Inspection·November 22, 2023

F 0585 Level of Harm - Potential for minimal harm Residents Affected - Many Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observations, interviews, and record reviews, the facility failed to inform residents individually and through postings of their grievance process and procedures including contact information of the grievance official, reasonable expected time frame for reviewing and responding to grievances, the right to obtain a written decision regarding his or her grievance, and the contact information of independent entities such as the state agency with whom grievances may be filed. This failure has the potential to affect all residents residing in the facility. Findings include: On 11/20/23 from 02:09 PM - 2:30 PM R2, R7, R10, R17, R18, R41, R47, R49, R53, and R63 reported they have not been informed about the procedure of filling a grievance at the facility. On 11/21/23 at 10:52 AM Observed only one sign with information on the facility's grievance procedure on the facility's lower level board area near the elevators in an area not easily observed by staff or visitors. Observed there were no other grievance procedure signs posted anywhere else in the facility. On 11/21/23 at 10:56 AM V1 (Administrator) stated residents are informed of the facility's grievance procedures through the admissions packet and through signage. On 11/21/23 11:55 AM V1 (Administrator) stated he understood the concern regarding posting and education of the facility's grievance procedures. V1 stated he will address this moving forward. Resident council meeting reports from June - November 2023 do not document a review of the facility's grievance procedures. The facility's admission packet reviewed 11/21/2023 does not include information about the facility's grievance procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145468 If continuation sheet Page 2 of 7 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 145468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Skokie, The 9615 North Knox Avenue Skokie, IL 60076 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record reviews, the facility failed to administer medications as ordered. There were 25 opportunities with two errors resulting in 8% medication error rate. These failures applies to one (R65) resident observed during the medication administration on the sample list of 51. Residents Affected - Few Findings include: R65 admitted in the facility on 09/01/22 with diagnoses of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease; Type 2 Diabetes Mellitus with Unspecified Diabetic Retinopathy without Macular Edema; Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified; Other Specified Diabetes Mellitus with Diabetic Nephropathy; and Other Chronic Pancreatitis. POS (Physician Order Sheet) dated recorded: 05/22/23: Creon Oral Capsule Delayed Release Particles 12000-38000 unit (Pancrelipase Lipase-Protease-Amylase) give one capsule by mouth with meals. 08/09/23: Insulin Lispro Injection Solution 100 unit/ml (unit per milliliters) inject 2 units subcutaneously in the morning. On 11/19/23 at 11:35 AM, V4 (Licensed Practical Nurse, LPN) was observed preparing R65's 9 AM medications. V4 stated, It's the morning medications that I am passing right now. All of R65's scheduled morning medications were prepared except Creon and Insulin Lispro. V4 was asked why she did not prepare Creon and Insulin Lispro. V4 stated, This medicine (pertaining to Creon) has to be taken with meals. I have not given this medication this morning. I did not give Insulin this morning, too. During medication administration, R65 verbalized, No, I have not taken the Creon this breakfast and she (V4) did not give me the Insulin this morning. On 11/19/23 at 12:30 PM, V5 (Registered Nurse, RN) and V6 (RN) both stated that all residents' medications are administered between the 8 AM to 8:30 AM for the scheduled 9 AM medication time. V5 stated, We pass medications between 8 to 8:30 in the morning, an hour before and an hour after. Medication time is 9 AM. V6 also verbalized, Breakfast is 8 AM. Morning shift starts at 7 AM to 3 PM. By 10:00 AM, medication pass should be done, ideally. V4 was asked regarding medication pass for today (11/19/23). V4 replied, Medication pass is at 9 AM, an hour before or an hour after. I came in at 7 AM. End of medpass should be at 10 AM. I was late in giving medpass today. I only come on weekends and not used into these residents. I know, 10:30 AM medpass is late. On 11/20/23 01:40 PM, V2 (Director of Nursing) was asked regarding medication administration. V2 stated, Medpass times for daily dosing is 9AM; 6AM for stomach medications or thyroid medications. For twice a day medications, it would be 9 AM and 5 PM. Three times a day is 9 AM -1 PM -5 PM. If medication is in the morning, it should be given by 9 AM, an hour before and an hour after. 