Inspection·September 27, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review the facility failed to follow their Fire Watch policy by failing to provide all staff with an in-service related to Fire Watch and fire safety procedures and failed to notify the Fire Department and State Health Agency after all systems have been restored. These failures have the potential to affect all 175 residents and facility staff safety related to fire safety emergencies. Findings include: On 9/24/2024 at 9:31 AM, V1 (Administrator) stated that the box for the water sprinkler has a problem. If the water sprinkler will turn on, it will be low pressure after 7 minutes. The fire department needs to come and connect a water hose to help water pressure in the sprinklers. We (the facility) were on fire watch. On 9/24/2024 at 1:42 PM, surveyor requested to meet with V3, listed as Building Manager on the facility directory provided by V1. V1 stated that V3 had not worked in the facility for quite some time and the best person to answer questions is either him (V1) or V4 (Corporate Maintenance). V1 stated that fire sprinklers were not functioning from 9/11/2024 to 9/17/2024. V1 stated that sprinkler pressure decreases if it goes to a certain amount of time. As a result, the fire department needs to connect a hose to help in the water needs of the sprinklers. V1 stated that V21 (Fire Sprinkler Repair Company) came the first day to repair and several times in between and it did not fix the problem until the last day, 9/17/2024. After the repair, a test was done to test the sprinklers. When asked if an in-service was provided to facility staff regarding Fire Watch, V1 stated, I am not sure if there was an in-service given. V1 was informed that it should be given to all staff at the beginning of every shift per policy. V1 stated, does the policy say that every shift? After looking at the policy, V1 stated, No, in-service done for everybody. V1 stated that there may have been some sort of in-service and had to check with V4. On 9/24/2024 at 2:15 PM, V5 (VP of Facilities Environmental Services and Life-safety) stated that since he was near the facility he came because he knew about the situation. V5 was asked who the Building Manager was of the facility since V3 is not anymore connected with the facility. V5 stated that V1 the administrator is in-charge of the whole facility, and that the facility just hired a new Building Manager. V5 stated that V3 was not employed with the facility for over six (6) months. For that reason, V4 came out to the facility the first day of Fire Watch (9/11/2024). The reason for the problem was that the fire sprinkler pump control failed. Parts were ordered but take time to arrive. V5 stated that V4 did an in-service for certain staff but did not have any form of documentation. V5 stated that V4 did in-service the first shift and first shift in-serviced the next shift, so on and so forth. (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 4 Event ID: 145888 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 145888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Northmoor 5831 North Northwest Highway Chicago, IL 60631 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)