Health inspection·April 5, 2024

F 0554 Level of Harm - Minimal harm or potential for actual harm anorectal cream) was obtained 4/4/2024 at 11:57 AM. The order for self-administration of Dicofenac Sodium Gel was obtained on 4/4/2024 at 12:01 PM. Review of Medication Pass policy adopted January 5, 2016 and revised July 28, 2023 states in part It is the policy of the facility to adhere to all federal and state regulations with medication pass procedures. Residents Affected - Few Review of Self-Administration of Medication policy adopted December 3, 2015 and revised July 28. 2023 states: Policy Statement: A resident who requests to self-administer medications will be assessed to determine if resident is able to safely self-medicate. Procedure 1. The IDT will assign a staff to evaluate resident's ability to safely administer medication. A self-administration evaluation will be filled out to determine capability. A return demonstration will be done to accurately evaluate resident's ability after the health teaching. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 2 of 26 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 04/05/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a timely person-centered care plan until after a resident experienced a forty-five-pound weight loss in less than 3 months from the date of admission. This failure affected 1 (R20) out of 4 residents who were reviewed for nutrition in the final sample of 19 residents. Findings include: During interview with R20 on 04/02/24 at 10:48 AM, R20 stated that the food is good. On 4/3/2024 at 12:36 PM, R20 stated that R20 knows that R20 has lost weight. R20 stated that R20 is happy with the weight loss but wants to gain some of the weight back. During review of record, on 4/3/2024 at 10 AM, R20 was admitted on [DATE]. R20's Minimum Data Set (MDS) dated [DATE] showed it was completed on 2/1/24. R20's weights were documented as: 1/18/2024 280 pounds, 2/7/2024 - 274 pounds, 3/9/2024 - 235 pounds. Dietary assessment dated [DATE] was reviewed on 4/3/2024 at 11 AM. The summary stated that the goal for R20 was weight maintenance or gradual weight loss. Dietary Care Plan was not initiated and entered by V14 (Registered Dietician) until 3/30/2024. It was reviewed on 4/3/2024 at 2 PM and stated that R20 has a nutritional problem related to overweight. R20 triggered for significant weight loss at one month which was unintentional and likely related to R20's eating habits being better than when he was living out in the community. The goal was for R20 to maintain body weight within ideal body weight range through the next review date. Interventions included encouraging R20 to follow health eating behaviors, preparing, and serving the prescribed diet as ordered, and weight to be obtained as ordered by physician. During interview with V17 (Care Plan Coordinator) on 4/3/2024 3:00 PM, V17 stated that for new admissions, a care plan is completed within 72 hours. At a minimum, the care plan should include Nursing, Social Services, Restorative, Dietary and Skin. V17 stated that the care plan is updated quarterly, annually and if there is a significant change in condition. V17 described a significant change in condition as a decline in resident function, weight change, decline in eating, or fall. If there is a significant change in condition, the care plan should be updated with interventions. V17 stated, If today we observe something, we must add to the care plan interventions. During interview with V2 (Director of Nursing) on 04/04/24 9:31 AM, V2 stated that at a minimum, the admission care plan should include Nursing, Social Services, Dietary, Restorative and Skin. V2 stated that if there is a significant change in a resident's condition, it should be care planned. Significant change in condition would include weight change, eating problems or ADLs. If there was a significant change in condition, the issue would be raised by the Nurse, Physical Therapy or Social Services. V2 stated, We also meet every morning to discuss care plans. V2 reviewed the care plan for R20. V2 confirmed that R20 had no care plan or dietary assessment from 1/19/2024 until 3/30/2024. When asked if a 45-pound weight loss in less than 3 months would raise concern as a significant change in condition, V2 stated yes. V2 stated that they changed dieticians. V14 (Registered Dietician) started 2 weeks ago. V2 stated, The previous dietician should have caught that. V2 stated that the facility has one person doing the weights so they should raise a concern about weight change and give that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 3 of 26 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 04/05/2024 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 0656 information directly to the Dietician. Level of Harm - Minimal harm or potential for actual harm The policy titled Care Plan adopted November 28, 2023 and revised July 27, 2023 states in part Residents Affected - Few Policy Statement: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. Procedures 4. After the comprehensive assessment (state/federal/-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 4 of 26 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 04/05/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) On 04/02/24 at 11:40 AM, R85 stated, I smoke and have my cigarettes and lighter right here. R85 reached into a black plastic bag at bedside and took out a pack of cigarettes and a lighter. R85 was initially admitted to the facility on [DATE]. R85's diagnosis included but not limited to Tobacco Use, Psychoactive Substance Abuse, Atherosclerotic Heart Disease, Insomnia, Chronic Pain, Major Depressive Disorder, Iron Deficiency Anemia, Type 2 Diabetes Mellitus, Hyperlipidemia, Hypothyroidism, Personal History of Pulmonary Embolism. R85's MDS (Minimum Data Set) dated 02/23/24 indicates intact cognition with BIMS (Brief Interview for Mental Status) 15/15. R85's initial Smoking Program Evaluation in R85's electronic health record (EHR) completed 11/17/23 documents in part resident agrees to follow smoking rules, is considered a safe smoker and may use/access smoking materials consistent with facility policy, staff is not required to remain in attendance while resident is smoking, and resident is a safe and independent smoker. On 04/04/24 at 8:28 AM, V8 (Social Service Director) reviewed R85's electronic health record (EHR) with surveyor. V8 stated R85 has a Smoking Program Evaluation completed 11/17/23 when R85 was first admitted to the facility. V8 stated R85 should have had another Smoking Program Evaluation completed in February 2024 when quarterly MDS was done. V8 stated a quarterly smoking assessment was not done and it should have been completed because they are supposed to be completed on a quarterly basis. Based on interview and record review, the facility failed to ensure that smoking assessment/evaluation were completed on a quarterly basis. This failure could potentially affect 3 (R16, R78 and R85) of 5 residents reviewed for smoking in a total sample of 19. The findings include: 1.) R16's health record documented admission date on 12/15/23 with diagnoses not limited to schizoaffective disorder bipolar type, Chronic obstructive pulmonary disease, Essential (primary) hypertension, other hyperlipidemia, other seizures, other specified anemias, Gastro-esophageal reflux disease without esophagitis, Human Immunodeficiency Virus (HIV) disease. On 4/2/24 at 10:48am observed R16 alert and oriented x 3, verbally responsive. Stated he is a smoker. MDS dated [DATE] showed R16's cognition was intact. Care plan dated 2/6/2024 documented in part: R16 is a smoker and expresses the desire to smoke at this facility. Assess the resident for smoking safety according to facility policy [assessment/evaluation]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 5 of 26 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 04/05/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm R16's Smoking assessment dated [DATE] documented in part: Resident is considered a safe smoker and may use/access smoking materials consistent with facility policy. Staff is not required to remain in attendance while resident is smoking. 