11:00 AM medpass is considered late. I do expect that staff assess residents and inform doctors. With medication orders with meals, it should be given with meals or with foods. Facility's policy titled, Administering Medications dated December 2022 documented in part but not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145468 If continuation sheet Page 3 of 7 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 145468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Skokie, The 9615 North Knox Avenue Skokie, IL 60076 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 0759 limited to the following: Level of Harm - Minimal harm or potential for actual harm Policy: Medications shall be administered in a safe and timely manner, and as prescribed. Procedure: Residents Affected - Few 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145468 If continuation sheet Page 4 of 7 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 145468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Skokie, The 9615 North Knox Avenue Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow their food service and safety policies by not ensuring refrigerated foods were properly stored; food items in the cooler not labeled and dated; foods not removed from the cooler after disposal date; and not maintaining proper general cleanliness and organization in the kitchen. These failures have the potential to affect all residents who reside in the facility and receive services from the kitchen. Findings include: The following observations were conducted in the facility kitchen on 11/19/23 from 9:50 AM to 10:40 AM: At 9:55AM with V8 (Cook) the walk-in cooler was observed to have five heads of putrid lettuce, moldy tomatoes stored in a box, an opened package of corn tortillas with no date, four boiled eggs in bowls (undated), personal beverages, an undated bowl of cooked mashed potato, two packages of undated opened lunch meat; one plastic container labeled strawberry preserves 1/26/23 opening with discard date 3/27/23, the container was noted with red syrup and black fuzzy spots. A plastic container of tuna salad dated 11/12/23 that looked dry in some areas and very white in others- V8 said this was expired and removed it from the cooler. On a tray was ready to cook items including: three raw hamburger patties, three hot dogs, and four chicken tenders were placed on a tray. V8 said they would be prepared as alternates for lunch. V8 said that it was okay to have the foods on the same tray uncooked because the foods were on foil sheets and not touching. One uncooked ham was on the second rack not contained, and underneath was a tray of ready to eat foods prepared for lunch service, which included fruit trays and fresh salads. V8 said, the ham was thawing for a later date, and moved the fruit and salad to be on the same level as the thawing meat. Outside of the cooler, a plastic container of onions was found under the meat thawing sink, when V8 opened the cover, flies were noted inside. Two soup base bucket containers were also found under the prep table. At 10:09 AM, V9 Dietary Aid was seen placing clean plates in the warming box which had visible crumbs and other food debris. V14 Dietary Aid was seen washing some dishes in the three compartment sink, which did not appear to have any sanitizer in it. The solution container as seen under the sink appeared to be almost empty of pink liquid and when V8 pushed the dispenser, nothing came out. V8 then poured the small content remaining in the bottle directly into the sink. V9 was asked to test the solution and when they tried the testing strips, there was no color change. V9 said, this would indicate that there was not enough solution diluted in the water to provide proper sanitization. V14 was noted wiping a prep table with towels from a sanitation bucket. V9 tested the solution and the color did not change on the strip. On 11/21/23 at 11:37 AM V7 Dietary Manager said, the cooks should monitor the integrity of the foods and the stock individual and myself will make sure it is organized. Cross contamination, infection control and food safety would be of concern if the foods were not maintained. Meats can be thawed under running water or pulled and put into the refrigerator. Should the meat be in the fridge, it would be on top of a pan so that nothing can drip down underneath. Anything that needs to be cooked to a higher temperature would be on the bottom of the cooler racks because if it was being stored on top, we have risk of it dripping down which could cause cross contamination. The cooks should be cleaning the shelves out regularly. Generally, the person who stocks is picking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145468 If continuation sheet Page 5 of 7 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 145468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Skokie, The 9615 North Knox Avenue Skokie, IL 60076 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 up the mats and cleaning the floor of the cooler and they are