Inspection·May 30, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's Smoking Policy (7/28/23) showed, Residents that do not abide by the facility's smoking policy will be re-educated about safe smoking practices. Facility may keep the resident's smoking materials when not being used by the resident. Those who are assessed as unsafe smokers will be provided supervision during smoking. 2. On 5/29/24 at 9:27 AM, R24 dressed with a sling on her right arm and propelling herself into her room in her wheelchair. R24 stated she is a smoker and goes outside to the covered area to smoke. R24 stated she goes out and smokes alone and does not have any designated time to smoke. R24 stated her smoking materials are kept by the nurse and she just asks for them when she goes outside to smoke. On 5/30/24 at 10:26 AM, R24 was sitting in her room in her wheelchair. R24 stated she can go outside to smoke whenever she wanted, doesn't have to have anyone with her, and has to get smoking materials from the nurse. R24 stated she has never worn a smoking apron. V9 (Registered Nurse) was outside of R24's room and stated she was R24's nurse for the day. V9 stated that she doesn't give R24 a smoking apron and that the facility does not have them. On 5/30/24 at 12:05 PM, V1 (Adminstrator) stated the facility has smoking aprons available. The Admit/Readmit Follow Up Note dated 5/10/24 for R24 showed she has dementia; she is alert and oriented 1-2 (person & time); forgetful. Requires frequent reorientation to reality and redirection by staff. Fall precautions observed at all times. The Smoking Contract dated 5/8/24 for R24 showed, a resident who intends to smoke has been made aware that they have to wear a smoking apron. The Smoking assessment dated [DATE] for R24 showed poor judgement or decision making skills are present. The assessment showed R24 is considered a safe smoker and may use/access smoking materials consistent with the facility policy. Staff is not required to remain in attendance while resident is smoking. Resident agrees to follow smoking rules. The Care Plan dated 5/16/24 for R24 showed, the resident is a smoker and expresses the desire to smoke at this facility. The resident is aware of the following rules and his/her responsibility to fully abide by these rules. The Care Plan Note dated 5/28/24 for R24 showed, R24 is status post hospitalization due to a fall at her memory care facility. R24 was diagnosed and treated for a right shoulder fracture and dislocation. R24 shows decreased safety awareness and her level of assist needed fluctuates. She is recommended assist with activities of daily living when she discharges. Discharge planner present to review discharge date .as well as recommendation for 24-hour supervision upon discharge. The Face Sheet dated 5/30/24 for R24 showed medical diagnoses including chronic obstructive pulmonary disease, centrilobular emphysema, metabolic encephalopathy, atrial fibrillation, peripheral vascular disease, aortic valve stenosis, right shoulder dislocation, and right humerus fracture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145706 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 145706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall of Deerfield 300 Waukegan Road Deerfield, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheter tubing was not laying or dragging on the floor for 1 of 3 residents (R434) reviewed for indwelling urinary catheters in the sample of 28. The findings include: On 5/28/24 at 11:48 AM, R434 was sitting in a high back wheelchair in the common area of the dining room. R434 had an indwelling urinary catheter, and the tubing was laying on the floor. R434 was propelling his wheelchair back and forth and the tubing was dragging on the ground. At 11:56 AM, V5 (Registered Nurse) pushed R434 to the dining room table with his catheter tubing dragging on the floor. On 5/29/24 at 11:01 AM, V2 (Director of Nursing) stated the catheter tubing should not be on the floor for infection control. V2 stated there would also be a chance that the tubing would get pulled out. The Face Sheet dated 5/29/24 for R434 showed medical diagnoses including chronic obstructive pulmonary disease, atherosclerosis, sick sinus syndrome, hypertension, hypercholesterolemia, and right femur fracture. The Nurse Practitioner's Note dated 5/28/24 for R434 showed additional diagnoses including dementia with other behavioral disturbance, mitral regurgitation, paroxysmal atrial fibrillation, and stage 3 chronic kidney disease. R434 has in indwelling urinary catheter in place. De-catheterization trial scheduled at the facility on 6/4/24 however patient is constantly pulling at catheter especially overnight. The Physician Orders dated 5/29/24 for R434 showed, indwelling catheter change, change bag with catheter. The Care Plan dated 5/18/24 for R434 showed, R434 is on enhanced barrier precaution due to presence of indwelling urinary catheter. Ensure that gown and gloves are used during high-contact resident care activities R434's care plan did not have any other catheter concern in place or interventions. The admission