Inspection·February 2, 2024

F 0656 Level of Harm - Actual harm Residents Affected - Few 89%-91% RA denies difficulty breathing. At 2:27pm NOD called ER to get discharge report and per operator no nurse available to take the call. At 3:20pm NOD f/up called ER and per nurse (name) resident was given Narcan at 12:50pm d/t Opioid overdose with no discharge instructions. At 3:38 pm NOD notified V23 (Primary Physician) of discharge Dx and made aware that resident current orders for Norco and Methadone and asked for parameter orders for B/P and P and Oxygen at 2-3L per NC PRN for SOB. At 3:30pm (son) made aware that resident returned to facility and notified of current condition. R3's care plan includes the following: R3 has been determined by community access assessment to be able to access the community with supervision. Date Initiated: [DATE]. Intervention (includes): I am on supervised access to the community. R3 is receiving Methadone/Norco for pain. Date Initiated: [DATE]. Interventions (include): For respiratory depression: Monitor respirator rate, depth and effort after administration of pain medications. Monitor for altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress, sedation, urinary retention. Observer for adverse reactions with every interaction with the resident. Behavioral Symptoms - Narcotic Seeking R3 has a history of substance abuse and chemical dependency and engages in medication seeking behaviors. R3 demands medications be provided to her outside of physician prescription and prior to the time medications are scheduled to be provided to her and makes demands that personnel assist her with obtaining illegal substances. R3 and her son demand to be provided high dosages of medication and then claim that she receives too much medication. When blood pressure is low and the physician orders medications held, R3 and her son demanded that methadone/medications be provided to R3 anyway. R3 is receiving psychological services and participating in substance mitigation programming to address addictions, substance use/abuse, and healthy/productive coping strategies. Date Initiated: [DATE]. Interventions are included in the plan of care with date initiated [DATE]. R3's physician orders upon admission to the facility include Methadone and Norco; both are opioid medications. Physician Orders include: Methadone HCL Oral Tablet 10 MG (Methadone HCL) Give 1 tablet by mouth one time a day for pain Order Date [DATE], Start Date [DATE]. Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain - Order Date [DATE], Start Date [DATE]. It is to be noted that there was no physician order or care plan interventions for R3 related to history or risk substance abuse disorder or opioid reversal medication at the time of admission. On [DATE] at 1:58PM, V7 (RN) confirmed she was the nurse on duty when R3 had the overdose on [DATE]. Surveyor asked V7 what symptoms R3 was exhibiting when she assessed R3. V7 said R3 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 2 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 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 0656 Level of Harm - Actual harm Residents Affected - Few unresponsive, cold, clammy, and sweaty. V7 said (overdose) did not cross her mind because R3 took Methadone regularly and if the resident had a history of opioid overdose, then maybe it would have clicked in her mind. V7 added R3's son would visit often and sometimes V7 would hear them argue. On [DATE] at 4PM, V1 (Administrator) stated he believed R3 was a drug addict, and he suspected her son was bringing her drugs. Surveyor asked what made V1 think R3's son was bringing her drugs and V1 responded her behavior would change, like she was disconnected when he was here. Surveyor asked what if anything the facility did to act on this suspicion? V1 responded nothing was ever confirmed but if it was, it would have been something social work would have been involved with but V1 didn't think anything was ever confirmed. [DATE] at 4:12PM, V10 (Social Services Director) was asked if she was ever made aware of any concern R3's son was providing R3 with illicit drugs. V10 responded, it was never brought to her attention as a concern. V10 added she was aware R3 had a history of drug use. [DATE] at 4:19PM V11 (Social Service Designee) stated she facilitates care between the facility and CAP (methadone clinic) and is responsible for care planning residents for substance abuse and the Methadone use. It is to be noted there was no physician order or care plan interventions for R3 for any substance abuse disorder or opioid reversal medication at the time of admission. R3's care plan was updated on [DATE] to reflect Behavioral Symptoms - Narcotic Seeking, with Date Initiated: [DATE]. Interventions are included in the plan of care with date initiated [DATE]. On [DATE] at 2:03PM, V11 (Social Service Designee) was asked what changed on [DATE] when R3 had an addition to the care plan related to narcotic seeking behaviors. V11 responded, On this particular day I got a report one of the CNA's went to the nurse and told the nurse the resident (R3) asked her for some type of illicit drug. She (R3) had never done this before. This was a really big surprise to me because she (R3) was always very proud of her sobriety. She (R3) said she's been sober for years, ever since she went to