Health inspection·May 29, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few When the wound doctor places new orders it is the wound coordinators responsibility to carry out the wound care orders on the residents POS. At that time there was no wound care coordinator. V3 then explained that if a treatment is not signed out indicates that the treatment was not performed. V3 further explained if a residents treatment is not performed the residents wound can worsen or become infected. On 05/28/25, at 10:37 AM, V4 (Licensed Practical Nurse, LPN, Wound Care Nurse) stated that upon a residents admission to the facility, the admitting nurse is responsible for making sure the residents wound care orders are carried out on the Physician Order Sheet unless the wound care team assesses the resident first. V4 explained that if a resident is admitted with wound care orders that are not carried out on the residents physician order sheet the residents wounds can get infected, worsen, and the resident is at risk for further skin breakdown. V4 then stated that V4 does not know why R1's wound care orders were not carried out on the physicians order sheet when R1 was readmitted to the facility on [DATE]. V4 then explained that if R1's Treatment Administration Record (TAR) has days where there are no signatures and left blank, then it is assumed that R1's treatment was not performed. V4 further explained if a residents wound care treatment is not performed the residents wounds can be left exposed to elements, further skin breakdown, and can become contaminated. On 05/28/25, at 11:06 AM, V5 (LPN, Wound Care Coordinator) stated that R1 had multiple wounds and that V5 recalls caring for R1's wounds once when R1 resided at the facility. V5 stated that when a resident admits to the facility, the floor nurse completes an initial skin assessment. If the resident has wounds, then the floor nurse is responsible for contacting the residents physician and initiating treatment orders for the residents wounds. V5 also explained that wound care updates the wound care orders if necessary after wound care completes their skin assessment with the resident. V5 stated if a resident who has wounds does not have wound care orders carried out the residents wounds can worsen and become infected. V5 explained if the residents treatment order is not signed out it can be assumed that the residents treatment was not done. V5 further explained if a resident has wound care orders, and the residents treatment is not performed the resident can acquire an infection. Surveyor and V2 (Director of Nursing/DON) reviewed R1's TAR and POS which did not indicate a treatment order for R1's left buttocks, left hip, and sacral wounds upon R1's readmission to the facility on [DATE]. R1's wound assessment dated [DATE], authored by V8 (Wound Nurse Practitioner) shows that on 12/18/24, R1 had wounds to left breast, bilateral buttocks, left buttocks, left hip, sacral and umbilicus at the facility, however no treatment orders for these areas documented on R1's Physician Order Sheet (POS). R1's Weekly Wound assessment dated [DATE], authored by V4 (LPN, Wound Care Nurse) shows R1 had wounds to sacrum, left hip, left buttocks, bilateral buttocks, however no treatment orders for these areas documented on R1's Physician Order Sheet (POS). R1's Physician Order Sheet (POS) dated active orders as of 12/17/24, does not show R1 with treatment orders for left buttocks, left hip, sacral, and bilateral buttocks area. R1's Treatment Administration Record (TAR) dated 12/01/24 through 12/31/24 shows missing signatures for R1's wound care treatment to the left abdomen for 12/13/24 and 12/18/24. R1's Care Plan dated 12/19/24, documents, in part: R1 has pressure ulcers (Left buttocks, left hip (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 05/29/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and sacrum) r/t (related to) immobility. However, no orders for R1's left buttocks, left hip and sacrum wound has orders on R1's POS. R1's hospital record dated 12/11/24, documents in part: On assessment all present on admission: full thickness wounds: abdomen left, left buttocks, left thigh, posterior right upper leg all related to pressure injury, stage 2 pressure ulcers. Red granulation tissue. Minimal serosanguinous drainage. The facility's document dated 12/18/24 through 12/19/24 and titled Wound Details shows that R1 had wounds to bilateral buttocks, left buttocks, left hip, and sacral area. However, there are no orders for these sites on R1's physician order sheet. The facility's undated job description titled Wound Nurse documents, in part: Summary: the wound nurse is responsible for providing primary skin care to residents under the medical direction and supervisor of the residents' attending physician, the director of nursing, or the medical director of the facility, with emphasis on treatment and therapy of skin disorders. Essential duties and responsibilities: Identify, manage, and treat specific skin disorders and primary and secondary lesions, such as skin abrasions, foot problems such as corns and calluses, decubitus ulcers, bacterial, parasitic, and viral and infections, scaling popular diseases, and benign tumors . Implement and maintain established policies and procedures relative to skin care treatments. Interpret these to the physician, resident family members, and public as appropriate. The facility's undated job description titled Registered Nurse documents, in part: Summary: the RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the director of nursing to ensure the highest degree of quality care is maintained at all times. Essential Duties and Responsibilities: Complete and file required record keeping forms/ charts upon the residence admission, transfer and or discharge. Receive and transcribe telephone orders from physician and record on the physician order form. Chart nurses notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the residents response to the care period fill out and complete accident/incident reports and submit to director as required. Perform routine charting duties as required and in accordance with the established charting and documentation policies and procedures. Prepare and administer medications as ordered by the physician . Administer professional services such as catheterization, tube feeding, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages in range of motion exercises, etc. (etcetera) as required. The facility's undated job description titled Licensed Practical Nurse documents, in part: Summary: the RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the director of nursing to ensure the highest degree of quality care is maintained at all times. Essential Duties and Responsibilities: Complete and file required record keeping forms/ charts upon the residence admission, transfer and or discharge. Receive and transcribe telephone orders from physician and record on the physician order form. Chart nurses notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the residents response to the care period fill out and complete accident/incident reports and submit to director as required. Perform routine charting duties as required and in accordance with the established (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 05/29/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few charting and documentation policies and procedures. Prepare and administer medications as ordered by the physician . Administer professional services such as catheterization, tube feeding, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages in range of motion exercises, etc. (etcetera) as required. The facility's policy dated 1/15/18 and titled Pressure Ulcer Prevention documents, in part: Purpose: To prevent and treat pressure sores/pressure injury. The facility's policy dated 01/31/18 and titled Physician Orders-Entering and Processing documents, in part: Purpose: To provide general guidelines when receiving, entering, and confirming physicians or prescribers orders. (a prescriber is noted as physician, nurse practitioner, and a physician's assistant.). Guidelines: 6. Verbal and Telephone orders will be documented as such in the Electronic Medical Record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145867 If continuation sheet Page 4 of 4