Inspection·November 1, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to follow standards of practice during medication administration for one (R63) out of three residents reviewed during medication administration observations. Residents Affected - Few Findings include: R63's admission Record documents in part medical diagnoses of Alzheimer's disease; dementia; muscle wasting and atrophy; weakness; age-related physical debility; and adult failure to thrive. R63's Order Summary Report documents in part orders for Aspirin, Ferrous Sulfate, Jardiance, and Sertraline. It also documents in part that staff may crush medications if manufacturer allows or give liquids if R63 is unable to take intact dosage form. On 10/30/2024 at 9:59 AM, Observed V10 (Nurse) prepare R63's morning medications which included one tablet of Aspirin 81 mg (milligram), one tablet of Ferrous Sulfate 325 mg, one tablet of Jardiance 10 mg, and one tablet of Sertraline Hydrochloride 50 mg. At 10:04 AM, V10 placed all four tablets in a clear, plastic packet and crushed them using a pill crusher. V10 poured the crushed contents into a medicine cup and mixed it with apple sauce. V10 administered the mixture to R63 at 10:09 AM. On 10/30/2024 at 2:30 PM, V29 (Pharmacist) stated nurses must crush each medication individually and administer each medication one at a time with the liquid or food they're mixing it with. Facility's Medication Administration: General Guidelines (dated 01/2022) documents in part: To ensure that medications are administered safely as prescribed. Facility's Crushing of Medications policy (dated 06/2022) does not include guidelines or procedures for when administering multiple crushed medications. An article from the American Association of Post-Acute Care Nursing (dated 2/12/2019) documents in part: A best practice for administering crushed medication is to crush and administer each medication separately. Crushing and combining medication may result in physical and chemical incompatibilities, leading to an altered therapeutic response. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 2 of 23 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 11/01/2024 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure incontinence care was provided in a timely manner for 1 (R66) resident who is dependent in toileting reviewed for activities of daily living (ADL) in a total sample of 33. Residents Affected - Few The findings include: R66's health record documented initial admission date on 4/1/2024 with diagnoses not limited to Chronic obstructive pulmonary disease, Hypertensive heart and chronic kidney disease with heart failure, Type 2 diabetes mellitus, Unspecified atrial fibrillation, Heart failure, Atherosclerotic heart disease of native coronary artery, Hyperlipidemia, Major depressive disorder, Insomnia, Post-traumatic stress disorder, Unspecified asthma, Other sequelae of cerebral infarction, Chronic kidney disease, Gastro-esophageal reflux disease, Gout, Dependence on supplemental oxygen, Anemia. On 10/29/24 at 11:14 AM R66 was observed lying in bed on moderate high back rest with oxygen inhalation via nasal cannula at 2L(liters)/min. Alert and oriented x 3, verbally responsive. R66 said she is using an incontinence brief and is incontinent of bowel and bladder. R66 stated at times she is not changed for almost 6 hours, lying on soiled brief. R66 stated she needed to pee at least 4-6x in her incontinence brief then she will be changed by staff. She stated she was last changed about an hour ago. At 2:44pm R66 was observed lying in bed on moderate high back rest, alert and oriented x 3, verbally responsive. R66 stated she was last checked and provided incontinence care an hour or so after breakfast. She stated she is wet and needed to be changed. At 2:46pm V11 (Licensed Practical Nurse/LPN) stated he (V11) has been working in the facility for 2 years and regularly assigned on the 2nd floor. V11 stated he is working with R66, incontinent of bowel and bladder. V11 stated rounding is done at least every 2 hours and as needed including incontinence care. V11 stated assigned CNA/Certified Nursing Assistant (V12) was sent home and R66 is assigned to V13 (CNA). Surveyor requested assigned CNA in R66's room. At 2:49pm V13 (CNA) and V14 (CNA) came to R66's room. Incontinence care observation conducted, R66 incontinence brief was soiled. Buttocks observed reddened and excoriated, V13 applied moisture barrier cream. Incontinence care was completed. At 2:55pm V14 (CNA) said she was with V12 when incontinence care was provided to R66 between 10-11am. She said rounding should be done at least every 2 hours including checking for incontinence episode and providing incontinence care. She said incontinence care should be done timely to prevent sore/breakdown. She said earlier during incontinence care between 10-11am, R66 buttocks was observed raw/reddened. V14 stated, R66 claimed that during night shift, it takes a little longer for her to be changed so it itches at times and she (R66) is scratching her bottom. On 10/30/24 at 4:03pm Interview with V3 (DON/DIRECTOR OF NURSING) stated rounding should be done by staff at least every 2 hours and as needed. Staff should be asking residents if they need to be changed and provide care, check if the resident is okay, and attend to their needs. If Incontinence care is not done in a timely manner the resident could develop a possible skin condition such as rash or redness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 3 of 23 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 11/01/2024 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS (Minimum Data Set) dated 9/25/24 showed R66 was cognitively intact. She needed substantial/maximal assistance with toileting hygiene. MDS showed R66 was frequently incontinent of bowel and bladder. Care plan dated 4/2/24 documented in part: R66 displays