Inspection·February 9, 2024

F 0550 at the same time so they can eat at the same time. Level of Harm - Minimal harm or potential for actual harm On 02/08/24 at 9:55 AM, V2 (Director of Nursing) stated private duty care givers are allowed to feed residents if they are trained. V2 stated R2 has a state issued care giver and that care giver has already received training on feeding. V2 stated staff and private duty care givers should be sitting down when feeding a resident because eating is a social activity. V2 stated standing over a resident means that person is not at the same level of the resident and when feeding a resident staff and care givers should be making eye contact the resident. V2 stated it is the facilities responsibility to make sure the private duty care givers are doing the correct thing on how to treat someone. V2 stated residents sitting at the same table should receive their meals at the same time assuming they can both feed themselves. V2 stated I think it is a dignity issue. V2 stated a resident could be hungry and should not have to sit and watch another person eating in front of them. V2 stated eating should be a good dining experience and if it was me, I would want to be served at the same time as the people I am sitting with. Residents Affected - Few On 02/09/24 at 8:15 AM, V20 (Consulting Registered Dietitian) stated resident sitting at the same table should be served their meal at the same time. V20 stated this is a dignity issue because a resident who might be hungry should not have to sit across from another resident watching them eat. V20 stated it is also a social issue because you want to eat with someone else at the same time. V20 stated staff should not be standing over the resident while feeding them. V20 stated they should be sitting, and feeding a resident at eye level so that it is comfortable for the resident, and they can better monitor the resident especially if the resident has swallowing issues. V20 stated it is also a dignity concern because staff should be interacting with the resident while feeding them by talking with them and maintaining eye contact with them, not rushing through feeding the resident. V20 stated R2 has swallowing problems is on pureed diet with nectar thickened liquids. V20 stated R2 cannot feed himself and that the caregiver should be sitting down and monitoring the resident closely because of R2's swallowing issues. R1's diagnosis which includes but not limited to Hypertension, Anemia, Dementia, Wernicke's Encephalopathy, Need for Assistance with Personal Care, Muscle Weakness (Generalized), Difficulty in Walking. R1's Physician Orders dated 02/07/24 documents in part Regular diet with thin liquids ordered 12/27/23. R1's MDS (Minimum Data Set) from 01/16/24 documents self-care assessment for eating as being setup or clean-up assistance, resident completes activity. R2's diagnosis which includes but not limited to Dysphagia, Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Muscle Weakness, Major Depressive Disorder. R2's Physician Orders dated 02/07/24 documents in part Pureed texture food with nectar thickened liquids ordered 01/25/24. R2's MDS (Minimum Data Set) from 01/23/24 BIMS (Brief Interview for Mental Status) was 09 out of 15 indicating moderately impaired cognition. R9's diagnosis which includes but not limited to Hyperlipidemia, Vascular Dementia, Muscle Weakness (Generalized), Lack of Coordination, Difficulty Walking, History of Falling, Unsteadiness on Feet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 2 of 24 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 02/09/2024 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 0550 R9's Physician Orders dated 02/08/24 documents in part Regular diet with thin liquids ordered 12/10/23. Level of Harm - Minimal harm or potential for actual harm R9's MDS (Minimum Data Set) from 12/31/23 BIMS (Brief Interview for Mental Status) was 11 out of 15 indicating moderately impaired cognition. Residents Affected - Few R9's MDS (Minimum Data Set) from 12/31/23 documents self-care assessment for eating as being setup or clean-up assistance, resident completes activity. Facility provided document from Resident Handbook undated which documented in part, the Harbors [NAME] to insure that all residents are afforded their right to a dignified existence and all staff will protect and promote the rights of each resident. Facility provided policy titled Assistance During Meal Times dated 10/20 which documented in part for residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity for example: not standing over residents while assisting them with meals. Facility provided policy titled Private Companions dated 10/17 which documented in part, any care performed by the privately employed personnel must at all times be within the scope of the individual qualifications and care to be provided by the privately employed personnel remains at the discretion and direction of the facility staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 3 of 24 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 02/09/2024 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 follow wound doctor's recommendations for a resident with an acquired pressure ulcer for 1 (R184) resident. The facility also failed to ensure that appropriate linen is used on an air loss mattress for one (R29) resident who is at risk in developing pressure ulcer. These failures affect two (R29 and R184) residents reviewed for pressure ulcer in a sample of 14. Residents Affected - Few The findings include: 1. R184 health record showed admission date on 7/23/21 with diagnoses not limited to Alzheimer's disease, Hyperlipidemia, Essential Hypertension, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Hypothyroidism, Hyperlipidemia, Dysphagia oropharyngeal phase. On 2/7/24 at 9:47am Wound care observation conducted with V26 (Wound care nurse) assisted by V25 (Certified Nursing Assistant/CNA). Observed R184 lying in bed, alert and verbally responsive, with oxygen inhalation via nasal cannula at 2L/min, air loss mattress in place. R184 appears comfortable and wearing bilateral heel lift boots. Observed right heel with dressing in placed and was removed by V26, wound bed cleansed with NSS (normal saline solution). Observed wound bed pale looking with granulating tissue (beefy red) about 20-30%. No signs and symptoms of wound infection. Observed surrounding wound area with some brownish - blackish discoloration. Observed LPN applied calcium alginate with silver and covered with dry dressing. V26 said that right heel is classified as Stage III pressure ulcer. R184 electronic health record reviewed with V26 and stated it started as DTI (Deep Tissue Injury) on 11/9/23 measuring 6.2cm x 5.8cm x not measurable (Length x Width x Depth). V26 stated on 11/16/23 wound assessment was identified as Stage III. She said R184 is followed by wound MD on a weekly basis and latest wound measurement