Inspection·March 29, 2024

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 the facility failed to implement its policy on resident self-administration of medication. This deficiency affects 1 of 1 resident (R84) in the sample of 21 reviewed for Resident Self administration of medication. Residents Affected - Few Findings include: On 3/26/24 at 12:21PM, observed a nasal spray bottle at bedside of R84. R84 said that she brought the medication from the hospital, and she has been taking it since she came to this facility. R84 said that she is taking it on daily basis every 4 to 6 hours. The medication is not labeled. Called V14 (Licensed Practical Nurse/LPN) who is the nurse assigned to R84 and showed observation made. V14 said that she is not aware that R84 has medication at bedside. V14 said that R84 did not have order for nasal spray. V14 added that R84 does not have order to have medication at bedside. V14 said that all resident's medication should be kept in medication cart and should be given by the nurse. V14 said that she will call the doctor. On 3/26/24 at 12:35PM, Review R84's active physician order sheet indicates no order for nasal spray. Progress notes and Care plan does not indicate that R84 preferred to take nasal spray at bedside. On 3/26/24 at 2:28PM, Informed V3 (Assistant Director of Nursing) of the above observation made. V3 said that no medication at resident's bedside unless ordered by primary care physician. All medications taken by a resident in the building should have a physician order. Requested the policy. On 3/26/24 at 5:02PM, Informed V1 (Administrator) and V2 (Director of Nursing) of above observation made. V2 gave surveyor the policy on Resident Self-administration of medication. On 3/27/24 at 9:30AM, observed R84's nasal spray at bedside table not in locked drawer. Review R84's physician order sheet indicates nasal spray nasal solution 1 spray in each nostril every 6 hours as needed for stuffy nose. Patient may keep at bedside and self-administer. No skill assessment tool was done to evaluate R84's competency for self-administration of medication. No IDT (Interdisciplinary Team) documentation of determining R84's ability to self-administration of medication. On 3/27/24 at 9:48AM, Review policy with V2 and informed her that they did not implement their policy for R84. They did not complete Assessment for Self-administer medications tool to determine R84's ability to self-administer. Medication is not kept in locked drawer in the resident room. The IDT did not formulate care plan intervention for R84's self-administration of medication. V2 said they don't have the assessment form indicated in the policy. V2 said V11 (Unit Manager) documented R84 demonstrated self-administration of nasal spray to her and called physician for medication to be administered at bedside. Surveyor informed V2 that R84's care plan has impaired cognitive function/dementia or impaired thought processes related to impaired decision making which needs IDT to determine R84's ability for self-administering of medication. On 3/27/24 at 1:50PM, V2 presented another policy for Resident Self-Administration. Review policy provided which still indicates that facility failed to implement its policy. On 3/28/24 at 10:05AM, Informed V2, V3, V21 (Nurse Consultant) and V23 (Vice President of Clinical Operations) of the above concerns. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145971 If continuation sheet Page 2 of 12 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 145971 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Health and Rehab 4101 Lake Cook Road Northbrook, IL 60062 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 0554 Level of Harm - Minimal harm or potential for actual harm R84 was admitted on [DATE] with diagnosis listed in part but not limited to Acute respiratory failure with hypoxia, anxiety disorder. R84 is alert and oriented. She can verbalize her needs to staff. Medication Administration Record (MAR) indicates: nasal spray nasal solution 1 spray in each nostril every 6 hours as needed for stuff nose. Patient may keep at bedside and self-administer dated 3/26/24. No documentation that R84 self-administered the medication. Residents Affected - Few Facility's policy on Self Administration of Medication and Treatments indicates: General: Self-administration of medications and treatments are done to prepare a resident for discharge and to help the resident maintain their independence. The decision for self-administration is done by the interdisciplinary team. Policy: 1. Self-administration of medications and treatments are determined by physician order after determining that a resident is able to self-administer. 