rehab. After the overdose in June, I did talk to her (R3) because she didn't feel well and was wondering what happened. We focused on her blood pressure was maybe low. Surveyor asked V11 if she talked to R3 about the overdose after it happened and if she questioned R3 about taking any illicit substances. V11 responded she did not. V11 said, I did not ask her any questions. (i.e . did you take something, etc.). I did not feel comfortable asking her those questions. That's why I had the psychotherapist come with me; because she had a good rapport with her. It didn't cross my mind she n(R3) had possibly taken anything. [DATE] at 12:18PM V22 (Regional Director of Clinical Services) was asked why there was no care plan related to R3's substance abuse risk or use of Naloxone per their Naloxone Clinical Guidelines policy. V22 responded the policy was created on [DATE]th, but it wasn't started until the in-services were done. So, guideline didn't take effect until it was completed - [DATE]rd. Prior to this we didn't have a policy. V22 then affirmed they accepted a resident (R3) with a history of substance abuse and on Methadone without having a plan in place if R3 was to overdose. [DATE] at 1:47PM, V23 (Medical Director) stated, When this (overdose) happened to her (R3), they (facility) did notify me the patient was sent out. I think no one knew. It looks like someone might have given her something or she took something illicit. I think the nurse thought it was more of a cardiac issue. I have been the medical director there for 25 years and this is the first time something (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 3 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 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 0656 Level of Harm - Actual harm like this happens. The nurses have been there for a long time and can recognize when the patients are inebriated or something. Proactively, I think we will institute in-service for the nurses on recognizing the signs and symptoms of overdose and when to administer the Narcan. Residents Affected - Few Facility provided documented titled, Naloxone Clinical Guidelines, dated [DATE], which reads: I. Purpose: Upon a physician's medication order per resident or facility standing order, naloxone may be administered by a licensed nurse or authorized staff to resident as indicated for the complete or partial reversal of suspected opioid-induced respiratory depression and/or unresponsiveness and/or possible respiratory/ cardiac arrest. Naloxone (Narcan®, Evzio) is a prescription medication can block or reverse the effects of an opioid overdose. Prompt and timely Administration of naloxone can save the life of someone overdosing on opioids, including heroine or prescription medicines like OxyContin® or Percocet®. II. Procedures: 1. Facility will assess a resident on admission who is at risk for opioid abuse or overdose. o Person with recent inpatient hospitalization for suspected opioid use and overdose o Person with diagnosis of opioid use disorder o Person with history of opioid use or dependence, or diagnosed substance use disorder o Person with current prescribed opioid orders o Person with current prescribed opioid and benzodiazepine orders o Past opioid use and justice involved resident o Current or recent registrant of a methadone maintenance program, or a detox program o Visitor: Friends and family members of the above who may visit the resident and provide illicit or prescription opioids o Resident who frequently attempts to elope or leave the facility premises with current prescribed opioid or history of opioid dependence 2. Obtain Standing Order for Naloxone Use and Indication for at risk resident. Standing Order for Use of Naloxone for Resident o Indication: Unresponsiveness and/or difficulty breathing due to suspected opioid-induced respiratory depression. o Exclusions, if known: Comfort care plan, hospice, or end-of-life care; known allergy to naloxone. o Order: Naloxone nasal spray (4mg) or available supply and dosage form, repeat dose in 2 to 3 minutes for unresponsiveness or difficulty breathing (e.g., RR < 8 cycles/min), until individual is breathing (respiratory rate greater than 10). Initiate emergency medical response protocol (call 911) and transfer the individual to the hospital emergency department. Notify the attending physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 4 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 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 0656 and/ or appropriate medical practitioner. Level of Harm - Actual harm 3. Signs of Symptoms of Opioid Overdose Residents Affected - Few o Slowed/ dyspnea (RR < 8cycles/min); irregular, or no breathing o Skin, nails turn blue o Extreme sleepiness o Unresponsive to sternal rub or when shaken o Pinpoint pupils o Low 02 Saturation (e.g., <85%) 4. Standardized Procedure for Naloxone Administration 1. Confirm signs and symptoms of potential opioid overdose (see item #3) 2. Call 9-1-1 and administer naloxone as follows (select dispensed dosage form). Start CPR as indicated. A. Single-Step Intranasal Naloxone: ( 2mg/0.1ml or 4mg/0.1 ml) o Peel back the package to remove the device o Hold the device with your thumb on the bottom of the plunger and 2 fingers on the nozzle o Place and hold the tip of the nozzle in either nostril