Inspection·September 14, 2025

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 interview and record review, the facility failed to ensure a resident positive with Covid-19 was quarantined for 10 days prior to cohorting with a non-positive Covid-19 resident to prevent the spread of Covid-19 virus. This failure affected 2 (R2 and R4) residents reviewed for infection control in the total sample of 4 residents. Findings include: R2's admission Record documented that R2's diagnoses (include but not limited to) attention-deficit hyperactivity disorder, generalized anxiety disorder, and secondary hypertensionR2's census list documented that R2 was in the current room since 02/23/2023. R4's admission Record documented that R4's diagnoses (include but not limited to) covid-19, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and vascular dementia. R4's census list documented that R4 was initially admitted on [DATE] and was moved to R2's room on 08/31/2025. R4's (08/27/2025) Hospital Record documented, in part Collection Time: 08/22/2025 COVID/FLU/RSV (respiratory syncytial virus) panel. Result SARS-COV-2 by PCR (polymerase chain reaction). Value: Detected. Ref(erence) Range: Not detected. R4's (08/28/2025) care plan documented, in part is on strict Droplet/CONTACT PRECAUTIONS related to covid 19. Infection will be resolved or controlled. Maintain contact isolation precaution in accordance with Centers for Disease Control (CDC) guidelines. On 09/12/2025 at 4:03pm, V2 (Assistant Director of Nursing/ADON) stated the facility has to isolate the resident for 10 days from the day the resident tested positive with Covid-19. If the resident tested positive on 08/22/2025, she (R4) should be out of the isolation on 09/01/2025. The purpose of quarantining a resident for 10 days is to control the spread of infection. The Covid positive resident should not be cohorted with a resident who is not Covid 19 positive if not yet quarantined for 10 days. Technically, the facility would want to isolate a resident if they have covid to prevent the spread of covid 19. V2 stated he will not cohort the resident who is not covid positive with a resident who tested positive with Covid-19 because the resident who is not positive can get it.On 09/12/2025 at 4:25pm, V22 (Infection Preventionist/Licensed Practical Nurse) stated the expectation is to quarantine a covid positive resident for 10 days; from the day the resident tested positive. If a resident tested positive on 8/22/2025, the resident should be on quarantine from 8/22 to 8/31 then on 9/1/25, the resident can cohort with another resident. She should not be moved to another room on 8/31 because she (R4) has not completed the quarantine days yet. She can cohort with another resident on 9/1/2025. On 09/12/2025 at 4:52pm, V8 (Assistant Administrator) stated he miscalculated the count and thought that on the 10th day of isolation she (R4) could come off isolation.The (07/16/2025) Preventing and Controlling Acute Respiratory Illness Outbreaks in Skilled Nursing Facilities and Other Facilities Providing Skilled Care documented, in part This guidance replaces previous COVID-19 disease-specific guidance. It is based on the CDC's guidance for the control of respiratory illnesses, including COVID-19, influenza, and other respiratory illnesses, in health care settings. Recommended Precautions for Common Respiratory Viruses. RESPIRATORY VIRUS: COVID-19. TYPE OF PRECAUTION: Contact precautions, N95, and eye Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145670 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 145670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chalet Living & Rehab 7350 North Sheridan Road 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)