Inspection·June 6, 2025

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** 2. On 6/3/25 at 10:33 AM, R87 was in bed. Her hair was not combed and greasy. R87 stated, It's been a while since they shampooed my hair. I would like my hair washed and combed. Residents Affected - Some R87's MDS dated [DATE] shows she is moderately impaired in cognition. R87's care plan dated (5/12/25) shows she has an ADL functional performance deficit due to diagnosis of major depressive disorder, hypokalemia, iron deficiency anemia, hyperlipidemia, CHF (Congestive Heart Failure), GERD (Gastro-esophageal reflux disorder), and Osteoarthritis of hip. Intervention: Assist with ADL tasks as needed. 3. On 6/3/25 at 11:14 AM, R2 was in bed. She had hair on her chin and upper lip. R2 stated, I wanna be shaved. It doesn't look good. R2's MDS dated [DATE] shows she is cognitively intact. R2's care plan dated (7/24/24) shows she has an ADL Self Care Performance deficit due to diagnosis of encounter for surgical aftercare following surgery. Intervention: Assist with ADL tasks as needed. 4. On 6/3/25 at 11:20 AM, R121 was in bed. Her hair was not combed and it was greasy. R121 stated, I didn't get a shower one day last week. They said they are short of CNA's (Certified Nursing Assistants). They don't wash my hair. I want it washed and combed. R121's MDS dated [DATE] shows she is cognitively intact. R121's care plan dated (7/26/24) shows she has an ADL Self Care Performance Deficit due to muscle weakness; decrease mobility related to diagnosis of rhabdomyolysis, lower back pain, abnormalities of gait, and radiculopathy/lumbar region. Intervention: Assist with personal hygiene as needed. Allow enough time for completion of ADL tasks. Do not rush the resident. 5. On 6/3/35 at 11:27 AM, R149 was in his room in bed. His nails on both hands were long and had a black substance underneath his nail tips. He stated he wanted his nails cut. He had a beard and he stated he wanted to be shaved. R149's MDS dated [DATE] shows he is cognitively intact. R149's care plan dated (5/27/25) shows he has an ADL functional performance deficit due to spondylosis, major depressive disorder, COPD, anemia, mild neurocognitive disorder, and essential tremor. Interventions: Assist with ADL tasks as needed. On 6/4/25 at 2:09 PM, V16 (ADON-Assistant Director of Nursing/IP-Infection Preventionist) stated, Typically CNA's are responsible for shaving, providing nail care and washing/combing residents' hair. Facility's policy titled Bath, Tub, or Shower (9/2020) shows: Policy: 1. To provide cleanliness and comfort to the resident. Facility's policy titled Shaving The Resident (9/2020) shows: Purpose: To remove facial hair and improve the resident's appearance and morale. Facility's policy titled Hair and Scalp Care (9/2020) shows: Purpose: 1. To clean hair and scalp. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 2 of 13 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 06/06/2025 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 3. To provide the resident with an attractive appearance and improve morale. Level of Harm - Minimal harm or potential for actual harm Facility's policy titled Nails (Care Of) (9/2020) shows: Policy: All residents will have clean, well-trimmed nails. Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents who require assistance with their ADLs. This applies to 5 of 5 residents (R2, R21, R87, R121, R149) reviewed for ADL's in a sample of 32. The findings include: 1. On 06/03/25 at 3:25 PM, R21 was in the dining room reclined and slouched in a high-back wheelchair. On the table in front of R21 was a brown semi-liquid substance with some dried areas that smelled like a bowel movement. R21 was playing with the brown substance using her left fingers like finger painting on the table. V4 (Activity Aide) told V3 (Registered Nurse/RN) that R21 needed to be cleaned up, showing V3 the brown substance. R21 was sitting in the wheelchair with a visible dried brown substance on the front of her pants and the side of the right armrest. On 06/03/25 at 3:47 PM, V6 (Certified Nursing Assistant/CNA) and V7 (CNA) brought R21 to her room. The mechanical lift sling under R21 was soaked and soiled. After removing R21's soiled and wet pants, R21 was positioned lying on her right side while V6 was performing incontinence care with disposable personal wipes to clean a significantly soft, loose bowel movement. A line of dried stool was noted on R21's left buttock, lower hip, and upper outer thigh. V6 continued to clean the buttocks and placed her left gloved hand on the area of the dried stool. R21 had a small soft splint on her right hand. V6 and V8 said R21's hands were both cleaned. After removing the soft splint in R21's right hand, the soft splint was noted to be soiled with a brown substance. When R21's hands were wiped again with the personal disposable wipes, the wipes had shown brown soiling. As V6 and V8 prepared to transfer