Inspection·December 17, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. R5 is a [AGE] year old with diagnosis of dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Care plan for ADLs dated 10/6/23 showed (R5) has ADL self care performance deficit and impaired mobility related to generalized weakness, decreased range of motion, easy fatigability, poor endurance, limited activity tolerance and impaired mobility. Interventions: Bed Mobility: requires substantial assistance with repositioning and turning in bed. Transfer: requires substantial assistance with transferring. Eating: requires partial assistance with eating: requires substantial assistance toileting. Personal hygiene/oral care: requires substantial personal hygiene and oral care assistance. Bathing: (R5) requires substantial assistance with bathing. On 12/17/23 at 10:55 AM, R5 was observed naked in bed, breasts exposed, and wearing only an incontinence brief. Her call light was placed behind the bed away from R5's reach in order to get assistance. R5 appeared confused and was heard mumbling words. V15 was asked about R5's current condition, V15 stated, I was just going to change her. I went to get supplies so I can change her linens. Surveyor asked if she normally would leave the resident naked in bed alone to get supplies, V15 stated, No but I just changed her diaper and I went to get new sheets. After V15 was changing the linens on the bed, V15 started putting a clean gown on the resident to cover up her body, surveyor asked the aide to stop and requested to check the incontinence pad on the resident. V15 stated, I already changed that. Surveyor asked to see the under the incontinence pad to verify check her skin. V15 removed the incontinence brief and revealed a large amount of feces that spread up toward the residents vaginal area. V15 stated, She must have done that while I went to get linens because I had just changed her. 3. R6 is [AGE] year old with diagnosis of vascular dementia, hemiplegia, diabetes, and history of falling. Care plan dated 1/6/23 reads in part, R6 has an ADL self care performance deficit related to generalized weakness, impaired mobility, decreased activity tolerance secondary to multiple complex diagnosis. Goal: Resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review. Interventions: Bed Mobility: resident require extensive (2) staff participation to reposition and turn in bed. Transfer: resident requires total (2) staff participation with transfers Dressing: resident require(s) extensive (1) staff participation to dress. Toileting: require(s) extensive (2) staff participation to use toilet. Personal hygiene/oral care: requires extensive(1) staff participation with personal hygiene and oral care. Bathing: resident requires extensive(2) staff participation with bathing. On 12/17/23 at 11:15 AM, R6 was observed in bed fully naked with V17 (agency CNA) cleaning the resident with feces being wiped away from the resident's genitals. Surveyor asked how long R6 was in bed with the amount of feces that were on the resident, V17 stated, I have no idea. I'm agency and I don't really know this resident. I saw him earlier and he was asleep but I didn't check if he was dirty or anything like that if that is what you're asking. Surveyor asked if providing a bath for the resident was warranted, V17 stated, No. I can clean him up good. Surveyor asked if he was going to ask for assistance to reposition the resident so he could clean R6's underside, V17 stated, I have this section and I wouldn't be able to get someone to help me anyway. R6 appeared disheveled with long matted gray hair, full gray beard, and both legs that were severely dry and cracked. The air mattress the resident was on had remnants of food and dry skin and other bodily stains. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 2 of 5 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 12/17/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Policy dated August 5, 2023 titled ADL care reads in part, ADL care is provided for each resident in the facility in accordance to the resident's comprehensive assessment and care plan in order to identify, evaluate, and intervene to, maintain, improve or prevent an avoidable decline in ADLs' ADL nursing care is performed daily for the residents based on the comprehensive assessment, plan of care, physician orders. Such care may include as appropriate: maintaining good body alignment and proper positioning. Recognizing and assessing an inability to perform ADL's or at risk for decline. Encouraging and assisting bedfast residents to change positions at least every two hours. Making every effort to keep residents active and out of bed for reasonable periods of time. Incontinent care and bowel and bladder training as indicated. Daily assistance in eating, grooming and hygiene, transfer, locomotion and mobility. Policy dated 7/28/23 titled Incontinent and perineal care reads in part, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 3 of 5 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 12/17/2023 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 ensure infection control procedures were followed and implemented to prevent the spread and transmission of COVID-19 within the facility during a COVID outbreak. Facility staff failed to conduct proper hand hygiene, gowning and doffing, and proper wearing of PPE (Personal Protective Equipment) to contain the spread of infectious disease. This failure has the potential to affect all 231 residents currently residing in the facility. Residents Affected - Many Findings include: At time of entrance, facility provided census indicating 231 residents currently in the facility. On 12/16/23 at 9:50 AM, surveyor entered the facility and asked V4 receptionist if there was any COVID-19 in the facility whereupon V4 indicated that she was uncertain if there was any at all because she only worked part time on Saturdays and Sundays and was not informed of any. Surveyor