Inspection·September 13, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Activities of Daily Living (ADL) cares including showers and shaving were being completed for 4 of 31 residents (R123, R125, R52 and R35) reviewed for ADL's in the sample of 31. Residents Affected - Some The findings include: 1.) On 9/11/23 at 10:43 AM, R123 said his biggest complaint about the facility is the fact he is not getting showered regularly, and also has not been shaved in 2-3 weeks. He said he is supposed to receive showers on Tuesday and Friday evenings. R123 had scruffy facial hair and a partial beard growing. He said, When I ask about a shower or shaving I get told they are too busy or short staffed and cannot do it but look at me I have never had a beard. R123's facility assessment completed on 7/3/23 shows his cognition is intact. R123's ADL care plan initiated on 9/13/22 shows he requires extensive staff assistance with his ADL's including grooming and showering. The facility shower schedule reviewed on 9/12/23, shows R123 should receive showers on Tuesday and Friday evenings. The shower book was also reviewed by this surveyor on 9/12/23 and it had 1 shower sheet in it for R123 dated 7/18/23. On 9/13/23 the facility provided shower sheets for R123. Those sheets dated between 8/17/23 and 9/11/23 show he had a shower on 8/17/23 and again on 8/31/23. The sheets indicate he either refused a shower, or was given bed baths on 8/21, 8/24, 8/28, 9/4, 9/7 and 9/11. On 9/12/23 at 1:34 PM, R123 was in his room visiting with V12 (R123's family member). V12 said she went out and bought R123 a electric razor and a hair trimmer in hopes that would help get someone to shave him and clip his hair. V12 said it is a big problem here, with R123 not being showered regularly. This surveyor asked R123 if he had in fact received a bed bath on Monday 9/11/23 (as the shower sheets indicated) and R123 said he did not receive a bed bath, and his shower days are Tuesdays and Fridays. On 9/12/23 at 1:51 PM, V11 (Certified Nursing Assistant/CNA) said R123 does complain a lot about not getting showered on the evening shift. She said they cannot do all of the showers on day shift but she tries to help out and do extra when she can. R123 said she did in fact shave R123 but it has been 2-3 weeks since she did. On 9/13/23 at 9:47 AM, V10 (Agency CNA) said residents can be shaved when they are showered but they also have shaving days where staff go around and shave residents. 2.) On 9/11/23 at 11:28 AM, V9 (R125's family member) was in the bathroom with R125 shaving him. V9 said there is a problem at the facility with showers and shaving. He said R125 is not getting showered or shaved regularly by the facility. V9 said he has mentioned it many times to staff when R125 does not receive his shower. V9 also said R125 is alert and with it and he knows if he had a shower or not. He said, today is supposed to be his (R125's) shower day but watch he won't end up getting one. On 9/12/23 at 1:49 PM, both V9 and R125 said that R125 did not receive his shower on 9/11/23. V9 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 2 of 12 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said I reminded several staff before I left yesterday (9/11/23) that he (R125) still needed his shower. V9 said the only reason R125's hair is not greasy is because he took him down for a hair cut and they washed it. On 9/12/23 at 1:42 PM, V8 (CNA) said residents should be showered 2 times a week, and they document it is done on shower sheets that are then placed in the shower book and also in the computer in residents medical record. V8 was asked by the surveyor if R125 had received his shower on 9/11/23 and she confirmed he did not receive one due to time constraints. The facility shower sheets in the shower book shows R125 is scheduled for showers on Monday and Thursdays on day shift. The facility provided shower sheets to the surveyors on 9/13/23 (that were not in the book on 9/12/23). Those shower sheets have documented and signed off that R125 not only received a shower on 9/11/23 but also on 9/14/23, 9/18/23, and 9/21/23. The sheets appear to be already filled out and signed for his upcoming showers. R125's electronic medical record (EMR) task charting for showers show his last documented shower was 8/31/23. 