Health inspection·March 2, 2023

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that the nurse must ensure that the resident has swallowed the medication before leaving the room. V2 stated that there must be an assessment done for residents to self-administer their own medication and that the medications will then be locked in the resident's room. V2 stated that R11 has no assessment for self-administration of medications. V2 stated that the nurse should not leave meds at bedside. R11' Medication Administration Record (February 2023) documents, in part, the following daily 6:00 am scheduled medications: Omeprazole 20 mg (milligram) capsule by mouth every morning, Gabapentin 100 mg capsule (4 capsules) by mouth every three times a day and Levothyroxine 50 mcg (microgram) tablet by mouth every morning. R11's Care Plan, dated 1/5/22, documents, in part, a plan that R11 has impaired cognition related to dementia. Review of R11's electronic medical record (EMR) including the physician order sheet, progress notes, resident assessment and care plan does not show documentation of R11's ability to self-administer medications. The facility policy titled Medication Administration and dated 9/27/19, documents, in part, 3. Medications must be administered in accordance with the orders, including any required time frame. 23 Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so. The facility policy titled Self-Administration of Medications and dated 3/2019, documents, in part, . 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 2 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that a resident who depended on staff's assistance with ADL (Activities of Daily Living) care received assistance with personal hygiene. This failure affected 1 resident (R11)) reviewed for ADL care in the total sample of 29 residents. Residents Affected - Few Findings include: On 02/28/2023 at 9:48am, R11 was noted with facial hair on the upper lip and chin. This surveyor pointed out this observation with V4 (Licensed Practice Nurse). V4 stated, She (R11) has hair on the upper lip and chin. On 02/28/2023 at 9:50am, surveyor inquired if R11 was aware of the facial hair on the upper lip and chin. R11 stated, I (R11) did not know I (R11) have them. Nobody told me (R11) I (R11) have them. This surveyor inquired if a staff member offered assistance to shave R11's facial hair. R11 stated, Nobody offered and I (R11) want it shaved. On 03/01/2023 at 10:25am, surveyor inquired about shaving of facial hair on female resident. V2 (Director of Nursing) stated, Expectation with staff is to offer it and if a resident said 'yes!' they need to do it. If the resident said 'don't want it shaved' staff has to explore why. I (V2) am an advocate for resident's preference. My (V2) teaching with my (V2) staff is not to go against the wishes of the resident. R11's admission Record documented that R11's diagnoses include but not limited to: muscle weakness, dementia, and lack of coordination. R11's (10/30/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 9. Indicating R11's mental status as moderately impaired. Section G. Functional Status. G0110 Activities of Daily Living (ADL) Assistance. J. Personal hygiene - how resident maintains personal hygiene, including shaving. 2/2 coding Limited assistance / One person physical assist. R11's (start: 01/05/22) Care Plan documented, in part Category: 2 Cognitive Loss. (P) Problem: has impaired cognition related to dementia. (G) Goal: will maintain the ability to function in my (R11) daily routine and activities with coaching from staff. R11's (start 12/18/20) Care Plan documented, in part Category: 5. ADL function Rehab. (P) Problem: requires assistance with ADL's r/t (related to) weakness. (G) Goal: will have ADL needs met with staff assistance. The (undated) Care Partner Job Description documented, in part Position Summary. The Care Partner is responsible, under the direct supervision of the Charge Nurse and in accordance with prescribed procedures and established quality care standards, for providing direct personal and restorative nursing care to an assigned number of resident, while at all time ensuring the safety and well-being of all our residents. Essential Functions. Provides and/or assist resident will all aspects of personal hygiene and activities of daily living in accordance with established care procedures and standards. Provides and/or assist with grooming, such as shaving FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 3 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the low air loss (LAL mattress was not layered with multiple linens which affected one resident (R26) in the sample of 29 residents reviewed for pressure ulcers. Residents Affected - Few