Health inspection·August 30, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow a physician's order for the use of a brace to treat a fractured wrist for 1 of 29 residents (R16) reviewed for physician orders in the sample of 29. Residents Affected - Few The findings include. R16's face sheet showed R16 had a closed displaced transverse fracture of the right radius and dementia. R16's Progress Note dated 8/17/23 showed R16 was seen by a hand surgeon for a fractured right wrist. The note indicated the fracture was going to be treated non-operatively with a brace. R16's Doctor Note dated 8/14/23 showed R16 had a distal radius fracture. R16 was to wear a brace at night and during the day for the fracture. The brace was to be removed for hygiene purpose and to work on gentle range of motion. R16's Order Summary Report showed an order for the brace to be on night and day. The brace could be removed for hygiene purpose and to work on gentle range of motion. On 8/28/23 at 10:00 AM, R16 was in her room sitting on the edge of her bed. R16 did not have the brace on her wrist. The brace was sitting on R16's bedside table. At 11:01 AM and 11:33 AM, the brace was not on R16's wrist. R16 was not receiving hygiene or range of motion at those times. On 08/30/23 at 09:18 AM, R16 was sitting at the edge of her bed holding a pillow with her right hand. The brace was not on R16's wrist and R16 was not receiving hygiene or range of motion. The brace was sitting on R16's wheeled walker. On 08/29/23 at 01:01 PM, V7 (Licensed Practical Nurse) said he was familiar with R16 and R16 did not refuse to wear the brace. V7 said R16 needed staff assistance to put the brace on. According to V7, sometimes when he started his shift V7 would not have the brace on. V7 said physician orders, such as the order for R16's brace, should be followed and if they can not be followed the doctor should be informed to adjust the treatment/orders. R16's Medication Administration Record from August 1-30 did not indicate R16 refused to wear the brace. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145582 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 145582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565 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 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 R30 was provided with fingernail care for 1 of 29 residents (R30) reviewed for Activity's of Daily Living in the sample of 29. Residents Affected - Few The findings include: On 08/28/23 at 1:57 PM, R30's fingernails on the right and left hand extended past the tips of his fingers. There was a dark substance under R30's nails. On 08/28/23 at 1:57PM, R30 said, I do not recall having my fingernails cut at the facility. I have made requests.multiple requests to have my fingernails trimmed. As a [NAME] Belt in Judo, I have always maintained good grooming practices that include keeping my nails trimmed short. No one in the facility has ever assisted me in trimming my fingernails. On 08/29/23 at 1:06 PM, V10 CNA-Certified Nursing Assistant said, nail care is provided as needed. R30 is alert. He can tell us when his nails need to be trimmed. R30's Minimum Data Set, dated [DATE] shows, Personal Hygiene: Extensive assistance. R30's electronic medical record on 08/28/23 shows, diagnosis of type two diabetes mellitus with hyperglycemia. The facility's Care of Nails policy dated 09/2020 shows, fingernails of diabetic residents are to be cut by the nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145582 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 145582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565 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 - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to implement R52's pressure reduction interventions for 1 of 5 residents (R52) reviewed for pressure ulcer prevention in the sample of 29. Residents Affected - Few The findings include: On 08/29/23 at 10:40 AM, R52's right and left posterior heels were resting on the foam filled mattress. On 08/29/23 at 1:09 PM, V10 CNA-Certified Nursing Assistant said, R52 should have heels elevated, he spends most of his time in bed. On 08/29/23 at 1:18 PM, V12 Wound Care Nurse said, R52 is a high risk for pressure ulcer development. Heel elevation is to prevent pressure ulcer development. Elevating the heels off the bed helps to off load pressure. R52 does not have independent mobility in bed. R52's Pressure Ulcer Risk Scale dated 08/03/23 shows, high risk for pressure injury. R52's current Care Plan on 08/29/23 shows, R52 has potential for alteration in skin integrity. Goal: R52's Skin will remain intact through next review. Interventions: Elevate heels off bed. The facility's Prevention and Treatment of Pressure Injury and Other Skin Alterations policy dated 03/02/21 shows, implement preventative measures and appropriate treatment modalities for Pressure Injuries and/or other skin alterations through individualized Resident Care Plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145582 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 145582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565 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. Based on observation, interview, and record review the facility failed to ensure a medication was safely disposed of to prevent a resident from accessing