2.) Residents Affected - Few R78's health record documented admission date on 5/12/22 with diagnoses not limited to Unspecified fracture of upper end of right tibia, Opioid dependence, Unspecified osteoarthritis, Atherosclerotic heart disease of native coronary artery without angina pectoris, Diabetes mellitus, Major depressive disorder, Migraine, Gastro-esophageal reflux disease without esophagitis, Hyperlipidemia, Essential (primary) hypertension, Chronic obstructive pulmonary disease, Vitamin d deficiency, Pure hyperglyceridemia, History of falling, Insomnia, Bipolar disorder, Generalized anxiety disorder, Tobacco use, Bipolar disorder, Alcohol dependence with intoxication, Nondisplaced fracture of right tibial tuberosity. On 4/2/24 at 10:51am observed R78 sitting on the side of the bed, alert, and oriented x 3, verbally responsive. Stated she is a smoker and showed her cigarette inside her bag to the surveyor. MDS dated [DATE] showed R78's cognition was intact. R78's Smoking Program Evaluation dated 7/27/23 documented in part: Resident is considered a safe smoker and may use/access smoking materials consistent with facility policy. Staff is not required to remain in attendance while resident is smoking. Care plan dated 2/6/2024 documented in part: R78 is a smoker and expresses the desire to smoke at this facility. On 4/2/24 at 2:25pm V8 (Social Service Director) said Smoking assessments are done upon admission, quarterly, and as needed. She stated the purpose of completing the smoking assessment is to evaluate the resident to make sure the resident is a safe smoker. On 4/4/24 at 11:21 am reviewed R16's electronic health record (EHR) with V8 and stated 2 recent smoking assessment were done on 12/16/23 and 4/2/24. She said 2 recent R78's smoking assessment were done on 7/27/23 and 4/2/24. Facility's smoking policy dated 7/28/23 documented in part: -It is the facility's policy to monitor and assess residents that smoke to promote smoking in a safe manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 6 of 26 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 04/05/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow the dietary recommendations for residents who have weight loss for 3 (R45, R58, R66) out of 4 residents reviewed for nutrition in the final sample of 19 residents. Residents Affected - Few Findings Include: 1.) On 4/02/24 at 12:22 PM, R45 was eating lunch in R45's room. R45's lunch tray consisted of one serving of noodles, one serving of fish, one serving of spinach, apple crisp, coffee, and juice. R45's meal ticket dated 4/2/24 does not indicate double portions. On 4/03/24 at 12:32 PM, R45 was eating lunch in R45's room and R45's lunch tray consisted of one piece of pork roast, one dinner roll, one scoop of mashed potato, juice, coffee, one serving of broccoli florets, and pudding. R45's meal ticket dated 4/3/24 does not indicate double portions. R45's progress notes dated 1/11/2024 at 11:28 PM documented by V15 (Former Registered Dietitian) reads in part: Diet order: CCHO (Consistent Carbohydrate Diet), regular, thin liquids. No known food allergies. Salad added to L/D (Lunch/Dinner). Weight: 128 lbs. (pounds) 1/8/24; BMI 17.9 - -7.2%, -10lb weight loss in 1 month compared to 12/5/23 weight of 138lbs. (R45) with a good appetite, adequate oral intakes 75-100% intakes. No chewing or swallowing difficulty. Food preferences up to date. (R45) at nutritional risk due to dementia diagnosis, HIV; will monitor need for CCHO diet, most recent HgA1C is WNL (within normal limits), good control. Will order 2 boiled eggs to breakfast, will order double protein portions for L/D. Goal for wt. (weight) stability, gradual wt. gain ideal, labs WNL. Recommended to continue with nutrition plan of care, no significant changes since last assessment. R45's weight shows: 3/9/2024 132.0 Lbs., 2/16/2024 134.0 Lbs., and 1/12/2024 136.0 Lbs. R45's physician orders do not show any order for double portion as recommended by V15. 2.) On 4/03/24 at 12:27 PM, R58 was eating lunch in R58's room. R58's lunch tray consisted of one serving of ground pork, one serving of broccoli florets, one serving of mashed potato, one serving of pudding, juice, and coffee. R58's meal ticket dated 4/3/24 does not indicate double portions. R58's progress notes dated 12/5/2023 at 11:26 PM documented by V15 reads in part: Diet: General, Mechanical Soft, Thin Liquids; PO intake 75-100%, Weight 12/5/23 126.0lbs, significant loss of 10.6%, -15lbs compared to 10/26/23 weight of 141.0lbs, -10.6%, -15lbs compared to 6/9/23 weight of 141.0lbs. BMI 20.3-underweight for advanced age. R58 significant loss is undesirable as BMI considered underweight. Since appetite and PO intake is intact, will order double entrée portions to help prevent further weight loss, promote weight gain. Will also order house supplement BID. Weight maintenance or gain desired. R58's progress notes dated 3/14/24 at 11:22 AM documented by V15 shows R58 should be receiving double entrée portions. R58's weights show: 10/26/23 141 pounds, 12/5/23 125.4 pounds, 1/12/24 125 pounds, 2/16/24 125 pounds, and 3/9/24 128 pounds. R58's physician orders do not show any order for double portion as recommended by V15. On 4/3/24 at 11:34 AM, V14 (Registered Dietitian) stated that it is important to follow the dietary recommendations for the residents especially with weight loss to prevent malnutrition. V14 stated that double portions are recommended for R45 and R58 to provide extra calories to prevent further weight loss. V14 stated that it is the responsibility of the Dietitian to communicate dietary recommendations to the staff and to enter order in the residents' electronic charting. V14 stated that R45 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 7 of 26 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 04/05/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and R58 should have orders for double portions as recommended by V15. V14 stated that Dietary recommendations should be reflected in the residents' meal tickets. 3.) R66 clinical record indicates in part, R66 was admitted on [DATE] with the medical diagnosis of hemiplegia affecting left side, heart disease, osteoarthritis, schizoaffective disorder bipolar type, anxiety, recurrent depressive disorders, essential hypertension, cerebral infarction, chronic obstructive pulmonary disease, prediabetes, and dizziness. Minimum Data Set Brief Interview Mental Status scored (11) indicates R66 is cognitively intact. R66's care plan documented in part: 1/24/24- R66 has actual decline in ability to feed self, and needs staff to set up tray, and monitor. Provide assistance to R66 to scoop food onto spoon with each bite of food. 12/2/22- R66 will be free of significant weight changes of greater than 5%. 12/2/22- Prepare R66's diet as ordered: Regular diet, thin liquids with double portions at mealtimes. R66 weights: lbs. (Pounds) 4/2/24-147lbs., 3/9/24-160.0 lbs., 2/16/24-162.0lbs., 1/12/24- 163.0 lbs., 12/5/23-158.5lbs., 11/10/23-163.0lbs., and 10/26/23-171.0lbs. R66 progress notes in part: 11/15/2023 16:35-Nutrition (Former Dietary) Note Text: Weight Assessment R66, 66 y/o male. PMHx (past medical history) swelling, bipolar disorder, paranoid personality disorder, HTN (hypertension), dysphagia. AOx3. Diet order: general, regular, thins. PO (oral) intake mostly 75-100%. Weight: 163lbs; BMI 24.8-WNL; significant weight loss -11.4%, 21.0lbs compared to 5/5/2023 weight of 184lbs. R66 reports a good appetite, recent oral intakes 75-100%. Since appetite and intake are intact, will order double entrée portions at all meals. Goal is for weight stability, adequate oral intakes. V14 (Registered Dietician/RD)] Progress Note: 4/3/2024 10:15 Nutrition (Dietary). Note Text: Significant weight loss review. RD received notification from Restorative Director about R66's weight loss. Current weight record for 4/2/24 is 147# (pounds). Weight over 1, 3, and 6 months are as follows: 1 month - 3/9/24 160(8.1%), 3 months - 1/12/24 - 163(9.8%), and 6 months - 10/26/23 - 171(14.0%). Significant weight loss at 1, 3, and 6 months, which is planned and likely related to R66 purposely trying to lose weight as he reports