Inspection·October 31, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents) all the time, they (fellow residents) are used to it. I don't want to come in to work for that, when enough is going to be enough. I've never seen R93 get into a physical altercation with anyone, but she came up to me, threatened me with a fist and cussed at me. On 10/30/24 at 02:06 PM, V1 (Administrator/Abuse Prevention Coordinator) stated, my role as a abuse prevention coordinator consists of two parts, to make sure staff knows what abuse is, and to make sure reporting and investigation is conducted immediately. Staff received abuse related education during every annual skill fair training and upon hire. Every new employee gets in depth abuse training. Every facility abuse allegation is investigated thoroughly. Most common abuse occurring in the facility are physical and verbal. Verbal abuse is when one resident yells or curses at another resident. If staff witnesses verbal abuse occurrence, they should separate residents and provide monitoring to both, perpetrator, and a victim. Next, staff should call me, and then I continue with the abuse complete the investigation. V1 not aware of verbal abuse occurrence witnessed by the surveyor, staff did not report verbal abuse occurrence to V1. The facility Abuse Prevention Program (no date) reads in part, As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual; Require staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 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 10/31/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide consistent monitoring and supervision for a verbally aggressive resident (R93) throughout the entire lunchtime meal in-service in the second floor dining room. This failure affects three of eighteen residents (R6, R25 and R52,) in which R93 was verbally aggressive toward while staff was not monitoring R93. The Findings include: R25 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus, Malignant Neoplasm of Prostate, Personal History of Transient Ischemic Attack (TIA), Paranoid Schizophrenia, and Major Depressive Disorder. R6 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Traumatic Subdural Hemorrhage without Loss of Consciousness, Unspecified Visual Disturbance, Bipolar Disorder, and Schizoaffective Disorder. R52 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Dementia, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant side, Vascular Dementia, and Major Depressive Disorder. R93 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Psychosis, Chronic Obstructive Pulmonary Disease, Hypertension, Alcohol Abuse, Nicotine Dependence, and Anxiety Disorder. R25's care plan dated 10/07/2024 includes (but not limited to): Abuse, Neglect, Trauma factors I do not present with unusual or uncommon factors for mistreatment, victimization or exploitation. I am an adult living with schizophrenia, MDD and cognitive loss. I have a legal guardian. My awareness of person, place, time, situation is poor. My care partners recognize that long term care admission may represent and/or rekindle trauma secondary to feelings of loss of control, loss of autonomy and I am considered a vulnerable, older adult in need of 24-hour care. I appreciate the compassion and sensitivity I am afforded in this setting. During observations on 10/28/2024, and 10/29/2020 between 12:00PM and 12:15PM, in the 2nd Floor Dining Area, multiple residents were observed during lunchtime meal in-service and were not being monitored by any facility staff. While residents were eating R93 was being verbally aggressive, yelling and making hand gestures and no staff came to monitor, supervise or redirect the aggressive behavior being displayed towards others. On 10/28/2024 at 12:52 during an interview with V10 (Certified Nursing Assistant/CNA), V10 said they all monitor the dining room, that no one is specifically assigned to the dining area. They will rotate shifts to make sure they cover and watch the dining area. On 10/29/2024 at 9:10AM during an interview with V9 (Activities Director), V9 said staff will (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 10/31/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few usually rotate and cover the dining area. He is not aware if anyone is scheduled to just monitor the residents during mealtimes. On 10/29/2024 at 9:20AM during an interview with V7 (Licensed Practical Nurse/LPN), V7 said nurses will assist the certified nursing assistants and rotate to cover the dining area. She said there's no set schedule for staff to monitor the dining area. On 10/29/2024 at 9:30AM during an interview with V3 (Assistant Director of Nursing), V3 said Certified Nursing Assistants/CNA's will rotate days to cover the dining area. She said no one's specifically assigned or scheduled to monitor residents during mealtimes. V3 said the aids will determine their own schedule for coverage and nurses will usually assist when they are available. On 10/30/2024 at 9:30AM during an interview with V2 (Director of Nursing), V2 said all facility staff including managers should monitor residents in the dining area while eating. He said while certified nursing assistants are passing out trays to residents in their rooms managers should go to assigned areas to help monitor dining areas. Facility policy titled, Safety and Supervision of Residents (July 2017) includes: Individualized, Resident-Centered Approach to Safety. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Facility Job Description for Certified Nursing Assistant (CNA) includes but not limited to Job Summary: The Certified Nursing Assistant (CNA) helps patients/residents with comprehensive health care needs under the supervision of a nurse. The CNA assists patients/residents with activities of daily living to include bathing, dressing, eating, grooming, toileting and exercising. This role is also responsible for the successful transfer of residents to and from activities. Duties/Responsibilities: Notes and communicates patient/resident behaviors and changes in mood. 