2. Medications and treatments that are self-administered are kept in a locked drawer in the resident room. 3. All medications and treatments that are self-administration are signed out in the EMAR (Electronic Medication Administration Record) and ETAR (Electronic Treatment Administration Record). Procedure: 1. If it determined by a member of the interdisciplinary team, or of the resident requests to self-administer, a self-administer assessments completed, it is documented in the resident's chart and the physician is called for an order to self-administer medications and keep the medications at the bedside. 2. Assessment of the ability to self-administer medications will be done by nursing using the tool Assessment for Self-Administer Medications. 6. A care plan is for resident who self-administer, and documentation should be present in the nursing notes of teaching related to self-administration of the medications or treatments. Facility's on Policies and Procedures- Pharmacy Services for Nursing Facilities Revised [DATE] IIA10: Self -Administration of Medications: Policy: In order to maintain the resident's high level of independence, residents who desire to self-medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Procedure: A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team (IDT) of the resident's cognitive (including orientation to time), physical and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145971 If continuation sheet Page 3 of 12 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 145971 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Health and Rehab 4101 Lake Cook Road Northbrook, IL 60062 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 0554 visual ability to carry out this responsibility during the care planning process. Level of Harm - Minimal harm or potential for actual harm C. For those residents who self-administer, the IDT verifies the president's ability to self-administer medications by means of a skill assessment conducted on a quarter basis or when there is a significant change in condition. Residents Affected - Few 5. Similar reviews of administration technique is conducted for other dosage forms such as inhalers, sublingual tablets, eye drops, injections, etc. 6. The resident is asked to complete a bedside record indicating the administration of the medication (If bedside storage is to be used). D. The results of the IDT assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each authorized for self-administration, the label contains a notation that it may be self-administered. E. If the resident demonstrates the ability to safety self-administer medications, a further assessment of the safety of bedside medication storage is conducted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145971 If continuation sheet Page 4 of 12 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 145971 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Health and Rehab 4101 Lake Cook Road Northbrook, IL 60062 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 implementation of pressure ulcer prevention as ordered by the physician to a resident who is at high risk for developing skin impairment. This deficiency affects 1 of 3 residents (R48) in the sample of 21 reviewed for Pressure Ulcer Prevention Program. Residents Affected - Few Findings include: On 3/26/24 at 12:01PM, observed R48 lying in bed with V13 (Licensed Practical Nurse/LPN). Bilateral heel protector/heel boots are at bedside chair. V13 said that R48 uses the bilateral heel protectors only at night. R48 is admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus (DM), need for assistance with personal care, non-traumatic intracerebral hemorrhage. Active physician order sheet indicates: Offload bilateral heels with pillows when in bed. Monitor heels for significant changes every shift for protection. Care Plan indicates: R48 is at risk for skin impairment/pressure injury. Fragile thin skin, impaired/limited mobility, incontinence. Intervention: Bilateral heel lifts on all the time. R48 has impaired circulation related to Type 2 DM. R48 has an ADL (Activity of Daily Living) self-care performance deficit. Braden scale for predicting pressure sore risk dated 2/22/24 indicated that R48 is at moderate risk. On 3/26/24 at 2:28PM, V3 (Assistant Director of Nursing/ADON) said that she is also the Wound Care Nurse (WCN) while V10 is on training for WCN. V3 said that she has taken care of R48. Informed V3 of above observation. V3 said that R48 should have bilateral heel protector at all times. On 3/27/24 at 9:36AM, V2 (Director of Nursing/DON) and V21 (Nurse Consultant) said that they are expected to implement intervention for prevention of skin impairment as indicated in physician order and resident's care plan. On 3/28/24 at 9:38AM, observed R48 in her room with V3 (ADON). Observed R48's bilateral heels with blanchable redness. Facility's policy on Wound Prevention indicates: Purpose: Identify those residents that are high risk for developing pressure areas using Braden Plus form. Relieve or remove pressure. Stimulate circulation. Management of interventions: 1. Staff will care for residents as indicated in the resident's care plan, regarding individualized interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145971 If continuation sheet Page 5 of 12 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 145971 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Health and Rehab 4101 Lake Cook Road Northbrook, IL 60062 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 0687 Provide appropriate foot care. 