3.) On 9/11/23 at 9:32 AM, R52 said he had a spinal cord injury and now requires a lift to transfer out of bed. He said when asks about getting a shower he is told that they have to use a lift to transfer him to the shower chair and don't have enough people to do that. R52 said he has been at the facility since February and has probably had 2-3 showers and 6 bed baths in total. He said he has refused a bed bath on one occasion due to them coming to his room very late in the evening. R52 said he is supposed to receive his showers on Tuesday and Friday evenings. On 9/12/23 at 1:51 PM, V11 (CNA) said R52 does complain that he is not receiving his showers on the evening shift. R52's 8/22/23 facility assessment show his cognition is intact and he requires extensive staff assistance with his ADL's including bathing and grooming. The facility shower book shows R52 should receive his showers on Tuesday and Friday evenings. On 9/12/23 the shower book had no shower sheets for R52 inside. The facility provided shower sheets to the surveyors on 9/13/23 that had documented R52 received bed baths on 8/22/23, 8/25/23, and 9/5/23. Those sheets also document that R52 refused showers on 9/1/23 and 9/8/23 and the sheet for 9/12/23 is pre-signed but not indicated if he had a shower or not. R52's (EMR) task charting for showers show his last documented shower was 9/9/23 and that shower documentation says he receives showers on Wednesdays and Saturdays. The dates in the computer and the documented bed baths/showers for R52 do not correspond with the sheets provided by the facility. On 9/13/23 at 9:51 AM, R52 said he did not receive his scheduled shower on 9/12/23. He said he even reminded several staff it was his shower day but still didn't get one. R52 said he has not recently refused any showers or bed baths and he last received a bed bath 3 weeks ago. R52's active care plan does not show any refusals of care documented. 4.) On 9/12/23 at 11:27 AM, R35 was in bed. Her hair appeared very messy and to have not been brushed in awhile. She had some dried food on her chin and gown. R35 said she has not been getting baths (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 3 of 12 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 recently. She said when she asks about one the staff tell her the shower bed is broken. Level of Harm - Minimal harm or potential for actual harm R35's facility assessment dated [DATE] shows her cognition is intact and she requires extensive staff assistance with her ADL's including bathing and grooming. Residents Affected - Some The facility shower book shows that R35 should receive showers on Tuesday and Friday evenings. The shower book reviewed on 9/12/23 had 1 documented shower on 8/10/23 for R35. R35's EMR shower task charting shows 1 documented shower for R35 on 8/25/23. That charting has no documented refusals of showers. The facility provided shower sheets on 9/12/23 show R35 refused showers on 8/15/23, 8/18/23, 8/22/23, 8/29/23, 9/1/23 and 9/12/23. The sheets have documented that R35 received a bed bath on 8/18/23, 8/22/23, 9/5/23 and 9/8/23. On 9/13/23 at 9:45 AM, R35 said, I have not refused a shower. I want a shower but they tell me the shower bed is broken. It has been a month since I had a shower. R35's active care plan does not show any refusals of care documented. The facility provided ADL policy dated 9/20 for Bath,Tub or Shower, and Shaving the Resident says the purpose is to bring comfort and cleanliness to the resident. The policies do not address time frames that showers should be given or the required documentation. The policy does list shaving should also be completed for the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 4 of 12 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure treatment orders were implemented for a resident with a fungal infection and failed to ensure a resident's eye was assessed and treatments ordered in a timely manner for 2 of 31 residents (R83 and R100) reviewed for quality of care in the sample of 31. Residents Affected - Few The findings include: 1. R83's Face Sheet shows that she was admitted to the facility on [DATE] with diagnoses of: cellulitis of buttock, local infection of the skin, dermatitis and non-pressure chronic ulcer of buttock. R83's Infectious Disease Hospital Consult Note dated 8/16/23 shows, Assessment/Plan: Probable fungal dermatitis/diaper rash of the buttocks .Recommend: Topical nystatin (antifungal) to the buttocks at least 3 weeks. R83's Medication List from the local hospital dated 8/16/23 shows nystatin topical to be applied three times a day. R83's Wound Physician Notes dated 8/22/23 shows, Assessment and Plan: Diaper dermatitis-Apply miconazole (antifungal) 2% cream bid (twice a day) and prn (as needed) Pressure ulcer of right buttock, stage 3 miconazole 2% cream in periwound area . R83's Wound Physician Notes from 9/5/23 and 9/12/23 document the same as above. On 9/11/23 at 12:32 PM, V22 (Wound Care Licensed Practical Nurse) performed a dressing change to R83's Stage 3 buttock pressure ulcer. R83's left and right buttock was bright red. V22 applied a dressing to the pressure wound and applied zinc ointment to R83's buttocks. On 9/13/23 at 12:08 PM, V22 said that she just started the miconazole cream on 9/12/23. V22 said that she had just been using zinc in the past. V22 said that miconazole cream is used for fungal infections. R83's August and September Medication Administration Record shows that she did not receive miconazole cream until 9/12/23. 