functional incontinence due to weakness. Will show no complications secondary to incontinence. Skin will remain intact. Provide assistance with toileting. Facility's policy for perineal care dated 9/2020 documented in part: To cleanse the perineum. To maintain skin integrity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 4 of 23 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 11/01/2024 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview and record review the facility failed to follow plan of care and apply splint to both hands as prescribed by doctor for 1 (R136) resident reviewed for limited range of motion in a sample of 33. The findings include: R136's health record showed initial admission date on 7/21/2023 with diagnoses not limited to Permanent atrial fibrillation, Encounter for attention to gastrostomy, Hypertensive heart disease with heart failure, Chronic systolic (congestive) heart failure, Anemia in chronic kidney disease, Rheumatoid arthritis, Pressure ulcer of sacral region stage 4, Pressure ulcer of right upper back stage 4, Hypothyroidism, Adult failure to thrive, Anxiety disorder, Dependence on supplemental oxygen, Chronic embolism and thrombosis of other specified veins, Gastro-esophageal reflux disease, Adjustment disorder with mixed anxiety and depressed mood. On 10/29/24 12:04pm R136 Observed lying in bed, alert and oriented x 4, and verbally responsive. R136's hands were both contracted, with no splint or device in place. R136 stated she has crippled rheumatoid arthritis. She stated staff is putting a splint on both hands x 2 hours each hand. R136's POS (Physician order sheet) showed: Splint to: right resting hand - apply 2 hrs in am, 2 hrs in pm. May remove during adl care and skin checks. Splint to: left resting hand - apply 2 hrs in am, 2 hrs in pm. May remove during adl care and skin checks. Between 1:30pm to 3pm R136 lying in bed, no device or splint observed on either hand. She said hand splint is applied between 7am - 9am on 1 hand then removed after 2 hours and applied to another hand between 9 - 11am, removed after 2 hours. She said in the afternoon it is applied between 1pm to 3pm. On 10/30/24 between 10am to 12noon R136 Observed lying in bed, alert and oriented x 4, verbally responsive with contractures on both hands. No splint or device observed on either right or left hand. She said splint is applied 2 hours in the morning and 2 hours in the afternoon on each hand. On 10/31/24 at 10:05am interview with V3 (Director of Nursing / DON) said has been working in the facility for over 6years, transitioned as DON for over 2 years. Stated she oversight Restorative currently, 2 new restorative nurses are still on orientation. Stated the purpose of splint is to assist resident with prevention of further contractures or maintain current mobility. Splint could be put in 2 hours on or 4 hours off every day, could be twice a day. There should be a doctor's order and should be care planned. If splint is not provided or applied could sustain further contracture. V3 stated R136 has contractures to both hands. Reviewed electronic health record (EHR) with V3 and stated R136 has active order of resting hand splint to be applied twice a day. Apply 2 hours in am and 2 hours in pm. Restorative aid and nurses applying the device. Should be documented in the task or R136's record that splint was applied. Nursing standards of practice if not documented it was not done or provided. Refusal of splint application should also be documented. Reviewed R136's task record for splint application showed splint were not documented as applied twice daily as ordered on 10/5/24, 10/9/24, 10/14/24, 10/17/24, 10/20/24, 10/26/24, 10/29/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 5 of 23 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 11/01/2024 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R136's order summary report dated 10/31/24 showed active order not limited to splint to: right resting hand - apply 2 hrs in am, 2 hrs in pm. May remove during adl care and skin checks. Splint to: left resting hand apply 2 hrs in am, 2 hrs in pm. May remove during adl (activities of daily living) care and skin checks. Care plan dated 4/1/24 showed in part: SPLINT RESTORATIVE PROGRAM: R136 requires a splint secondary to Rheumatoid Arthritis. R136 to wear left and right resting hand splint 2 hours in the morning and 2 hours in the afternoon with assistance of CNA/Nurse. Apply splint/brace per MD order to affected area. MDS (Minimum Data Set) dated 10/8/24 showed R136 was cognitively intact. She needed total assistance or dependent with staff with oral, toileting and personal hygiene, upper and lower body dressing. MDS showed restorative nursing programs - splint or brace assistance. Facility's policy for splint or brace assistance dated 3/10/22 documented in part: Splint or brace assistance refers to a scheduled program of applying and removing a splint or brace These sessions are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 6 of 23 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 11/01/2024 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to have a spare tracheostomy (trach) tube at bedside for R14 for one of two residents reviewed for tracheostomies. Residents Affected - Few Findings include: R14's admission Record documents in part medical diagnoses of chronic respiratory failure with hypoxia and encounter for attention to tracheostomy. R14's Order Summary Report documents in part the type and brand of trach tube for R14. Trach size of 7.5 mm (millimeter). It also documents in part an order for Trach Care: In case of emergency, trained nurse may reinsert outer cannula of tracheostomy as needed (active 07/01/2024). On 10/29/2024 at 12:05 PM, R14 was alert and oriented to person, place, and time. During interview, R14 did not know the type of trach [R14] had or the size of the trach