Health inspection·December 19, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm The (Rev. 225; Issued: 08-08-24) State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities documented, in part 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145479 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 145479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Health Care Center 1425 West Estes Avenue Chicago, IL 60626 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure an allegation of sexual assault was thoroughly investigated. This failure affected 1 (R2) resident reviewed for abuse in the total sample of 6 residents. Residents Affected - Few Findings include: R2's (12/06/2024) Preliminary 24-hour Incident Investigation Report documented, in part Date, Time, Location and Circumstance of Alleged incident. On 12/06/2024 at approximately 3:30pm, R2 alleged that she was sexually assaulted on 09/25/2024 by an unidentified male staff member. On 12/16/2024 at 12:58pm, R2 stated I was sleeping, I don't remember the time. I know it was 3rd shift early morning of 9/25/24. 3rd shift starts at 11PM. The (09/24/2024 and 9/25/2024) daily staffing forms indicated that V17 (Certified Nursing Assistant) worked on second floor on 3rd shift. The (09/24/2024) Unit 2, Shift 11-7 Certified Nursing Assistant Assignment sheet documented that V17 was assigned to R2. V17's (pay period 12/082024-12/21/2024) Time report indicated that V17 worked on 12/09, 12/10, 12/11, 12/14, 12/16. The (12/11/2024) R2's Investigation packet did not include V17's witness statement. On 12/17/2024 at 4:27pm, V17 stated I never heard of R2's allegation. This is my first time hearing about it. No one reached out to me and informed me that I need to write a witness statement. On 12/17/2024 at 3:28pm, V4 (QA nurse/RN) stated we looked thru the schedule to check who worked on those days 11pm -7am shift on 9/24 and early morning of 9/25. When I spoke with her (R2), she said it was early morning of 9/25. So, we checked the daily schedule on 9/24. (V1 -Administrator) agreed to go back a day, on the 2 days schedule 9/24 and 9/25. This surveyor handed the daily schedule forms from 9/24 - 9/26 to V4. V4 stated I did not directly interview the staff. I helped identify who worked on 09/24 - 9/25. On 12/18/2024 at 12:21pm, V1 (Administrator/Abuse Coordinator) stated the investigation starts by interviewing the resident who made the allegation and try to get as much information as I can. We start to interview staff and other residents that may have knowledge about the abuse allegation. For the residents, we interview the roommate, and the residents on either side of the room, rooms adjacent to the left and the right. With the staff, we interview the one who was assigned to the resident on the alleged date of abuse and additional staff that may have heard or have knowledge about the abuse allegation. If the perpetrator is unknown, we checked the daily schedules: the schedules prior to, during, and after the date of allegation because the staff may have knowledge about the allegation. For this sexual assault allegation, all were interviewed except for one staff. I was told he (V17) was on vacation. It is expected of the DON or ADON or QA nurse to reach to the staff if possible to determine whether the staff may have heard or seen something. Once the staff comes back to work after the vacation, the expectation is to get his statement prior to returning to work. Because we need to interview anyone that may have had knowledge of the allegation. We don't know who the perpetrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145479 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 145479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Health Care Center 1425 West Estes Avenue Chicago, IL 60626 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was and anyone of them may have had knowledge about this alleged sexual assault. This surveyor inquired if the investigation was thoroughly done knowing that one staff was not interviewed. V1 stated No. in the sense that I did not take the opportunity to interview this gentleman. The (undated) Abuse Prevention Program documented, in part Policy: This facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse of its residents. The purpose of this facility is to assure that the facility is doing all that is within its control to prevent occurrence of abuse. This will be done by: implementing systems to investigate all reports and allegations promptly and aggressively. Filing accurate and timely investigate reports. Definitions: Sexual Abuse includes sexual assault. The (11/2013) Abuse Prevention Program Facility Procedures documented, in part VII. Internal Investigation. 2. Any incident or allegation involving abuse will result in an investigation. 4. Investigation Procedures. The appointed investigator will, at a minimum, attempt to interview anyone likely to have direct knowledge of the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145479 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 145479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Health Care Center 1425 West Estes Avenue Chicago, IL 60626 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 Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F689 Based on interview and record review, the facility failed to uodate a plan of care and provide assistance to one resident (R1) who required supervision assistance when ambulating. This failure affected one resident (R1) in a total sample of three residents reviewed for falls. Findings include: R1's diagnoses include but are not limited to type 2 diabetes, chronic obstructive pulmonary disease, schizoaffective disorder, essential hypertension, history of falling, bilateral primary osteoarthritis of knee. