Inspection·March 2, 2023

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess and provide adaptive hand support to a resident with hand contracture, to prevent further reduction in mobility and ROM (range of motion). This applies to 1 of 2 resident (R55) reviewed for mobility and range of motion in the sample of 30. The findings include: R55 was admitted to the facility on [DATE]. R55 has multiple diagnoses which includes hemiplegia following cerebrovascular disease affecting the right dominant side, left and right-hand contracture and weakness, based on the diagnosis/history sheet. R55's quarterly MDS (Minimum Data Set) dated January 31, 2023 shows that the resident is severely impaired with cognition. The same MDS showed that R55 required extensive to total assistance from the staff with his ADLs (Activities of Daily Living). On February 27, 2023 at 11:12 AM, R55 was sitting in his high back reclining wheelchair, inside the unit dining area. R55 was alert but with confusion. R55's bilateral hands were contracted, however, only his left hand had a hand roll. On February 28, 2023 at 12:00 PM, R55 was sitting in his high back reclining wheelchair, inside the unit dining area. R55 was alert and verbally responsive. R55's bilateral hands were contracted with a hand roll only on his left hand. During this observation, V4 (Director of Quality Management/Infection Preventionist) and V12 (Nurse) were present. V4 stated that because of R55's hand contractures he will ask the therapy department to evaluate the resident. On February 28, 2023 at 2:36 PM, V13 (Occupational Therapist) stated that she had evaluated R55 that day. V13 stated that R55 was admitted at the facility with bilateral contractures, had bilateral hand surgery and was using bilateral hand splints. V13 stated that R55 had received OT (occupational therapy) services from December 5, 2022 through February 15, 2023, and during those OT services, the resident was still tolerating his ordered bilateral hand splints. However, at some point (does not know when) R55 started refusing the hand splints because he was not able to tolerate it. According to V13, based on her evaluation of R55 on February 28, 2023, she is recommending that the resident use bilateral hand roll to prevent further contracture and to ensure skin integrity. R55's occupational therapy screening form dated February 28, 2023 showed, Therapy recommends bilateral upper extremity hand rolls for contracture management and skin integrity. Patient is unable to tolerate bilateral upper extremity splints at this time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145956 If continuation sheet Page 2 of 6 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 145956 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel at Casa Scalabrini 480 North Wolf Road Northlake, IL 60164 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide two staff assistance and supervision during transfer and toilet use to promote resident safety. This applies to 1 of 1 resident (R9) reviewed for transfer and toilet use in the sample of 30. The findings include: R9 has multiple diagnoses which include Alzheimer's disease, dementia with behavioral disturbance, difficulty in walking, lack of coordination, abnormal posture, weakness and need for assistance with personal care, based on the diagnosis/history list. R9's quarterly MDS (Minimum Data Set) dated January 3, 2023 shows that the resident is severely impaired with cognition. The same MDS showed that R9 required extensive assistance by two or more staff with transfer and toilet use, including during transfers on/off the toilet. On February 28, 2023 at 1:28 PM, V11 (CNA/Certified Nursing Assistant) wheeled R9's wheelchair inside the unit dining area washroom to take the resident to the toilet. V14 (CNA/ Certified Nursing Assistant) went inside the same washroom to assist V11. While V14 was washing her hands inside the washroom, V11 asked R9 to transfer from the wheelchair to the toilet. R9 stood up and with her bent knees, took two small steps, then pivoted to sit on the toilet while holding on to the grab bar. V11 did not use a gait belt, did not support R9's arm and did not wait for V14's assistance. While R9 was in the toilet, V14 left the washroom. At 1:39 PM, V11 assisted the resident to stand and hold on the grab bar. While R9 was standing and holding on the grab bar, V11 started cleaning the resident. While being cleaned, the resident stated that she needed to go back and sit on the toilet again. R9, who was standing with her bent knees and holding on to the grab bar, took a step back to sit on the toilet while V11 was guiding the resident's hips. During this procedure the resident was shouting and was expressing fear of falling. V11 did not hold the resident's arm and/or did not use a gait belt during this transfer procedure. When R9 finished using the toilet, V11 asked the resident to stand up and hold on to the grab bar while she cleaned and applied a new disposable brief to the resident. While standing and holding on to the grab bar, R9's bilateral knees were bent. V11 then asked the resident to transfer to her wheelchair. R9 with bent knees took two steps backwards, while holding on to the grab bar. V11 guided the resident's hips during the transfer to sit on the wheelchair while R9 was shouting and expressing fear of falling. V11 did not hold the resident's arm and/or did not use a gait belt during this transfer procedure. On March 1, 2023 at 12:21 PM, V4 (Nurse/Director of quality management) stated that, based on R9's most current MDS dated [DATE], the resident required extensive assistance by two or more staff with transfer and toilet use, therefore, extensive assistance by at least two staff should be provided to R9 during transfer and toilet use, to ensure safe transfer and to prevent potential accident and/or fall. V4 stated that two staff assistance meant each staff should be positioned on each of the resident, each staff should be supporting the resident by placing one hand