tube. R14 gave permission for surveyors to search tracheostomy care supplies at bedside. Surveyors did not find a spare trach tube. At 12:16 PM, V6 (Nurse) entered the room. V6 stated V6 regularly cared for R14 but could not recall the type or size of R14's trach tube. Surveyor inquired about a spare trach tube for R14. V6 searched R14's room, and stated there wasn't a spare trach tube for R14 at bedside. At 12:17 PM, V6 searched the supply room by the nurses' station but there were no extra trach tubes. At 12:18 PM, V6 went into the unit's medication room. V6 found a box of 6.5 mm inner cannulas but no spare outer trach tube for R14. On 10/30/2024 at 10:15 AM, V3 (Director of Nursing) stated the facility did not have a policy on respiratory services specifically related to tracheostomies. However, V3 stated the facility does have a respiratory therapist (V7) that assists with care for residents with tracheostomies on a regular and as needed basis. During a telephone interview on 10/30/2024 at 10:54 AM with V7 (Respiratory Therapist), V7 stated there should be a spare trach at R14's bedside in case it comes out. V7 stated the facility should have one that is the same size or smaller if the resident's trach is difficult to put back in. V7 stated that a spare trach at bedside is required for all tracheostomy residents, and it should be care planned as part of the interventions. R14's comprehensive care plan contains focus of R14's potential for complications secondary to tracheostomy. It documents in part that [R14] has been noted to take out [R14's] trach at times despite education and redirection (initiated 6/10/2024). Interventions do not include to keep a spare tracheostomy tube at bedside in case of emergency. Facility's clinical practice guidelines for Comprehensive Care Plans (dated 11/2017) documents in part: An individualized, person-centered comprehensive care plan, including measurable objectives with timetables to meet Resident's physical, psychosocial and functional needs, is developed and implemented for each Resident. Care plan interventions are initiated based on an analysis of information (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 7 of 23 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 11/01/2024 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)

F 0695 collected throughout the comprehensive assessment process. Level of Harm - Minimal harm or potential for actual harm Facility's clinical practice guidelines for Tracheostomy Care (dated 09/2020) did not contain interventions to keep a spare tracheostomy tube at bedside in case of emergency. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 8 of 23 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 11/01/2024 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)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to recognize and offer pain medication to resident experiencing pain and failed to update or revise comprehensive care plan to reflect resident's pain status, goals and preferences. These failures affected 1 (R35) resident reviewed for pain management in a sample of 33. Residents Affected - Few The findings include: R35's health record showed initial admission date on 5/26/2021 with diagnoses not limited to Chronic obstructive pulmonary disease, Hypertensive heart and chronic kidney disease with heart failure, Heart failure, Cervicalgia, Non-pressure chronic ulcer of left calf with fat layer exposed, Type 2 diabetes mellitus with diabetic polyneuropathy, Schizoaffective disorder, Gastro-esophageal reflux disease, Chronic venous hypertension (idiopathic) with ulcer of unspecified lower extremity, Other specified peripheral vascular diseases, Anxiety disorder, Hypothyroidism, Hyperlipidemia, Other specified arthritis, Anemia, Dependence on supplemental oxygen, Chronic kidney disease, Chronic respiratory failure. On 10/29/24 At 11:36AM R35 was observed lying in bed on moderate high back rest, alert and oriented x 3, verbally responsive. R35 stated she has been residing in the facility for 3 years. R35 stated she has constant neck and shoulder pain. R35 stated she was unable to turn neck on her left side and requested surveyor to stay on right side. She said she has been getting Tylenol #3 with some relief and she is also on scheduled pain medication. On 10/30/24 at 12:30PM R35 observed lying in bed on moderate high back rest, alert and oriented x 3, verbally responsive. R35 claimed she has constant neck and shoulder pain, and as needed pain medication was not given yet. Observed R35 with stiff neck unable to turn to left side. V11 (Licensed Practical Nurse/LPN) said he is working with R35. Reviewed R35's EMAR (Electronic Medication Administration Record) and stated Prn (as needed) Tylenol #3 was last given yesterday 10/29/24 and 2pm. Surveyor informed V11 that R35 needed pain medication due to neck pain. On 10/31/24 at 10:17am Interview with V3 (DON/DIRECTOR OF NURSING) said nurses are expected to assess pain every shift and as needed. V3 stated scheduled pain medication should be given as ordered or offer PRN pain medication. V3 stated nurses should also provide Nonpharmacological interventions. V3 stated nurses should asess and evaluate pain level, acknowledge pain, and inform MD accordingly if pain is not managed. V3 stated resident will be uncomfortable and in pain, if PRN pain medication is not given or offered. Reviewed electronic health record with V3 noted R35's care plan documented potential for pain. V3 said R35's care plan should reflect the pain status of the resident. R35's October MAR (Medication Administration Record) showed pain evaluation recorded pain level from 1-5/10 almost every day. MAR showed order of Acetaminophen-codeine oral tablet 300-30mg (milligrams) give 1 tablet by mouth every 8 hours as needed for pain management, documented that it was given on 10/29/24 at 2:14pm and on 10/30/24 at 12:40pm