Inspection·May 5, 2023

F 0688 2. Prevent contractures via range of motion (ROM) activity, and splints/braces Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146145 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mather Evanston, The 425 Davis Street Evanston, IL 60201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its fall precautions protocol by failure to complete root cause analysis and update care plan after each fall incident occurrence to a resident who is at high risk for falls. This deficiency affects one (R18) of three residents in the sample of 13 reviewed for Fall prevention program. Findings include: On 5/2/23 at 10:10am, V10 (Registered Nurse/RN) said that R18 is on fall precaution. R18 ambulates with rolling walker and wheelchair. R18 is confused due to his dementia. V10 said that they don't have list of residents on fall precaution program. V10 said that V3 (Assistant Director of Nursing/ADON) has the list. On 5/2/23 at 1:48pm, observed R18 lying on bed, sleeping. His bed in not in the lowest position. Rolling walker at bed side. On 5/3/23 at 12:50pm, observed R18 with V3 (ADON), R18 sleeping on low bed. His low bed in the lowest position. On 5/4/23 at 11:25am, V3 (ADON) said that she is the Fall Coordinator. She said that they have fall prevention program, and R18 in on the list. V3 said that the floor nurse is the one who completes and updates the post fall investigation and care plan. V3 with QAPI (Quality Assurance and Performance Improvement) review the fall post fall investigation and update the care plan as needed. On 5/4/23 at 11:30am, review R18's medical records with V3 (ADON) and V5 (Clinical Manager). R18 is admitted on [DATE] with diagnoses listed in part but not limited to Repeated falls, Dementia. admission fall assessment dated [DATE] indicated at high risk for fall. Care plan indicated that he has memory problem, impaired decision making and judgement. He has an ADL (Activity of Daily Living) self-care performance deficit related to Dementia. He requires one staff assistance to use toilet and transfer. He needs supervision to reposition/turn in bed. He is at risk for falls characterized by history of falls prior to admission and new environment. R18's Fall incident reports: 1)12/3/22 Unwitnessed fall, observed R18 lying supine on floor in his room. He sustained superficial bruise to left knee and complained of chest pain. He was sent to the hospital and admitted with diagnosis of chest pain and fall secondary to syncope. R18 returned on 12/5/22. V3 (ADON) said that she did not update R18's fall care plan after he came back from the hospital. 2) 1/9/23 Unwitnessed fall, observed sitting on the floor in his room. R18 said I got up to use the bathroom, missed the step and fell on my butt. V3 (ADON) said that they don't have documentation that they check R18 every hour as indicated in fall intervention to ensure safety. 3) 1/16/23 Unwitnessed fall, observed crawling on floor in his room. R18 said he wanted to get to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146145 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mather Evanston, The 425 Davis Street Evanston, IL 60201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 the bathroom. Post fall investigation dated 1/16/23 indicated R18's bed should be at lowest position. Level of Harm - Minimal harm or potential for actual harm 4) 1/18/23 Unwitnessed fall, observed R18 on the floor attempted to crawl to his walker to the bathroom. Fall care plan is not updated after the fall occurrence. Residents Affected - Few 5) 4/21/23 Unwitnessed fall, observed R18 sitting on the floor with bilateral lower extremities extended. R8 said that he came from the bathroom and lost his balance going back to bed. No post fall investigation/root cause analysis done. On 5/4/23 at 11:58am, informed both V3 (ADON) and V5 (Clinical Manager) that Fall care plan was not updated after fall occurrence on 1/18/23. No post fall investigation/root cause analysis done on 4/21/23. All the unwitnessed fall from 1/9/23, 1/16/23, 1/18/23 and 4/21/23 are related to going to the bathroom, as verbalized by R18 in the incident report, but they were not addressed in fall care plan intervention. V5 said that R18's bed should be on the lowest position while on bed. Informed V5 that R18 was observed with V3 (ADON), lying on low bed, not in lowest position. On 5/4/23 at 12:30pm, informed both V1 (Administrator) and V2 (Director of Nursing/DON) of above concern. V2 said that the floor nurse is the one who completes the post-fall investigation/root cause analysis, then the Fall Coordinator with QAPI team will review and updates the care plan. Fall care plan should be updated after each fall occurrence to prevent future falls. On 5/4/23 at 1:40pm, V17 (Agency Nurse) said she does not know who the residents on fall precautions are. She searched the endorsement binder and nursing station but unable to find the list. On 5/4/23 at 1:58pm, review QAPI fall meeting report with V1 (Administrator). V1 said that the QAPI meeting minutes did not indicate the discussion of the root cause analysis/post fall investigation and formulation of new fall intervention to prevent future falls. V1 said that she will talk with fall QAPI team. Facility Fall precautions Protocol indicates: Purpose: This protocol outlines the procedures for implementing fall precautions across the continuum. Standard of practice: 1. Fall precautions are designed by the care venue's multidisciplinary team. These interventions may be discussed in the quality assessment performance (QAPI) team meeting, morning meetings, shift reports, post fall huddles and or care plan/service plan conferences. 3. Interventions are documented in the resident's care plan/service plan. Post fall actions: 6. The resident's care plan/service plan is reviewed after a fall event and new interventions considered as per assessment and the post fall review. 8. A root cause analysis may be completed for certain falls, per policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146145 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mather Evanston, The 425 Davis Street Evanston, IL 60201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Communication of fall risk and falls to IDT (interdisciplinary Team): Level of Harm - Minimal harm or potential for actual harm 1. Communication of resident's fall risk and plan of care to the IDT is a step in the fall reduction process. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146145 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mather Evanston, The 425 Davis Street Evanston, IL 60201 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 follow their policy on dating opened food Items and discarding expired foods in the refrigerator for 23 of 24 residents that receive meals from the dining room. Findings include: On 5/2/2023 at 10:30am during a tour of the dietary department V14 (Culinary Director/Executive Chef) observed with the surveyor in the refrigerator, Dill sauce with a use by date of 4/23/2023, Vitamin D milk with a use by date of 5/1/2023, Mozzarella Cheese with a use by date of 5/1/2023. Salad dressing open no date, Parmesan Cheese open no date, sliced meat open no date, liquid eggs open no date. On 5/2/2023 at 11:00am, V14 said all expired foods should be discarded, and all open foods should have a date. Facility Policy: Food Storage and Refrigeration Management-Effective date: December 2019, Revised February 2022, Revised March 2023e Purpose: This policy reviews the process for food storage and refrigeration management in the life plan communities. Process: 7. Store food in original container if the container is clean, dry, and intact. If necessary, repackage food in clean, date marked and labeled, airtight containers. 7.1 This also can be done after a package is opened. 2. Dispose of items that are beyond the expiration or use by date FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146145 If continuation sheet Page 6 of 6