Health inspection·September 5, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R4's nurses note dated 8/24/23 documents by V18, R4 in room crying she reported that a staff member that had been working with her earlier was rude to her and unkind. R4 is noted with a skin tear to her right lower extremity. V17 (RN- Registered Nurse) alerted. On 8/29/23 at 11:20 AM, V1 confirmed on 8/25/23, V16 reported R4 said a staff member was being rough during cares. Confirmed she did not report to the state agency because R4 makes false allegations about staff. The facility's Initial Report dated 8/29/23 ( 4 days later) documents on 8/25/23, V1 received an allegation of verbal and physical abuse and report of bruises against V20 (Certified Nursing Assistant) on 8/24/23. The facility's Abuse Prevention and Reporting Policy revised 10/22 states, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment .this will be done by .identifying concerns of residents allegations of deprivation of goods and services by staff .filling accurate and timely investigative reports .any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 2 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure an alleged allegation of abuse was investigated. This applies to 1 of 3 residents (R4) reviewed for abuse in the sample of 31. Residents Affected - Few The findings include: R4's face sheet shows she is [AGE] year old female, date of birth [DATE] with diagnosis including COPD, chronic kidney disease stage 3, congestive heart failure, osteoarthritis, anxiety, major depressive disorder and bipolar disorder. R4's Minimum Data Set assessment dated [DATE] shows her cognition is mildly impaired, no behaviors of delusions or hallucinations, no rejection of cares, and total dependent with two person assist for transfers. On 8/28/23 at 9:45 AM, R4 said today is my 94th birthday. She said one day last week either Thursday or Friday a staff member grabbed her arm while transferring her using the mechanical lift. A oval shaped light purple bruise was observed to mid inner forearm. She said during the transfer her right leg was bumped on the mechanical lift arm as well. A foam dressing dated 8/25/23 to her right lower leg was in place. She said I screamed and told the staff member to get out of here. I reported this to V16 (Activity Director). On 8/29/23 at 12:27 PM, V16 confirmed R4 reported a staff member was being rough during transferring her last week. She said someone hurt me and was being rough. V16 said R4 is mostly oriented and confirmed she transfers using the mechanical lift. V16 said he reported the alleged abuse to V1 (Administrator). On 8/29/23 at 11:20 AM, V1 confirmed on 8/25/23 V16 reported R4 said a staff member was being rough during cares. Confirmed she did not investigate the allegation because R4 has a history of making false allegations. Typically she would investigate all allegations of abuse. The facility's Initial Report dated 8/29/23 ( 4 days later) documents on 8/25/23, V1 received an allegation of verbal and physical abuse and report of bruises against V20 (Certified Nursing Assistant) on 8/24/23. The facility's Abuse Prevention and Reporting Policy revised 10/22 states, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment .this will be done by .identifying concerns of residents allegations of deprivation of goods and services by staff .implementing systems to promptly and aggressively investigate all reports and allegations of abuse .filling accurate and timely investigative reports .Any incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident properly occurred, was alleged or suspected. Any incident or allegation involving abuse .will result in an investigation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 3 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a treatment orders was provided to a resident with a non-pressure wound. This applies to 1 of 31 (R4) residents reviewed for quality of life in the sample of 31. Residents Affected - Few The findings include: R4's face sheet shows she is a [AGE] year old female with diagnosis including peripheral vascular disease, Chronic Obstructive Pulmonary Disease, chronic kidney disease, long term use of anticoagulants, anxiety and congestive heart failure. R4's Minimum Data Set assessment dated [DATE] show no behaviors of delusions or hallucinations, no rejection of cares, and total dependent with two person assist for transfers. R4's Treatment Administration Record dated August 2023 shows orders for wound treatment to right lower leg cleanse with saline, pat dry, apply xeroform and foam dressing daily. The T.A.R. shows the treatment was signed off as performed on 8/26/23, 8/27/23, and documented R4 refused on 8/28/23. On 8/28/23 at 9:45 AM, R4 was lying in bed. A foam dressing dated 8/25/23 was observed to her right lower extremity. She said her leg was bumped during a transfer with the mechanical lift. On 8/29/23 at 9:10 AM, R4 was lying in bed. The dressing to her right lower extremity was dated 8/25/23. On 8/29/23 at 9:33 AM, V14 (Wound Nurse) said R4's dressing should be done according to the physician's order. V14 said V15 (Wound Nurse) should be performing R4's treatment as ordered. On 8/29/23 at 1:55 PM, V14 confirmed R4's dressing was dated 8/25/23 and should be changed daily. On 8/30/28 at 10:28 AM, V15 (Wound Nurse) said he provides wound treatment to R4. Confirmed he dates the dressing the date it was changed and if resident refuses the dressing it should be offered again at a later time. R4's Wound Assessment Report dated 8/25/23 documents an abrasion trauma wound measuring 1.0 cm (centimeters) x 1.0 cm x 0.10 cm .bumped leg during transfer. The facility's Skin Condition Assessment & Monitoring -Pressure and Non Pressure revised 6/2018 states, To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented .dressings which are applied to pressure ulcers, skin tears, wounds or lesions or incisions shall include the date of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness and signs and symptoms of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 4 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to safely transfer a resident (R69) via wheelchair. This failure resulted in R69 sustaining a fall with injury which included a laceration to her forehead that required sutures. The facility failed to ensure a resident was safely transferred from wheelchair to bed. These failures apply to 2 of 31 residents (R69, R37) reviewed for resident safety/supervision in the sample of 31. The findings include: 1. R69's care plan dated February 2022, showed R69 was cognitively impaired with poor judgement and poor safety awareness related to her diagnosis of dementia. The care plan showed R69 also had a diagnosis of Parkinson's disease which put her at risk for falls due to her impulsive behavior movements while sitting in her wheelchair. The care plan showed staff will continue to