R21 from the bed to the wheelchair, this it was noteds that the wheelchair had a dried brown substance on the inside of its right armrest. V8 propelled R21 to the bathroom, and V6 carried the garbage in her bare hands to the soiled utility room. While cleaning R21's hands with a washcloth at the sink in the bathroom, the washcloths were visibly soiled. V6 and V8 threw the soiled washcloths into the sink when they were done. R21's EMR (Electronic Medical Record) showed R1 has diagnoses including hemiplegia and hemiparesis affecting the right side, dementia, contracture of the right elbow, aphasia, and tinea unguium (nail fungus). The MDS (Minimum Data Set) dated 04/02/2025 showed R21's cognition was severely impaired. R21 had impairment of both the upper and lower extremities on one side. The MDS shows R21 was dependent on staff for toileting, bathing, dressing, and personal hygiene. R21 was always incontinent of bowel and bladder. The Care Plan indicated that R21 had an Activities of Daily Living (ADL) self-care deficit, requiring assistance with ADLs for hygiene, toileting, and bathing, with interventions that included two persons to perform these tasks. R21 required the use of a mechanical lift for transfers. The care plan showed R21 had bowel and bladder incontinence with a goal to be socially continent, clean, dry, and odor-free, with interventions including checking and changing R21 after incontinence episodes. R21 has impaired cognition and a deficit in the ability to self-understand due to a past cerebrovascular accident. On 06/05/2025 at 2:52 PM, V2 (DON) stated that the facility doesn't have a policy on how often a resident needs to be checked or when the incontinence brief should be changed, but it should usually (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 3 of 13 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 06/06/2025 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 be done every two hours and as needed. If the resident is soiled or wet, they should be changed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 4 of 13 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 06/06/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on observation, interview, and record review, facility failed to follow up with a Wound Consult ordered on 5/27/25 which resulted in the resident not being seen until 6/5/25. This failure resulted in a delay in Wound consult, assessment and implementation of new interventions for a pressure wound that deteriorated to an unstageable pressure injury.The findings include:R95's most recent pressure ulcer risk assessment (dated 04/22/25) showed R95 is at Mild Risk for developing pressure ulcers.On 06/03/25 at 9:51 AM, R95 was sleeping in bed. At 9:53 AM, V38 (CNA-Certified Nursing Assistant) said R95 had some redness on her backside. V38 said she was unsure if R95 had any wounds because she only cleans the skin around a dressing when providing incontinence care. At 10:07 AM, V32 (R95's POA-Power of Attorney) said that the facility had not mentioned anything about R95 having any pressure sores or open skin.On 06/04/25 at 2:10 PM, V16 (ADON-Assistant Director of Nursing/IP-Infection Preventionist) reviewed the EBP (Enhanced Barrier Precautions) list and said that R95 was not on the list since she does not have any wounds. V16 stated R95 has only exhibited some rash-like redness and was receiving treatment for Moisture-Associated Skin Damage (MASD).On 06/05/25 at 9:49 AM, V14 (RN-Registered Nurse) said that she had already changed R95's dressing earlier that morning. V14 stated that R95 did not have any pressure-related wounds and only had redness with some open skin. Per V14, R95's current wound treatment orders were only for the prevention of pressure injury. At 10:00 AM, V14 and V34 (CNA-Certified Nursing Assistant) turned R95 to her left side and V14 removed R95's undated dressing from her sacrum. The dressing was saturated with red and yellow fluid. R95's sacral area had a round, open area, and the wound bed was covered with thick, yellow, stringy slough adhered to it. The wound had a dark gray perimeter around the slough. V14 measured the wound and stated R95's wound was a pressure sore. At 10:15 AM, V14 stated that the last time she saw R95's wound was on 06/03/25 (2 days earlier) and she described it as a little open with little slough.V14's 6/5/25 1:24 PM wound assessment showed R95 has a sacral unstageable pressure ulcer with 90% slough and moderate serosanguinous discharge, with peri-wound measuring [in cm- centimeters] 6.2 cm x 4.2 cm with a pressure ulcer in the center that measured 3.2 cm x 3 cm with an undetermined depth. R95's EMR (Electronic Medical Record) did not include any previous wound assessments for R95's pressure ulcer.R95's POS (Physician Order Sheet) showed a 5/27/2025 order from V33 (PA- Physician Assistant) for a foam dressing and Medi-honey to R95's sacrum every day and evening for skin condition. The