Inspection·May 11, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm for a code status. V2 stated, when the code status physician order is placed in the EMR, it flows through to the profile (section). When asked if a physician order is needed for a code status of full code or DNR (do not resuscitate), V2 stated, Yes. When asked about the purpose of nurses being able to locate the code status of a resident, V2 stated, in an emergency, the nurse will know what treatment to do. V2 stated that the code status physician order is what is needed to be done to the resident. Residents Affected - Few On [DATE] at 12:01 pm, V11 (Social Services Director/SSD) stated, if the resident is not admitted to the facility with advance directives and does not complete a POLST form in the facility, the resident is considered a full code and must still have a code status physician order in the EMR indicating full code. This surveyor requested R40's POLST form from V11. On [DATE] at 12:36 pm V11 (SSD) stated to this surveyor that R40 has not completed a POLST form in the facility and has no advance directives. Facility policy titled Advance Directives, dated [DATE], documents, in part, Upon admission: 1. Designated staff will review and explain the Statement on Illinois Law addressing Advance Directives option and Life Sustaining Treatment with the resident and/or representative. 2. Staff will provide the resident and/or representative with information regarding advance care planning which will address types of Advance Directives, treatment options and refusal of treatment . 5. Appropriate information will be added to Physician Order Sheet (POS) . 10. If the resident is unable or chooses not to initiate any type of Advance Directive, it is the policy of this facility for the resident to be a Full Code and receive appropriate life sustaining treatment interventions such as CPR (Cardiopulmonary Resuscitation). 2. R73's admission record includes but not limited to diagnoses of schizoaffective disorder, atherosclerotic heart disease, chronic obstructive pulmonary disease, encephalopathy, hypertension, anxiety, and paranoid schizophrenia. R73's ([DATE]) Brief Interview of Mental Status documents a score of 15. (Cognitively intact). R73's Order Summary Report printed on [DATE], documents no physician order for an advance directive (Full code or DNR [Do Not Resuscitate] status) for R73. R73's ([DATE]) care plan documents in part, Advance Directive Status (Code Status; Full Code). Interventions: As indicated, document the code status on the Physicians' Order Sheet (POS) in the EMR (Electronic Medical Record) system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 2 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 - Actual harm Based on observation, interview, and record review the facility failed to provide a working wound vacuum and failed to assess one resident's (R85) wound. These failures affected one resident (R85) causing (R85's) wound to have a foul odor, purulent greenish drainage and (R85) feeling embarrassed due to the odor that permeated (R85's) room. Residents Affected - Few Findings include: R85's Face sheet documents R85 has a diagnosis that include but not limited to acute hematogenous osteomyelitis left ankle and foot, unspecified abnormalities of gait and mobility, other lack of coordination, peripheral vascular disease, idiopathic aseptic necrosis of the femur, complete traumatic amputation at level between knee and ankle unspecified lower leg sequela and acquired absence of unspecified foot. R85's Brief Interview for Mental Status (BIMS) dated 03/20/23 documents that R85 has a BIMS score of 15 which indicates that R85 is cognitively intact. On 05/08/23 at 10:49 am, Surveyor observed R85's room door closed. Upon opening R85's room door, surveyor observed R85 in bed asleep and R85's room with a foul odor. Surveyor unable to interview R85 due to R85 asleep. On 05/08/23 at 3:00 pm, V2 (Director of Nursing/DON) stated, V2 was the facility's wound care nurse. Surveyor requested to see R85's wound. V2 stated, that R85's wound is changed on Monday's Wednesday's and Friday's and was already changed and will not be changed again until Wednesday May 10, 2023. On 05/09/23 at 11:40 am, Surveyor and V2 observed R85 sitting in a wheelchair in R85's room with a wound vacuum device in place on R85's amputated left leg area between R85's knee and ankle area and a foul odor in R85's room. R85 stated, Now that my machine (referring to R85's wound vacuum device) is back working, what is the smell and this green drainage in this container (referring to the wound vacuum device canister)? Surveyor and V2 observed R85's wound vacuum canister with moderate amount of foul odorous green drainage. V2 replied to R85, That is the drainage. When V2 was asked regarding the odor in R85's room V2 stated that the foul odor in R85's room was from R85's drainage from R85's wound (referring to R85's wound to left leg area between R85's knee and ankle area). V2 also stated, R85's wound vacuum device was not working for a few days and that R85 was giving a new wound device on May 9, 2023. On 05/09/23 at 11:45 am, R85 stated that on May 5, 2023, R85 informed the nurse (unknown nurse) that R85's wound vacuum device was not working. R85 stated, the broken wound device stayed in place to R85's wound and R85 did not receive a working wound vacuum device until 05/09/23. R85 stated, On 05/07/23 is when I noticed my room developed a foul smell from my wound that made me feel embarrassed. R85 stated, I told V20 yesterday about the smell and V20 did not do anything. I don't want people to think that I smell. My wound vacuum cord was broken, and I only needed a new cord and they (referring to the nurses) waited until Monday to order a whole new machine. On 05/09/23 at 11:47 am, Surveyor and V20 (Licensed Practical Nurse/LPN) observed a foul odor in R85's room. When V20 was asked regarding R85's foul room odor R85 stated, It (referring to R85's foul room odor) is better today. Yesterday it (referring to R85's foul room odor) was bad because R85's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 3 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 - Actual harm Residents Affected - Few wound vacuum was not working. When V20 was asked regarding R85's wound vacuum not working. V20 stated, V20 was aware that R85's wound device stopped working on May 6, 2023, and that V20 informed V2 (DON) on May 8, 2023. V20 explained, R85's wound only gets changed on Monday, Wednesday, Fridays and that R85's wound vacuum device was replaced on Monday May 8, 2023, and that R85 received a new wound vacuum dressing then. V20 was asked regarding the facility's policy for a wound vacuum device if it is not working. V20 stated, We (referring to staff) have to tell the DON. On 05/10/23 at 9:30 am, Surveyor requested to see R85's wound and V2 stated that R85 was not in the building and that R85 was sent to the wound clinic for R85's wound to R85's left leg area between R85's knee and ankle area to be assessed. V2 also stated that V21 (Nurse Practitioner/NP) saw R85 on 05/09/23 and ordered for R85 to go to the wound clinic. On 05/10/23 at 12:43 pm, Surveyor requested R85's wound assessments for the past four weeks from V2 (DON). V2 stated, I (V2) do not have it. I usually do it (referring to R85's weekly wound assessment) every week but I (V2) did not do it. R85's last assessment I (V2) completed in the system was April 5, 2023. On 05/10/23 at 1:45 pm, V21 (Nurse Practitioner) stated, R85 is an alert and oriented resident and that V21 last