after surveyor alerted V11 due to R35 complaint of neck pain. R35's care plan dated 9/13/21 documented in part: (R35) has the potential for pain related to cervicalgia, diabetic neuropathy, arthritis. Administer pain strategies according to MAR. Monitor for nonverbal indicators of pain daily with care tasks and activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 9 of 23 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 11/01/2024 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)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete MDS (Minimum Data Set) dated 10/7/24 showed R35 was cognitively intact. MDS showed numeric pain rating scale of 4/10. Facility's pain management evaluation policy dated 9/2020 documented in part: Facilitate resident independence, promote resident comfort and preserve resident dignity. During pain evaluation, determine the most workable pain rating scale for the resident. The following scales are available: 1-3 (mild), 4-6 (moderate), 7-10 (severe). Pain will be evaluated every shift. Event ID: Facility ID: 145888 If continuation sheet Page 10 of 23 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 11/01/2024 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews, and record reviews, the facility failed to account for and dispose of controlled medications in a manner that would decrease the possibility of loss or diversion. This failure affected two residents (R2, R115) during narcotic reconciliation for one out of four medication carts. Findings include: R2's admission Record documents in part a medical diagnosis of chronic pain syndrome and osteoarthritis. R2's Order Summary Report documents in part an order for Tramadol HCl (Hydrochloride) 50 mg (milligram) one tablet by mouth every eight hours as needed for pain. R115's admission Record documents in part a medical diagnosis of polyosteoarthritis, adjustment disorder with anxiety, and encounter for palliative care. R115's Order Summary Report documents in part an order for Lorazepam 1 mg one tablet by mouth every two hours as needed for anxiety and restlessness. It also contains an order for Oxycodone HCl 5 mg one tablet by mouth every four hours as needed for pain management. On 10/29/2024 at 10:20 AM, surveyor reviewed the Team Two medication cart with V9 (Nurse). In the narcotics bin, there was a blister packet for R2's Tramadol HCl 50 mg. There were ten tablets in the blister packet. The number ten slot was compromised and had a piece of transparent tape over the back. V9 was not sure if the white, round tablet in the number ten slot was Tramadol. V9 stated the nurse who broke the seal should have thrown out the tablet in the sharps and had it witnessed by another nurse. In the same narcotic bin, there was a blister packet for R115's Oxycodone HCl 5 mg. There were four remaining tablets. R115's Controlled Drug Record corresponding to the Oxycodone blister packet documents in part that there should be three remaining tablets. In addition to R115's Oxycodone, there was a medication bottle for R115's Lorazepam 1 mg. There were two tablets left in the bottle. R115's Controlled Drug Record corresponding to the Lorazepam documents in part that there should be three tablets left in the bottle. V9 stated administering a Lorazepam dose to R115 earlier that morning and must have signed in the wrong Controlled Drug Record. During an interview with V4 (Assistant Director of Nursing) and V30 (Assistant Director of Nursing) on 10/31/2024 at 9:34 AM, both stated if a resident refuses a controlled substance, the nurse should discard the medication in the sharps or flush it with two nurses present. Nurses should recount the controlled substances and make sure the drug records are correct. V4 and V30 stated nurses should not attempt to return controlled medications once their original seal or packaging is broken. Facility's policies and procedures for Storage/Labeling/Packaging of Medications (dated 01/2022) documents in part: To store medications and biologicals under proper conditions of temperature, light, and security. Each resident's medications are stored in original containers and must be properly labeled. Medications are only administered from their originally dispensed containers. Medication containers that are damaged, soiled, contaminated, or outdated are immediately removed and either returned or disposed of according to procedure. Reorder from the pharmacy as applicable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 11 of 23 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 11/01/2024 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Facility's policies and procedures for Disposal/Destruction of Discontinued Controlled Drugs (dated 09/2022) documents in part: Purpose: To provide for the disposal/destruction of any discontinued controlled substances in a safe and controlled manger in accordance with the regulations set forth by the Drug Enforcement Agency (DEA). Disposal of controlled drugs will be conducted within the facility. This may be done by two licensed healthcare professionals. Under no circumstances should controlled substances be returned to the pharmacy. Event ID: Facility ID: 145888 If continuation sheet Page 12 of 23 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 11/01/2024 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy to complete AIMS (Abnormal Involuntary Movement Scale) Assessment in a timely manner. These failures could potentially affect one (R26) of seven residents reviewed for Unnecessary Psychotic Medication Use in a sample of 33. The findings include: R26's electronic health record (EHR) documented admission date 04/11/22 with diagnosis includes but not limited to Unspecified Dementia, Unspecified Psychosis, Unspecified Mood Affective Disorder, Dysphagia, Atherosclerotic Heart Disease. R26's MDS (Minimum Data Set) from 10/22/24 documents in part, R26 is taking high risk