized in this facility shall be maintained, operated, and repaired as directed. Repair. If equipment shows sign of needing repair (e.g. handrails) staff shall immediately stop usage of the equipment and report it to maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 12 of 12