Health inspection·April 28, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm asked if there were other omissions or inaccuracies not presented to surveyor, V1 and V2 stated, No we reported everything to you. (Further review of V1 and V2's reports of accidents and incidents show another facility-reported incident involving (R2) was not presented to surveyor as originally requested.) Residents Affected - Some Interview with V12 (LPN) on 4/21/23 at 2:30 PM, V12 stated, I recall the incident with R1, that was during dinner time. I saw R1 on the other side of the hallway by the window maybe about 15 -20 feet away from me. I just saw her when she was on her way down, falling. The CNA's and I tried to get to her. I recall V9 (CNA) running to catch her before she fell too. We both tried to rush to her, but she fell and we couldn't get to her. R1 had some minimal bleeding when she fell, and we stopped that bleeding and she was assessed. I was there and other staff members came running in to help stop the bleeding and do an assessment. Surveyor asked if there was some sort of code to prompt other nurses to come rushing into the unit, V12 stated, No. they probably just heard all the commotion. Surveyor asked if R1 only had minimal bleeding, why other staff rushed in to stop the bleeding, V12 stated, They just tried to help me because I was busy trying to do other things like call the ambulance. Surveyor asked if there was any specific staff member assigned to monitor the residents in the dining area, V12 stated, V9 (CNA) was supposed to watch R1 and the rest of the residents that day but the CNAs get too busy and have other duties. Surveyor asked if she could recall how many resident's she normally took care of in the dementia unit, V12 stated, If it's a full house we usually have 33 residents and I think we were full then. Surveyor asked how many nurses and aides there were in the unit, V12 stated, There are usually 3 aides. sometimes we get agency CNA's, but there's normally 1 nurse. Surveyor asked what fall prevention measures were discussed or she did training on, V12 stated, Not too long ago we had a meeting and that was one of the subjects was about falls. Surveyor asked how she was trained to manage falls in the unit, V12 stated, There's been so many falls here. I've been here 26 years in the facility, and we have a lot of falls. That seems a lot, but you know, people get weak, and we discuss falls on a case-to-case basis. These residents, when they get older, they get more confused, so they will generally fall a lot. Surveyor asked what the facility did to prevent falls since, by her own account, there are a lot of falls, V12 stated, Like I said, residents have a right to fall, we can't prevent them from falling as much as we try. It's just a case-by-case basis. Interview with V9 (CNA/Certified Nursing Aide) on 4/21/23 at 3:50 PM contradicts V12's (LPN) account of R1's incident. V9 stated, I just tried to help her after she fell. I help the nurse because she called for help. Surveyor asked what he was doing at the time R1 fell from her chair, V9 stated, In this time I passed the trays for dinner, so I'm not involved in that when (R1) fell, I just heard a loud boom (V9 clapping his hands a hard motion) but I never saw her fall. When I heard a boom and I saw her on the floor and she was bleeding on her face and the nurse (V12) was shouting help! help!, but I was busy passing trays so I did not see her fall, I just heard loud boom on the floor. Surveyor asked if the sound he heard was an alarm, V9 stated, No, she not have alarm, I heard her just fall because I hear just boom sound. Surveyor asked if he knows about the blue stars on the doors and when he was last trained on fall prevention, V9 stated, I don't know what that is (referring to blue stars) but we get Inservice all the time, I don't remember when. 2. R2 is a [AGE] year-old having diagnoses listed in part with aphasia following stroke, anxiety disorder, gait abnormality, and fracture of left femur. Care plan dated 1/2/2023 reads in part, R2 is at risk for falls related to deconditioning, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 2 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gait/balance problems, CVA (stroke). Goal: R2 will be free of falls through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Care plan dated 4/11/23 reads in part, The resident has had an actual fall: unwitnessed fall 4/8/23, unwitnessed fall 4/12/23. Interventions: Physical therapy to evaluate and treat when resident returns from the hospital. Bed alarm will be provided to alert staff that resident requires assistance. A review of facility records discovered R2's fall incident not reported to surveyor as requested. Interview with V1 (Administrator) stated, I discussed this with V2 (Director of Nursing) and it was just an error on his part. Surveyor reminded V1 that V2 also did not accurately report R1's fracture along with not providing R2's incident involving a fracture and asked how V2 could make several omissions for two very significant events. V1 responded that he would discuss this with V2. Facility progress notes show on 4/12/2023 at 04:45 AM, V16 (RN) wrote, Note Text: Prior to the incident, at around 4:00 AM, the resident was observed sleeping on her bed. At approximately, 4:45 AM, this writer heard the resident calling for help, this writer immediately rushed to the room, and observed the resident sitting on the floor next to her bed. When resident was asked what caused the fall, resident stated that she was trying to go use the washroom, but she lost her balance and fell. Head to toe assessment completed, resident complained of pain on the left hip area, left hip was kept immobilized, and resident sent out to ER for further evaluation. On 4/12/2023 at 08:39 AM, V17 (LPN) wrote, Nurses Note: Resident complaints of pain on left leg pain and unable to move and stated that she might have broken something. Resident was moaning and crying due to pain. NP informed and sent out to ER to be assessed. Pain medication administered. Family informed and verbalized understanding. Resident picked up by ambulance at 9:15 am, resident transferred from bed to stretcher with no issues. Documents and bed hold policy given to EMT. On 4/12/2023 14:54, V17 (LPN) wrote: Nurses Note: Called hospital for updates, RN stated that resident has been admitted to hospital for left hip fracture. On 4/21/23 at 10:20 AM, R2 was observed in her room asleep laying in her bed. R2's call light was hanging from the right side of the bed on to the floor. At 12:19 PM, R2 was observed shouting out to the hall for help but did not have her call light activated. Surveyor entered R2's room and asked if she needed help, R2 tried to let surveyor know what she wanted but was unable to make clear sentences to convey what she wanted so R2 pointed to the chair in the corner. R2's call light remained on the floor and her bed appeared to be waist high off the floor and not lowered to the ground. There were no floor mats or bed alarm that appeared to be on her bed. V9 (CNA) entered the room, and had difficulty understanding what R2 wanted. R2 was able to say, Water, I want water, white water. V9 left the room and came back with a pitcher of water. Surveyor asked V9 if the call light should be on the ground, V9 went over and placed R2's call light back onto R2's bed within her reach. V9 stated, It was on her last time. Sometime if falls down. Surveyor asked if her bed should be that high up from the ground, V9 stated, No I will lower it down. Interview with V3 (Restorative Fall Nurse) on 4/21/23 at 2:30 PM stated, (R2) fell trying to get up from her bed. The nurse assessed her, but it was an unwitnessed fall, and she sustained a hip fracture. We discussed her fall in our team meeting and we are going to have PT/OT pick her up. We placed a bed alarm, and she is able to follow command, but we still caught her trying to get up herself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 3 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Even when we give her medication, she tries to get up. Surveyor asked what other interventions the facility has tried to prevent R2 from falling, V3 stated, That's all we do for her to prevent her from falling. Surveyor asked again whether there were any other preventative measures used for R2 but V3 (Restorative Fall Nurse) could not provide any other examples of assistive devices such as fall mats, call lights within reach, frequent monitoring, or low bed to prevent R2 from falling again. Residents Affected - Some 3. R3 is a [AGE] year-old diagnosed in part with Alzheimer's Disease, Chronic obstructive Pulmonary Disease, injury of the face, and traumatic hemorrhage of cerebrum. R3's care plan with multiple dates reads in part, R3 is at risk for falls related to gait/balance problems. On 2/19/21-resident fell in her room with laceration on top right forehead noted. sent to hospital for evaluation. 10/23/21: Unwitnessed fall resulting in hematoma to chin. Sent to ER and returned without new orders. 