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 necessary foot care and treatment for diabetic resident. This deficiency affects 1 of 3 residents (R48) in the sample of 21 reviewed for Foot Care Management. Residents Affected - Few Findings include: On 3/26/24 at 12:01PM, observed R48 lying in bed with V13 (Licensed Practical Nurse/LPN). Observed bilateral heel protectors/heel boots were in the bedside chair. Surveyor requested V13 to check for R48's feet. V13 lifted the top sheet covering the feet of R48. Observed bilateral long thick yellowish brown colored toenails, with dry scaly skin and swollen feet. V13 said that podiatrist comes every Thursday to the facility. The Wound care nurse is the one scheduling resident to be seen by podiatrist. V13 added that R48 is diabetic. On 3/26/24 at 2:28PM, V3 (Assistant Director of Nursing/ADON) said that she is helping V10 (Wound Care Nurse/WCN) while he is on training. V13 said that the WCN is responsible for referring resident to be seen by podiatrist. Informed V3 of above observation made. V13 said that she has taken care of R48 but didn't notice of her long toenails. V3 said that the podiatrist comes every Thursday and will refer R48. Surveyor requested foot care management. R48 is admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus (DM), Need for assistance with Personal care, non-traumatic intracerebral hemorrhage. Active Care Plan indicates: R48 has an ADL (Activity of Daily Living) self-care performance deficit. R48 has impaired circulation related to Type 2 DM. Intervention: Podiatry consult PRN (as needed). R48 has potential for hyper/hypoglycemia related to DM. Intervention: Refer to podiatrist as needed. Take care when providing foot care to monitor for changes in condition and report PRN. R48's last podiatrist consultation was on 5/4/23 indicated: R48 seen for assessment and medically necessary debridement of painful long thickened nails several years duration gradually worsening over the last several weeks. On 3/27/24 at 2:00PM, V2 (Director of Nursing/DON) and V1 (Administrator) said that they don't have policy and procedure for Diabetic Foot Care Management. On 3/28/24 at 9:38AM, observed R48 in her room with V3 (ADON). Observed R48's bilateral heels with blanchable redness. Redness on right side on the great long toenails. R48 still with long thick yellowish brown colored toenails on both feet. Facility unable to provide policy on Diabetic foot care management. Facility's policy on Foot Care revision date 10/18/22 indicates: Policy: Foot care is given to promote cleanliness, prevention infection, control odor, provide comfort, monitor for skin breakdown, promote healing, and includes treatment to prevent complications from a variety of conditions that affects optimal foot health. Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145971 If continuation sheet Page 6 of 12 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 145971 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Health and Rehab 4101 Lake Cook Road Northbrook, IL 60062 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 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 8. Resident requiring foot care who have complicating disease processes must be referred to qualified professionals (i.e., podiatrist, a Doctor of Medicine (MD) and a doctor of osteopathy) who can treat foot problems/disorders. 9. Facility staff will also assist the resident, if necessary, in making appointments to visits a qualified person as well as help with arranging transportation to and from such outside appointments. Event ID: Facility ID: 145971 If continuation sheet Page 7 of 12 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 145971 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Health and Rehab 4101 Lake Cook Road Northbrook, IL 60062 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to elevate the head of bed at least 30-degree angle and check for Gastrostomy Tube (GT) placement prior to water flush, administering feeding and medication to GT site. This deficiency affects 1 of 3 residents (R157) in the sample of 21 reviewed for Tube feeding Management. Findings include: On 2/26/24 at 3:04pm observed V16 (Agency Registered Nurse) preparing for R157's GT (Gastrostomy tube) feeding and reading instructions of GT tubing connector. On 3/26/24 at 3:30PM, observed V16 hang and connect the feeding bottle of (brand name of tube feeding) 1.2 liter to the GT feeding pump. R157 lying in bed with head of the bed less than 30-degree angle elevation. On 