the disposed medication. This applies to 1 of 29 residents (R118) reviewed for safety in the sample of 29. The findings include: R118's face sheet showed R118 had the diagnoses of restlessness, delusional disorders, dementia, and Alzheimer's. On 08/28/23 at 09:52 AM, R118 was in bed. Sitting on R118's bedside table was a cup of water. The cup was filled 1/3 of the way with water. Submerged in the water was a pill. The pill was red, transparent, and oval shaped. No staff were present in R118's room. R118 said she did not know what the pill was, where it came from, or if the pill was for her. On 08/28/23 at 10:14 AM, V6 (Licensed Practical Nurse- LPN) said R118 was not assessed to self administer medications. V6 said the cup and pill were disposed of in the garbage can in R118's room. According to V6, R118 removed the cup with the pill from the garbage can. V6 said R118 has a history of taking things out of the garbage. V6 said the medications should not have been disposed of in the garbage can of R118's room because of R118's history of taking things out of the garbage can. R118's progress note written by V6 dated 8/28/23 at 9:00 AM, showed there was a cup of water in R118's garbage can and R118, dug in the trash. removing the cup of water and a docusate sodium pill. R118's Order Summary Report showed R118 had an order for docusate sodium. R118's Medication Administration Record showed R118 received her docusate sodium on 8/28/23 at 9:00 AM. R118's care plan showed R118 has impaired cognition, low level of function, paces on the unit, wanders on the unit, explores the environment, goes into peers rooms, rummages and takes items thinking they are hers, and engages in, bizarre and odd behaviors. The care plan also indicated R118 will remain safe and under supervision. On 08/29/23 at 1:44 PM, V2 (Director of Nursing) said medications should be disposed of safely by placing the medication in the sharps containers. V2 said by disposing of the medication in the sharps container it ensures the medication is not reachable by residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145582 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 145582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 a resident with chronic pain was provided ordered pain medication. This applies to 1 of 29 (R110) reviewed for pain in the sample of 29. Residents Affected - Few The findings include: On 8/28/2023 at 12:38AM, R110 said she has generalized abdominal and stoma pain rating her pain 8 out of 10. R110 said she hasn't had her Dilaudid (Hydromorphone) pain medication for a few days. R110 said she has been receiving Tylenol but it does not work as well Dilaudid. R110 said she is upset about not having her Dilaudid. On 8/29/2023 at 1:20PM, V4 Licensed Practical Nurse (LPN) said R110 has an order for Dilaudid. V4 said the Dilaudid is not currently in stock. V4 said R110 last received Dilaudid on 8/22/2023. On 8/30/2023 at 9:40AM, R110 said she still had not received her Dilaudid for pain control. On 8/30/2023 at 10:58AM, V4 said R110 received Tylenol for pain this morning. V4 said R110's Dilaudid had not shown up to the facility from the pharmacy. V4 said R110 was asking if her Dilaudid had arrived. V4 said R110 rated her pain level at a 5 out of 10. V4 said Dilaudid is a stronger pain medication than Tylenol. On 8/29/2023 at 1:49PM, V2 Director of Nursing (DON) said pain medication should be available if the resident has an order for pain medication. V2 said the resident may be in more pain without their ordered pain medication. R110's MDS dated [DATE] section C shows R110 as cognitively intact. R110's Medication Administration Record (MAR) dated 8/1/2023 - 8/31/2023 shows an order for Hydromorphone HCL (Dilaudid) oral tablet 2mg by mouth every 4 hours as needed for pain related to chronic pain, ordered on 6/1/2023. R110s MAR shows receiving a dose of Dilaudid 2mg on 8/22/2023 and no additional doses of Dilaudid we administered as of 8/29/2023. R110's MAR shows she received Dilaudid for pain control 20 days out 22 days from 8/1/2023 - 8/22/2023. The facility's Pain Management Evaluation policy dated September 2020 shows, our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. Chronic pain or persistent pain refers to a pain state that continues for a prolonged period of time or recurs more than intermittently for months or years. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145582 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 145582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviewed the facility failed to ensure a resident's pain medication was available. This applies to 1 of 29 (R110) reviewed for pharmacy services in the sample of 29. The findings include: On 8/28/2023 at 12:38AM, R110 said she has generalized abdominal and stoma pain rating her pain 8 out of 10. R110 said she hasn't had her Dilaudid (Hydromorphone) pain medication for a few days. R110 said the facility has issues with ordering her pain medication on time and she has gone without her ordered pain medication. R110 said she has been receiving Tylenol but it does not work as well Dilaudid. R110 said she is upset about not having her Dilaudid. On 8/30/2023 at 9:40AM, R110 said she still had not received her Dilaudid for pain control. R110 said she was told by facility staff pain medication would be available