monitor how resident is sitting in her wheelchair . R69's Nurses Notes dated August 13, 2023, showed a certified nursing assistant (CNA) was pushing R69 in her wheelchair. The CNA suddenly stopped pushing R69 in her wheelchair which caused R69 to fall forward out of her wheelchair, onto the floor. The note showed R69 sustained a 2.5 cm (centimeter) laceration on her left forehead with bleeding due to the fall. 911 was called. R69 was sent to the hospital, via ambulance, for an evaluation. R69 returned to the facility, from the hospital, on August 13, 2023, after receiving five sutures to repair her forehead laceration. On August 29, 2023, at 11:51 AM, V10 CNA stated, An agency CNA was pushing (R69) down the hall in her wheelchair. I was walking next to them. (R69) was in her wheelchair. I had taken the leg rests off her wheelchair earlier that day. A resident that was walking in front of (R69) stopped suddenly so the CNA, pushing (R69), had to stop. When he stopped, (R69) went forward out of her wheelchair. She hit her head on the floor. She had a cut on her head. She was not scooted back in the seat of her wheelchair before she fell. I kept telling her to scoot back in her wheelchair, but she didn't listen. On August 29, 2023, at 12:29 PM, V12 Restorative Nurse stated, (R69) has dementia and is very confused. She has no safety awareness. She has a high-back, reclining wheelchair because she tends to lean forward in her chair. She has poor trunk control. When she is up in her wheelchair, the leg rests should be on the chair, with her legs on the rests, to help position her back in the seat of the chair. If she is leaning forward in her chair, staff need to direct her to sit back. Staff should make sure she is not leaning forward in her wheelchair when transporting her. If she is not positioned correctly in her chair, she could fall forward out of the chair. On August 29, 2023, at 1:01 PM, V13 Nurse Practitioner stated R69 has a high-back, reclining wheelchair because she has a tendency to lean forward and has slid out of her wheelchair before. V13 stated, (R69) is very confused and has poor safety awareness. If she is scooted forward in her wheelchair or leaning forward in her chair, staff should reposition her towards the back of the wheelchair to make sure she's safe when transporting her. 2. R37's assessment dated [DATE], showed R37 was severely cognitively impaired. The assessment showed R37 required the extensive assistant of 2 staff for transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 5 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 - Actual harm Residents Affected - Few On August 28, 2023, at 12:15 PM, R37 was seated in a wheelchair next to her bed as V3 CNA stood next to her. V3 CNA transferred R37, from her wheelchair to the bed, by holding onto R37's pants with her right hand. No gait belt was used during the transfer. V3 CNA was the only staff in the room. On August 29, 2023, at 12:38 PM, V12 Restorative Nurse stated R37 should be transferred by 1-2 staff, with the use of a gait belt. V12 stated gait belts should be used when transferring all residents. The facility's Manual Gait Belt and Mechanical Lifts policy dated January 19, 2018, showed, Use of gait belt for all physical assist transfers is mandatory. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 6 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to ensure urinary catheter tubing was below the level of the bladder and failed to ensure urinary catheter drainage bags were placed in a manner to prevent infection for 2 of 6 residents (R56, R108) reviewed for urinary catheters in the sample of 31. The findings include: 1. On 08/28/23 at 10:48 AM, R56's urinary catheter tubing was coming from the resident and placed up over a wedge cushion next to R56 on the bed. R56's catheter tubing had clear yellow urine in tubing that was unable to drain. On 08/28/23 at 12:15 PM, R56's urinary catheter tubing remained up over the wedge cushion and had and increased amount of urine in the tubing that was unable to drain. On 08/28/23 01:40 PM, R56's urinary catheter tubing was still draped over wedge cushion with increased urine moving back and forth in the tubing, unable to flow into the drainage bag. On 08/29/23 at 01:21 PM, V2 Director of Nursing said urinary catheter drainage bags should not be on floor for infection control reasons. V2 said urinary catheter tubing should not be kinked, it should be able to flow into the bag to prevent urine from backing up into the bladder which could cause infection. R56's Physician Orders dated 8/28/23 shows an order indwelling urinary catheter. Diagnosis: retention of urine. 2. On 08/29/23 at 12:27 PM, R108's urinary catheter bag was laying on floor next to R108's bed. R108's Physician Orders dated 8/23/23 shows insert urinary catheter. Diagnosis: coccyx wound. The facility's Urinary Catheter Care Policy dated 2/14/19 shows Catheters shall be positioned to maintain a downhill flow of urine to prevent a back flow of urine into the bladder or tubing, during transfer, ambulation and body positioning. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 7 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete quarterly and significant change dietary assessments on residents. The facility failed to ensure dietary assessments were completed by the Registered Dietician. The facility failed to identify resident weight loss prior to the weight loss becoming significant. The facility failed to ensure weight loss treatment interventions were initiated in a timely manner, once resident weight loss was identified. These failures resulted in R37, R69, R144, R9, and R79 sustaining a significant weight loss. These failures apply to 5 of 10 (R37, R69, R144, R9, R79) residents reviewed for weight loss in the sample of 31. Residents Affected - Some These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/27/23, when the facility's Registered Dietician (V6) failed to assess and complete a dietary assessment on R37, upon her admission to the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 8/31/23 at 12:46 PM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 9/1/23 however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. R37's admission Record dated 3/27/23, showed R37 was admitted to the facility with diagnoses of dementia and a left hip wound related to recent hip surgery. An admission dietary profile for R37, dated 4/13/23, showed the profile was completed by V7, a non-certified Dietary Manager. R37's electronic medical records dated 3/27/28-4/25/23 were reviewed and showed no admission dietary assessment was completed by V6 Registered Dietician (RD). R37's Weight Report dated 8/29/23 showed R37 weighed 119.4 pound (lbs) upon admission to the facility. The record showed R37 weighed 118 lbs on 4/4/23 and 89 lbs on 4/25/23 which resulted in a significant weight loss of 24.5 % (29 lbs) in 21 days. R37's dietary note date 