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, which indicates R1's cognition is intact. R1's MDS dated [DATE] section for functional abilities and goals documents in part, GG0115. Functional Limitation in Range of Motion .B. Lower extremity (hip, knee, ankle, foot) 2 .Impairment on both sides .GG0170. Mobility .I. Walk 10 feet: Once standing the ability to walk at least 10 feet in a room, corridor, or similar space .05. Set up or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. R1's care plan titled Falls dated 03/11/22 and updated 04/12/22 and 11/05/24 documents in part, At risk for falls related to incidence of use of psychotropic medication or new medication that may cause dizziness .Resident will be free of falls .Resident will be free of injury. R1's care plan titled Toileting Assistance dated 11/05/21 documents in part, Resident requires supervision in toileting hygiene and transfer .Resident will be able to maintain toilet hygiene with staff assistance .Provide degree of assistance to toilet resident as needed. R1's 3 Day Functional Abilities Evaluation dated 09/16/24 documents in part, 130. Self-Care .170. Mobility .F1 Toilet transfer: The ability to get on and off a toilet or commode .03. Partial/Moderate Assist. R1's progress note dated 11/05/24 by V8 (Licensed Practical Nurse/LPN) documents in part, At 5:00am during rounds resident was observed on the floor in his bathroom. Physical assessment completed noted laceration to the back of the head with minimal bleeding .Upon interview resident stated, I lost balance when going to the bathroom and fell hitting my head. R1's hospital after visit summary dated 11/05/24 documents in part, Reason for visit: Trauma .Diagnoses: Fall, Laceration of scalp without foreign body. On 12/17/24 at 12:38pm V8 (LPN) stated that she was making rounds around 5am and found R1 laying on the bathroom floor. V8 stated that she assisted R1 back to bed and noticed a gash on R1's head. V8 stated that she called 911 to have R1 sent to the hospital. V8 stated that rounds should be made at least every two hours on fall risk residents and that toileting should be offered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145479 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 145479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Health Care Center 1425 West Estes Avenue Chicago, IL 60626 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 Residents Affected - Few On 12/18/24 at 11:15am V15 (Certified Nursing Assistant/CNA) stated that he is not aware if R1 is a fall risk or not. V15 stated that management tells them who is a fall risk and also there is a list of residents at risk for falls at the nurse's station. V15 stated that he did not witness R1 fall and was called to R1's room by V8 (LPN) and informed of R1's fall. V15 stated that extra rounds are made on residents at risk for falls. On 12/16/24 at 12:30pm, surveyor observed an undated form at the nurse's station titled List of residents (Risk for Falls). R1 is not included on the fall risk form. On 12/18/24 at 11:41am V2 (Director of Nursing/DON) stated that the facility's risk for falls list is updated quarterly or when a resident has a fall. V2 stated she is unaware of who is responsible for updating the risk for falls list. V2 stated that R1 should be listed on the risk for falls list. V2 stated that she was not aware of the physical therapy recommendations for R1. On 12/16/24 at 12:25pm V5 (LPN) stated that she is unsure if R1 is a fall risk. V5 stated that R1 does have intermittent confusion. On 12/16/24 at 12:52pm V7 (CNA) stated that he doesn't know if R1 is a fall risk. V7 stated that he doesn't know if R1 has had a recent fall. V7 stated that there is a list of fall risk residents at the nurse's station. On 12/17/24 at 2:50pm V13 (Physical Therapy Director) stated that R1 has had physical therapy several times during his admission to the facility because he is a fall risk. V13 stated that R1 has a gait/balance impairment. V13 stated that R1 needs a staff member with him when R1 is toileting. V13 stated that the therapy department verbally informs the restorative coordinator of the recommendations for the residents, and they also document in the electronic medical records. V13 stated that the restorative coordinator informs the nursing staff about the resident's physical therapy recommendations. On 12/18/24 at 2:06pm V20 (Restorative Coordinator) stated that R1's functional level was changed from independent to supervision in August 2024. V20 stated that she was on vacation when R1's functional level changed, and no one had informed her of the change when she returned to work. V20 stated that she was informed on 12/18/24 of R1's August 2024 functional level change. Facility's policy dated 11/2024 titled Falls and Fall Prevention documents in part, Policy: 2. To ensure a fall prevention program will include measures which will determine the individual need of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices as indicated based on assessment .Procedure: 6. Resident will be assisted to the toilet, bathe and shower, and will be supervised .10. Nursing staff will be informed of residents who are at risk of falling .12. Residents will be reminded as needed to call for assistance before attempting to ambulate .13. The frequency of safety monitoring will be determined by the resident's risk factors and care plan. Facility's job description titled Nurse (RN, LPN) documents in part, Resident Care Functions: 1. Review care plans monthly, and as needed should a significant change occur, to ensure that appropriate care is being rendered .4. Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs. 5. Ensure that your assigned CNAs are aware of and use the resident care plans in administering care to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145479 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 145479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Health Care Center 1425 West Estes Avenue Chicago, IL 60626 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 Facility's job description titled Certified Nursing Assistant documents in part, Care plan functions: 1. Review care plans weekly and when changes occur to determine if changes in the resident's daily care routine have been made on the care plan. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145479 If continuation sheet Page 7 of 7