Health inspection·January 20, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some calling the staff using my telephone, but no one picks up the phone at the nursing station, so I have to call my family every time, and this makes my family mad. On 01/17/23 at 11:37 AM, V7 (Certified Nursing Assistant/CNA) observed R15's call light lying on top of R15's side table. V7 stated that R15's call light was not within reach of R15 and that the call light should be within R15's reach so R15 can alert the staff if R15 needs assistance. On 01/17/23 at 12:41 PM, surveyor observed R82 lying in bed with the call light tucked inside 2nd drawer of side table, which is located behind and out of reach of R82. R82 stated that R82 uses the call light to ask the nurses for help, but that it's never near me for me to use. R82 stated that if the call light was near me, I'd press the little red button to call the nurse. R82 stated, I don't know where the call light is right now. On 01/17/23 at 12:45 PM, V8 (Registered Nurse/RN) entered R82's room per surveyor's request and observed R82's call light tucked into R82's side table drawer. V8 quickly took the call light out of the drawer and placed it on R82's bed to put it within R82's reach. V8 stated that the call light should be near R82 so that R82 can always reach it. On 01/18/23 at 12:42 PM, V2 (Director of Nursing/DON) stated that all residents should have access to call lights and that the call lights should be within reach of the resident. V2 stated that there is risk if a resident does not have access to the call light because the resident could end up falling by trying to get up on their own. R15 has diagnoses which include but not limited to Multiple Sclerosis, Personal History of Traumatic Fracture, Unspecified Osteoarthritis. R15's MDS (Minimum Data Set) from 11/03/22 BIMS (Brief Interview for Mental Status) score is 07 indicating severely impaired cognition and section G (Functional Status) documents in part R15 requires extensive assistance for bed mobility, transfer, toilet use, locomotion on/off unit. R15's nursing care plan, dated 10/20/2021, documents in part that R15 is at risk for falls/injury and call light kept within reach. Care plan dated 04/14/2020, documents in part that R15 has an activity of daily living self-care performance deficit related to impaired mobility and intervention includes but not limited to encourage the resident to use bell to call for assistance. R15's care plan, dated 04/14/2020, documents in part that R15 is at high risk for fall due to impaired mobility related to multiple sclerosis and be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. R82 has diagnoses which includes but not limited to Unspecified Dementia, Muscle Weakness, Unsteadiness on Feet, Unsteadiness on Feet, Unspecified Fall, Multiple Fractures of Ribs, Unspecified Dislocation of Right Acromioclavicular Joint, Syncope & Collapse. R82's MDS (Minimum Data Set) from 11/16/22 BIMS (Brief Interview for Mental Status) score is 01 indicating severely impaired cognition and section G (Functional Status) documents in part R82 requires extensive assistance for bed mobility, transfer, toilet use, locomotion on/off unit, eating, dressing, personal hygiene. R82's nursing care plan dated 05/16/2022 documents in part that R82 is at high risk for falls related to history of falls, decreased mobility, and be sure the resident's call light is within reach (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 2 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0558 and encourage the resident to use it for assistance as needed. Level of Harm - Minimal harm or potential for actual harm Facility document titled Morse Fall Scale dated 09/23/22 for R82 documents in part score 75, indicating high fall risk. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 3 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's care plan was revised related to the discontinuation of the use of splints for 1 (R76) resident in a sample of 30 residents reviewed for care plans. Findings Include: R76 was admitted to the facility on [DATE] with diagnoses not limited to Contracture, Right Elbow, Contracture, Right Hand, Contracture, Right Knee, Low Back Pain, Functional Quadriplegia, Cord Compression, Spondylosis with Myelopathy, Cervical Region, Fusion of Spine, Cervical Region, Spinal Stenosis, Cervical Region, Major Depressive Disorder and Disorders of Muscle. R76 MDS (Minimum Data Set) Section C Cognitive Patterns BIMS (Brief Interview for Mental Status) score of 08 indicating moderately impaired. Order Summary Report dated 01/18/23 document in part: Right elbow, right hand, right knee splints to be on after breakfast and off before lunch daily as tolerated. Order date: 11/16/21. Order status: Discontinued. Apply Right Elbow Extension brace and Right-Hand roll resting splint daily for 2 hours. Order date: 11/04/21. Order status: Discontinued. Apply splints to right hand, right elbow, right knee to be on after breakfast and off before lunch and as tolerated. Order date: 01/20/22. Order status: Discontinued. Care Plan document in part: R76 has ADL (Activities of Daily Living) self-care performance deficit r/t (Related to) lumbar vertebral fracture, spondylosis with myopathy, functional quadriplegia. Restorative right hand, right elbow, right knee splints, 6-7x/week. Date initiated 05/05/21. Goal: R76 will maintain current level of function with ADLs through review date. Date initiated 05/05/21. Interventions/Tasks: Restorative splints program: Right elbow, right hand, right knee splints to be on after breakfast and off before lunch daily as tolerated. Date initiated: 11/16/21. R76 splints were discontinued on 01/20/22 with no new order for the use of splints to prevent further contractures. On 01/17/23 at 11:35 AM, R76 was observed lying in bed with a heel boot to the left lower extremity. R76 right elbow and right hand was observed to be contacted and R76 was unable to open the right hand. R76 stated, There is a leather glove that they use to put on my hand. I do not receive any therapy. On 01/18/23 at 10:54 AM, R76 was observed in bed with no splints in use. On 01/18/23 at 11:02 AM, V6 (Infection Preventionist) stated, I do not recall the splint for R76. On 01/18/23 at 11:12, AM V6 (Infection Preventionist) enter R76's room, then returned to the nurse station and stated, I am going to follow up on the splints. I noticed R76's right hand is contracted. On 01/18/23 at 10:51 AM V2 (Director of Nursing/DON) stated, The Restorative Nurse resigned in December. I am not aware that R76 has contractures. The splint was discontinued 01/20/22. If the splints (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 4 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete were discontinued the care plan should have been updated and revised. The intervention was initiated 11/16/21. Policy: Titled Care Plans, Comprehensive Person - Centered revised 12/16 document in part: A comprehensive, person - centered care that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Procedure: 8. The comprehensive, person - centered care plan will: b. Describe the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being. M. Aid in preventing or reducing decline in the resident's functional status and/or functional levels: n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 14. Interdisciplinary Team must review and update the care plan: d. at least quarterly, in conjunction with the requires quarterly MDS (Minimum Data Set) assessment. Event ID: Facility ID: 145982 If continuation sheet Page 5 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 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 observations, interview, and record review, the facility failed to meet professional standard in providing pharmaceutical services as to timely administering medication scheduled as per policy and procedure for residents (R105, R118, R93, R87, R77, R26, R82, R24, R44, R29, R67, R57, R112, R134, R56). And failed to follow professional standard for licensed staff permitted to administer medication by not following physician's order in giving the right dose of insulin for 1 resident (R118). Residents Affected - Some These failures have the potential to affect 15 residents (R105, R118, R93, R87, R77, R26, R82, R24, R44, R29, R67, R57, R112, R134, R56) not receiving medications needed on time, and one resident (R118) not receiving correct dose of insulin. Findings include: On 01/17/2023 at 10:58 AM, V30 (Licensed Practical Nurse/LPN) was still passing medication for R105 and R118. After V30 prepared medications for R118, V30 said that R118 often refused medication. V30 tried to give R118 medication but refused to take all his (R118) medicines. V30 was asked what time schedule of medicine R118 and R105 was she giving? V30 stated These medicines are for 9:00 AM medication, but I still have a few left to give. Yes, it is supposed to be given an hour before and an hour after. Yes, between 8:00 AM to 10:00 AM. On 01/17/2023 at 12:06 PM, V30 was observed giving insulin (Lispro) medication via subcutaneous injection to R118. V30 said that she will give 1 unit to R118, then administered the medication by injecting it to R118's right upper arm. Review of R118 medication current physician orders, in part reads: Insulin Lispro Inject 12 unit subcutaneously every 6 hours for diabetes mellitus. And sliding scale when blood sugar results 150 and up. On 01/18/2023 at 2:08 PM, V30 was asked to clarify why she gave 1 unit of insulin for a standing order of 12 units. V30 said, R118 sugar was low. Then V30 checked R118's physician order and said, R118 blood sugar was 107. Yes, there is a standing order for 12 units. And sliding scale starts from 2 units. I don't know why I gave 1 unit. But I will notify the doctor so that insulin can be reviewed. On 01/18/2023 at 10:34 AM, V8 (Registered Nurse/RN) was observed still passing medications. When asked how many residents still did not receive their medications, Nurse stated that she still needs to administer medications of the following residents: R105, R118, R93, R87, R77, R26, R82, R24, R44, R29, R67, R57, R112, R134, R56. On 01/19/2023 at 12:12 PM, V2 (Director of Nursing/DON) stated, Facility follows 1 hour before and after the allotted time for medication administration as ordered by physician. And insulin must be given as ordered by the physician. If the order is for 12 units, then it must be given per physician's order. I heard that the Nurse Practitioner did not change the order for R118 insulin. Administering Medication policy dated as reviewed 12/17, in part reads: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 6 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0658 Level of Harm - Minimal harm or potential for actual harm Medications shall be administered in safe and timely manner, and as prescribed. Only person licensed or permitted by this State to prepare, administer, and document the administration of medication may do so. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time frame. Residents Affected - Some Per schedule of Routine Dose of Medication Administration not dated, it reads: Medications are administered 60 minutes prior to or after its scheduled time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 7 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility has the following failures for 3 out of 6 residents (R6, R25 and R91) for a total sample of 30 residents reviewed for pressure ulcers: Failed to follow their wound prevention and management policy to ensure residents does not develop pressure ulcers. Failed ensure that residents received wound treatments. Failed to follow manufacture's instruction for proper settings on the low air mattress. Failed to maintain correct dressing per physician's order. Failed to monitor skin status for prevention of pressure ulcers. Failed to refer residents with new and worsening pressure ulcers to wound care physician for assessment and treatment. Residents Affected - Few These failures resulted in R6 sustaining 4 new facility acquired pressure ulcers on her right lower extremities. R25 sustaining 2 facility acquired pressure ulcers on the sacral pressure ulcer that further deteriorate with size, characteristic and appearance, and left heel pressure ulcer that was identified on its late stage (Stage 3). R91 sustaining left buttock pressure ulcer that worsened. Findings include: R25 was [AGE] years old, initially admitted on [DATE] with medical diagnoses of hemiplegia and hemiparesis. R25 brief interview of mental status 12/16/2022 has a score of 14 that means R25 cognitive status is intact. On 01/17/2023 at 11:22 AM. R25 stated that he cannot remember anyone did change his dressing today. R25 said that he has wound on his back and shook his head when asked if it gets any better. R25 was seen closing his eyes most of the time and fall asleep but responded short response during conversation. On 01/18/2023 at 10:16 AM, V18 (Wound Coordinator / Licensed Practical Nurse) stated that R25 has unstageable pressure ulcers on both his left heel and sacrum and that both wounds were acquired in the facility. And the most recent was V18's left heel pressure ulcer that was initially identified on 1/3/2023. When asked about the status of both sacral and left heel pressure ulcers. V18 said, It worsened, but there was a time that it was getting better. Both pressure ulcers are unstageable because of the presence of sloth. And when asked about the plan of care related to both pressure ulcers. V18 said, I do not do care plan. It is done by the MDS coordinator. It is part of my contract when I accepted the job as wound coordinator not to do care plan. V18 was asked if she was coordinating with the person doing the care plan since she was the staff that is doing direct care such as changing the dressing and alike. V18 said, If she (MDS Coordinator) asks me, I will give her information. But if you ask me what the interventions for R25's pressure ulcers right now. I don't have the information. I understand what you mean that it is supposed to be interdisciplinary coordination since I perform the care plan, there should be communication between me and the person doing the care plan to determine if interventions are effective. On 01/19/2023 at 09:08, V18 to perform treatment or pressure ulcer care of R25's sacral and left heel. Prior to dressing change V30 (Licensed Practical Nurse/LPN) stated that R25 had a lot of bowel movement earlier. And that she (V30) does not know what was ordered dressing for R25 sacral pressure ulcer. And that she (V30) and V10 (Certified Nursing Assistant/CNA) just cover it with dry dressing. Per physician order, the current and correct treatment is to cleanse sacral pressure ulcer with (Type) topical antiseptic solution pack inside cavity with moist gauze and cover with dressing. After V18 took off the covered dressing that V30 placed. The inside of the wound (pressure ulcer) was packed with gauze that was brownish in color and was soaked with drainage. V18 said, This is the gauze that I placed yesterday around 3:30 PM. After all the gauzed that was packed were taken out. Cavity of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 8 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 Level of Harm - Actual harm Residents Affected - Few pressure ulcer became visible, and it was deep that it appears to be reaching the bones. Although a partial slough that cover portion of the bed of the pressure ulcer does not allow the bones to be seen. V18 stated, Yes, it is deep enough that it may reach the bone. During dressing change V18 measured both sacral and left heel pressure ulcers. Sacral wound measures in centimeters: 5.0 by 6.0 by 2.0 (length by width by depth) with 7 to 2 o'clock undermining. V18 said that there was undermining when she inserted the stick with cotton tip underneath R25's wound moving from 7 to 2 o'clock. Left heel measurement in centimeters: 2.3 by 2.4. Then V18 said, This is 100% slough. Pointing at R25's left heel pressure ulcers that the whole area was covered with slough. On 01/19/2023 at 10:06 AM, V18 (Wound Coordinator / Licensed Practical Nurse) was asked if nursing staff on the floor knows how to access wound treatment orders for them to place the correct dressing as ordered by physician in case dressing becomes soiled or wet. V18 said, Staff (nursing) staff on the floor can access treatment orders. And must know what dressing to place when needed. They have been informed and instruction were given to them. But I totally agree with you. Wound treatment must be performed correctly by both nursing staff on the floor and wound care staff. V18 was asked about the process to document treatment that was done in the treatment administration record (TAR). And was also asked if it should be sign on the same day the treatment was done. V18 said, I don't sign on the treatment administration record (TAR) after I performed the treatment. But I tried to sign it by the end of the day. And yes, sacral wound, you may say it worsen if the skin was intact with redness and later opens. V18 was asked, since there was a clear deterioration of R25's sacral pressure ulcer since 9/30/2022 until currently, why was the wound not seen by a wound doctor until 01/16/2023? V18 said, I tried to do the treatment on my own. I guess it would help but there are times that R25's wounds seem to be improving. V18 was also asked about R25's left heel since it was discovered already in stage 3, if nursing staff was monitoring R25's left heel should it be in an earlier stage when it was easy to manage? V18 said, I don't know. But when it was discovered, it was already stage 3. Per R25's notes dated 9/12/2022 in part reads that R25 skin on the sacral area was intact but with redness. Then foam dressing was applied. Per physician's order, foam dressing needs to be applied to R25's sacrum to start on 9/14/2022. Per R25's treatment administration record (TAR), for foam dressing was not signed as being perform on 9/14/2022 and from 9/20/2022 up to the end of the month no treatment was signed as being performed. On 9/30/2023, R25's sacrum pressure ulcer worsened from skin intact redness to open pressure ulcer measuring in centimeters as follows: 1.5 by 1.0 by 0.10 (length by width depth). Compared to sacral pressure ulcer assessment dated [DATE] measuring in centimeters as follows: 4.0 by 6.0 by 1.5 (length by width by depth). As to R25's left heel pressure ulcer, it was first identified on 1/3/2023 as stage 3 with measurement in centimeters as follows: 2.0 by 3.0 by 0.10 (length by width by depth). On 01/09/2023, left heel pressure ulcer was reclassified as to its stage from stage 3 to unstageable due to 100 % of the area of the pressure ulcer was covered with slough. On 01/19/2023 at 11:34 AM, V33 (Wound Doctor) said, I only see residents that was referred to me by the primary physician. And it was the first time R25 was referred to me, so I cannot make any determination or comparison as to the status of R25's pressure ulcers. But what is documented on her assessment dated [DATE] was the basis of the status of the wound. Yes, the presence of slough means wound deterioration and that a skin intact with redness that opened means worsening of the wound. It can be attributed to many factors including not performing of treatment. Per V33 documentations: R25 was only seen 1 time on 01/16/2023 although R25's sacral pressure ulcer was initially identified as having redness on 09/12/2022 and opened on 09/30/2022 that worsen overtime per facility Wound Round Assessments. And only saw R6's 4 pressure ulcers on resident's right lower extremities after facility was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 9 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 informed that R6's wounds are being reviewed. Level of Harm - Actual harm On 01/19/2023 at 12:12 PM, V2 (Director of Nursing/DON) said, All pressure ulcers besides stage 1 must be seen as soon as possible by Wound Doctor. The process for the primary care physician to give a referral for the wound doctor to see resident. Residents Affected - Few R25's Health Records are as follows: Per R25's notes dated 09/12/2022, reads in part that R25 has blanchable pink noted to sacral area. Notes dated 01/11/2023 in part reads that R25 left heel and sacral wound declined. R25's treatment administration records (TAR) for the months of September, October, and November 2022 have multiple days that were not signed as treatment ordered by physician was being performed on the sacral pressure ulcer. Per facility Wound Rounds assessment R25's pressure ulcer was initially opened on 09/30/2022 and later deteriorates as to size, characteristic and appearance. From 1.5 by 1.0 by 0.10 centimeters (length by width by depth) on 09/30/2022 to 4.0 by 6.0 by 1.5 centimeters (length by width by depth). And even increased in size when seen on 01/19/2023 with the following measurements: 5.0 by 6.0 by 2.0 centimeters (length by width by depth) with 7 to 2 o'clock undermining. Per V33 wound assessment, it was the first time she saw R25 when sacral pressure ulcer had already worsened. Per facility assessment Wound Rounds left heel was initially assessed on its late stage (Stage 3) on 01/03/2023. Later left heel pressure ulcer on assessment dated [DATE] became unstageable due to slough white fibrinous covered 100% of the wound. Care plan for left heel was initiated on 01/08/2023, 5 days after pressure ulcer was identified. And later developed slough on 01/09/2023. Facility submitted Wound Care Pressure Ulcer Avoidability assessment dated [DATE] and signed by V33 (Wound Care Doctor) on 01/20/2023 although, V33 only saw R25 the first time on 01/16/2023. The same assessment was more than 3 months ago dated 09/30/2022 is still showing in progress today (01/20/2023). Dressings, Dry/Clean policy of the facility dated as revised 4/2022, in part reads: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Under preparation: Verify that there is a physician's order for this procedure. Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. Check treatment record. Under documentation, the following information should be recorded in the resident's medical record, treatment sheet or designated wound form: The date and time the dressing was changed. On 1/17/23 at 11:30 AM, observed R91's wound care completed by V18 (Wound Care Nurse). Observed R91's left buttock area with an open wound noted with small portion of the wound was bright red and the rest of the wound was filled with a white thick non removable appearance. R91 stated, This air mattress is too hard and makes my butt hurt. On 1/19/23 at 9:52 AM, V18 (Wound Care Nurse) stated, I am a Licensed Practical Nurse for 4-years. I received my wound care certification in April 2022. I have been the only full-time wound care nurse here for the last two years. I work Monday thru Friday, and the weekend supervisor will complete the wound care treatments. V33 (Wound Care Physician) comes in the facility on Mondays, at least once per week to assess residents on her (V33) list. V33 only assess wounds that are declining, infected, or change in condition. Typically, I manage the wounds unless I think the wound physician needs to get involved. If I feel the wound physician needs to assess a wound, I will call the resident's primary care physician for an order to allow V33 to assess the resident. I'm not sure what the PUSH acronym or the score located on the wound summary means. Once I enter the wound description the PUSH (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 10 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 Level of Harm - Actual harm Residents Affected - Few score is generated, the higher the number the worse the wound. However, in that square box underneath the title PUSH there is an arrow either pointing up or down. Arrow pointing up means the wound is worsening, and an arrow pointing down means the wound is improving. R91 was re-admitted to the facility on [DATE] with the Left buttock stage 3 pressure ulcer wound. On 1/10/23, I assessed R91's the left buttock wound, tissue was 100% bright beefy red, with scant serosanguineous drainage. R91's left buttock wound measures L[Length] 0.50cm x W [Width] 1.00cm x D[Depth] 0.10cm with the PUSH score of 5, no arrow was there because it was the first assessment completed. On 1/18/23 R91's left buttock wound was assessed as a stage 3 pressure ulcer wound, the tissue was 50% bright beefy red and 50% slough white fibrinous, with scant serosanguineous drainage. R91's left buttock wound measures L[Length] 2.00cm x W[Width] 0.50cm x D [Depth] 0.10cm with the PUSH score of 7 with the arrow pointing up, which indicated R91's wound has got worse. R91's wound interventions are an air mattress, encourage R91 to reposition, and heel boots while in bed. The air mattress is set per the resident's weight, he [ R91] weighs 134 pounds. I noticed during R91's wound care that his [ R91] air mattress was set at 300 pounds, which makes the mattress hard and firm. The air mattress is set at the wrong weight and can potentially cause the wound to worsen. R91 was not referred to V33, because I felt like I could handle the wound care alone. From 1/10/23 to 1/18/23, R91 wound did decline. On 1/19/23 at 11:30 AM, V33 (Wound Care Physician) stated, I worked in this facility for two years, assessing, and treating referred residents with all pressure ulcers, vascular ulcers, surgical wounds, all stage non-healing wounds and infected skin areas. Once I assess a resident my documentation is on an application, V2 (DON) and V18 has access to those assessments. I have not assessed R91's wound, because I have not received any referral from R91's physician or V18. If a resident has a stage 3 wound, I will think certainly, I should have been referred to assess that resident's wound. If a wound goes from 100% beefy red to 50% slough, and larger in size, the wound has worsened. The air mattress is an intervention of residents with pressure ulcers. The air mattress settings are based on the resident's weight. If the air mattress is set at a higher weight, it could potentially cause a wound and or an existing wound to worsen. On 1/19/23 at 12:10 PM, V2(DON) stated, V18 needs to refer a resident to V33 with a referral from the resident's physician. V33 is supposed to see all pressure ulcers as soon as possible. V18 should obtain an order for the wound care physician as soon as possible for all wounds. The air mattresses are set on the resident's weight for proper air distribution for residents with pressure ulcers. If the bed is set on a higher weight, it could potentially cause their wound to worsen. Reviewed R91's medical record documented in part: R91 was re-admitted on [DATE] with medical diagnoses of neuropathy, end stage renal disease, type 2 diabetes, liver transplant, kidney transplant, gastrostomy, gastritis, urinary tract infection, dysphasia, abnormal gait immobility, lack of coordination, hyperkalemia, heart failure, acute respiratory failure malnutrition, depressive disorder, seizures, chronic pain, cirrhosis of the liver, sepsis, and pneumonia. Physician order- dated 1/11/23, left buttock-cleanse with normal saline, apply (brand) non-adherent wound contact dressing , adaptic, and foam dressing every day shift on Tuesday, Thursday, Saturday, and Sunday. Face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS], care plans, medication administration record, treatment administration record, and progress notes. Policy; Documents in part -Prevention of Pressure Ulcers/Injuries dated 7/2017 Support Surfaces and Pressure Redistribution' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 11 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 -Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors Level of Harm - Actual harm Monitoring Residents Affected - Few -Evaluate, report and document potential changes in the skin -Review the interventions and strategies for effectiveness on an ongoing basis R6 is an [AGE] year-old female initially admitted to the facility 11/28/2017. R6's diagnosis includes but is not limited to, Parkinson's Disease, Unspecified Dementia, Functional Quadriplegia, Dysphagia, Gastrostomy, Fracture of Lower End of Femur. R6 was hospitalized from [DATE]-[DATE] for distal right femur fracture and readmitted with right lower extremity (RLE) hinge brace and an order for the brace to be worn at all times except for hygiene. Skin was intact upon readmission based on Nursing Admission/readmission Assessment completed on 11/26/22. R6's Braden Score for predicting pressure sore risk on 11/26/22 was assessed as being at high risk based on score of 10. R6 is NPO and receiving all nutrition from enteral feedings via gastrostomy tube. R6 developed four pressure injuries identified on 01/11/23 in the following locations: right Achilles, right lateral lower leg, right inner ankle, and right outer ankle. Per facility document titled, Wound Assessment Details Report dated 01/12/23 performed by V18 (Wound Care Coordinator) documents in part, right Achilles unstageable with wound measurements (2.3x2.5x0.1) 100% slough white fibrinous, right lateral lower leg unstageable with wound measurements (0.90x2.0x0.1) 100% slough white fibrinous, right inner ankle unstageable with wound measurements (1.4x2.0x0.1) 95% slough white fibrinous 5% bright beefy red, right outer ankle unstageable with wound measurements (4.5x1.3x0.1) 95% slough white fibrinous 5% bright beefy red. On 01/18/23 at 11:24 AM, V8 (Registered Nurse/RN) stated that before 01/03/23, R6 was wearing a right lower extremity leg brace all the time and that there were special instructions not to remove it. V8 stated that before 01/03/23, R6's leg brace was not being removed for any reason. V8 stated that the Certified Nursing Assistants notify the nurses if any skin alterations are identified. On 01/18/23 at 2:33 PM, surveyors observed V18 (Wound Care Coordinator) providing wound care treatment to R6. V18 stated that R6 had four unstageable pressure wounds that were caused by the friction from R6's right lower extremity leg brace. V18 stated that the hinge type of brace is known to cause friction which is a risk factor for developing a skin alteration. V18 stated that the unstageable pressure wounds were identified when R6's leg brace was taken off to give R6 a shower (01/11/23). V18 stated that the wound care doctor was at the facility on Monday (01/16/23) but did not see R6 or R6's pressure wounds. V18 stated that the wound care physician did not see R6 because V18 did not refer R6 to the wound care physician. V18 stated that V18 only refers residents with wounds to the wound care physician if the wounds are declining or infected or healing is not progressing. Surveyors observed right inner ankle, right outer ankle, and right Achilles covered with alginate dressing. When alginate dressing was removed surveyors observed the right inner ankle, right outer ankle, and right Achilles covered in slough with drainage. V18 stated that V18 used a different treatment dressing (alginate) other than what is ordered ({brand} enzymatic debriding wound agent, adaptic dressing) because V18 had observed an increase in drainage from these wounds yesterday during wound treatment. V18 stated, I haven't had a chance to change the treatment order yet. Surveyors observed V18 take measurements of wounds. V18 verbalized out loud the measurements obtained with the results as follows: right inner ankle (1.5x2.3x0.1), right outer ankle (4.5x1.4x0.1), right lateral leg (1.6x1.6x0.1). No (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 12 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 measurement was provided for the wound to right Achilles. Level of Harm - Actual harm On 01/19/23 at 9:30 AM, V34 (Nurse Practitioner/NP) stated that V34 was not aware that R6 had developed pressure wounds and that the last time V34 had seen R6 was on 12/7/22. V34 stated, I remember them calling me about R6 needing a doppler study, but I was not notified about the four unstageable pressure wounds. It looks like they notified R6's primary physician. V34 stated that R6 is wearing a hinge brace which is known to cause friction which has the potential to lead to skin issues. V34 stated that if the staff was conducting daily skin checks they would observe any signs of skin deterioration on pressure point areas quickly. Residents Affected - Few On 01/19/23 at 11:40 AM, V33 (Wound Care Physician) stated that V33 assesses and treats residents referred with all pressure ulcers, vascular ulcers, surgical ulcers, surgical wounds and all