Findings include: On 2/27/23 at 12:12 pm, R26 was observed in bed on a LAL mattress with a white fitted sheet with the two upper mattress corners pulled tightly and pinching corners. This surveyor observed multiple layers of linen under R26. V19 (Private Care Giver) donned gloves and pulled back R26's blanket to expose that R26 was wearing an incontinence brief with an incontinence pad, flat sheet that is quadruple folded and a fitted sheet on top of the LAL mattress. On 2/28/23 at 11:28 am, R26 was observed in bed on a LAL mattress with a white fitted sheet with the two upper mattress corners pulled tightly and pinching corners. This surveyor observed multiple layers of linen under R26. V20 (Private Care Giver) pulled back R26's blanket to expose that R26 was wearing an incontinence brief with an incontinence pad, flat sheet that is quadruple folded and a fitted sheet on top of the LAL mattress. R26's Minimum Data Set (MDS), dated [DATE], documents, in part, that R26's Brief Interview for Mental Status (BIMS) score is 12 indicating that R26 has moderate cognitive impairment. R26's Skin Conditions for Stage 3: Full thickness loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Sough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling with a number of 3. R26's Skin and Ulcer/Injury Treatments include pressure reducing device for bed. R26's Face Sheet (Detailed Summary) documents, in part, R26's diagnoses of pressure ulcer of right heel stage 3, pressure ulcer of left heel stage 3, wedge compression fracture of third and fifth lumbar vertebrae, muscle weakness and abnormalities of gait and mobility. R26's Braden Scale for Predicting Pressure Sore Risk, dated 2/4/23, documents, in part, a score of 14, and If the residents total is 14 or less, consider him/her at risk for pressure ulcer/injury development. R26's Care Plan, dated 2/23/23, documents, in part, a plan for pressure ulcers that (R26) has the potential for pressure ulcers related to decrease mobility due to pain with dx (diagnosis) severe low back pain 2/2 (secondary to) metastatic spinal disease with an action of use turn sheet and protective film to prevent shear and friction. On 3/1/23 at 1:27 pm, when asked about the linens that should be used on top of a LAL mattress, V2 (Director of Nursing, DON) stated that the nursing staff use one layer and can use a turning sheet. The one thing that we (staff) don't use is the fitted sheet. It's so tight. (They) use a flat sheet and something for a turning sheet. I (V2) don't support the use of multiple linens. One flat sheet and one turning sheet to (help) reducing surface friction. One flat sheet and not the fitted mattress should be preference. There is not a lot of surface area in between the resident and the LAL mattress. When asked what does surface area mean, V2 stated, Linens. V2 stated that the purpose of a LAL mattress cells fill with air to relieve pressure of the resident's body and that a fitted mattress (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 4 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 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 - Minimal harm or potential for actual harm would impede the air expansion in the cells. When asked about a resident having a private care giver, does the nurse and CNA staff educate the private care giver on the resident's planned care. V2 stated, It's team work. V2 stated that private care givers are hired by family members from an external agency, and the resident's plan of care is reviewed with the external agency and that V2 will verbally educate private care givers on plan of care. Residents Affected - Few Facility policy titled Pressure Ulcer/Injuries Overview and dated October 2022, documents, in part, Purpose: The purpose of this procedure is to provide information regarding definitions and clinical features of pressure injuries. MDS assessments reference current definition in the Resident Assessment Instrument User's Manual. Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to medical and other device. Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear, Friction/shearing: 'Friction' is the mechanical force exerted on skin that is dragged across any surface. 