10/23/21: Witnessed fall. 3/29/21 Witnessed fall; 5/25/22 Witnessed fall, 10/8/22-Unwitnessed fall; 4/8/23 Unwitnessed fall. Interventions: Resident will be close to the nurse's station for close monitoring; wheelchair axle lowered to ensure resident is sitting at the lowest position of the wheelchair; the resident uses chair and bed electronic alarm. Ensure the device is in place as needed. A facility incident written by V18 (RN) dated 4/8/23 shows in part, Prior to incident at around 2:50 PM, the resident was sitting on her wheelchair at the dining room. At approximately 3:00 PM, other nurse on duty observed the resident trying to get up from her wheelchair and ran to her but could not get to the resident on time to prevent the fall. Nurse on duty immediately went to assess the resident. Resident was laying on her right side and noted bleeding by her head. Head to toe assessment done. Applied pressure dressing and cold pack to stop the bleeding. Called 911 to send to the ER for further evaluation. Facility incident report does not indicate whether a chair alarm activated nor identified the other nurse on duty. Interview with V2 (Director of Nursing) on 4/21/23 at 10:15 AM stated, V18 (RN) wrote the incident report but she was not the one that observed this fall. Surveyor asked if V18 didn't observe the fall, why she made the entry in the nursing notes, V2 stated, That's just how we do incidents here. Surveyor asked if R3 should have a chair alarm to alert staff if she stood up from the chair, V2 stated, She should but I see that V18 didn't put that in her report, so I don't know whether she did or not. On 4/11/23, R3 was readmitted back to the facility. V19 (RN) wrote in part: 4/11/2023 15:00 admission Summary: re-admitted this [AGE] year old, female, white from hospital per stretcher accompanied by 2 paramedics with the diagnosis of Frontal Lobe Hematoma, alert with periods of confusion and forgetfulness, physical assessment done, abdomen soft and non-tender with colostomy bag on right mid abdomen intact and patent, lungs field clear and no congestion, old bruise on right forehead with skin tear with 4 stitches, dry and clean, bruise on right eye. Interview with V3 (Restorative Fall Nurse) on 4/21/23 at 2:30 PM stated, (R3) is wheelchair bound and she was in her wheelchair at the time of this incident and she tried to get up and she fell because she doesn't have good balance. We had a chair alarm for her to prevent her from falling. V5 (RN) happened to be in same hallway when she attempted to prevent the resident from falling but the resident she fell to the right side of forehead. Surveyor asked what fall preventative measures the facility used for R3, V3 stated, We tried to encourage her to sit by the nurse's station because she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 4 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some moves herself and we try to get more supervision. Surveyor asked whether she was present during R3's fall incident, V3 stated, No she fell over the weekend, so I did not see it, it was just reported to me and we talked about it in our morning meeting. Surveyor asked if she knew whether the chair alarm was activated for R3 as there is no indication of it in the incident report going off to warn staff the resident was about to fall, V3 stated, I don't know for sure, I just know staff should have it on when R3 is in her wheelchair. Surveyor asked whether R3's latest fall was witnessed or unwitnessed as the care plan listed the fall as an unwitnessed fall, but the incident report showed it was witnessed, V3 stated, I don't know. 4. R4 is a [AGE] year-old cognitively impaired resident with diagnoses of dementia, unsteadiness of feet, nondisplaced fracture of 5th cervical vertebra, fracture of shaft of humerus (left arm), and fracture of left rib. R4's care plan showed previous falls: 15 unwitnessed and 2 witnessed falls. Care plan reads in part, (R4) is at risk for falls related to overactive bladder, osteoporosis, dementia, anxiety, major depression, and partial hearing loss. Interventions: The resident will be provided with a helmet to prevent injuries; Resident will use a bed alarm to alert staff that resident requires staff assistance; Offer and assist the resident to use the bathroom at night at least every 2 hours. Resident was provided visual reminders to call for assistance with activities of daily living; the resident uses chair electronic alarm. ensure the device is in place as needed. Interview with V3 (Restorative Falls Nurse) on 4/21/23 at 2:30 PM stated, When R4 last fell (3/31/23), She tried to get up from the wheelchair. She got another cut to her right side of her head, and she was sent out 911. She received sutures. Surveyor asked how many falls R4 had and what the facility was doing to prevent further falls, V3 stated, I know she fell a lot, but we are using a geriatric chair instead of a wheelchair, we tried to use a geriatric chair and there is an alarm on her geriatric chair. I think we just put her on a geriatric chair after this last fall. 5. R5 is a cognitively impaired [AGE] year-old with diagnoses listed in part with dementia, hemiplegia and hemiparesis, and history of falling. R5's care plan dated 3/10/21 reads in part (R5) is high risk for falls related to right side hemiparesis and hemiplegia, gait/balance problems. unwitnessed fall 3/10/21, 3/28/21, 6/16/22, 8/31/22. Interventions: Frequently remind resident to ask for assistance when transferring and standing; Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed; The resident uses bed electronic alarm. No chair alarm is listed as part of R5's intervention as an assistive/alerting device to prevent falls. Observations conducted on 4/22/23 at 11:53 am in R1's previous nursing unit showed 30 residents in the dining area with 1 nurse (V15-LPN/Licensed Practical Nurse) present in the room and 3 aides currently assisting residents during mealtime. Surveyor asked about 1 resident sitting in a wheelchair and asked whether R5 was a fall risk, V15 stated, Yes, she is a fall risk, and we use the chair alarm for her to keep her from falling. Observations of the chair alarm showed the alarm was turned off. Surveyor asked V15 whether the alarm should be off while R5 was seated in her chair, V15 stated, No, that should be switched on. She just came back from an activity and V16 (CNA) just brought her back but that should always be on when she is in her chair to alert us. Surveyor asked who was responsible for ensuring the chair alarm was activated and working, V15 stated, Her CNA should make sure it's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 5 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on when they put them in the wheelchair. It must have been off while she was in the activity too. I'm sorry about that. Surveyor asked V16 (CNA) if she is responsible for ensuring the chair alarms were on, V16 stated, No. I don't touch that (referring to the alarms). Surveyor asked whether R5 was able to use a call light or be encouraged to use a call light (as per care plan), V15 stated, 'No she is too confused. 6. R6 is a cognitively impaired [AGE] year-old with diagnoses listed in part with Parkinson's disease, dementia, and senile degeneration of the brain. R6's care plan dated 1/2/2023 reads in part, (R6) is at risk for falls related to gait/balance problems, dementia, Parkinson's disease, and a history of falls. (R6) has had unwitnessed fall-1/30/23, witnessed fall 2/19/23, unwitnessed fall 2/25/23, and 3/15/23. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; chair alarm will be place on the resident's wheelchair to alert staff when assistance is needed (initiated 2/19/23); the resident will use a bed alarm to alert the staff that assistance is needed. Observations conducted on 4/22/23 at 11:53 am, with R6 seated in a wheelchair with chair alarm turned off. Surveyor asked about R6's chair alarm that was switched off, V15 (LPN) stated, She must have reached back and turned it off. Surveyor asked how R6 would be capable of reaching back behind her to turn off an alarm, V15, stated, She just came back from visiting with her family, so they may have turned the alarm off. Surveyor asked again who was responsible to ensure the chair alarms were activated, V15 stated, We are. 7. R7 is a cognitively impaired [AGE] year-old with diagnoses listed in part with dementia, seizures, and senile degeneration of the brain. Care plan dated 12/16/21 shows in part, (R7) is at risk for falls related to senile degeneration of brain, dementia, altered mental status. Interventions: The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; The resident uses chair and bed electronic alarm, ensure the device is in place as needed. Observations conducted on 4/22/23 at 11:53 am showed R7 in a geriatric chair with both legs hanging over the left arm of the chair. Surveyor asked about R7, V15 (LPN) approached R7 and placed the resident back to her proper seated position and stated, Sorry, she does that all the time, but she normally doesn't fall over. Surveyor asked whether R7 was a fall risk and whether she needed any device or chair alarm to prevent her from falling, V15 stated, She is a fall risk, but we don't use any alarms on her. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 6 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 provide care in accordance with professional standards of quality by failing to prevent multiple falls with significant injuries; failed to train facility nursing staff on fall prevention and implementation of assistive and alerting devices to prevent falls; and failed to develop a fall prevention policy and procedure. These failures affect 7 (R1, R2, R3, R4, R5, R6, R7) of 7 residents reviewed for fall-risk in the sample of 7 residents; and has the potential to affect all 117 residents residing in the facility. Residents Affected - Many Findings include: On 4/21/23 at 10:15 AM, V1 (Administrator) and V2 (DON/Director of Nursing) presented surveyor with the facility matrix roster showing 117 residents. V2 also presented surveyor with R1's facility-reported incident of 1/30/23 and with all requested reportable and non-reportable incidents along with incidents the facility was currently investigating. Interview with V2 stated, R1 was observed falling from her wheelchair while in the dining room during dinner. The nurse heard R1's alarm go off but (V12) was unable to get to her in time. R1 fell to the ground, and she had a cut to her chin and was sent out to the hospital and came back with sutures but no other injuries. Review of R1's progress notes contradicts V2's statement that R1 required only suturing when sent to the hospital. Facility progress notes written by V12 (LPN/Licensed Practical Nurse) dated 1/30/2023 10:15 PM showed, Incident Note: Received a call from on-call guardian, stated that resident is admitted for observation due to lung bruising and rib fractures. V2 (DON -Director of Nursing) notified. 1. R1 is a [AGE] year-old having diagnoses listed in part with dementia, gait abnormality, lack of coordination, fracture of humerus, laceration of part of head, maxillary fracture, and fracture of body of mandible. Hospital records dated 1/30/23 reads in part, Date of admission: [DATE]. Chief complaint: Fall. History of Present Illness: (R1) is a [AGE] year-old female with primary history significant for general weakness, dementia, depression, epilepsy, right humerus fracture, presents due to witnessed fall at nursing home. Got up from bed and fell onto face. Reports mild pain around mouth. Very poor historian. Does not recall events. In the ER: found to have a pulmonary embolism, Multiple facial fractures. Assessment and plan: Suspected mechanical fall out of bed and sustained facial trauma-- fractures of maxilla and mandible, including into teeth. ER consulted plastics and maxillofacial surgeon. Started on antibiotics for head/neck coverage regarding lip laceration and facial fractures. V1 (Administrator) and V2 (Director of Nursing) were interviewed again regarding the inaccuracies of V2's report showing R1's report of injury, V1 and V2 stated, We're sorry, we just realized that the report was wrong and we will correct the report today to be submitted to your office. Surveyor asked if there were other omissions or inaccuracies not presented to surveyor, V1 and V2 stated, No we reported everything to you. (Further review of V1 and V2's reports of accidents and incidents show another facility-reported incident involving (R2) was not presented to surveyor as originally requested.) R1's care plan dated 11/18/22 revised 3/22/23 reads in part, R1 has had an actual fall due to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 7 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 0658 Level of Harm - Minimal harm or potential for actual harm dementia, poor balance, unsteady gait with witnessed fall on 11/17/22, unwitnessed fall on 11/26/22, witnessed fall on 12/2/22, unwitnessed fall on 12/23/22, and witnessed fall on 1/30/23. Goal: The resident will resume usual activities without further incident through the review date. Interventions: Resident will use a bed alarm to alert staff that the resident requires assistance; Resident will use geriatric chair to sit while in the dining room. Residents Affected - Many Interview with V3 (Restorative Falls Nurse) on 4/21/23 at 2:30 PM stated, I am in charge of the falls. I am the restorative nurse and fall nurse. Surveyor asked about R1's last fall that occurred in January. V3 stated, The nurses let me know about (R1)'s fall. I found out it happened when the staff were passing dinner trays and the resident fell when she got up from where she was sitting, and she fell forward. She got stitches to her chin when she went to the emergency room and then she came back. Surveyor asked if those were the only injuries R1 sustained, V3 stated, Yes, that's what we talked about as a team in the morning meeting the next day. Surveyor asked what team she was referring to, V3 stated, The Administrator (V1), DON (V2), me, and all the department heads. We try to come up with good interventions to prevent falls and we usually refer all falls to physical therapy for working with balance and strength. Surveyor asked what fall preventative measures the facility used for high-risk residents, V3 stated, If they are unable to press the call light, we use bed alarms and chair alarms to alert staff. Surveyor asked if the facility developed a fall policy that the facility followed, V3 stated, We don't have a fall policy, we just discuss it. Surveyor asked how she conveyed to staff how to prevent falls without a policy, V3 stated, I don't know, but I will ask the DON. Surveyor asked if she was involved in training staff on how to prevent falls, V3 stated, Yes, I do the in-servicing on fall documentation, and we did it during a skill fair last month. Surveyor asked if there were any programs or symbols for staff to follow to identify residents that were at risk for falls, V3 stated, No we just discuss it, but what we last talked about with nurses was just how to document on falls. Surveyor clarified whether it was just documenting of falls when they occurred and not fall prevention that was in-serviced, V3 stated, Yes, I just talked about documentation. Interview with V12 (LPN) on 4/21/23 at 2:30 PM, V12 stated, I recall the incident with R1, that was during dinner time. I saw R1 on the other side of the hallway by the window maybe about 15-20 feet away from me. I just saw her when she was on her way down, falling. The CNA's and I tried to get to her. I recall V9 (CNA) running to catch her before she fell too. We both tried to rush to her, but she fell, and we couldn't get to her. R1 had some minimal bleeding when she fell, and we stopped that bleeding and she was assessed. I was there and other staff members came running in to help stop the bleeding and do an assessment. Surveyor asked if there was some sort of code to prompt other nurses to come rushing into the unit, V12 stated, No. they probably just heard all the commotion. Surveyor asked if R1 only had minimal bleeding, why other staff rushed in to stop the bleeding, V12 stated, They just tried to help me because I was busy trying to do other things like call the ambulance. Interview with V9 (CNA/Certified Nursing Aide) on 4/21/23 at 3:50 PM contradicts V12's (LPN) account of R1's incident. V9 stated, I just tried to help her after she fell. I helped the nurse because she called for help. Surveyor asked what he was doing at the time R1 fell from her chair, V9 stated, In this time I passed the trays for dinner, so I was not involved in that when (R1) fell, I just heard a loud boom (V9 clapping his hands a hard motion) but I never saw her fall. When I heard a boom and I saw her on the floor and she was bleeding on her face and the nurse (V12) was shouting help! help! but I was busy passing trays, so I did not see her fall, I just heard loud boom on the floor. Surveyor asked if the sound he heard was an alarm, V9 stated, No she does not have an alarm, I heard her just fall because I heard just boom sound. Surveyor asked if he knows about the blue stars on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 8 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many doors and when he was last trained on fall prevention, V9 stated, I don't know what that is (referring to blue stars) but we get in-service all the time, I don't remember when. Observations conducted on 4/22/23 at 11:53 am, in R1's previous nursing unit showed 30 residents in the dining area with 1 nurse (V15-LPN/Licensed Practical Nurse) present in the room and 3 aides currently assisting residents during mealtime. Surveyor asked if she knew about R1, V15 (LPN) stated, Yes, I remember her, but I was not here when she fell. Surveyor asked if R1 was one of the residents that had a chair alarm, V15 stated, Yes, but they just started using it after that last fall in January. Surveyor asked if R1 was a frequent faller, V15 stated, Oh yes, she has fallen multiple times, but she is very difficult to manage, she is always trying to sit up and get out of her chair. Surveyor asked whether someone with that history of behaviors and falling