stages of non-healing wounds and infected skin areas. V33 stated that V33 works on a consult basis, and therefore the nurse needs to obtain an order from the primary physician for V33 to assess a resident. V33 stated V33 was consulted today to assess R6, and that it is the initial assessment for R6, so it is the first time V33 is doing measurements of R6's wounds. V33 attributes R6's unstageable pressure wounds to the leg brace worn by R6 and stated that the brace can cause friction which is a risk factor for developing pressure wound(s). V33 stated that the facility should be doing daily skin checks to identify skin changes. V33 stated that it is important for the wound treatment orders to be followed as prescribed and that the nurse should not be changing the order(s). On 01/19/23 at 12:00 PM, V18 (Wound Care Coordinator) provided to surveyor documents titled, Visit Report for R6 on 01/19/23 signed by V33 at 10:58:06 AM on 01/19/23 which documents in part that R6 has an unstageable pressure injury on right lateral lower log, right Achilles area, right lateral ankle and right medial ankle since 01/11/23, and the patient had a right leg brace for acute complex fracture of distal femoral metaphysis since 11/23/22, the patient is at increased risk for pressure injury due to the decreased mobility and the patient should be on a turning schedule. Measurements of the pressure injuries are documented as follows: right lateral leg (1.0x1.8x0.1) with small amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough; right Achilles (2.2x2.5x0.1) with medium amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough; right medial malleolus (right inner ankle) (1.0x2.0x0.1) with medium amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough; right lateral malleolus (right outer ankle) (4.2x1.3x0.1) with medium amount of serous drainage and large (67-100%) amount of necrotic tissue within the wound bed including Adherent Slough. Note there is a discrepancy between the measurements provided on V33's documentation compared to the wound measurements taken by V18 and observed by surveyors on 01/18/23. On 01/19/23 at 12:09 PM, V2 (DON) stated that the overall goal is to keep resident's skin condition intact and not have any acquired pressure injuries. V2 stated that R6 was wearing a hinge leg brace which can cause friction and that the brace was the cause of pressure wounds R6 acquired. V2 stated that the interventions put in place when R6 returned from the hospital with the leg brace included checking the leg brace every shift and doing daily skin checks. V2 stated that the purpose of the daily skin check is to monitor the skin for any breakdown or issues with circulation. V2 stated that it is the nurse's responsibility is to do the daily skin checks. V2 stated that when a wound is identified the resident should be seen as soon as possible by the wound care physician. V2 stated that the skin treatment orders should be followed as prescribed and not changed because if the orders are changed it is not possible to know if the treatment was effective or not which could hinder the wound healing process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 13 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 Level of Harm - Actual harm On 01/20/23 at 9:52 AM, V35 (Registered Dietitian) stated that R6 is receiving tube feeding formula and a commercial protein supplement via feeding tube for nutrition which is providing a total of 1320 calories, 77 gm protein. V35 estimated R6's nutritional needs as 1040-1300 calories, 62-73 grams protein. V35 stated R6 is receiving adequate nutrition from tube feedings with use of commercial protein supplement. Residents Affected - Few R6's MDS (Minimum Data Set) dated 12/02/22 BIMS (Brief Interview for Mental Status) score is 0 indicating severe cognitive response (rarely/never understood) and section G (Functional Status) documents in part R6 requires total dependence for transfer and extensive assistance with bed mobility, dressing, toilet use and personal hygiene and limited range of motion on both upper and lower extremities. R6's Order Summary Report dated 01/18/23 documents in part check circulation, motion, sensation of right lower extremity every shift for brace right lower extremity (RLE) (12/06/22), check skin daily (12/06/22), and skin check daily under brace (RLE) every evening shift (12/14/22). R6's Treatment Administration Record dated 01/01/23-present documents in part, right lower leg: cleanse with normal saline, apply (Brand) enzymatic wound debriding agent to open areas, adaptic, dry dressing every day shift for RLE wounds dated 01/12/23. Facility policy titled, Prevention of Pressure Ulcers/Injuries dated July 2017 documents, in part assess the resident on admission for existing pressure ulcer/injury risk factors and repeat the risk assessment weekly, identify areas of impaired circulation due to pressure from positioning or medical devices and inspect the skin on daily basis, identify any signs of developing pressure injuries (i.e. non-blanchable erythema) and inspect pressure points. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 14 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 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 provide services to prevent further decline in range of motion for one (R76) resident reviewed for contractures in a sample of 30. Findings include: R76 was admitted to the facility on [DATE] with diagnoses not limited to Contracture, Right Elbow, Contracture, Right Hand, Contracture, Right Knee, Low Back Pain, Functional Quadriplegia, Cord Compression, Spondylosis with Myelopathy, Cervical Region, Fusion of Spine, Cervical Region, Spinal Stenosis, Cervical Region, Major Depressive Disorder and Disorders of Muscle. R76 MDS (Minimum Data Set) Section C Cognitive Patterns BIMS (Brief Interview for Mental Status) score of 08 indicating moderately impaired. Order Summary Report dated 01/18/23 document in part: Right elbow, right hand, right knee splints to be on after breakfast and off before lunch daily as tolerated. Order date: 11/16/21. Order status: Discontinued. Apply Right Elbow Extension brace and Right-Hand roll resting splint daily for 2 hours. Order date: 11/04/21. Order status: Discontinued. Apply splints to right hand, right elbow, right knee to be on after breakfast and off before lunch and as tolerated. Order date: 01/20/22. Order status: Discontinued. Care Plan document in part: R76 has ADL (Activities of Daily Living) self-care performance deficit r/t (Related to) lumbar vertebral fracture, spondylosis with myopathy, functional quadriplegia. Restorative right hand, right elbow, right knee splints, 6-7x/week. Date initiated 05/05/21. Goal: R76 will maintain current level of function with ADL's, through review date. Date initiated 05/05/21. Interventions/Tasks: Restorative splints program: Right elbow, right hand, right knee splints to be on after breakfast and off before lunch daily as tolerated. Date initiated: 11/16/21. On 01/17/23 at 11:35 AM, R76 was observed lying in bed with a heel boot to the left lower extremity. R76 right elbow and right hand was observed to be contacted and R76 was unable to open the right hand. R76 stated, There is a leather glove that they use to put on my hand. I do not receive any therapy. On 01/18/23 at 10:54 AM, R76 was observed in bed with no splints in use. On 01/18/23 at 11:02 AM V6 (Infection Preventionist) stated, I do not recall the splint for R76. On 01/18/23 at 11:12 AM, V6 (Infection Preventionist) enter R76 room then returned to the nurse station and stated, I am going to follow up on the splints. I noticed R76 right hand is contracted. On 01/18/23 at 10:51 AM, V2 (Director if Nursing/DON) stated, The Restorative nurse resigned in December. I am not aware that R76 has contractures. The splint was discontinued 01/20/22. If the splints were discontinued the care plan should have been updated and revised. The intervention was initiated 11/16/21. I will have therapy see if we can resume the splints. There is a potential that R76 can become more contracted to the right hand, right elbow and right leg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 15 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 01/18/23 at 11:31 AM, V39 (Certified Nurse Assistant/CNA) stated, R76 usually has a splint on but now I don't know. Policy: Titled Assistive Devices and Equipment reviewed 12/21 document in part: Our facility provides, trains, and supervises the use of assistive devices an equipment for residents. 1. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include, but are not limited to: d. Splint, 2. Recommendations for the use of device and equipment are based on the comprehensive assessment and documented in the resident plan of care. Event ID: Facility ID: 145982 If continuation sheet Page 16 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observation, interview and record review, the facility failed to provide oral nutritional supplement as prescribed by physician. This failure resulted in a significant weight loss (>5% change over a span of 1 month and >10% change over a span of 6-month period) for 1 (R57) of 7 residents reviewed for nutrition in a total sample of 30. Findings include: On 01/17/23 at 12:16 PM, surveyor observed V10 (Certified Nursing Assistant/CNA) feeding R57 in the unit dining room, with R57 eating very slowly with eyes closed and overall poor intake less than 50% of lunch meal. No supplement observed on lunch tray. On 01/18/23 at 08:55 AM, surveyor observed V37 (Restorative Coordinator) feeding R57 in unit dining room. No commercial oral supplement observed on breakfast tray. No commercial oral supplement listed on R57's meal ticket. On 01/18/23 at 9:13 AM, V16 (Speech Language Pathologist) stated that R57 requires 1:1 feeding assistance. On 01/18/23 at 11:25 AM, V19 (Certified Nursing Assistant/CNA) re-weighed R57 upon request of the surveyor using the wheelchair scale on the unit. V19 stated that this is the scale used by staff to weight V19 every month. Surveyor observed R57 being weighed in R57's wheelchair with fleece lap blanket and sheet. This weight was 198.4 pounds. The weight reading was confirmed by V19 saying the weight scale reading out loud. After lunch at 2:08 PM, V19 transferred R57 to bed and R57's wheelchair was weighed without R57 sitting in it. R57's wheelchair plus the additional items of the fleece lap blanket and sheet was wheeled back onto the unit scale and the weight of was 80.4 pounds. The weight reading was confirmed by V19 saying the weight scale reading out loud. The difference between these two numbers makes the weight of R57 to be 118 pounds. On 01/18/23 at 12:21 PM, V8 (Registered Nurse/RN) stated that V8 did not give anyone on the unit Ensure supplement this morning as part of medication pass. V8 stated that there is not any Ensure supplement