Inspection·January 27, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to administer the medication as ordered for one (R163) of eight residents observed for medication administration in a sample of 36. Residents Affected - Few Findings include: On 01/25/2023 at 2:20PM during observation, V19 (Licensed Practical Nurse - LPN) was observed administering medication for R163 through the gastric tube. Record review revealed order for medication Carbidopa - Levodopa tablet 25-100 milligrams by mouth three times a day. Care plan reviewed 12/16/22 indicated R163 is receiving the medication and interventions include to administer medication as ordered. On 01/25/2023 at 2:59PM, V2 (Director of Nursing) stated that she expects the nurses to administer the medication as ordered. Facility Policy: Title: Physician Orders Reviewed: 7/28/2022 Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (Physician Order Sheet). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 2 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure physician orders were followed for 1 of 7 residents R99, reviewed for edema, the facility also failed to implement a comprehensive person-centered care plan intervention for 1 of 1 resident R99 in a sample of 36. Residents Affected - Few Findings include: On 1/24/2023 at 11:10am R99 was observed up in her wheelchair with edema to her bilateral lower legs. R99 said via V7(Translator/Social Worker) that she was waiting for the nurse to wrap her legs which should be completed before getting up to her wheelchair and its never completed. On 1/24/2023 at 11:115am V8 (Registered Nurse-RN) said R99 should have her legs wrapped for edema at 6am before getting out of bed. On 1/26/2023 at 11:30am V2 (Director of Nursing-DON) said she expect the nurses to follow the Physicians order and apply the leg wraps, the treatment should also be care planned. On 1/26/2023 at 11:50am V9(Minimum Data Set-MDS NURSE) said that R99 leg wraps should be care planned and will add it to the care plan now. 1/26/2023 A Order Summary Report dated 1/24/2023 indicates that R99 has an order dated 11/2/2021 for leg wraps to both lower extremities on in morning and off in the evening for edema. A care plan dated 1/26/2023 a focus of impaired circulation related to edema and intervention to apply leg wraps to bilateral lower extremities in the morning and remove at bedtime. Facility Policy: Physician Orders Revised 7/28/2022 Policy statement It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the (POS-Physician Order Summary). 6. Physician orders will be carried out at a reasonable time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 3 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that physician orders was followed regarding pressure ulcer preventive measures for one resident (R188) out of eight residents reviewed for ulcer preventive measures in the sample of 36. Residents Affected - Few Findings include: On 1/24/2023 at 3:10 PM, R188 was observed in his bed without his heels offloaded with pillows or heel boots. On 1/25/2023 at 11:35 AM, surveyor observed R188 in bed without his heels offloaded with pillows or heel boots with V4 (Nurse). On 1/25/2023 at 11:37 AM, V4 (Nurse) said that R188 should have his heels offloaded with pillows or heel boots. On 1/25/2023 at 3:09 PM, V2 (DON) said that her expectation is for the staff to carry out the physician's order. R188, a [AGE] year old male was admitted on [DATE] with diagnosis not limited to Alzheimer's disease, retention of urine, and other abnormalities of gait and mobility. Review of R188's physician orders of 11/29/2022 documents: offload heels with pillows or heel boots when resident is in the bed. Review of R188's care plan initiated on 11/29/2022 documents: R188 has a potential impairment to skin integrity and was assessed to be at risk for further skin breakdown related to presence of current skin impairment, incontinence of bowel, decreased ADLs functional ability, Braden Score: 13 and secondary to disease process/DX : HTN, PBH, ALZHEIMER'S DISEASE, CAD. Legacy HealthCare Physicians Orders Revised: 7/28/2022 Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS. Procedures: 6. Physician orders will be carried out at a reasonable time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 4 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. 