POS also included another order for in-house Wound Consult. No other new orders or interventions were included in R95's POS to address the unstageable pressure ulcer.On 06/06/25 at 11:03 AM, V33 (PA-Physician Assistant) said that on 05/27/25, facility staff notified her regarding a skin issue with R95's and she did not examine R95's skin herself and based her order for Medi-honey on the staff's description of R95's skin. V33 confirmed that Medi-honey is for pressure-related wounds and stated that she would have ordered a different topical treatment if R95 only had redness.On 06/05/25 at 12:30 PM, V31 (Wound Doctor) said that he had been in the facility on 06/03/25 and was not notified of R95's Wound Consult order and he did not see R95. V31 confirmed that Medi-honey is not an appropriate treatment for redness or MASD as it is typically used as a debridement agent for pressure-related wounds.R95's 12/14/23 care plan showed R95 with a potential alteration in skin integrity .previously with MASD to upper inner buttock/gluteal cleft area. R95's care plan had not been updated to include her actual pressure ulcer until 6/5/25, during the survey, and nine days after the Medi-honey order.The facility's policy on Prevention and Treatment of Pressure Injury and other Skin Alterations includes identifying residents at risk for developing pressure injuries, identifying the presence of pressure injuries and/or other skin alterations, and implementing preventative measures and appropriate treatment modalities for Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 5 of 13 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 06/06/2025 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 0686 Level of Harm - Actual harm pressure injuries and/or other skin alterations through an individualized resident care plan. The policy also states that at least daily, staff should remain alert for potential changes in the skin condition during resident care . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 6 of 13 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 06/06/2025 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 safely secure an oxygen cylinder. to prevent from tipping over and potentially causing a fire or explosion. Residents Affected - Some This applies to 1 out of 3 residents (R143) reviewed for oxygen tanks in a sample size of 32. The findings include: On 6/3/2025 at 10:11 AM, 6/4/2025 at 9:05 AM and 6/4/2025 at 9:21 AM, a portable oxygen cylinder was unsecured on the floor. The oxygen cylinder was located on the head part on the right side of R143's bed and was half full. R143 said he does not use oxygen. On 6/5/2025 at 8:35 AM , V2 (DON-Director of Nursing) said portable oxygen cylinders should be secured in a container to keep from tipping over. She said oxygen is flammable and if it tips over, may cause a fire or explosion. R143's POS (Physician Order Sheet) showed no order for oxygen and his MDS (Minimum Data Sheet) dated 5/15/2025 documents that R143 has intact cognitive functions. Facility's undated Policy and Procedure on Oxygen storage documents the following: Policy Oxygen will be stored in accordance with applicable regulations. Procedure: 1. All oxygen containers (compressed tanks and liquid cylinders) will be restrained while in storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 7 of 13 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 06/06/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to practice safe food preparation, and properly label/date/seal/store food items in the facility kitchen. Residents Affected - Many This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 6/3/25 documents that the total census was 162 residents. On 6/3/25 at 10:29 AM, V20 (Dietary Manager) said they only have 1 NPO (Nothing By Mouth) resident. On 6/3/25 starting at 9:30 AM, the facility kitchen was toured independently and the following was found: In Main Kitchen Area: 1.4 different prescription pills were found sitting on a plate on the food preparation counter. V25 (Dietary Aide) said the pills were hers. 2. The robo-coup blender and large plastic storage container of thickener with the lid off were located within splash distance of the handwashing sink. In the walk-in cooler: 3. There was no room to walk in the cooler, there were four different carts on wheels stored in the cooler, one of the two tall rolling carts only had two small food items on it. The over-crowding of the cooler noted for potential to prevent proper air circulation and cooling of food items. 4. Small silver bin dated 5/19/25 with what appeared to be either tuna or chicken salad. Bin unlabeled. 