on the nursing unit or in the medication cart to give out. V8 stated that R57 did not receive (Brand) nutritional supplement this morning from nursing. On 01/19/23 at 9:40 AM, V34 (Nurse Practitioner/NP) stated that V34 has not seen R57 in person since 11/2022 but V34 did give a verbal order over the phone to approve R57 for labs, chest x-ray, speech evaluation and calorie counts. V34 stated that V34's expectation is that if R57 has an order for oral supplement then R57 should be receiving the supplement as ordered and that the purpose of the supplement is to provide R57 with additional calories to prevent weight loss. V34 stated that R57's weight loss is not desired or planned and is concerning since R57 is continuing to lose weight. On 1/19/23 at 9:45 AM, V26 (Dietary Manager) stated that when commercial oral supplements such as (Brand) are ordered with meals then the (Brand) oral nutritional supplement is provided by the kitchen and put on resident meal trays for that meal. V26 stated that if a resident has a physician order for (Brand) oral nutritional supplement, then that supplement will be listed on the resident's meal ticket, so the kitchen staff knows to add the supplement to the resident's meal tray. V26 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 17 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0692 Level of Harm - Actual harm Residents Affected - Few that (Brand) oral nutritional supplement was in stock and available in the kitchen for use. V26 stated that a doctor or registered dietitian can order a supplement and that the staff notifies the kitchen when this occurs so that the kitchen can enter this information into the kitchen computer system which then generates the supplement on the meal ticket. V26 reviewed R57's menu profile in the kitchen computer system and stated that R57 does not have (Brand) nutritional supplement listed on R57's meals tickets and therefore is not receiving (Brand) nutritional supplement from the kitchen. On 01/19/23 at 10:00AM, V31 (Dietary Technician) stated that calorie counts were conducted last week but only given to V31 this morning to calculate. V31 stated that R57 is consuming an average intake of 732 calories per day based on the calorie count results and that R57 is not consuming enough calories to maintain R57's weight. V31 reviewed electronic medical record and stated, I do see the order for (Brand) oral nutritional supplement. V31 stated that R57 is not receiving (Brand) oral nutritional supplement from the kitchen at this time. V31 stated that if a resident had an order for a supplement but was not receiving the supplement the resident may not be able to maintain weight, and this could cause further weight loss because the purpose of the supplement is to provide extra calories. V31 stated that V31 was not aware of R57's weight loss and that a weight loss puts a resident into a high-risk category, which would require a referral to the registered dietitian for an assessment. On 01/19/23 at 10:47 AM, surveyor conducted interview with V35 (Registered Dietitian) over the phone. V35 stated that V35 worked remotely this week and that V35 had not been notified about R57's weight loss this month yet. V35 stated that current interventions in place include use of (Brand) oral nutritional supplement once per day at breakfast meal which would provide approximately 350 calories. V35 was not aware that the kitchen was not giving R57 the (Brand) oral nutritional supplement and stated, I am surprised that the kitchen has not been giving what is ordered. V35 stated that if a resident is not receiving a supplement as ordered, it has the potential risk for causing continued weight loss. V35 reviewed the diet technician's progress note documenting the calorie count results and stated that the calories R57 is consuming is not adequate and that without increasing R57's calorie intake, further weight loss is likely. R57 was admitted to the facility on [DATE] and has diagnoses which includes but not limited to: Unspecified Dementia, Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting Right Dominant Side, Type 2 Diabetes Mellitus, Schizoaffective Disorder. R57's Order Summary Report dated 01/18/23 documents in part (Brand) oral nutritional supplement, one time a day for supplement at breakfast with order date from 11/08/22. R57's MDS (Minimum Data Set) from 11/15/22 BIMS (Brief Interview for Mental Status) was not calculated but indicated in section C0600 resident was unable to complete BIMS and indicated short and long-term memory problem. R57's MDS section G (Functional Status) dated 11/15/22 documents in part, limited assistance with eating and section GG (Functional Abilities and Goals) substantial/maximal assistance with eating. R57's care plan dated 11/09/22 documents in part, R57 is underweight, malnourished and to provide diet supplement as prescribed by physician. R57's Nutrition/Dietary progress note dated 01/19/23 completed by V35 at 11:15 AM documents in part, R57 has had a significant weight loss based on -9.7% change in 1 month, -10.5% change in 3 months, and -16% change in 6 months. V35 used the following weights to complete the progress note: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 18 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0692 Level of Harm - Actual harm Residents Affected - Few (01/11/23) 122.4 pounds, (12/5/22) 135.5 pounds, (10/5/22) 136.8 pounds, (07/1/22) 146.2 pounds. V35 assessed R57's BMI (20.4) as being low for R57's age and that calorie count results show R57's average daily intake is 732 kcals which is not enough to maintain and/or gain weight. Facility document titled, Weights & Vitals dated 01/18/23 documents, in part, R57's weights as follows: (1/11/23) 122.6 pounds, (12/5/22) 135.5 pounds, (11/8/22) 135.5 pounds, (10/13/22) 136.8 pounds, (7/8/22) 146.4 pounds. Facility policy titled, Nutrition (Impaired)/Unplanned Weight loss - Clinical Protocol dated 09/2017 documents, in part, that the staff will report to the physician significant weight losses. Facility policy titled, Supplements undated documents in part that nutritional supplements will be provided as ordered to clients, nursing and dietary will distribute the nutritional supplement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 19 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 follow their enteral tube feeding via pump policy to ensure 2 (R31, R91) of 6 (R6, R42, R108, R118) residents enteral nutrition bottles were labeled before administration in a sample of 30 reviewed for enteral tube feeding. Findings include, On 1/17/23 at 11:21 AM, observed R91's enteral gastric feeding bottle half-filled and water bag was mapped through the pump without R91's information on the blank labels. On 1/17/23 at 11: 38 AM, observed R31's enteral gastric feeding bottle one -fourth filled and water bag was mapped through the pump without R31's information on the blank labels. On 1/17/23 at 11:46 AM, V11 (Licensed Practical Nurse/LPN) stated, I worked here for 1 year, but have been a nurse for 2 years. Upon starting the gastric tube feeding, that nurse was supposed to label the feeding formula bottle and water bag with the resident's information: name, date, time, rate, and type of formula. Usually, the evening nurse starts the gastric feeding and should have labeled R91's feeding and water bottle. On 1/17/22 at 1: 10 PM, V13 (Registered Nurse/RN) stated, I worked here in this facility for 13 years. R31's feeding bottle and water bag should have been labeled and dated at time of opening. I will label the bottles now. On 1/19/23 at 12:10 PM, V2 (Director of Nursing/DON) stated, All gastric feeding bottles and water bottles are labeled with the resident's name, room number, date opened, time opened, formula type, rate flow, and water flow rates. If the feeding and water bottles are not labeled, the resident could potentially receive old, spoiled formula and water. The next nurse would not know when or how much feeding formula or water the resident received. That could potentially cause harm to the resident, such as weight loss, infection, or wrong formula given. R91's medical record documented in part: R91 was re-admitted on [DATE] with medical diagnoses of neuropathy, end stage renal disease, type 2 diabetes, liver transplant, kidney transplant, gastrostomy, gastritis, urinary tract infection, dysphasia, abnormal gait immobility, lack of coordination, hyperkalemia, heart failure, acute respiratory failure malnutrition, depressive disorder, seizures, chronic pain, cirrhosis of the liver, sepsis, and pneumonia. Physician order dated 1/9/23, Enteral Bolus Feed: Nepro with Carb Steady at 400 ml QID with 150 ml water flush before and after feeds. Four times a day for supplement, -Enteral Bolus Feed: Nepro with Carb Steady @ 400 ml QID with 150 ml water flush before and after feeds. Four times a day for supplement. Reviewed R91's Face-sheet, medical diagnosis, physician order sheets, Minimum Data Set [MDS], care plans, medication administration record, treatment administration record, and progress notes. R31's medical record documented in part: R31 was admitted on [DATE] with medical diagnoses of acute kidney failure, pneumonia, tracheostomy, gastrostomy, acute embolism, dysphasia, malnutrition, cognitive communication deficit, disorders of the lung, acute respiratory failure, essential hypertension, atrial fibrillation, hypothyroidism, sepsis, and depression. Physician order dated 12/5/22 NPO [ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 20 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 Nothing by mouth], dated 12/5/22 enteral feed order every 8hours flush enteral tube with 150ml of water, dated 12/6/22 enteral feed order three times daily with 60ml water flush before and after each feeding. Reviewed R31's Face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS], care plans, medication administration record, treatment administration record, and progress notes. Residents Affected - Few Policy-Documents in part: -Check the enteral nutrition label against the order before administration such as resident name, room number, type of formula, date, time the formula was prepared and opened, route of delivery, access site, method and rate of administration of formula and or water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 21 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 their Intravenous Policy to ensure one (R91) of 5 (R98, R110, R139, R239) residents midline dressing was changed, in a sample of 30 reviewed for intravenous access. Residents Affected - Few Findings include, On 1/17/23 at 11:20 AM, observed R91 lying in bed resting with a midline in his upper right extremity. The midline dressing dated 1/9/23 and was halfway lifted up from R91's skin, with a dark brown substance on the bandage. On 1/17/23 at 11:28 AM, V11 (Licensed Practical