yesterday. R110 said the facility keeps blaming the pharmacy for the error. On 8/29/2023 at 1:49PM, V2 Director of Nursing (DON) said pain medication should be available if the resident has an order for pain medication. V2 said the resident may be in more pain without their ordered pain medication. V2 said if a resident is running out of medications the doctor should be notified and the reorder prescription should be faxed to the pharmacy outside of the facility. V2 said the prescription should be delivered to the facility from the pharmacy within approximately 24 hours. On 8/30/2023 at 10:39AM, V8 Nurse Consultant said R110's Dilaudid refill request was sent on 8/20/2023 to the pharmacy but was not filled. V8 said the pharmacy was contacted on 8/23/2023 and another fax was sent regarding the prescription. V8 said the pharmacy was contacted an additional time on 8/28/2023 and another fax was sent to the pharmacy to refill the order. V8 said the pharmacy did not submit the refill request to the insurance company and that's why it wasn't filled. V8 said Dilaudid was available in the facility's controlled substance box but facility staff were unable to access the box. V8 said they were unable to access the box because the pharmacy wouldn't release the code to unlock it due to the fact the prescription wasn't a new order. R110's MDS dated [DATE] section C shows R110 as cognitively intact. R110's Medication Administration Record (MAR) dated 8/1/2023 - 8/31/2023 shows an order for Hydromorphone HCL (Dilaudid) oral tablet 2mg by mouth every 4 hours as needed for pain related to chronic pain, ordered on 6/1/2023. R110s MAR shows receiving a dose of Dilaudid 2mg on 8/22/2023 and no additional doses of Dilaudid we administered as of 8/29/2023. R110's MAR shows she received Dilaudid for pain control 20 days out 22 days from 8/1/2023 - 8/22/2023. R110's Order Audit Report dated 8/30/2023 shows a reorder of Hydromorphone HCL Oral Tab 2mg on 8/20/2023. R110's Pharmacy Requisition shows a fax date of 8/23/2023 and 8/28/2023. The facility's Reordering Medication policy dated March 2021 shows, medications are reordered in advance so as not to have lapses in therapy. The nursing staff is responsible for reordering medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145582 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 145582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to ensure residents on a pureed diet were served a full serving of pureed pork and a dinner roll at the noon meal. The facility also failed to ensure residents were served the full serving of vegetables. This applies to 7 of 29 residents (R35, R43, R79, R133, R85, R99 & R22) reviewed for following menus in the sample of 29. The findings include: The facility's Spring/Summer Regular Menu 2023 for Monday August 28, 2023 shows, marinated pork loin, mashed potatoes, zucchini & tomatoes, dinner roll or bread, margarine, pineapple tidbits, beverage of choice. 1. On August 28, 2023 at the noon meal, V14 Dietary Aide and V13 Food Service Director (FSD) were serving the residents the noon meal on the second floor. They served the puree pork using a beige # 10 scoop size (3 ounces). The puree residents (R35, R43, R79 & R133) did not receive a roll or any type of bread. They only received pureed pork, pureed vegetable, mashed potatoes and pureed soup. The facility's resident's with a pureed diet texture list provided on August 30, 2023 shows, R35, R43, R79 & R133 have a pureed diet. The facility's spreadsheet for the noon meal on August 28, 2023 shows, .Pureed: Marinated Pork Loin- #8 scoop (4 ounces), Dinner roll or bread- #20 scoop . On August 29, 2023 at 9:05 AM, V16 Executive Chef stated, she forgot to puree the dinner roll or bread. On August 29, 2023 at 9:07 AM, V13 FSD confirmed the #10 scoop was used giving the residents only 3 ounces of pork instead of using the # 8 scoop that would have been 4 ounces of pork. 2. On August 29, 2023, V14 Dietary Aide was serving the noon meal. She was not filling the ladle full of zucchini & tomatoes. She only filled it half full. Towards the end of the meal service she was running out of zucchini & tomatoes. V13 FSD brought her more zucchini & tomatoes but she still only filled the ladle half full. She did not have any more zucchini & tomatoes by the end of the meal service. The facility's spreadsheet for the noon meal on August 28, 2023 shows, Regular/NAS (No Added Salt)Zucchini & Tomatoes- 1/2 cup . On August 28, 2023 at 10:32 AM, R22 stated, he doesn't get that much food. On August 28, 2023 at 10:43 AM, R99 stated, meal portions are smaller. On August 28, 2023 at 10:58 AM, R85 stated, the portions sizes are small. If he asks for seconds they don't usually have more for extras. The facility's Menu policy dated March 2018 shows, Policy: Menus will be planned in advance. Purpose: To incorporate resident food preferences while maintaining regulatory compliance. Procedure: 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145582 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 145582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565 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 0803 Menus will include portion sizes. 