2. On 1/24/2023 at 10:30am R132's door was observed with a falling leaf indicating that R132 is a high fall risk. R132 was observed in bed raised high off the floor, call light out of reach, and bed bolsters not on bed. Residents Affected - Few On 1/24/2023 at 10:40am V5(Licensed Practical Nurse-LPN) observed with the surveyor that R132 is a high fall risk indicated by the leaf on the door and fall interventions where not in place, V5 lowered the bed to the floor, placed the call light in reach and said she did not know if R132 had bed bolsters. On 1/24/2023 at 10:55am V6(Fall/Psych Coordinator) said R132 is in the falling leaf program indicated by the leaf on the door and all fall interventions should be in place and that the bed bolsters were put on the bed as of now. On 1/26/2023 at 11:00am V2(Director of Nursing-DON) said R132 is a high fall risk and that she expects all fall interventions in place for a resident that is at risk for falls. A Order Summary Report dated 1/24/2023 indicates that R132 has a history of repeated falls. A care plan dated 9/7/2021 that focus on high risk for falls, interventions dated 10/15/2021 to ensure call light is placed in reach, and bed bolsters on mattress dated 6/24/2022. Based on observation, interview and record review, the facility failed to ensure fall interventions were in place for three (R132, R141, R165) of fourteen residents reviewed for falls in a sample of 36. Findings include: 1. On 01/24/2023 at 11:10AM during observation in the dining room, R141 and R165 were observed sitting in the wheelchair with chair alarms. V25 (Certified Nursing Assistant - CNA) was asked for assistance to check if the chair alarm is working, chair alarm did not work when the cord was pulled out from the alarm. On 01/24/2023 at 11:12AM, V25 (CNA) stated that the chair alarms should be working because restorative checks it every morning. R141's Order Review Report dated 01/06/2023 indicated admission date of 11/02/2019 and diagnosis of but not limited to restless leg syndrome. R165's Order Review Report dated 01/06/2023 indicated admission date of 08/26/2021 and diagnosis of but not limited to hyperlipidemia. Facility Policy: Fall Prevention Program Guidelines Reviewed: August 5, 2022 Policy Statement: Fall prevention program guidelines shall be implemented to promote safety of all residents in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 5 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Procedure: Level of Harm - Minimal harm or potential for actual harm 2. Safety interventions shall be initiate and implemented for each resident identified at risk for fall. Residents Affected - Few 3. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. 7. An individualized evidence-based plan of care shall be created to reflect fall prevention interventions which include but not limited to: a. Place call device within reach at all times and respond to call light promptly. k. May utilize personal alarms when appropriate such as bed alarms, chair alarms and motion sensor alar and floor mat alarms p. Ensure equipment is properly functioning and maintained FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 6 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observations, interviews, and record review the facility failed to follow their care plan and monitor one resident (R170) of 1 resident reviewed for urinary catheters in a sample of 36. This failure resulting in one resident (R170) urinary catheter having sediments for 2 days without any interventions. Findings Include: On 01/24/23 at 12:58 PM R170's urinary catheter bag was uncovered and draining yellow urine with sediments. Observed urine with thick sediments in about 80% of tubing. On 01/25/23 at 1:46 PM with V16 (RN) observed sediments in catheter tubing. Observed the catheter is not attached/anchored to resident's leg. V16 states the catheter should be anchored to R170's leg. Surveyor pointed out the urinary catheter tubing to V16 and he states there are sediments in the catheter and when there are sediments in the catheter they call the nurse practitioner to make them aware. R170's nursing note dated 1/26/2023 at 11:26 AM documents: CNA reported resident noted with cloudy urine in foley bag. Writer observed sediment in foley bag. On 1/26/23 at 10:41 AM V2 (DON) states staff should empty foley every shift. The catheter should have a privacy bag and not be touching the floor. V2 states nurses should be assessing for functioning, color, output, and monitor for sediments daily. V2 DON states if sediments are found the nurse should irrigate and notify the doctor because maybe there is a urinary tract infection (UTI) or infection. R170 care plan documents: Resident has potential for infection related to presence of indwelling foley catheter related to urinary retention. Date 9/29/2022. Interventions: Monitor indwelling foley catheter for sediments and hematuria. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 7 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observations and interviews the facility failed to follow federal guidelines and have nurse staffing information readily available in a readable format to residents and visitors at any given time. This failure had the potential to effect all 195 residents living in the facility. Residents Affected - Many Findings include: On 1/24/2023 at 1:30 PM surveyor did not observe any Payroll Based Journaling (PBJ) posted in the lobby anywhere. V15 (ADON) is in the lobby reception area, then showed surveyor the staffing schedule, not the PBJ. On 1/25/2023 at 10:30 AM No PBJ posted in the lobby area or anywhere visible. On 1/26/2023 at 10:00 AM No PBJ observed posted in the lobby area or anywhere visible. On 01/26/23 10:38 AM V17 (Staffing Coordinator) states that she usually post the PBJ at the reception desk in the lobby but has not done it because the construction took it away. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 8 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to label and store medications properly for five of five medication carts and one of three medication room refrigerators reviewed for medication storage. Findings include: On 01/24/2023 at 3:17PM during observation with V20 (Registered Nurse - RN), 6th floor unit C and D medication carts were observed with the following: 1. R22's Calcitonin 200 units/actuation (act) nasal spray - no open date; label indicates discard after 30 days 2. R132's Calcitonin 200 units/act nasal spray - no open date; label indicates discard 3. R77's Tiotropium bromide 2.5micrograms (mcg)/act (3 sprays) - no open date; label indicates discard 3 months after 4. R77's Ipratropium bromide and albuterol 20mcg/100mcg/act inhalation spray (2 sprays) - no open date; label indicates discard 3 months after On 01/24/2023 at 3:42PM during observation with V21 (RN), 7th floor unit C and D medication cart was observed with the following: 1. House stock Diphenhydramine 25 milligrams (mg) caplets - manufacturer's expiration date 08/2021 2. Glucosamine & Chondroitin 500mg/400mg tablets - manufacturer's expiration date 09/2022 3. 2 opened bottles of clear emollient lubricant gel drops - manufacturer's expiration date 10/2020 4. R4's Insulin glargine 100 units/milliliter (mL) - no open date; label indicates once opened refrigerated or not discard after 28 days 5. R53's Insulin glargine 100 units/mL - no open date; label indicates once opened refrigerated or not discard after 28 days On 01/25/2023 at 9:38AM during observation with V22 (RN), 4th floor unit C and D medication cart was observed with the following: 1. R39's Budesonide 0.25mg/2mL nebulization suspension - one open foil pack noted inside the box with no open date; label indicated once foil pack opened use vials within 2 weeks 2. Opened Calcitonin 200 units/act nasal spray - not in a labeled bag, no open date 3. Opened and unlabeled lubricant eye drops - manufacturer's expiration date 11/2022 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 9 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm On 01/25/2023 at 10:08AM during observation with V19 (Licensed Practical Nurse - LPN), 5th floor unit C and D medication cart was observed with the following: 1. Resealable bag labeled with R141's name with opened without box umeclidinium and vilanterol 62.5mcg/25mcg inhalation powder with open date 11/20/2022. Inhaler indicated discard 6 weeks after. Residents Affected - Some 2. Resealable bag labeled with R33's name with opened without box fluticasone furoate and vilanterol 200mcg/25mcg inhalation powder without open date and indicated discard 6 weeks after. On 01/25/2023 at 11:00AM during observation with V4 (LPN), 3rd floor unit A and B medication cart was observed with the following: 1. R146's umeclidinium 62.5mcg inhalation powder without foil tray - no open date; label reads discard 6 weeks after foil tray opened 2. R177's ipratropium bromide and albuterol 20mcg/100mcg/actuation inhalation spray with open date 01/21/2022 - label reads discard 3 months after opening 3. Two of R2's fluticasone furoate and vilanterol 200mcg/25mcg inhalation powder - no open date; label reads discard 6 weeks after opening On 01/25/2023 at 11:26AM during observation with V4 (LPN), 3rd floor medication room refrigerator was observed with last temperature check on September 6, 2022. On 01/24/2023 at 3:34PM, V20 stated that there should be an open date on the nasal sprays and inhalers. She also said that the expired medications should be removed from the cart immediately upon expiry. On 01/24/2023 at 4:05PM, V21 