my doctor told me. Writer followed up with CNAs (Certified Nursing Assistants), in which CNAs also confirmed that resident has been cutting back on his intake purposely to adhere to his doctor's orders. MD will be notified of R66's significant weight loss. Weight fluctuations may also occur due to fluid shifts and diuretic use. BMI: 22.3 - underweight; desirable BMI for age >65: 23-29.9 kg/m2. Diet: Regular, thin liquids. Per staff, resident is observed to have fair PO intake at mealtimes. No edema noted. Skin remains intact. Meds: lisinopril, furosemide, atorvastatin calcium, docusate sodium, lactulose, carvedilol, famotidine, polyethylene glycol powder, melatonin. Continue double entrée portions at all meals to promote weight maintenance. On 04/2/24 at 11:47 AM, observed R66 eating lunch alone without staff assistance or encouragement. On R66's plate was one strip piece of [NAME] lemon pepper fish, 4 ounces of buttered chopped (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 8 of 26 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 04/05/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm spinach, 4ounces of buttered egg noodles, one dinner roll, half cup of apple crisp, eight ounce of whole milk, six ounces of red sugar free punch. R66 ate 2 bites of fish and one fork full of his spinach. R66 stated, I don't really have an appetite. I try to eat as much as I can and my clothes are getting big on me, I wonder how much I weigh. I have not been weighed in a few months. Most of the time the food is too salty and greasy, I have not tried or wanted to lose weight, I just don't like how the food is made and I am not hungry. Residents Affected - Few On 4/2/24 at 12:10 PM, Surveyor accompanied V12 (CNA) and R66 in his wheelchair down to the ground level therapy gym to be weighed. V13 (Restorative Aide) turned on the wheelchair scale and zero out the scale. V13 then pushed R66 while sitting in wheelchair without any leg rest, onto the scale and secured the wheelchair. Surveyor, V12 and V13 witnessed the total of the wheelchair and R66 was 189.0 pounds. V12 and V13 took R66 back to his bed and brought the empty wheelchair to the therapy gym. Surveyor and V13 witnessed the empty wheelchair weighed 42.0 pounds. V13 stated, R66 weight is 147.0 pounds. I assist with monthly weights. I am not sure how R66 lost 13 pounds in one month, on 3/9/24 R66 weighed 160.0 pounds. On 4/3/24 at 12:05 PM, V14 stated, I only been working for this facility for two weeks. I have been a registered dietician for five years. Today was my first day working with R66. He said to me that he was purposely trying to lose weight. I spoke to several certified nurse assistants confirmed that R66 has been cutting back on his intake purposely to adhere to his doctor's orders. A weight loss trend for significant weight loss is 5% or more in one month, 7.5% in three months, or 10% or more in six months. R66 weighed 160 pounds on 3/9/24 and on 4/2/24 he weighed 142pounds. R66's clinical record showed, 1 month 3/9/24 - 160(8.1%), 3 months - 1/12/24 - 163(9.8%), and 6 months - 10/26/23 - 171(14.0%). Significant weight loss was noted at 1, 3, and 6 months. If a resident weight is trending down, I would recommend supplements, sandwich, snacks, or double portions to increase calories. I can enter the recommendation in the facility physician order system as a pending order. The floor nurse would call and give my recommendations to the physician for approval, once the physician approves my recommendation, then the nurse would confirm the recommendation that will become a standing order. Once approved, then I would email the dietary manager my recommendations. My recommendations should be followed out and printed on the resident's diet slip for the next meal. If the physician denied my recommendation, there would be a progress note to reflect the physician's decision. After reviewing the former dietitian assessment notes, double portions were recommended on 11/15/23, I placed in the order for double portions today. R66 was eating well according to his meal intake documentation 76-100% of his meals. If the facility followed the recommendation of double portions dated 11/15/23, it could have potentially slowed down or prevented R66's weight loss, but there is other illness that can also cause weight loss. Surveyor gave V14 R66's physician orders, dietary slip, March 2024, and April 2023 meal intake documentation to review. V14 stated, I do not see any physician order that document for R66 to eat less or to lose weight. I do not see any physician order or diet order that has double portions for R66. Looking at R66 dietary slip dated 4/2/24 and labeled Tuesday Lunch does not reflect R66 to receive double portions. R66's meal intakes from March to present, the majority document that R66 ate 76 to 100% of his meals. After I reviewed R66's progress notes, he did not have any illness documented that would account for a thirteen-pound weight loss in one month. I am not sure where the weight loss in the last thirty days came from. On 4/4/24 at 11:26 AM, V2 (Director of Nursing) stated, A few years ago the facility gave the dieticians access to our system to place in their own recommendations. The floor nurse will open the resident's chart and see there is an order pending, the nurse confirms order with physician then on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 9 of 26 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 04/05/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm computer and the recommendation becomes an order. The nurse then completes a dietary slip and take the order to the kitchen manager. If a recommendation for double portions was placed in the system and given to the kitchen for R66, it could have potentially prevented or slowed down his weight loss. Policy documents in part: Residents Affected - Few Nutritional Assessment (No Date) -The nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Weights dated 7/28/23. -The significant weight changes will be assessed and addressed by the interdisciplinary team which includes but not limited to the dietician, physician, and nurses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 10 of 26 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 04/05/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly discard multi dose insulin vial after 28 days of opening for 1 (R32) resident and properly date opened multi-dose nasal spray for 1 (R83) resident. The facility also failed to properly discard 2 expired house stock multi dose insulin pens from 2 of 3 medication carts and medication storage room inspected for medication storage and labeling. The findings include: 1.) R32's health record documented admission date on [DATE] with diagnoses not limited to Type 2 diabetes mellitus. Atherosclerotic heart disease of native coronary artery, Anxiety disorder, Heart failure, Primary generalized (osteo)arthritis, schizoaffective disorder bipolar type, Major depressive disorder, Hyperlipidemia, Gastro-esophageal reflux disease without esophagitis, Chronic obstructive pulmonary disease, Other psychoactive substance use substance-induced persisting dementia, Essential (primary) hypertension, Nondependent opioid abuse, Alcohol dependence. R32's Physician Order Sheet (POS) with order not limited to Admelog solution 100unit/ml inject as per sliding scale: If 0-150=0 u; 151-200=1u; 201-250=2u; 251-300=3u; 301-350=4u; 351-400=5u. Call MD if BS <60 or >400, subcutaneously with meals. 