until your fingers touch the bottom of the patient's nose o Press the plunger firmly to release the dose into the patient's nose o Repeat if there is no response after 2-3 minutes B. Auto-Injector Naloxone: (0.4mg/0.4ml) or Pull auto-injector from outer case and pull off red safety guard o Place the black end of the auto-injector against the outer thigh, through clothing if needed, press firmly and hold in place for 5 seconds Repeat if there is no response after 2-3 minutes. C. Naloxone HCl injection vial 0.4mg/ml (requires a syringe for administration) Naloxone Hydrochloride Injection 0.4 mg/ml 11. o Inspect the solution for injection for any particulate matter or discoloration before use. o Remove cap from vial and clean with alcohol swab. Remove cap from needle of syringe. o Withdraw 1mL (0.4mg) from vial. o A deep intramuscular administration may be used and injected into a large muscle such as the thigh or deltoid muscle or if the subcutaneous route is selected, inject beneath the skin or an initial dose of 0.4 mg (1ml) of Naloxone hydrochloride may be administered intravenously as a push injection. o Response to naloxone may be slower with an intramuscular or subcutaneous injection. o Do not leave the resident and continue to monitor response to the medication. o Start supportive or resuscitative measures until emergency medical assistance arrives. o If the desired degree of counteraction and improvement in respiratory functions are not obtained, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 5 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 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 0656 repeat the injection at two-to-three-minute intervals. Level of Harm - Actual harm o If no response is observed after a total of 10 mg of Naloxone hydrochloride has been administered, the diagnosis of opioid-induced or partial opioid-induced toxicity should be questioned Residents Affected - Few References: National Library of Medicine 2013; Lippincott Manual in Nursing 2015; IDPH.illinois.gov.opioids 2010; IPRO [NAME]-QIO Resource Library 2021/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 6 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to recognize a resident was experiencing an opioid overdose and failed to administer Narcan (opioid reversal agent) for a resident with a known history of substance abuse who was currently on opioid pain medication as well as Methadone; the facility failed to have protocols in place were in accordance with recommendations from SAMHSA (Substance Abuse and Mental Health Services Administration). This failure applied to one (R3) of one resident reviewed for overdose and resulted in R3 being emergently transferred to local hospital due to being found unresponsive and requiring administration of opioid reversal agent (Narcan). The Immediate Jeopardy began on 6/13/23 when R3 overdosed while in the facility and V7 (RN) failed to identify R3 was experiencing an overdose and failed to administer opioid overdose reversal agent. V2 (Director of Nursing) and V22 (Regional Director of Clinical Services) were notified on 1/31/24 at 11:50AM of the Immediate Jeopardy. V21 (Vice President of Operations) was also called on phone conference at time the Immediate Jeopardy was called. The immediacy was removed on 1/31/24 but noncompliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R3 is a [AGE] year-old female with history of COPD, substance use disorder, hypertension, failure to thrive, and aphasia. R3 was admitted to the facility on [DATE] and discharged to home on [DATE]. R3 was admitted to the facility on [DATE] after a brief hospital stay, where R3 was admitted for adult failure to thrive. Hospital discharge paperwork includes information related to safe opioid use and includes there is a potential for serious increased sedation and life-threatening respiratory depression when taking an opioid pain product at the same time as a benzodiazepine (such as Xanax, Ativan, Klonopin, etc.). Review of R3's nursing progress notes document the following: 06/13/2023 15:43 Health Status Note Note Text: At 2:20pm resident came back from ER via ambulance on stretcher assisted by 2 staff. A/Ox3, responsive and verbalized feeling nauseated. Vitals checked B/P113/92, P64, R 18, T97.6F O2 sat 89%-91% RA denies difficulty breathing. At 2:27pm NOD called ER to get discharge report and per operator no nurse available to take the call. At 3:20pm NOD f/up called ER and per nurse (name) resident was given Narcan at 12:50pm d/t Opioid overdose with no discharge instructions. At 3:38 pm NOD notified V23 (Primary Physician) of discharge Dx and made aware that resident current orders for Norco and Methadone and asked for parameter orders for B/P and P and Oxygen at 2-3L per NC PRN for SOB. At 3:30pm (son) made aware that resident returned to facility and notified of current condition. On 01/26/24 at 1:58PM, V7 (RN) confirmed she was the nurse on duty when R3 had the overdose on 6/13/23. Surveyor asked V7 what symptoms R3 was exhibiting when she assessed R3. V7 said R3 was unresponsive, cold, clammy, and sweaty. V7 said she does take vitals before giving Methadone and would not have given it if the patient was showing any symptoms like low blood pressure, respiratory rate, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 7 