said that expired medications should be removed from the cart. She also said that insulins should have open dates on them. On 01/25/2023 at 10:00AM, V22 said that medications that are already expired should be discarded. She also added that nasal sprays and inhalers should have open dates. On 01/25/2023 at 10:35AM, V19 said that inhalers should have open date and discarded per manufacturer's guidelines. On 01/25/2023 at 11:23AM, V4 stated that the expired medications should have had opened dates and discarded after the manufacturer's recommended discard date. At 11:27AM, she said that the refrigerator temperature should have been checked by night shift daily. On 01/25/2023 at 2:59PM, V2 (Director of Nursing) said that she expects the nurses to remove and discard all expired medications, put open date on inhalers and nasal sprays, and check and monitor the medication refrigerator temperatures daily. Facility policies: Title: Medication Storage, Labeling, and Disposal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 10 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Reviewed: 10/24/2022 Level of Harm - Minimal harm or potential for actual harm Policy Statement: It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. Residents Affected - Some Procedures: 2.And the medication automatically expires based on the expiration date based on the manufacturer's guidelines. Title: Medication Pass Reviewed: 7/28/2022 Procedures: Medication Labeling 3. Follow pharmacy recommendation as to when the medication should be discarded after opening. Title: Refrigerator and Resident Appliance Maintenance Service Reviewed: 07/28/2022 Policy Statement: It is the policy of this facility to provide maintenance services for refrigerator units in resident rooms, common areas/dining rooms and nurses station. Procedures: 2. The facility will perform the following refrigerator checks: c. Temperature is maintained below 41F and above 32F using a thermometer with +-3 degrees temperature variance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 11 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to follow their policy on storing and dating opened food Items in the refrigerator cooler for 94 of 95 residents eating in the facility. Residents Affected - Many Findings include: On 1 /24/2023 at 10:00am during an initial tour of the kitchen, the surveyor observed in the refrigerated cooler had 9 large pans of prepared raw beef with out a covering or a date, 2 large containers without a covering of raw white potatoes cut and peeled in water no date. On 1/24/2023 at 9:50am V10(Food Service Director) said all food that is prepared or open should be covered and dated. Facility Policy: Kitchen Revised 7/28/2022 Policy Statement The facility will comply with state and federal regulations in operating facility's kitchen. Procedures: 1.Food Storage e. Refrigerated food should be covered, dated, labeled, and shelved to allow air circulation. h. Open containers or potentially hazardous food or leftover should be dated and used within 3-5 days in the refrigerator. Based on observation, interview and record review, the facility failed to monitor the resident's refrigerator temperature for five (R128, R171, R184, R134, R82) of seven residents observed for food safety in a sample of 36. Findings include: On 01/24/2023 at 10:21AM during observation with V24 (Licensed Practical Nurse - LPN), R128's refrigerator was observed with last temperature check on July 22, 2022. On 01/24/2023 at 10:23AM during observation with V24, R171's refrigerator was observed with last temperature check on May 16, 2022. On 01/24/2023 at 10:26AM during observation with V24, R184's refrigerator was observed with last temperature check on May 16, 2022. On 01/24/2023 at 10:29AM during observation with V24, R134's refrigerator was observed with last temperature check on May 16, 2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 12 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 01/24/2023 at 10:32AM during observation with V24, R82's refrigerator was observed with last temperature check on May 16, 2022. On 01/24/2023 at 10:30AM, V24 said that the refrigerator temperature should be monitored daily. On 01/25/2023 at 2:59PM, V2 (Director of Nursing) stated that all refrigerator temperatures should be monitored daily by housekeeping. R128's Order Review Report dated 01/06/2023 indicated admission date of 08/17/2019 and diagnosis of but not limited to essential hypertension. R171's Order Review Report dated 01/06/2023 indicated admission date of 10/22/2021 and diagnosis of but not limited to essential hypertension. R184's Order Review