2. On 9/11/23 at 9:30 AM, R100 was laying in bed. R100's left eye was red and had crusty discharge present. R100 stated, It hurts really bad and itches. On 9/11/23 at 9:30 AM, V17 (Certified Nursing Assistant) said that R100's eye was red yesterday (9/10/23) but it looked worse today. V17 said that she had told the nurse about his eye. On 9/12/23 at 1:23 PM, V17 said that both of R100's eyes were red and had drainage when she saw him in the morning. V17 said that she told the nurse after she cleaned them off. On 09/12/23 at 1:50 PM, V19 (Registered Nurse) said that she saw R100's red eyes when she was doing medication pass in the morning and called the physician to notify them. V19 said that the physician ordered antibiotic ointment for his eyes. V19 said that if a resident is complaining of discomfort, drainage or their eyes are red, they should be assessed right away and the physician should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 5 of 12 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 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 0684 notified. Level of Harm - Minimal harm or potential for actual harm R100's Nursing Notes dated 9/12/23 at 11:01 AM shows, Resident both eyes have yellowish drainage, redness and verbalized discomfort in both eyes. Notified [Nurse Practitioner] order for ABT (antibiotic) ointment . Residents Affected - Few R100's Nursing Notes from 9/10/23 to 9/12/23 does not document anything about R100's eyes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 6 of 12 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review the facility failed to ensure a resident was safely transferred using a gait belt for 1 of 31 residents (R100) reviewed for safety in the sample of 31. Residents Affected - Few The findings include: On 9/11/23 at 9:30 AM, V17, Certified Nursing Assistant (CNA) assisted R100 to sit on the side of the bed. V17 stated, I know, you are weak and not feeling good today. V17 then assisted R100 to transfer to the wheelchair by holding onto the back of his pants and under his arm. R100 appeared very unsteady. V17 then assisted R100 back to bed by lifting him from under his arm to help him stand from the wheelchair. On 9/13/23 at 9:13 AM, V6 (Physical Therapist) said that they did not see R100 on 9/11/23 because he was not feeling good. V6 said that if R100 is sick and weak, a gait belt should be used when helping him transfer. The facility's Gait Belt/Transfer Belt Policy dated 9/2020 shows, To assist with a transfer or ambulation. A gait belt will be used with weight-bearing residents who require hands on assistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 7 of 12 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure pureed rice was prepared and served in a smooth, palatable consistency for 4 of 14 (R105, R154, R68, and R64) residents reviewed for food palatability in the sample of 31. Residents Affected - Some The findings include: The facility's Diet Type Report dated 9/11/23 shows R105, R68, R64, and R154 are all on a pureed diet. During the initial kitchen tour on 9/11/23 at 9:21 AM, V13, Cook, said they are having chicken, broccoli and rice for the lunch meal. On 9/11/23 at 10:58 AM, V13 said when making pureed foods he wants to make it to a smooth, pudding like consistency. V13 said he tastes the pureed foods to make sure they are very smooth. On 9/11/23 at 12:53 PM, a sample tray of the pureed lunch meal was obtained and tasted by the survey team. The pureed rice had an unappetizing, chunky texture which required chewing. The facility's Puree Prep Policy (revised 8/18) shows puree food will be palatable, attractive and prepared in a safe manner and will be puree to mashed potato or applesauce consistency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 8 of 12 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure symptomatic residents were immediately isolated and tested for COVID-19 to prevent to spread of infection and failed to ensure appropriate personal protective equipment was used when entering a contact/droplet isolation room for 5 of 31 residents (R10, R83, R100, R115 and R121) reviewed for infection control in the sample of 31. Residents Affected - Some The findings include: 1. On 9/11/23 at 9:30 AM, R100 was laying in bed coughing and had a hoarse voice. R100 said that he had been coughing since yesterday (9/10/23). V17 (Certified Nursing Assistant) provided incontinence care and a transfer for R100. R100 was not on isolation. On 9/12/23 at 1:23 PM, there was a sign outside of R100's room that showed that he was on contact droplet isolation. The sign showed, Droplet Precautions-Everyone must: .Make sure their eyes, nose and mouth are fully covered before room entry [picture of a person with a faceshield on and a picture of a person with goggles on] .Remove face protection before room exit. There was an isolation cart outside of R100's room. This cart did not contain any faceshields or goggles. V17 donned a surgical mask, gloves and gown before entering the room. V17 did not apply any eye protection. On 9/12/23 at 9:20 AM, V17 stated that she started getting sick last night