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety oxygen saturation below baseline. V7 was asked if V7 received any training or in-service related to use of Methadone. V7 stated, Not really, we just follow the protocol from the Methadone clinic. V7 said (overdose) did not cross her mind because R3 took Methadone regularly and if the resident had a history of opioid overdose, then maybe it would have clicked in her mind. V7 added R3's son would visit often and sometimes V7 would hear them argue. Residents Affected - Few Review of Pre-hospital Care Report Summary (ambulance run sheet) documents: Call Received: 12:13:38 On Scene: 12:18:36 Patient Contact: 12:20:13 Left Scene: 12:33:53 At Destination: 12:37:28 Transfer of Care: 12:40:42 Flowchart documents patient's breathing is slow and shallow; capillary refill is delayed, skin temperature is cool and diaphoretic; unresponsive; Vitals at 12:23:13 BP 150/120 Pulse 64 Respirations 2, Effort: shallow; SPO2: 96 with )2 > 3 LPM. Narrative History Text: UOA pt found lying in bed unresponsive. Staff says pt was last seen normal approx. 20 minutes prior to our arrival. Pt is cool and diaphoretic and is having agonal respirations approx. twice per minute and has a weak carotid pulse. Pt has a valid DNR but specifies to use comfort measures only. No change to pt status through duration of the call. Pt moved to MICU. (hospital) contacted without orders. Pt transported without incident. (hospital) contacted without orders. Hospital Encounter Summary includes the following documentation: Reason for Visit - Altered Mental Status Description - Opioid overdose, accidental or unintentional, initial encounter (HCC) (Primary Dx) Vitals Taken: Blood Pressure 92/53, Pulse 88, Respiratory Rate 18, Oxygen Saturation 100% on NRB (non re-breather mask) at 15L, adequate oxygenation. Patient presenting to the emergency department with complaint of altered mental status. Patient was noted to be unresponsive in her nursing home and agonal breathing with her last known well 30 minutes prior to arrival. She is noted to be DNR/DNI with comfort care measures. Patient's glucose was in the 90s. She was agonal breathing on arrival. Methadone and Norco noted to be in her med list so 2mg Narcan given to the patient without symptomatic improvement. Attempted to contact patient's son but unable to so a message was left on his phone answering for his machine. Administered Medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 8 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 6/13/23 12:50PM CDT naloxone (Narcan) 2MG/2ML injection given. Level of Harm - Immediate jeopardy to resident health or safety ED Course / Re-exam . Residents Affected - Few Discharge Rx: New Prescriptions 1347 Patient continues to be alert and responsive. Possible Narcan working and patient is now alert. Naloxone HCL (Narcan) 4MG/0.1ML LIQD Call 911 - Administer single spray in one nostril upon signs of opioid overdose - may repeat in alternating nostril after 2-3 minutes if no response - if repeat is needed, a new container must be used. R3's care plans were noted that there was no physician order or care plan interventions for R3 related to history or risk substance abuse disorder or opioid reversal medication at the time of admission or prior to overdose incident on 6/13/23. 1/29/24 at 1:51PM V2 (DON) said staff were in-serviced on using overdose signs and symptoms and use of Narcan (initiated on) June 22 or 23 and then the Narcan was delivered from the Pharmacy on 6/21/23. V2 said, We did the in-service in June because of the change from the pharmacy to corporate and pharmacy changed to nasal and to be incorporated into the crash cart. So, starting at time, we started keeping it on the crash cart rather than for the individual. We have pharmacy general meds on the 2nd floor, like a house stock. When (R3) was initially sent to the hospital I know the nurse didn't think she was having an overdose. Her Methadone is standard, and the Norco is PRN (as needed), so the nurse didn't think it was an overdose. The nurse was thinking it was more sepsis or something cardiac. At the time of the overdose, we did have Narcan in the convenience box. Surveyor asked why R3 did not have orders for any opioid reversal agents at the time of overdose per their policy dated June 5, 2023. V2 said, I know that's on our policy, but we followed what came on the discharge summary from (hospital). We do relay that information to the doctor and the NP (nurse practitioner). Pharmacy delivery manifest documents delivery for R3 on 6/21/23 at 6:35AM of Naloxone 4MG/0.1ML NASAL SPRAY, Quantity 2. V24 (Pharmacy Representative) on 1/30/24 interviewed from 4:25PM - 4:49PM. V24 confirmed pharmacy sent the Naloxone to the facility for R3 on 6/21/23 at approximately 6:35AM according to manifest. V24 attempted to pull facility transaction report and stated there was nothing on the report because there was no pull for the residents in this building, indicating Naloxone provided by pharmacy had not been used or needed to be replaced due to being used for any resident. It is to be noted the Naloxone for R3 was sent eight days after R3's overdose incident. On 1/31/24 at 11:47AM, V2 said, We did not do an investigation to try to determine the cause of the overdose. V22 (Regional Director of Clinical Services) added, It seemed like her (R3) meds, so we don't know how it happened. Social Services did a room search and didn't find anything. I don't believe the son visited that day and he had visited I think, two days prior. The nurse didn't think of anything related to opioid overdose because she was looking at her medical issues. The nurse thought it was something cardiac related. Surveyor asked how facility could determine if R3 had used illicit drugs versus nurse error without an investigation or review of Controlled Substance logs (Narcotic Count sheet) for R3. V2 did not respond. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 9 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety During this investigation, facility failed to provide documentation a complete and thorough investigation related to overdose for R3 was conducted. Facility was asked to provide documentation of controlled substance count sheet for R3 during her stay at the facility but it was not provided. There was no documentation of room search in R3's medical record or per interviews with social service staff. R3's physician orders were reviewed and include (but not limited to): Residents Affected - Few Methadone HCL Oral Tablet 10 MG (Methadone HCL) Give 1 tablet by mouth one time a day for pain Order Date 05/01/23, Start Date 05/02/23. Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain - Order Date 05/01/23, Start Date 05/02/23. Review of R3's MAR (Medication Administration Record) documents on 6/13/23, R3 was given all medications as ordered and vitals taken during mediation administration were within R3's baseline (BP documented on MAR at 0900 is 121/67). There is no documentation of PRN (as needed) Norco being administered on 6/13/23. 1/31/24 at 12:07PM V25 (CAP/Methadone Clinic Representative) stated he could neither confirm nor deny any specifics related to R3 because the patient has not signed a release but can answer general questions. Surveyor asked V25 what is the likelihood of an overdose for patient who has been on the same dose of Methadone for several years? V25 said, It is very unlikely. I would only say if they were taking illicit drugs paired with their methadone then overdose would become more likely. If combined with [NAME] or unprescribed suboxone or any other type of opioid or opiate, then there is a higher chance. Patients can be prescribed Norco while being on Methadone, but the doctor must be aware they are being prescribed Methadone and we have a letter from the doctor being aware. Otherwise, then anything shows up (in urine sample) shows up as illicit. We do check urine monthly and the urine results come back in a week. If urine sample comes back dirty then we keep in mind if they are asking for increase, etc. The only thing we would punish them for would be they would have less available on hand. While in a nursing home, they can pick it up or a worker for the site will come with an ID badge and lock box and they can pick it up for them. 1/31/24 at 12:18PM V22 (Regional Director of Clinical Services) was asked why there was no care plan related to R3's substance abuse risk or use of Naloxone per their Naloxone Clinical Guidelines policy. V22 responded the policy was created on June 5th, but it wasn't started until the in-services were done. So, guideline didn't take effect until it was completed - June 23rd. Prior to this we didn't have a policy. V22 then affirmed they accepted a resident (R3) with a history of substance abuse and on Methadone without having a plan in place if R3 was to overdose. 1/31/24 at 1:47PM, V23 (Medical Director) stated overdoses can happen with use of illegal drugs. V23 said, Maybe we can add random drug tests. There's no way they can overdose on prescribed narcotics because they are giving specific dose. Those doses are all within the recommended doses and they are within the recommended guidelines. On a regular patient with a regular prescription the chance of overdose is zero. Surveyor asked if there is there a concern a resident getting opioids on a regular basis can overdose? V23 said, Everything is documented in the eMAR (electronic medication administration record), so the chance of duplicating a dose is very rare. When this (overdose) happened to her (R3), they (facility) did notify me the patient was sent out. I think no one knew. It looks like someone might have given her something or she took something illicit. I think the nurse thought it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 10 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety was more of a cardiac issue. I have been the medical director there for 25 years and this is the first time something like this happens. The nurses have been there for a long time and can recognize when the patients are inebriated or something. Proactively, I think we will institute in-service for the nurses on recognizing the signs and symptoms of overdose and when to administer the Narcan. Facility provided documented titled, Naloxone Clinical Guidelines, dated June 5, 2023, which reads: Residents Affected - Few I. Purpose: Upon a physician's medication order per resident or facility standing order, naloxone may be administered by a licensed nurse or authorized staff to resident as indicated for the complete or partial reversal of suspected opioid-induced respiratory depression and/or unresponsiveness and/or possible