2.) R83's health record documented admission date on [DATE] with diagnoses not limited to Other asthma, Major depressive disorder, Encounter for screening for other viral diseases, Insomnia, Neuralgia and neuritis, Atherosclerotic heart disease of native coronary artery, Anxiety disorder, Chronic obstructive pulmonary disease with (acute) exacerbation, Gastro-esophageal reflux disease without esophagitis, Polyosteoarthritis, Essential (primary) hypertension, Opioid dependence, Mixed hyperlipidemia. R83's POS with order not limited to Fluticasone Propionate nasal suspension 50mcg/act 2 spray in each nostril one time a day. On [DATE] at 11:15am 1st floor medication cart inspected with V6 (Registered Nurse/RN) and observed R32's Admelog insulin vial date opened [DATE] (expiration date [DATE]) was found inside the medication cart. Pharmacy label indicated: Once opened, refrigerated, or not discard after 28 days. V6 stated insulin should be discarded after 28 days of opening. Observed clear plastic box inside the refrigerator with 4 insulin pens and found 2 expired Glargine insulin pens with manufacturer expiration date on 3/2024. V6 said 2 Glargine insulin pens expiration date was 3/2024, these should be discarded. On [DATE] at 12:05pm 2nd floor medication cart inspected with V7 (RN) and found R83's Fluticasone 50mcg/act nasal spray opened with no date labelled. V7 stated medication should be dated once opened to know when it was opened and when to discard the medication. On [DATE] at 11:08am V2 (Director of Nursing) said medications should be dated once opened. She said dating/labeling opened medication is important to know when it was opened and when to discard the medication. V2 said nasal spray medication should be dated once opened. She said expired medication/insulin should be discarded as it could potentially put resident at risk or could be hazardous if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 11 of 26 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 04/05/2024 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 0761 expired medication was given to resident. Level of Harm - Minimal harm or potential for actual harm Facility's medication storage, labeling and disposal policy dated [DATE] documented in part: -It is the facility's policy to comply with federal regulations in storage, labelling and disposal of medications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 12 of 26 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 04/05/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to prepare and serve mechanical soft food at the appropriate texture. This failure affected 8 (R8, R12, R16, R36, R42, R44, R58, R62) of 12 residents reviewed for mechanical soft diet prepared in the facility's kitchen, in a total sample of 19 residents. Findings Include: On 04/03/24 at 11:45 AM, during tray line observations observed V10 (Dietary Aide) calling out for a mechanical soft/ground diet order. Observed V23 (Cook) give V26 (Cook) slices of pork loin. V26 brought the slices of pork loin to a cutting board near the stove and began to chop the pork using a knife. V26 stated I'm helping to cut this food up for the mechanical soft diets. Observed the final chopped pork product to have no uniformity in size with larger and smaller pieces mixed together and the overall consistency appeared very dry. V26 placed the chopped pork into a container and gave it to V23. On 04/03/24 at 11: 50 AM, observed V23 portion chopped pork onto a plate for a resident's meal ticket which read mechanical soft/ground. No gravy or sauce was served with the chopped pork. On 04/03/24 at 11:55 AM, V23 stated there is no difference between the mechanical soft/ground diets and the mechanical soft/chopped diet. V23 stated for both the ground and chopped diet consistencies the cooks manually chop the meat using a knife and do not put meat through a commercial food processor unless the meat is very tough. On 04/03/24 at 12:05 PM, V9 (Culinary Service Manager) stated the mechanical soft/ground should be prepared using the commercial food processor not chopped with a knife by hand. V9 stated this is because the chopped consistency is not the same as the mechanical soft/ground. V9 stated the chopped consistency has bigger pieces than the mechanical soft and if residents on a mechanical soft/ground diet are given a chopped consistency it could be a choking hazard. On 04/03/24 at 12:14 PM, V25 (Contracted Regional Director of Operations) stated, they should not be serving the same consistency to both mechanical soft/ground and chopped. V25 stated chopped is bite sized pieces and mechanical soft/ground should be run through the commercial food processor to break down the food. On 04/04/24 at 11:34 AM, during phone interview V27 (Speech Language Pathologist) stated residents may need to be on an altered diet consistency if they do not have any teeth, or refuse to wear dentures, or if they have dysphagia which is a swallowing disorder. V27 stated residents with dysphagia are at Increased risk for aspiration which is when food/liquid goes into a resident's trachea or airway instead of going down their esophagus. V27 stated the kitchen should be following the specific diet order. V27 stated meat tends to be dry and therefore V27 recommends that the meat be served with a gravy because having an extra sauce or gravy softens the meat further to ensure safety and to make it easier to chew. 1.) R8's diagnoses includes but not limited to Dysphagia, Chronic Obstructive Pulmonary Disease. R8's Physician Orders ordered 06/22/22 documents in part, diet order is mechanical soft texture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 13 of 26 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 04/05/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm R8's nutrition care plan documents in part, R8 has the following risk factors that place resident at risk for alteration in nutritional status: dysphagia, mechanically altered diet. R8's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. Residents Affected - Some 2.) R12's diagnoses includes but not limited to Dysphagia, Oropharyngeal Phase, Cerebral Infarction, Dysphagia Following Other Cerebrovascular Disease, Chronic Obstructive Pulmonary Disease. R12's Physician Orders ordered 10/29/21 documents in part, diet order is mechanical soft texture, honey thick liquids consistency. R12's nutrition care plan documents in part, R12 has the potential for alteration in nutritional status related to dysphagia, history of G-tube feedings, cerebral infarction, COPD, mechanically altered diet and need for thickened liquids. R12's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground, honey liquids and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 3.) R16's diagnoses includes but not limited to Chronic Obstructive Pulmonary Disease. R16's Physician Orders ordered 12/21/23 documents in part, diet order is mechanical soft texture. R16's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 4.) R36's diagnoses includes but not limited to Chronic Obstructive Pulmonary Disease. R36's Physician Orders ordered 07/14/23 documents in part, diet order is mechanical soft texture. R36's nutrition care plan documents in part, R36 has the potential for alteration in nutritional status related to COPD, mechanically altered diet. R36's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 5.) R42's diagnoses includes but not limited to Chronic Obstructive Pulmonary Disease. R42's Physician Orders ordered 06/30/21 documents in part, diet order is mechanical soft texture. R42's nutrition care plan documents in part, R42 has the potential for alteration in nutritional status related to COPD, mechanically altered diet. R42's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 6.) R44's diagnoses includes but not limited to Chronic Obstructive Pulmonary Disease, Bell's Palsy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 14 of 26 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 04/05/2024 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 0805 R44's Physician Orders ordered 01/11/23 documents in part, diet order is mechanical soft texture. Level of Harm - Minimal harm or potential for actual harm R44's nutrition care plan documents in part, R44 is at risk for alteration in nutritional status related to mechanically altered diet order. Residents Affected - Some R44's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 7.) R58's diagnoses includes but not limited to Dysphagia, Chronic Obstructive Pulmonary Disease. R58's Physician Orders ordered 04/02/20 documents in part, diet order is mechanical soft texture. R58's nutrition care plan documents in part, R58's nutritional status is compromised due to need for mechanically altered diet order. R58 is edentulous and is without dentures. R58's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. 