'Shearing' occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 5 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 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. Based on observation, interview, and record review, the facility failed to follow their policy of monitoring the temperature of the refrigerator used for storing vaccine twice daily and failed to ensure the refrigerator temperature log sheet has no missing entries. These failures have the potential to affect all the 17 residents on the 8th floor. The (02/27/2023) resident census on the 8th floor was 17. On 02/28/23 at 10:49 am, the Refrigerator Temperature Log Sheet inside the medication storage room had missing entries on the Temperature and Nurse's initial columns. This surveyor requested V4 to check what days the log sheet had missing entries. V4 stated, Days without log were on the 12th, 22nd, and 23rd, 24th, 25th, and 27th of February. This surveyor inquired who was responsible in checking the temperature of the refrigerator. V4 stated, Night shift checks the temperature every day. This surveyor inquired what medications were inside the refrigerator. V4 opened the refrigerator, showed the content of the refrigerator, and stated, We have controlled medications, house stock flu vaccine and PPD (PPD stands for purified protein derivative The PPD skin test is a method used to diagnose silent (latent) tuberculosis infection) for TB testing). This surveyor inquired how many times the refrigerator was checked daily. V4 stated, We check the temperature once daily only. On 03/01/2023 at 10:30am, surveyor inquired about the purpose of checking the temperature of the refrigerator inside the medication storage room. V2 (Director of Nursing) stated, Purpose of checking the temperature is to make sure the refrigerator meets the required temperature. Night shift should monitor it once a day. The reason we want to keep the medications in the fridge is to maintain the efficacy of the medications. That is why we wanted the refrigerator temperature monitored. The (02/2023) Medications Only Refrigerator Temperature Log Sheet had missing entries on days 12, 22, 23, 24, 25, and 27. Of note, the Refrigerator Temperature Log Sheet had one column for 'Day', one column for 'Temperature' and one column for 'Nurse's Initial'. The (3/19) Storage of Medications documented, in part Policy. Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Temperature. C. Medications requiring refrigeration are kept in refrigerator at temperature between 2C (36F) and 8C (46F) with a thermometer to allow temperature monitoring. E. The facility should maintain a temperature log in the storage area to record temperatures at least once a day. F. The Facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC Guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 6 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 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 discard food products before expiration date; failed to perform proper hand washing and use of gloves during kitchen tasks and after staff touched self; failed to follow proper food storage practices and label/date food; failed to maintain daily refrigerator temperature log; failed to maintain daily sanitization log; failed to maintain clean kitchen appliances; and failed to maintain safe food handler certification to prevent the spread of food-borne illness and contamination. These failures have the potential to affect all 32 residents currently receiving meals from the kitchen. Findings include: On 02/27/23 at 10:59 AM Initial kitchen tour with V10 (Director of Culinary Services) Walk in Refrigerator: Container of diced yellow fruit identified by V10 as diced peaches unlabeled no open date or use by date. V10 stated, should put open date and use by date. Container of brown gel-like substance in plastic container with dates of 2/24 and 3/25 on container. V10 unable to identify open date or use by date V9 (Clinical Dietitian) joined surveyor and V10 during tour. Lemon juice 946ml opened 2/23/23 no use by date Fruit plate prep date 2/24 use by 2/20 Food tray in walk in refrigerator with debris, crumbs, and dried substance with food sitting on tray Beef base 16oz dated 2/23/22 no exp date Opened sauteed vegetable base no open or use by date 3 slices of bread in plastic sleeve no open or use by date Opened S****** O**** chili 136 oz 2/25/22 no use by date creamy peanut butter 5 lb dated 10/13/22 no use by date Stainless steel mixer next to ice machine on cart with food crumbs and debris Opened whole dutch poppy seed open 8/20/20 exp 4/20/21 V9 stated, we should throw it out. Open bottle of H******* genuine chocolate flavor 24 oz no open or expiration date, sitting on shelf not refrigerated, food item label states refrigerate after opening. V10 stated, this should be kept in the refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 7 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 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 Meat slicer with crumbs and debris on cart with food scales below with debris and crumbs. V10 stated, we clean before we use it and we do not use it every day. We clean and sanitize after use. 2/27/2023 at 1:05pm 9th floor kitchen tour with V9 and V10 9th floor