should have been on some assistive device to prevent falls, V15 stated, Yes. We should have put a chair alarm and bed alarm on her sooner. Surveyor asked about the blue stars on resident doors and what they signified, V15 stated, You know the DON (V2) was here and told me that I should know about these stars which mean the resident is a fall risk. I've been here over 20 years and no one's every told me about any blue stars, but he (V2) just told me I should know about the blue stars but never came back and did any in-service on them. Surveyor asked if V3 (Fall Nurse) ever came to do training on the blue stars, V15 stated, Never. On 4/22/23 at 1:55 PM, V1 (Administrator) was asked about the facility fall policy referred to as their Falling Star Program, V1 stated, we don't have a policy we just have meetings about who is at high risk for falls. Surveyor asked what the blue star decal on each door signified, V1 stated, I don't really know but I will find out about it. Surveyor asked whether it was the responsibility of the Administrator to know about a falls program given that falls are discussed during their morning team meetings, V1 stated, Yes, I should know but I will find out about the program and get back to you. V1 returned a half hour later and explained to surveyor that there was no policy or procedures pertaining to the Falling Star Program referred to by V15 but was in the process of being developed. 2. R2 is a [AGE] year-old having diagnoses listed in part with aphasia following stroke, anxiety disorder, gait abnormality, and fracture of left femur. On 4/21/23 at 10:15 AM, V1 (Administrator) and V2 (Director of Nursing) were requested to present the incident reports pertaining To R1 and any other reportable incidents currently being investigated. V2 returned 30 minutes later and presented surveyor with R1's incident report but omitted presenting any report for R2. Surveyor asked again whether all reportable incidents including any ongoing facility investigations were presented to the surveyor, V2 stated, Yes, I gave you everything. A review of facility records discovered R2's fall incident not reported to surveyor as requested. Interview with V1 (Administrator) stated, I discussed this with V2 (Director of Nursing) and it was just an error on his part. Surveyor reminded V1 that V2 also did not accurately report R1's fracture along with not providing R2's incident involving a fracture and asked how V2 could make several omissions for two very significant events. V1 responded that he would discuss this with V2. On 4/12/2023 14:54, V17 (LPN) wrote: Nurses Note: Called hospital for updates, RN stated that resident has been admitted to hospital for left hip fracture. Care plan dated 1/2/2023 reads in part, R2 is at risk for falls related to deconditioning, gait/balance problems, CVA (stroke). Goal R2 will be free of falls through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 9 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Care plan dated 4/11/23 reads in part, The resident has had an actual fall: unwitnessed fall 4/8/23, unwitnessed fall 4/12/23. Interventions: Physical therapy to evaluate and treat when resident returns from the hospital. Bed alarm will be provided to alert staff that resident requires assistance. On 4/21/23 at 10:20 AM, R2 was observed in her room asleep laying in her bed. R2's call light was hanging from the right side of the bed on to the floor. At 12:19 PM, R2 was observed shouting out to the hall for help but did not have her call light activated. Surveyor entered R2's room and asked if she needed help, R2 tried to let surveyor know what she wanted but was unable to make clear sentences to convey what she wanted so R2 pointed to the chair in the corner. R2's call light remained on the floor and her bed appeared to be waist high off the floor and not lowered to the ground. There were no floor mats or bed alarm that appeared to be on her bed. V9 (CNA) entered the room, and had difficulty understanding what R2 wanted. R2 was able to say, Water, I want water, white water. V9 left the room and came back with a pitcher of water. Surveyor asked V9 if the call light should be on the ground, V9 went over and placed R2's call light back onto R2's bed within her reach. V9 stated, It was on her last time. Sometime if falls down. Surveyor asked if her bed should be that high up from the ground, V9 stated, No I will lower it down. Interview with V3 (Restorative Fall Nurse) on 4/21/23 at 2:30 PM stated, (R2) fell trying to get up from her bed. The nurse assessed her, but it was an unwitnessed fall and she sustained a hip fracture. We discussed her fall in our team meeting and we are going to have PT/OT pick her up. We placed a bed alarm, and she is able to follow command but we still caught her trying to get up herself. Even when we give her medication, she tries to get up. Surveyor asked what other interventions the facility has tried to prevent R2 from falling, V3 stated, That's all we do for her to prevent her from falling. Surveyor asked again whether there were any other preventative measures used for R2 but V3 (Restorative Fall Nurse) could not provide any other examples of assistive devices such as fall mats, call lights within reach, frequent monitoring, or low bed to prevent R2 from falling again. Review of R2's progress notes on 4/23/23 showed a 3rd preventable fall: On 4/23/23 at 04:08 am, V16 (RN) wrote, Nurses Note: She tried a couple of times to get out of bed but much better than yesterday. She followed Nurse instruction . (There was no documentation as to what R2 needed from the nurse or what instructions or interventions V16 (RN) did to prevent R2 from falling out of bed.) On 4/23/23 at 8:00 AM, V7 (LPN) wrote, Incident Note. Prior to incident 7:30 a.m. resident was observed sleeping on her bed and bed set at lowest position with call light within reach and with bed alarm. Around 8:00 a.m. bed alarm went off and staff member rushed into the room and saw resident on the floor in an upright sitting position next to her bed. Staff alert this writer that the resident was observed on the floor. Writer quickly went to the room to check on resident and asked resident what happened, and resident stated she tried to get out of bed to go use the bathroom but felt weak and lost balance and fell. Head to toe assessment completed. No new redness or swelling noted, no shortening on any extremities. Resident verbalized pain in the back of her head. No bruise or lumps felt on back of head upon assessment at that time. Resident appeared agitated and anxious. No loss of consciousness. Able to move all extremities at baseline without complain of pain. Tramadol and Xanax given. Vital signs taken; Family notified and verbalized understanding. NP notified with orders to send the resident via 911 to hospital for further evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 10 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3. R3 is a [AGE] year-old diagnosed in part with Alzheimer's Disease, Chronic obstructive Pulmonary Disease, injury of the face, and traumatic hemorrhage of cerebrum. R3's care plan with multiple dates reads in part, R3 is at risk for falls related to gait/balance problems. On 2/19/21-resident fell in her room with laceration on top right forehead noted. sent to hospital for evaluation. On 10/23/21: Unwitnessed fall resulting in hematoma to chin. Sent to ER and returned without new orders. On 10/23/21: Witnessed fall. On 3/29/21 Witnessed fall; On 5/25/22 Witnessed fall, On 10/8/22-Unwitnessed fall; On 4/8/23 Unwitnessed fall. Interventions: Resident will be close to the nurse's station for close monitoring; wheelchair axle lowered to ensure resident is sitting at the lowest position of the wheelchair; the resident uses chair and bed electronic alarm. Ensure the device is in place as needed. A facility incident written by V18 (RN) dated 4/8/23 shows in part, Prior to incident at around 2:50 PM, the resident was sitting on her wheelchair at the dining room. At approximately 3:00 PM, other nurse on duty observed the resident trying to get up from her wheelchair and ran to her but could not get to the resident on time to prevent the fall. Nurse on duty immediately went to assess the resident. Resident was laying on her right side and noted bleeding by her head. Head to toe assessment done. Applied pressure dressing and cold pack to stop the bleeding. Called 911 to send to the ER for further evaluation. Facility incident report does not indicate whether a chair alarm activated nor identified the other nurse on duty. Interview with V2 (Director of Nursing) on 4/21/23 at 10:15 AM stated, V18 (RN) wrote the incident report but she was not the one that observed this fall. Surveyor asked if V18 didn't observe the fall, why she made the entry in the nursing notes, V2 stated, That's just how we do incidents here. Surveyor asked if R3 should have a chair alarm to alert staff if she stood up from the chair, V2 stated, She should but I see that V18 didn't put that in her report, so I don't know whether she did or not. On 4/11/23, R3 was