dated 2/1/24 documented 2.7cm x 2.6cm x 0.3cm. On 2/8/23 at 11:13am V36 (Wound Doctor) stated that she is following R184 right heel wound is classified as Stage III pressure ulcer, acquired. She stated that wound is improving with no signs and symptoms of infection. V36 stated that Right heel wound is unavoidable due to multiple comorbidities. She stated that recommendations such as vitamin C and Zinc Sulfate will aid / help in wound healing. V36 said that R184 has decreased perfusion right foot thus Doppler was recommended. She said that wound is improving as evidenced by decrease in wound size and no signs and symptoms of wound infection. V2 stated that Vitamin C and Zinc Sulfate are ordered today (2/8/24). MDS dated [DATE] showed R184's cognition was severely impaired. R184 needed partial/moderate assistance with eating; Substantial/maximal assistance with oral hygiene, upper and lower body dressing; Total assistance/Dependent with toileting and personal hygiene, shower/bathe self, chair/bed transfer. MDS showed always incontinent of bowel and bladder. MDS also indicated R184 had 1 Stage 3 pressure ulcer that was facility's acquired. Wound evaluation electronically signed by V36 (Wound Doctor) documented in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 4 of 24 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 02/09/2024 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 On 11/9/23 Unstageable DTI (deep tissue injury) to right heel measuring 6.2cm x 5.8cm x not measurable. Level of Harm - Minimal harm or potential for actual harm On 11/16/23 Right heel classified as Stage III pressure ulcer measuring 5.8 x 5.6 x 0.3cm. Residents Affected - Few On 2/1/24 Stage III pressure ulcer to Right heel measured 2.7 x 2.6 x o.3cm. Goal of treatment is healing evidenced by a 3.7% decrease in surface area and a 25.0% decrease in nonviable tissue within the wound bed. Recommendations: Zinc Sulphate 220mg (milligrams) oral once a day for 14 days. Bilateral lower extremity arterial doppler, Pre-albumin, A1C, Vitamin C 500mg (milligrams) oral twice daily. On 2/8/24 Stage III pressure ulcer to right heel measured 2.5 x 2.4 x 0.3cm. R184 Physician order sheet (POS) dated 2/7/24 document no order for Vitamin C and Zinc Sulfate. Facility provided POS dated 2/8/24 with order not limited to: - Vitamin C 500mg tablet once a day for 30 days, order date 2/8/24. - Zinc Sulfate 50mg 1 tablet twice a day for 14 days. Order date 2/8/24. 2. On 2/6/24 at 10:45 AM, surveyor observed R29 lying on R29's back on an air loss mattress with a spread sheet, pad, and a diaper. V38 (CNA) at bed side, V38 stated yes, R29 is lying on air loss mattress with a spread sheet, a pad, and R29 is wearing a diaper. On 2/7/24 at 11:54 AM, V27 (LPN) and the surveyor entered R29's room, surveyor and V27 observed R29 lying on air loss mattress with a spread sheet, pad, and a diaper. V27 stated R29 is on air loss mattress with a spread sheet, pad, and a diaper. On 2/8/24 at 9:35 AM, V2 (Director of Nursing) stated air loss mattress is one of the facility pressure ulcers preventative measures. Based on best practice, it is good for the air loss to have one spread sheet and that is why V2 has trained staff to use one spread sheet to have the full benefit of the air loss mattress which is to prevent bed ulcers. Using of a spread sheet, pad, and a diaper will defeat full benefit of the air loss mattress based on best practice. The Braden Scale score of 16 shows that R29 is moderately at risk of developing pressure ulcers more so that R29 is not ambulatory. V2 agreed that staff should be using one sheet on an air loss mattress as the facility pressure ulcers preventative measure. R29 Minimum Data Set (MDS) dated [DATE] shows R29 is not cognitively intact and at risk of developing pressure ulcers. Braden scale score of 21 dated 01/26/23, and score of 16 dated 12/15/23 shows R29 is at risk of developing pressure ulcers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 5 of 24 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 02/09/2024 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 0695 Provide safe and appropriate respiratory care 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** On 02/06/24 at 12:30 PM, surveyor observed R14 up in chair, Oxygen tubing and Nebulizer treatment mask were not in a plastic bag when not in use. Residents Affected - Few On 02/07/24 at 12:34 PM, surveyor and V27 (Licensed Practical Nurse) entered R14's room, V27 and surveyor observed R14's Oxygen Nasal Cannula not in a plastic bag and Nebulizer treatment Mask not in a plastic bag. V27 stated having the nebulizer mask and oxygen nasal cannula out makes R14 at risk for breathing in germs like bacteria. The oxygen nasal cannula and mask should have been contained in a plastic bag when not in use. On 2/8/24 at 9:30 AM, V2 (Director of Nursing) stated, it is V2's expectation that nurses will keep oxygen nasal cannula tubing and nebulizer treatment mask in a plastic bag when not in use to maintain good hygiene and prevent infection. R14 Minimum Data Set, dated [DATE] shows R14 is cognitively intact. R14 Physician Order Sheet (POS) with active orders as of 2/6/24 shows an order for Pulmicort 1 mg/2ml suspension for nebulization inhalation twice a day. Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedure to ensure oxygen (O2) tubing and nebulizer machine and mask were stored inside a plastic bag when not in use for two (R4, R14) of two residents reviewed for respiratory care in a final sample of 14. Findings Include: On 2/06/24 at 11:19 AM, R4 was sitting on R4's wheelchair in R4's room with V35 (R4's Caregiver) at bedside. R4's nebulizer machine was not being used and was on top of R4's nightstand. R4's nebulizer machine was not inside a plastic bag. R4's nebulizer mask was sitting on top of the nebulizer machine and was not inside a plastic bag. R4 stated that R4 has not received R4's nebulizer treatment yet. V35 stated that R4 just came back from the hospital for Pneumonia. R4 stated that the nebulizer treatment helps R4 breaths better. On 2/8/24 at 9:27 AM, V2 (Director of Nursing) stated that oxygen tubing and nebulizer mask need to be changed weekly and dated. V2 stated that when not being used, the oxygen tubing and the nebulizer mask should be stored inside a clear bag for infection control protocol. V2 stated, When administering the nebulizer, the nurse has to stay in the room with the resident until it's completed then remove, wash and clean the mask, and stored inside the clear bag. It should not be exposed. Same thing with oxygen tubing if not being used to put it in the container in a clear bag. To maintain hygiene. R4's clinical records show R4 has diagnoses not limited to Acute Bronchitis, Essential Hypertension, and Myocardial Infarction. R4's Minimum Data Set (MDS) dated [DATE] shows R4 is cognitively intact. R4's physician orders show Ipratropium 0/5mg-albuterol 3 mg nebulization