saw R85 on May 09, 2023. V21 explained, R85 has a vascular wound to her lower left extremity with a wound vacuum device in place that is changed on Monday's, Wednesdays, and Fridays by the facilities nurses as well as R85 also goes to wound clinic (unsure of how often). V21 stated, on May 09, 2023, V21 assessed R85's wound with a foul odor and green drainage in R85's canister. V21 stated, R85's wound should be assessed every time R85's wound vacuum dressing is changed on Monday's, Wednesday's, and Friday's. V21 also explained, If R85's wound vacuum is left in place and goes without being changed or unassessed there is a possibility of sepsis and infection occurring to R85's wound. Surveyor asked V21 if R85's wound vacuum device is not working, what should happen to R85's wound. V21 stated, R85's wound vacuum device should be removed immediately, and a wet-to-dry dressing should be applied to avoid infection from occurring to R85's wound. V21 was asked signs of infection. V21 stated, Foul odor and green drainage are signs of an infection. V21 stated, On May 9, 2023, staff informed V21 that R85's wound vacuum stop working on May 05, 2023, and that R85's wound vacuum was not replaced until May 09, 2023. V21 stated, V21 ordered for R85 to go to the wound clinic on May 10, 2023 and a culture of R85's wound to be collected at R85's wound clinic. On May 10, 2023, at 2:15 pm, V2 (DON) stated that if a residents wound vacuum device is not draining the drainage properly from the wound, then the wound will deteriorate and show signs of infection. V2 stated, Signs of infection include green drainage and foul odor. V2 stated, The purpose of the wound vacuum is to drain the wound drainage, prevent signs of infection and help with wound healing. V2 also stated, If a wound vacuum is left in place and not working for several days the wound can deteriorate and have and odor and show signs and symptoms of infection. V2 explained, the floor nurses are in charge of changing R85's wound vacuum dressing and that V2 was told on May 8, 2023, that R85's wound vacuum device was not working since May 05, 2023. V2 stated on May 08, 2023, V2 called the Durable Medical Equipment (DME) supplier right away to get R85 another wound vacuum device. V2 also explained, R85 was given a working wound vacuum device on May 09, 2023, that was delivered by the wound DME supplier. V2 was asked regarding assessment of R85's wound. V2 stated, R85's wound is expected to be assessed at least weekly and should be assessed every time R85's wound vacuum is removed three times a week. V2 explained, if a wound goes more than a week without being assessed the wound can deteriorate and can have signs of infection. V2 also stated that if a wound vacuum device is not working properly, the wound vacuum device should be reported to V2 immediately, the wound should have a dry dressing placed until the equipment is replaced and the equipment should be replaced as soon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 4 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 as possible. V2 stated, This did not happen with R85. I am not sure why I was not immediately informed. Level of Harm - Actual harm R85's POS (Physician Order Sheet) dated 03/29/23 documents, in part: Change wound vac (vacuum) dressing every 3 days and PRN (as needed) monitor wound weekly every day shift every Monday, Wednesday, Friday related to complete traumatic amputation at level between knee and ankle unspecified lower leg sequela. Residents Affected - Few R85's progress note dated 05/09/23 authored by V2 (DON) documents, in part: R85 noted with mild odor and mild greenish drainage in wound vac . R85 offered to go to the hospital for further evaluation of wound . drainage in vac tubing pale brown in color. R85's care plan dated 03/28/2023 documents, in part: Focus: R85 has venous/stasis ulcer related to PVD (Peripheral Vascular Disease). Goal: R85 will have no signs/symptoms of infection through next review dated. Interventions: Monitor/document/report to MD (Medical Doctor) as needed for signs/symptoms of infection: green drainage, foul odor, redness and swelling, red lines coming from wound, excess pain, fever. R85's care plan dated 03/28/23 documents, in part: Interventions: Change dressing using the topical and dressing materials ordered at the prescribed frequency . Frequently reassess the integrity of the dressing. Reinforce dressing as needed. Monitor for changes in amount, type, odor and frequency of drainage and need for reinforcement. R85's Wound Assessment Details Report dated 04/05/23 and authored by V2 (DON) documents R85's last wound assessment prior to 05/10/23. The facility's policy dated 07/28/22 and titled Skin Care Treatment Regimen documents, in part: Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown. Procedure: . 2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 5 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to label and date oxygen equipment (oxygen tubing) per the facility policy. This failure affected one resident (R14) reviewed for oxygen equipment, in a total sample of 47 residents. Residents Affected - Few Findings include: On 05/08/23 at 11:05 am, Surveyor observed R14 in bed awake and alert. R14 was observed with 1 liter (L) nasal cannula (NC) tubing in place unlabeled and not dated. When R14 was asked regarding R14's NC oxygen tubing R14 stated, They (referring to staff) change it (referring to R14's nasal cannula oxygen tubing) about once of month. It (referring to R14's NC oxygen tubing) should be changed once a week but they (referring to staff) don't do it. On 05/09/23 at 10:30 am, Surveyor observed R14 in bed awake and alert. R14 was observed with 2 liters (L) nasal cannula (NC) tubing in place unlabeled and not dated. On 05/10/23 at 11:40 am, V2 (Director of Nursing/DON) stated, oxygen tubing should be changed weekly by the floor nurse to prevent the resident from getting an infection. V2 explained when oxygen tubing is not labeled with a date no one knows how long the patient has been wearing the oxygen tubing which can also cause the resident to get an infection. When V2 was asked regarding the last time R14's oxygen tubing was changed. V2 stated, I do not know, they (referring to staff) should change it every week. R14's Face sheet documents that R14 has a diagnosis that include but not limited to personal history of COVID 19, essential primary hypertension, and chronic obstructive pulmonary disease. R14's Brief Interview for Mental Status (BIMS) dated 03/01/23 documents that R14 has a BIMS score of 15 which indicates that R14 is cognitively intact. R14's Physician Order Sheet (POS) dated 08/01/22 documents, in part: oxygen supplemental concentrator via nasal cannula 2-4 L/ per Minute for comfort while in room as needed for shortness of breath. R14's POS dated 08/01/22 documents, in part: change oxygen tubing as needed, and every night shift every Friday concentrator and the inogen (sic). The facility's policy dated 07/28/22 and titled Oxygen Therapy and Administration documents, in part: Purpose: To assure adequate oxygenation . c. oxygen setups should be changed every seven days and as needed if heavy soiling is present. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 6 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on observation, interview, and record review the facility failed to assess and rate pain for one resident (R73) that was experiencing a tooth ache and failed to administer pain medication as ordered. This failure resulted in R73 experiencing severe pain with facial grimacing and pain with eating. Residents Affected - Few Findings Include: R73's admission record includes but not limited to diagnoses of schizoaffective disorder, atherosclerotic heart disease, chronic obstructive pulmonary disease, encephalopathy, hypertension, anxiety, and paranoid schizophrenia. R73's (2/21/23) Brief Interview of Mental Status documents a score of 15. (Cognitively intact). On 5/8/23 at 10:55 am surveyor observed R73 lying in bed with the covers pulled over R73's head. R73 pull the covers from over her head and surveyor observed R73 with facial grimacing when talking. R73 stated, My tooth hurts. I told the nurse, but they haven't given me anything. The doctor said he was going to order me some oral gel, but I haven't gotten it yet. My pain is an 8 on a pain scale of 1 to 10. I can hardly eat. I have to switch the food from side to side in my mouth when I'm eating because of the pain. On 5/8/23 at 11:05 am surveyor informed V9 (Registered Nurse/RN) that R73 stated she has tooth pain. V9 stated, I will go and see R73 and call the doctor. On 5/9/23 at 10:20 am surveyor observed R73 in room lying in bed. R73 stated, I still have tooth pain and still haven't gotten anything for my pain. R73 stated, The pain is a 4 on a pain scale of 1 to 10. The surveyor asked R73 if V9 (RN) gave her something for the tooth pain yesterday (5/8/23). R73 stated, No, I didn't get anything. On 5/9/23 at 10:25 am surveyor asked V9 if V9 administered R73 any pain medication for R73's toothache on 5/8/2023 when surveyor informed V9 that R73 was in pain. V9 stated, I did not go into R73's room. I did not give R73 anything for pain or call the doctor yesterday (5/8/23) because I was busy. Surveyor asked V9 if residents are assessed for pain. V9 stated, No I do not ask if the residents are in pain. I only ask if I know someone has chronic pain then, I will ask if they are in pain today. V9 stated, I will call the doctor. R73's (4/25/23) active orders, documents in part, oral relief give 1 application by mouth every 24 hours as needed for tooth pain. On 5/10/23 at 1:40 pm V21 (Nurse Practitioner) stated, R73 said she had tooth pain and needed something for the pain. V21 stated, Oral gel was order for the tooth pain. V21 stated, Nurses are expected to carry out orders and I wasn't aware that R73 did not receive the ordered medication. On 5/10/23 at 2:15 pm V2 (Director of Nursing) stated, pain assessment is done as soon as the resident complain of pain and is documented on the MAR (Medication Administration Record) or progress notes. Nurses are expected to carry out physician orders and manage resident's pain. Surveyor asked if a resident reports pain to nurse, what is the expectation of the nurse? V2 stated, The nurse should go and immediately assess the resident for pain, ask the pain scale and give the appropriate pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 7 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 0697 relief medication. V2 stated, It is not acceptable for a nurse to not assess a resident for pain and say they are too busy. Level of Harm - Actual harm Residents Affected - Few On 5/10/23 at 2:30 pm, surveyor and V9 (RN) checked the medication cart for R73's oral relief medication ordered on 4/25/23. Medication was not observed on second floor medication cart by surveyor and V9. V9 stated, I will reorder and call the pharmacy. R73's MAR (Medication Administration Record) documents, in part, Oral Relief for dry mouth, Mouth/Throat Gel (Artificial Saliva) Give 1 application by mouth every 24 hours as needed for tooth pain-Start Date4/25/2023. Review of MAR shows no documentation R73 received ordered medication from 4/25 to 5/10/23. R73's MAR documents in part, Acetaminophen Tablet 650 mg give 1 tablet by mouth every 4 hours as needed for General Discomfort. Review of MAR shows no documentation R73 received ordered medication from 4/25 to 5/10/23. R73's electronic records shows no pain assessment documentation noted on pain assessment flow sheet, MAR, or progress notes from 4/25/23 to 5/10/23. R73's last pain assessment was documented on 11/16/22. R73's care plan dated 2/21/23 documents in part, at risk for acute and chronic pain. Interventions: observe for non-verbal signs of pain, provide analgesic as ordered, utilize non-pharmacological intervention. Facility Registered Nurse Job Description (5/5/2015) documents, in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guest ER serve, the Registered Nurse (RN) plays a critical role in providing superior customer service and nursing care to all Guests and guest. The RN provides supervision of staff and will safeguard the health, safety, and welfare of all Guest/guest under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: 7. Place pharmacy orders, for and administer all newly prescribed medications and document. Facility Pain Policy (7/28/22), documents, in part, Policy Statement: It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain. For pain complaints and for situations/ incidents that might result to pain (Example: fall incident, altercation, cuts, bruises, wound care, etc.), the nursing staff may document it in any part of the resident's medical record that includes Nurses Notes, Incident Report, and Medication Administration Record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 8 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 staff failed to complete the controlled drug count sheet which is utilized to complete a shift-to-shift count for controlled substances. This failure has the potential to affect all 31 residents on the second floor and all 33 residents on the third floor. Findings include: On 05/09/2023 at 10:50 AM surveyor with V6(Licensed Practical Nurse/LPN) reviewed the third-floor medication cart Controlled Drug Count Sheets for April 2023 and May 2023. V6 stated, these forms are used by the facility for shift change accountability for controlled substances. Document review showed the Nurse Leaving and/or Nurse Arriving initial boxes were left blank for the following dates and shifts: April 06, 2023, 11pm-7am shift (arriving nurse) April 07, 2023, 7 am-3pm shift (leaving nurse) April 09, 2023, 11pm-7am shift (arriving nurse) April 10, 2023, 7 am-3pm shift (leaving nurse) April 10, 2023, 7am-3pm shift (arriving nurse) April 10, 2023, 3pm-11pm shift (leaving nurse) April 10,2023, 3pm-11pm shift (arriving nurse) April 10, 2023, 11pm-7am shift (leaving nurse) April 11, 2023, 3pm-11pm shift (arriving nurse) April 11, 2023, 11pm-7am shift (leaving nurse) April 19, 2023, 3pm-11pm shift (leaving nurse) April 20, 2023, 11pm-7am shift (arriving nurse) May 04, 2023, 11pm-7am shift (arriving nurse) May 05, 2023, 7am-3pm shift (leaving nurse) May 07, 2023, 3pm-11pm shift (leaving nurse) On 05/09/2023 at 1:56 PM surveyor with V9 (Registered Nurse/RN) reviewed the second-floor medication cart Controlled Drug Count Sheet for May 202.3. V9 stated, this form is used by the facility for shift change accountability for controlled substances. Document review showed the Nurse Leaving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 9 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 and/or Nurse Arriving initial boxes were left blank for the following dates and shifts: Level of Harm - Minimal harm or potential for actual harm May 06, 2023, 7am-3pm shift (arriving nurse) May 06, 2023, 3pm-11pm shift (leaving nurse) Residents Affected - Some May 06, 2023, 11pm-7am shift (arriving nurse) May 07, 2023, 7am-3pm shift (leaving nurse) The missing initials indicate the controlled substance