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 10/31/2024 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medications per facility policy for one of two residents (R40) reviewed for medication administration on the total sample of 42. Findings include: R40 admitted to the facility on [DATE] with diagnosis including but not limited to Type Diabetes Mellitus, Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Major Depressive Disorder, and Schizophrenia. On 10/29/24 at 08:41 AM, during R40's medication administration V12 (Licensed Practical Nurse) left the medication cup with 15 scheduled medications. V12 (LPN) stated, I let her take medications and go in and out of the room to monitor. I checked R40's vital signs this morning, her blood pressure was 110/58 and pulse 76. I will hold R40's medications for high blood pressure because R40's blood pressure is on the lower side. I usually wait and then recheck the vital signs later and give R40 her high blood pressure medications. On 10/29/24 at 10:50 AM R84 appeared angry, and stated she was told to go back to her room because state regulatory agency is in the building. R84 stated to the surveyor that her medications are left at the bedside and she is never told to go to her room and be monitored during medication administration, things are different during this week because surveyors are here. On 10/29/24 at 10:55 AM, clarified with V12 (LPN) whether R84's statement related to medication administration is correct, V12 (LPN) affirmed that that's what she told R84. V12 (LPN) stated that she gives the cup of medications to R84, and she should not have done that. On 10/29/24 at 01:40 PM during follow up with V12 (LPN) regarding medication administration for R40 earlier that day, V12 (LPN) stated, I left medications on R40's nightstand. That was a mistake. I usually give it to her in the hallway. I have to catch her before she goes to have a cigarette because then she is not back until 11a. I rechecked R40's blood pressure and pulse and gave her four high blood pressure medications that I held this morning, but I don't know if she took any of her medications because they were all left at the bedside. On 10/30/24 at 12:23 PM V2 (Director of Nursing) stated, during medication administration, nurses are expected to give medications no more than an hour before or an hour after the scheduled time. Nurse should also observe to make sure that a resident took their medication. It is not appropriate to leave medications at the bedside for the resident to self-administer unless resident has self-administration assessment and is deemed as appropriate. Neither R40 or R84 have the self-administration assessment; therefore, they are not appropriate to take medication by themselves and should always be monitored during medication administration process. There are parameters for high blood pressure medications established by the physician. Before administering those, the nurse should always check residents' vital signs, including blood pressure and pulse, and check against the parameters to make sure high blood pressure medications are appropriate to administer. If the vital signs are within parameters, the nurse should administer high blood pressure medications. R40's MAR (medication administration record) documents R40 received 9:00 AM dose for Actos Oral (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 10/31/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Tablet 45 MG, Ascorbic Acid Tablet 500 MG, Centrum Ultra Womens Oral Tablet, [NAME] Oil Capsule 500 MG, Latuda Oral Tablet 20 MG, LORazepam Oral Tablet 0.5 MG, Losartan Potassium Tablet 100 MG, Montelukast Sodium Tablet 10 MG, UTI-Stat Oral Liquid, Vitamin B Complex Tablet, Vitamin D3 Capsule 125 MCG, Vitamin E-400 Capsule, Benadryl Allergy Oral Tablet 25 MG, Benztropine Mesylate Oral Tablet 0.5 MG, Ferrous Sulfate Tablet 325 (65 Fe) MG, cloNIDine HCl Oral Tablet 0.2 MG, hydroCHLOROthiazide Tablet 25 MG, Calcium Carbonate Tablet Chewable 500 MG, and hydrALAZINE HCl Oral Tablet 25 MG. V12 (LPN) unsure if R40 took any or all of her scheduled 9:00 AM medications. R40's physician orders show R40 to receive: - Actos Oral Tablet 45 MG (Pioglitazone HCl) Give 1 tablet by mouth one time a day for DIABETES - Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day for Supplement - Centrum Ultra Womens Oral Tablet (Multiple Vitamins w/Minerals) Give 1 tablet by mouth one time a day for Supplement - [NAME] Oil Capsule 500 MG Give 1 capsule by mouth one time a day for supplementation - Latuda Oral Tablet 20 MG (Lurasidone HCl) Give 1 tablet by mouth one time a day related to SCHIZOPHRENIA - LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day for anxiety - Losartan Potassium Tablet 100 MG Give 1 tablet by mouth one time a day for Hypertension Hold if SBP (systolic blood pressure) is below 100 and HR (heart rate) below 60 - Montelukast Sodium Tablet 10 MG Give 1 tablet by mouth one time a day for asthma - UTI-Stat Oral Liquid (Cranberry- Vitamin C-Inulin) Give 30 ml by mouth one time a day for UTI Prophylaxis -Vitamin B Complex Tablet (B Complex Vitamins) Give 1 tablet by mouth one time a day for Supplementation - Vitamin D3 Capsule 125 MCG (5000 UT) (Cholecalciferol) Give 2 tablet by mouth one time a day for low vit d level - Vitamin E-400 Capsule (Vitamin E) Give 1 capsule by mouth one time a day for Supplement for 30 Days - Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 1 tablet by mouth two times a day for allergies - Benztropine Mesylate Oral Tablet 0.5 MG (Benztropine Mesylate) Give 1 tablet by mouth every 12 hours for EPS (continued on next page) 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 10/31/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - cloNIDine HCl Oral Tablet 0.2 MG (Clonidine HCl) Give 1 tablet by mouth two times a day for HTN Hold if SBP is below 100 - Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 tablet by mouth two times a day for supplementation - hydroCHLOROthiazide Tablet 25 MG Give 1 tablet by mouth two times a day for HTN/edema Hold if sbp is below 100 - Calcium Carbonate Tablet Chewable 500 MG Give 2 tablet by mouth with meals for GERD -hydrALAZINE HCl Oral Tablet 25 MG (Hydralazine HCl) Give 1 tablet by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION The facility pharmacy Medication Administration policy dated July 2024 reads in part, Medications are administered in accordance with written orders of the attending physician; Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with facility procedures for self-administration of medications; If a dose of regularly scheduled medication is withheld, refused, or given at other time than the scheduled time, the MAR should reflect documentation as to the reason medication could not be administered. Tips for Safe Medication Administration: Administer medications and remain with resident while medication is swollen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145468 If continuation sheet Page 7 of 7