5. A large silver bin or facility prepared egg salad dated 5/28/25. Salad looked wet and watery. At 10:26 AM V20 (Dietary Manager) said prepared salads are only good in the refrigerator for 1-2 days. 6. A half of a deli ham was dated 5/27/25. At 10:27 AM V20 said the ham is safe in the refrigerator for 4-5 days. 7. A white paper bag with unlabeled and undated plastic container of what appears to be a salsa like food item. Appears to be a personal staff or resident food item. 8. A plastic grocery store bag with 2 small plastic containers of liquid food items. Appears to be resident or staff personal food items inside. Food is unlabeled. In the Dry Storage: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 8 of 13 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 06/06/2025 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 0812 9. 4 large plastic bins on wheels labeled: Sugar, Rice, Oatmeal, and Flour, not dated. Level of Harm - Minimal harm or potential for actual harm 10. 2-3lb (pound) 14 ounce cans of mushroom pieces and stems on circulation rack with large dents in the side of both cans. Residents Affected - Many 11. 50lb bag of long grain white rice opened, not sealed, with a Styrofoam cup stored inside bag. 12. 1lb bag of jumbo marshmallows with a hole ripped in the side of the bag, not sealed or wrapped. After the kitchen tour was completed independently on 6/3/25, around 10:15 AM, the tour was re-walked with V20 (Dietary Manager) and he was shown all of the above concerns found. On 6/4/25 at 2:40 PM, V20 said the food in the walk-in cooler was not staff food, it was resident food brought in by family. V20 and V26 (Corporate Chef) said the facility does not have any policies that talk about storing scoops/cups in dry food items, storage of resident food brought in by family, storage of food/carts in walk-in cooler to allow for proper air circulation, any policies specific to how long prepared salads and/or deli meats are good for in the refrigerator, or labeling and dating of dry foods. V20 and V26 said all time/temperature controlled for safety foods are good in the refrigerator for 3-7 days. On 6/5/25 at 10:38 AM, V20 said kitchen staff should not have their personal prescription pills out on the food preparation counter because of the risk of the pills getting mixed into resident foods. V20 said if a resident consumes a pill that is not their prescription it can harm the resident. V20 said the robo-coup and uncovered thickener container should not be stored within splash distance of the handwashing sink because of the risk of cross-contamination that can lead to resident illness. V20 said the sugar, rice, oatmeal, and flour bins should be dated for food safety and dented cans should be taken out of circulation because of the risk of botulism and resident death. V20 said a Styrofoam cup should not be stored inside of the rice bag because of the risk of cross-contamination and all opened food items should be resealed/wrapped to prevent contamination from dust, flies, or any kind of bacteria in the air. V20 said overcrowding in the walk-in cooler could affect the air circulation and food quality. V20 said all food items in the kitchen should be labeled and dated for food safety and quality. V20 said food brought in by resident families should not be stored in the walk-in cooler with other resident food because they don't know what is in the food and it can cause cross contamination. The facility policy titled, Cleaning and Storing of Dishwares last revised 3/22 states, Policy: Dishwares will be cleaned and stored in a manner to decrease the risk of cross contamination. Purpose: To reduce the risk of cross contamination. Procedure: . 4.dishwares will be stored .in such a location as to prevent splash . The facility policy titled, Food Storage Guidelines last revised 8/18 states, Policy: Food will be stored and used in an acceptable amount of time. Purpose: To reduce the risk of food borne illness. Procedure: . 3. Refrigerated TCS (Time/Temperature Controlled for Safety) food may be kept 3-7 days . The facility's policy titled, Dented Cans last revised 3/24 states, Policy: Cans will be rejected if compromised. Purpose: To reduce the risk of food borne illness. Procedure: .2. Compromised cans will be stored on a shelf marked - do not use . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 9 of 13 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 06/06/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's policy titled, Visitor Procured Food last revised 8/18 states, .Procedure: .2. Food & Nutrition Services will provide visitors a tip sheet on safe food handling. The tip sheet will highlight proper food handling practices .3. Food & Nutrition Services when assisting visitors with reheating or other preparation activities will use safe food handling practices . The facility's undated tip sheet titled, Food Safety Information for Families and Visitors Tips to Keep Food Safe states, .Holding Foods: . Resident food should be in a tight container labeled with name, food item, and date it was prepared .Each facility has specialty designated area(s) where resident food .may be stored . Event ID: Facility ID: 145379 If continuation sheet Page 10 of 13 