medication reconciliation at the end/ beginning of shift was not completed. On 05/09/2023 at 10:50 AM V6 (LPN) stated, the nurses are responsible for completing the controlled drug count sheet. V6 stated, the arriving nurse is to count the controlled substances with the leaving nurse and both the nurses are to verify the count for the controlled substances is correct. V6 both nurses will initial the controlled drug count sheet verifying the count of the controlled substances in the medication cart is correct. V6 stated, the nurses are to notify the Director of Nursing if the controlled substances check form is not completed by both nurses and/or the count for the controlled substances is not correct. On 05/09/2023 at 2:10 PM V9 (RN) stated, the nurse is responsible for completing the controlled drug count sheet. V9 stated, the purpose of the controlled drug count sheet is to log in which nurse is taking care of the controlled substance medications on a set date and hour. V9 stated, I am unaware if the nurses are supposed to report to the Director of Nursing if there are missing nurse's initials on the controlled drug count sheet. On 05/10/2023 at 2:20 PM V2 (Director of Nursing) stated the nurses are responsible for completing the controlled drug count sheet. V2 stated the nurses must do the reconciliation for the controlled substance medications and complete the endorsement between the two nurses. V2 stated this is done to ensure that the count of the controlled substances is correct. V2 stated, the form should be initialed by the arriving and leaving nurses, this is verifying that both nurses have counted the controlled substances and agree the count is correct. V2 stated, if there are no documented initials from a nurse, there was no reconciliation of the controlled substance medications that happened between two nurses. Facility's policy (revision date of 07/27/2022) titled Controlled Medications Count which documents, in part, Policy Statement: It is the policy of the facility to maintain an accurate count of Scheduled II (2) controlled medications. Facility's job description for RN (Registered Nurse) dated 05/05/2015 which documents, in part, underneath Essential Functions 6. Review daily the documentation of the dispensing of the controlled substances and narcotics. Ensure that drugs covered by controlled substances laws are verified by inventory. Facility's job description for LPN (Licensed Practical Nurse) dated 05/05/2015 which documents, in part, underneath Essential Functions 6. Review daily the documentation of the dispensing of the controlled substances and narcotics. Ensure that drugs covered by controlled substances laws are verified by inventory. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 10 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 ensure that residents' food items in the facility kitchen are properly labeled, dated when received and when opened, and a food package is securely sealed after opening. The facility failed to discard expired food items; failed to store drink items 6 inches off the floor; failed to ensure staff store their food and drinks out of the facility kitchen used for residents. The facility failed to maintain the proper sanitation levels of the kitchen sanitation buckets and the kitchen's low temperature dishwasher; failed to accurately test the sanitation level of the low temperature dishwasher; and failed to ensure that all kitchen staff were up to date with their food handler certifications. These deficient food storage and sanitation practices have the potential to affect all 94 residents receiving oral diets from the facility's kitchen. Findings include: On 5/8/23 at 9:26 am, during the initial kitchen tour with V4 (Dietary Director), this surveyor observed a 16.9-ounce water bottle in the white, reach in freezer, located against the east wall in the kitchen. When asked about the water bottle, V4 stated that it should be labeled and could be a staff member's personal water, said It shouldn't be in the freezer. In the same reach in freezer, this surveyor also observed a round, frozen biscuit in no package or container at the bottom of the freezer. When asked what food item this is, V4 stated that it is a biscuit, and it should not be stored without any packaging. Next, this surveyor observed, in the same reach in freezer, two pieces of white fish in a clear, plastic bag along with ice crystals inside the bag, and no label or date noted on the plastic bag. When asked what item this is, V4 stated that it's fish and confirmed with this surveyor that there is no label or date on the package. V4 stated that it should have been tossed. On 5/8/23 at approximately 9:42 am, this surveyor entered the kitchen's walk-in refrigerator and observed on the shelving unit two bottles of flavored coffee creamers (28 ounces) with one visibly open with dried, residual creamer noted on the lid. When asked when the flavored coffee creamer is used, V4 stated that it's the staff member's coffee creamers and shouldn't be in the kitchen refrigerator. This surveyor then observed two foil wrapped portions of white cheese slices (opened and verified by V4) with no label or date on the foil package. On the same refrigerated shelving unit, one clear, plastic package of flour tortilla shells observed opened and is not dated or labeled. V4 stated that these items shouldn't be stored in the refrigerator with no date or label. Next, a 5-pound container of low-fat cottage cheese observed in the walk-in refrigerator with a manufacturer's Best Use By date printed on it of 2/10/23. The low-fat cottage cheese container observed with a written date in black marker of 4/28/23 on the lid, and both dates were verified with V4. V4 stated, This should have been thrown out. Then a 6.5-pound container of strawberry compost observed with a manufacturer's Best Use By date printed on it of best use by date printed by manufacturer as 5/13/22. Strawberry Compost container with written black marker of 4/3/23 and verified both dates with V4. V4 stated that this strawberry compost is expired and should have been removed from the refrigerator. Next, a log of pasteurized processed Swiss cheese slices observed with opened packaging at one end, and this surveyor can visibly see the cheese slices through the opening of the package. No date is written on the packaging of when it was opened. When asked when this log of Swiss cheese slices was opened, V4 stated, I (V4) can't tell you that. V4 stated that any package of food should be dated when it's opened. On this same shelving unit in the walk-in refrigerator, a foil covered item on a plate with no label or date was observed. When asked what this is, V4 peeled back the foil covering to show cut pieces of cheesecake. V4 stated that this was from the weekend when a facility staff member had a baby (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 11 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 shower. V4 stated, This shouldn't be in there. In the walk-in refrigerator, on the opposite side shelving unit, fresh green onions bundles, and fresh broccoli heads observed in cardboard boxes with the top flaps of the boxes opened all the way, and no date is noted on the box. When asked when the green onions and broccoli were received, V4 stated that it would have been within 2 weeks, but that the food should be labeled when the fresh vegetables were received in the facility. In between both shelving units in the walk-in refrigerator, a black milk crate containing 5 milk cartons (half pint) observed stored directly