8.) R62's diagnoses includes but not limited to Dysphagia, Chronic Obstructive Pulmonary Disease, Adult Failure to Thrive. R62's Physician Orders ordered 02/03/21 documents in part, diet order is mechanical soft texture. R62's nutrition care plan documents in part, R58's nutritional status is compromised due mechanically altered diet, dysphagia, need for 1:1 feeding assistance, history of unintentional weight loss, adult failure to thrive diagnosis. R62's meal ticket dated 04/03/24 documents in part diet Mechanical Altered/Ground and lists Mechanically Altered/Ground Pork Roast Loin Garlic Herb to be served. Facility's policy titled, Consistency Modified Diets undated documents in part, mechanical soft consists of ground meats, and lists allowed protein foods as ground eggs, meats, poultry, pork, seafood, meat analogues, legumes, nuts, and seeds served with sauce or gravy, and not allowed protein foods as tough or dry meat products that cannot be served as a moist and cohesive product. Kitchen recipe titled Pork Roast documents in part for ground to grind to appropriate consistency. If needed, add gravy or broth to moisten meat. Kitchen spreadsheet titled Southern SS Diet Guide Sheet for Wednesday (Day 25) lunch mechanical altered/ground pork roast loin garlic herb. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 15 of 26 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 04/05/2024 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review the facility failed to ensure there are no more than 14 hours between the evening meal and breakfast the following day and failed to serve a substantial or nourishing snack at bedtime to residents who are not provided with an individualized evening snack. This deficient food service practice has the potential to affect 64 residents in a total sample size of 94 residents receiving an oral diet from the facilities kitchen. Findings include: On 04/02/24 after initial kitchen tour and tray line observation, V9 (Culinary Service Manager) provided mealtime schedule which documents range of mealtimes between 4:45 PM-5:05 PM for dinner and 7:15-7:35 AM for breakfast and that the nursing units are scheduled to be delivered in the same order for every meal (1st floor, then 2nd floor, and finally 3rd floor). The mealtime schedule documents in part, the 1st floor receives dinner at 4:45 PM and breakfast at 7:15 AM, the 2nd floor receives dinner at 4:55 PM and breakfast at 7:25 AM, the 3rd floor receives dinner at 5:05 PM and breakfast at 7:35 AM. On 04/03/24 at 3:40 PM, V9 stated the delivery mealtimes were changed and are now being used as of 04/02/24 because V25 (Contracted Dietary Regional Director of Operations) said the kitchen needed more time to get the meals out. V9 provided copy of updated meal schedule which documents range of mealtimes between 4:15 PM - 5:15 PM for dinner and 7:15 AM - 8:05 AM for breakfast and that the nursing units are scheduled to be delivered in the same order for every meal (1st floor, then 2nd, and finally 3rd floor). The revised mealtime schedule documents in part, the 1st floor receives dinner between 4:10-4:15 PM and breakfast between 7:15 - 7:25 AM, the 2nd floor receives dinner between 4:20 - 4:45 PM and breakfast between 7:30 -7:45 AM, the 3rd floor receives dinner between 4:50-5:15 PM and breakfast between 7:50-8:05 AM. On 04/02/24 at 10:30 AM, V9 stated not all residents receive an evening snack. V9 pointed to a list posted which listed residents' names by unit and specific food items to be prepared for them. V9 stated the residents on that list receive individual labeled evening snacks after the dinner meal because they are specifically ordered by the resident's doctor or the dietitian. V14 stated that if a resident does not have a specific order for an evening snack. On 04/03/24 at 3:43 PM, observed evening snacks for 04/03/24 prepared for 1st/2nd/3rd floor located in kitchen's walk-in cooler. Each tray contained individually labeled snacks for some residents. Surveyor did not observe any additional snack items on the trays and per observation there was not enough snacks on the trays for all the residents on the floor. On 04/03/24 at 4:18 PM, V9 stated V25 wants the kitchen to start giving snacks out so everyone can get an evening snack so for the past three weeks the kitchen has been sending up cookies when in stock along with the individually labeled snacks. V9 stated prior to this the kitchen was only sending snacks to the residents who were on the list to receive individually labeled snacks. V9 stated because of this change V9 has started to order packaged cookies but said, we don't have any in stock right now. On 04/03/24 at 4:40 PM, observed dinner meal trays in hallway by the elevator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 16 of 26 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 04/05/2024 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 04/04/24 at 8:08 AM, observed breakfast meal trays in the hallway by the elevator. V23 (Cook) stated these trays were being delivered to the 2nd floor. On 04/03/24 at 3:48 PM, V28 (Registered Nurse) stated snacks delivered to the 3rd floor after dinner are individually labeled with the resident's name and not all the residents get an individually labeled snacks. V28 stated the kitchen sometimes sends up cookies and juice for the other residents who do not receive individually labeled snacks. V28 stated for some of the resident's the cookies are not enough and those resident's ask us for more food because they complain about still being hungry. V28 stated V28 tells them to talk to the dietitian so they can get something more substantial than cookies for snack. On 04/03/24 at 3:54 PM, viewed the 3rd floor pantry with V28. V28 stated no extra food is stored in the pantry and the kitchen does not stock the pantry with any items for the residents. V28 stated the refrigerator is used only for staff food. V28 stated if a resident complains of hunger in the evening the only thing V28 can give them is a cookie if there are any still left over or available. On 04/03/24 at 3:58 PM, V30 (Registered Nurse) stated V30 was a Certified Nursing Assistant for 10 years and has been a RN for the past seven years. V30 stated V30 works on the 2nd floor usually on the (11-7) shift but that every Wednesday V30 does a double shift working from (3-11) and (11-7) shift. V30 stated dinner arrives by 5:00 PM and breakfast is served between 8:00-8:15 AM. V30 stated V30 knows the time breakfast is served because it arrives as V30 is leaving the unit which is around 8:00 AM. On 04/03/24 at 4:02 PM, V31 (Certified Nursing Assistant) stated V31 has been working at the facility for three years and that V31 works the 3-11 shift on the 2nd floor. V31 stated dinner is served by 5:00 PM and snacks arrive after dinner. V31 stated some of the resident's receive individually labeled snacks. V31 stated if a resident does not have an evening snack but wants a snack, the residents can ask the nurse to put in a request for one. V31 stated once the kitchen closes at 7:00 PM we cannot do anything about it and the resident just needs to wait. V31 stated no extra food is served on the unit or in the pantry unit. On 04/03/24 at 4:08 PM, V32 (Registered Nurse) stated the evening snacks arrive on the 1st floor unit between 6:00-6:30 PM. V32 stated some of the residents receive individually labeled snacks. V32 stated for the residents who do not receive an individually labeled snack the kitchen will send up one cookie and some juice. V32 stated if the resident is still hungry after eating the one cookie V32 cannot do anything about it. V32 stated the kitchen closes at 7:00 PM and the kitchen does not stock the unit pantry with any food. V32 stated the residents would like to receive something more substantial for the evening snack like sandwiches instead of only one cookie. V32 stated some of the residents can buy snacks from the vending machines downstairs but that is only if those residents have their own money. On 04/03/24 at 12:32 PM, V14 (Registered Dietitian) stated if there is more than a 14-hour difference supper and breakfast everyone should have access to a snack. V14 stated this is done for nourishment purposes because it is a long period to go without nourishment so that is why they need to have a snack in place. On 04/04/23, surveyor asked V9 for Food Committee Meeting Minutes for the past 12 months and V9 stated V9 could only find minutes from 12/13/23. Surveyor reviewed Resident Council Food Committee Meeting Minutes dated 12/13/23 and there was no mention of resident request or approval for mealtimes to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 17 of 26 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 04/05/2024 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 0809 be extend beyond 14 hours lapse time between dinner and breakfast meal. Level of Harm - Minimal harm or potential for actual harm Kitchen facility policy titled, Bedtime (HS) Snacks dated 07/27/23, documents in part: 1.) The facility will provide the residents bedtime snacks in accordance with the federal regulations, Residents Affected - Some 2.) The facility must offer snacks at bedtime daily. 