drug class antipsychotic on a routine basis and on 08/19/24 GDR (Gradual Dose Reduction) has been documented by a physician as clinically contraindicated. R26's Order Summary Report dated 10/31/24 documents in part, Olanzapine 7.5 mg (milligram) give 0.5 tablet by mouth two times a day related to Unspecified Psychosis with start date of 06/26/23. Review of R26's EHR discontinued orders shows order for Olanzapine 7.5 give 0.5 mg tablet by mouth two times a day started initially upon admission on [DATE]. R26's Consent for Psychotropic Medication in R26's EHR documents in part for Olanzapine 7.5 mg give 0.5 tablet by mouth two times a day dated 04/12/22. R26's care plan initiated 04/11/22 documents in part, R26 is receiving antipsychotic medication Olanzapine noted to have diagnosis of Unspecified Psychosis and interventions include but not limited to AIMS per protocol for anti-psychotic use, monitor for signs and symptoms of side effects. On 05/31/24, V30 (Assistant Director of Nursing/Psychotropic Nurse/Infection Preventionist) provided copy of R26's Nursing: Abnormal Involuntary Movement Scale (AIMS) Assessment started 04/11/22 but not signed to complete it and R26's Nursing: AIMS Assessment completed 11/23/22. On 10/31/24, reviewed in R26's EHR Consultant Pharmacist's Medication Record Regimen Review dated 10/23/24, 09/23/24, 08/05/24, 07/17/24, 06/20/24, 05/08/24, 04/09/24 with no recommendations. On 10/31/24 at 10:15 AM, V30 stated AIMS Assessments are completed upon admission, and then quarterly/annual/significant change/readmission for residents receiving antipsychotic medications. V30 stated the purpose of the AIMS Assessment is to see if the resident is having any potential side effects from the psychotropics medications including involuntary movements such as tremors, gait change, abnormal facial/oral movements. V30 stated it is important for the AIMS Assessment to be done for safety because if the medication is causing side effects the facility would want to notify the doctor. V30 stated the potential problem if the AIMS Assessment is not done is that no one would see if there were any changes in side effects potentially caused by the psychotropic medication which would be a safety concern. V30 stated the doctor would need to be informed of any changes so they could evaluate if the medication dose needed to be lowered or changed. V30 stated the AIMS Assessments are filed under Assessments in the resident's EHR and if the AIMS Assessment is not in the resident's EHR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 13 of 23 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 11/01/2024 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete then they were not done. V30 stated they do not do paper AIMS Assessments. V30 reviewed R26's EHR and AIMS Assessment completed 11/23/22. V30 stated V30 did not know why that was the last AIMS completed for R26 and that an AIMS Assessment should have been completed as part of the last quarterly MDS which was on 10/22/24. Facility provided policy titled Psychotropic Medications - Use of dated 09/2020 which documents in part ongoing monitoring for side effects of all psychotropic medications will be completed and a baseline AIMS assessment, will be initiated when receiving antipsychotic medications. A re-assessment will be completed every six months. Event ID: Facility ID: 145888 If continuation sheet Page 14 of 23 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 11/01/2024 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews, the facility failed to follow their policy by not ensuring that medications are stored in original containers and labeled for one out of four medication carts reviewed for medication storage and labeling. This failure was found in the third floor's Team A medication cart and affected 24 residents. Findings include: On 10/29/2024 at 10:04 AM, V6 (Nurse) stated the facility assigned V6 to the third floor's Team A medication cart. V6 stated the cart housed medications for 24 residents. In one of the top drawers, observed three white round tablets in a clear plastic bag. The bag did not have a label to indicate what the tablets were or who they belonged to. V6 stated [V6] didn't know what medications the tablets were or who placed them in the plastic bag. V6 stated nurses should not have done that and should discard the tablets instead. During an interview with V4 (Assistant Director of Nursing) and V30 (Assistant Director of Nursing) on 10/31/2024 at 9:34 AM, V30 stated that unknown tablets should be discarded in the sharps' container. V30 stated no medication should be saved on the side. If a nurse needs a medication, they can always access the electronic dispensing system for additional medications. Facility's policies and procedures for Storage/Labeling/Packaging of Medications (dated 01/2022) documents in part: To store medications and biologicals under proper conditions of temperature, light, and security. Each resident's medications are stored in original containers and must be properly labeled. Medications are only administered from their originally dispensed containers. Medication containers that are damaged, soiled, contaminated, or outdated are immediately removed and either returned or disposed of according to procedure. Reorder from the pharmacy as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 15 of 23 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 11/01/2024 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to follow standardized pureed recipe during food preparation. This failure has the potential to affect 4 residents (R34, R71, R95, R160) receiving pureed diets prepared in the facility's kitchen based on Diet Type Report dated 10/31/24. Findings Include: On 10/29/24 at 12:30 PM, observed vegetable soup being served with lunch meal which contained pasta, fresh spinach, carrots, and celery. Residents on pureed