Inspection·February 20, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/18/25 at 1:02pm, V6 (LPN/Licensed Practical Nurse) stated I (V6) don't know about urinating but he (R2) pretty much defecates on the floor and on his bed. I spoke to him myself, he got angry about it. I said the bathroom is right here, you (R2) can go to the bathroom you can use it. You have 2 roommates over here, why don't you go to the bathroom? He just said I don't want you to tell me anything. Surveyor inquired what was on R2's mattress V6 responded Actually, this looks like a pad with mess on it. R3 replied He puts it on the floor and then puts it on the bed. V6 affirmed If he (R2) puts it on the floor, it's a mat. Surveyor inquired about the dried brown substance on R2's mattress and floor mat V6 stated I don't know what it is, but it looks like dried poop, disgusting. It's disrespectful for somebody to be pooping like this, it's different when you poop in a diaper. Surveyor inquired what was beneath R2's bed V6 responded That looks like 2 bed pans and 4 urinals to be exact. Why are they (staff) giving him 4 urinals? V6 proceeded to move R2's bed and affirmed Oh sorry, it's not 4 it's 6 urinals. Surveyor inquired if R2's urinals appeared clean V6 replied No, they're nasty. V6 subsequently turned R2's bathroom light on (as requested) and a loud continuous screeching noise was noted to be coming from the bathroom exhaust fan. Surveyor inquired about the noise in R2's bathroom V6 stated Sound like some old engine. On 2/18/25 at 1:19pm, surveyor inquired where R2 urinates V4 (LPN) stated He (R2) has a urinal at his bedside and the CNA (Certified Nursing Assistant) gonna empty if it needs to. Surveyor inquired if R2 urinates on the floor V4 responded (R3) told me that he was doing that but I (V4) never seeing that. Surveyor inquired what staff implemented to prevent R2 from urinating on the floor V4 replied They're making a behavioral note for that patient (R2) because I'm (V4) not the one assigned, the Nurse in charge reported that too. On 2/19/25 at 1:41pm, surveyor inspected R2 & R3's room with V7 (Maintenance Director) and inquired about the appearance of the walls which were notably damaged V7 stated It could use some painting. Surveyor inquired if the walls also need repair V7 responded I should say patching and painting. Surveyor inquired about the spray foam protruding from the baseboard onto the floor V7 replied Looks like some foam, I'm guessing there was a hole in the corner, and they (staff) sealed it up with some foam. Surveyor inquired about the holes in the wall V7 stated There's two, something may have been hanging here. Surveyor inquired about the baseboard which was dangling on the floor beneath the heater V7 responded Looks like it's peeling off the wall. Surveyor inquired about the appearance of the air conditioner V7 replied That's foam to protect the air from coming inside. It just was oozing outta there I guess. Surveyor inquired about the notably discolored ceiling tile with 2 large rectangular openings V7 stated It's stained and poorly cut, there's big holes. V7 subsequently inspected R2 & R3's bathroom and 4 unlabeled urinals were present, surveyor inquired if urine was present in 2 of the urinals V7 responded Yeah, it should have been cleaned up. Upon further inspection, 2 additional urinals were observed under R2's bed. R2's (1/30/25) BIMS determined a score of 12 (cognition intact). R2's progress notes state (1/9/25) resident alert and oriented x3. Resident roommate notified staff that resident intentionally urinated on the floor. Resident verbalized that it was water on the floor, not pee. Resident was teaching to use urinal and ask for assistance as needs and stop urinating on garbage cans or on the floor. (1/10/25) Resident observed urinating on the floor and then placed a sheet over it. Explained to resident to use the urinal, also did teaching with resident on how to use urinal. Resident continues to urinate on the floor. Nursing supervisor made aware. (1/24/25) Resident was seen defecating on the facility's sheet which he spread on the floor. CNA stated that he told her to dump the sheet in the garbage. Writer educated resident on the importance of infection control. Resident was angry and told writer to get out of the room. Two roommates sharing the room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145867 If continuation sheet Page 2 of 8 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 02/20/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that he does it regularly especially at nights. Administrator was made aware. (1/30/25) Despite encouragement to call for assistance to use bathroom he continues to poop in the sheet and throw it on the floor or in the garbage cans. Two other roommates in the room keep complaining about it. Social Service staff spoke with resident and pointed out his behavior was not acceptable. Educated resident to use the bathroom when voiding/defecating. Resident acknowledged and verbalized understanding. He agreed to use the bathroom. (2/3/25) Resident is defecating