3.) There must be no more than 14 hours between a substantial evening meal and breakfast the following day. 4.) However, if a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day. On 4/3/24 at 10:15 AM, during the Resident Council Meeting interview, one of the concerns brought up by the group was the lack of evening snacks provided on a consistent basis and the evening snacks not being substantial enough. On 4/3/24 at 10:37 AM, R47 stated R47 gets hungry at bedtime because no evening snack is provided. On 4/3/24 at 10:42 AM, R73 stated the facility offers one cookie and a cup of juice sometimes, but not every day. R73 stated just one cookie is not enough for R73. On 4/3/24 at 12:15 PM, V9 (Culinary Service Manager) stated we do not provide bedtime snacks for every resident. V9 stated we provide bedtime snacks to a few residents on the Snacks list. On 4/4/24 at 9:40 AM, R60 stated R60 eats dinner around 4:30 PM and that is too early for R60. On 4/4/24 at 10:05 AM, R52 stated R52 does not receive an evening snack every day. R52 stated sometimes the staff offers R52 something, but other times they do not give R52 anything for an evening snack. R52 stated R52 would like to get an evening snack every night. On 4/2/24, surveyor reviewed Resident Council Meeting Minutes dated between 04/2023 to 03/2024 provided by the facility and there was no mention of resident request or approval for mealtimes to be extend beyond 14 hours lapse time between dinner and breakfast meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 18 of 26 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 04/05/2024 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 observations, interviews, and record reviews, the facility failed to a.) ensure refrigerated food items were dated with a use by date, b.) discard expired and/or rotten foods, c.) follow manufacturer guidelines for storage, d.) keep food storage areas clean, e.) monitor chemical sanitizer concentrations of dish machine for dishware to be properly sanitized, f.) label and date dry storage items stored in bins, g.) clean ice machine and monitor for working order. These failures have the potential to affect all 94 residents receiving food prepared in the facility's kitchen. Findings include: On 04/02/24 at 9:15 AM, during initial kitchen tour V9 (Culinary Service Manger) stated refrigerated items should be labeled with a delivery date, the date the item was opened and the use by date. V9 stated the use by date varies depending on what the food item is. V9 stated the kitchen follows the guidelines titled Expiration Dates posted outside the walk-in cooler V9 stated each kitchen employee is responsible for doing their own labeling and dating after using a product. On 04/02/24 at 9:25 AM, observed the following items in the walk-in cooler: 1.) Opened 1 gallon container Barbeque Sauce dated with delivery date 03/12/24 and opened date 03/27/24. No use by date was documented on the product. V9 stated the Barbeque Sauce should be labeled with a use by date so the staff knows when to discard the product. V9 stated this is important so the product is not used beyond the discard date to cut down on food borne illness. V9 stated upon opening, this product is good for 30 days so the use by date of this product should have been written on the label as 04/27/24. 2.) Opened 1 gallon container Sweet Pickle Relish dated with delivery date 01/02/24 and opened date 03/24/24. No use by date was documented on product. V9 stated once the product was opened should have been labeled with a use by date per policy. 3.) Half case of fresh lemons packed on 01/09/24 and delivered 01/23/24 per packing stickers on the side of the box. No use by date was documented on the product. Observed most of lemons to be very soft and discolored in light brown and pale gray areas. V9 observed the fresh lemons and stated these should have been thrown out because they are rotten and have gone bad. 4.) Two cases of (Name brand shakes) labeled with delivery date 01/24/24. V9 stated this product arrives frozen and is stored in the freezer until it is removed and put into the walk-in cooler so it can be defrosted for use. V9 stated the product is served to the residents after it has been defrosted. V9 stated he remembers seeing the cases taken out of the freezer and put into the walk-in cooler to be defroster when V9 first started working at the facility which was toward the end of February 2024. V9 was not sure how long the items could be kept in the refrigerator after they had been defrosted. On 04/02/24 at 9:42 AM, observed the floor in the walk-in cooler underneath the metal shelving along the perimeter and behind the cases of food to be dirty with layers of grime and food wrappers. V9 observed the area and stated that area has been neglected, the staff are only cleaning in the middle of the cooler, and that they do not pull anything out to get behind the metal racks to clean the area properly. V9 stated the staff should pull everything away from the walls of the cooler to clean (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 19 of 26 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 04/05/2024 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 the hard-to-reach areas. Level of Harm - Minimal harm or potential for actual harm On 04/02/24 at 9:45 AM, observed black material around the exhaust fan in the walk-in cooler, and gray fuzzy material stuck on the ceiling of the walk-in cooler near the exhaust fan extending toward the door. V9 observed the material and stated, they look like dust bunnies. V9 stated that is a physical contaminant because the dust can fall on the open boxes with raw vegetables them. Residents Affected - Many On 04/02/24 at 9:51 AM, observed two staff members working in the dish room area cleaning dishes. V9 stated the test trips should read 100 parts per million (ppm) which is dark purple color based on the test strip indicator on the side of the bottle. Surveyor asked V10 (Dietary Aide) to run a test strip through the dish machine. Observed V10 send multiple test strips through the dish machine and test the water directly in the side drain. V10 stated V10 has checked the test strips 3-4x and none of them are reading anything. V10 showed surveyor the test strip which was wet but still white. It had not changed any color. V9 stated if there is no change in color then that means there is no sanitizing solution in the system and the items are not getting cleaned properly. V9 stated sanitizing solution is needed to disinfect and sanitize the dishes to keep the germs out. V9 stated the dishes are not fully cleaned until they are sanitized. On 04/02/24 at 10:07 AM, observed in the dry storage room white sugar in a bin in a closed bag not labeled or dated and white rice in a bin not labeled or dated. V9 stated both items should have been labeled and dated when they were filled up. On 04/02/24 at 10:15AM, observed in cook area where spices were stored the following: 1.) Opened 1 quart bottle of lemon juice dated with an opened date 03/21/24. On the bottle manufacturer instructions document refrigerate after opening for best results. V9 stated this lemon juice should be stored in the refrigerator based on the manufacturer guidelines. 