diets received thin broth. The pureed broth was not blended with anything. V42 (Dietary Aide) stated that is the way the pureed soup usually looks (broth only). On 10/30/24 at 10:38 AM, V37 (Chef) stated when preparing soup for a meal first, the soup is made for the regular diets and then portions of the regular soup are placed in a large strainer to separate the liquid from the solids. V38 stated the strained off liquid is then used as soup for the pureed diets. V37 stated no solids from the regular soup are given to the pureed diets only the broth is given. V37 stated the soup for the pureed diets is not prepared using a blender. On 10/30/24 at 10:52 AM, observed V37 added an unmeasured but large amount of cream of mushroom soup into an industrial sized strainer. The solids from the regular soup appeared to be celery, potatoes and mushrooms were left in the strainer and the strained liquid was then placed in a container to be served at lunch to the residents on pureed diets. On 10/31/24 at 8:51 AM, V34 (Dietary Supervisor) stated the cooks should be following the recipes especially the procedure on how to prepare the item. V34 stated it is important for the cooks to follow the recipes to ensure standardization and to make sure the item being prepared has the right amount of nutritional value it is supposed to have. V34 stated based on the recipe pureed soup should be prepared using the food processor to blend the regular soup to pureed consistency. V34 stated the recipe does not call for the cooks to strain out the solids of the soup. V34 stated it is important for the cooks to blend the soup for the pureed diets to make sure they are getting all the nutrition needed from the soup. On 10/31/24 at 11:30 AM, V36 (Consultant Registered Dietitian) stated via phone interview that the menus are put together to provide adequate nutrition for the resident. V36 stated tor this reason, all items listed on the menu should be provided and the kitchen should follow the standardized recipes. V36 stated if the recipes are not followed the amount of calories, protein, and fat provided in the diet could be off which could change the nutritional quality of the diet. V36 stated residents on a pureed diet are potentially at higher nutritional risk due to chewing/swallowing problems. V36 stated residents receiving pureed diets should receive the same items as residents on regular diets except in pureed form unless contraindicated. For example, if regular diet consistencies are being served soup, then the pureed diets should also receive the same soup except in pureed form. V36 stated recipes for pureed soup should be followed and if the cooks are straining regular soup of the solids and only giving the pureed diets the strained broth then those residents are missing out on protein and carbohydrates. V36 stated pureeing the regular soup in a blender with the solids would provide more nutrition and the extra calories and protein could be helpful in providing more nutrients to the resident and potentially prevent weight loss and/or muscle loss if the resident is having (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 16 of 23 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 11/01/2024 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)

F 0803 decreased oral intake and/or only eating the soup. Level of Harm - Minimal harm or potential for actual harm R34's diet order per Order Summary Report dated 10/31/24 documented in part, pureed texture, thin liquids ordered 06/11/24. Residents Affected - Some R71's diet order per Order Summary Report dated 10/31/24 documented in part, pureed texture, nectar consistency ordered 07/19/24. R95's diet order per Order Summary Report dated 10/31/24 documented in part, pureed texture, honey consistency ordered 06/21/24. R160's diet order per Order Summary Report dated 10/31/24 documented in part, pureed texture, honey consistency ordered 10/14/24. Summer/Fall Regular Menu 2024 documents in part, Tuesday lunch vegetable soup and Wednesday lunch cream of mushroom soup. Summer/Fall Regular Menu 2024 Spreadsheets documents in part, 10/29/24 lunch vegetable soup for regular diet and pureed vegetable soup for pureed diet. Summer/Fall Regular Menu 2024 Spreadsheets documents in part, 10/30/24 lunch cream of mushroom soup for regular diet and pureed cream of mushroom soup for pureed diet. Kitchen recipe titled Pureed Soup Vegetable documents in part, 1.) Prepare according to regular recipe. 2.) Measure desired # of servings into food processor. Blend until smooth. Add commercial thickener if product needs to be thickened. Kitchen recipe titled Pureed Soup Cream of Mushroom documents in part, 1.) Prepare according to regular recipe. 2.) Measure desired # of servings into food processor. Blend until smooth. Add commercial thickener if product needs to be thickened. Document titled Job Description for Chef/Cook undated documents in part, essential functions - prepare food in accordance with standardized recipes. Kitchen document titled, Puree dated 07/2013 document in part, this diet is designed for people who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 17 of 23 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 11/01/2024 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)