touching the floor. V4 stated that the milk cartons in the crate should not be stored on the floor and should be stacked up off the floor. On 5/8/23 at approximately 9:55 am, this surveyor asked V4 to check the sanitation levels of the sanitation buckets in kitchen. For the #1 sanitation bucket near the food preparation table (south end of kitchen), V4 removed a test strip from the quaternary ammonium (quat) test strips and placed it in solution in bucket #1 for approximately 2 seconds. V4 removed the quat test strip, and the test strip turned dark green in color. When asked how does V4 interpret the reading of the quat test strip, V4 held the test strip up to color indicators on the quat test packaging and stated, 400 (parts per million, ppm). Over. When asked to clarify what the dark green color of the test strip means, V4 stated, It's heavy. When asked what the appropriate level of sanitation should read on the quat test strip for the no-rinse sanitation buckets, V4 stated 100 to 400 (ppm). This surveyor then asked V4 to perform the quat testing on the #2 sanitation bucket near the cook station near the north wall of the kitchen. V4 removed a strip from the quat test strips container and placed it in the bucket #2 for approximately 2 seconds. V4 removed the quat test strip, and it turned dark green in color. When asked to interpret the test result, V4 stated, The same. When asked what the sanitation level is interpreted from the dark green color of the test strip results, V4 stated, About 400 (ppm). On 5/9/23 at 10:29 am, during a revisit to the facility kitchen, this surveyor asked V4 to check the sanitation buckets again for the concentration of the no-rinse sanitizer. For the #1 sanitation bucket (south), V4 removed a test strip from the quat test strips package and placed it in bucket for approximately 2 seconds. The test strip turned dark green in color. When asked how does V4 interpret this test strip color reading, V4 held the dark green test strip up to colors on the packaging and stated, 400 (ppm). For the #2 sanitation bucket (north), V4 removed another test strip from the quat test strips package and placed it in the bucket for approximately 2 seconds. The test strip turned dark green in color. When asked how does V4 interpret this color reading, V4 held the test strip up to the colors on quat test strip packaging and stated, Same. 400 (ppm). On 5/9/23 at 10:33 am, V4 and this surveyor were near the kitchen's dishwasher, and V4 stated that it's a low temperature (temp) dishwasher. When asked to perform a sanitation test with the low temp dishwasher, V4 removed a test strip from the vial labeled for the chlorine testing. V4 placed the chlorine test strip on a fork, placed the fork with the test strip on a dish rack along with other ware and ran a dishwasher cycle. When the cycle was complete, V4 pulled out the rack from the dishwasher, and the chlorine test strip on the fork was white in color. V4 compared the white test strip to the color squares on the vial of chlorine test strips container. When asked what the reading of this chlorine test strip is, V4 stated, 10 (ppm). When asked what the chlorine test strip reading should be for this low temp dishwasher, V4 stated that it's per the manufacturer's recommendation. When asked what is the proper sanitation reading needed on the chlorine test strip, as this surveyor is viewing the chlorine test strips vial with the colors and numbers of 10 ppm color of very light gray, 50 ppm color of medium purple, 100 ppm color of dark purple, 200 ppm color of very dark purple, near black, V4 stated, To the best of my knowledge, as long as it reads (on the test strip), it's legal. V4 stated that if it's below or above the low (10 ppm) and high (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 12 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 (200 ppm) ranges on the chlorine test strip, then it's not sanitized. V4 stated that V4 doesn't know when the last time that this low temp dishwasher was serviced, but V4 is concerned about the calibration of the dishwasher. When asked what is used as a sanitizer for this low temp dishwasher, V4 pointed to container under the dishwasher with the label of (Chlorine Additive) solution. This surveyor then asked V4 to review the dishwasher sanitation log, and V4 retrieved the May 2023 log from a plastic holder on the wall near the dishwasher. Three columns were noted on the May 2023 dishwasher log with the last entry noted 5/9/23 for breakfast with a sanitizer level of 100 ppm. V4 stated that facility staff test the low temperature dishwasher three times a day. V4 stated that the dishwasher was tested last after breakfast today, 5/9/23, and the reading was 100 ppm. This surveyor asked V4 to run another sanitation test of the low temp dishwasher, where V4 used the same process of placing the chlorine test strip on a fork and ran it through a complete cycle of the dishwasher. The test strip on the fork was a very faint light gray color. V4 interpreted the chlorine test strip color as light gray, and V4 said, 10 (ppm). This surveyor noted an operations requirements sticker mounted on the front of the facility's low temp dishwasher reading, Required - 50 PPM Available Chlorine. On 5/9/23 at 12:58 pm, during a revisit to the kitchen, this surveyor asked V16 (Dietary Aide) to perform a chlorine test strip with the low temp dishwasher. V4 was present at the dishwasher station. V16 reached for the chlorine test strips containers, and V4 said to V16 put it in on a fork. V16 removed a chlorine test strip, put on a fork, and placed the fork in with rack with lid covers. V16 ran the dishwasher cycle of the rack, and when completed, the test strip disappeared off the fork. On 5/9/23 at 1:02 pm, V16 (Dietary Aide) ran another chlorine test strip through the low dishwasher cycle on a fork with trays and lids on the rack. When the dishwasher cycle ended, V16 pulled out the wet test strip on the fork, and this surveyor asked what the sanitation test reading was, and V16 stated, It (color) didn't change. It's white. V16 stated that V16 did not do the chlorine testing for the dishwasher this morning (5/9/23), when pointing at the log that the surveyor was holding. V16 stated that the initials on the log were from V17 (Dietary Aide). On 5/9/23 at 1:07 pm, this surveyor showed V17 (Dietary Aide) the dishwasher test log from 5/9/23 breakfast section, and V17 confirmed that V17 did the sanitation testing of the low temp dishwasher. When asked when V17 performed the dishwasher chlorine test this morning (5/9/23) after the breakfast meal service, what color did the test strip turn, and V17 stated, Red. This surveyor asked the question again, and V17 reiterated red. This surveyor showed V17 the chloride test strip container with the 4 colored squares, and V17 stated, It was kind of pinkish as a result of the chlorine test for the 5/9/23 breakfast service. This surveyor showed V17 the 4 colors squares on the chlorine test strip vial (controls) of very light gray, 50 ppm color of medium purple, 100 ppm color of dark purple, 200 ppm color of very dark purple, near black, and V17 pointed to the light gray square saying, It was closest to this. Light gray. Asked what the test result for light gray color is, and V17 stated, 10 ppm. This surveyor showed V17 the dishwasher sanitation log for 5/9/23 breakfast service and asked what V17 documented, and V17 said, 100. When asked how could V17 have documented 100 ppm for this morning, 5/9/23, when V17 stated that the chlorine test strip color was light gray