2.) Opened 1 gallon container of hot sauce labeled with delivery date 06/01/23 and opened date 08/17/23. V9 stated once opened the hot sauce is good for 6 months. V9 stated the hot sauce is over the 6-month period and should not be used and will be thrown out. 3.) Opened 2-quart bottle of low sodium soy sauce dated with a delivery date 02/28/24 and opened date 03/16/24. On the bottle manufacturer instructions document refrigerate after opening. V9 stated the kitchen follows manufacturer guidelines so this item should have been refrigerated after opening. V9 stated by not storing the lemon juice and low sodium soy sauce in the refrigerator per the manufacturers guidelines those items could grow bacteria which could be harmful to residents if they were to consume them. On 04/02/24 at 10:23 AM, observed ice machine dripping water from the outside front corner onto the tiled floor. Also observed a white drainage pipe extending from behind the ice machine actively draining large amounts of water (constant stream) into a floor drain near the front corner of the ice machine. The titled area around the front corner of ice machine was observed to have large amounts of wet black material imbedded into the grout and the tile was covered in a white, grayish material. Also, observed a lot of condensation around the lid of the ice machine, and some standing water on the inside lid of the ice machine. Surveyor asked V9 why there was so much running water from the white drainage pipe and V9 stated the drainage pipe was draining water from the ice machine and that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 20 of 26 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 04/05/2024 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 ice machine should not be draining water like that. Surveyor asked how often the ice machine is cleaned and V9 stated we don't clean it; an outside company comes to the facility to do the cleaning. V9 stated the last time the outside company was here to clean the ice machine was 09/11/23. V9 stated the wet black material around the tiles looks like mold. On 04/04/24 at 8:21 AM, observed (Brand name shakes) carton. Printed on the side of the carton by the manufacturer documented Thaw under refrigeration (40 degrees or below). Shake well before using. Open top, then pour and serve. After thawing keep refrigerated. Use within 14 days after thawing. On 04/02/24, V9 provided list of diet orders for all residents in the facility printed 04/02/24 at 11:05 AM. V9 stated everyone receives a tray from the kitchen and none of the residents receive nothing by mouth (NPO). Facility provided kitchen policy titled; Food Receiving and Storage undated which documents in part, culinary services will maintain clean food storage areas at all times, dry foods that are stored in bins will be labeled and dated (use by date), and all goods stored in the refrigerator will be covered, labeled and dated (use by date). Facility provided kitchen document titled, Expiration Dates undated which documents in part foods that expire 60 days after opening: BBQ Sauce. Facility provided document titled TCS (Temperature Control for Safety) Foods & 7-Day Labeling dated 2024 documents in part follow the 7-day rule, trust your senses, if the food looks, seems or smells bad before then, throw it out. Facility provided policy titled Cleaning Guidelines Ice Machine undated which documents steps for cleaning. Facility provide policy titled Dishwashing Machine Use undated which documents in part dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine 50-100 ppm and a supervisor will check the dishwashing machine for proper concentrations of sanitizer solution after filling the dishwashing machine. Facility provided product description of Sysco Imperial Shakes which documents in part thaw under refrigeration and refrigerate for up to 14 days. Facility provided document titled SAFE Food Handling Standards and Procedures undated which documents in part, the purpose is to establish consistent standards and procedures when serving and delivering food this is important because harmful bacteria can be introduced into food causing foodborne illness. Based on observations, interviews, and record reviews, the facility failed to a.) ensure refrigerated food items were dated with a use by date, b.) discard expired and/or rotten foods, c.) follow manufacturer guidelines for storage, d.) keep food storage areas clean, e.) monitor chemical sanitizer concentrations of dish machine for dishware to be properly sanitized, f.) label and date dry storage items stored in bins, g.) clean ice machine and monitor for working order. These failures have the potential to affect all 94 residents receiving food prepared in the facility's kitchen. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 21 of 26 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 04/05/2024 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 On 04/02/24 at 9:15 AM, during initial kitchen tour V9 (Culinary Service Manger) stated refrigerated items should be labeled with a delivery date, the date the item was opened and the use by date. V9 stated the use by date varies depending on what the food item is. V9 stated the kitchen follows the guidelines titled Expiration Dates posted outside the walk-in cooler V9 stated each kitchen employee is responsible for doing their own labeling and dating after using a product. Residents Affected - Many On 04/02/24 at 9:25 AM, observed the following items in the walk-in cooler: 1.) Opened 1 gallon container Barbeque Sauce dated with delivery date 03/12/24 and opened date 03/27/24. No use by date was documented on the product. V9 stated the Barbeque Sauce should be labeled with a use by date so the staff knows when to discard the product. V9 stated this is important so the product is not used beyond the discard date to cut down on food borne illness. V9 stated upon opening, this product is good for 30 days so the use by date of this product should have been written on the label as 04/27/24. 2.) Opened 1 gallon container Sweet Pickle Relish dated with delivery date 01/02/24 and opened date 03/24/24. No use by date was documented on product. V9 stated once the product was opened should have been labeled with a use by date per policy. 3.) Half case of fresh lemons packed on 01/09/24 and delivered 01/23/24 per packing stickers on the side of the box. No use by date was documented on the product. Observed most of lemons to be very soft and discolored in light brown and pale gray areas. V9 observed the fresh lemons and stated these should have been thrown out because they are rotten and have gone bad. 4.) Two cases of (Name brand shakes) labeled with delivery date 01/24/24. V9 stated this product arrives frozen and is stored in the freezer until it is removed and put into the walk-in cooler so it can be defrosted for use. V9 stated the product is served to the residents after it has been defrosted. V9 stated he remembers seeing the cases taken out of the freezer and put into the walk-in cooler to be defroster when V9 first started working at the facility which was toward the end of February 2024. V9 was not sure how long the items could be kept in the refrigerator after they had been defrosted. On 04/02/24 at 9:42 AM, observed the floor in the walk-in cooler underneath the metal shelving along the perimeter and behind the cases of food to be dirty with layers of grime and food wrappers. V9 observed the area and stated that area has been neglected, the staff are only cleaning in the middle of the cooler, and that they do not pull anything out to get behind the metal racks to clean the area properly. V9 stated the staff should pull everything away from the walls of the cooler to clean the hard-to-reach areas. On 04/02/24 at 9:45 AM, observed black material around the exhaust fan in the walk-in cooler, and gray fuzzy material stuck on the ceiling of the walk-in cooler near the exhaust fan extending toward the door. V9 observed the material and stated, they look like dust bunnies. V9 stated that is a physical contaminant because the dust can fall on the open boxes with raw vegetables them. On 04/02/24 at 