also responsible for cleaning the wall and the shelves. Produce that is rotting or moldy should be thrown away. I would have them date tuna salad for only three days, which is typical for prepared foods and any leftovers. We use a Quaternary sanitizer. The dispenser over the sink is calibrated to dispense the proper amount of solution and then we test it before washing the dishes to be sure it is appropriate part per milliliter. No one has made any complaints about the sanitizer not working. This is the same solution is used for the buckets, dispensed from the same pump. Food and Nutrition Services Policies were reviewed and all policies were reviewed 5/2014 : Storage of Refrigerated Foods- Policy: Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality. Food in the refrigerator is covered, labeled and dated with a used by date. Raw food is stored below cooked food, or ready to eat food. Refrigerated Food- Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by. This includes leftovers. The discard/use by date will be a maximum of six days after preparation. The day of preparation is counted as Day 1. Manual sanitizing in Three-Compartment Sink: Policy: A sink with three compartments is used for manually washing, rising and sanitizing utensils and equipment that can be submerged. It may also be used for tableware. After washing and rinsing utensils or equipment are sanitized in the third sink by immersion in either: Hot water or chemical sanitizing solution used according to manufacturer's instruction. The most common chemical sanitizers are chlorine, iodine and quaternary ammonia. The manufacturer's label is referenced for the appropriate concentration of the sanitizing solution and for length of submersion time. A test strip is used to accurately determine the concentration of the sanitizing solution. The strip is dipped into the sanitizing solution and held for the seconds specified on the test kit. Once removed from the sanitizing solution, the strip is compared to the color on the char. If the color is not within the correct rang, adjustment is made until the sanitizing solution is the correct concentration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145468 If continuation sheet Page 6 of 7 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 145468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Skokie, The 9615 North Knox Avenue Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who required transmission based precautions was placed on contact isolation after readmitting from the hospital. This failure applied to one (R307) of one resident reviewed for infection control on the sample list of 51. Residents Affected - Few Findings include: R307 originally admitted to the facility on [DATE], was sent to the hospital on [DATE], and readmitted to the facility on [DATE]. R307 was admitted back to the facility with multiple diagnoses including but not limited to the following: sepsis due to E. Coli, bacteremia, acute cholecystitis, and ESBL (Extended-spectrum beta-lactamases) resistance. On 11/19/23 at 10:45AM, R307 was observed to not be on isolation. No isolation signs or personal protective equipment (PPE's) noted outside of R307's room. Observed V10 (Licensed Practical Nurse) walk in to room while not wearing any PPE's. On 11/20/23 at 12:40PM, V12 (Registered Nurse) was interviewed regarding R307. V12 said R307 readmitted to the facility on Saturday evening, (11/18/23). R307 has ESBL bacteremia in his blood and should have been on isolation upon readmitting from the hospital. V12 said when a resident is on contact isolation, the staff should be wearing proper PPE's to help prevent the spread of infection. This includes a gown, gloves, and a mask and should be worn every time they enter the room. At 1:10PM, V3 (Assistant Director of Nursing/Infection Preventionist) was interviewed regarding R307 and isolation procedures. V3 said R307 readmitted to the facility 11/18/23, however was not placed on isolation until the afternoon of 11/19/23. I reviewed his hospital records on 11/19/23 and realized he should be on isolation. Typically the admitting nurse should review the hospital records and let the housekeeping staff know. There are housekeepers here on the weekends and they have access to the isolation bins and signs. Hospital records dated 11/1/23-11/18/23 indicate resident currently is being treated for sepsis due to ESBL bacteremia. Facility policy titled Isolation-Initiating Transmission-Based Precautions with revision date of October 2018 states in part but not limited to the following: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection, arrive for admission with symptoms of an infection, or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Procedure: Determine the appropriate notification on the room entrance door and ensures that protective equipment is maintained outside the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145468 If continuation sheet Page 7 of 7