F 0803 have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect their airway. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 18 of 23 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 11/01/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to follow manufacturer's guidelines for food storage and failed to follow their policy to ensure ready to eat food items were not refrigerated for longer than seven days. These failures have the potential to affect all 163 residents receiving food prepared in the facility's kitchen. Findings include: On 10/29/24 at 9:19 AM, V34 (Dietary Supervisor) stated items should be labeled with a delivery date, an opened or prepared date and a use by date. V34 stated prepared foods and/or ready to eat items should be used within seven days of preparation and/or when opened. V34 stated the reason food items should be labeled and dated is so the staff knows the expiration date of items and when to discard them so expired items are not served to the residents. On 10/29/24 at 9:38 AM, during initial kitchen tour with V34 and V35 (Company Dietary Coordinator) observed in the Walk-In Refrigerator the following items: 1.) Opened Pre-Sliced Cooked Turkey wrapped in plastic wrap dated with delivery date 10/16/24, opened date 10/19/24. There was no use by date labeled on the product. 2.) Opened package labeled Buffet Ham wrapped in plastic wrap dated with delivery date 10/04/24, opened date 10/09/24. There was no use by date labeled on the product. On 10/29/24 at 9:41 AM, V35 stated there is no use by date labeled on the items and there should be. V35 stated V35 did not know how long the products are good for once opened and will have to check. On 10/29/24 at 9:58 AM, observed opened 1-quart Lemon Juice labeled with delivery date 08/21/24. No opened or use by date was labeled. Observed manufacturer label on Lemon Juice bottle printed, Refrigerate After Opening. V25 stated whether the Lemon Juice needs to be refrigerated is debatable but yes it should have been stored in the refrigerator based on the manufacturer's guidelines. On 10/31/24 at 8:48 AM, V34 stated the precooked ham/turkey found in the Walk-In Refrigerator during the initial kitchen tour should have been thrown out after seven days from the opened date as per the facility policy. Facility provided policy titled, Labeling & Dating dated 7/23 documenting in part, ready-to-eat time/temperature control for safety foods may be stored in the refrigerator held at 41 degrees F (Fahrenheit) for 7 days and the purpose is to reduce the risk of food borne illness. Facility provided document titled, Food Expiration Dates Guidelines Chart undated documents in part, fully cooked ham whole 7 days, fully cooked ham half 3 to 5 days, fully cooked ham slices 3 to 4 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 19 of 23 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 11/01/2024 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)

F 0812 Facility provided document titled, Diet Type Report dated 10/29/24 listing residents with their diet orders indicating there are six residents who are receiving nothing by mouth (NPO). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 20 of 23 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 11/01/2024 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)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow Influenza and Pneumococcal Immunization policy related to determining, offering, and providing the vaccine for five [R93, R124, R145, R150, R158] residents reviewed in the sample of 33. Residents Affected - Some Findings Include: On 10/31/24 at 9:22 AM, R145 stated, I would like my Influenza and pneumonia shot, but I was not offered. R145's minimum data set [MDS]section [C] brief interview dated 10/9/24, indicates R145 is alert, oriented and cognitively intact. R145's MDS section [O] dated 10/9/24 indicates R145 was not offered influenza vaccine, and R145 was not eligible to receive pneumococcal vaccine. R145 is a [AGE] year-old with the following medical diagnosis in part; Peripheral vascular disease, type II diabetes, essential hypertension, and long-term use of insulin. On 10/31/24 at 9:26 AM, R158 stated, I was admitted here in July. The nurse told me they did not give out the flu shots until October, but tomorrow is November, and I have not received my flu shot, I don't want to get sick, and I have heart problems. I would like the pneumonia shot as well to help me. R158's minimum data set [MDS]section [C] brief interview dated 10/14/24, indicates R158 is alert, oriented and cognitively intact. R158's MDS section [O] dated 10/14/24 indicates R158 was not offered influenza vaccine because not in season, and R158 was not offered the pneumococcal vaccine. R158 is a seventy-five-year-old with the following medical diagnosis in part; chronic atrial fibrillation, essential hypertension, adult failure to thrive, and obesity. On 10/31/24 at 9:43 AM, observed R93 sitting his recliner wheelchair. Alert and confused. R93's minimum data set [MDS]section [C] brief interview dated 9/25/24, indicates R93 is moderately cognitively impaired. MDS section [O] dated 8/23/24 indicates R93 received influenza vaccine on 11/16/23, pneumococcal vaccine was not offered dated 8/23/24. R93 is a seventy-two-year-old with the following medical diagnosis in part; cerebral infarction, atherosclerotic heart disease, essential hypertension, type II diabetes, age related debility, and long-term use of insulin. [R93 was not offered the influenza vaccine this flu season nor the pneumococcal vaccine] On 10/31/24 at 9:55 AM, R124 stated, I finally received my influenza vaccine on 10/1/24, but I been asking for my influenza since March. The pneumococcal vaccine I consented to in March, and I have not received it. R124's minimum data set [MDS]section [C] brief interview dated 8/7/24, indicates R124 is alert, oriented and cognitively intact. R124's MDS section [O] dated 8/7/24 indicates R124 was not offered influenza vaccine because not in season, and R124 was not offered the pneumococcal vaccine. R124 is a ninety-year-old with the follow medical diagnosis in part; chronic congestive heart failure, chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease stage 3, and squamous cell carcinoma of skin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 21 of 23 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 11/01/2024 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)