4/26/23, showed V6 RD's first visit/assessment of R37. The note showed R37 was not assessed by V6 RD until 28 days after admission and not until after R37 had sustained significant weight loss. A Dietary Note for R37, dated 5/15/23, showed R37 was assessed by V6 RD. The note showed, unintended weight loss . The note showed R37 was started on a diuretic on 4/21/23 but R37 had only been on the medication three days prior to the significant weight loss being discovered. On 8/29/23 at 10:00 AM, V6 RD stated, I am not full time or part time in the facility. I work in the facility on a consulting basis. I don't complete the admission, quarterly (every 3 months), or annual dietary assessments on the residents. The CDM (certified dietary manager) does those assessments. I don't routinely see residents unless they have significant weight loss, pressure wounds, are on dialysis, or require tube feeding. A resident could potentially be in the facility for months to years before I would need to see them. I don't see residents with dementia or with surgical wounds unless they have significant weight loss. Dementia and surgical wounds can put residents at risk for weight loss but those are not reasons or triggers for me to see a resident. The goal is to intervene (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 8 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 - Immediate jeopardy to resident health or safety Residents Affected - Some before weight loss becomes significant. I did not see (R37) until after she had already had significant weight loss. I don't know why her admission dietary assessment was not completed until 4/13/23. I don't know exactly why she had such a significant weight loss. V6 RD stated she was aware V7 was not a certified Dietary Manager. On 8/29/23 at 1:12 PM, V7 Dietary Manager stated he was not certified in dietary management but, he was currently enrolled in school for dietary management. V7 stated he had no certifications in food service management, did not have an associate's degree, and had no past work experience in long term care facilities. V7 stated, I do the admission, quarterly, and annual dietary assessments on residents. The admission assessment should be done within 48 hours of admission. I am not sure why I did (R37's) admission assessment so late. I must have overlooked it. Nursing should be monitoring residents for weight loss. I only look at weights when I am doing a residents' quarterly assessments . V7 stated he did not routinely complete residents' dietary assessments collaboratively with V6 RD, despite him not being a certified dietary manager. V7 stated he had never completed a dietary assessment on a resident prior to him being hired by the facility. On 8/31/23 at 8:23 AM, V13 Nurse Practitioner (NP) stated the expectation is that the Registered Dietician assesses residents upon admission and quarterly to monitor residents for weight loss, weight gain, or any changes in nutritional needs. V13 stated any changes need to be reported to the physician or nurse practitioner immediately. V13 stated, If a Registered Dietician is not assessing residents at least quarterly, changes in a resident's condition could get missed which includes not catching a resident's weight loss. If weight loss is not caught in time, residents could develop malnutrition and/or wounds. On 8/31/23 at 8:23 AM, V1 Administrator stated V6 RD should be completing admission, quarterly, annual, and significant change dietary assessments on all residents. V1 stated she was notified on 8/30/23, that V6 RD was not completing the necessary dietary assessments on all residents. V1 stated, I didn't know, until yesterday, that (V6 RD) was not doing all the assessments. Nursing is responsible for monitoring residents for weight loss. (V6 RD) is responsible for running the weekly weights to see who triggers for significant weight loss or is losing weight. We want to stop the weight loss before it become significant. The Registered Dietician is also responsible for making sure the residents get the proper nutrition, proper diet, and for noticing any changes in weight. V1 stated because V7 (Dietary Manager) was not certified, he was not to be completing any resident dietary assessments, on his own. On 8/30/23 at 10:55 AM, V32 Regional Director of Operations stated, We have some concerns about (V6 RD's) job performance. We are in the process of letting her go. All resident admission, quarterly, annual, and significant change dietary assessments should be completed by the Registered Dietician. V32 stated he was aware V7 Dietary Manager was not certified. 2. R69's admission Record dated 2/11/22 showed R69 had diagnoses including Parkinson's disease, dementia, dysphagia, and muscle wasting/atrophy. R69's electronic medical records dated 8/1/22-8/27/23 were reviewed. The records showed the last dietary profile/assessment completed on R69 was 2/21/23, done by the previous CDM. No quarterly dietary assessment dated on or around 5/21/23 was noted for R69. R69's Weight Report printed 8/29/23 showed R69 weighed 143.2 lbs in May 2023 and 129.9 lbs in August 2023. This showed R69 sustained a significant weight loss of 9.3% (13.3 lbs) in three months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 9 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 - Immediate jeopardy to resident health or safety Residents Affected - Some A Dietician Evaluation for R69, was completed by V6 Registered Dietician on 8/28/23, after R69 had sustained significant weight loss. The note showed, Unintended weight loss . V6 RD started R69 on nutritional supplements/weight loss treatment interventions on 8/28/23. On 8/29/23 at 10:00 AM, V6 RD stated, I didn't see (R69) until yesterday (8/28/23). Her last dietary assessment was completed on 2/21/23. I am not sure why she did not have as assessment done in May 2023. No one called me from the facility to tell me she was losing weight. I ran the facility's weight reports sometime during the middle of July (2023). I knew about (R69's) weight loss in July (2023) but did not put any interventions or supplements in place until yesterday. It was an oversight on my part. It got overlooked. That was my responsibility. On 8/29/23 at 1:01 PM, V13 Nurse Practitioner (NP) stated she was not aware of R69's significant weight loss from May 2023-August 2023. V13 stated, We should have been notified of (R69's) weight loss as soon as it was discovered so we could have implemented interventions. If (V6 RD) was aware of (R69's) weight loss in July (2023), she should have implemented interventions immediately. 