Inspection·October 24, 2024

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many shots through facility and we have to sign a consent or refusal, but I am new in this building. I have not signed any refusals or consents for flu or Covid here at this building yet or receive any education for Covid-19 or flu. On 10/23/24 at 10:37 AM, V2 stated, So, every time there is a new Covid booster out, when staff picks up their checks, we talk about vaccine and the staff will say sign me up. If there is no new booster out, we still talk about it, but it is their choice. We talk about what is available to them. We do encourage them to take the Covid vaccine. The memo is just telling them where they can go get it. People from outside must come here to do it. The outside vendors will do staff vaccinations as well. (V3, Human Resource) will post something by the time clock and those who want the vaccine will put their name down. For flu, we do have declinations, but for Covid they do not have to sign a declination. At the beginning of Covid, they did have to sign a refusal. I do not remember when having the declination signed by the staff stopped for Covid. I usually talk about how they can get flu and Covid vaccines, and when to get it, and when to stay home as education. I can look through my binder to see if I have sign in sheets for in-services for the education part of that. On 10/23/24 at 11:32 AM, V2 provided Covid policy and stated, We do educate them if they have any symptoms and should not come to work. We do not screen employees for Covid. We do not any longer get signed declinations for Covid vaccine, but we encourage all staff to get the Covid vaccines yearly when we do the flu vaccine, or a new booster comes out. I do not have any declinations for Covid vaccine. The in-services I provided to you are the only education we offer regarding the Covid vaccine. Vaccination status is documented by getting a copy of their vaccination cards and keep copy in the binder for Covid vaccines. If staff get another vaccine, they provide us with a copy of new card/vaccine documentation for binder. On 10/23/24 at 1:56 PM, V2 was asked for documentation for screening for Covid vaccinations. V2 stated No, we do not have anything like that. We do not screen for Covid vaccine. On 10/23/24 at 2:25 PM, V2, DON/IP, provided surveyor with a report listing employees and Covid vaccination dates, but complete documentation omitted for V10 (New Staff) and V11 (Staff) and V12 (Staff) with religious exemption. Surveyor asked V2 if that was all the documentation that she had regarding Covid vaccine education, screening, and offering vaccines to employees. V2 stated, Yes the in-services I provided to you is all I have. V2 provided surveyor Covid 19 documents posted by the time clock and Memo date 01/01/2024 to all Skokie Staff stating, This is a reminder to get your COVID vaccine/boosters. Please scan below QR codes for information on the vaccines. You can easily receive your COVID vaccine/booster at your local pharmacy or at your primary care provider. If you do receive the vaccine, please bring a copy of your vaccine card to (V3, Business Office Manager). This memo had education pages that did not document risks/benefits of vaccine attached to memo, but had QR codes that goes to link with risk/benefits of each Pfizer and Moderna covid vaccines. V2 could not provide a list of staff that received this memo. In-service document provided and dated as follows (in part): Date: 7/12/23, Topic: Covid Guidance Updates, summarize what you discussed: New Hospital admission Rate Date: 1/5/24 Topic: Covid Policy Discussed: The facility will manage residents with confirmed or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145869 If continuation sheet Page 2 of 3 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 145869 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Skokie 4626 Old Orchard Road Skokie, IL 60076 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many suspected Covid-19 infection in accordance with recommendations from the CDC, state and local health department. Date: 1/29/24 and 11/29/24 Topic: Covid-19 Symptomatic Discussed: Should individual with symptom consistent of Covid-19 have negative results from a rapid antigen test, they should remain excluded from work and/or isolated pending results of confirmatory PCR testing. Date: 1/26/24 Topic: Covid-19 Discussed: All staff members to put N96 masks on each time going to patients rooms. Proper PPR donning and doffing needs to be done Must take vitals every 4 fours. Door kept close at all times. During the course of the survey, the facility did not provide requested Covid-19 declination forms to surveyors nor staff education in-services for current 2024 (fall season) Covid-19 vaccine. The facility's policy, dated 07/2023, Covid-19 Vaccination Policy stated (in part): Policy Vaccination remains critically important in reducing risk of hospitalization and death due to Covid-19. The facility will encourage staff to remain up to date with Covid-19 vaccination, including all eligible booster doses. Education 1. The facility will provide education to all staff and residents regarding the COVID-19 vaccine they are offered, in a manner they can understand, including information on the benefits and risks consistent with the CDC (Centers for Disease Control and Prevention) and/or FDA (Food and Drug Administration) information. This education will at a minimum include the FDA EUA (Emergency Use Authorization) Fact Sheet or Vaccine Information Sheet for the vaccine(s) being administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145869 If continuation sheet Page 3 of 3