solution nebulizer treatment every 6 hours as needed. The facility's policy titled; Respiratory Care Infection Prevention dated 10/21 reads in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 6 of 24 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 02/09/2024 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 0695 The purpose of this policy is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and associates. Level of Harm - Minimal harm or potential for actual harm Infection Prevention Related to Oxygen Administration Residents Affected - Few Keep the oxygen cannulas and tubing used PRN in a plastic bag when not in use. Infection Prevention Relate to Nebulizers Store the circuit in plastic bag, marked with date and resident's name, between uses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 7 of 24 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 02/09/2024 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 - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedure to ensure medications were stored safely and securely for one (R4) resident out of 14 residents reviewed for medication storage in a final sample or 14. Findings Include: On 2/06/24 at 11:19 AM, R4 was sitting on R4's wheelchair in R4's room with V35 (R4's Caregiver) at bedside. Surveyor noted a nebulizer machine and two ampules of Ipratropium-Albuterol solutions on top of R4's nightstand. R4 stated that R4 has not received R4's nebulizer treatment yet. V35 stated that R4 just came back from the hospital for Pneumonia. R4 stated that the nebulizer treatment helps R4 breaths better. At 11:40 AM, V5 (Registered Nurse) stated that there is no resident in the unit that is self-administered with medications. V5 stated that all residents' medications should be kept inside the medication cart and not at resident's bed side. On 2/8/24 at 9:27 AM, V2 (Director of Nursing) stated that all medications should be stored securely in either the medication cart or locked refrigerator depending on the pharmacy guidelines of that medication. V2 stated that for the safety of the resident, the process when administering any medication, the nurse will take the medication in the resident's room and administer the medication. V2 stated that no medications should be stored in the residents' room. R4's clinical records show R4 has diagnoses not limited to Acute Bronchitis, Essential Hypertension, and Myocardial Infarction. R4's Minimum Data Set (MDS) dated [DATE] shows R4 is cognitively intact. R4's physician orders show Ipratropium 0/5mg-albuterol 3 mg nebulization solution nebulizer treatment every 6 hours as needed. The facility's policy titled; Storage of Medications dated 11/23 reads in part: 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. Procedure E. Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 8 of 24 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 02/09/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 2/06/24 at 12:40 PM, V6 (Certified Nursing Assistant) was assisting R20 for lunch in the 9th floor dining room. R20 received pureed soup, pureed meat, pureed cauliflower, mashed potato, and thickened water. R20 did not receive the pureed macaroni salad and pureed cookie that were listed on the menu. On 2/07/24 at 12:16 PM, V39 (Certified Nursing Assistant) was assisting R20 for lunch in the 9th floor dining room. R20 received pureed soup, pureed biscuit, pureed chicken, pureed green beans, and thickened water. At 12:41 PM, R20 finished eating lunch, and did not get any dessert. R20's clinical records show R20 has a diagnosis of Dementia. R20's Minimum Data Set (MDS) dated [DATE] shows R20 has severely impaired cognitive skills for decision making and has short- and long-term memory problems. R20's physician orders show R20's diet order of pureed diet with honey thickened fluids. Based on observation, interview, and record review the facility failed to serve food as planned on the pureed and mechanical soft menu, and failed to ensure standardized recipes were followed during food preparation. This failure has the potential to affect five residents (R2, R6, R20, R22, R184) receiving mechanically altered diets prepared in the facility's kitchen. Findings Include: On 02/06/24 at 12:04 PM, V14 (Kitchen Server) stated all food is prepared in the main kitchen and sent up in bulk to the unit kitchen/dining room for V14 to serve. V14 stated residents receiving a regular diet will be receiving for lunch soup, a barbeque pulled pork sandwich on a bun, cauliflower, macaroni salad and a soft cookie. V14 stated residents on a mechanical soft diet are being served for lunch soup, pulled pork with barbeque sauce, ground cauliflower, and mashed potatoes. V14 stated residents on mechanical soft diets are not receiving a bun, or macaroni salad or a cookie. V14 stated for dessert the mechanical soft diets will either receive applesauce or yogurt or gelatin, not the soft cookie. V14 stated residents on a pureed diet will be receiving pureed soup, pureed pork, mashed potatoes. V14 stated the main kitchen did not send up any pureed cauliflower or pureed bun for V14 to serve. V14 stated only the regular diets are receiving macaroni salad and that the mechanical soft and pureed diets are receiving mashed potatoes instead. V14 stated residents on pureed diets will either receive applesauce or yogurt or gelatin for dessert. V14 stated pureed cookies were not sent up by the main kitchen for V14 to serve. On 02/06/24 at 1:12 PM, V17 (Cook) stated V17 is the cook who prepared the food for lunch today including regular, mechanical soft and pureed food. V17 stated V17 did not prepare pureed bun, or pureed macaroni or pureed cookie or soft macaroni for the mechanical soft diets. At 1:17 PM, V17 stated the mechanical soft and pureed diets did not get macaroni salad because it has raw vegetables in it, they can only get cooked vegetables. At 1:23 PM, V17 stated, I don't follow any recipes when preparing the pureed or mechanical soft diets. I didn't follow any recipes this morning when preparing the food for lunch. At 1:52 PM, V17 stated V17 did not make ground pulled pork at lunch and that the regular and mechanical soft diets received the same pulled pork. On 02/06/24 at 1:28 PM, V19 (Dining Supervisor) stated pureed and mechanical soft diets do not get cookies at lunch and that those diets always get either pudding or applesauce, or ice cream at lunch (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 9 of 24 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 02/09/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some because it's available from the unit dining room. V19 stated those diets get the same dessert as the regular diets in altered consistency form for dinner only, not lunch. V19 stated, I've been working here for two months, and I've never seen any cookies pureed for the pureed diets at lunch. On 02/06/24 at 1:36 PM, V7 (Director of Culinary Services) stated the