refrigerator temperature log for month of February 2023 with missing temperature reading for: 2/1/23 4:00pm, 2/4/23 4:00pm, 2/13/23 4:00pm. V9 stated, temperature should be recorded twice a day on temperature log. 8th floor kitchen tour On 2/27/2023 at 1:20pm Surveyor asked V9 to test sanitizing bucket sitting on counter. V9 unable to locate test strips and requested staff member to go to other floor to obtain test strips. V9 obtained testing strips and tested sanitizing bucket with reading observed at 170ppm. V9 stated, this does not have enough sanitizer. V9 further stated, sanitizing bucket solution should be replaced every 2 hours and there should be test strips on each floor. V9 further stated, sanitizing bucket solution should be checked when bucket filled with sanitizing solution from the kitchen and there should be testing strips on each floor. On 2/28/2023 at 10:48am Puree Observation with V11 (Cook) Surveyor observed V11 with gloved hands prepare cheesy hash brown mechanical food. V11 obtained temperature before putting food in food processor. Cheesy hash brown temperature 182 degrees and post temperature 146 degrees. V11 stated I am going to puree broccoli after this. V11 did not perform any hand hygiene and with same gloves on touched V11's apron, then touched food blender, put hands on countertop, then walked over to clean dish rack and obtained 4 stainless steel food containers, returned to complete mechanical diet with no hand hygiene or changing of gloves observed by surveyor. V11 continued to wear same gloves and put broccoli into blender and puree broccoli. Once broccoli was pureed, V11 wiped food thermometer with alcohol wipe then obtained food temperature then put pureed broccoli in serving dish, walked to food warmer, opened food warmer with same gloves and placed pureed broccoli into food warmer, walked back to prep counter and began to prepare to make mechanical soft broccoli using food processor. V11 check temperature of broccoli then put broccoli into food processor, and once broccoli consistency of mechanical soft, cleaned food thermometer with alcohol wipe and obtained food temperature. Food temperature 132 degrees. V11 then proceeded to put mechanical soft broccoli into microwave container walked over to microwave, opened microwave and placed mechanical soft broccoli into microwave put on desired settings, then upon microwave completion opened microwave door and wiped food thermometer with alcohol then took temperature of broccoli. V11 stated, this is not warm enough. V11 put mechanical soft broccoli back into microwave, adjusted temperature and time and once microwave stopped, cleaned food thermometer with alcohol and food temperature 170 degree. V11 removed mechanical soft broccoli, walked back to prep area and put mechanical soft broccoli into stainless steel container, covered container with plastic wrap then walked to food warmer, opened food warmer and placed mechanical soft broccoli in warmer. V11 remained in same gloves and did not perform any hand hygiene. 2/28/2023 at 11:27am surveyor observed cart with meat slicer on top and food scale on the bottom, both shelves with food crumbs and debris. Observed stainless steel cart next to ice machine with mixer on top and food scale on bottom both shelves with food particles and debris on food scale and mixer. Poppy seed food container remains on shelf with open date 08/20/20 and use by date 4/20/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 8 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 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 9th floor refrigerator temperature log for month of February 2023 with missing temperature date for: 2/1/23 4:00pm, 2/4/23 4:00pm, 2/13/23 4:00pm Level of Harm - Minimal harm or potential for actual harm 8th floor sanitizer bucket for month of February 2023 missing test for: Residents Affected - Many AM Shift: 2/1/23, 2/3/23, 2/4/23, 2/4/23, 2/6/23, 2/7/23, 2/8/23, 2/20/23, 2/26/23, and 2/27/23 PM Shift: 2/4/223, 2/11/23, 2/25/23 Current staff Food Handler certificate: V21 (Food Server) training certificate completed: February 26, 2020, expiration February 26, 2023. Facility Handwashing Policy Department: Dining Services with revision date 2/2020 documents in part: Policy: All Culinary service employees should wash hands according to the guidelines listed in order to prevent and control the spread of infection. Food handlers must wash their hands: After Touching apron or clothing, after Touching anything else that might contaminate hands, such as unsanitized equipment, work surfaces, or wash cloths Facility Sanitation of Equipment Policy with revision date 2/2022 Department: Dining Services documents in part: Policy: It is the policy of the Dining Service Department to adequately sanitize all food contact surfaces on an appropriate schedule utilizing mandated procedures and methods. This will be accomplished through use of soap, water and quaternary solutions I spray bottles and properly labeled buckets. Procedures: 1. Sanitizing solution buckets will be made at the beginning of each shift and changed as needed. Reasons for changing solutions include the solution becoming diluted from use or every 2 hours (failing to meet concentration standards.) 