with a cough and congestion. V17 stated, Everyone is sick. On 9/12/23 at 1:09 PM, V18 (CNA) said that when entering a contact/droplet isolation room staff should put on gloves, gown and a surgical mask. R100's Nursing Notes dated 9/7/23 at 7:13 AM shows, Resident w/ (with) on and off cough, runny nose .DON (Director of Nursing) updated. Will monitor. R100's Nursing Notes dated 9/11/23 at 1:45 PM shows, Resident noted with hoarse voice and occasional dry cough .Rapid COVID 19 test negative, place on contact/droplet isolation due to COVID-19 symptoms . On 9/12/23 at 11:53 AM, V5 (Infection Prevention Nurse) said that symptoms of COVID 19 include: sore throat, cough, runny nose, increased weakness, confusion, muscle aches and fever. V5 said that a resident should be immediately place on contact/droplet isolation if they have any COVID-19 symptoms. V5 said that the resident should then be tested for COVID-19. V5 said that the facility is only currently using rapid COVID tests and not doing PCR testing. V5 said that staff should wear a surgical mask, faceshield, gloves and gown when entering a contact/droplet isolation room. V5 said that it should be documented in the nursing notes if a COVID test was performed. On 9/13/23 at 12:48 PM, V5 said that in the evening of 9/12/23 (5 days after R100's documented symptoms) when he was working the floor, he tested R100 for COVID-19 and placed him on isolation. The only COVID-19 testing that was provided as being done for R100 was a rapid test that was performed on 9/12/23. 2. On 9/11/23 at 10:25 AM, R121 was walking down the hallway and coughing. R121 sat in a chair near (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 9 of 12 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm the nurse's station. Two other residents were sitting in chairs on each side of R121. The residents were not 6 feet apart and did not have masks on. The other two residents were cough. On 9/12/23 at 9:00 AM, R121 was in his room. R121 said that he has been coughing and short of breath since Friday. R121 was not on isolation and R121 had a roommate. Residents Affected - Some R121's Nursing Notes dated 9/11/23 at 1:23 PM shows, Resident complaining about coughing. [Nurse Practitioner] made aware, per NP received new order chest x-ray, and mucinex 600 mg twice a day R121's Electronic Medical Record from 9/8/23-9/12/23 does not document that the resident was placed on isolation or COVID-19 tested. On 9/13/23 at 12:48 PM, V5 (Infection Control Nurse) said that in the evening of 9/12/23 when he was working the floor, he tested R121 for COVID-19 and placed him on isolation. 3. On 9/12/23 at 9:09 AM, R83 was heard from the hallway coughing. R83 said, I wish I could quit hacking. R83 was not on isolation and had a roommate present in her room. R83 said that she has had a cough and sore throat for about 3 days. R83's Electronic Medical Record from 9/8/23 to 9/12/23 does not document that she has a cough or sore throat or that she was COVID-19 tested. On 9/12/23 at 1:38 PM, V20 (Licensed Practical Nurse) said that she was not aware that R83 had a cough or sore throat. On 9/13/23 at 12:48 PM, V5 (Infection Control Nurse) said that he is not aware that R83 has a cough or sore throat. V5 said that he is not sure how often the nurse's assess the resident for signs and symptoms of COVID-19 but he thinks it might be once a shift. The facility's Managing of Residents with Confirmed or Suspected COVID-19 Infection or Identified as a Close Contact Policy dated 7/2023 shows, Residents Suspected to have COVID-19-Test symptomatic residents regardless of vaccination status .Resident placement: Single room with door closed if safe to do so .If limited single rooms are available or if numerous resident are simultaneously identified to have COVID-19 exposure or symptoms draw a privacy curtain between the beds, and wait for test results Isolate empirically using Transmission-Based Precautions until results of tests are known .Monitor resident at least daily screen for signs and symptoms of COVID-19 Staff must wear full PPE (N95 respiratory, gown, gloves, eye protection) when providing care The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current COVID-19 infection for a resident with symptoms of COVID-19 can be made based on having negative results from one PCR test. 4. On 9/11/2023 at 10:48 AM, 12:22 PM, and 1:41 PM no isolation signs of any kind were observed outside of R10's room. No isolation cart or Personal Protective Equipment (PPE) was observed outside of R10's room either. On 9/11/2023 at 12:36 PM, V5 Infection Control Preventionist (ICP) said R10 developed a cough on 9/9/2023. V5 said R10 was swabbed for COVID-19 and was placed on contract/droplet isolation. V5 said the testing used was a rapid test and no PCR tests were completed for any residents tested for COVID-19. V5 said R10 should have still been on isolation on 9/11/2023. V5 said staff members caring for residents with COVID-19 symptoms but negative test