kitchen prepares everything listed on the production sheets. V7 stated recipes are in the binder in the production area and the cooks should be following recipes for everything they make. V7 stated based on the menu mechanical soft diets received soup, pulled pork (ground) on a bun with barbeque sauce, roast cauliflower, buttered cooked macaroni (chopped) and cookie if soft. V7 stated pureed diets received pureed soup, pureed pork, pureed bun, pureed cauliflower, pureed buttered cooked macaroni salad, and pureed cookie. V7 stated it is important that the residents on pureed and mechanical soft diets get the same food as everyone else except in altered texture form because this is a dignity issues and shows respect to the residents. On 02/07/24 at 11:01 AM, observed V17 prepare pureed food for lunch. V17 stated there are three residents on pureed diets. Observed V17 take a cooking spoon (not measured) and scooped out seven spoonfuls of an unmeasured amount of Chicken a La King and place into a blender. V17 then added 28-ounce ladles of vegetable broth to the same blender and then turned on the blender to puree the Chicken A La King. The pureed mixture looked very thin. V17 then stated V17 needed to add thickener to make the mixture thicker because otherwise it is too thin. Observed V17 add 1/2 cup food thickener to the pureed Chicken a La King mixture. The final product was smooth but still appeared thin. V17 then divided up the pureed Chicken a La King between three containers without measuring the amount going into each container. V17 stated the pureed portion of Chicken a La King served to the residents for lunch will be 4 ounces. On 02/07/24 at 11:13 AM, V17 took cooking spoon (not measured) and scooped out six unmeasured spoonfuls of green beans and placed into a blender. V17 then added 3- 8-ounce ladles of vegetable broth to the blender and then 2-1/2 cups of food thickener and pureed in blender. V17 then divided up pureed green beans between three containers in unmeasured amounts. V17 stated the pureed portion of green beans served to the residents for lunch will be 4 ounces. On 02/07/24 at 11:20 AM, V17 stated, I don't follow a recipe. V17 pointed to the paper on the wall on a clip board and stated they made this recipe yesterday for V17 to follow. V17 stated V17 usually just takes the regular food V17 makes for the regular diets and puree it in a blender with some broth and thickener as needed. V17 stated V17 knows from experience how much broth and thickener V17 needs to use. On 02/08/24 at 11:17 AM, V9 (Executive Chef) provide the recipe the cook followed for yesterday's lunch meal to surveyor. V9 reviewed recipe. Surveyor asked what utensil the cook should have used to portion out 8 ounces of Chicken a La King as stated in the recipe. V9 showed the surveyor a 8 ounce scoop. Surveyor showed V9 the regular spoon (unmeasured) that the cook used to portion out the Chicken a La King based on observations conducted on 02/07/24. V9 stated that the regular spoon is a cooking utensil and does not contain a measured amount and does not provide a controlled portion. V9 stated the cook needs to use the measured scoop to portion out food when following the recipe in order to make sure the residents are hitting their required dietary needs to keep them healthy and well fed. V9's expectation is that the cook purees the item and then gradually add a small amount of liquid at little at a time instead of adding too much liquid all at once and then having to use a lot of thickener thicken it up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 10 of 24 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 02/09/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 02/09/24 at 8:05 AM, V20 (Consulting Registered Dietitian) stated menus are created to make sure they hit the major food groups and give the correct servings for fruit/vegetables/starch/protein. TV20 stated the production sheets and recipes are then based off the menus and there are specific serving sizes for each item which should be followed based on what the recipe says. V20 stated it is important for the menus and recipes to be followed so that they are giving the right portion size, so residents get the correct amount of calorie and protein because it important for the residents to get the right amount of nutrition. Residents may be on a pureed diet due to dysphagia or swallowing issues, poor dentition, or lack of teeth and being on a pureed diet places residents at a higher nutritional risk for decreased oral intake, and weight loss because most residents on a pureed diet do not care for the taste and texture of the pureed foods. V20 stated if too much liquid is added, then the texture could be too liquidly, and it could potentially affect the amount of nutrients the resident is getting from the product. V20 stated residents receiving a pureed diet should receive the same food as residents on regular diets except in pureed form assuming the item can be pureed. V20 stated for example, instead of serving cold macaroni salad they could have pureed hot macaroni. V20 stated we try to make the pureed diet as similar to the regular diet as we can. V20 stated the cook should be following the spreadsheets/recipes across all consistencies. V20 stated the cook should be following the menu as printed and if they are missing an item, they would need to reach out to a manager or myself. V20 stated V20 was not called this week about any missing items or substitutions. V20 stated it is important to provide a variety of foods to reduce redundancy, and V20 does not want residents receiving the same thing every day as this could potentially have an effect on their meal intake. R2's diet order per Physician Orders dated 02/07/24 documented as pureed texture with nectar thickened liquid ordered 01/25/24. R6's diet order per Physician Orders dated 02/07/24 documented as Mechanical Soft with nectar thickened liquids ordered 03/01/22. R20's diet order per Physician Orders dated 02/07/24 documented as Pureed Diet ordered 10/24/22 with honey thickened fluids ordered 12/29/22. R22's diet order per Physician Orders dated 02/07/24 documented as Mechanical Soft ordered 12/02/21 and nectar thickened liquid ordered 01/27/24. R184's diet order per Physician Orders dated 02/07/24 documented as Mechanical Soft with nectar thickened fluids ordered 01/21/23. Kitchen Production Summary Worksheet with Temperature dated 02/06/24 for lunch meal documents in part the following items to be prepared: buttered macaroni (chopped), buttered macaroni (pureed), pulled barbeque pork on bun (ground), roasted cauliflower (pureed). Kitchen recipe provided titled Pork Shoulder to yield 160 portions. Kitchen recipe provided titled How To Make THE BEST Macaroni Salad to yield 50 servings. Kitchen recipe provided titled Roasted Cauliflower to yield 4-6 servings. Kitchen document provided titled Puree - Chicken a La King documents in part, place 8 ounces Chicken a La King in Vitamix. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 11 of 24 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 02/09/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Kitchen document titled Puree - Sauteed [NAME] Beans documents in part, place 8 ounces [NAME] Beans in Vitamix. Kitchen policy titled Dining Service in the Health Center dated 2/2020 documents in part menus are planned in accordance with the Recommended Dietary Allowances of the Food and Illinois Department of Public Health and menus are prepared in advance and food is prepared in a form designed to meet individual resident needs, including mechanical alteration of food as required. Kitchen policy titled Job Description for [NAME] dated July 2021 documents in part essential functions include to assist with all meals by correctly portioned and following the production sheet and preparing all foods as stated on the production sheet and serve quality products by following and extending recipes. On 2/6/24 at 12:28 PM, R184's lunch plate was observed with a scoop of mashed potatoes, ground cauliflower and pulled pork that did not appear ground. Observed staff provided Nectar Thick Liquid (lemon water). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 12 of 24 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 02/09/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to prepare and serve mechanical soft food at the appropriate texture. This failure affected 1 (R184) of 4 residents reviewed for mechanical soft diet prepared in the facility's kitchen, in a total sample of 31 residents. Findings Include: R184's diagnoses includes but not limited to Dysphagia Oral Phase, Dysphagia Oropharyngeal Phase, Alzheimer's Disease, Unspecified Dementia. R184's Physician Orders for 02/07/24 document diet order is mechanical soft with nectar thick liquids ordered 01/21/23. R184's MDS (Minimum Data Set) from 12/24/23 BIMS (Brief Interview for Mental Status) was 03 out of 15 indicating severely impaired cognition. R184's nutrition care plan documents in part, R184 is at nutrition risk related to altered texture diet for dysphagia. R184's Speech Language Pathology Evaluation and Plan of Care dated 11/02/22 documents in part, R184's diet was downgraded to mechanical soft, nectar thick liquids following MBSS (Modified Barium Swallow Study) and resident continues to be at risk for aspiration choking. On 2/06/24 at 12:28 PM, R184 was observed by fellow surveyor eating lunch. R184 received on lunch plate with mashed potatoes, ground cauliflower and pulled pork topped with barbeque sauce. The pulled pork did not appear to be ground consistency. On 02/06/24 at 12:05 PM, observed V14 (Kitchen Server) portioning out food for residents in the unit dining room. V14 stated residents on regular diet and mechanical soft diets both receive the same pulled pork, there is no difference in the consistency. Surveyor observed the pulled pork which contained a mixture of long pieces of pulled pork mixed with larger sized solid chunks of pulled pork. On 02/06/24 at 1:12 PM, V17 (Cook) stated she is the cook who prepared the food for lunch today including regular, mechanical soft and pureed foods. At 1:23 PM, V17 stated, V17 did not follow any recipes this morning when preparing the food for lunch. At 1:52 PM, V17 stated V17 did not make ground pulled pork at lunch and that the regular and mechanical soft diets received the same pulled pork consistency. V17 stated the mechanical soft pulled pork was not ground or chopped because V17 thought the pulled pork looked soft enough. On 02/06/24 at 1:36 PM, V7 (Director of Culinary Services) stated the kitchen prepares everything listed on the production sheets. Reviewing a copy of the production sheets surveyor pointed out to V7 that the pulled pork is listed to be prepared as ground consistency. V7 stated that ground pulled pork is what should have been made. On 02/07/24 at 11:36 AM, V22 (Speech Language Pathologist) stated a mechanical soft that consistency can range between grilled cheese no crust to soft fish but that hard vegetables, pork, beef, chicken should be a ground consistency. V22 stated V22's expectation is mechanical soft is ground, not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 13 of 24 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 02/09/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm chopped. V22 stated chopped is a step up from ground and if a resident has a history of dysphagia with an impaired cognitive status V22 would air on the side of caution and give ground consistency. V22 stated pulled pork has longer pieces and could be mixed with different sized pieces of meat which could be more difficult for a resident with swallowing issues to handle. V22 stated R184 has a history of dysphagia and is on a mechanical soft diet with nectar thickened liquids. Residents Affected - Few Facility's Policy titled, Diet Order Procedures dated 2/2020 documents in part, the diets have been approved for use as defined in the Diet and Nutrition Care Manual by (Consulting Nutrition Company) including mechanical soft and pureed diets. Consulting Nutrition Company's Diet and Nutrition Care Manual dated 2019 documents in part for diet titled Dysphagia Mechanically Altered or Mechanical Soft Diet that protein foods such as meat must be tender and moist, ground or chopped to less than 1/4 inch cubes as tolerated and mechanically altered foods consist of ground meats. Kitchen Production Summary Worksheet with Temperatures dated 02/06/24 list Pulled BBQ Pork on Bun 3 ounces ground. Kitchen provided recipe for Pork Shoulder which does not document in preparation need to ground pork. On 2/6/24 at 12:28 PM R184's lunch plate was observed with mashed potatoes, ground cauliflower and pulled pork that did not appear ground. Observed staff provided Nectar Thick Liquid (lemon water). R184'S Diet order states: Mechanical Soft, Nectar Thick Liquids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 14 of 24 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 02/09/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to a.) ensure kitchen staff wore beard covering in the kitchen during meal preparation, b.) food items were properly labeled, dated, and stored, c.) discard expired foods. These failures have the potential to affect all 31 residents receiving food prepared in the facility's kitchen. Findings include: On 02/06/24 at 9:21 AM, during initial kitchen tour observed V8 (Cook) placing carrots in the steamer and then pulling carrots out of the steamer. V8 had a beard with hair extending past V8's jaw line. V8 was not wearing a beard protector. On 02/06/24 at 9:22 AM, V7 (Director of Culinary Services) stated that everyone entering the kitchen should be wearing a hairnet and beards should also be covered. V7 stated the purpose of the hair nets and beard coverings is so that hair does not fall into the food and cause