readmitted back to the facility. V19 (RN) wrote in part: 4/11/2023 15:00 admission Summary: re-admitted this [AGE] year old, female, white from hospital per stretcher accompanied by 2 paramedics with the diagnosis of Frontal Lobe Hematoma, alert with periods of confusion and forgetfulness, physical assessment done, abdomen soft and non-tender with colostomy bag on right mid abdomen intact and patent, lungs field clear and no congestion, old bruise on right forehead with skin tear with 4 stitches, dry and clean , bruise on right eye. Interview with V3 (Restorative Falls Nurse) on 4/21/23 at 2:30 PM stated, (R3) is wheelchair bound and she was in her wheelchair at the time of this incident and she tried to get up and she fell because she doesn't have good balance. We had a chair alarm for her to prevent her from falling. V5 (RN) happened to be in same hallway when she attempted to prevent the resident from falling but the resident she fell to the right side of forehead. Surveyor asked what fall preventative measures the facility used for R3, V3 stated, We tried to encourage her to sit by the nurse's station because she moves herself and we try to get more supervision. Surveyor asked whether she was present during R3's fall incident, V3 stated, No she fell over the weekend so I did not see it, it was just reported to me and we talked about it in our morning meeting. Surveyor asked if she knew whether the chair alarm was activated for R3 as there is no indication of it in the incident report going off to warn staff the resident was about to fall, V3 stated, I don't know for sure, I just know staff should have it on when R3 is in her wheelchair. Surveyor asked whether R3's latest fall was witnessed or unwitnessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 11 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 0658 Level of Harm - Minimal harm or potential for actual harm as the care plan listed the fall as an unwitnessed fall, but the incident report showed it was witnessed, V3 stated, I don't know. 4. R4 is a [AGE] year-old cognitively impaired resident with diagnoses of dementia, unsteadiness of feet, nondisplaced fracture of 5th cervical vertebra, fracture of shaft of humerus (left arm), and fracture of left rib. Residents Affected - Many R4's care plan showed previous falls: 15 unwitnessed and 2 witnessed falls. Care plan reads in part, (R4) is at risk for falls related to overactive bladder, osteoporosis, dementia, anxiety, major depression, and partial hearing loss. Interventions: The resident will be provided with a helmet to prevent injuries; Resident will use a bed alarm to alert staff that resident requires staff assistance; Offer and assist the resident to use the bathroom at night at least every 2 hours. Resident was provided visual reminders to call for assistance with activities of daily living; the resident uses chair electronic alarm. ensure the device is in place as needed. Interview with V3 (Restorative Fall Nurse) on 4/21/23 at 2:30 PM stated, When R4 last fell (3/31/23), She tried to get up from the wheelchair. She got another cut to her right side of her head, and she was sent out 911. She received sutures. Surveyor asked how many falls R4 had and what the facility was doing to prevent further falls, V3 stated, I know she fell a lot but we are using a geriatric chair instead of a wheelchair, we tried to use a geriatric chair and there is an alarm on her geriatric chair. I think we just put her on a geriatric chair after this last fall. 5. R5 is a cognitively impaired [AGE] year-old with diagnoses listed in part with dementia, hemiplegia and hemiparesis, and history of falling. R5's care plan dated 3/10/21 reads in part (R5) is high risk for falls related to right side hemiparesis and hemiplegia, gait/balance problems. unwitnessed fall 3/10/21, 3/28/21, 6/16/22, 8/31/22. Interventions: Frequently remind resident to ask for assistance when transferring and standing; Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed; The resident uses bed electronic alarm. No chair alarm is listed as part of R5's intervention as an assistive/alerting device to prevent falls. Observations conducted on 4/22/23 at 11:53 am in R1's previous nursing unit showed 30 residents in the dining area with 1 nurse (V15-LPN/Licensed Practical Nurse) present in the room and 3 aides currently assisting residents during mealtime. Surveyor asked about 1 resident sitting in a wheelchair and asked whether R5 was a fall risk, V15 stated, Yes she is a fall risk, and we use the chair alarm for her to keep her from falling. Observations of the chair alarm showed the alarm was turned off. Surveyor asked V15 whether the alarm should be off while R5 was seated in her chair, V15 stated, No, that should be switched on. She just came back from an activity and V16 (CNA) just brought her back but that should always be on when she is in her chair to alert us. Surveyor asked who was responsible for ensuring the chair alarm was activated and working, V15 stated, Her CNA should make sure it's on when they put them in the wheelchair. It must have been off while she was in the activity too. I'm sorry about that. Surveyor asked V16 (CNA) if she is responsible for ensuring the chair alarms were on, V16 stated, No. I don't touch that (referring to the alarms). Surveyor asked whether R5 was able to use a call light or be encouraged to use a call light (as per care plan), V15 stated, 'No she is too confused. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 12 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 6. R6 is a cognitively impaired [AGE] year-old with diagnoses listed in part with Parkinson's disease, dementia, and senile degeneration of the brain. R6's care plan dated 1/2/2023 reads in part, (R6) is at risk for falls related to gait/balance problems, dementia, Parkinson's disease, and a history of falls. (R6) has had unwitnessed fall-1/30/23, witnessed fall on 2/19/23, unwitnessed fall on 2/25/23, and 3/15/23. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; chair alarm will be place on the resident's wheelchair to alert staff when assistance is needed (initiated 2/19/23); the resident will use a bed alarm to alert the staff that assistance is needed. Surveyor asked about R6's chair alarm that was observed switched off, V15 (LPN) stated, She must have reached back and turned it off. Surveyor asked how R6 would be capable of reaching back behind her to turn off an alarm, V15, stated, She just came back from visiting with her family, so they may have turned the alarm off. Surveyor asked again who was responsible to ensure the chair alarms were activated, V15 stated, We are. 7. R7 is a cognitively impaired [AGE] year-old with diagnoses listed in part with dementia, seizures, and senile degeneration of the brain. Care plan dated 12/16/21 shows in part, (R7) is at risk for falls related to senile degeneration of brain, dementia, altered mental status. Interventions: The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; The resident uses chair and bed electronic alarm, ensure the device is in place as needed. Surveyor asked about R7 who was observed with both her legs hanging over the left hand side of her geriatric chair, V15 (LPN) approached R7 and placed the resident back to her proper seated position and stated, Sorry, she does that all the time but she normally doesn't fall over. Surveyor asked whether R7 was a fall risk and whether she needed any device or chair alarm to prevent her from falling, V15 stated, She is a fall risk, but we don't use any alarms on her. A facility policy dated March 2018 titled Assessing Falls and Their Causes does not address fall prevention but shows policy and procedures for assessing falls after they've already occurred. This facility policy reads in part, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 13 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and/or follow any fall prevention policy and procedures; failed to implement fall-risk care plan interventions to ensure the resident's immediate environment was free of accident hazards; failed to adequately supervise and monitor residents; and failed to ensure assistive/alerting devices were in place to prevent accidental falls with injuries for 4 (R1, R2, R3, R4) of 4 residents reviewed for accident/hazards in the sample of 7 residents. Theses failures resulted in R1 sustaining multiple fractures to the face, ribs, and shoulder, R2 sustaining a hip fracture with surgical intervention, R3 with massive bleeding due to head trauma with required suturing, and R4 with head trauma, bleeding, and sutures. All 4 residents required emergent transfers to the hospital for medical treatment. Findings include: 1. R1 is a [AGE] year-old having diagnoses listed in part with dementia, gait abnormality, lack of coordination, fracture of humerus, laceration of part of head, maxillary fracture, and fracture of body of mandible. On 4/21/23 at 10:15 AM, V1 (Administrator) and V2 (DON/Director of Nursing) presented surveyor with R1's facility-reported incident of 1/30/23 and with all requested reportable and non-reportable