respiratory/ cardiac arrest. Naloxone (Narcan®, Evzio) is a prescription medication can block or reverse the effects of an opioid overdose. Prompt and timely Administration of naloxone can save the life of someone overdosing on opioids, including heroine or prescription medicines like OxyContin® or Percocet®. II. Procedures: 1. Facility will assess a resident on admission who is at risk for opioid abuse or overdose. o Person with recent inpatient hospitalization for suspected opioid use and overdose o Person with diagnosis of opioid use disorder o Person with history of opioid use or dependence, or diagnosed substance use disorder o Person with current prescribed opioid orders o Person with current prescribed opioid and benzodiazepine orders o Past opioid use and justice involved resident o Current or recent registrant of a methadone maintenance program, or a detox program o Visitor: Friends and family members of the above who may visit the resident and provide illicit or prescription opioids o Resident who frequently attempts to elope or leave the facility premises with current prescribed opioid or history of opioid dependence 2. Obtain Standing Order for Naloxone Use and Indication for at risk resident. Standing Order for Use of Naloxone for Resident o Indication: Unresponsiveness and/or difficulty breathing due to suspected opioid-induced respiratory depression. o Exclusions, if known: Comfort care plan, hospice, or end-of-life care; known allergy to naloxone. o Order: Naloxone nasal spray (4mg) or available supply and dosage form, repeat dose in 2 to 3 minutes for unresponsiveness or difficulty breathing (e.g., RR < 8 cycles/min), until individual is breathing (respiratory rate greater than 10). Initiate emergency medical response protocol (call 911) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 11 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 and transfer the individual to the hospital emergency department. Notify the attending physician and/ or appropriate medical practitioner. Level of Harm - Immediate jeopardy to resident health or safety 3. Signs of Symptoms of Opioid Overdose Residents Affected - Few o Slowed/ dyspnea (RR < 8cycles/min); irregular, or no breathing o Skin, nails turn blue o Extreme sleepiness o Unresponsive to sternal rub or when shaken o Pinpoint pupils o Low 02 Saturation (e.g., <85%) 4. Standardized Procedure for Naloxone Administration 1. Confirm signs and symptoms of potential opioid overdose (see item #3) 2. Call 9-1-1 and administer naloxone as follows (select dispensed dosage form). Start CPR as indicated. A. Single-Step Intranasal Naloxone: ( 2mg/0.1ml or 4mg/0.1 ml) o Peel back the package to remove the device o Hold the device with your thumb on the bottom of the plunger and 2 fingers on the nozzle o Place and hold the tip of the nozzle in either nostril until your fingers touch the bottom of the patient's nose o Press the plunger firmly to release the dose into the patient's nose o Repeat if there is no response after 2-3 minutes B. Auto-Injector Naloxone: (0.4mg/0.4ml) o Pull auto-injector from outer case and pull off red safety guard o Place the black end of the auto-injector against the outer thigh, through clothing if needed, press firmly and hold in place for 5 seconds. Repeat if there is no response after 2-3 minutes. C. Naloxone HCl injection vial 0.4mg/ml (requires a syringe for administration) Naloxone Hydrochloride Injection 0.4 mg/ml 11. o Inspect the solution for injection for any particulate matter or discoloration before use. o Remove cap from vial and clean with alcohol swab. Remove cap from needle of syringe. o Withdraw 1mL (0.4mg) from vial. o A deep intramuscular administration may be used and injected into a large muscle such as the thigh or deltoid muscle or if the subcutaneous route is selected, inject beneath the skin or an initial dose of 0.4 mg (1ml) of Naloxone hydrochloride may be administered intravenously as a push injection. o Response to naloxone may be slower with an intramuscular or subcutaneous injection. o Do not leave the resident and continue to monitor response to the medication. o Start supportive or resuscitative measures until emergency medical assistance arrives. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 12 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few o If the desired degree of counteraction and improvement in respiratory functions are not obtained, repeat the injection at two-to-three-minute intervals. o If no response is observed after a total of 10 mg of Naloxone hydrochloride has been administered, the diagnosis of opioid-induced or partial opioid-induced toxicity should be questioned References: National Library of Medicine 2013; Lippincott Manual in Nursing 2015; IDPH.illinois.gov.opioids 2010; IPRO [NAME]-QIO Resource Library 2021/2023 CMS State Operations Manual requires the following for skilled nursing facilities: According to the Substance Abuse and Mental Health Administration (SAMHSA), opioid overdose deaths can be prevented by administering naloxone, a medication approved by the Food and Drug Administration to reverse the effects of opioids. The United States Surgeon General has recommended naloxone be kept on hand where there is a risk for an opioid overdose. Facilities should have a written policy to address opioid overdoses. The SAMHSA website houses a number of resources related to opioid management including this document intended for prescribers which addresses appropriate prescribing, monitoring for adverse effects, and treating overdoses: SAMHSA Opioid Overdose Prevention Toolkit: Information for Prescribers, https://www.samhsa.gov/resource/ebp/opioid-overdose-prevention-toolkit. The Immediate Jeopardy began on 6/13/23 was removed on 1/31/24 when the facility took the following actions to remove the immediacy. On 2/1/24 the survey team verified by observations, interviews, and record review the facility implemented the following to remove the immediacy. The facility abatement plan includes the following: 1) R3 is no longer a resident of this facility and was discharged to the community in stable condition as planned on 9/11/23. 