for 10 ppm, and V17 said, I (V17) was going too fast. On 5/9/23 at 1:10 pm, when asked what the proper level for chloride sanitation for the low temp dishwasher machine in facility, V4 stated, What I (V4) remember, it's 10 to 200 (ppm). Not above or below that. V4 stated that V4 inherited this (kitchen) staff. V4 stated that V4 is the dietary director and is responsible for the kitchen staff. Facility's quat test strips packaging documents, in part, Dip paper in quat solution, not foam (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 13 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 surface, for 10 seconds. Don't shake. Compare colors at once. Level of Harm - Minimal harm or potential for actual harm Facility's chlorine test strips packaging documents, in part, 100 Chlorine Test Strips. Dip and remove quickly. Blot immediately with paper towel. Compare to color chart at once. Measured in ppm. Residents Affected - Many Facility document provided by V4 from the facility dishwasher's supply company, undated and titled National Science Foundation (NSF) Operation Requirements as Manufactured by (Dish machines Company), documents, in part . Required - 50 PPM Available Chlorine. Facility document dated May 2023 and titled Dishwashing Machine Form, documents, in part three sanitizer readings daily (from 5/1/23 breakfast to 5/9/23 breakfast) of 100 ppm and initials of each entry by kitchen staff members. On 5/10/23 at 10:40 am, V4 (Dietary Director) stated when facility received food deliveries, the kitchen staff will label the food items with the date that they are received. When asked about staff labeling the food items for use, V4 stated that when kitchen staff use the food item (more than one item) for the first time, they will write the open date on the container or package and will follow the use by date from manufacturer. When asked if food should be used after the manufacturer's use by date, V4 stated, No. V4 stated that V4 does not expect for expired foods to be stored or to be used after that date and should be discarded. V4 stated that opened protein items expire in 3 days. When asked about the best use by dates for fresh vegetables such as the green onions or broccoli, V3 stated that it's still 3 days. When asked about the purpose of dating foods when received and when first used, V4 stated, It's quality control. It's the best usage of food, or it will break down and degrade. When asked about using foods before the expiration dates so expired foods are not consumed by residents (with example given of observation on 5/8/23 with strawberry compost manufacturer expiration date in 2022 and then an open date by kitchen staff written in April 2023), No, it's for safety of foods. When asked about the containment of food items once they are opened from the original packaging, V4 stated that kitchen staff are to be resealing packages after opening (multi-item package). V4 stated that staff should open the package and close it; then label and put the use by date on the opened package. When asked the observation on 5/8/23 of Swiss cheese slices with the packaging that was open with cheese slices exposed to the air, V4 stated that it should be tossed. V4 stated, If no date or not sealed then it's tossed. When asked the purpose of removing the non-dated or non-sealed food items, V4 stated, Cross contamination is possible. When asked about the purpose of labeling food items, V4 stated that so staff know what food item they are using to prepare for the residents. V4 stated, No date, no label, it's tossed. When asked where personal food and drink items are to be stored, V4 stated they are not to be stored in with the resident's food. V4 stated, It's never done. Don't want them to intermix. When asked why it is important not to intermix staff and resident food items in the kitchen, V4 stated that the kitchen is only for resident food and drink. V4 stated, I (V4) have a budget to resident food. This should never be done (having staff food or drink stored with resident food/drink items). When asked about the two produce cases with lids open (green onions, broccoli), V4 stated that when food items are delivered, the staff needs to date them. V4 stated that packages are to be closed to prevent cross contamination. V4 stated that it's everyone's responsibility in the kitchen for labeling, dating, and packaging items closed. V4 stated that any item (food or drink) should be stored 6 inches off the floor, and when asked why, V4 stated, That's been the rule forever. V4 stated, Pests. (Food items) shouldn't be on the floor. V4 stated that food or drink packaging can be damaged, water could get into the boxes and for sanitation reasons. V4 confirmed that quat (quaternary ammonium chloride) solution is used for the sanitation buckets in the kitchen. When asked what the proper sanitation level is when the sanitation bucket is prepared, V4 stated, 100 to 300 (ppm). V4 stated that when V4 tested the two sanitation buckets with this surveyor on 5/8/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 14 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 and 5/9/23, V4 stated, It was heavy (on level of quat) and that the kitchen staff is using the pump to put the quaternary ammonium chloride into the buckets with the water. When asked what the effect on residents is if kitchen ware and equipment is being tested with 400 ppm on the quat test strips, V4 stated, It's too high. There's residual sanitation. Cross contamination which can make residents sick. When asked about the low temp dishwasher usage, V4 stated that the dishwasher must reach a sanitation point due to no hot water reaching 180 degrees. When asked what the proper level of chlorine for sanitation in the facility's low temp dishwasher machine is, V4 stated, 50-100 ppm. When asked about the testing process of chlorine for the low temp dishwasher, V4 stated, I (V4) put (the chlorine test strip) on fork, run through machine. That's been the practice in place. V4 stated that V4 hasn't worked with a low temp dishwasher before. V4 stated, I have been following that process (for testing low temp dishwasher). I have no excuses. When asked if V4 has trained the kitchen staff in preparing the quat sanitation buckets, V4 stated that V4 has not walked through this process with kitchen staff. V4 stated that V4 has had no breakdown on the PPM with kitchen staff about the appropriate sanitation level for the quat solution. V4 stated, I (V4) took this unit on to turn it around. They (kitchen staff) have not been trained properly. This is still a work in progress. When asked how kitchen staff are trained, V4 stated they have different competencies and that they do online certifications. On 5/10/23 at 12:22 pm, V23 (Dishwasher Supply Company Representative) was interviewed via V4's cellular phone with the speaker phone engaged where V4 present for V23's interview. When this surveyor's request was made from V23 for the operations manual for the facility's low temp dishwasher, V23 stated that V23 does not have a manual. V23 stated that the facility's low temp dishwasher's operation requirements are printed on the front of the dishwasher, and that V4 made a copy for this surveyor. V23 stated that the printed and posted operation requirements have the wash temp, rinse temp, required chlorine and optimum fill cycle. This surveyor informed V23 that the dishwasher's posted operation requirements were presented by V4. V4 stated that testing of chlorine sanitation for the facility's low temp dishwasher machine is when the load is done. V23 