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 06/06/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices. Residents Affected - Few This applies to 2 of 2 residents (R11 and R21) observed for infection control in a sample of 32. Findings include: 1. On 06/03/25 at 3:25 PM, R21 was in the dining room reclined and slouched in a highback wheelchair. On the table in front of R21 was a brown semi-liquid substance with some dried areas that had the odor of excrement. R21 was playing with the brown substance using her left fingers, like finger painting on the table. V4 (Activity Aide) brought R21 to the nurse's station and, without donning gloves, used a dry paper towel to wipe the right armrest and R21's right arm, which was covered in the brown substance. After wiping R21's arm and armrest, V4 threw away the soiled paper towel and, without performing hand hygiene, punched in the code to access the clean utility room. Without performing hand hygiene, V4 donned gloves to clean off the table in the dining room. On 06/03/25 at 3:47 PM, V6 (Certified Nursing Assistant/CNA) and V7 (CNA) brought R21 to her room. Using her dry, soiled left hand, R21 was touching V7's bare right upper arm. V7 was unaware R21's hand was soiled. V8 (CNA) assisted V6 (CNA) in lifting R21 in the total body mechanical lift. V8 instructed R21 to hold the bar on the total body mechanical lift with her left hand. R21 held the bar briefly with her left hand. The mechanical lift sling under R21 was soaked and soiled. After removing R21's soiled pants and without removing her soiled gloves, V8 opened the closet door and removed clean pants. While V6 and V8 remained in the room, V7 (CNA) removed and disposed of her gloves, put hand sanitizer into her right hand and then opened the bedroom door before using the hand sanitizer. R21 was positioned lying on her right side while V6 was performing incontinence care with disposable personal wipes to clean a significant amount of soft, loose bowel movement. A line of dried stool was noted on R21's left buttock, lower hip, and upper outer thigh. V6 continued to clean the buttocks and placed her left gloved hand on the area of the dried stool. When V6 needed to change gloves, she reported that she did not have more gloves in the room and was required to obtain some. V6 removed the soiled gloves and left the room, touching the door handle with bare hands without washing her hands or performing hand hygiene. During this time, V8 continued to clean R21's left thigh. V6 returned, and both V6 and V8 continued providing incontinence care for R21. After completing incontinence care and without removing their soiled gloves, V6 and V8 applied a clean incontinence brief to R21. V8 then removed R21's soiled shirt and assisted in donning a clean shirt R21 without changing gloves. V8 removed her soiled gloves and without performing hand hygiene, grabbed the door handle, opened the door, walked to the shower room, punched in the code, opened the door, went into another room, punched in the code of the soiled utility room, opened that door, then got on the elevator saying she needed to go to the second floor to find a clean mechanical lift sling for R21. At 4:06 PM, as V6 and V8 prepared to transfer R21 from the bed to the wheelchair, R21's wheelchair had a dried, brown substance on the inside of its right armrest. Once R21 was in the wheelchair, V6 and V8 (CNAs) separated the soiled linens into a separate bag from the garbage, then placed both the garbage and the soiled linen bag onto the bedside table before closing each bag. V6 and V8 each removed their gloves but did not perform hand hygiene. V8 held the handrest of the highback wheelchair to propel R21 to the bathroom, and V6 carried the garbage in her bare hands to the soiled utility room. While cleaning R21's hands with a washcloth at the sink in the bathroom, V6 and V8 threw the soiled washcloths into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 11 of 13 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 06/06/2025 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 sink when they were done. Level of Harm - Minimal harm or potential for actual harm R21's EMR (Electronic Medical Records) showed R21 has diagnoses including hemiplegia and hemiparesis affecting the right side, dementia, contracture of the right elbow, aphasia, and tinea unguium (nail fungus). R21's Minimum Data Set (MDS) dated [DATE] showed R21's cognition was severely impaired. R21's care plan showed R21 had bowel and bladder incontinence with interventions including checking and changing R21 after incontinence episodes. Residents Affected - Few The facility's Hand Hygiene policy dated 10/2024 showed hand hygiene should be performed by washing hands with soap and water or using hand sanitizer to reduce the potential spread of pathogens. The policy includes performing hand hygiene prior to touching a resident when moving from a soiled body site to a clean body site of the same resident, after touching a resident or their immediate environment, and immediately upon removing gloves. Hand hygiene with soap and water should be performed when hands are visibly soiled or after any contact with blood, body fluids, or contaminated surfaces. Gloves or the use of perineal wipes are not substitutes for hand hygiene. 