contamination. V7 saw that V8 was not wearing a beard covering and told V8 to go put a beard covering on. On 02/06/24 at 9:26 AM, V8 stated my beard is a little long right now and it should be covered and I'll go and cover it now. On 02/06/24 at 9:27 AM, observed V8 leave the cook station and returned wearing a beard covering. V8 stated V8 got the beard covering from a box of beard coverings stored by the lockers. On 02/07/24 at 11:12 AM, observed V8 preparing food with a disposable face mask on. The disposable face mask did not cover V8's facial hair from V8's beard. Surveyor could view V8's facial hair hanging below the face mask toward V8's neck. All V8's facial hair was not fully covered. V8 was not wearing a beard protector. Surveyor asked V8 to put on a beard protector and V8 left the kitchen and returned wearing a beard protector covering all of V8's facial hair. On 02/06/24 at 9:30 AM, V7 stated everything in the refrigerators needs to be labeled and dated using a sticker. V7 stated on the sticker the staff are expected to write the preparation (or open date) and the use-by-date (or shelf-life date). On 02/06/24 at 9:42 AM, observed in walk-in dairy cooler opened package of hamburger buns dated with prep date 01/28/24 and use-by-date 02/05/24. Observed nickel sized circle of green fuzzy material on one of the hamburger buns. V7 viewed the hamburger buns and stated that has mold on it and it's old moldy bread and that the bread was past the expiration date and should not be served to the residents. On 02/06/24 at 9:45 AM, observed opened 1 gallon container labeled as Mustard, Dijon [NAME] without a label. The container was not labeled with a manufacturer use by date. V7 opened the lid of the mustard to show the surveyor that the container had been opened and stated that the item should be labeled and dated indicating an open and use-by-date so staff would know when to discard the item. On 02/026/24 at 9:55 AM, toured dry storage area and observed opened hard plastic container labeled as pastry flour. The lid of the hard plastic container was not closed tightly so that one corner of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 15 of 24 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 02/09/2024 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 the lid was lifting upward. The hard plastic container was not fully closed. V7 stated opened items and storage containers should be sealed tightly so there is no contamination from bugs or leaky water pipe. On 02/06/24, V7 provide surveyor with list of residents and diet order. V7 stated all of the residents receive food from the kitchen, none of the skilled nursing residents receive NPO (Nothing by Mouth). Residents Affected - Many Kitchen policy titled, Hygiene dated 04/19/22 documents in part, every employee has a role in reducing the potential for food contamination by following food hygiene practices and all hair must be covered, and facial hair exceeding half an inch must be covered. Kitchen policy titled Food Labeling dated 04/19/22 documents in part, all dry goods must be labeled with a date received, date opened and use by date and all items opened and out of original packaging should be stored in tightly sealed bag or container. Kitchen policy titled Food Storage dated 02/02/22 documents in part, plastic containers with tight fitting covers must be used for flour. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 16 of 24 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 02/09/2024 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to follow facility policy for personal refrigerators by not keeping a temperature log to ensure refrigerator is at proper temperature, labeling items with a date, monitoring food for quality for potential concerns and disposal of items from resident's personal refrigerators for two (R8, R17) residents reviewed in the sample of 4 for safe personal food storage. Residents Affected - Few Findings include: On 02/06/24 at 11:20 AM, observed in R17's personal refrigerator in R17's room undated plastic container full of diced cheese chunks and the chucks of cheese were covered in multiple spots of fuzzy green circles. Also, observed an undated container of what appeared to be chicken and potatoes. Did not observe a thermometer inside R17's refrigerator or a temperature log on or near R17's personal refrigerator. On 02/06/24 at 11:23 AM, R17 stated that no one monitors her refrigerator and that they should be dating the items in there because she does not know what is inside it. On 02/06/24 at 11:26 AM, V11 (Certified Nursing Assistant) observed the undated plastic container of cheese from R17's refrigerator and stated that it looks like mold is on the cheese. V11 stated there is no date on the container of cheese so V11 does not know how long it has been in the refrigerator. V11 stated R17 should not eat the cheese because it could make R17 sick. On 02/06/24 at 11:29 AM, V12 (Housekeeper) stated V12 has been working at the facility for 5 years and the Certified Nursing Assistants are the ones who check the resident's personal refrigerators, not housekeeping. V12 stated V12 does not know if there are thermometers in the resident personal refrigerators or if anyone is monitoring the temperatures of the refrigerators. On 02/06/24 at 11:34 AM, V10 (Licensed Practical Nurse) observed the undated plastic container of cheese from R17's refrigerator and stated the cheese is covered in mold. V10 stated no one is monitoring the resident's personal refrigerators but someone should be because if R17 ate those items they could make R17 sick. V10 stated V10 does not know how long the cheese, or the chicken/potatoes have been in R17's refrigerator because they are not dated but the container should be dated. On 02/06/24 at 11:39 AM, in R8's personal refrigerator observed a dry, hard egg sandwich and hashbrown patty covered in bits of frozen ice chunks in a cardboard container. The cardboard container was not dated. There was no thermometer inside R8's refrigerator and there was no temperature log on the outside of R8's refrigerator or nearby. V13 (Private Duty Care Giver) viewed the items inside the cardboard container from R8's personal refrigerator and stated V13 would not feed that to R8 because V13 does not know how long it has been in the refrigerator. V13 stated it looks like it's been in there a long time and there is no date on it. On 02/08/24 at 8:30 AM, V7 (Director of Culinary Services) stated the kitchen is not responsible for monitoring the resident's personal refrigerators in their room. On 02/08/24 at 9:22 AM, V32 (Housekeeper) stated she has been working at the facility for 10 years and stated she has nothing to do with the resident's personal refrigerators in their room. V32 stated V32 does not look in the resident refrigerators and said, I only clean their room. V32 stated V32 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 17 of 24 