incidents, along with incidents the facility was currently investigating. Interview with V2 stated, R1 was observed falling from her wheelchair while in the dining room during dinner. The nurse heard R1's alarm go off but (V12) was unable to get to her in time. R1 fell to the ground, and she had a cut to her chin and was sent out to the hospital and came back with sutures but no other injuries. Review of R1's progress notes contradicts V2's statement that R1 required only suturing when sent to the hospital. Facility progress notes written by V12 (LPN/Licensed Practical Nurse) dated 1/30/2023 22:15 showed, Incident Note: Received a call from on-call guardian, stated that resident is admitted for observation due to lung bruising and rib fractures. DON (V2-Director of Nursing) notified. V12 (LPN) wrote a subsequent entry in the progress note dated 2/2/2023 at 4:47 PM admission Summary: readmitted this [AGE] year-old female with diagnosis of maxillary fracture, fracture of mandibular condyle, laceration of lips and chin, right side Pulmonary Embolism, Lower Left Extremity Deep Vein Thrombosis. Transferred resident to bed by ambulance crew. Resident is awake and verbally responsive. Confused and disoriented. Able to somehow respond appropriately to closed ended questions. Denies pain at this time. Notified MD/ NP, orders verified, noted, and carried out. On-call guardian notified of readmission, also consents obtained for psycho-therapeutic medications. Hospital records dated 1/30/23 reads in part, Date of admission: [DATE]. Chief complaint: Fall. History of Present Illness: (R1) is a [AGE] year-old female with primary history significant for general weakness, dementia, depression, epilepsy, right humerus fracture, presents due to witnessed fall at nursing home. Got up from bed and fell onto face. Reports mild pain around mouth. Very poor historian. Does not recall events. In the ER: found to have a pulmonary embolism, Multiple facial fractures. Assessment and plan: Suspected mechanical fall out of bed and sustained facial trauma-- fractures of maxilla and mandible, including into teeth. ER consulted plastics and maxillofacial surgeon. Started on antibiotics for head/neck coverage regarding lip laceration and facial fractures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 14 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 V1 (Administrator) and V2 (Director of Nursing) were interviewed again regarding the inaccuracies of V2's report showing R1's report of injury, V1 and V2 stated, We're sorry, we just realized that the report was wrong and we will correct the report today to be submitted to your office. Surveyor asked if there were other omissions or inaccuracies not presented to surveyor, V1 and V2 stated, No we reported everything to you. Residents Affected - Some (Further review of V1 and V2's reports of accidents and incidents showed another facility-reported incident involving (R2) was not presented to surveyor as originally requested.) R1's care plan dated 11/18/22 revised 3/22/23 reads in part, R1 has had an actual fall due to dementia, poor balance, unsteady gait with witnessed fall on 11/17/22, unwitnessed fall on 11/26/22, witnessed fall on 12/2/22, unwitnessed fall on 12/23/22, and witnessed fall on 1/30/23. Goal: The resident will resume usual activities without further incident through the review date. Interventions: Resident will use a bed alarm to alert staff that the resident requires assistance; Resident will use geriatric chair to sit while in the dining room. MDS (Minimum Data Set) assessment dated [DATE] showed R1 as having severe cognitive impairment and required extensive assistance in all activities of daily living including transfers and mobility. Further review of MDS assessment section P (restraints and alarms) showed no usage of bed or chair alarms as per R1's care plan. Review of R1's prior MDS assessments dated 12/23/22, 1/30/23, and 2/9/23 all show R1 as requiring extensive assistance in all ADLs (activities of daily living) and again do not indicate usage of any bed alarms or chair alarms to prevent R1 from continued falling. Interview with V3 (Restorative Falls Nurse) on 4/21/23 at 2:30 PM stated, I am in charge of the falls. I am the restorative nurse and fall nurse. Surveyor asked about R1's last fall that occurred in January. V3 stated, The nurses let me know about (R1)'s fall. I found out it happened when the staff were passing dinner trays and the resident fell when she got up from where she was sitting, and she fell forward. She got stitches to her chin when she went to the emergency room and then she came back. Surveyor asked if those were the only injuries R1 sustained, V3 stated, Yes, that's what we talked about as a team in the morning meeting the next day. Surveyor asked what team she was referring to, V3 stated, The Administrator (V1), DON (V2), me, and all the department heads. We try to come up with good interventions to prevent falls and we usually refer all falls to physical therapy for working with balance and strength. Surveyor asked what fall preventative measures the facility used for high-risk residents, V3 stated, If they are unable to press the call light, we use bed alarms and chair alarms to alert staff. Surveyor asked if the facility developed a fall policy that the facility followed, V3 stated, We don't have a fall policy, we just discuss it. Surveyor asked how she conveyed to staff how to prevent falls without a policy, V3 stated, I don't know, but I will ask the DON. Surveyor asked if she was involved in training staff on how to prevent falls, V3 stated, Yes. I do the in-servicing on fall documentation, and we did it during a skill fair last month. Surveyor asked if there were any programs or symbols for staff to follow to identify residents that were at risk for falls, V3 stated, No we just discuss it, but what we last talked about with nurses was just how to document on falls. Surveyor clarified whether it was just documenting of falls when they occurred and not fall prevention that was in-serviced, V3 stated, Yes, I just talked about documentation. Interview with V12 (LPN) on 4/21/23 at 2:30 PM, V12 stated, I recall the incident with R1, that was during dinner time. I saw R1 on the other side of the hallway by the window maybe about 15 -20 feet away from me. I just saw her when she was on her way down, falling. The CNA's and I tried to get to her. I recall V9 (CNA) running to catch her before she fell too. We both tried to rush to her, but she fell, and we couldn't get to her. R1 had some minimal bleeding when she fell, and we stopped (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 15 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 - Some that bleeding and she was assessed. I was there and other staff members came running in to help stop the bleeding and do an assessment. Surveyor asked if there was some sort of code to prompt other nurses to come rushing into the unit, V12 stated, No. they probably just heard all the commotion. Surveyor asked if R1 only had minimal bleeding, why other staff rushed in to stop the bleeding, V12 stated, They just tried to help me because I was busy trying to do other things like call the ambulance. Surveyor asked if there was any specific staff member assigned to monitor the residents in the dining area, V12 stated, V9 (CNA) was supposed to watch R1 and the rest of the residents that day but the CNA's get too busy and have other duties. Surveyor asked if she could recall how many residents she normally took care of in the dementia unit, V12 stated, If it's a full house we usually have 33 residents and I think we were full then. Surveyor asked how many nurses and aides there were in the unit, V12 stated, There are usually 3 aides. sometimes we get agency CNA's, but there's normally 1 nurse. Surveyor asked what fall prevention measures were discussed or she did training on, V12 stated, Not too long ago we had a meeting and that was one of the subjects was about falls. Surveyor asked how she was trained to manage falls in the unit, V12 stated, There's been so many falls here. I've been here 26 years in the facility, and we have a lot of falls. That seems a lot, but you know, people get weak, and we discuss falls on a case-to-case basis. These residents, when they get older, they get more confused, so they will generally fall a lot. Surveyor asked what the facility did to prevent falls since, by her own account, there are a lot of falls, V12 stated, Like I said, residents have a right to fall, we can't prevent them from falling as much as we try. It's just a case-by-case basis. Interview with V9 (CNA/Certified Nursing Aide) on 4/21/23 at 3:50 PM contradicts V12's (LPN) account of R1's incident. V9 stated, I just tried to help her after she fell. I helped the nurse because she called for help. Surveyor asked what he was doing at the time R1 fell from her chair, V9 stated, In this time I passed the trays for dinner, so I was not involved in that when (R1) fell, I just heard a loud boom (V9 clapping his hands in a hard motion), but I never saw her fall . When I heard