summary dated [DATE] for R434 showed Resident presented with a surgical incision to the right hip and catheter size 16 French. Resident post hip repair surgery. Resident alert and oriented x 1 (to person), calm, and cooperative. The facility's Indwelling Catheter policy (7/28/23) did not show any procedure related to keeping the catheter tubing from dragging or laying on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145706 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 145706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall of Deerfield 300 Waukegan Road Deerfield, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident took their medications. This applies to 1 of 1 resident (R79) reviewed for medication administration in the sample of 28. The findings include: R79's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include rheumatoid arthritis, neurocognitive disorder with Lewy bodies, dementia without behavioral disturbance, hypertension, chronic kidney disease, cardiac arrhythmia, and anxiety disorder. R79's facility assessment 4/19/24 showed she has moderate cognitive impairment. R79's current Physician Order Sheet showed an order for Telmisartan 40 MG, Give 1 tablet by mouth two times a day for hypertension . On 5/28/24 at 10:50 AM, R79 was in her room sitting on her bed. R1 had a medication cup on her bedside table that had a white pill in it. There were powdery pill fragments in the cup as well. R79 said, I had a bunch of pills, this is the only one left. There were two white ones, I had one that was broken, and I need to know which one I swallowed. I need a nurse to come talk to me. On 5/28/24 at 11:00 AM, V10 (Registered Nurse) came and retrieved the pill cup. V10 said, This isn't from me. This might be from night shift nurse because I stay and watch her take them 1 by 1 to make sure she takes them. V10 looked through R79's medications in the nursing medication cart and determined the pill that was left in R79's medication cup was Telmisartan 40 mg (a blood pressure medication). V10 said R79's Telmisartan is scheduled twice a day, once in the morning and once in the evening. On 5/30/24 at 11:04 AM, V2 (Director of Nursing), I would expect the nurses to stay with the resident while they take their medications to make sure they take them all. The facility's policy and procedure with revision date of 7/28/23 showed, Medication Pass . Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145706 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 145706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall of Deerfield 300 Waukegan Road Deerfield, 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 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 a resident's soup was nectar thick for 1 of 4 residents (R68) reviewed for thickened liquids in the sample of 28. Residents Affected - Few The findings include: On 5/29/24 at 11:38 AM, R68 was sitting in his wheelchair at the dining room table and V6 CNA (Certified Nursing Assistant) put R68's tray in front of him and removed the lids to his food and soup. V6 walked away and R68 began feeding himself. R68 had garden vegetable soup in a coffee cup that appeared to be a thin liquid. At 11:49 AM, V6 was asked to check R68's soup. The thickener was at the bottom of the coffee cup and not mixed into the soup to make it nectar thick. V6 stirred the soup, and it did not become nectar thick. V6 stated he had additional thickener available, went and got the thickener and added more to R68's soup. V6 stated he did not know why R68 was on nectar thick liquids. R68 was asked if he knew why he had thickened liquids and he stated, Because I eat a lot. R68 was asked if he had any problems swallowing and he stated, No. The meal ticket dated 5/29/24 for lunch on R68's tray showed he is on a regular diet, chopped with ground meat, and nectar thick liquids. The meal ticket showed he was supposed to have nectar thick garden vegetable soup. On 5/29/24 at 2:23 PM, V7 (Registered Dietician) stated R68 was on the nectar thick liquids because he is not swallowing properly. V7 stated V8 (Speech Therapist) had upgraded R68's liquids and then downgraded them. R68 stated she thought because R68 is cognitively impaired he is holding his food and not swallowing properly. V8 probably noted a cough when he was swallowing. Because of cognitive issues R68 needs maximum cues and has dysphagia. R68 is at his maximum potential; a mechanical soft nectar thick diet is his desired diet. R68 was put on the diet to prevent aspiration. The facility's Face Sheet dated 5/29/24 for R68 showed medical diagnoses including neurocognitive disorder with Lewy bodies, Parkinson's disease, gastro-esophageal reflux disease, hypertension, hyperlipidemia, paroxysmal atrial fibrillation, and atherosclerotic heart disease. The Physician Order Review Report dated 5/29/24 for R68 showed a diet order entered on 4/19/24 for mechanical soft chopped with ground meat texture and nectar thick liquids. R68's Care Plan dated 4/16/24 showed he is at risk for alteration in nutritional status. A general pureed diet with nectar thick liquids was