Inspection·February 24, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On February 18, 2025 at 1:53 PM, V7 (CNA) said, I wrote a report and gave it to my supervisor. I was training another CNA (V6). [R1] wanted a shower. He did not want a bed bath. We transferred him to the shower chair next to his bed. We used the sit-to-stand lift. When we finished, we went back to the room, and I told him to hold onto the lift. I told the other CNA where to hook the sling for the sit-to-stand, and when he was standing, she was able to guide him to the bedside, and he was screaming he wanted us to go faster. He let go of the handles, and the sling from the lift was hitting his arm by his intravenous line on his arm. He got really angry, and he said his arm hurt. He was saying his arm hurt a lot. He was literally about six inches above the mattress when [R1] let go of the sit-to-stand handles and his butt just lowered the six inches to the mattress. He never fell. I notified the nurse. On February 18, 2025 at 1:40 PM, V4 (LPN) said, [R1] let go of the sit-to-stand during transfer. He did not fall. I did not assess his pain or skin. I asked the wound care nurse to do that. On February 19, 2025 at 10:23 AM, V3 (WCN) said, I remember the resident. His skin was intact. I put A&D ointment on it for protection. I don't remember much about it. I was only there to look at his skin. I did not assess his pain or range of motion. On February 19, 2025 at 8:52 AM, V2 (DON-Director of Nursing) said the facility does not have documentation to show R1 was assessed following the incident on September 5, 2024 involving the sit-to-stand mechanical lift. V2 continued to say if the resident was complaining of extreme pain, the resident should have been assessed, including vital signs, range of motion, and level of pain. On September 6, 2024 at 6:09 PM, V26 (NP-Nurse Practitioner) documented, [R1] seen and examined. Patient seen lying in bed with left arm swelling, erythema, and warmth to touch. Patient with limited ROM (Range of Motion) and inability to straighten elbow and is in severe pain during physical assessment. Doppler and X-ray orders sent to NOD. [V8] (Spouse of R1) came to my office later in the day asking about ultrasound and room status. Directed to social services or admission for room concerns, NOD check on STAT orders for doppler ultrasound and X-ray. Later in the day, DON contacted me reporting testing was not yet completed and patient's wife requesting to send patient out for quicker evaluation and results. Agreed to sent patient out to ED. V23's (RN) SBAR (Situation, Background, Appearance, Review and Notify) Communication Form dated September 6, 2024: Upon greeting patient in AM, noticed that left forearm is bruised and swollen and area directly under PICC (Peripherally Inserted Central Catheter) line is reddened. Forearm is warm to touch and patient having difficulty moving arm. The form continues to show V8 (Spouse of R1) was notified on September 6, 2024 at 11:00 AM. On February 19, 2025 at 11:19 AM, V23 (RN) said, I was not in the facility on the day of the incident (September 5, 2024). When I went in to see him on September 6, I noticed his left arm was swollen. It was swollen from the elbow down. The dressing on his midline catheter was intact. [R1] said he had a fall, and he was telling me it was hurting and sore, and when I touched the arm, his arm felt boggy, and I told him I would have the nurse practitioner look at it. I put in STAT orders from the nurse practitioner for a left arm X-ray and venous doppler. When [V8] (Spouse of R1) came in, I updated her and told her about the orders and told her the nurse practitioner saw [R1]. When the resident told me he was in pain, I offered morphine, and he declined. He left the facility around dinnertime. I never saw any open skin on his arm. Hospital records show R1 had an ultrasound venous doppler of his left arm on September 6, 2024. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145458 If continuation sheet Page 2 of 7 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 145458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Rehab at Oak Brook 2013 Midwest Road Oak Brook, IL 60521 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few results showed: Conclusion: 1. Left upper extremity DVT (Deep Vein Thrombosis) with occlusive axillary vein thrombus possibly extending into junction with one of the brachial veins in the proximal arm. Left forearm X-rays completed at the hospital on September 6, 2024 were negative for acute fracture or subluxation. On February 20, 2025 at 10:43 AM, V19 (Physician) said facility staff should assess a resident following an incident where the resident complains of extreme pain. The facility's policy entitled Accidents and Incidents - Investigating and Reporting revised September 2021 shows: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); .g. The time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions; h. the date/time the injured person's family was notified and by whom; i. the condition of the injured person, including his vital signs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145458 If continuation sheet Page 3 of 7 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 145458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Rehab at Oak Brook 2013 Midwest Road Oak Brook, IL 60521 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's leaking indwelling urinary catheter was changed in a timely manner, and a resident's indwelling urinary catheter was changed monthly as documented by the physician. This applies to 2 of 3 residents (R2, R4) reviewed for