F 0883 Level of Harm - Minimal harm or potential for actual harm On 10/31/24 V10 [Registered Nurse] stated, If a resident expresses to the floor nurse that they want the influenza or pneumococcal vaccine. I would first check with the physician or nurse practitioner to ensure it would be okay to given, then I would place in the order. Once the vaccine is received from the pharmacy, then the floor nurse would administer the vaccine, and document under the immunization tab in the resident's electronic chart. Residents Affected - Some On 10/31/24 at 11:00 AM, V30 [Assistant Director of Nursing/Psychotropic Nurse/Infection Preventionist] stated, Flu season is from October first to March thirty first. All new admissions are offered the influenza and pneumococcal vaccinations. If the resident is admitted from April to September, which is not flu season then the resident is not offered the flu shot, but should be offered the pneumonia shot, and documented under the immunization tab in the resident's electronic chart. The nurse should also ask the resident if they received the pneumonia shot previously and look at their medical paperwork from the hospital to observed which pneumococcal vaccination and when it was administered. On 10/31/24 at 11:15 AM, V4 [Assistant Director of Nursing/Infection Control Preventionist] stated, I usually start asking all residents consents for the influenza, pneumococcal, and covid at the beginning of September. Then I have a head count to give the pharmacy. The pharmacy will set up dates that they will come out for a vaccination clinic. We had a vaccination clinic on 10/18/24. The next clinic will be on 11/21/24. Some residents did not want to take all vaccinations at the same time. If a resident is admitted and requests a vaccination, and is appropriate, the resident should receive the vaccination within a week. Pneumococcal vaccine has guidelines; The age is 65 years or older, or have chronic health problems such as alcoholism, heart disease, lung disease, leukemia, kidney disease or failure, diabetes, HIV infections, cirrhosis, sickle cell disease, lymphoma, Hodgkin's disease or organ transplants should be offered the Pneumococcal vaccine at any age. The influenza vaccine is offered from October first to March 31st, annually to all residents. I believe the admitting nurses may have indicated some of the residents was not eligible for the vaccine due to their age alone and did not investigate the qualifying medical diagnosis. I will in-service the nursing staff. On 10/31/24 at 12:10 PM, V3 [Director of Nursing] stated, All residents should be offered the influenza vaccine during flu season and administered. The staff nurses should not wait for the vaccination clinic. The staff nurse is able to order the vaccine and administer. All residents of 65 years or older and or any one with chronic illness should be offered the Pneumococcal vaccine, and not wait for the vaccination clinic. The vaccination is offered to give the resident an extra layer of protection. The vaccines do not prevent the infection, but it will help the resident's immune system fight the infection, and hopefully prevent hospitalization. If a resident does not receive the requested vaccine, it could potentially cause a negative outcome on a resident's health with some one that has a chronic illness. Policy documented in part: Pneumococcal vaccine [ No date] It is the policy of this facility that residents will be offered in immunizations against pneumococcal disease. Pneumococcal vaccine guidelines by the CDC; residents aged 65 years or older or and residents with immune compromising conditions, chronic renal failure, HIV, Hodgkin's disease, leukemia, myeloma, organ transplant, alcoholism, chronic heart disease, liver disease, lung disease, chronic renal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 22 of 23 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 11/01/2024 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)

F 0883 disease, cigarette smoking, diabetes, cancer, sickle cell disease or other hemoglobin diseases. Level of Harm - Minimal harm or potential for actual harm If consented or declined it will be documented in the resident's medical records. Historical information will be entered, if available. Residents Affected - Some Influenza Vaccination Influenza vaccinations to be offered October 1st through March 31st annually. All new admissions will be offered the influenza vaccine during October 1st through March 31st unless ordered otherwise or has received the vaccine. If consented or decline it will be documented in the residence's medical records. R150's health record showed admission date on 4/25/2024 with diagnoses not limited to Acute and chronic respiratory failure with hypoxia, Chronic obstructive pulmonary disease, Unspecified systolic (congestive) heart failure, Hypertensive heart disease with heart failure, Dementia in other diseases classified elsewhere, Vascular dementia, Alzheimer's disease, Schizophrenia, Anxiety disorder, Type 2 diabetes mellitus, Benign prostatic hyperplasia, Insomnia, Spinal stenosis, Other pulmonary embolism without acute cor pulmonale, Dependence on supplemental oxygen, Unspecified chronic bronchitis, Other emphysema, Polyosteoarthritis. On 10/29/24 11:32 AM R150 Observed sitting on the side of the bed, alert and oriented x 3, verbally responsive. R150 said he has been residing in the facility since April, with oxygen inhalation via nasal cannula at 2L (liters)/min. He (R150) stated he wanted to receive pneumonia vaccine but was not offered and was not given. R150 order summary report dated 10/30/24 with active order not limited to: May receive pneumonia vaccine as appropriate for age and date of last dosage unless contraindicated. MDS (Minimum Data Set) dated 9/27/24 showed R150 was cognitively intact, did not receive pneumococcal vaccine and was not offered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 23 of 23