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 02/09/2024 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 0813 thinks the kitchen is in charge of the refrigerators inside the resident's rooms. Level of Harm - Minimal harm or potential for actual harm On 02/08/24 at 9:46 AM, V2 (Director of Nursing) stated the personal refrigerators should be monitored by the nursing staff. V2 stated the resident personal refrigerators should be checked daily to throw out food that is not dated, expired, and check the temperature to make sure refrigerator is function correctly. V2 stated all opened items should be dated so the staff knows how long the items has been in the refrigerator and to avoid the residents from eating something that has spoiled. V2 stated resident who are not alert and oriented could potentially eat something that has spoiled, and this could make them sick. Residents Affected - Few R8's diagnosis which includes but not limited to Parkinson's Disease, Dementia. R8's Physician Orders dated 02/07/24 documents in part Regular diet with thin liquids ordered 11/09/23. R8's MDS (Minimum Data Set) from 11/26/23 BIMS (Brief Interview for Mental Status) was 05 out of 15 indicating severely impaired cognition. R17's diagnosis which includes but not limited to Heart Failure, Dementia, Diabetes, Dysphagia. R17's Physician Orders dated 02/08/24 documents in part Regular diet with thin liquids ordered 02/11/21. R17's MDS (Minimum Data Set) from 01/21/24 BIMS (Brief Interview for Mental Status) was 06 out of 15 indicating severely impaired cognition. Facility provided policy titled, Personal Refrigerators dated 10/22 documents in part residents may store items in a personal refrigerator to balance resident choice and a home like environment with meeting the safety needs of the resident and the procedure includes but not limited to: 1.) A temperature log will be kept to ensure the refrigerator is at proper temperature 2.) All opened items must be placed in a re-sealable container and dated. 3.) All food items will be discarded by the resident as needed. Facility provided policy titled, Use and Storage of Food and Beverage Brought In For Residents, Food Procurement dated 1/18 documents in part, it is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors, and to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Procedure steps include but not limited to: 1.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 18 of 24 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 02/09/2024 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Facility staff will be appointed to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items per facility policy. 2.) Facility staff will be appointed to check resident rooms through daily housekeeping process for food and beverage items for safe and sanitary storage and handling. 3.) Staff will examine food for quality (smell, packaging, appearance) to identify potential concerns. If concerns are identified, staff will notify the resident or resident representative of findings and necessary actions per proper food and beverage safe handling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 19 of 24 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 02/09/2024 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to establish an antibiotic stewardship program that includes a protocol and a system to monitor antibiotic use and failed to use an infection assessment tool to determine if the antibiotic is indicated or needs to be adjusted for four (R15, R23, R25, R27) of four residents reviewed for antibiotic use in a sample of 14. Residents Affected - Some The findings include: R15 health record showed admission date on 1/24/23 with diagnoses not limited to Multiple Sclerosis, Presence of right artificial shoulder joint, Hyperlipidemia, Non ST elevation (NSTEMI) myocardial infarction, Major depressive disorder, Polyneuropathy, Type 2 diabetes mellitus, Hypothyroidism, Morbid obesity, Other specified disorders of bladder, Acute respiratory failure with hypoxia. R23 health record showed admission date on 10/18/23 with diagnoses not limited to Other toxic encephalopathy, Epilepsy, Essential Hypertension, Atrial fibrillation, Gastro-esophageal reflux disease, Hyperlipemia, Obstructive sleep apnea, Acute embolism and thrombus deep vein lower extremity, Acute cystitis, Non traumatic intracranial hemorrhage, Dysphagia. R25 health record showed admitted on [DATE] with diagnoses not limited to Covid 19, Altered mental status, Essential hypertension, Chronic atrial fibrillation, Hyperlipidemia, Benign prostatic hyperplasia, Generalized muscle weakness, Repeated fall, Multiple sclerosis, Other seizures. R27 health record showed admission date on 2/9/23 with diagnoses not limited to Unspecified displaced fracture of 2nd cervical vertebra, Unspecified fall, Hyperlipidemia, Depression, Generalized anxiety disorder, Rhabdomyolysis, Covid 19, UTI. On 2/6/24 at 02:06pm V4 (Infection Preventionist/IP nurse) stated that she is using an assessment tool which is McGreer criteria for residents on antibiotic and makes sure that resident is meeting criteria. V4 stated that she is also checking signs and symptoms of infection. V4 showed December 2023 tracker for residents on antibiotic but unable to provide assessment tool / McGreer criteria assessment for residents on antibiotic use. V4 stated that she is using McGreer criteria as a guide but not completing the assessment. V2 (DON/Director of Nursing) and V4 said that standard of nursing practice if it was not documented it was not done. V4 unable to provide January and February tracker for residents on antibiotic use. V4 stated that she did not do January and February antibiotic tracker yet, unable to identify who are the residents on antibiotic. On 2/8/24 at 9:47am V4 stated that if antibiotic use is not monitored or tracked on an ongoing basis, not able to determine if antibiotic is appropriate or necessary for the resident. Stated that McGreer assessment tool is important to assess signs and symptoms of infection and to determine if resident is meeting criteria for antibiotic use. R15 Physician order sheet (POS) dated 2/8/24 with order not limited to: Bactrim DS 800mg-160mg (milligrams) by mouth twice a day for 12 days. R23 POS dated 2/8/24 with order not limited to: Doxycycline hyclate 100mg by mouth once a day for UTI (urinary tract infection) prophylaxis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 20 of 24 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 02/09/2024 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 0881 Level of Harm - Minimal harm or potential for actual harm R25 POS dated 2/8/24 with order not limited to: Meropenem 1gram intravenous solution every 8 hours x 7 days. R27 POS dated 2/8/24 with order not limited to: Doxycycline hyclate 100mg by mouth twice a day ongoing staph infection. Residents Affected - Some Facility's Antibiotic stewardship