on the bed, doesn't want to put diaper on and does not use call light to help to go to the toilet. Roommates are complaining. Not compliant with instruction is spite of re-enforcing to use the call light. NOD's (Nurse on Duty) attention was called by staff that the resident is wrapping linen in a garbage bag with bowel movement in it. NOD talked to the resident that the behavior is not acceptable, explanation and education given. Resident verbalized understanding. (2/6/25) Social Service staff met with the resident and discussed his reported inappropriate behavior. It was reported that he used the bed sheet to defecate and threw the bed sheet in the garbage. He used the urinal to void and threw the urine in the bathroom sink instead of the toilet. Resident denied the behavior but later admitted his action. On 2/19/25 at 2:02pm, surveyor inquired if R2 uses the bathroom R2 stated I go and pointed towards the bathroom. Surveyor inquired if R2 wasn't using the bathroom due to loud noise coming from the exhaust fan R2 nodded his head yes. The (8/23/17) resident rights policy states exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. The (undated) housekeeping services policy states it is the policy of the facility to maintain a clean, odor free, comfortable, and orderly environment in all health care and public areas, which meet the sanitation needs of the facility and residents right for a safe, clean, comfortable homelike environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145867 If continuation sheet Page 3 of 8 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 02/20/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff/visitors are aware of required PPE (Personal Protective Equipment) prior to entering isolation rooms, failed to ensure that PPE is properly disposed of, and failed to ensure that required isolation signs were posted for two of four residents (R1, R4) reviewed for infection control. These failures have the potential to affect 153 residents. Residents Affected - Many Findings include: The (2/18/25) facility census includes 153 residents. The weekly isolation log affirms: R1 is on droplet/contact isolation for Influenza A and RSV (Respiratory Syncytial Virus) start date: 2/15/25, end date: 2/21/25. R4 is on droplet/contact isolation for Influenza start date: 2/16/25, end date: 2/22/25. On 2/18/25 at 12:07pm, a sign was posted on R1 and R4's (roommates) door which states, Enhanced Barrier Precautions [droplet/contact isolation and required PPE were excluded] and the door was wide open. On 2/18/25 at 12:11pm, surveyor inquired if R1 is on isolation V4 (LPN/Licensed Practical Nurse) stated Yes, he (R1) tested positive for Influenza A on 2/15 (3 days prior) and affirmed that R4 is also on isolation for RSV. Surveyor inquired about required PPE for influenza V4 responded Mask, gown, gloves, and shield [N95 was excluded]. R1's care plan (initiated 2/17/25 - 2 days after testing positive for Influenza A) includes Droplet Precaution for positive Influenza A and positive RSV on 2/15/25, intervention: maintain isolation precautions per facility policy. On 2/18/25 at 12:23pm, surveyor entered R1's room and the following were observed: a small (uncovered) trash can (with clear plastic liner) which contained a disposed gown and mask. 2 large black trash cans (with lids) which also contained clear plastic liners [red biohazard bags and/or red bins were excluded]. On 2/18/25 at 12:42pm, surveyor inquired where doffed PPE should be placed in R1's room V5 (Wound Care Nurse) stated, There should be an isolation bin. Surveyor inquired where R1's isolation bin is located V5 responded Those are our isolation bins and pointed to the large black trash cans. Surveyor inquired what was placed in the small (uncovered) trash can in R1's room V5 replied The isolation gown and mask. Surveyor inquired if there was a lid on R1's trash can with discarded PPE V5 stated No. Surveyor inquired if red biohazard bags were placed in R1's large black trash cans and/or small trash can V5 affirmed they were not. On 2/18/25 at 1:19pm, surveyor inquired which type of isolation R1 and R4 are currently on V4 (LPN) stated Contact and droplet. Surveyor inquired about the isolation sign currently posted on R1 and R4's door V4 responded Right now, its enhanced barrier. Surveyor inquired why a contact/droplet sign was not posted on R1 and R4's door (as required) V4 replied Probably it fell off because a while ago it was there. On 2/20/25 at 12:18pm, surveyor inquired where isolation signs should be posted V3 (Infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145867 If continuation sheet Page 4 of 8 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 02/20/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Prevention Nurse) stated Directly on the door. Surveyor inquired about required isolation for Influenza A V3 responded When they (residents) are symptomatic they immediately go on protocol for isolation. They would go on a contact and droplet isolation, and they would remain on isolation for 7 days. Surveyor inquired