3. When preparing sanitizing solution for food contact surfaces the concentration must be 272-700 ppm. Facility Refrigerated Storage Policy with revision date 2/2022 Department: Dining Services documents in part: Purpose: To ensure all food products are safe and to prevent foodborne illnesses Policy: Establish a standard on all items stored in refrigerator. Procedure: 7. All food is labeled, if taken out of original packages, food will be labeled and dated. Facility Safe Food Storage Policy with revision date 2/2022 Department: Dining Services documents in part: All food that is removed from original packaging or is leftover hall be handled in accordance with state guidelines. All food products that are stored in refrigerators, freezers or dry storage areas shall be sealed completed, and labeled with a common name and clearly indicated production or opened date, use-by , or discard date. Procedure: All potentially hazardous, ready-to-eat food stored in refrigeration shall be properly packaged, labeled and dated and discarded if not used within 7 days of preparation, Keep all storage areas clean and dry, Keep the carts or other vehicles that transport food clean and free of debris, All potentially hazardous ready-to-eat food should be labeled with the date it should be sold, consumed, or discarded Facility Puree Texture Diet Policy with revision date July 2022 Department: Dining Services documents in part: The kitchen will prepare the altered texture diet for the healthcare floors. Responsibility: Cooks Procedure: 1. [NAME] will wash hands according to handwashing policy and wear gloves during preparation. Facility [NAME] Job Description undated documents in part: Department: Culinary Services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 9 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 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 Position Summary: The [NAME] prepares meals and achieves dining objectives by controlling food preparation and sanitation in all areas of dining service. Essential Function Adheres to all department sanitation and safety control policies, including but not limited to, hand washing throughout shift, wearing gloves when handling food, properly labeling and dating all foods, Maintains sanitation through completion of all sanitation duties that are scheduled Residents Affected - Many Facility Server Job Description undated documents in part: Department: Culinary Services Position Summary: The server provides culinary information to residents and guests for ordering meals, presents and serves meals to residents Education and Experience Illinois Food Handler Training required FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 10 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to display the proper isolation signage for a COVID-19 positive resident; failed to don personal protective equipment (PPE) before entering a COVID-19 isolation room (contact and droplet precautions); failed to redirect a resident who was on contact and droplet precautions back into the isolation room; and failed to perform hand hygiene to prevent the spread of microorganisms including COVID-19 which affected R3, R5, R9, R19, R23, R24 and R25 and had the potential to affect 16 residents residing on the 8th floor. Residents Affected - Some Findings include: On 2/27/23 at 11:08 am, R24's isolation signs were noted visibly posted outside R24's room reading Contact Precautions and Droplet Precautions with a bin storing PPE outside R24's room. On 2/27/23 at 11:10 am, R5, R9, R19, R23 and R25 were observed sitting in the living room on the 8th floor along with V5 (Care Partner, Certified Nursing Assistant, CNA) who was wearing a surgical mask. On 2/27/23 at 11:12 am, R24 (who was not wearing a face mask) exited R24's contact and droplet isolation room by propelling R24's self in a wheelchair and wheeled across the hallway into the living room where R5, R9, R19, R23 and R25 were located. On 2/27/23 at 11:13 am, V5 then touches R24's wheelchair handles without gloves and wheels R24 back into R24's contact and droplet isolation room without donning gown, gloves, N95 mask or face shield. V5 then walked out of R24's room without performing hand hygiene (alcohol-based hand sanitizer (ABHS) or soap and water hand washing). On 2/27/23 at 11:43 am, R3's isolation signs were posted visibly outside R3's door reading Enhanced Barrier Precautions and Droplet Precautions with a PPE bin stocked outside R3's room. On 2/27/23 at 11:45 am, R24 observed wheeling R24's self out of R24's room into the hallway wearing no face mask. On 2/27/23 at 11:47 am, V4 (Licensed Practical Nurse, LPN) walks up to R24 and V1 (Administrator) who is standing next to R24 sitting in the wheelchair in the hallway. V4 then places a surgical mask on R24's face, touching R24's face and ear lobes and wheeled R24 back inside of R24's room. V4 did not don a gown, gloves, face shield or N95 mask and is only wearing a surgical face mask. On 2/27/23 at 2:31 pm, R24 propelled R24's self in the wheelchair out of R24's room with a surgical face mask on and moved down the hallway to V14 (Care Partner/CNA) who was standing at the nurse's desk. V14 walked past R24 in the hallway and did not redirect R24 back to R24's room. R24 continued propelling R24's self in the wheelchair up and down the 8th floor hallway until 2:39 pm when V4 (LPN) pushes R24 in the wheelchair back inside R24's room near R24's bed. V4 did not don a gown, gloves, N95 mask or face shield to enter R24's contact and droplet isolation room. Facility document titled Residents with Confirmed or Suspected Case of COVID and dated 2/27/23 documents, in part, R3 and R24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 11 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 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 R3's Face Sheet (Detailed Summary) documents, in part, R3's diagnoses of COVID-19, Type 2 diabetes dementia and transient cerebral ischemic attack. R3's Minimum Data Set (MDS), dated [DATE], documents, in part, that R3's Brief Interview for Mental Status (BIMS) score is 2 indicates that R3 has severe cognitive impairment. Residents Affected - Some R3's laboratory test result, dated 2/17/23, documents that R3 is positive for COVID-19. R3's Physician Orders Statement (POS), printed on 2/28/23, documents, in part, an order with date of 2/27/23 of Off COVID isolation on 2/28/23. R3's Care Plan, dated 3/16/20, documents, in part, a plan for (R3) might have had underlying health conditions that make (R3) at greater risk from COVID-19 with actions of Follow Facility Protocol for COVID-19 Screening/Precautions and Provide contact/airborne room signage precautions, provide PPE for staff. R24's Face Sheet (Detailed Summary) documents, in part, R24's diagnoses of COVID-19, dementia and abnormalities of gain and mobility. R24's MDS, dated [DATE], documents, in part, that R24's BIMS score is 2 indicates that R24 has severe cognitive impairment. R24's laboratory test result, dated 2/17/23, documents that R24 is positive for COVID-19. R24's Physician Orders Statement (POS), printed on 2/28/23, documents, in part, an order with date of 2/27/23 as Off COVID isolation on 2/28/23. R24's Care Plan, dated 11/4/21, documents, in part, a plan for (R24) is at risk for infection related to failure to avoid pathogen secondary to exposure to COVID-19 with actions of Follow Facility Protocol for COVID-19 Screening/Precautions and Provide contact/airborne room signage precautions, provide PPE for staff. On 2/27/23 at 2:41 pm, surveyor asked what type of isolation is R24 on. V4 (LPN) stated, R24's is on contact and droplet precautions due to testing positive for COVID-19. When asked what PPE staff or visitors are to wear went entering R24's room, V4 stated Gown, gloves and a mask. When asked what type of face mask is to be worn inside R24's room, V4 stated, N95 mask. Asked if there is any additional PPE to be worn, and V4 stated, Goggles or a face shield. When asked V4 what type of isolation is R3 on, V4 stated, The same (as R24). This surveyor pointed to R3's isolation sign of Enhanced Barrier Precautions. When asked V4 what Enhanced Barrier Precautions means, V4 stated, With high contact areas (inside room), you have to be careful. V4 stated that staff must dress in a gown when coming in contact with these areas inside the room. When asked if Enhanced Barrier Precautions and Contact Precautions are the same isolation precaution, V4 stated, No. V4 stated that for contact precautions, staff must clean hands and wear gloves and gown every time when entering the room. When asked when hand hygiene is to be done, V4 stated, After every person (resident). When asked where hand hygiene is to be performed, V4 stated, Prior to going in (room) and after going out of room and that ABHS dispensers are inside each resident room and by the dining room, nurse's desk and medication cart. On 3/1/23 at 1:27 pm, when asked what isolation