2) Nurse on duty for R3 was educated on 6/23/23 on Naloxone Clinical Guidelines and has been re-educated 1:1 by DON and/or designee on 1/31/24 regarding Naloxone Clinical Guidelines but not limited to the facility's Naloxone clinical guidelines and identifying signs and symptoms of overdose in residents with a substance use disorders and medication pass policy and procedure with an emphasis on narcotic administration and monitoring adverse reactions. 3) Naloxone spray is available in all crash carts in the facility. Implementation started on 6/23/23 and is ongoing. 4) On 6/23/23 all nurses were re-educated on but not limited to the facility's Naloxone clinical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 13 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 guidelines and identifying signs and symptoms of overdose in residents with a substance use disorders this education is ongoing as of 1/31/24. Level of Harm - Immediate jeopardy to resident health or safety 5) Residents Affected - Few Current residents with substance use disorders (10 total) were identified on 6/23/23 and updated on an ongoing basis. Updated again on 1/31/24 and this list is available to staff at each nurse's station and reception desk. Staff are being re-educated on the location of this list on 1/31/24. 6) Current 10 residents with substance use disorders were assessed on 1/31/24 to ensure there are no active signs or symptoms of overdose. 7) On 1/31/24, All other residents receiving narcotic medications were identified, total of 22 residents, and will be monitored daily for any signs and symptoms of overdose. 8) All nurses are being re-educated on but not limited to the medication pass policy and procedure with an emphasis on narcotic administration and monitoring adverse reactions on 1/31/24 and will be ongoing. 9) Staff are being re-educated on but not limited to the facility's Naloxone clinical guidelines and identifying signs and symptoms of overdose in residents with a substance use disorder on 1/31/24. This will continue for any newly hired staff or PRN staff. 10) Monitoring for residents with substance use disorders was implemented on or around December 18th, 2023, any residents with a substance use disorder goes out on pass or has a visitor is monitored every hour thereafter for the first 24 hours for any signs and symptoms of overdose. This is ongoing. 11) Quality assurance audit will be conducted daily by the DON and/or designee to ensure staff are identifying any signs or symptoms of overdose timely and administering Narcan timely when indicated. This will start on 1/31/24 and continue for the first month. All identified trends will be reviewed by the monthly QAPI committee, and a plan will be discussed and implemented until resolution. 12) The incident and abatement plan will be discussed and reviewed with the facility medical director on 1/31/24 at 3pm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 14 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 13) Level of Harm - Immediate jeopardy to resident health or safety Emergency QAPI meeting will be conducted on 1/31/24 at 3:30pm. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 15 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain resident medical records in accordance with accepted professional standards and practices by not having complete and readily accessible records available for healthcare oversight activities which included administration of resident medication administration. This failure applied to one of one (R3) resident reviewed for medical records. Findings include: R3 is a [AGE] year-old female with history of COPD, substance use disorder, hypertension, failure to thrive, and aphasia. R3 was admitted to the facility on [DATE] and discharged to home on [DATE]. Review of R3's nursing progress notes document the following: 06/13/2023 15:43 Health Status Note Text: At 2:20pm resident came back from ER via ambulance on stretcher assisted by 2 staff. A/Ox3, responsive and verbalized feeling nauseated. Vitals checked B/P113/92, P64, R 18, T97.6F O2 sat 89%-91% RA, denies difficulty breathing. At 2:27pm NOD called ER to get discharge report and per operator no nurse available to take the call. At 3:20pm NOD f/up called ER and per nurse (name) resident was given Narcan at 12:50pm d/t Opioid overdose with no discharge instructions. At 3:38 pm NOD notified V23 (Primary Physician) of discharge Dx and made aware that resident current orders for Norco and Methadone and asked for parameter orders for B/P and P and Oxygen