9:51 AM, observed two staff members working in the dish room area cleaning dishes. V9 stated the test trips should read 100 parts per million (ppm) which is dark purple color based on the test strip indicator on the side of the bottle. Surveyor asked V10 (Dietary Aide) to run a test strip through the dish machine. Observed V10 send multiple test strips through the dish machine and test the water directly in the side drain. V10 stated V10 has checked the test strips 3-4x and none (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 22 of 26 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 04/05/2024 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 of them are reading anything. V10 showed surveyor the test strip which was wet but still white. It had not changed any color. V9 stated if there is no change in color then that means there is no sanitizing solution in the system and the items are not getting cleaned properly. V9 stated sanitizing solution is needed to disinfect and sanitize the dishes to keep the germs out. V9 stated the dishes are not fully cleaned until they are sanitized. Residents Affected - Many On 04/02/24 at 10:07 AM, observed in the dry storage room white sugar in a bin in a closed bag not labeled or dated and white rice in a bin not labeled or dated. V9 stated both items should have been labeled and dated when they were filled up. On 04/02/24 at 10:15AM, observed in cook area where spices were stored the following: 1.) Opened 1 quart bottle of lemon juice dated with an opened date 03/21/24. On the bottle manufacturer instructions document refrigerate after opening for best results. V9 stated this lemon juice should be stored in the refrigerator based on the manufacturer guidelines. 2.) Opened 1 gallon container of hot sauce labeled with delivery date 06/01/23 and opened date 08/17/23. V9 stated once opened the hot sauce is good for 6 months. V9 stated the hot sauce is over the 6-month period and should not be used and will be thrown out. 3.) Opened 2-quart bottle of low sodium soy sauce dated with a delivery date 02/28/24 and opened date 03/16/24. On the bottle manufacturer instructions document refrigerate after opening. V9 stated the kitchen follows manufacturer guidelines so this item should have been refrigerated after opening. V9 stated by not storing the lemon juice and low sodium soy sauce in the refrigerator per the manufacturers guidelines those items could grow bacteria which could be harmful to residents if they were to consume them. On 04/02/24 at 10:23 AM, observed ice machine dripping water from the outside front corner onto the tiled floor. Also observed a white drainage pipe extending from behind the ice machine actively draining large amounts of water (constant stream) into a floor drain near the front corner of the ice machine. The titled area around the front corner of ice machine was observed to have large amounts of wet black material imbedded into the grout and the tile was covered in a white, grayish material. Also, observed a lot of condensation around the lid of the ice machine, and some standing water on the inside lid of the ice machine. Surveyor asked V9 why there was so much running water from the white drainage pipe and V9 stated the drainage pipe was draining water from the ice machine and that the ice machine should not be draining water like that. Surveyor asked how often the ice machine is cleaned and V9 stated we don't clean it; an outside company comes to the facility to do the cleaning. V9 stated the last time the outside company was here to clean the ice machine was 09/11/23. V9 stated the wet black material around the tiles looks like mold. On 04/04/24 at 8:21 AM, observed (Brand name shakes) carton. Printed on the side of the carton by the manufacturer documented Thaw under refrigeration (40 degrees or below). Shake well before using. Open top, then pour and serve. After thawing keep refrigerated. Use within 14 days after thawing. On 04/02/24, V9 provided list of diet orders for all residents in the facility printed 04/02/24 at 11:05 AM. V9 stated everyone receives a tray from the kitchen and none of the residents receive nothing by mouth (NPO). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 23 of 26 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 04/05/2024 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 provided kitchen policy titled; Food Receiving and Storage undated which documents in part, culinary services will maintain clean food storage areas at all times, dry foods that are stored in bins will be labeled and dated (use by date), and all goods stored in the refrigerator will be covered, labeled and dated (use by date). Facility provided kitchen document titled, Expiration Dates undated which documents in part foods that expire 60 days after opening: BBQ Sauce. Facility provided document titled TCS (Temperature Control for Safety) Foods & 7-Day Labeling dated 2024 documents in part follow the 7-day rule, trust your senses, if the food looks, seems or smells bad before then, throw it out. Facility provided policy titled Cleaning Guidelines Ice Machine undated which documents steps for cleaning. Facility provide policy titled Dishwashing Machine Use undated which documents in part dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine 50-100 ppm and a supervisor will check the dishwashing machine for proper concentrations of sanitizer solution after filling the dishwashing machine. Facility provided product description of (Brand name shakes) which documents in part thaw under refrigeration and refrigerate for up to 14 days. Facility provided document titled SAFE Food Handling Standards and Procedures undated which documents in part, the purpose is to establish consistent standards and procedures when serving and delivering food this is important because harmful bacteria can be introduced into food causing foodborne illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 24 of 26 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 04/05/2024 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: On 4/2/24 at 9:25 AM, during the entrance conference with V1 (Administrator), V1 stated that the facility has multiple residents' rooms that are less than the required square footage per resident and that requires a variance. At 11:57 AM, V3 (Maintenance Director) stated that there are 6 residents' rooms in the facility that have waivers, and they are rooms 107, 108, 207, 208, 307, and 308. V3 stated that all 6 rooms have almost the same measurements. At 11:58 AM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. At 12:01 PM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. At 12:03 PM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. At 12:05 PM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. At 12:07 PM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. At 12:09 PM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. On 4/4/24 at 11:10 AM, V1 stated that the requirement is 80 square footage per resident in a multi bed resident's room. V1 stated that there are currently 6 residents' rooms that do not meet the requirement and that there are 3 beds in each of those rooms. V1 state that the facility has not made any changes in the size of the rooms since the last annual re-certification survey. The 4/2/24 facility daily roster documented that there are 48 rooms in the facility and rooms 107, 108, 207, 208, and 308 are 3-resident rooms. The (undated) room [ROOM NUMBER], 108, 207, 208, 307, and 308 floor plans documented the room floor areas ranges from 205 square feet to 223 square feet. These indicate that each resident is provided 68.3 square feet to 74.3 square feet size space in the room. 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 documents in part, This is a request for a variation/waiver of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 25 of 26 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 04/05/2024 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 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. The variation/waiver is requested for rooms numbered 108, 208 and 308 at [facility]. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 26 of 26