on his care plan on 4/11/24. R68's diet on his care plan was changed as follows: 4/13/24 - ground; 4/15 - chopped; 4/12 - thin liquids. R68's care plan was not updated on or after 4/19 to show he is on nectar thick liquids. The Speech Therapy Evaluation and Plan of Treatment dated 5/20/24 for services from 4/12/24 - 5/10/24 and 5/15/24 - 5/20/24 for R68 showed diagnoses including dysphagia, neurocognitive disorder with Lewy bodies, and cognitive communication deficit. Clinical Impressions: Patient appears slightly below cognitive baseline and with moderate oral-pharyngeal dysphagia. Speech therapy warranted to determine safest and least restrictive diet and return to prior level of function. Patient will tolerate the safest and least restrictive diet . mechanical soft, chopped, and nectar thick liquids. The facility's Dysphagia and Aspiration Clinical Guidelines policy (7/17/23) showed, Downgrading diet consistency (for example, from thin to thickened liquids or mechanical soft to pureed) will only occur after a review and discussion with the physician and consideration of all relevant factors. If (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145706 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 145706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall of Deerfield 300 Waukegan Road Deerfield, 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete it is decided that alterations in food of fluid consistency are indicated, the physician and/or staff will document why such alterations are right for the resident given the various risks and relevant factors involved for that individual and show that pertinent medical conditions or medication side effects have been considered. The staff and physician will identify individuals whose swallowing capabilities decline, fluctuate, or result in clinically significant complications and will adjust diet and food consistency where relevant and make the appropriate interventions. Event ID: Facility ID: 145706 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 145706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall of Deerfield 300 Waukegan Road Deerfield, 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 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 change gloves while using the dishwasher and failed to sanitize food thermometers in a manner to prevent cross contamination. This applies to all residents residing in the facility. The findings include: The CMS 671 form dated 5/28/24 showed 139 residents residing in the facility. 1. On 5/28/24 at 10:31 AM, V14 (Dietary Aide) was wearing gloves while loading dirty dishes into the dishwasher. V14 wore the same gloves to dip a test strip into the 3-compartment sink. V14 returned to the dishwasher and continued loading dirty dishes. V14 was observed repeatedly loading and unloading dishes while wearing the same contaminated gloves. On 5/29/24 at 1:47 PM, V12 (Dietary Manager) stated dirty dishes should be rinsed and loaded into the dishwasher by one person then another person puts the clean items away. If the same person is loading and unloading, they need to change gloves or wash their hands in between. It prevents the dishes from getting dirty. The items can get contaminated with bacteria. Staff need clean hands and clean gloves whenever they are touching food and other surfaces. The facilities undated Cleaning Dishes/Dish Machine policy states: 2. The person loading dirty dishes will not handle the clean dishes unless they change into a clean apron and wash hands thoroughly before moving from dirty to clean dishes. 2. On 5/28/24 at 10:45 AM, V13 (Cook) took temperatures of the food items on the steam table. V13 pulled a metal-type thermometer out of the holder and stuck it into the pureed pork. V13 used a brown paper towel to wipe it off between each food he was testing, including pulled pork, pureed vegetables, mashed potatoes, and soup. A second reading was required for the pureed pork, vegetables, and potatoes. V13 used the same thermometer to test the foods but ran it under the water before using it. At 11:19 AM, V15 (Cook) tested the temperature of the baked chicken. V15 wiped the thermometer off with a brown paper towel, once after using it. V13 and V15 did not sanitize the thermometers before, during or after use. On 5/29/24 at 1:50 PM, V12 (Dietary Manager) stated food thermometers need to be cleaned before using them. Wiping it down with a paper towel is fine. We don't use anything special, but it should be sanitized prior to use. At least wash it between foods to be sure it is clean. The facility's undated Taking Accurate Temperatures policy states: 1. To take temperatures, a clean, rinsed, sanitized, and air-dried thermometer that is the metal stem type .is needed. **Thermometers should be sanitized according to manufacturer's instructions. Bimetallic thermometers may be sanitized using a dish washer or three sink method. In between uses at one meal, an alcohol swab may be used to sanitize. (Use a new swab for each sanitizing.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145706 If continuation sheet Page 7 of 7