3. R144's admission Record dated 4/5/23 showed R144 was admitted to the facility with diagnoses of a stroke (CVA/cerebral infarction), dementia, aphasia (inability to verbally communicate), and subdural hemorrhage (brain bleed). An admission dietary profile for R144, dated 4/16/23, showed the profile was completed by V7, the non-certified Dietary Manager. R144's electronic medical records dated 4/5/23-7/27/23 were reviewed and showed no admission dietary assessment completed by V6 RD. R144's Weight Report dated 8/31/23 showed R144 weighed 135 lbs in June 2023 and 120 lbs in July 2023. This showed R144 sustained a significant weight loss of 11.1 % (15 lbs) in one month. A Dietician Evaluation for R144, was completed by V6 RD on 7/28/23, after R144 had sustained significant weight loss. The note showed, Unintended weight loss related to decreased PO (oral) intakes as evidenced by chart review . On 8/31/23 at 9:18 AM, V6 RD stated she was unaware R144's oral intake had decreased until after R144 had sustained significant weight loss. V6 stated, I didn't assess her until after she had significant weight loss. I did not see her upon admission because she wasn't on dialysis, tube fed, and didn't have any pressure wounds. 4.) R9's face sheet shows she was admitted to the facility on [DATE] and has diagnoses including: Type 2 diabetes with diabetic neuropathy, depression, anxiety, adjustment disorder with depressed mood, vascular dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R9's electronic medical record shows she had a dietary assessment completed on 10/27/23 on admission, a quarterly dietary evaluation/assessment was completed on 2/1/23 (both completed by a former dietary manager). The next dietary evaluation was not completed until 8/29/23 after V6 Registered Dieitican (RD) was made aware of R9's significant weight loss by the surveyor. R9's weight and vitals summary shows she weighed 245 lbs. on 6/8/23 and weighed 220.5 lbs. on 7/19/23 a 10% - 24.5 lb weight loss in one month. R9's 8/11/23 weight was 223 lbs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 10 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 - Immediate jeopardy to resident health or safety Residents Affected - Some R9's electronic medical records dated 5/1/23-8/29/23 were reviewed. These records showed no documentation R9 was ever assessed by V6 (RD) even after R9 sustained a significant weight loss. 8/29/23 1:07 PM, V7 (non-certified Dietary Manager)- said he is responsible for the quarterly dietary assessments and then gets the RD involved after he sees the resident. He said he was not aware of R9's significant weight loss and that there really is no process in place for notifying him of significant weight loss for residents. V7 said now that he is aware of R9's significant weight loss he will notify V6 and let her know because she would be the person to recommend interventions. On 8/29/23 at 1:41 PM, V6 (RD) said R9's weight loss should have triggered in the computer for a significant weight loss. She said it was towards the end of the month when she got the resident weights for July so she decided to wait to see Augusts weights. She said she can't speak for the programmers, but this is pretty concerning that PCC (electronic medical record/EMR) is not triggering significant weight loss. V6 said she does not believe she has done any assessment on R9, the last quarterly assessment was last done in 2/1/2023. (No quarterly assessment was done in May or August of 2023 no significant weight loss assessment has been done as of today). V6 said the computer should have also triggered for a quarterly assessment and then V7 should completed those, but if the computer does not trigger it then he would not know to do one and quarterly assessments are being missed. On 8/29/23 at 2:01 PM, V1 (Administrator) said V6 (RD) is responsible to be reviewing weights to see who triggers for significant weight loss. 5.) R79's face sheet shows he was admitted to the facility on [DATE] and has diagnoses including: end stage renal disease, type 2 diabetes, congestive heart failure and acquired absence of below the knee amputation. R79 had a dietary evaluation completed on admission on [DATE], and again on 3/20/23. R79's 3/20/23 assessment completed by V6 (RD) shows he had a recent unplanned weight loss a current pressure injury. R79 went to the hospital for a medical procedure and a dietary re-assessment was completed on 5/1/23 upon his return. R79's EMR shows There are no additional quarterly or significant change dietary assessments or evaluations done on R79 after 5/1/23. R79's weights and vitals summary showed on 4/1/23 he weighed 366.3 pounds. On 8/6/23 he weighed 324 pounds. A total weight loss of 42.3 pounds (11.55%) in 4 months. On 8/28/23 at 10:53 AM, R79 said he has lot a lot of weight loss, over 85 lbs. and no one from dietary is seeing him that he is aware of. On 8/28/23 at 1:14 PM, V7 (non-certified Dietary Manager) said he is unaware if the facility follows the 3 month weight loss if it is 7.5%, he thinks the facility just follows the 5% and 10% weight loss to determine significant weight loss. V7 said R79 was last seen by him on 4/24/23 and he was not aware of significant weight loss for R79. On 8/8/23 at 1:35 PM, V6 (RD) said she was not aware of significant weight loss for R79 and she last saw him on 5/1/23. V6 said he also should have triggered in the computer for significant weight loss and a quarterly assessment but for some reason did not. The facility's Weight Assessment and Intervention policy dated 2020 showed, The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 11 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Any weight change of 5% of more since the previous weight assessment shall be re-taken the next day to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as the physician, Registered Dietician, Dining Services Manager, or other members of the interdisciplinary team within 24 hours. Verbal notification must be writing . The policy defined significant weight loss as a loss of 5% of a resident's weight in one month, 7.5% in three months, or 10% in six months. The facility's Registered Dietician Roles and Responsibilities policy dated 2020 showed, The Registered Dietician will provide routine scheduled consultations to monitor compliance with state and federal regulations and plan nutritional care for residents. The policy showed the Registered Dietician (RD) will assess/monitor the nutritional needs of residents and keep the physician and appropriate staff informed of the nutritional status of residents. The policy showed the RD will provide nutrition documentation for residents according to established schedules and guidelines including assessment and changes in resident nutritional plans . The Immediate Jeopardy that began on 3/27/23 was removed on 9/1/23, when the facility took the following actions to remove the immediacy: 1. R144's dietary orders have been updated to reflect current recommendations including Ensure (7/31/23) and frozen nutritional treats (8/1/23). Weights are currently being monitored-monthly weight increase of 3 lbs in August. R144 will be reassessed by Dietician on 9/1/23. 