3/26/24 at 3:47PM, observed V16 use the graduated cylinder to get 200ml of water from the bathroom faucet. V16 flushed the 200ml water using 60ml syringe without checking for placement. Surveyor asked V16 what angle of degree R157's head is positioned? V16 said that R157 is on 10-degree angle head elevation. Then V16 connected the feeding tube to R157 GT site and turned on the feeding pump. V16 elevated R157's head. On 3/26/24 at 3:52PM, R157's feeding pump machine alarming sound. V16 Agency Nurse turned off the feeding machine and V16 prepared medication for R157. After preparing for R157's medication (Valproic Acid 10ml placed in medicine cup). V16 aspirated the medication in the medication cup using 60ml syringe and flushed the GT site without checking for placement. After administered the medication she turned on the feeding pump machine. On 3/26/23 at 4:03PM, R157's feeding pump machine keeps on alarming sound. V16 called V15 (Registered Nurse/RN) to help her with trouble shooting R157's feeding pump. V15 checked the feeding pump and informed V16 the reason for the feeding pump's malfunction/alarming because V16 did not reset the volume to be infused. On 3/26/24 at 4:09PM, asked both V15 and V16 what was the GT feeding administration procedure. V15 said that they have to check the GT placement via auscultation using stethoscope prior to start of feeding, flushing or medication administration. V15 added that resident should be positioning at least 30-degree angle or higher. Informed both of observation made with V16 that she did not check GT placement before flushing with 200 water to start R157's GT feeding. R157 was position at 10-degree angle (less than 30 degree) when V16 administered water and feeding via GT. On 3/26/24 at 4:30PM, Informed V19 (Unit Manager) of above observation made and requested for Policy on Tube Feeding Management. On 3/26/24 at 5:02PM, Informed V1 (Administrator) and V2 (Director of Nursing/DON) of above observation made and requested for policy. On 3/27/24 at 9:38AM, V2 (DON) presented policy on Gastrostomy Tube feeding and Care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145971 If continuation sheet Page 8 of 12 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 145971 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Health and Rehab 4101 Lake Cook Road Northbrook, IL 60062 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/28/24 at 10:02AM, V3 (Assistant Director of Nursing/ADON) said that they verify/check GT the placement via auscultation using stethoscope. V3 said that she listens to the air as she instills into the GT. On 3/28/24 at 10:05AM, V2 said that they check GT placement via auscultation. On 3/28/24 at 10:08AM, Informed V2 (DON), V3 (ADON), V21 (Nurse Consultant) and V23 (Vice President of Clinical Operation) that the facility is not following its policy on checking for tube placement. They are using auscultation instead of aspiration as indicated in their policy. Surveyor requested for Nursing competency skills for Gastrostomy tube feeding and care since the last survey. V2 DON said that they do not have any. R157 is re-admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Dysphagia, gastrostomy status. Active physician order sheet indicates: Enteral feed order every shift (brand name of tube feeding) 1.2 at 65ml/hr x 17 hours total of 1100ml infused. Flush G-tube with 200ml of water every 4 hours. Flush feeding tube with 20ml water before and after medication every shift. Care plan indicates R157 requires tube feeding related to poor appetite and weight loss. Intervention: Check tube placement as needed. Keep head on bed elevated while tube feeding is infusing. Facility's policy on Gastrostomy Tube-Feeding and Care effective date: 5/17/22 indicates: Purpose: To provide nutrients, fluids, and medications as per physician orders to residents requiring feeding through an artificial opening into the stomach. Procedure: 5. Position resident on his/her back with head elevated to minimal 30 degree and preferable 45 degrees. 7. Observe for tube feeding placement before: a) Starting feeding b) Water flushes and hydration and c) Medication administration. Checking for tube placement: a. Aspirate to visually verify stomach contents. Gastric fluid normal appears clear or yellow with mucus or may appear milky if residual remains from previous feeding. Aspirated contents must be returned to the stomach to maintain pH, fluid, and electrolyte balance. Facility's policy on General guidelines for administering medication via enteral tube Revised [DATE] indicates: Policy: The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Procedures: B. Inservice training on bacteriological safely, administration and monitoring of enteral solutions and medication via the enteral tube is provided by the facility to nursing personnel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145971 If continuation sheet Page 9 of 12 