type for is used for positive COVID-19 residents, V2 (Director of Nursing, DON) stated that it's contact and droplet precautions. V2 stated that all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 12 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 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 residents who test positive for COVID-19 are placed on contact and droplet precautions for 10 days. V2 stated that contact precautions means when staff are entering into COVID-19 positive room, staff must wear gown, gloves and a face mask. V2 stated that for droplet precautions, staff must wear a face mask and face shield. When asked what mask staff are to wear in the facility, V2 stated that staff are to wear the surgical face masks. V2 stated that N95 masks are put at entrance of a COVID positive room, and that staff must change their surgical face mask to the N95 mask to enter the COVID-19 room. V2 stated that the facility is not short of supply of the N95 masks. When asked why an N95 mask is used for positive COVID-19 residents, V2 stated, Regulation for the N95 masks is to prevent or lessen the chance to being exposed to COVID. V2 stated that PPE is used for the isolation rooms because staff come into contact the environment of the isolated resident. When asked how staff know what type of PPE to wear for isolation rooms, V2 stated that the isolation signage is to direct staff for contact and direct precautions. V2 stated that Enhanced Barrier Precautions is not for COVID-10 isolation. V2 stated that V2 was aware of R3's isolation sign of Enhanced Barrier Precautions, and stated We use contact and droplet isolation for COVID. (V1) put it up. It was a mistake. No one caught it. When asked when hand hygiene performed by staff, V2 stated, All the time. Before and after staff provide care. In between care. Before entering room. (ABHS) is right there. Going in room and exiting room. V2 stated that the purpose of performing hand hygiene is to prevent transfer of infection and to stop chain to transmit something to someone else. When asked what is something, V2 stated, Infectious organism. V2 stated that the best practice is to wash hands to reduce transmission. V2 stated that if staff see an isolation resident out of the room, staff must redirect the resident back to the isolation. On 2/27/23 at 3:03 pm, V1 (Administrator) stated that V1 is responsible for putting up the COVID isolation signs outside resident rooms. V1 stated that contact and droplet isolation are necessary for COVID-19 positive residents. V1 stated that V1 mixed the signs (Enhanced Barrier Precautions and Contact Precautions) up due to them being similar colors. V1 stated, It was a clerical oversight. R5's Face Sheet (Detailed Summary) documents, in part, R5's diagnoses of pulmonary embolism, hypotension, dementia and abnormalities of gait and mobility. R5's MDS dated [DATE], documents, in part, that R5's BIMS score is 4 indicates that R5 has severe cognitive impairment. R9's Face Sheet (Detailed Summary) documents, in part, R9's diagnoses of peripheral vascular disease, Parkinson's, dementia, COVID-19 and abnormalities of gait and mobility. R9's MDS dated [DATE], documents, in part, that R9's BIMS score was unable to be done. R9's Staff Assessment for Mental Status indicates that R9 has short and long term memory loss with severely impaired cognitive skills for daily decision making. R19's Face Sheet (Detailed Summary) documents, in part, R19's diagnoses of epilepsy, Parkinson's, vascular dementia, COVID-19 and pleural effusion. R19's MDS dated [DATE], documents, in part, that R19's BIMS score was unable to be done. R19's Staff Assessment for Mental Status indicates that R19 has short and long term memory loss with severely impaired cognitive skills for daily decision making. R23's Face Sheet (Detailed Summary) documents, in part, R23's diagnoses of dementia, COVID-19 and peripheral vascular disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 13 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 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 R23's MDS dated [DATE], documents, in part, that R23's BIMS score is 3 indicates that R23 has severe cognitive impairment. R25's Face Sheet (Detailed Summary) documents, in part, R25's diagnoses of vascular dementia and muscle weakness. Residents Affected - Some R25's MDS dated [DATE], documents, in part, that R25's BIMS score was unable to be done. R25's Staff Assessment for Mental Status indicates that R25 has short and long term memory loss with severely impaired cognitive skills for daily decision making. Facility isolation sign titled Enhanced Barrier Precautions (untitled) documents, in part, Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use