about required isolation for RSV V3 replied It's the same thing as the flu we do 7 days protocol as well. Surveyor inquired about disposal of PPE in the facility V3 stated Per the protocol here they (staff) generally just use the clear trash bags for that. Surveyor inquired how many facility residents were recently diagnosed with Influenza V3 responded A total of 14 but some are hospital acquired. I have 1 that was hospital acquired so it would be 13 that are not hospital acquired. The first case was identified the 14th of this month (2/14/25). Surveyor inquired if the residents that were influenza positive reside on the same units V3 replied Essentially it looks like more in the lower numbers on team 1, team 2, and I believe team 3. On 2/20/25 at 1:17pm, V3 presented the weekly isolation log and stated, There were 2 residents with influenza that were hospital acquired, not 1 and affirmed that 12 residents (R1, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15) acquired Influenza in the facility. The infection precaution guidelines (revised 5/15/23) state Transmission-Based Precautions will be employed for known or suspected infections for which the route of transmission/prevention is known. The transmission-based categories are the following: airborne, droplet, contact. All personal protective equipment should be discarded in either the trash or used linen receptacle before you leave the room. Precaution signs will be utilized to alert staff and visitors to see the nurse for instructions prior to entering room. The influenza transmission-based precautions include contact and droplet precautions for 7 days after onset of illness or 24 hours after the resolution of fever, whichever is longer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145867 If continuation sheet Page 5 of 8 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 02/20/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to address reported pest/rodent sightings and failed to maintain an effective pest control program for three of three residents (R1, R2, R3) reviewed for pests/rodents. These failures have the potential to affect 153 residents. Residents Affected - Many Findings include: The (2/18/25) facility census includes 153 residents. R1's (1/3/25) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 2/18/25 at 12:23pm, surveyor inquired about concerns at the facility R1 stated Mice was in the other room where they (staff) moved me (R1), while this room (current room) was being repaired. I (R1) reported it to (V1/Administrator). He (V1) got maintenance (staff) they searched around the room and found holes in the wall. R1 affirmed that (R2) and (R3) currently reside in the other room where mice were sighted. R3's (1/16/25) BIMS determined a score of 15 (cognition intact). On 2/18/25 at 12:45pm, surveyor inquired if a mouse was observed in R3's facility bedroom R3 stated It wasn't a mouse it was a rat that was in here and right over there in that (pointing towards the bedroom heater) there was a roach. R3 presented a video (on his phone) of a roach crawling on the wall behind his facility bed and picture of a dead roach on the facility heater. R2's (1/30/25) BIMS determined a score of 12 (cognition intact). On 2/19/25 at 2:02pm, surveyor inquired if roaches were observed in R2's room R2 stated Sometimes and pointed towards the bedroom heater. On 2/19/25 at 9:32am, surveyor requested the January and February (2025) pest control invoices. V1 (Administrator) presented the (1/23/25) pest control service report and stated, There is none for February because they haven't come out yet and for January there's just one. Surveyor inquired how frequent pest control comes to the facility V1 responded We (facility) do have em scheduled on our contract; they (Pest Control) do come out. They came out once last month for the monthly visit and affirmed I would have to check the policy. Surveyor inquired if the facility received recent reports of roaches and/or mice V1 replied I (V1) have not heard anything. Surveyor inquired where rodent and/or pest sightings are documented V1 stated The pest control binder is at the front desk; everybody has access to that. Our maintenance director (V7) looks at that every day and calls (Pest Control) and sees that they (Pest Control) take care of that. On 2/19/25 at 9:51am, V1 affirmed that pest control comes to the facility Monthly and as needed per the facility contract. The (1/23/25) pest control service report states Today I inspected and treated kitchen area, food prep area, cafeteria, storage area however inspection of resident rooms and/or other areas within the facility were excluded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145867 If continuation sheet Page 6 of 8 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 02/20/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 2/19/25 at 1:14pm, surveyor inquired about the facility pest control program V7 (Maintenance Director) stated They (Pest Control) come out monthly, part of their monthly routine is they inspect the dietary areas, common areas