Health inspection·July 9, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility will report reasonable suspicion of a crime. The facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done: 7. Filing accurate and timely investigative reports. 7. Reporting. a. The administrator or designee will also inform the residents representative of the report of an occurrence of potential mistreatment and that an investigation is being conducted. Event ID: Facility ID: 145888 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 145888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency within the mandated timeframe and failed to ensure an allegation of abuse was reported to the State Agency. These failures affected 2 (R1 and R2) residents reviewed for reporting of abuse allegations in the total sample of 10 residents. Findings include: 1. On 07/07/2025 at 2:43pm, V13 (Unit Manager) stated that on 07/01/2025 (Tuesday) she was standing by the 3rd floor's nurse's station putting the transportation form back in the binder when (R1) stated she wanted to speak with the Administration. She (R1) did not want to tell her. She just kept repeating I want to talk to somebody. V13 stated that she (R1) seemed upset and that she (V13) ended up going downstairs to talk to (V11 - Assistant Administrator). V13 stated that she told (V11) that something is going on, on the 3rd floor, she (V11) needed to talk to the resident (R1), and that she (R1) is upset. (V11) was on a call and she (V11) said she would talk to the resident. V13 stated she did not see her (V11) talk to the resident (R1). V13 stated she went back along with her day. V13 stated that she (V13) saw (V7 -CNA/Certified Nurses Assistant) who informed her (V13) that (R1) was saying that a nurse stuck up the middle finger at her (R1). V13 stated she went straight to the office and informed V11. V13 stated sticking up a middle finger is considered mental abuse. She went straight to the admin office and told (V11) that a nurse stuck up the middle finger at (R1). V13 stated that she (V11) will deal with it. On 07/07/2025 at 3:20pm, V11 (Assistant Administrator) stated she started about a month ago. Somebody reported to her that (R1) was upset. She thinks it was (V13) who told her on Tuesday probably sometime in the morning. V11 stated (V13) might have come to her twice and that she (V11) was busy with 'payroll'. V11 stated if a nurse stuck up the middle finger at (R1) it is probably mental abuse. V11 stated if there was an allegation of abuse, whether true or not, it should be investigated and it should be reported to IDPH as soon the facility has the information. At this time, this surveyor handed V11 the facility abuse policy and procedure. V11 then stated an allegation of abuse should be reported within 24 hours. If there was an allegation of mental abuse on Tuesday (07/01/2025) then it should be reported immediately within 24 hours. V11 stated the allegation of mental abuse was reported on 07/03/2025, the facility is not within the regulation of reporting the allegation of abuse. R1's admission Record documented that R1's diagnoses (include but not limited to) presence of right artificial knee joint, open angle bilateral glaucoma, and dementia. R1's (06/23/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R1's mental status as cognitively intact. R1's Initial reportable, dated 07/03/2025, documented, in part Resident reported that a staff member on her floor told her to shut up. Resident could not recall when this occurred. Resident could not describe staff member other than he was a male. Of note, initial reportable was submitted more than 24 hours after the facility was made aware of the allegation on 07/01/2025. 2. On 07/05/2025 at 11:02am, V2 (Director Of Nursing) stated it was reported to her on 06/26/2025 by (V7CNA) that (V3-LPN/Licensed Practical Nurse) told (R2) show me your n***r strength. She (V2) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 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 145888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm pulled (V3) to investigate. (V3) stated he was just repeating the story about (R2) spilling the water and (V3) gave (R2) a paper towel and refused to give back the paper towel to him, she was resisting, and he said to her, Wow, you are so strong. and she (R2) said to him I am N***r Strong. He was repeating the story to the staff on 6/26/25. V2 stated that she told (V3) I understand you are repeating a story but that is inappropriate language and should not be used in the building. Residents Affected - Few On 07/08/2025 at 12:52pm, V2 (Director of Nursing) stated she did the investigation and did not find anything, and she did not submit an initial reportable to the State because the racial slur was not directed to the resident. V2 added she should have reported it to the State as an allegation of verbal abuse. R2's admission Record documented that R2's diagnoses (include but not limited to) dementia, age related osteoporosis, and history of falling. R2's (04/23/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 6. Indicating R2's mental status as severely impaired. R2's Initial reportable, dated 07/09/2025, documented, in part On 06/26/25 a staff member reported that another staff member made a racial slur towards a resident while providing care. The resident could not recall this incident. The staff member was suspended on 06/26/2025. Of note, R2's initial reportable was sent to State Agency more than 24 hours after the allegation was made. The Abuse Policy, dated 03/25, documented, in part Policy: affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility will report reasonable suspicion of a crime. The facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done: 7. Filing accurate and timely investigative reports. 7. Reporting. Initial reporting of allegations shall be completed immediately upon notification of that allegation. The written report shall be sent to the Department of Public Health. g. the report must be made not later than 24 hours after forming a suspicion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145888 If continuation sheet Page 4 of 4