Health inspection·August 4, 2023

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure that 2 residents were free from physical restraints. This failure affected 2 residents (R51 and R57) reviewed for restraints in a total sample of 21. Residents Affected - Few Findings include: On 8-1-23 and 8-2-23, observed R51 and R57 seated in an armed chair (unable to get up from the side of the chair) with their seatbacks against the wall (without space to move backwards) and the table directly in front of the resident (without space to move forward) with other residents seated around the table. The table was noted extending over the resident's lap without the possibility of the resident standing up unless the table was moved forward as witnessed by V5 (Certified Nursing Assistant/CNA), V3 (Director of Nursing/DON), and V22 (Regional Director). On 8-2-23 at 12:11 PM, V6 (Registered Nurse/RN) said a physical restraint prevents a resident from moving freely and physical restraints are not used at the facility. On 8-2-23 at 12:13 PM, V5 (CNA) said physical restraints do not allow a resident to have free movement from the bed or chair. V5 said restraints are allowed with a MD order. On 8-2-23 at 12:15 PM, V3 (DON) said a physical restraint is a barrier that prevents a person from freely moving. V3 said the facility is restraint free unless ordered by MD. V3 said she will adjust the chairs and tables to allow more space for the residents to move their seat backwards from the table. On 8-3-23 at 9:00 AM, R51 and R57 were observed seated at the table with more space from the wall and the seatback of the chair which would allow R51 and R57 more space to move the chair backwards to get up from their chair. Residents' Rights Booklet documents: You have a right to be free from physical or chemical restraints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145122 If continuation sheet Page 2 of 8 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 145122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dobson Plaza 120 Dodge Avenue Evanston, IL 60202 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** Residents Affected - Few Based on observation, interview and record review, the facility failed to correctly use pressure relieving mattress for residents at risk for skin alteration for three of four residents (R11, R28, R69) reviewed for pressure ulcers in a sample of 21. Findings include: On 08/01/2023 at 10:45AM, during observation, R69 was observed lying on low-air-loss mattress with flat sheet, pad and folded flat sheet between her and the mattress. At 10:47AM, R11 was also observed lying on low air loss mattress with flat sheet, pad and folded flat sheet between her and the mattress. At 10:53AM, R28 was also observed lying on low-air-loss mattress with flat sheet, pad and folded flat sheet between her and the mattress. At 11:10AM, during observation with V3 (Director of Nursing/DON), R69, R11 and R28 were again observed under the same circumstances. On 08/01/2023 at 11:10AM, V3 said that there should only be one flat sheet between the resident and the mattress if they are on a low air loss mattress because if there are multiple layers of linen between the resident and the mattress, the benefit of the low-air-loss mattress cannot be maximized. R69's Order Summary Report dated 08/03/2023 indicated admission date 3/15/2023, and diagnoses including unsteadiness on feet, other lack of coordination, and other abnormalities of gait and mobility. R69's Braden Scale for Predicting Pressure Sore Risk (pressure ulcer risk assessment) dated 7/27/2023 indicated score of 16 which is categorized as at risk. R69's care plan revised on 3/15/2023 indicated R69 is at risk for alteration in skin integrity and interventions include R69 needs pressure relieving/reducing mattress to protect skin while in bed. Minimum Data Set (MDS) dated [DATE] indicated R69 is totally dependent with locomotion on and off unit and uses wheelchair as mobility device. R11's Order Summary Report dated 08/03/2023 indicated admission date 02/04/2021, and diagnoses including unsteadiness on feet, other lack of coordination, and restless leg syndrome. R11's pressure ulcer risk assessment dated [DATE] indicated score of 17 which is categorized as at risk. R11's care plan revised on 7/12/2023 indicated R11 is at risk for skin breakdown and interventions include pressure relieving mattress when in bed. MDS dated [DATE] indicated R11 is totally dependent with locomotion off unit, needs extensive assistance with locomotion on unit, and uses wheelchair as mobility device. R28's Order Summary Report dated 08/03/2023 indicated admission date 4/29/2021, and diagnoses including unsteadiness on feet, other lack of coordination, other abnormalities of gait and mobility, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R28's pressure ulcer risk assessment dated [DATE] indicated score of 14 which is categorized as at