Inspection·October 11, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few related to limited mobility. When transferring or changing R1, there should be two staff because R1 was not able to move her body to reposition herself or assist staff with turning herself or repositioning. V2 stated V9 should not have been cleaning R1 by herself because R1 was a two person assist resident, and maybe turning and repositioning R1 alone could have contributed to R1 falling and swelling (hematoma) on the forehead. V2 stated R1 was sent to the local hospital. Later that day, V8 (Licensed Practical Nurse-LPN) called the local hospital and was informed R1 was admitted with diagnosis of right femur fracture. V2 stated the facility staff are supposed to follow residents care plans and keep the residents safe and prevent falls.V9 was in-serviced about repositioning R1 in the middle of the bed after R1 fell. On 10/10/2024, at 1:28 PM, V10 (Advanced Nurse Practitioner) said R1 was a new patient for her and had just started providing services to R1 and V10 further stated that the morning of 7/15/2024 when R1 fell, V10 had just seen R1 for a cough, and V10 had observed R1 in bed awake with no bruises or swellings.V10 stated she was still in the building when she received a call that R1 had fallen. V10 stated she went back to R1's room and found R1 on the floor on the right side of the bed. R1 had a large hematoma on her forehead and a small amount of blood was observed on her gums. V10 stated the large hematoma was secondary to the fall because V10 had just seen R1 that morning and R1 did not have a hematoma. V10 said after she assessed R1, she gave orders to V8 (LPN) to call 911 to transport R1 to the local hospital for further evaluation and later found out R1 was admitted to the hospital with a femur fracture on the right leg, and R1 was also on blood thinners. V10 stated R1 had left side hemiparesis (paralysis) due to a stroke. She had never seen R1 get out of bed by herself or turn or reposition herself in bed. But V10 has seen R1 eat things like popcorn by herself using the right hand. R1 might have slid out of bed if she was not positioned properly. V10 stated R1 did not complain she was in pain before the ambulance got to the facility, but R1 might have been in shock due to the fall. She was also on scheduled gabapentin 100mg (milligrams) three times a day. V10 stated she hopes staff monitor residents, so they do not fall to prevent any resident injuries. R1 should have been monitored to prevent falls. On 10/09/2024 at 12:25PM, V6 (Director of Rehabilitation) stated R1 was referred to therapy on 05/18/2023, for Physical Therapy/ Occupation Therapy (PT/OT) related decline in strengthen and balance, positioning and safety while seated in wheelchair. V6 stated R1's bed/wheelchair mobility evaluation/assessment was done on May 18th, 2023. The evaluation determined R1 was dependent on bed/wheelchair mobility, meaning she needed 100% assistance with bed/wheelchair mobility, and staff have to do all the work. V6 said R1's PT ended on June 14th, 2024. R1 did not show any improvement and continued to be dependent on 05/18/2024. R1 was working on bed/wheelchair mobility, but R1 was not able to turn or reposition herself and remained dependent on staff for bed/wheelchair mobility. Therefore, R1 was discharged from therapy. V6 stated for dependent residents, when positioned by staff, the resident will remain the same until repositioned again because the resident cannot move her/himself. Therefore, staff have to move the resident. V6 stated he was familiar with R1 and she could not move or reposition herself independently in bed or in wheelchair. On 10/10/2024, at 12:56PM, V7 (Restorative Director) stated the Fall Risk Assessment shows which resident is at a high risk for falls and stated R1's fall risk assessment on 07/17/2024, two days after the fall. V7 stated the fall risk assessment is supposed to be completed on the day of the resident fall. V7 stated R1's initial fall risk assessment was completed on 12/28/2023, and R1's score was 10. V7 said a score of 10 indicates the risk for falls is high and fall precautions are put in place such as the blue star program where a blue star is put on the door of the at fall risk resident to let staff know the resident is at a high risk for fall. V7 stated R1 was a blue star resident. Her bed should have been in low position. R1 was not ambulatory, was a two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145867 If continuation sheet Page 2 of 4 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 145867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Rehab at Fairmont 5061 North Pulaski Road Chicago, IL 60630 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 - Actual harm Residents Affected - Few person assist with toileting, needed the mechanical lift from bed to wheelchair and vice versa. V7 stated R1 was on a high back wheelchair, meaning the wheelchair could be reclined at a slight angle. V7 stated R1 was on the restorative program and was receiving Passive Range of Motion for left upper and left lower extremity because R1 has left side weakness and had a splint on her left ankle and left hand. V7 said R1 was receiving active range of motion for her right upper and lower extremities. V7 stated R1 could not roll from left to right or right to left by herself unless assisted by two staff. V7 stated R1 was dependent moving from chair to bed, putting on upper/lower body dressing, laying to sitting on the side of the bed, to shower, sit to laying, and toilet hygiene. V7 stated dependent means the staff do all the work. V7 stated a dependent resident like R1 cannot fall out of bed if positioned properly because R1 would need staff to do the movement for her. V7 stated R1's Resident Functional Ability was conducted on 6/11/2024, and documents R1's detailed summary of R1's abilities as: Eating-setup or cleanup assistance, oral hygiene, R1 needs supervision/touching, for toilet hygiene, shower/bathing self, upper/upper body dressing, putting on/taking off footwear-dependent, roll left/right-dependent, sit to laying, laying to seating on edge of bed, Chair/bed to chair transfer, toilet transfer, R1 is dependent. Car transfer, walk 10 feet, walk 50 feet, walk 150 feet- was not applicable. Wheelchair wheeling dependent. Sit to stand was not attempted due to medical condition or safety concerns. R1's Facility Reported Incident Report sent to Illinois Department of Public Health on 07/15/2024 documents: - On 7/15/24 at 11:00 AM, R1 was observed lying on the floor beside her bed. R1 sustained a bumped to the forehead and a skin tear to the mouth, R1 sent to the local hospital. At around 7:38 PM, follow up made to the hospital and informed that R1 was admitted with a diagnosis of right femur fracture. R1's progress notes document: 7/15/2024, 2:05 PM-Fall Description: R1 had an un-witnessed fall 07/15/2024 11:00 AM Location of Fall: At bedside. R1 was noted face down on the floor between the bed and the wall by the window, responsive to verbal stimuli. 7/15/2024, 7:38 PM-R1 was admitted to local hospital with diagnosis of Right femur Fracture. 7/17/2024 11:10 AM-V9 (certified Nursing Assistant-CNA) was in-serviced on positioning resident in the center of the bed and with proper level of assistance. R1's care plan dated: 03/26/2024 documents: -R1 has Potential for falls related to: decreased mobility, incontinence, weakness, -Goals- R1 will have no significant injuries related to falls thru next review date, will have no falls thru next review date. -Interventions: Assess for fall risk per facility, assess for toileting, half rails to assist with transfers, keep bed in locked position, keep frequently used items in reach, Non-skid footwear when up. Fall policy titled Fall Prevention Program dated 11/21/17 documents: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145867 If continuation sheet Page 3 of 4 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 145867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Rehab at Fairmont 5061 North Pulaski Road Chicago, IL 60630 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 -The bed will be maintained in position appropriate for resident transfers. Level of Harm - Actual harm -The bed locks will be checked to assure they are in locked position at all times Residents Affected - Few -The resident's personal possessions will be maintained within reach when possible. -Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care. -Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. -the resident will be reminded as needed to call for assistance before attempting to ambulate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145867 If continuation sheet Page 4 of 4