at 2-3L per NC PRN for SOB. At 3:30pm (son) made aware that resident returned to facility and notified of current condition. On 1/31/24 at 11:47AM, V2 (Director of Nursing) said, We did not do an investigation to try to determine the cause of the overdose. V22 (Regional Director of Clinical Services) added, It seemed like her meds, so we don't know how it happened. Social Services did a room search and didn't find anything. I don't believe the son visited that day and he had visited I think, two days prior. The nurse didn't think of anything related to opioid overdose because she was looking at her medical issues. The nurse thought it was something cardiac related. Surveyor asked how facility could determine if R3 had used illicit drugs versus nurse error without an investigation or review of Controlled Substance logs (Narcotic Count sheet) for R3. V2 did not respond. During this investigation, facility failed to provide documentation that a complete and thorough investigation related to overdose for R3 was conducted. Facility was also asked to provide documentation of controlled substance count sheet for R3 during her stay at the facility and that was not provided. There was no documentation of room search in R3's medical record or per interviews with social service staff. R3's physician orders were reviewed and include (but not limited to): Methadone HCL Oral Tablet 10 MG (Methadone HCL) Give 1 tablet by mouth one time a day for pain Order Date 05/01/23, Start Date 05/02/23. Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain - Order Date 05/01/23, Start Date 05/02/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 16 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of R3's MAR (Medication Administration Record) documents that on 6/13/23, R3 was given all medications as ordered and vitals taken during mediation administration were within R3's baseline (BP documented on MAR at 0900 is 121/67). There is no documentation of PRN (as needed) Norco being administered on 6/13/23. 01/27/24 at 1:50pm V19 (Medical Records) said the narcotic reconciliation forms were being looked for because forms for the entire 3rd floor are missing, and they might be in storage out of the building. Facility provided document titled, Storage and Destruction of the Designated Record Set, last revised 11/19/23, which reads: Policy Statement I. The Facility will maintain accurate and complete medical and billing records for each Facility resident in a designated record set, in a secure manner, at locations approved by the Facility in accordance with Facility policy. II. PHI is kept in locations approved by Facility administration. Guideline I. Content of Designated Record Set A. The resident's Designated Record Set is comprised of the resident's medical record and billing record. (See HIPAA Glossary) B. The Designated Record Set may be physically maintained in different locations at the Facility (e.g., medical record kept at the Nursing Station and billing, or financial record is kept in the business office). C. Facility staff will ensure that documentation in the resident's medical record complies with the Facility's Medical Records policies and procedures, particularly in relation to accuracy, completion, and legibility. D. Original hard copy documents that have been scanned to Point Click Care PCC) will be retained by the Medical Record Staff for 90days. i. Upon scanning documents to PCC, the Medical Record Staff will view the document within PCC to ensure it was uploaded properly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 17 of 18 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 145011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Care of Evanston 500 Asbury Street Evanston, IL 60202 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 0842 ii. Level of Harm - Minimal harm or potential for actual harm After the 90-day retention period and prior to destruction of the original document, the Medical Record Staff will validate that the document is present and properly scanned to PCC. Residents Affected - Few E. Copies of all IDPH reports involving residents (incidents, accidents, abuse, neglect) shall be retained for three years. II. Storage of Designated Record Set A. The Facility will follow storage procedures in order to ensure that PHI is accessed by authorized individuals. B. Medical Record Storage Resident medical records will be stored in a secure location for a period of 10 years after discharge. Unless there is notice of a litigation hold which will require maintaining the records indefinitely or until Legal has notified medical records that the litigation hold is concluded allowing destruction of records. i. Active medical records will be stored either in the Medical Records Office or at the Nursing Station. ii. Archived medical records may be stored in the Medical Records Office or at a secured off-site location. iii. The Medical Records Office will be locked when unoccupied. iv. Nursing stations that have paper records will have reasonable physical safeguards to prevent unauthorized access. C. Records which are involved in open investigations/litigation or audit will be safeguarded against loss and destruction, even if the maximum retention period has elapsed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145011 If continuation sheet Page 18 of 18