2. R9's dietary orders have been updated to reflect current recommendations including Glucerna (8/30/23). Weights are currently being monitored-monthly weight increase of 2.5 lbs. Reviewed by Dietician on 8/29/23. Resident will be reassessed by Dietician on 9/1/23. 3. R37's dietary plan has been updated to reflect current recommendations. Weights are currently being monitored-monthly weight increase of 2.3 lbs. Reviewed by dietician on 8/29/23. Resident will be reassessed by Dietician on 9/1/23. 4. R79's dietary orders have been updated to reflect current recommendations including Glucerna (8/30/23). Weights are currently being monitored. Reviewed by the Dietician on 8/30/23. Resident will be reassessed by Dietician on 9/1/23. 5. R69's dietary orders have been updated to reflect current recommendations including frozen nutritional treats (8/29/23) and calorie count for 3 days (8/30/23). Weights are currently being monitored-monthly weight increase of 2.5 lbs. Reviewed by the Dietician on 8/28/23. Resident will be reassessed by Dietician on 9/1/23. 6. Medical Director was notified of Immediate Jeopardy 8/31/23 at 1:32 PM. 7. Facility will audit current residents and all new admissions in the last 30 days to ensure required dietary assessments are completed by a Registered Dietician by 9/7/23. 8. All residents' weights will be obtained by nursing and the restorative team by 9/1/23. 9.The facility Weight Policy was updated to include that losses greater than 5 lbs in one calendar month will be referred to RD and MD will be informed. The DON, ADON, and/or Designee will monitor weights to discover loss prior to it becoming significant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 12 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 - Immediate jeopardy to resident health or safety 10. Facility nurses and CNAs will be educated on reporting changes in intake, changes in diet preferences, and changes in condition to the DON, ADON, and/or designee. 11. The facility held an emergency QAPI meeting on 8/31/23 to discuss the policy relating to dietary assessments, quarterlies, and significant changes, along with interventions for residents with significant weight loss. Residents Affected - Some 12. The Nurse Consultant, Director of Nursing, and/or designee will conduct chart audits to review that residents who have had significant weight loss will have interventions implemented starting 8/28/23. 13. The Nurse Consultant, Director of Nursing, and/or designee will audit to ensure that all required admission, readmission, quarterly, annual, and significant change assessments are completed by a Registered Dietician. Future audits will be completed daily for two weeks, then two times per week for four weeks, followed by weekly for 6 weeks. Any findings of noncompliance will be immediately reported to the Attending Physician and Family. 14. Findings of the QA audit shall be used to determine the level of compliance and need for additional training will be completed immediately and shall be submitted to the QAPI Committee for review and follow-up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 13 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review the facility failed to ensure tube feedings orders were followed for a resident who has fed exclusively by tube feed for 1 of 2 residents (R108) in the sample of 31. Residents Affected - Few The findings include: On 08/28/23 at 10:35 AM, R108's tube feeding pump was not connected to R108. There was a bottle of glucerna 1.2 hanging on the pump. On 08/28/23 at 01:47 PM, R108's tube feeding pump was not connected and the pump was not on. On 08/29/23 at 09:00 AM, R108's tube feed pump was not connected and there was no bottle of tube feeding hanging on the pump. On 08/29/23 at 09:05 AM, V21 Licensed Practical Nurse stated I told R108's feeding was off at 6, but let me check in Medication Administration Record. Oh it's supposed to be off at 5 AM and on at 8 AM. Oh, I need to start it. It's scheduled off for 3 hours only. R108 is NPO (nothing by mouth). I will start it now. R108's Physician Orders shows an order dated 5/11/23 NPO (nothing by mouth) and an order dated 6/5/23 enteral feed order every shift Glucerna 1.2 cal/ml tube feeding run at 75 cc/hr x 21 ours per g-tube. Off at 5 AM and ON at 8 AM. On 08/29/23 at 01:21 PM, V2 Director of Nurses said nurses should follow tube feeding orders to make sure the resident is getting the needed nutrition. The facility's Gastrostomy Tube Feeding and Care Policy dated 8/3/20 shows to provide nutrients, fluids and medications, as per physician orders, to residents requiring feeding through an artificial opening into the stomach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 14 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 ensure a resident had prescribed oxygen therapy orders and failed to ensure a resident's nasal cannula tubing was changed and labeled according to professional standards of practice for 1 of 12 residents (R96) reviewed for oxygen in the sample of 31. Residents Affected - Few The findings include: On 08/28/23 at 10:59 AM, R96 was in bed sleeping wearing a nasal cannula. R96 had an oxygen concentrator at the bedside running at 2.5 liters. There was no date on the nasal cannula tubing or humidifier bottle. On 08/28/23 at 12:25 PM, R96 stated I wear oxygen at night or when I'm sleeping. I used to have to wear cpap at night but I lost weight and now just wear oxygen. On 08/29/23 at 01:21 PM, V2 Director of Nursing said for residents on oxygen there is supposed to be an order for oxygen including how many liters, whether it's as needed or continuous, and how the oxygen is to be administered. V2 said the oxygen tubing should be changed weekly and dated, the nurses should change tubing. R96's Physician Orders show R96 has diagnoses of chronic respiratory failure, obstructive sleep apnea, dependence on other enabling machines and devices, and dependence of supplemental oxygen. There are no orders for oxygen via nasal cannula only orders for cpap every evening and night shift related to obstructive sleep apnea, take off at 7AM R96's Care Plan dated 8/12/2019 shows R96 has oxygen therapy related to congestive heart failure, ischemic cardiomyopathy and respiratory failure with interventions of oxygen therapy as ordered. The facility's Oxygen and Respiratory Equipment- Changing/ Cleaning Policy dated 1/7/19 shows Nasal cannulas are to be changed once a week and as needed to minimize the risk of infection transmission and to ensure the safety of residents by providing maintenance of all disposable respiratory supplies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 15 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to ensure residents were supervised during medication administration for 2 of 31 residents (R54, R9) reviewed for pharmacy services in the sample of 31. The findings include: 1. R54's current care plan showed R54 was severely cognitively impaired related to her diagnoses