a boom and I saw her on the floor and she was bleeding on her face and the nurse (V12) was shouting help! help! but I was busy passing trays, so I did not see her fall, I just heard a loud boom on the floor. Surveyor asked if the sound he heard was an alarm, V9 stated, No she does not have an alarm, I heard her just fall because I heard just boom sound. Surveyor asked if he knows about the blue stars on the doors and when he was last trained on fall prevention, V9 stated, I don't know what that is (referring to blue stars) but we get in-service all the time, I do not remember when. Efforts to reach R1's attending physician for interview were left unanswered. Interview with V14 (Medical Director) on 4/21/23 at 2:55 PM, R1 is not my patient but I am involved with the quality assurance meetings which was just this past Wednesday of last week. We talked about falls and standard discussions. I usually ask whether a fall was preventable or could we have done something better. Sometimes falls are unpreventable falls due to psychiatric disorders, etc. Some repetitive fallers, we see if we can do something differently such as frequent rounding by staff, keeping the resident close to the nursing station, are they able to wear a helmet or use of a bed alarm or chair alarm, safety feature to the chair like anti-fallback mechanisms for the chair. We sometimes we ask families to come by more often because we can't have staff take the full burden of preventing falls. Surveyor asked whether R1 was discussed in one of their meetings, V14 stated, Yes, I recall it was a pretty significant fall with fractures and the Administrator and Director of Nursing were all involved in discussing that fall. Surveyor asked who informed her of R1's fall with fracture, V14 stated, V2 (Director of Nursing) was the one who told me because I remember we went through the standard questions and interventions and things, and I asked whether it was preventable. Surveyor asked if there was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 16 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 - Some any consensus on whether the fall was preventable, V14 stated, I'm not sure about that. I just know that there were evaluations done and I believe the staff initiated some additional interventions, but specifically for R1 I am not certain. Surveyor asked whether she knew if R1 fell prior to the last significant fall, V14 stated, From what V2 told me, that was the only one. Surveyor asked if she was aware or had any further input with the falls occurring in the facility, V14 stated, We discuss falls and I believe there has been some improvement. We've implemented a lot of different interventions specific to the resident and staff should ensure that these interventions are in place to make sure they are effective. Observations conducted on 4/22/23 at 11:53 am in R1's previous nursing unit showed 30 residents in the dining area with 1 nurse (V15-LPN/Licensed Practical Nurse) present in the room and 3 aides currently assisting residents during mealtime. Surveyor asked if she knew about R1, V15 (LPN) stated, Yes, I remember her, but I was not here when she fell. Surveyor asked if R1 was one of the residents that had a chair alarm, V15 stated, Yes, but they just started using it after that last fall in January. Surveyor asked if R1 was a frequent faller, V15 stated, Oh yes, she has fallen multiple times, but she is very difficult to manage, she is always trying to sit up and get out of her chair. Surveyor asked whether someone with that history of behaviors and falling should have been on some assistive device to prevent falls, V15 stated, Yes. We should have put a chair alarm and bed alarm on her sooner. Surveyor asked about the blue stars on resident doors and what they signified, V15 stated, You know the DON (V2) was here and told me that I should know about these stars which mean the resident is a fall risk. I've been here over 20 years and no one's every told me about any blue stars, but he (V2) just told me I should know about the blue stars but never came back and did any in-service on them. Surveyor asked if V3 (Fall Nurse) ever came to do training on the blue stars, V15 stated, Never. On 4/22/23 at 1:55 PM V1 (Administrator) was asked about the facility fall policy referred to as their Falling Star Program, V1 stated, we don't have a policy we just have meetings about who is at high risk for falls. Surveyor asked what the blue star decal on each door signified, V1 stated, I don't really know but I will find out about it. Surveyor asked whether it was the responsibility of the Administrator to know about a falls program given that falls are discussed during their morning team meetings, V1 stated, Yes, I should know but I will find out about the program and get back to you. V1 returned a half hour later and explained to surveyor that there was no policy or procedures pertaining to the Falling Star Program referred to by V15 but was in the process of being developed. 2. R2 is a [AGE] year-old having diagnoses listed in part with aphasia following stroke, anxiety disorder, gait abnormality, and fracture of left femur. On 4/21/23 at 10:15 AM, V1 (Administrator) and V2 (Director of Nursing) were requested to present the incident reports pertaining To R1 and any other reportable incidents currently being investigated. V2 returned 30 minutes later and presented surveyor with R1's incident report but omitted presenting any report for R2. Surveyor asked again whether all reportable incidents including any ongoing facility investigations were presented to the surveyor, V2 stated, Yes, I gave you everything. A review of facility records discovered R2's fall incident not reported to surveyor as requested. Interview with V1 (Administrator) stated, I discussed this with V2 (Director of Nursing) and it was just an error on his part. Surveyor reminded V1 that V2 also did not accurately report R1's fracture along with not providing R2's incident involving a fracture and asked how V2 could make several omissions for two very significant events. V1 responded that he would discuss this V2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 17 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 - Some Facility progress notes show on 4/12/2023 04:45 V16 (RN) wrote, Note Text: Prior to the incident, at around 4:00 AM, the resident was observed sleeping on her bed. At approximately, 4:45 AM, this writer heard the resident calling for help, this writer immediately rushed to the room, and observed the resident sitting on the floor next to her bed. When resident was asked what caused the fall, resident stated that she was trying to go use the washroom, but she lost her balance and fell. Head to toe assessment completed, resident complained of pain on the left hip area, left hip was kept immobilized, and resident sent out to ER for further evaluation. On 4/12/2023 08:39 AM V17 (LPN) wrote, Nurses Note: Resident complaints of pain on left leg and unable to move and stated that she might have broken something. Resident was moaning and crying due to pain. NP informed and sent out to ER to be assessed. Pain medication administered. Family informed and verbalized understanding. Resident picked up by ambulance at 9: 15 am, resident transferred from bed to stretcher with no issues. Documents and bed hold policy given to EMT. On 4/12/2023 14:54, V17 (LPN) wrote: Nurses Note: Called hospital for updates, RN stated that resident has been admitted to hospital for left hip fracture. Care plan dated 1/2/2023 reads in part, R2 is at risk for falls related to deconditioning, gait/balance problems, CVA (stroke). Goal R2 will be free of falls through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Care plan dated 4/11/23 reads in part, The resident has had an actual fall: unwitnessed fall on 4/8/23, unwitnessed fall on 4/12/23. Interventions: Physical therapy to evaluate and treat when resident returns from the hospital. Bed alarm will be provided to alert staff that resident requires assistance. On 4/21/23 at 10:20 AM, R2 was observed in her room asleep laying in her bed. R2's call light was hanging from the right side of the bed on to the floor. At 12:19 PM, R2 was observed shouting out to the hall for help but did not have her call light activated. Surveyor entered R2's room and asked if she needed help, R2 tried to let surveyor know what she wanted but was unable to make clear sentences to convey what she wanted, so R2 pointed to the chair in the corner. R2's call light remained on the floor and her bed appeared to be waist high off the floor and not lowered to the ground. There were no floor mats or bed alarm that appeared to be on her bed. V9 (CNA) entered the room and had difficulty understanding what R2 wanted. R2 was able to say, Water, I want water, white water. V9 left the room and came back with a pitcher of water. Surveyor asked V9 if the call light should be on the ground, V9 went over and placed R2's call light back onto R2's bed within her reach. V9 stated, It was on her last time. Sometimes it falls down. Surveyor asked if her bed should