risk. R28's care plan revised on 10/27/2022 indicated R28 is at risk for skin breakdown and interventions include pressure relieving mattress when in bed. MDS dated [DATE] indicated R28 is totally dependent with locomotion on and off unit and uses wheelchair as mobility device. Facility Documents: Title: Braden Scale for Predicting Pressure Sore (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145122 If continuation sheet Page 3 of 8 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 145122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dobson Plaza 120 Dodge Avenue Evanston, IL 60202 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 Copyrighted 2001 Level of Harm - Minimal harm or potential for actual harm At Risk (score of 15-18) - Pressure-reduction support surface if bed- or chair-bound Residents Affected - Few Title: Manufacturer's Manual Copyright 2014 Intended Use: This product intends to help reduce the incidence of pressure ulcers while optimizing patient comfort. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145122 If continuation sheet Page 4 of 8 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 145122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dobson Plaza 120 Dodge Avenue Evanston, IL 60202 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to post complete nurse staffing data in a prominent place readily accessible to residents and visitors. This failure can affect all 81 residents currently residing in the facility. Residents Affected - Many Findings include: On 08/01/2023 between 9:10AM - 12:10PM during observation, no nurse staffing information was observed at the front desk and on all three units. At 12:10PM, during observation with V1 (Administrator), no nurse staffing information was observed by the front desk and on the first-floor unit. On 08/01/2023 at 12:10PM, V1 said that the daily nursing assignment sheet serves as their staffing posting and is not aware of any other document the facility uses that specifically indicates the number of licensed and unlicensed nursing staff and the actual hours they worked. On 08/03/2023 at 11:50AM, V22 (Regional Director) said that V15 (Scheduler/Front Desk Supervisor) does the nurse staffing information and posts it but she does not know where. At 12:00PM, V22 presented a document for 8/3/2023 and said that it is the nurse staffing information, and it is kept under the pile of papers of the daily nursing assignment clipboard. On 08/03/2023 at 2:05PM, the daily assignment clipboard was observed with V15 noted with multiple sheets of daily nursing assignment sheets from previous days and said that he puts the nurse staffing information underneath those pile of papers. Daily Nursing Assignment Sheet does not indicate the current resident census, actual hours worked by the nursing staff, and specific categories of the nursing staff. Untitled document does not indicate facility name. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145122 If continuation sheet Page 5 of 8 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 145122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dobson Plaza 120 Dodge Avenue Evanston, IL 60202 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 follow their controlled substance policy. The facility failed to store and maintain controlled substance in a locked refrigerator. This failure effects one of two medication rooms reviewed for medication storage. The facility also failed to do accurate count of controlled drugs by failing to document in shift change accountability record for controlled substances form, and controlled drug receipt record form. This failure effects two of two medication carts reviewed for medication storage. This deficient practice affects 5 residents reviewed for medication storage in a total sample of 21 residents. Findings include: On 8/1/23 at 10:37 AM, first floor medication storage observation conducted with V14 (RN). Medication cart and binder for shift change accountability record for controlled drugs reviewed. Noted shift change accountability record for controlled substances in July 2023: 21st 3rd shift OFF, 25th 1st shift OFF, and 31st 3rd shift OFF are all empty and no initials. August 1st, 2023, shift OFF is also noted with no nurse initial. In addition, controlled drug receipt/record/disposition form reviewed and noted 2 forms for R47 and R2 were in the binder, however the form was incomplete. The signature of the nurse receiving medication, number of doses and date portion are empty and not filled in. R47's-controlled medication has a date received on 7/26/23 with 30 pills, and R2's-controlled medication has a date received on 6/17/23. On 8/1/23 at 10:45 AM, V3 (Director of Nursing/DON) stated that shift to shift count should be done by both incoming and off going nurses and both nurses must initial and document in the form. Our nursing practice if for the receiving nurse to fill in the portion