of dementia and Alzheimer's disease. On August 28, 2023, at 9:50 AM, R54 was seated in her room with her V5 (Family of R54) next to her. On the bedside table, in front of R54, was a medicine cup filled with applesauce that was mixed with multiple small pill fragments of varying size and color. A spoon was sticking out of the cup. When V5 was asked about the contents of the cup, V5 stated, Those are her 9:00 AM medications. She takes them with applesauce. They left them here for me to give to her. At 9:58 AM, R54's full medicine cup was shown to V4 Licensed Practical Nurse (LPN). V4 LPN stated, Those are her 9:00 AM meds. It's her Plavix, Xanax, Sertaline, and some other meds. I should not have left them there for (V5 Family of R54) to give to (R54). I should have administered her medications myself and watched her take them. R54's August 2023 Medication Administration Record showed R54's scheduled 9:00 AM medications included Levetiracetam (anti-seizure/pain medication), Vitamin D3, Sertaline (antidepressant), Famotidine (GI reflux medication), Plavix (blood thinning medication), and Xanax (anti-anxiety medication). The facility's Medication Administration policy dated January 1, 2015, showed, Only a licensed nurse is permitted to administer medications to residents. Medications shall always be prepared, administered, and recorded by the same licensed nurse . Medications must be administered in accordance with a physician's order, e.g., the right resident, right medication, right dosage, right route and right time . 2.) On 8/28/23 at 10:01 AM, R9 was in bed. On her bedside table was her breakfast tray and a clear plastic pill container with 5 pills inside of it. R9 said to the surveyor Oh those are my medications. V24 Certified Nursing Assistant (CNA) entered the room to provide care to R9. R9 told V24 she was having pain and needed a pain pill. At 10:14 AM, V23 Licensed Practical Nurse (LPN) came into R9's room to give her pain medication. V23 had to walk past the plastic pill container that still had R9's medication in it. V23 gave R9 the pain medication and left the room without ensuring R9 took her medication. On 8/29/23 at 8:35 AM, V25 (LPN) said there are no residents who have orders to be able to self administer their medications and all residents should be supervised taking their medications. R9's 8/1/23-8/31/23 Medication Administration Record shows she receives the following medication scheduled for 9:00 AM : Saccharomyces boulardii (probiotic), Docusate Sodium (stool softener)100 milligrams (Mg.), Metoprolol Tartrate (anti-hypertension) 25 Mg, Metformin 1000 Mg. (diabetes medication), Ashwagandha 1 capsule (herbal supplement) and Potassium Chloride 20 milliequivalants (potassium supplement). R9's physicians order sheet does not show any order for her to self-administer medications. A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 16 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 assessment was requested from the facility for R9's ability to self-administer her medication and was not provided during the survey. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 17 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a residents medication was given as prescribed and failed to ensure medication orders were transcribed correctly to avoid a significant medication error. This failure resulted in six of R9's medications being mistakenly discontinued without a physicians order. As a result of this failure R9 developed worsening psychiatric symptoms (paranoia) and was sent to the emergency room for evaluation. This applies to 1 of 7 residents (R9) reviewed for physician orders in the sample of 31. Residents Affected - Few This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/1/23, when the facility discontinued R1's medications without a physician order. V1 (Administrator) was informed of the Immediate Jeopardy on 8/30/23 at 2:21 PM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 8/31/23 however, noncompliance remains at a level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R9's face sheet shows she was admitted to the facility on [DATE] and has diagnoses including: Type 2 diabetes with diabetic neuropathy, migraine without migrainosus, depression, adjustment disorder with depressed mood, vascular dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R9's 8/3/23 minimum data set shows she has on going pain and depression. R9's active care plan initiated on 11/30/22 shows R9 has a severe mental illness and has symptoms of delusions, paranoia and poor insight and judgement. R9's care plan also shows she has potential for pain due to migraines and a history of a fracture. R9's physician order summary (p.o.s) show the following medication orders were all discontinued on 8/1/23 : Effexor XR (Venlafaxine HCl ER-extended release) (Anti-depression and anxiety medication) 150 milligrams (MG.) 1 tablet per day start date 10/26/22, bupropion HCL ER (SR) 150 MG. (Anti-depressant) 1 time per day start date 10/26/22, lamotrigine 25 MG. 3 times per day, (anti-seizure medication and also mood stabilizer) start date 10/26/22, Topiramate 25 MG./ Topamax 1 time per day, (medication to treat epilepsy and migraines) start date 10/25/22. Duloxetine (Anti-depressant/anti-anxiety) 60 MG. 1 time per day start date 6/9/23, and Gabapentin 400 MG. (used for neuropathy pain) 1 capsule 3 times a day start date 6/8/23. There are no notes in R9's electronic medical record indicating who discontinued the medications or why. A consultation report completed by V26 (Psychiatric Nurse Practitioner) on 6/30/23, shows he saw R9 and made no medication adjustments. The report identifies R9 is on the following psychotropic medications: Venlafaxine for depression and anxiety, Bupropion and duloxetine for depression, Lamictal and Topamax for mood stabilizers. The consultation report also says a gradual dose reduction of those medications are contraindicated and R9 is not a candidate at that time due to on going symptoms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 18 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 0760 Level of Harm - Immediate jeopardy to resident health or safety R9's 8/1/23 9:13 PM, nursing progress note shows R9 had returned from a doctor appointment and the doctor will fax a consultation report to the nurses station. The consultation report from a pain doctor on 8/1/23 at 3:16 PM, shows a prescription to increase R9's Gabapentin order to 600 MG. 3 times a day for neuropathy pain, and to change/ add Cymbalta 30 MG every 12 hours or two times a day. R9's MAR and pos show those ordered were not carried out. Residents Affected - Few A consultation report completed by V26 (Psych NP) on 8/29/23 states the following: Patient was last seen by writer on 6/30/23 and no medication changes were made. Cymbalta, Wellbutrin, Effexor, Lamictal, Topamax and Melatonin were discontinued on 8/1/23 for unknown reason. The