Inspection·September 14, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete be referred to the urologist for evaluation, at that time the nurse practitioner should have placed an order for the appointment and coordinated with the nurse to schedule a urology evaluation for him. V3 stated she did not find an order for a urology appointment in R199's physician order sheet at this time. V3 stated it was important to have R199's urology evaluation scheduled as soon as it was recommended by the nurse practitioner because if it is possible for R199's catheter to be removed it will reduce the risk of him developing an infection. V3 stated whenever a catheter is in place it increases the risk of infection. Event ID: Facility ID: 145171 If continuation sheet Page 2 of 4 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 145171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Northbrook 270 Skokie Highway Northbrook, IL 60062 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 observations, interviews, and record reviews the facility failed to follow their policy and procedures for serving food under sanitary conditions by not properly wearing hair restraints, not practicing hand hygiene when necessary, not ensuring sanitizer solution was replaced when needed, not ensuring kitchen appliances were properly cleaned and stored, not ensuring the ice machine was thoroughly clean when in use, and not recording final cook temperatures. This failure has the potential to affect all 210 residents in the facility. Findings include: 09/11/2023 at 10:23 AM - 10:40 AM, Observed a large ice machine filled with ice to have heavy rust like buildup inside of the machine at the hinge of the door. Observed V4 (Director of Dining Services) was able to wipe away the buildup with his finger. V4 stated the ice machine is cleaned weekly. V4 stated the buildup in the ice machine could possibly be rust. V4 stated the ice machine should be free of any buildup. Observed the meat slicer to have stuck on and loose food particles once the plastic bag cover was removed by V4. Observed V4 firmly rub the area of the meat slicer with the stuck-on food particles and state the particles don't come off. V4 stated the meat slicer should be cleaned after each use and he will have it recleaned. Observed V5 (Dietary Aide) and V6 (Dietary Aide) with hair exposed from the sides and back of their hairnets while working in the food prep area. Observed the sanitizer bucket in the food prep area with no sanitizer solution in it when tested. V4 stated the sanitizer solution in the bucket had not been changed. V5 stated the sanitizer solution in the bucket needed to be changed. 09/12/2023 at 10:05 AM - 11:30 AM, Observed V5 (Dietary Aide), V6 (Dietary Aide), and V7 (Cook) with hair exposed from the sides and back of their hairnets while working in the food prep area. Observed V7 pick up an oven mitten from the floor with gloved hands, place on the oven mitten over his glove, pick up a large pan of melted butter from the stove and transfer it to the food prep table then remove the oven mittens and gloves. Observed V8 (Dietary Aide) with hair exposed from the sides and back of her hair while rolling silverware. Observed V7 temp the chicken fried steaks before removing them from the oven then have them placed in a separate container and moved to the steam table without recording the final cook temp. Observed V5 place the cooked mixed vegetables that were held on the stove and purees held in the heated oven/hot box for several minutes on the steam table. Observed V7 temp the foods on the steam table while V5 documented the temperatures on the temp log in the section for held food temperatures. Observed the food temperature log dated 09/12/2023 did not include the final cooking temperatures of the prepared food. Observed V6 remove four slices of bread from a package of bread and pack them into small bags with her bare hands. Observed V6 then seal the package of bread and set aside for later use. V6 stated she was packing the bread to be sent out with residents who will be leaving for an appointment. V4 stated he did observe V5, V6, and V8's hair was exposed from underneath their hairnet. V4 stated the hair of staff working in the kitchen should be fully covered by their hairnet. 09/12/2023 at 10:30 AM V4 (Director of Dining Services) stated he observed V6 (Dietary Aide) had handled bread with her bare hands in the kitchen on 09/12/2023 and she knows this is not appropriate. V4 stated no food being prepared for service should be touched with bare hands. V4 stated gloves should be changed and hands washed after handling contaminated items such as when V7 (Cook) picked up the oven mitten off the floor with his gloved hands. V4 stated he was never instructed that the temperatures of foods when removed from the oven needed to be documented. V4 stated the facility was only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145171 If continuation sheet Page 3 of 4 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 145171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Northbrook 270 Skokie Highway Northbrook, IL 60062 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 advised that the final temperatures of foods when held on the steam table needed to be documented. V4 acknowledged that the food temperature logs include a section for documentation of food temperatures when removed from the oven and stated he was never instructed that he must complete that section of the log. The facility's Hair Restraints Policy reviewed 09/13/2023 states:Hair restraints shall be worn by all Dining Services staff when in food production areas. Hair restraints shall be used to prevent hair from contacting exposed food. The facility's Food Preparation Policy reviewed 09/13/2023 states: Food is prepared using safe food handling methods which protect the food from contamination, prevent food-borne illness and preserve nutritive value of the food. Avoid bare hand contact with any food. The facility's Proper Hand Washing and Glove Use Policy reviewed 09/13/2023 states: All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines. Gloves are changed any time hand washing would be required. This includes if gloves become contaminated by touching a non-food contact surface. The facility's Food Temperature Policy reviewed 09/13/2023 states: Food and Nutrition Services employees will practice safe food handling to prevent food borne illness. It is the policy of the dietary department to take and record final cook temperature. Food will be removed from the oven and placed directly in the steam table. Temperature will immediately be taken and recorded as the final cook temperature. The correct temperature will be recorded in a temperature log. The facility's Sanitizer Policy/Procedure reviewed 09/13/2023 states: Buckets should be changed every 2-4 hours or more as needed to keep the water clean and the sanitizer effective in use. The facility's Cleaning Instructions for Slicer reviewed 09/13/2023 states: Slicer will be cleaned and sanitized after each use. The facility's Cleaning Instructions for Ice Machine and Equipment reviewed 09/13/2023 states: Ice machine and equipment will be kept clean and sanitized. Wash inside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145171 If continuation sheet Page 4 of 4