be that high up from the ground, V9 stated, No I will lower it down. Interview with V3 (Restorative Fall Nurse) on 4/21/23 at 2:30 PM stated, (R2) fell trying to get up from her bed. The nurse assessed her, but it was an unwitnessed fall, and she sustained a hip fracture. We discussed her fall in our team meeting and we are going to have PT/OT pick her up. We placed a bed alarm, and she is able to follow command but we still caught her trying to get up herself. Even when we give her medication, she tries to get up. Surveyor asked what other interventions the facility has tried to prevent R2 from falling, V3 stated, That's all we do for her to prevent her from falling. Surveyor asked again whether there were any other preventative measures used for R2 but V3 (Restorative Fall Nurse) could not provide any other examples of assistive devices such as fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 18 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 mats, call lights within reach, frequent monitoring, or low bed to prevent R2 from falling again. Level of Harm - Actual harm Review of R2's progress notes on 4/23/23 showed a 3rd preventable fall: Residents Affected - Some On 4/23/23 at 04:08 am, V16 (RN) wrote, Nurses Note: She tried a couple of times to get out of bed but much better than yesterday .She followed Nurse instruction . (There was no documentation as to what R2 needed from the nurse or what instructions or interventions V16 (RN) did to prevent R2 from falling out of bed.) On 4/23/23 at 8:00 AM, V7 (LPN) wrote, Incident Note. Prior to incident 7:30 a.m. resident was observed sleeping on her bed and bed set at lowest position with call light within reach and with bed alarm. Around 8:00 a.m. bed alarm went off and staff member rushed into the room and saw resident on the floor in an upright sitting position next to her bed. Staff alert this writer that the resident was observed on the floor. Writer quickly went to the room to check on resident and asked resident what happened, and resident stated she tried to get out of bed to go use the bathroom but felt weak and lost balance and fell. Head to toe assessment completed. No new redness or swelling noted, no shortening on any extremities. Resident verbalized pain in the back of her head. No bruise or lumps felt on back of head upon assessment at that time. Resident appeared agitated and anxious. No loss of consciousness. Able to move all extremities at baseline without complain of pain. Tramadol and Xanax given. Vital signs taken; Family notified and verbalized understanding. NP notified with orders to send the resident via 911 to hospital for further evaluation. 3. R3 is a [AGE] year-old diagnosed in part with Alzheimer's Disease, Chronic obstructive Pulmonary Disease, injury of the face, and traumatic hemorrhage of cerebrum. R3's care plan with multiple dates reads in part, R3 is at risk for falls related to gait/balance problems. On 2/19/21-resident fell in her room with laceration on top right forehead noted. sent to hospital for evaluation. On 10/23/21: Unwitnessed fall resulting in hematoma to chin. Sent to ER and returned without new orders. On 10/23 21: Witnessed fall. On 3/29/21 Witnessed fall; On 5/25/22 Witnessed fall, On 10/8/22-Unwitnessed fall; and on 4/8/23 Unwitnessed fall. Interventions: Resident will be close to the nurse's station for close monitoring; wheelchair axle lowered to ensure resident is sitting at the lowest position of the wheelchair; the resident uses chair and bed electronic alarm. Ensure the device is in place as needed. A facility incident written by V18 (RN) dated 4/8/23 shows in part, Prior to incident at around 2:50 PM, the resident was sitting on her wheelchair at the dining room. At approximately 3:00 PM, other nurse on duty observed the resident trying to get up from her wheelchair and ran to her but could not get to the resident on time to prevent the fall. Nurse on duty immediately went to assess the resident. Resident was laying on her right side and noted bleeding by her head. Head to toe assessment done. Applied pressure dressing and cold pack to stop the bleeding. Called 911 to send to the ER for further evaluation. Facility incident report does not indicate whether a chair alarm activated nor identified the other nurse on duty. Interview with V2 (Director of Nursing) on 4/21/23 at 10:15 AM stated, V18 (RN) wrote the incident report but she was not the one that observed this fall. Surveyor asked if V18 didn't observe the fall, why she made the entry in the nursing notes, V2 stated, That's just how we do incidents here. Surveyor asked if R3 should have a chair alarm to alert staff if she stood up from the chair, V2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 19 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 stated, She should but I see that V18 didn't put that in her report, so I don't know whether she did or not. Level of Harm - Actual harm On 4/11/23, R3 was readmitted back to the facility. V19 (RN) wrote in part: 4/11/2023 15:00 admission Summary: re-admitted this [AGE] year old, female white, from hospital per stretcher accompanied by 2 paramedics with the diagnosis of Frontal Lobe Hematoma, alert with periods of confusion and forgetfulness, physical assessment done, abdomen soft and non-tender with colostomy bag on right mid abdomen intact and patent, lungs field clear and no congestion, old bruise on right forehead with skin tear with 4 stitches, dry and clean , bruise on right eye. Residents Affected - Some Interview with V3 (Restorative Falls Nurse) on 4/21/23 at 2:30 PM stated, (R3) is wheelchair bound and she was in her wheelchair at the time of this incident and she tried to get up and she fell because she doesn't have good balance. We had a chair alarm for her to prevent her from falling. V5 (RN) happened to be in same hallway when she attempted to prevent the resident from falling but the resident fell to the right side of forehead. Surveyor asked what fall preventative measures the facility used for R3, V3 stated, We tried to encourage her to sit by the nurse's station because she moves herself and we try to get more supervision. Surveyor asked whether she was present during R3's fall incident, V3 stated, No she fell over the weekend, so I did not see it, it was just reported to me and we talked about it in our morning meeting. Surveyor asked if she knew whether the chair alarm was activated for R3 as there is no indication of it in the incident report going off to warn staff the resident was about to fall, V3 stated, I don't know for sure, I just know staff should have it on when R3 is in her wheelchair. Surveyor asked whether R3's latest fall was witnessed or unwitnessed as the care plan listed the fall as an unwitnessed fall, but the incident report showed it was witnessed, V3 stated, I don't know. 4. R4 is a [AGE] year-old cognitively impaired resident with diagnoses of dementia, unsteadiness of feet, nondisplaced fracture of 5th cervical vertebra, fracture of shaft of humerus (left arm), and fracture of left rib. R4's care plan showed previous falls: 15 unwitnessed and 2 witnessed falls. Care plan reads in part, (R4) is at risk for falls related to overactive bladder, osteoporosis, dementia, anxiety, major depression, and partial hearing loss. Interventions: The resident will be provided with a helmet to prevent injuries; Resident will use a bed alarm to alert staff that resident requires staff assistance; Offer and assist the resident to use the bathroom at night at least every 2 hours. Resident was provided visual reminders to call for assistance with activities of daily living; the resident uses chair electronic alarm. ensure the device is in place as needed. Interview with V3 (Restorative Fall Nurse) on 4/21/23 at 2:30 PM stated, When R4 last fell (3/31/23), She tried to get up from the wheelchair. She got another cut to her right side of her head, and she was sent out 911. She received sutures. Surveyor asked how many falls R4 had and what the facility was doing to prevent further falls, V3 stated, I know she fell a lot but we are using a geriatric chair instead of a wheelchair, we tried to use a geriatric chair and there is an alarm on her geriatric chair. I think we just put her on a geriatric chair after this last fall. A facility policy dated March 2018 titled Assessing Falls and Their Causes does not address fall prevention but shows policy and procedures for assessing falls after they've already occurred. This facility policy reads in part, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 20 of 21 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 145741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Glenview,the 1700 East Lake Avenue Glenview, IL 60025 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 There was no policy or procedures for the facility's Falling Star program for residents considered at-risk for falls. According to V1 (Administrator), the program policy had not yet been developed. Level of Harm - Actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145741 If continuation sheet Page 21 of 21