report shows that R9 is having depression an increased episodes of inappropriate behaviors, insomnia, anxiety and agitation. R9's Medication Administration Summary (MAR) from 8/1/23 to 8/31/23 show she received 1 dose of Effexor, bupropion, Duloxetine, and Topiramate on 8/1/23 and then it was discontinued and no further doses were received in August. R9 missed 30 doses of each of those medications in the month of August. The MAR also shows R9 received 3 doses of each of Gabapentin and lamotrigine on 8/1/23 (ordered to be given 3 times a day) and then it was discontinued and no further doses were given in August. In total R9 missed 90 doses of each of those medications. R9's Nurse Practitioner Progress Note completed by V27 (Nurse Practitioner/NP) on 8/8/23 at 9:47 AM, shows R9 is having an increase in paranoid symptoms. Nursing progress notes for 8/29-8/30/23 show R9 was increasingly paranoid and was calling 911 to report feeling unsafe and seeing people with a knife hidden being their ear. Police arrived at the facility and R9 made an allegation of an assault occurring. R9 was sent to the emergency room for evaluation. Medication orders were obtained for R9 to be started on a mood stabilizer (Depakote) and a anti psychotic medication (Seroquel) due to her psychotic symptoms. R9 returned from the emergency room on 8/30/23. On 8/30/23 at 9:05 AM, V2 (Director of Nursing) said she was not aware why R9's psychotropic and pain medications were stopped abruptly but she will investigate it. At 9:56 AM, V2 said what happened with R9's medication was R9 had went out for a doctor appointment to the pain clinic on 8/1/23 and then returned to the facility. The nurse on duty ( V22-Nurse Supervisor) mistakingly thought R9 had went to the hospital so she discontinued all of R9's medications. When R9 returned to the facility later that evening V22 tried to add the medications back and missed a few. V2 said V22 should not have discontinued R9's medications and she also did not call the physician to verify any of the pain doctors new orders. On 8/30/23 at 9:33 AM, V26 (Psych NP) said he was called to see R9 on 8/29/23. He said he could not figure out who stopped and why her psychiatric medications were stopped. He verified he was not the one who had given orders to discontinue those medications. V26 said he would say that R9 was having an increase in her paranoia from the last time he saw her until yesterday. At 12:56 PM, V26 said the obvious effect of R9 being off her medications would be an increase in psychiatric symptoms including mood, paranoia, and hallucinations. On 8/30/23 at 10:22 AM, (V22) said she made a huge mistake with R9's medication orders. She said she was told by another nurse that R9 was in the hospital so automatically I discontinued the medication orders and then when R9 returned and I learned she only went to a medical appointment I tried to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 19 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 0760 Level of Harm - Immediate jeopardy to resident health or safety reinstate her orders and I thought I had gotten everything but I missed a few. No one ever questioned it until now why all of R9's psychotropic medications and some of her pain medications were stopped. V22 said she did not call any physicians to verify any of the orders after R9 returned from the pain appointment. V22 said she should not have discontinued the medications, and it is protocol that after appointments or hospital stays the medication orders are verified with the physician and carried out but she missed the new orders also. Residents Affected - Few On 08/30/23 11:56 AM - V27 (NP) said her office was not called to discontinue R9's psychiatric or pain medications and she believes R9's topamax and lamotrigine medications were being used more for migraines. She said she would be even more concerned if R9 had a active seizure disorder and if the medications were for seizures then missing them would put her at risk for an increase in seizures. V27 said by R9 missing her other medications there could be changes in mood and behaviors and increased pain. V27 said the facility should contact their office if a resident goes out and comes back to verify medication orders. On 8/31/23 at 9:11 AM, R9 said she does not recall making any accusations to anyone. She was paranoid about talking with this surveyor and stated, Maybe I need my family here I don't know what you are up too. R9 said she has diabetic neuropathy and has pain all the time. On 8/31/23 9:08 AM, V31 (Licensed Practical Nurse/LPN) said R9 been asking for increased amounts of PRN (as needed) norco (pain medication) this past week and has an increase in paranoia. He said he was there on 8/29/23 in the evening when R9 called 911 and was later sent to the hospital. R9 was seeing people with pocket knives, and saying she doesn't feel safe in facility. On 8/31/23 9:13 AM- V24 (Certified Nursing Assistant/CNA) said R9 has had increase in paranoia over this past month and has been hallucinating seeing children, cats, and monkeys. The facility provided Transcription of Physician Orders- Procedure effective date 11-3-22 says nurses should review the discharge summaries or records from other facilities and verify with the residents physician of any new or changes in medication orders. All orders should be checked to verify they were entered into the electronic medical record correctly. The Immediate Jeopardy that began on 8/1/23 was removed on 8/31/23 when the facility took the following actions to remove the immediacy: 1. Staff involved and all Nurses on the AM and PM shifts were in-serviced on 8/30/23 about discontinuing physician orders, medication administration policy and transcription of orders. 2. The Nurse Consultant/DON will perform chart audits for all discontinued medication orders for the month of August 2023. 3. The Nurse Consultant will provide in-servicing and training for licensed nurses including agency and prn nurses who are on vacation or medical leave. They will be required to completed the in-servicing before the start of their shift. All nurses will receive the in-servicing by 9/9/23. 4. The Nurse Consultant/ DON will train all newly hired nurses will also receive education regarding the new policy on a second double check system where new orders are verified by two nurses. This will be completed by in house nurses by 8/30/23. Any staff on vacation or on leave will be notified via telephone. On going education for new hires and agency staff will continue prior to the start of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 20 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 0760 their shift for all new hires. Level of Harm - Immediate jeopardy to resident health or safety 5. The Nurse Consultant and DON will conduct char audits for all charts of all residents who have had appointments or hospital stays in the month of August 2023. These audits will be done by 9/1/23. Future audits will be completed daily for two weeks, then two times per week for four weeks, followed by weekly for six weeks. Residents Affected - Few 6. The medical director and attending physician were notified of the medication error on 8/30/23. 