results should wear mask, gloves, gown, and face (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 10 of 12 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm shield while caring for the resident. V5 said an isolation cart with PPE should be placed outside of the room for any resident on isolation. R10's Order Summary Report dated 9/11/2023 shows an order for isolation contact and droplet precautions with a start date of 9/9/2023 and end date of 9/19/2023. Residents Affected - Some 5. On 9/11/2023 at 9:40 AM, R115's room was observed to have an enhanced barrier precautions (EBP) sign on the door, but no isolation supply cart or PPE outside of the door. On 9/11/2023 at 9:42 AM, R115 said he had a stuffed-up nose and was swabbed for COVID-19 last week but was never placed on the correct isolation. R115 said facility staff had not been wearing masks when coming into his room since he was swabbed. R115 said he had some medic training in the military and understands some level of infection control practices. On 9/11/2023 at 12:24 PM, R115's room was observed to have an EBP sign but no other isolation sings and no isolation cart outside of the resident's room. On 9/11/2023 at 12:30 PM, V24 Registered Nurse (RN) said she was assigned to R115's room. V24 said R115 should be on contact/droplet isolation for COVID-19 exposure or symptoms. On 9/13/2023 at 12:36 PM, V5 said R115 was swabbed using a rapid test for COVID-19 on 9/7/2023 due to occasional coughing and complaints of body aches. V5 said R115 should have remained on isolation until 9/12/2023, pending three negative COVID-19 testing results. R115's Physician Order's show an order for contact droplet isolation with a start date of 9/7/2023 and end date of 9/17/2023. R115's Minimum Data Set (MDS) section C dated 8/18/2023 shows a BIMs score of 15, cognitively intact. The facility provided COVID-19 testing plan policy states rapid antigen testing should be performed for staff and/or residents who develop symptoms consistent with COVID-19 (even mild symptoms), regardless of their vaccination status. Should an individual with symptoms consistent with COVID-19 have negative results from a rapid antigen test, they should remain excluded from work and/or isolated pending the results of confirmatory PCR testing. The facility provided Management of Resident with Confirmed or Suspected COVID-19 Infection or Identified as a Close Contact policy states the decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current COVID-19 infection for a resident with symptoms of COVID-19 can be made based upon having negative results from one PCR test. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 11 of 12 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident dining area was safe and free from electrical hazards. This applies to 1 of 31 residents (R58) reviewed for safety hazards in the sample of 31. The findings include: On 9/11/23 at 12:45 PM, R58 was sitting in the dining room in her wheelchair. R58 had her back to the wall/window and her wheelchair was locked in place. R58's arms and legs are in constant motion (symptom of her diagnosis) and R58 constantly places her right hand in her mouth. On the wall behind R58 the plate covering the electrical outlet was broken and coming off of the wall. Two times R58 grabbed onto plate with her right hand and pulled at it, spinning it around with her wet fingers behind the plate. During the second time of holding onto the outlet V14 (MDS Coordinator) who was sitting at the table next to R58, saw what R58 was doing and removed her hand from the outlet cover. On 9/12/23 at 8:28 AM, V15 (Maintenance) stated, The staff usually text me when they need something fixed. I come up every morning about 6:30 AM and talk to the night shift and day shift and see if there is anything they need. There are also sheets in the folders at the nurse's station they can fill out and leave for me. The only thing on the third floor today is a toilet in room [ROOM NUMBER]. Surveyor walked with V15 to the dining room and showed him the broken cover on the electrical outlet. R58 was again sitting in front of the outlet. V15 stated, I can go downstairs and grab a new one right now. V15 was asked if there was any danger in the outlet cover being broken and R58 playing with it. V15 stated, I'm sure if she stuck a fork in it or something she could get shocked. On 9/12/23 at 8:35 AM, V15 asked V3 (Assistant Administrator) to stand by R58 while he went downstairs to get the new outlet cover. V3 stated that R58 has oral fixation and puts everything in her mouth. V3 stated that R58 grabs at everything around her and they have to be careful where they place her. R58's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with early onset and Unspecified Psychosis not due to substance or known psychological condition. R58's Minimum Data Set Assessment of 6/14/23 shows that R58 has severe cognitive impairment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 12 of 12