and they also do the rodent bait stations that are on the outside of the facility and then anything else that's needed is treated as well [resident room inspections were excluded]. Surveyor inquired about reported pest/rodent concerns V7 responded What they (staff/residents) recently reported is written in here (referring to the pest control sighting log), I (V7) check it weekly (not every day as V1 stated). When I check it (pest control sighting log), I inspect the area they are complaining about and if I see any activity I contact pest control and let them know so on they (Pest Control) next visit they can do a treatment. I make sure that the area is clean, and I have an insecticide that we use just for preventative measures it's supposed to kill spiders, roaches, ants, and stuff like that. Surveyor inquired if R2 and R3's current room was recently treated for roaches V7 replied Yes, I believe it was, but I didn't see any activity in that room. Surveyor inquired if rodents were observed in R2 and R3's current room V6 stated No, there was complaints but no activity. Surveyor inquired about the (January & February 2025) reported pest/rodent sightings V7 responded Looks like here we (facility) have some complaints on roaches and mice that's what's written on here. On January 20 there was a complaint that (room [ROOM NUMBER]) had roaches, I'm not sure what day that I saw this but there was roaches by the refrigerator (in the room) so I cleaned it and sprayed the room. R2 and R3 (2/3/25) had complaint of mice, we (staff) did inspect the room didn't see any mice droppings, we did see a few holes for rodents to enter so we sealed them just in case. On February 6 the same room (R2 and R3) reported mice but again no activity. We sealed up potential entry points, set up glue traps, and nothing came from that. On February 14 there was concern with room [ROOM NUMBER] with roaches, upon following up I didn't see any activity and we most likely cleaned the rooms and sprayed the insecticide just in case [room [ROOM NUMBER] is on the unit adjacent to room [ROOM NUMBER] and also adjacent to R2 & R3's room]. Surveyor inquired if pest control inspected room [ROOM NUMBER] on 1/23/25 (because roaches were reported 3 days prior) V7 reviewed the 1/23/25 service report and replied, I don't see any notes specific to that room. Surveyor inquired when pest control is coming to the facility (because roaches were reported on 2/14/25 - 5 days prior) V7 stated Sometime in the middle of the month. Surveyor inquired why the (9/19/24-2/14/25) pest control log includes pest problems however Date Treated and Tech Initials are blank for each entry V7 responded I have a separate log for what I follow up on that I could grab for you. [Reported rodent sighting in R2 and R3's current room was excluded from the log]. On 2/19/25 at 1:37pm, V7 presented a (6/10/24-2/17/25) log which includes the date, problem reported, staff observation, action taken, 24-hour follow-up observation and staff initials. Surveyor inquired about the 2/3/25 and 2/6/25 reported mice in room (R2 and R3's room) (which were excluded from the log) V7 stated I must have not followed-up on those or I must not have written it down. The 2/17/25 entry (documented 3 days after 2/14 sighting) states problem reported roaches (room [ROOM NUMBER]) action taken cleaned room however applied treatment was excluded. [Reported complaints of rodents and alleged inspection/treatment for roaches in R2 and R3's current room were excluded]. On 2/19/25 at 1:41pm, V7 and surveyor inspected R2 and R3's room the following was identified: Surveyor inquired if there was an open area between the wall and the heater V7 stated There's a gap its insulation. Surveyor inquired about the bait station beneath the heater which was covered in dust V7 responded This is old. Surveyor inquired if the bait station was set to catch anything V7 replied I'm not sure, I don't even know how to use that. Just looks like it's been there for a while. V7 opened the bait station (as requested) and affirmed it was not set. Surveyor inquired about the device on the floor in front of the closet V7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145867 If continuation sheet Page 7 of 8 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 02/20/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete stated It's a glue station. V7 subsequently picked the glue station up and there was a large live insect and several small insects adhered to the device. Surveyor inquired what was adhered to the glue station V7 responded A live roach and a couple more babies. Surveyor inquired about the ceiling tile in R2's room (with 2 large openings) V7 replied There's big holes, it could be better cut. The pest control policy (revised 9/1/22) states the Environmental Services Director will be responsible for coordinating the facility pest control. The pest control program will be conducted on a regular and as needed basis. All building openings shall be tight-fitting and free of breaks. Event ID: Facility ID: 145867 If continuation sheet Page 8 of 8