7. An emergency QA meeting was held by the facility on 8/30/23. The audit findings will continue to be reviewed during QA meetings. Findings of the QA audit will be used during QAPI review and will determine compliance level and additional follow up as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 21 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R139's Facesheet printed 8/31/23 showed R139 was originally admitted to the facility on [DATE]. Residents Affected - Few R139's initial Dietary Assessment was completed on 5/22/23 by V7 (non-certified) Dietary Manager. R139's next Dietary Assessment was completed on 8/29/23 by V7 (non-certified) Dietary Manager. R139's first Dietician Assessment, completed by V6 Registered Dietitian, was done on 8/28/23, which referred to R139 already having significant weight loss. The facility's Organizational Plan and Roles of Key Staff policy dated 2020 showed the Dining Services Manager (certified Dietary Manager) reports directly to the Administrator, in addition to receiving frequently scheduled scheduled consultations and guidance from the Registered Dietitian . The policy showed the Registered Dietician will assess and monitor the nutritional status of residents. Based on interview and record review the facility failed to ensure residents' dietary assessments were completed by qualified dietary staff for 3 of 31 residents (R37, R144, R139) reviewed for qualified dietary staff in the sample of 31. The findings include: 1. R37's admission Record dated 3/27/23, showed R37 was admitted to the facility with diagnoses of dementia and a left hip wound related to recent hip surgery. An admission dietary profile for R37, dated 4/13/23, showed the profile was completed by V7, the non-certified Dietary Manager. R37's electronic medical records dated 3/27/28-4/25/23 were reviewed and showed no admission dietary assessment was completed by V6 Registered Dietician (RD). A Dietary Note for R37, dated 4/26/23, showed a brief, initial dietary note documented by V6 RD. The note showed R37 was not assessed by V6 RD until 28 days after admission and not until after R37 had sustained significant weight loss. On 8/29/23 at 1:12 PM, V7 (non-certified) Dietary Manager stated he was not certified in dietary management but, he was currently enrolled in school for dietary management. V7 stated he had no certifications in food service management, did not have an associate's degree, and had no past work experience in long term care facilities. V7 stated, I do the admission, quarterly, and annual dietary assessments on residents. The admission assessment should be done within 48 hours of admission. I am not sure why I did (R37's) admission assessment so late. I must have overlooked it. V7 stated he did not routinely complete residents' dietary assessments collaboratively with V6 RD, despite him not being a certified dietary manager. V7 stated he had never completed a dietary assessment on a resident prior to him being hired by the facility. On 8/29/23 at 10:00 AM, V6 RD stated, I am not full time or part time in the facility. I work in the facility on a consulting basis. I don't complete the admission, quarterly (every 3 months), or annual dietary assessments on the residents. The CDM (certified dietary manager) does those assessments . V6 RD stated she was aware V7 was not a certified Dietary Manager. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 22 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 0801 Level of Harm - Minimal harm or potential for actual harm On 8/31/23 at 8:23 AM, V1 Administrator stated V6 RD should be completing admission, quarterly, annual, and significant change dietary assessments on all residents. V1 stated she was notified on 8/30/23, that V6 RD was not completing the necessary dietary assessments on all residents. V1 stated, I didn't know, until yesterday, that (V6 RD) was not doing all the assessments . V1 stated because V7 (Dietary Manager) was not certified, he was not to be completing any resident dietary assessments, on his own. Residents Affected - Few On 8/30/23 at 10:55 AM, V32 Regional Director of Operations stated, All resident admission, quarterly, annual, and significant change dietary assessments should be completed by a Registered Dietician. V32 stated he was aware V7 Dietary Manager was not certified. 2. R144's admission Record dated 4/5/23 showed R144 was admitted to the facility with diagnoses of a stroke (CVA/cerebral infarction), dementia, aphasia (inability to verbally communicate), and subdural hemorrhage (brain bleed). An admission dietary profile for R144, dated 4/16/23, showed the profile was completed by V7, the non-certified Dietary Manager. R144's electronic medical records dated 4/5/23-7/27/23 were reviewed and showed no admission dietary assessment was completed by V6 RD. R144's initial Dietician Evaluation was completed by V6 RD on 7/28/23, after R144 had sustained significant weight loss. The note showed, Unintended weight loss related to decreased PO (oral) intakes as evidenced by chart review . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 23 of 24 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 145304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Riverwoods 3705 Deerfield Road Riverwoods, IL 60015 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 ensure the lunch meal was a smooth pureed consistency for four of four residents (R29, R82, R6, R53) reviewed for pureed diets in the sample of 31. The findings include: The list of pureed diets provided by the facility on August 30, 2023 shows that R29, R82, R6, and R53 were on pureed diets. On August 28, 2023 at 10:10 AM, V33 [NAME] pureed small chunks of chicken with gravy. V33 did not sample the pureed chicken. At 10:23 AM, V33 pureed frozen peas and carrots mixture. V33 did not sample the pureed frozen peas and carrots mixture. At 12:35 PM, a lunch test tray was sampled. The pureed peas and carrots were not smooth consistency and had pea shells in it. The pureed chicken had small chunks of chicken. The pureed chicken was not a smooth pureed consistency. At 12:43 PM, V7 Dietary Manager sampled the same test tray and said the pureed peas and carrots could be pureed more. V 7 said pureed foods should be smooth and pudding consistency. The facility's Pureed Food Preparation policy dated 2020 shows, Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value. Pureed foods will be the consistency of applesauce or smooth, mashed potatoes. Staff will be in-serviced on proper preparation of pureed foods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145304 If continuation sheet Page 24 of 24