number of doses and date, and nurse's signature when the controlled medication was received by the nurse on duty. On 8/1/23 at 11:00 AM, first floor medication room observation conducted with V14 (Registered Nurse/RN). Medication room needs to be unlocked by V14. Inside this first-floor medication room, observe a refrigerator, unlocked and with 2 controlled substances for R20's liquid hydromorphone and R69's liquid lorazepam. On 8/1/23 at 11:05 AM, V3 (DON) checked the first-floor medication room refrigerator, inserted the key, and locked it. Unable to pull the refrigerator open. V3 then talked to V14 stating that in order for refrigerator to be locked, V14 need to turn the key all the way. V14 answered saying that V14 checked the refrigerator in the morning, and it is locked. Also stating that surveyor pulled it hard and so the refrigerator opened. Confirmed with V3 that refrigerator should not open if it is locked. On 8/1/23 at 11:30 AM, second floor medication storage observation conducted with V7 (Registered Nurse/RN). Medication cart and binder for shift change accountability record for controlled drugs reviewed. Noted R53 has a controlled medication initiated on 7/10/23 with 30 pills, and on 7/31/23 with 8 pills left. Medication Bingo card reviewed and there are 9 pills left in the card. V7 stated she does not know why there is an extra pill left when it supposed to be 8. V7 stated that she worked 2 days in a row, and she knows she gave the medication to R53. V7 also stated that she did the controlled medication count with the off going shift nurse this morning, also stated she might have overlooked the pills and the form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145122 If continuation sheet Page 6 of 8 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 145122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dobson Plaza 120 Dodge Avenue Evanston, IL 60202 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 On 8/3/23 at 1:00 PM, V3 (DON) stated that she spoke to V7 (RN) and V7 (RN) cannot explained why there is an extra pill for R53's Alprazolam 0.25mg. V7 reported to V3 that she gave the medication and counted the medication with another nurse every time she worked the floor.V3 also state she does not also have an explanation why there is an extra pill if this was given daily to R53. Controlled Substances policy (not date) reads in part: Medication included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. All controlled substances are stored and maintained in a locked cabinet compartment. If refrigeration is required, the refrigerator or container kept in the refrigerator is locked. Policy for Controlled Substances dated August 2017, reads in part: In addition, a PROOF OF USAGE SHEET shall be used to record their administration. This form shall become part of the resident's permanent record. The shift change accountability record for controlled substances must also be completed by the nurses for each shift change. All Class II controlled substances will be locked in the narcotic box. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145122 If continuation sheet Page 7 of 8 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 145122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dobson Plaza 120 Dodge Avenue Evanston, IL 60202 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 follow its standard precaution policy for one resident (R59) of twelve residents, observed for infection control practices during dining observation in a sample of 21 residents. Residents Affected - Few Finding include: On 8/2/23 at 12:00pm, during dining observation, V9 (Activity Aid) was observed picking R59's fruit cup from the floor. V9 failed to perform hand hygiene after picking up R59's fruit cup from the floor. V9 proceeded to open the fridge to look for an extra fruit cup, V9 then received a new fruit cup from V8 (Food Service Supervisor) without washing her hands or applying hand sanitizer. On 8/2/23 at 12:00pm, V9 stated, I should've washed my hands or used hand sanitizer after picking the cup from the floor. On 8/2/23 at 12:05pm, V8 (Food Service) stated that staff should clean their hands after picking an object from the floor. Facility policy titled Standard Precautions revised 2/2014 reads: Policy Statement; standard precaution will be used in the care of all residents regardless of their diagnosis, or suspected confirmed infection status . Standard precautions include the following practice: 1. Hand hygiene a. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or using alcohol-based hand rub (gels, foams, rinses) that do not require access to water. b. Hands shall be washed with soap and water whenever visibly soiled with dirt, blood, or body fluids, or after direct or indirect contact with such and before eating and after using the restroom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145122 If continuation sheet Page 8 of 8