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: 145582 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 145582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents understood the arbitration agreement. This applies to 2 of 3 residents (R22 and R134) reviewed for arbitration agreements in the sample of 29. Residents Affected - Few The findings include: 1. R22's face sheet shows, he was admitted to the facility on [DATE]. R22's Minimum Data Set, dated [DATE] shows, he is cognitively intact. R22's Arbitration Agreement dated April 18, 2023 shows, R22 signed the document as well as V15 Admissions Director. On August 30, 2023 at 11:06 AM, R22 stated, he didn't remember signing the arbitration agreement. He didn't remember them going over what it was. He didn't even know what it was. He stated, if they had gone over it with him, he would have not signed it. 2. R134's face sheet shows, he was admitted to the facility on [DATE]. R134's Minimum Data Set, dated [DATE] shows, he is cognitively intact. R134's Arbitration Agreement dated May 9, 2023 shows, R134 signed the document as well as V15 Admissions Director. On August 30, 2023 at 12:34 PM, R134 stated, he didn't remember signing the arbitration agreement. He stated, he was out of it when he first got to the facility. He didn't know what the agreement was and would not sign it now. On August 30, 2023 at 9:05 AM, V15 Admission's Director stated, she goes over the information with the residents when they first come to the facility. They should know what they are signing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145582 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 145582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were offered the pneumococcal vaccine. This applies to 3 of 5 residents (R66, R35, R392) reviewed for immunizations in the sample of 29. Residents Affected - Few The findings include: 1. R66's face sheet shows, she was admitted to the facility on [DATE] and she is [AGE] years old. R66's immunization report shows, she received a pneumovax on September 25, 2020. The report does not show which pneumovax she received just that she received one. The same report also shows, Prevnar 13 as not eligible and Prevnar 23 (hx (history)) with a date of October 2, 2019. 2. R35's face sheet shows, she was admitted to the facility on [DATE] and she is [AGE] years old. R35's face sheet lists her diagnoses to include: chronic kidney disease and type II diabetes mellitus. R35's immunization report shows, Pneumovax 23 (hx) with October 23, 2013 and June 21, 2018 dates. There is no other documentation of another pneumococcal vaccine given. 3. R392's face sheet shows, he was originally admitted to the facility on [DATE] and he is [AGE] years old. R392's immunization record shows, Prevnar 13 was given on September 24, 2020. There is no other documentation of another pneumococcal vaccine given. On August 29, 2023 at 1:26 PM, V17 Infection Control Nurse stated, pneumococcal vaccines are offered on admission. They offer both vaccines or whatever is needed. On August 30, 2023 at 1:12 PM, V8 Nurse Consultant stated, R66, R35 & R392 were all due for another pneumococcal vaccine. They were just not offered one. The facility's Pneumococcal vaccine program dated September 2021 shows, Policy: It is the policy of this facility that residents will be offered immunization against pneumococcal disease. Pneumococcal disease is a serious illness that can cause sickness and even death. The CDC (Centers for Disease Control) estimated pneumococcal illness occurred in 13,500 cases in 2013 among adults age [AGE] years and older. According to the CDC, the highest mortality rate due to pneumococcal meningitis and bactermia occurs among the elderly who have underlying medical conditions. The mortality rate among the elderly may be as high as 61%. Purpose: To reduce the incidence of pneumococcal disease and the morbidity and mortality attributed to this infection. Procedure: Vaccine Guidelines: 1. The pneumococcal vaccine program as recommended by the CDC varies for patients by age group. 2. There are two pneumococcal vaccines available for use in the United States; 13 valent pneumococcal conjugate vaccine (PCV13) and 23- valant pneumococcal polysaccharide vaccine (PPSV23). 3. The Advisory Committee on Immunization Practices (ACIP) for the CDC recommends that the two vaccines be given in a series to immunocompetent adults greater than and equal to [AGE] years of age. 4. The ACIP recommends that immunocompetent adults aged greater than or equal to 65 years who have not received pneumococcal vaccine receive a dose of PVC13 followed after at least one year by PPSV23. The two vaccines should not be given together . 8. People less than [AGE] years old with chronic liver disease, chronic cardiovascular (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145582 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 145582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565 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 0883 Level of Harm - Minimal harm or potential for actual harm disease, chronic obstructive pulmonary disease, diabetes, candidates for cochlear implants, cerebrospinal fluid leak, functional or anatomic asplenia, immunocompromising conditions, solid organ transplant recipients and chronic renal failure or nephrotic syndrome should also receive PPSV23 and one dose of PCV13 vaccine . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145582 If continuation sheet Page 12 of 12