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 145971 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Health and Rehab 4101 Lake Cook Road Northbrook, IL 60062 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that no medication is kept at bedside and safely stored and locked in medication cart. This deficiency affects 1 of 3 (R84) residents in the sample of 21 reviewed for Medication storage and safety. Findings include: On 3/26/24 at 12:21PM, observed a nasal spray bottle at bedside of R84. R84 said that she brought the medication from the hospital, and she has been taking it since she came to this facility. The medication is not labeled. Called V14 (Licensed Practical Nurse/LPN) who is the nurse assigned to R84 and showed observation made. V14 said that she is not aware that R84 has medication at bedside. V14 said that R84 did not have order for nasal spray. V14 added that R84 does not have order to have medication at bedside. V14 said that all resident's medication should be kept in medication cart and should be given by the nurse. V14 said that she will call the doctor. On 3/26/24 at 2:28PM, informed V3 (Assistant Director of Nursing/ADON) of above observation made. V3 said that no medication is allowed at resident's bedside unless ordered by primary care physician. All medications taken by a resident in the building should have physician order. On 3/26/24 at 5:02PM, informed V1 (Administrator) and V2 Director of Nursing (DON) of the above observation made and requested the policy. R84 was admitted on [DATE] with diagnosis listed in part but not limited to Acute respiratory failure with hypoxia, anxiety disorder. As of 2/26/24, the active physician order sheet does not indicate that R84 has an order for nasal spray. R84 is alert and oriented x 3. She can verbalize her needs. Facility's policy on Policy and Procedures- Pharmacy Services for Nursing Facilities Revised [DATE] indicates: IIA1: Equipment and supplies for administering medications Policy: The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. Procedures: A. The following equipment and supplies are acquired and maintained by the facility for the proper storage, preparation, and administration of medications. 1. Lockable medication carts, cabinets, drawers and or rooms with well lit medication preparation areas. IIA2: Medication Administration- General Guidelines Policy: Medications are administered as prescribed in accordance with good nursing principles and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145971 If continuation sheet Page 10 of 12 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 145971 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Health and Rehab 4101 Lake Cook Road Northbrook, IL 60062 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 practices and by persons legally authorized to do so. Level of Harm - Minimal harm or potential for actual harm Procedures: A. Preparation Residents Affected - Few 1. Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by the state laws and regulations to prepare and administer medications. B. Administration 1. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications 2. Medications are administered in accordance with written order of the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145971 If continuation sheet Page 11 of 12 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 145971 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Health and Rehab 4101 Lake Cook Road Northbrook, IL 60062 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow its infection control protocol for the after care of a nebulizer mask after resident use. This deficiency affects 1 of 3 (R84) residents in the sample of 21 reviewed for infection control. Residents Affected - Few Findings include: On 3/26/24 at 12:21PM, observed R84's nebulizer mask exposed on top of the bedside drawer. No plastic bag available at bedside for the nebulizer mask. R84 said that the nurse administered her breathing treatment to her. On 3/26/24 at 2:28PM, informed V3 (Assistant Director of Nursing/Infection Control) of the above observation. V3 said that the nebulizer mask should be cleaned and placed in plastic bag after each use for infection control. Requested the policy from V3. R84 is admitted on [DATE] with diagnosis listed in part but not limited to Acute Respiratory Failure with Hypoxia, Anxiety Disorder. Active Physician order sheet indicates: Albuterol Sulfate HFA Aerosol Solution 108(90 Base) MCG/ACT Give 2 inhalation orally every 4 hours as needed for SOB or wheezing maximum 12 inhalations/24hrs; Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3ml inhale orally every 6 hours as needed for wheezing. Facility policy on Nebulizer-Medication Administration effective 5/19/22 indicates: Guidelines: Nebulizer-Administering medications through a small volume (Handheld) Nebulizer 23. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145971 If continuation sheet Page 12 of 12