Report dated 01/06/2023 indicated admission date of 08/18/2022 and diagnosis of but not limited to type 2 diabetes mellitus. R134's Order Review Report dated 01/06/2023 indicated admission date of 10/07/2022 and diagnosis of but not limited to hyperglyceridemia. R82's Order Review Report dated 01/06/2023 indicated admission date of 12/07/2021 and diagnosis of but not limited to secondary hypertension. Facility Policy: Title: Refrigerator and Resident Appliance Maintenance Service Reviewed: 07/28/2022 Policy Statement: It is the policy of this facility to provide maintenance services for refrigerator units in resident rooms, common areas/dining rooms and nurses station. Procedures: 2. The facility will perform the following refrigerator checks: c. Temperature is maintained below 41F and above 32F using a thermometer with +-3 degrees temperature variance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 13 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to post visual alert signs at the entrance of the facility notifying visitors entering the building about facility's COVID-19 status. They also failed to sanitize the glucometer in between resident's use and post the transmission-based precaution sign on R1's door affecting three of eight residents reviewed for infection control in a sample of 36. Residents Affected - Many Findings include: 1. On 1/24/23 at 9:30 am, the entrance of the facility was observed with no sign notifying visitors of the facility's COVID-19 status. During an interview on 1/24/22 at 9:30 am, V2 (Director of Nursing) stated that the facility currently has four COVD-19 residents. On 1/26/23 at 9:30 am, V15 (Infection Retentionist) stated that a sign should be posted with the facility's COVID-19 status at the facility's entrance. Facility's policy titled: COVID 19 Testing Plan and Response Strategy revised 1/6/22 reads. Infection Prevention and Control Interventions. 4. Screening: Instead the facility must establish a process to inform HCP, residents, and visitors of recommended actions to prevent the transmission of COVID-19 by posting visual alerts (e.g sings, posters) at the entrance and other strategic places. These alerts should include instructions about current infection prevention control recommendations (e. g, when to use source control and perform hand hygiene). 2. On 01/24/2023 at 10:25AM during observation, R1's door was not observed with any transmission-based precaution (TBP) sign and cart. On 01/25/2023 at 9:05AM during observation, R1's door was again observed without any TBP sign and cart. On 01/25/2023 at 10:49PM during observation, V19 (Licensed Practical Nurse - LPN) was observed checking blood sugars of R136 then immediately proceeded to checking blood sugar of R10 without disinfecting the blood glucose machine. On 01/25/2023 at 2:00PM during observation, V19 observed the order for isolation - contact precautions for R1. R1's room was also observed with V19 and V26 (LPN) and noted without any TBP sign and cart at the door. On 01/25/2023 at 10:55AM, V19 stated that he is not sure if he needs to disinfect the blood glucose machine in between residents. On 01/25/2023 at 2:00PM, V26 said that the isolation has been discontinued. When the order was presented to her, she said she will call the Infectious Disease and ask if it needs to be discontinued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 14 of 15 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 01/25/2023 at 3:45PM, V3 (Wound Care Director) said that R1 is not on any contact precaution but he is on Enhanced Based Precaution (EBP) due to his wounds. She said that EBP does not need a physician order, but TBP cart and sign should be placed on the door. R1's Order Review Report dated 01/06/2023 indicated admission date of 10/08/2021 and diagnosis of but not limited to protein-calorie malnutrition. Facility Policy: Title: Glucose Meter Cleaning Reviewed: 7/28/22 Policy Statement: To ensure safe, convenient and proper cleaning and disinfection of Blood Glucose Meters in accordance to CDC (Center for Disease Control and Prevention) guidelines and manufacturer's instructions to help prevent device exposure to bloodborne pathogens. Procedures: 4. Clean and disinfect glucose meter with Clorox Healthcare Bleach Germicidal Wipes/Microkill Wipes/Microdot Wipes/Avert Wipes before after each resident use. Title: Observational Competency: Blood Glucose Monitoring Task: 6. After checking the blood sugar of the resident, the nurse cleaned the accu-check machine using the disinfectant solution as per facility's policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 15 of 15