stated that there's two types of ways of testing chlorine sanitation with that staff can take a test strip and put it in puddle on the washed load or put the test strip in the front of the dishwasher where the plunger goes up and down to fill and pump. V23 stated that the sump fills with water; starts the detergent and washes; then drain will open; food comes out; and when the drain closes, then it pumps rinse and sanitizer into the load. This surveyor then asked for V4 to explain to V23 how V4 and the kitchen staff were testing for chlorine sanitation of the ware in the low temp dishwasher. V4 stated that they put the test strip on a plate or fork and run the machine for a cycle then read the test strip. V23 stated, Oh no. Then it (test strip) would be white. V23 stated that testing for chlorine in low temp is done after the wash mode. When asked about how this testing process was presented to the facility kitchen staff using the low temp dishwasher, V23 stated, Typically there is a wall chart, and it's on the chlorine test strip (container). When asked if V4 and kitchen staff were testing for chlorine with the test strips the way V4 explained, would V23 expect for the kitchen staff to get a reading of 100 ppm? V23 stated, No. It wouldn't come out a viable reading. When asked to explain the specifics of using the chlorine test strips, V23 stated that staff are to dip the test strip in the solution in front of the machine where the plunger is and put the test strip in when the sump is open, or they can put the strip on a puddle (of sanitation moisture) on a coffee cup after the cycle is completed. V23 stated that staff are to dip the chlorine test strip in during the machine running or after the cycle, so They are testing the same (sanitizing) solution that is all over the dishes. When asked what does V23 expects the chlorine test strip to read for dishware to be properly sanitized in low (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 15 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 temp dishwasher machine, V23 stated, 50 to a little over 100 ppm. Level of Harm - Minimal harm or potential for actual harm On 5/9/23 and 5/10/23, this surveyor reviewed the licenses and certifications of V4, V24 (Registered Dietitian) and the kitchen staff. V4's foodservice manager certificate is up to date. V17's food handler training certificate expired 4/11/22. On 5/10/23 at 1:32 pm, V4 stated that V17 stated that V17 did renew the food handler training certification, but V4 cannot find it. V4 then provided this surveyor with a receipt, dated 5/10/23, for V17's renewal of the food handler training certificate. Residents Affected - Many On 5/11/23 at 11:06 am, V24 (Registered Dietitian) stated that V24 is the dietitian for the facility and visits the facility once a week. V24 stated, When I (V24) am there, I am definitely in the kitchen throughout the day. V24 stated, I (V24) am available for kitchen staff for questions. When asked about V24 providing education to the kitchen staff about food handling safety and kitchen processes, V24 stated, I (V24) have not at this time. That's more what the director (V4) does. (V4) would take the lead on that. When asked if all the kitchen staff have up to date with their food handler certifications, V24 stated, To my knowledge, yes. V24 stated that V24 will check the kitchen staff's certifications annually with myself and (V4) and self-audit to make sure they are up to date. When asked V24 when was the last audit of staff's certificates that V24 performed, V24 stated, It probably would have been 1 year ago with the old manager. When asked if V24 provides training on the sanitation testing in the kitchen, like for the sanitation levels of the dishwasher or sanitation buckets, V24 stated, I (V24) have not. When asked who is responsible for the training of sanitation testing in the kitchen, V24 stated, The food service director is. When asked about the certified foodservice manager certificates, what does it entail, and V24 stated that it includes more in-depth information on handling safe foods and more up to date knowledge to ensure food is safe from start to finish in the kitchen. When asked if the sanitation of kitchen equipment and ware in the kitchen is included in this training, V24 stated, Sanitation. It would encompass sanitation in the kitchen. When asked what's the difference between a foodservice manager certificate and a food handler certification, V24 stated, There is more in-depth training, and there's quite a bit of overlap. (Foodservice manager) certification is more in depth. V24 stated that the food handler certificates do need to be renewed. V24 stated that they expire differently depending on what company is used, but They do need to renew. Not just one time. V24 stated that there are different types of dishwashers: low temperatures, and high temperatures. When asked if in the foodservice manager certification, is there education on how to test for the appropriate sanitation levels needed in the kitchen, V24 stated, I (V24) believe so. It would talk about temperatures to reach (for sanitation) as well as using test strips (for sanitation). When asked if the foodservice manager certification would include training on setting up and testing sanitation buckets using quat solutions and testing dishwashers' chlorine levels, V24 stated, Yes, it would be included. On 5/11/23 at 11:31 am, V1 (Administrator) stated that all the kitchen staff are contracted from an external food service company. Facility document, undated and titled (External Food Service Company) Employees, documents, in part, the list of kitchen staff as contract employees with titles of Dietary Director, Dietary Aides and Registered Dietitian which includes V4, V16, V17 and V24's names. Facility document dated 5/8/23 and titled Diet Type Report, documents, in part, All facility residents, counted as 94, receive oral diet meals from the facility kitchen. Facility Safety Data Sheet, undated, for (Company name) Chlorine Additive, documents, in part, the recommended use is machine dishwashing, and the compositive on ingredients is Sodium Hypochlorite. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 16 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 Facility Safety Data Sheet, undated, for (Company name) No-Rinse Sanitizer, documents, in part, the recommended use is sanitizing nonporous surfaces, and the compositive on ingredients is Quaternary Ammonium Chlorides. Facility policy dated October 2019 and titled Food: Preparation, documents, in part, Policy Statement: It is the center policy that all foods are prepared in accordance with the guidelines of the FDA (Food and Drug Administration) Food Code. Definitions: . Cross-contamination - means the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, clothe towels, or utensils which are not cleaned after touching raw food, and then touch ready-to-eat food. Cross contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods. Action Steps: . 2. The Dining Services Director or Cook(s) are responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. 3. The Dining Services Director or [NAME] is responsible to ensure that all utensils, food contact equipment, and food contact surfaces are cleaned and sanitized after every use. Facility policy dated October 2019 and titled Receiving, documents, in part, Policy Statement: It is the center policy that safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. Action Steps: . 4. The Dining Services Director or designee ensures that all non-perishable foods and supplies are stored appropriately . 6. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. 7. All food items will be stored in a manner that insures appropriate and timely utilization based on the principles of 'first in - first out' (FIFO). Facility policy dated October 2019 and titled Food Storage: Cold, documents, in part, Policy Statement: It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code. Action Steps: 1. The Dining Services Director is responsible for storing all times 6 inches above the floor and 18 inches below the sprinkle unit . 5. The Dining Services Director/Cook(s) insures (ensures) that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Facility policy dated October 2019 and titled Ware Washing, documents, in part, Policy Statement: It is the center policy that all dishware and service ware will be cleaned and sanitized after each use. Action Steps: 1. The Dining Services Director insures (ensures) that the nutrition service staff is knowledgeable in proper technique for processing dirty dish ware to clean through the dish machine and proper handling of sanitized dish ware. 2. The Dining Services Director insures (ensures) that all dish machine water temperatures are maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. 3. The Dining Services Director is responsible for insuring (ensuring) appropriate completion of temperature and/or sanitizer concentration logs as appropriate. Facility job description, updated 5/5/2015, and titled Director of Dietary Services, documents, in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Director of Dietary Services position is responsible for providing nourishing food to Guests, guests and employees under sanitary conditions and in accordance with established policies and procedures. The Dietary Director manages the day-to-day operations of the dietary department by ordering food supplies, providing supervision of staff and working with the interdisciplinary team to ensure quality nutritional meals are delivered on-time. Essential Functions: . 1. Plans, directs, and supervises the activities of the dietary staff. 2. Operates the dietary department in a safe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 17 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 FORM CMS-2567 (02/99) Previous Versions Obsolete and sanitary manner by ensuring compliance with Federal, State, and local regulations and following established policies and procedures . 9. Responsible for training and educating staff members . 11. Following established safety precautions when performing tasks and using equipment and supplies. Facility job description, updated 5/5/2015, and titled Dietary Aide, documents, in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the dietary aide is responsible for providing superior customer service to guests and employees. The Dietary Aide will help to assure that the dietary department is maintained in a clean, safe, and sanitary manner by providing assistance in all dietary functions as directed and in accordance with established dietary policies and procedures. The Dietary Aide will assist in the preparation of food to assure that the quality of nutritional services are provided. Essential Functions: . 8. Assist in the operation of the dishwashing machine. Event ID: Facility ID: 145235 If continuation sheet Page 18 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide the required square footage of 80 square feet per resident for multiple resident bedrooms for 6 out of 48 rooms in the facility. Findings include: The 05/08/2023 Facility Daily Roster documented that there were 48 rooms in the facility and rooms 107, 108, 207, 208, 307, and 308 were 3-resident rooms. On 05/08/23 at 10:46am, there were 3 beds on R90's room. R90 stated my (R90) room is not that big and I (R90) am not putting my stuff animal on the floor. The room is too small. It should just be two people in this room not 3 people. On 05/08/23 at 10:53am, there were 3 beds on R21's room. R21 stated the room is too small and uncomfortable. There are too many people in one room. There should be just two people in the room. On 05/08/2023 at 11:32am, V7 (Maintenance Director) measured room [ROOM NUMBER] per this surveyor request and stated, the room is about 225 square feet. On 05/08/2023 at 11:38am, V7 stated, room [ROOM NUMBER] has been inspected and it has a waiver. The waiver is with the Administrator. Rooms 108, 208, 308, 107, 207, and 307 have almost the same measurements. On 05/08/2023 at 11:39am, there were 3 beds in room [ROOM NUMBER]. V7 measured room [ROOM NUMBER] per this surveyor request and stated the total area is about 225sq feet. On 05/08/2023 at 11:43am, R1 stated the room is not big enough. On 05/08/2023 at 11:51am, there were 3 beds in room [ROOM NUMBER]. V7 (Maintenance Director) measured room [ROOM NUMBER] and stated the total area is about 225 sq feet. On 05/08/2023 at 11:56am, there were 3 beds in room [ROOM NUMBER]. V7 measured room [ROOM NUMBER] and stated, the total area is about 225 square feet. On 05/08/2023 at 12:04pm, there were 3 beds in room [ROOM NUMBER]. V7 measured the room and stated the total area is about 225 square feet. On 05/08/2023 at 12:07pm, there were 3 beds in room [ROOM NUMBER]. V7 measured the room and stated, the total area is about 225 square feet. On 05/09/2023 at 11:55am, V7 stated, for rooms with multiple residents, the facility should provide 80 square feet for each resident. We (facility) are not in compliance with the room sizes. On 05/10/2023 at 2:14pm, V1 (Administrator) stated, the requirement for the room square footage is 80 square feet per resident in a multi bed resident's rooms. I (V1) have a waiver for rooms [ROOM NUMBER]. V1 stated, the waiver encompasses for all the rooms. It applies to all the rooms in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 19 of 20 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 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 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 0912 facility. We (facility) are not in compliance with room sizes that's why we (facility) have a waiver. Level of Harm - Potential for minimal harm The (undated) room [ROOM NUMBER], 108, 207, 208, 307, and 308 floor plans documented the room floor areas ranges from 205square feet - 223square feet. Indicating each resident was provided 68.3 square feet to 74.3 square feet size bedroom. Residents Affected - Some The (8/3/22) Facility Waiver Request Per F912, 42 CFR 483.90 (e) (1) (ii) Survey Type: Annual Certification Survey Date: 7/12/22 documented, in part This is a request for a variation/waiver of the requirement for

F912, 42 CFR 483.00 (e)(1)(ii), the requirement that the bedrooms measure at least 80 square feet per resident in multiple resident bedrooms. This variation/waiver is requested for rooms numbered 108, 208 and 308 at the (facility). The (05/11/2023) email correspondence with V1 documented the facility did not have a policy and procedure in reference to the required room size in the facility. The (10-21-22) State Operations Manual documented, in part (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; GUIDANCE: §483.90(e)(1)(ii) See §483.90(e)(3) regarding variations. The measurement of the square footage should be based upon the useable living space of the room. Therefore, the minimum square footage in resident rooms should be measured based upon the floor's measurements exclusive of toilets and bath areas, closets, lockers, wardrobes, alcoves, or vestibules. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 20 of 20