asked who the person in charge was for the weekend, V4 stated that V3 (Social Service Director) was the manager on duty. V4 was asked if there were any COVID in the facility and indicated that there was but was not certain the number of residents affected. V4 was asked by surveyor how as the manager on duty for the day, how she could contain the spread of COVID-19 within the facility, if she did not know which floors were affected by the outbreak, V4 stated, I can find out for you. Observations on 12/16/23 upon entrance to the facility showed no warning signs for visitors that the facility was under current COVID-19 outbreak status. On 12/116/23 at 10:40 AM, V3 (director of nursing) upon arrival to the facility later provided the accurate number of residents to the surveyor which were a total of 231 current residents and confirmed that there was a COVID-19 outbreak in the facility which included 15 COVID positive residents that resided on the 4th and 5th floors. On 12/16/23 at 10:10 AM, surveyor entered the 5th floor and approached V5 (LPN- licensed practical nurse) who offered surveyor an N95 mask and face shield. V5 stated, I'm sorry sir, they should have told you that it is required to have an N95 mask up here and also a face shield since we are on COVID outbreak status. V5 indicated that there were COVID positive residents on the floor and that staff were required to wear the appropriate PPE (personal protective equipment) such as gloves, gown, mask and faceshield when having any contact with the resident in the isolation room. Surveyor clarified if masks were required to be worn on the floor and which residents were on isolation, V5 stated, Yes all staff should wear their masks at all times especially when on this floor since this is where our COVID outbreak is, Rooms with red zone sign are on isolation and you'll see signs on the door and isolation cart outside the door. On 12/16/23 at 10:15 AM, V9 (Agency CNA- Certified Nursing Assistant) was observed going in and out of R3's room which had a red zone sign outside her room and isolation bins immediately outside indicating that the resident was on strict isolation. V9 was wearing gloves and a mask but did not wear a gown or face shield as she proceeded to conduct patient care on R3. V9 did not wash her hands prior to wearing gloves nor changed her gloves as she emptied the garbage and collect linens. V9 took the dirty and soiled linens, placed them in the bag and walked out of the room to throw the bag of linens in the linen room and returned back to R3's room without replacing her soiled gloves. Surveyor asked V9 if she was supposed to be washing her hands in between patient care and emptying the garbage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 4 of 5 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 12/17/2023 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 and changing linens, V9 stated, I guess so but I'm usually on the 4th floor and this is my first time up here. I'm agency so they didn't tell me anything about that. Surveyor asked if there were COVID patients on the 4th floor she had worked on, V9 stated, Yes I think so. I saw a lot of residents on isolation but they (referring to nurses) don't tell us if they're on isolation or for what. Surveyor clarified what floors she worked on, V9 stated, I've worked everywhere in this building and no one has told me anything about that because I'm agency. At 10:30 AM V10 (LPN) was standing in the hall by her medication cart and was asked about R3 and stated, I just got here and nobody told me anything about her. Surveyor asked if R3 was on any isolation precautions, V10 stated, I think so but I would have to check. Review of records showed R3 to be on strict isolation due to COVID-19 infection and readmission from the hospital. Surveyor asked if the 5th floor was her regular floor, V10 stated, No I'm not a regular here and I float (meaning can and have worked all floors). At 11:15 AM, R6 was observed in bed with V17 (Agency CNA) observed with a mask but no face visor as per the facility policy when working on a floor with active COVID. V17 was using a gloved hand to clean R6 and wiping the residents feces and throwing the dirty wipes in to a bag that was strewed on to the floor. Outside the residents room was also a dirty bag filled with linen and soiled cloths that was in the center of the common area. Surveyor asked V17 if the bag was his, V17 stated, Yes, I put it there because I'm going to throw it away once I'm done cleaning up (R6). Surveyor asked what was in the bag and if it should be on the ground in the middle of the hall, V17 stated, Sorry its soiled clothes and linens from another resident I cleaned so I put it there but I'll get rid of it as soon as I'm done here. V5 (LPN) was shown the bag in the hall and also a bag on the ground in the resident's room, V5 stated, No that should not be there. Surveyor asked if that was proper to maintain good infection control, V5 stated, No it is not. I will have him remove it immediately. Surveyor asked where V17 normally works, V5 stated, (V17's) agency so he works anywhere we are short-staffed. Revised policy dated 11/7/22 titled COVID 19 Guidelines and Emergency Preparedness Plan reads in part but not limited to: Inservice all staff on infection control procedures to prevent COVID 19 including but not limited to, risk of transmission, infection control practices including frequent handwashing x at least 20 seconds or use of alcohol gel, avoiding touching of face, nose, and mouth, and avoidance of crowded places or events, keeping a distance of 6 feet from individuals with respiratory illness, use of PPE, Standard, Contact, and Droplet Precautions, Proper Donning and Doffing of PPEs, Extended Use and Reuse of PPEs per CDC, staff and resident screening for COVID 19 and respiratory illness, Cough Etiquette, and Vaccination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145931 If continuation sheet Page 5 of 5