Nurse/LPN) stated, I am R91's nurse today. I've been working here for 1year. R91's midline dressing should be changed weekly and as need. The dressing is half off with the date of 1/9/23, the night nurse should have changed the dressing when she gave R91's antibiotic. I did not assess R91's midline dressing because his intravenous antibiotic is not due until later today. On 1/19/23 at 12:15 PM, V2 (Director of Nursing/DON) stated, All intravenous access such as midlines or PICC (Peripherally Inserted Central Catheter) lines, dressings are to be changed every 7days or as needed, from the last dressing change. If the dressing is not changed, it could potentially cause an infection. Reviewed R91's medical record documented in part: R91 was re-admitted on [DATE] with medical diagnoses of neuropathy, end stage renal disease, type 2 diabetes, liver transplant, kidney transplant, gastrostomy, gastritis, urinary tract infection, dysphasia, abnormal gait immobility, lack of coordination, hyperkalemia, heart failure, acute respiratory failure malnutrition, depressive disorder, seizures, chronic pain, cirrhosis of the liver, sepsis, and pneumonia. Physician order dated 1/9/23-Midline (RUA/1 lumen): Change Needleless Device q (every) week on Tuesdays and as needed in the morning every Tue for Change needleless device weekly and as needed for Change needleless device prn. Dated 1/9/23-Zosyn Intravenous Solution Reconstituted 4.5 (4-0.5) GM (Piperacillin Sodium-Tazobactam Sodium) Use 4.5 gram intravenously every 8 hours for Sepsis due to CAP for 9 Days. Face-sheet, medical diagnosis, physician order sheets, Minimum Data Set [MDS], care plans, medication administration record, treatment administration record, and progress notes. Policy; Documents in part -Intravenous Policy dated 10/25/2014 Change midline/PICC line dressings every 7days or as needed. Change if damp, loosened or soiled. -Anytime that dressing is not intact, or end caps are missing, the catheter has the potential for contamination. -Observe the insertion site every shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 22 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to label and date oxygen tubing for 5 (R94, R111, R127, R128, R238) residents reviewed for oxygen therapy out of a total sample of 30. Residents Affected - Some Findings include: On 01/17/2023 at 12:51 PM, surveyor was in R127's room for interview. Surveyor observed R127 on oxygen via nasal cannula. No label or date on the nasal cannula. On 01/18/2023 at 02:49 PM, surveyor reviewed R127's care plan. Focus created 12/06/2022 documents in part that R127 has altered respiratory function secondary to congestive heart failure, chronic obstructive pulmonary disease, and emphysema. Intervention created 12/06/2022 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. On 01/17/2023 at 12:24 PM, surveyor was in R128's room for interview. Surveyor observed R128 on oxygen via nasal cannula. No label or date on the nasal cannula. On 01/18/2023 at 03:01 PM, surveyor reviewed R128's care plan. Focus created 01/17/2023 documents in part that R128 has altered respiratory function. Intervention created 01/17/2023 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. On 01/17/2023 at 11:05 AM, surveyor was in R238's room for interview. Surveyor observed R238 on oxygen via nasal cannula. No label or date on the nasal cannula. On 01/18/2023 at 02:38 PM, surveyor reviewed R238's care plan. Focus created 01/18/2023 documents in part that R238 has altered respiratory function secondary to congestive heart failure. Intervention created 01/18/2023 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. On 01/17/2023 at 12:51 PM, surveyor was in R127's room for interview. Surveyor observed R127 on oxygen via nasal cannula. No label or date on the nasal cannula. On 01/18/2023 at 02:49 PM, surveyor reviewed R127's care plan. Focus created 12/06/2022 documents in part that R127 has altered respiratory function secondary to congestive heart failure, chronic obstructive pulmonary disease, and emphysema. Intervention created 12/06/2022 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. On 01/17/2023 at 12:24 PM, surveyor was in R128's room for interview. Surveyor observed R128 on oxygen via nasal cannula. No label or date on the nasal cannula. On 01/18/2023 at 03:01 PM, surveyor reviewed R128's care plan. Focus created 01/17/2023 documents in part that R128 has altered respiratory function. Intervention created 01/17/2023 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. On 01/17/2023 at 11:05 AM, surveyor was in R238's room for interview. Surveyor observed R238 on oxygen via nasal cannula. No label or date on the nasal cannula. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 23 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 01/18/2023 at 02:38 PM, surveyor reviewed R238's care plan. Focus created 01/18/2023 documents in part that R238 has altered respiratory function secondary to congestive heart failure. Intervention created 01/18/2023 documents in part: Change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. On 01/17/23 at 10:50 AM, surveyor observed R94 wearing nasal cannula with oxygen infusing. The humidification bottle dated 01/16/23. The oxygen tubing was not dated. On 01/17/23 at 11:19 AM, surveyor observed R111 wearing nasal cannula with oxygen infusing. The humification bottle was labeled 01/17/23. The oxygen tubing was not dated. R111 stated that the respiratory staff did not change the tubing that morning. On 01/17/23 at 11:22 AM, V8 (Registered Nurse/RN) observed R111's oxygen tubing and stated, There is no date on this tubing. V8 stated that if the tubing is not dated, then there is no way for the staff to know when the tubing was last changed. On 01/17/23 at 11:50 AM, V9 (Respiratory Therapist/RT) stated that oxygen tubing is changed weekly. V9 stated, I don't date the tubing, only the water bottle, because it all comes together. V9 stated that R111's humification bottle and tubing was changed this morning. On 01/17/23 at 11:55 AM, when surveyor reentered R111's room, there was new tubing compared to when R111's tubing was observed at 11:19 AM based on the opaqueness of the tubing and the length of the new tubing. On 01/18/23 at 12:40 PM, V2 (Director of Nursing/DON) stated that oxygen tubing is changed weekly or as needed and that the tubing and the water container should both be labeled. V2 stated the tubing should be dated separately from the water container because the humidification bottle may need to be changed more often. V2 stated that dating the oxygen tubing is Important so that the nurses know when the tubing was changed because it is a potential infection control risk to the resident. R94 has diagnoses not limited to Chronic Obstructive Pulmonary Disease, Heart Failure, Chronic Kidney Muscle Weakness, Protein-Calorie Malnutrition, Hemiplegia/Hemiparesis following Cerebral Infarction. R94's MDS (Minimum Data Set) from 11/20/22 BIMS (Brief Interview for Mental Status) score is 06 indicating severely impaired cognition. R94's Order Summary dated 01/18/22 documents, in part oxygen 2L via NC as needed for hypoxia. R94's care plan dated 11/23/22 documents in part, change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. R111 has diagnoses not limited to Emphysema, Chronic Obstructive Pulmonary Disease, Nonspecific Abnormal Finding of Lung Field, Pneumonia. R111's MDS (Minimum Data Set) from 12/31/22 BIMS (Brief Interview for Mental Status) score is 14 indicating intact cognition. R111's Order Summary dated 01/18/22 documents, in part oxygen at 3L per minute via NC every shift for shortness of breath. R111's care plan dated 03/30/22 documents in part, change oxygen bubbler and tubing weekly on Sunday and date and initial bubbler and tubing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 24 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide physician services for residents with new and worsening pressure ulcers for 3 out of 6 residents (R6, R25 and R91) for a total sample of 30 residents reviewed for pressure ulcers. Residents Affected - Few These failures have the potential to affect 3 residents (R6, R25 and R91) from needed medical care that wound physician can provide. Findings include: The following residents have new or worsening pressure ulcers: R6 sustained 4 new facility acquired pressure ulcers on her right lower extremities on 01/09/2023. Pressure ulcers were not seen by V33 (Wound Care Physician) until facility was notified that those 4 pressure ulcers are being reviewed. R25 sustained 2 facility acquired pressure ulcers on the sacral area on 09/12/2023 as redness with skin intact, then skin opened on 09/30/2023 that further deteriorate with size, characteristic and appearance. And left heel pressure ulcer that was identified on its late stage (Stage 3) on 01/03/2023. V33 saw R25 the first time on 01/16/2023 when both wounds deteriorated. R91 sustained left buttock pressure ulcer that worsened from 1/10/2023 to 1/18/2023. V33 never saw R91. All wounds were seen from 01/17/2023 to 01/19/2023 for accuracy of assessments. On 01/19/2023 at 10:06 AM, V18 (Wound Coordinator / Licensed Practical Nurse) was asked why, given the clear deterioration of R25's sacral pressure ulcer since 9/30/2022 until currently, the wound was not seen by a wound doctor until 01/16/2023. V18 said, I tried to do the treatment on my own. I guess it would help but there are times that R25's wounds seem improving. V18 was also asked about R25's left heel since it was discovered already in stage 3. If nursing staff was monitoring R25's left heel, should it be in an earlier stage when it was easy to manage? V18 said, I don't know. But when it was discovered, it was already stage 3. On 01/19/2023 at 11:34 AM, V33 (Wound Doctor) said, I only see residents that was referred to me by the primary physician. I have not assessed R91's wound, because I have not received any referral from R91's physician or V18. If a resident has a stage 3 wound, I will think, certainly, I should have been referred to assess that resident's wound. Per V33 documentations: R25 was only seen one time on 01/16/2023 although R25's sacral pressure ulcer was initially identified as having redness on 09/12/2022, opened on 09/30/2022, and worsen overtime per facility Wound Round Assessments. And only saw R6's 4 pressure ulcers on resident's right lower extremities after the facility informed that R6's wounds are being reviewed. On 01/19/2023 at 12:12 PM, V2 (Director of Nursing/DON) said, All pressure ulcers besides stage 1 must be seen as soon as possible by Wound Doctor. The process for the primary care physician to give a referral for the wound doctor to see resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 25 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medication scheduled as per policy and procedure for residents (R105, R118, R93, R87, R77, R26, R82, R24, R44, R29, R67, R57, R112, R134, R56); failed to follow physician's order in giving the right dose of insulin for 1 resident (R118) and failed to ensure medication was not left at the bed side of one (R31) resident. These failures have the potential to affect 15 residents (R105, R118, R93, R87, R77, R26, R82, R24, R44, R29, R67, R57, R112, R134, R56) not receiving medications needed on time, 1 resident (R118) not receiving the correct dose of insulin and ensuring 1 resident's medication is accessible only by those licensed or permitted to prepare and administer medications. Findings include: On 01/17/2023 at 10:58 AM. V30 (Licensed Practical Nurse/LPN) was still passing medication for R105 and R118. After V30 prepared medications for R118, V30 said that R118 often refused medication. V30 tried to give R118 medication but refused to take all his (R118) medicines. V30 was asked what time schedule of medicine R118 and R105 was she giving? V30 said, These medicines are for 9:00 AM medication, but I still have a few left to give. Yes, it is supposed to be given an hour before and an hour after. Yes, between 8:00 AM to 10:00 AM. On 01/17/2023 at 12:06 PM. V30 saw observed giving insulin (Lispro) medication via subcutaneous injection to R118. V30 said that she will give 1 unit to R118 then administered the medication by injecting it to R118's right upper arm. Review of R118 medication current physician orders, in part reads: Insulin Lispro Inject 12 unit subcutaneously every 6 hours for diabetes mellitus. And sliding scale when blood sugar results 150 and up. On 01/18/2023 at 2:08 PM, V30 was asked to clarify why she gave 1 unit of insulin for a standing order of 12 units. V30 said, R118 sugar was low. Then checked R118's physician order and said, R118 blood sugar was 107. Yes, there is a standing order for 12 units. And sliding scale starts from 2 units. I don't know why I gave 1 unit. But I will notify the doctor so that insulin can be reviewed. On 01/18/2023 at 10:34 AM, V8 (Registered Nurse/RN) was observed still passing medications. When asked how many residents still did not receive their medications, Nurse stated that she still needs to administer medications of the following residents: R105, R118, R93, R87, R77, R26, R82, R24, R44, R29, R67, R57, R112, R134, R56. On 01/19/2023 at 12:12 PM, V2 (Director of Nursing/DON) stated, Facility follows 1 hour before and after the allotted time for medication administration as ordered by physician. And insulin must be given as ordered by the physician. If the order is for 12 units, then it must be given per physician's order. I heard that the Nurse Practitioner did not change the order for R118 insulin. Administering Medication policy dated as reviewed 12/17, in part reads: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 26 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0755 Level of Harm - Minimal harm or potential for actual harm Medications shall be administered in safe and timely manner, and as prescribed. Only person licensed or permitted by this State to prepare, administer, and document the administration of medication may do so. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time frame. Residents Affected - Some Per schedule of Routine Dose of Medication Administration not dated, it reads: Medication s are administered 60 minutes prior to or after it scheduled time. On 1/17/22 at 1:05 PM, observed a half-filled bottle of Chlorhexidine Gluconate solution 0.12% with R31's name on the bottle. R31 was sitting up in her wheelchair, alert and oriented to self only. On 1/17/22 at 1:10 PM, V13 (Registered Nurse/RN) stated, I worked here in this facility for 13 years. I am R31's nurse today. I am sorry about the medication on R31's bedside table, I forgot to remove the bottle of medication Chlorhexidine. I will place it back on the medication cart now. On 1/19/23 at 12:10 PM, V2 (DON) stated, All medication is to be stored and locked in the medication cart at all times. No medication is to be left at the resident's bed side. The resident could take the medication and aspirate, choke, or overdose. R31's medical record documented in part: R31 was admitted on [DATE] with medical diagnoses of acute kidney failure, pneumonia, tracheostomy, gastrostomy, acute embolism, dysphasia, malnutrition, cognitive communication deficit, disorders of the lung, acute respiratory failure, essential hypertension, atrial fibrillation, hypothyroidism, sepsis, and depression. Physician order dated 12/5/22 NPO [ Nothing by mouth], dated 12/5/22 Enteral feed order every 8hours flush enteral tube with 150ml of water, dated 12/6/22 enteral feed order Jevity 1.5 at 1900ml with 60ml water flush before and after each feeding. Reviewed R31's Face-sheet, medical diagnosis, physician order sheets, Minimum Data Set [MDS] with Brief Interview for mental status score is 0, which indicates R31 is severely impaired cognitively, care plans, medication administration record, treatment administration record, and progress notes. Policy-Documents in part: -Storage of Medications Medications and biologicals are stored safely, securely, and properly FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 27 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 - 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to date insulin with open and expiration date for 4 residents (R79, R138, R32, R139). Failed to date eye drops with open and expiration date for 2 residents (R128, R17). Failed to maintain medication cart free from discontinued medication for 1 resident (R111). These failures have the potential to affect 7 (R79, R138, R32, R139, R128, R17, R111) residents in receiving quality medications. Findings include: [DATE] at 09:20 AM. With V11 (Licensed Practical Nurse/LPN) during medication review, administered 55 units of Insulin Degludec to R139. Upon review of insulin vial, no date was seen. And printed instructions that reads: Discard after 42 days after opening. On [DATE] at 12:47 PM, With V14 (Registered Nurse/RN), the medication cart was reviewed. When asked about insulin medication on the cart. V14 presented only 1 insulin pen and said, Yes, this is the only insulin I have in my cart. V14 was asked to accompany and provide entry to medication room. Inside the medication room, V14 opened the refrigerator, where multiple insulins pens and vials where found. Upon taking out of the refrigerator, V14 reviewed all insulins that are opened and used due to decrease of fluid content inside transparent area of the pen and vials. The following insulins were found not dated: R79 has 3 insulin Lispro Kwikpen R138 has 1 insulin Lispro Kwikpen Insulin Aspart Kwikpen without a name R32 has 1 insulin Lispro Kwikpen and 1 vial of Humalog, per V14, resident was already discharged . On [DATE] at 01:54 PM, With V11 (LPN), R20's Norco 5 per 325 MG has 3 separate bottles with 9, 25 and 28 tablets each separate bottles. And was repacked placed on a pill crusher bag and placed back on the bottle. R96 - Dulera 200 per 5 MG inhaler, without cover on the mouthpiece placed on the bottom of the surface of the medication cart. V11 stated that she understands that it is not clean when resident put it in her mouth later. On [DATE] at 11:32 AM, With V8 (Registered Nurse/RN) inside medication cart was the following eye drops: R111's Ciprofloxacin 0.3 % antibiotic eye drop was in the medication cart, V8 said that this medication was already discontinued. Order reads that Ciprofloxacin HCl Solution 0.3 % for 5 Days and was completed or discontinued on [DATE]. R128 and R17, both residents have Latanoprost eye drop that was opened and without date. R128 has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 28 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 [DATE] written on it. V8 said that the date [DATE] was the time it was opened. Both boxes have a print that reads: Refrigerate before opening. After opening, may store at room temperature. Throw away any drug left after 6 weeks. Also inside medication cart was a blue-grey Ventolin HFA inhaler without a cover on it and was left touching interior surface of the cart. V8 stated that there should be a cover on the mouthpiece of the inhaler to be clean when used. Residents Affected - Some On [DATE] at 12:12 PM, V2 (Director of Nursing/DON) stated, Insulin that are opened and not dated must be taken out of the cart or med room and discarded. The same as to eye drops, expired and discontinued medications. As to placing narcotic medication on a plastic bag used for crushing medication, I will talk to the nursing staff not to repackage narcotic medication. I think they do that to easily count during change of shift. Storage of Medication policy dated as reviewed [DATE], in part reads: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those is containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. Under expiration dating, certain medications or package type, such as multiple dose injectable vials, ophthalmic once opened, require expiration date shorter that the manufacturer's expiration date to insure medication purity and potency. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 29 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 store and prepare food under sanitary conditions. This has the potential to affect all 141 residents that receive nutrition services from the kitchen. Findings include: On 01/17/2023 at 09:16 AM, surveyor conducted an initial tour of the kitchen with V26 (Dietary Manager). At 09:24 AM, surveyor inspected facility's walk-in refrigerator that also leads into the freezer. Surveyor observed a cart full of individual whoopie pies and puddings uncovered in the middle of the refrigerator. V26 stated kitchen staff prepared them in the morning and facility will serve them for lunch. In the freezer, surveyor observed ice build-up at the bottom of the freezer's left fan. There was a box of breakfast sausage underneath the fan. The box had a build-up of ice on the top left side. V26 stated the freezer is supposed to go through a weekly defrost cycle. On 01/18/2023 at 09:00 AM, surveyor conducted a follow-up kitchen tour. Surveyor observed the facility's knife holder that was fastened on the wall. Knife holder had dust and residue build-up on the top. V26 stated facility stored the clean knives in the knife holder. At 09:58 AM, surveyor observed V29 (Cook) prepare pureed meal. V26 stated facility has one blender. Blender was wet with clear liquid. V29 poured lima beans into blender. V29 completed pureeing the lima beans. Kitchen staff washed the blender. At 10:06 AM, surveyor observed the blender wet. Facility did not air dry the blender. V29 proceeded to puree ham. On 01/19/2023 at 12:40 PM, V2 (Director of Nursing/DON) stated facility should have at least two or three blenders for purees, but at the bare minimum, staff should let the blender