policy dated February 2024 documented in part: Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Antibiotic stewardship policy is a commitment on a the part of the nursing care centers to optimize the treatment of infections, minimizing the emergence of antibiotic resistance while reducing the adverse events associated with the antibiotic use. The DON will with the clinical staff to ensure proper standards for assessing, monitoring and communicating changes in resident's condition regarding current or potential infection and antibiotic use. The DON will review patients weekly for appropriateness and resident improvement. Tracking: The antibiotic stewardship committee will determine what will be reviewed and tracked on a monthly basis during the committee meeting. Items tracked can include number and types of antibiotic, type of infectious agents, effectiveness and outcomes of treatment and appropriateness of medication prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 21 of 24 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 02/09/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations for 5 residents (R10, R23, R25, R27 and R28), Failed to assess eligibility and offer pneumococcal vaccinations to 4 (R10, R25, R27 and R28) residents and Failed to administer Pneumococcal vaccine for one (R23) resident eligible to receive the vaccine. These failures affect 5 (R10, R23, R25, R27 and R28) of eight residents reviewed for immunization. Residents Affected - Some The findings include: R10 health record showed admission date on 10/15/23, [AGE] years of age with diagnoses not limited to Type 2 Diabetes mellitus, Essential Hypertension, Fracture superior rim of right pubis, Hypothyroidism, History of falling, Depression, Atherosclerotic heart disease, Anemia, Paroxysmal atrial fibrillation. R23 health record showed admission date on 10/18/23, [AGE] years of age with diagnoses not limited to Other toxic encephalopathy, Epilepsy, Essential Hypertension, Atrial fibrillation, Gastro-esophageal reflux disease, Hyperlipemia, Obstructive sleep apnea, Acute embolism and thrombus deep vein lower extremity, Non traumatic intracranial hemorrhage, Dysphagia. R25 health record showed admission date on 1/12/24, [AGE] years of age with diagnoses not limited to Covid 19, Altered mental status, Essential hypertension, Chronic atrial fibrillation, Hyperlipidemia, Benign prostatic hyperplasia, Multiple sclerosis, Other seizures. R27 health record showed admission date on 2/9/23, [AGE] years of age with diagnoses not limited to Unspecified displaced fracture of 2nd cervical vertebra, Unspecified fall, Hyperlipidemia, Depression, Generalized anxiety disorder, Rhabdomyolysis, Covid 19. R28 health record showed admission date on 5/23/23, [AGE] years of age with diagnoses not limited to Parkinson's disease, Cardiomyopathies, Pain in left hip, Unilateral primary osteoarthritis. On 2/07/24 at 11:08am V4 (Infection Preventionist/IP Nurse) stated that all residents are screened for vaccination eligibility and education should be provided regarding risk and benefits of the vaccines. V4 said Pneumococcal vaccine is given every 5 years if eligible to receive and they are following CDC (Center for Disease Control and Prevention) guidelines. Reviewed immunization record of the following residents with V4: 1. V4 said R10 received PCV13 (Pneumococcal Conjugate) on 10/30/2015. PPSV23 (Pneumococcal Polysaccharide Vaccine) on 2/19/14. She said no screening for Pneumococcal vaccine was done and no education provided. V2 said Pneumococcal vaccine is given every 5 years. R10 was due to receive the vaccine on 10/2020. Per CDC recommendation (Pneumorecs Vax Advisor App), decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 22 of 24 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 02/09/2024 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 0883 2. Level of Harm - Minimal harm or potential for actual harm V4 said R23 received PPSV13 on 6/22/15. Pneumonia screening done on 5/15/23 and consented to receive the vaccine but no pneumococcal vaccine was not given. Residents Affected - Some Per CDC recommendation (Pneumorecs Vax Advisor App), give one dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of which vaccine is used (PCV20 or PPSV23), their pneumococcal vaccinations are complete. However, if PPSV23 is administered, decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. 3. V4 said R25 received PVC13 on 10/30/2015. Pneumococcal PPSV23 on 2/8/10. No screening was found for pneumococcal vaccine and no education provided. Per CDC recommendation (Pneumorecs Vax Advisor App), decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. 4. V4 said R27 received Pneumococcal PPSV23 on 01/01/11 and PCV13 on 8/21/18. No screening was found and no education provided regarding pneumococcal vaccine. Per CDC recommendation (Pneumorecs Vax Advisor App), decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. 5. V4 said R28 received PCV13 on 6/17/2016 and PPSV23 on 12/27/2001. No screening and education was found regarding pneumococcal vaccine. Per CDC recommendation (Pneumorecs Vax Advisor App), decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. V4 stated that pneumonia screening is important to determine if resident is eligible to receive the vaccine and education should be provided to either resident / family / representative regarding the risk and benefits of the vaccine. V4 stated that vaccine will prevent serious or severe complications and resident will not easily get the infection or virus. Facility's Pneumococcal vaccine policy dated February 2024 documented in part: Residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 23 of 24 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 02/09/2024 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 0883 Level of Harm - Minimal harm or potential for actual harm Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. - Residents Affected - Some Pneumococcal vaccine will be administered to residents per facility's physician-approved pneumococcal vaccination protocol. Administration of the pneumococcal vaccines will be made in accordance with current CDC recommendations at the time of the vaccination. Review of the CDC's Pneumococcal Vaccination: Summary of Who and When to Vaccinate, published online on [DATE] and again reviewed on September 22, 2023 revealed, Adults 65 Years or Older CDC recommends pneumococcal vaccination for all adults 65 years or older .For adults 65 years or older who have only received PCV13, CDC recommends you either Give 1 dose of PCV20 at least 1 year after PCV13 or Give 1 dose of PPSV23 at least 1 year after PCV13 . Received PCV13 at any age and PPSV23 after age [AGE] years use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV20 should be administered at least 5 years after the last pneumococcal vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146165 If continuation sheet Page 24 of 24