for central line, urinary catheter, feeding tube, tracheostomy, and wound care for any skin opening requiring a dressing. Facility isolation sign titled Contact Precautions (untitled) documents, in part, Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Facility isolation sign titled Droplet Precautions (untitled) documents, in part, Everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. Facility policy titled Handwashing/Hand Hygiene and dated October 2021, documents, in part: Policy Statement. This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents. i. After contact with a resident's intact skin . l. After contact with objects (e. g., medical equipment) in the immediate vicinity of the resident. n. Before and after entering isolation precaution settings. Facility policy titled Isolation-Categories of TBP (Transmission Based Precautions) and dated October 2021, documents, in part: Policy Statement: Transmission-based precautions are initiated when a resident develops of signs and symptoms of transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation. 2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. Contact Precautions: 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the residents or indirect contact with environmental surfaces or resident-care items in the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 14 of 15 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 146165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Admiral at the Lake, The 933 West Foster Avenue Chicago, IL 60640 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 environment. 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room . 8. Staff and visitors wear a disposable gown upon entering the room. Droplet Precautions: 1. Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of a procedure such as suctioning). 3. Masks are worn when entering the room. Depending on the organism, a N95 respirator may need to be worn. 4. Gloves, gown and goggles or face shields are worn. Facility policy titles COVID-19 PPE and dated August 2020, documents, in part, Policy Statement: Personal protective equipment is provided to all employees, contractors and volunteers free of charge. Policy Interpretation and Implementation. 4. When caring for a resident with suspected or confirmed SARS CoV-2 infection: a. Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection adhere to standard precautions and use a NIOSH (National Institute for Occupational Safety and Health)-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. b. Respirator: (1) An N95 respirator (or equivalent or higher-level respirator) is donned before entry into the resident room or care area. c. Eye Protection: (1) Eye protection (i.e., {that it} goggles or a face shield that covers the front and sides of the faces) is applied upon entry to the resident room or care area. d. Gloves: (1) Non-sterile gloves are applied upon entry into the resident room or care area. e. Gowns: (1) A clean isolation gown is donned upon entry into the resident room or area. Facility policy titled COVID-19 Testing and Response Plan and dated 6/11/2020, documents, in part, Policy, Purpose and Background: It shall be the policy of the Facility to guard against the introduction and spread of SARS-CoV-2 within its community of residents and staff. The Facility will continue to follow Core Principles of COVID-19 Infection Prevention and its policies: Hand hygiene (use of alcohol-based hand rub is preferred to soap and water). Appropriate staff use of PPE. Facility job description titled Licensed Practical Nurse (undated) documents, in part, Position Summary: The Licensed Practical Nurse is responsible for promoting and restoring residents' quality of life by providing nursing care as determined by the needs of the residents and their individual plan of care. Essential Functions: Educates nursing staff (i.e., care partners) on appropriate and person-centered clinical needs Supervises nursing staff (i.e., care partners) to ensure appropriate person-centered care is always being delivered to adhere to infection control policies. Facility job description titled Care Partner (undated) documents, in part, Position Summary: The Care Partner is responsible, under the direct supervision of the Charge Nurse and in accordance with prescribed procedures and established quality care standards, for providing direct personal and restorative nursing care to an assigned number of residents, while at all times ensuring the safety and well-being of all our residents. On 3/1/23 at 11:01 am, when asked about the staff's title of CNA versus Care Partner, V1 stated, CNA and Care Partner are the same. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 15 of 15