on resident's arm while their other arm is supporting the back area of the resident. According to V4, she had observed R9's standing and transfer status that morning (March 1, 2023) and had observed that R9's bilateral knees were bent while standing and during transfer. V4 stated that based on his observation of R9's standing and transfer status, he expects two staff assistance during transfers and toilet use with or without (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145956 If continuation sheet Page 3 of 6 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 145956 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel at Casa Scalabrini 480 North Wolf Road Northlake, IL 60164 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the use of the gait belt to ensure safe transfer because the resident cannot stand straight as evidenced by bilateral bent knees during the entire standing and transfer activities. On March 1, 2023 at 2:30 PM, V4 presented R9's ADL (activities of daily living) care card resident information, which according to V4 was available for staff review inside the resident's closet door on February 28, 2023. The said ADL care card information showed that the resident requires a gait belt as a transfer device with one person assist. According to V4, he will be updating R9's ADL care card to reflect the need to transfer the resident with two staff assistance with the use of a gait belt. The facility's policy and procedure regarding assisting a resident to walk to the bathroom showed in-part, H. Walk on the resident's weak side. Provide support as necessary. Walk next to the resident with one arm supporting the resident's bent arm and the other arm around the resident's back at waist level. If necessary for support, use a gait belt for safety. (Note: If two (2) assists are necessary, one should be on each side supporting the resident by placing one hand on the bent arm and the other arm around the resident's back at waist level. If necessary for support, use a gait belt for safety). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145956 If continuation sheet Page 4 of 6 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 145956 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel at Casa Scalabrini 480 North Wolf Road Northlake, IL 60164 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow serving portions for residents receiving pureed meals and failed to follow physician orders to administer nutritional supplements. Residents Affected - Some This applies to 4 of 4 residents (R43, R58, R152, and R21) reviewed for menu adherence and nutritional supplements in a sample of 30. The findings include: 1. The facility's Physician Orders List dated March 1, 2023, showed R43, R58, and R152 had orders for a pureed diet. On February 27, 2023, at 4:32 PM, V6 (Cook) scooped pureed chicken salad sandwiches onto R43, R58, and R152's plates. V6 said he did not know what size serving scoop he was using for the pureed chicken salad sandwiches. V7 (Registered Dietician) said she was unsure what size serving scoop was being used to serve the pureed chicken salad sandwiches. V7 said the recipe showed a four-ounce scoop should be used to serve the pureed chicken salad sandwich. On February 27, 2023, at 4:45 PM, V6 said he pureed the bread and chicken salad together for the pureed meals. On February 27, 2023, at 5:13 PM, V6 said he pureed the chicken salad and the bread together. V6 measured the scoop used to serve the pureed chicken salad sandwiches. V6 said the scoop measured to under half a cup. V7 said the scoop was smaller than what was required in the recipe. The facility's recipe titled Chicken Salad Sandwich, Puree, dated February 25, 2023, showed, Prepare puree chicken salad according to recipe number 5023. For each sandwich, place two slices of bread (with crust removed) in slurry until soft. Remove first slice and place on cold plate. Using a four-ounce scoop, add four ounces chicken salad on first slide of bread. Place second slice of bread over chicken salad. Cover and refrigerate until internal temperature reaches 41 degrees Fahrenheit. Portion size: one sandwich. 2. On February 27, 2023, at 4:20 PM, R21's meal ticket showed a nutritional supplement. R21's tray did not contain a nutritional supplement and was placed in a cart for delivery to R21's unit. On February 27, 2023, at 4:25 PM, V7 said the facility is not able to obtain the nutritional supplement from their supplier. V7 continued to say while the facility is unable to obtain the nutritional supplement, ice cream should be used as a replacement. V7 said R21 did not receive ice cream in place of her nutritional supplement on her meal tray. R21's Physician Orders dated March 2023, showed an order dated May 25, 2022, for [Nutritional Supplement] with dinner. The facility's policy titled Meal/Tray Assembly Procedures, revised on 1/23, showed, Policies: Meal service is prompt and accurate, to ensure temperatures and nutrient content of food is preserved. Procedures: Ensures current diet spreadsheet is available and followed at each meal period . Checks (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145956 If continuation sheet Page 5 of 6 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 145956 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel at Casa Scalabrini 480 North Wolf Road Northlake, IL 60164 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 0803 meals for accuracy . Level of Harm - Minimal harm or potential for actual harm The facility's policy titled, Resident Meal Identification, revised on 1/23, showed, Policies: A system will be in place to identify residents' meals served by the Food and Nutrition Department. Procedures: A meal ticket, menu, diet card, or roster will be utilized. It will include the resident's name, room number, diet, allergies, and other relevant dining information such as assistive devices or individual preferences . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145956 If continuation sheet Page 6 of 6