indwelling urinary catheters in the sample of 7. The findings include: 1. The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. The EMR continues to show R2 was sent to the local hospital on December 24, 2024 and returned to the facility on January 6, 2025. R2 has multiple diagnoses including, cellulitis of the left and right lower limbs, heart failure, chronic kidney disease, acute kidney failure, COPD (Chronic Obstructive Pulmonary Disease), lack of coordination, unstageable pressure ulcer of the sacral region, nicotine dependence, unsteadiness on feet, morbid obesity, and PVD (Peripheral Vascular Disease). R2's MDS (Minimum Data Set) dated January 9, 2025 shows R2 is cognitively intact, requires supervision with eating, partial/moderate assistance with oral hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R2's MDS continues to show R2 has an indwelling urinary catheter and is always incontinent of stool. The MDS continues to show R2 had one unstageable pressure ulcer present on admission to the facility. Facility documentation dated February 19, 2025 shows R2 has an unstageable pressure ulcer of the sacrum that was present on admission to the facility. R2's pressure ulcer measurements on February 19, 2025 were 9.0 cm. (centimeters) long by 8.0 cm. wide, by 2.5 cm. deep. On February 18, 2025 at 10:18 AM, R2 was lying in bed, on a low air loss mattress. The mattress was fully inflated. R2 had an indwelling urinary catheter with clear, yellow urine draining into the collection bag. R2 said several weeks ago, she experienced an entire day where her indwelling urinary catheter was leaking, and she felt she was soaking wet while lying in bed. R2 said she asked multiple staff members to check and change the catheter, but no staff addressed her concerns. On January 31, 2025 at 7:32 AM, V22 (RN-Registered Nurse) documented, At the end of shift, CNA (Certified Nursing Assistant) reported resident's [indwelling urinary catheter] was leaking, during report to oncoming nurse, writer informed nurse regarding [indwelling urinary catheter], and oncoming nurse acknowledged to follow up. On January 31, 2025 at 7:00 PM, V11 (LPN-Licensed Practical Nurse) documented, Around 7:30 AM, received report from night shift nurse, patient [indwelling urinary catheter] was leaking last night, it was reported by the staff CNA. Around 8:00 AM, nurse did rounds, noticed patient was a sleep. Around 8:30 AM, informed to the morning staff CNA to let me know if the patient is wet, the CNA stated She is passing morning breakfast, after she is done, she will check on the patient. 9:30 AM the CNA went to resident room to change the patient, noticed patient was on the phone talking to family. Around 9:40 AM, the CNA insisted to change patient briefs, patient refused. 10:40 AM, patient family POA (Power of Attorney) came, she was yelling to the staff nurse. The nurse tried to explain to the POA, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145458 If continuation sheet Page 4 of 7 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 145458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Rehab at Oak Brook 2013 Midwest Road Oak Brook, IL 60521 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the POA was over talking, Stating give me a [profanity] time, she was threatening saying I am going to call the police, she is going call the lawyer. On February 18, 2025 at 1:07 PM, V11 (LPN) said, I remember the catheter situation with [R2]. I received report in the morning around 7:15 AM from the night shift that the resident's indwelling urinary catheter needed to be observed by the nurse because the CNA said it was leaking. What the nurse told me was I needed to go and check on her. I finished report and then did the narcotic count. I went to check on her and she was asleep. I came out and I told my CNA to let me know if the catheter was leaking or not. The CNA was passing breakfast. She told me as soon as she was done passing breakfast she would go and check on her. Then the DON (Director of Nursing) sent me a message around 11:00 AM and said the catheter needed to be changed. I do not know if she was sitting in wetness from the day before. I was not aware of that. V11 said she did not change R2's indwelling urinary catheter as requested by the DON. On February 18, 2025 at 3:23 PM, V2 (DON) said on February 1, 2025 she was told R2 was having problems with her indwelling urinary catheter and gave directions to staff to change out the catheter. V2 said, I said, please change it out. I got an okay from [V11] (LPN), and then she told me she did not change it out. Then I was notified by [V13] (Daughter/POA of R2) that it still had not been changed out. I had to send someone else to change it. It was a considerable amount of time before it was changed. I expect the staff to follow my direction the first time. It sounds like [R2] had a lot of sediment in the tubing, and the night nurse flushed it, and she thought it was working. On February 19, 2025 at 9:19 AM, V13 (Daughter/POA of R2) said, The incident with the leaking catheter happened on January 31, 2025. I had to literally talk to [V2] (DON) before we could get something done about it. It took until the next day to get the catheter situation taken care of. In the meantime, she sat in a soaking wet bed with her huge pressure ulcer sitting in all that urine. Facility documentation shows R2's indwelling urinary catheter was noted leaking in the early morning hours of January 31, 2025. Facility documentation shows R2's indwelling urinary catheter was changed on February 2, 2025 at 12:48 PM. On February 2, 2025 at 12:48 PM, V16 (LPN) documented, [V13] (Daughter/POA of R2) .Resident [indwelling urinary catheter] leaking, catheter balloon deflated. Removed 30 cc (cubic centimeters) of sterile water. [Indwelling urinary catheter] replaced by Supervisor using sterile technique, 16 French catheter inserted with urine return noted. POA made aware. 2. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, metabolic encephalopathy, acute kidney failure, urinary tract infection, heart failure, low potassium, multiple sclerosis, hemiplegia, diabetes, anxiety disorder, lack of coordination, dementia, major depressive disorder, heart failure, and hypertension. R4's MDS dated [DATE] shows R4 is cognitively intact, requires supervision with eating and oral hygiene, partial/moderate assistance with personal hygiene, substantial/maximal assistance with toilet hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R4 has an indwelling urinary catheter and is always incontinent of stool. On February 19, 2025 at 10:27 AM, R4 was lying in bed in her room. R4 had an indwelling urinary catheter in place draining clear, yellow urine into a collection bag. R4 said she has had multiple UTIs (Urinary Tract Infections). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145458 If continuation sheet Page 5 of 7 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 145458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Rehab at Oak Brook 2013 Midwest Road Oak Brook, IL 60521 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 0690 The EMR shows the following order dated October 27, 2024: Insert [indwelling urinary catheter]. Level of Harm - Minimal harm or potential for actual harm Facility documentation shows R4 had multiple urine cultures with results indicating urinary tract infections with multiple organisms, including urine cultures dated November 4, 2024, December 19, 2024, and January 7, 2025. Residents Affected - Few Facility documentation shows R4 was hospitalized from [DATE] to November 29, 2024 due to UTI and altered mental status. On November 18, 2024 V19 (Physician) documented, Patient seen and examined for recurrent UTI, ESBL (Extended Spectrum Beta-Lactamases) UTI, mental status changes, diabetes mellitus type 2, history of CHF (Congestive Heart Failure), restless leg syndrome. Patient seen examined seems stable, seems to be doing well, no current complaints, tolerating medications, has completed the nitrofurantoin (antibiotic), and prophylactic antibiotics have been resumed. She continues with [indwelling urinary catheter] and we did discuss exchanging the catheter on a monthly basis. She seems to be tolerating this well . On December 12, 2024, V19 (Physician) documented, Bladder: Continue with [indwelling urinary catheter] and, exchanges monthly. On December 24, 2024, V19 (Physician) documented, Bladder: Continue with [indwelling urinary catheter] and, exchanges monthly. On December 26, 2024, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due this week. On December 30, 2024, V19 (Physician) documented, Patient seems stable, doing well. [Indwelling urinary catheter] has not been exchanged, we did discuss this with the nursing staff, they verbalized understanding. History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due this week. On January 6, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due this week. On January 9, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due this week. On January 23, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. On January 27, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. On February 3, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145458 If continuation sheet Page 6 of 7 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 145458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Rehab at Oak Brook 2013 Midwest Road Oak Brook, IL 60521 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On February 10, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. On February 13 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. On February 17, 2025, V19 (Physician) documented, History of multiple sclerosis with neurogenic bladder: Continue with [indwelling urinary catheter] and, exchanges monthly, due at the end of the month, round the 25th. The facility does not have documentation to show R4's indwelling urinary catheter was changed monthly as documented in V19's (Physician) progress notes. On February 20, 2025 at 10:43 Am, V19 (Physician) said R4 has had multiple UTIs, and it was his expectation that R4's indwelling urinary catheter be changed monthly. V19 continued to say he discussed changing the indwelling urinary catheter monthly with the nursing staff. The facility's policy entitled Equipment Replacement - Disposable - Nursing revised on 1-16-18 shows: Purpose: Equipment will be changed following established schedules to prevent contamination. a. [Indwelling urinary catheter] bags are changed only if they become cloudy, leak, or have an odor. b. [Indwelling urinary catheters] are changed only for system breakdown and prn (as needed) unless physician's order specifies otherwise . The facility's policy entitled Urinary Catheter Care revised on 2-14-19 shows: 10. Urinary catheter and tubing may be removed and reinserted when any of the following are observed: a. Inability to observe urine contents in the urinary drainage bag or tubing. b. Observation of gross contamination. c. Obstruction of the catheter or tubing. d. Upon physician's orders.17. The date of the catheter insertion shall be documented in the nurse's notes and Treatment Record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145458 If continuation sheet Page 7 of 7