dry in between uses. V2 also stated if facility is not storing and distributing food under sanitary conditions, there is potential for infection control concerns. Surveyor reviewed facility's Cleaning Procedure for Equipment and Utensils policy from the Food & Nutrition Services policy and procedure manual. Under the procedure for the blender, it documents in part: after rinsing and sanitizing the cannister, facility is to air-dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 30 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 Based on observation, interview and record review, the facility failed to a.) implement infection control measures for the disposal and containing of used isolation PPE (Personal Protective Equipment), garbage and linen in a designated container inside the resident rooms for 4 (R55, R86, R114, R128) of 10 (R22, R23, R60, R91, R104, R138) residents reviewed for transmission-based precautions, b.) ensure Infection Control policies and procedures were reviewed and revised annually to reflect current standards of practice, c.) perform hand hygiene before performing medication administration after touching high touched area for 1 resident (R6) and d.) failed to store inhalers by covering the mouthpiece to maintain clean area when used by mouth for 1 resident (R96). Residents Affected - Some Findings Include: R55 has diagnoses not limited to COVID-19 (Coronavirus), Essential (Primary) Hypertension, Pulmonary Embolism, Dementia, Schizoaffective Disorder, Major Depressive Disorder, Anxiety Disorder and Dysphagia. R55 Order Summary Report document in part: Contact/Droplet Isolation due to COVID + (Positive) for 10 days. R55 Care plan document in part: Focus: Contact/Droplet Isolation related to positive COVID -19 x 10 days until 01/17/23. Date Initiated 01/10/23. Interventions/Tasks: Bag and transport used linen per facility protocol. Date Initiated 01/10/23. Contact/Droplet precautions. Date Initiated 01/10/23. R55 has Positive COVID-19 infection. Date Initiated 01/10/23. R86 has diagnoses not limited to COVID-19, Wandering, Major Depressive Disorder, Mental Disorder, Dementia, Mood (Affective) Disorder and Anxiety Disorder. R86 Order Summary Report document in part: On Contact/Droplet Isolation due to COVID-19 + (Positive) every shift for + COVID for 10 days. On Contact/Droplet Isolation due to COVID-19 + until 01/17/23. R86 Care plan document in part: Focus: Contact/Droplet Isolation due to positive COVID - 19 x 10 days until 01/17/23. Interventions/Tasks: Bag and transport used linen per facility protocol. R86 has Positive COVID-19 infection. Date Initiated 01/10/23. R114 has diagnoses not limited to Influenza, Epilepsy, Dementia, Alzheimer's Disease, Dysphagia and Cognitive Communication Deficit. R114 Order Summary Report document in part: Contact/Droplet Isolation due to Influenza AB every shift for Influenza AB for 7 days. Order date 01/10/23. R114 Care plan document in part: Focus: Contact/Droplet Isolation related to Influenza until 01/17/23. Date Initiated 01/10/23. Interventions/Tasks: Bag and transport used linen per facility protocol. R114 has Influenza AB. Date initiated 01/10/23. On 01/17/23 at 01:17 PM, V23 (Registered Nurse/RN) accompanied the surveyor to R114 room then opened R114 door to check if there was a container to dispose of used PPE (Personal Protective Equipment) and linen. V23 stated, There is usually a container by the door, but there is no container near the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 31 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some door. V23 opened the bathroom door and did not locate a disposal container. V23 then proceeded to R55 and R86's shared room. V23 opened the door and stated, There is a garbage can between the two dressers in the middle of the room and near R55's bed, but there is no disposal container near the door. On 01/17/23 at 12:46 PM, V23 (RN) stated, A cart is placed outside of the resident's door for contact droplet precautions. We wear a N95 mask, face shield and gown. On 01/18/23 at 10:21 AM, V11 (Licensed Practical Nurse/LPN) stated, The PPE for the isolation rooms is disposed of in a special red container in the resident room by the door. The linen has a separate container and is located by the resident door for all residents on isolation. On 01/18/23 at 10:25 AM, the Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus Coronavirus-(COVID-19) revised 02/19 was reviewed with V6 (Infection Preventionist). V6 (Infection Preventionist) stated, This is the policy we have, and it has not been updated. I would have to tell the administrator about the policies being updated annually. I don't know if they do any revisions if there are any changes to the policy. We go with IDPH (Illinois Department of Public Health) and state regulations. On 01/18/23 at 11:31 AM, V39 (Certified Nurse Assistant/CNA) stated, When entering an isolation room, I put on goggles, gloves a mask and gown. Before exiting the room, the PPE (Personal Protective Equipment) in the container for garbage in a special red container lined with a plastic bag. There are two containers that are located near the door inside of the room for linen and garbage. On 01/19/23 at 09:35 AM, surveyor showed the policy Titled Infection Prevention and Control Program, revised 10/18, and the policy Titled Isolation - Initiating Transmission - Based Precautions, revised 10/18, to V1 (Administrator). Surveyor asked V1 (Administrator) how often the facility policies are reviewed and revised. V1 responded, We do it yearly, they are not dated. On 01/19/23 at 9:41 AM, V28 (Manager of Central Supply) stated, I make sure the PPE (Personal Protective Equipment) are near the residents' doors that are on isolation. I put the containers for the disposal of the PPE, garbage and dirty linen is inside of the resident room. The white container with a red bag is for PPE/garbage, and the white bag is for linen. The containers should be located near the door in the resident's room. If the containers are not in the room near the door there is a potential to spread the virus. On 01/19/23 at 10:04, V2 (Director of Nursing/DON) stated, There is supposed to be isolation bins in the resident rooms by the exit for linen and garbage. We use regular plastic bags for disposal. We do not use red bags unless there is blood and body fluids. The PPE (Personal Protective Equipment) is removed inside of the resident room and placed in a plastic bag then taken to soiled utility room. If there are no disposable bins by the exit of the resident room, that is not proper disposal of the contaminated linen, PPE, and garbage. There is a potential for cross contamination. On 01/18/23 at 10:51 AM, V2 (DON) stated, The policies are reviewed and revised annually. These deficient practices have the potential to affect all residents residing in the facility. Facility census of 143 residents was obtained from the Resident Census and Conditions of Residents CMS 672 form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 32 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 Policy: Level of Harm - Minimal harm or potential for actual harm Titled Infection Prevention and Control Program, revised 10/18 document in part; An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. Residents Affected - Some Titled Isolation - Initiating Transmission - Based Precautions revised 10/18 document in part: Transmission Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk for transmitting the infection to other residents. Procedure: g. Ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner, are places in or near the resident's room. Titled Medical Waste Handling revised 05/17 document in part: Medical waste will be handled and disposed of safely and in accordance with regulatory requirements. Procedure: 1. For the purpose of this policy, medical wastes include human blood and blood-soiled articles, contaminated items, and disposable sharps. Titled Medical Waste Storage revised 05/12 document in part: Medical waste stored for treatment, or pickup shall be protected in accordance with established policies and procedures. 11. Should our medical waste storage area become full or the maximum number of storage days be exceeded, the Infection Preventionist (or designee) will notify appropriate personnel/agencies and request that the waste be removed promptly. 12. The Infection Preventionist (or designee), with the assistance of administrative staff, shall monitor the medical waste storage area to assure that medical waste is treated, disposed of or picked up by the authorized vendor on a timely basis. R128 is a resident of the facility. R128's face sheet and care plan document in part a diagnosis of human metapneumovirus pneumonia. R128's physician order sheets document in part Contract/Droplet Isolation until 01/25/2023. On 01/17/2023 at 12:26 PM, surveyor noted no red, hazard, garbage bin in R128's room. In the bathroom, there was a small garbage bin with used, blue, isolation gowns overflowing onto the floor. On 01/17/2023 at 11:31 AM, with V8 (Registered Nurse/RN) during medication administration for R6 via enteral feeding. V8 uses the same gloves when preparing medication, then touching high-touched area on the med cart including side of the cart. Then moved the wheelchair using the same gloves without performing hand hygiene. Then resident checked patency by aspirating the tube and administered medication. V8 said, I understand that I need to perform hand hygiene after touching multiple high-touched areas or at least changed my gloves. On 01/17/2023 at 01:54 PM, with V11 (Licensed Practical Nurse) during review of medication cart. R96's inhaler (Dulera 200 per 5 MG) was seen without cover on the mouthpiece and was placed on the bottom of the surface of the medication cart. V11 stated, I agree, it is not clean later when resident puts it in her mouth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 33 of 34 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. 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 Level of Harm - Minimal harm or potential for actual harm On 01/19/2023 at 12:12 PM. V2 (DON) stated, Hand hygiene must be performed after touching high-touched areas like wheelchair, then performing medication administration via G Tube to prevent infection. Handwashing / Hand Hygiene policy dated 5/2018 in part reads: Residents Affected - Some This facility considers hand hygiene the primary means to prevent the spread of infections. Under procedure, all personnel shall follow the handwashing / hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use of alcohol-based hand rub or water and soap for the following situations: Before and after direct contact with residents. After contact with objects in the immediate vicinity of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145982 If continuation sheet Page 34 of 34