2. R11's EMR (Electronic Medical Records) showed R11 had diagnoses including vascular dementia, neuropathy, morbid obesity, tinea unguium, peripheral vascular disease, and contracture of the right and left knees. The MDS dated [DATE] showed R11's cognition was moderately impaired and was dependent on staff for toilet hygiene and bathing. R11 was always incontinent of bowel and bladder. On 06/03/25 at 3:26 PM, At the other table, R11 was sitting in a wheelchair asking for help, saying he p***ed himself and needs to be changed. Underneath R11's wheelchair was a large puddle of liquid. The front of R11's pants was saturated with water. V4 and V5 (Activity Aides) were present in the room by the water cart. On 06/03/2025 at 3:32 PM, V5 (Activity Aide) donned gloves and used a thin cloth to wipe up the liquid on the floor, but more liquid remained on the floor. At 3:33 PM, V4 (Activity Aide) walked through the wet trail of liquid/urine to clean up the dining room table. At 3:34 PM, R141 walked through the wet trail of urine in the dining room. R133 was in a wheelchair and propelled herself using her feet through the trail of urine. R133 was wearing socks only, no shoes. V5 then placed a towel over the area and left it. On 06/03/2025 at 3:36 PM, V6 (Certified Nursing Assistant/CNA) wiped the urine off the floor with a towel only. On 06/04/2025 at 3:32 PM, V4 (Activity Aide) stated that when a resident experiences an incontinence episode, they will notify the CNAs or nurses. V4 said they would clean up what they could and should wear gloves when cleaning it up. V4 said he should have had gloves on when cleaning R21 at the nurses' station, but there weren't any gloves available at the time. He cleaned the table with the purple top wipes but did not notify housekeeping to clean or disinfect the table or the floor on 06/03/2025, following R11 and R21's incontinence episodes. On 06/04/2025 at 4:07 PM, V3 (RN, MDS Coordinator) said the activity aide should put on gloves, then clean R21's hands and wheelchair with disposable cleaning wipes and paper towel. On 06/04/2025 at 4:07 PM, V3 (RN, MDS Coordinator) said the staff needed to call housekeeping if there were body fluids, such as urine or stool, on the table or the floor. During incontinence care, the nursing staff should use hand sanitizer, don gloves, remove the resident's soiled incontinence brief, clean the resident, then remove gloves, perform hand hygiene, and don new clean gloves before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 12 of 13 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 06/06/2025 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 Residents Affected - Few placing a new incontinence brief on the resident. If staff members need to exit the room to retrieve any items, they should remove their gloves and perform hand hygiene before touching anything else. V3 stated that staff should not place garbage bags or soiled linen bags on the bedside table or any other surface. On 06/04/2025 at 3:36 PM, V5 (Activity Aide) stated that if a resident had an incontinent episode that spilled onto any surfaces, they should call housekeeping to mop and clean the area. V5 stated on 06/03/2025 that they had only cleaned the floor with a towel and did not call housekeeping. On 06/05/2025 at 11:05 AM, V9 (Housekeeping Supervisor) stated that if body fluids, such as a bowel movement or urine, were present on the floor or table, staff should call housekeeping to disinfect the area. The staff can clean up the area to remove the body fluids, but we would be the last ones to come in to disinfect the areas. Housekeeping uses Oxivir Five 16 to clean the table surfaces and Prominence to clean the floors. On 06/05/2025 at 12:02 AM, V2 (Director of Nursing/DON), with V1 (Administrator) present, stated that if body fluids, such as stool or urine, were present on a table or floor, the staff should contact housekeeping to clean and disinfect the area. V1 (Administrator) said that, in theory, the staff can clean up the area as best they can, but they should still have housekeeping come in to clean up. V2 said hand hygiene should be performed after removing gloves, before touching another surface, and when going from a dirty to a clean area. If the gloves are visibly soiled, the staff should wash their hands with soap and water after removing them, or they can use hand sanitizer if the gloves are not visibly soiled. V2 said the staff should not place a garbage bag or a soiled linen bag on the floor or bedside table. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145379 If continuation sheet Page 13 of 13