Health inspection·January 19, 2024

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident receives the necessary amount of assistant during a meal. This deficiency affects one (R26) of three residents in the sample of 17 reviewed for Providing Resident's meal. Residents Affected - Few Findings include: On 1/17/24 at 12:47PM, Observed V11 (Activity Aide) went inside the R26's room knocking and placed the lunch tray on the bedside tray table on the right side of the bed and left. R26 is lying in bed. Before V11 left the room, surveyor informed him of observation made. V11 said that he left the lunch tray on the bedside table because R26 is sleeping, and he did not want to wake her up. R26 heard the conversation and said, I'm not sleeping, I'm just lying in bed. V10 (Unit Manager) came and was informed of the observation made. V10 explained to surveyor that when staff provide a lunch tray to the resident, staff should provide assistance as needed and set up the lunch tray for the resident. V10 asked R26 if she needs assistance in her lunch tray. R26 said Yes, that would be great, instead of just leaving the tray. On 1/17/24 at 12:57PM, Informed V2 (Director of Nursing) of the above observation. V2 said staff should inform the resident when the meal tray is brought to their room and ask if they need assistance. R26 was admitted on [DATE] with diagnosis listed in part but not limited to muscle weakness, need for assistance with personal care, morbid obesity. Care plan indicates she has ADL (Activity of daily Living) functional performance deficit related to weakness, deconditioned due to recent hospitalization. Intervention: Assist with ADL task. Provide needed level of assistance and support to complete ADL. admission MDS (Minimum Date Set) assessment dated [DATE] indicated Section GG 130 Self Care -5 Set up or clean up assistance. Facility's policy on Meal service indicates: Purpose: 4. To assure that each resident receives the amount of assistance necessary. Procedure: 1. Assist resident to comfortable position. Note: To encourage social interaction and mobility, all residents should be encouraged to eat meals in the dining room per facility policy. 2. Ensure accuracy of diet served to each resident. 3. Served tray to resident with food covered, remove cover(s) from food 4. Identify resident to ensure correct diet is being served. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145907 If continuation sheet Page 2 of 9 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 145907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Evanston 2520 Gross Point Road Evanston, IL 60201 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 0676 5. Place all utensils and food containers within easy reach of resident, assist as necessary. Level of Harm - Minimal harm or potential for actual harm 6. Cover or assist resident to cover clothing with napkin, or clothing protector as desired. 7. Allow the resident to enjoy his/her meal after you are sure you have provided adequate assistance Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145907 If continuation sheet Page 3 of 9 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 145907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Evanston 2520 Gross Point Road Evanston, IL 60201 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow manufacturer recommendation in using a low air loss mattress to resident with multiple pressure ulcers and arterial wound. This deficiency affects one (R42) of three residents in the sample of 17 reviewed for Pressure ulcer prevention and treatment management. Residents Affected - Few Findings include: On 1/18/24 at 11:09AM, Observed V10 (Unit Manager/Certified Nursing Assistant) and V13 (Wound Care Nurse) preparing R42 for wound care. R42 is on LAL (low air loss mattress) with a thick towel and flat sheet underneath him. R42 wears disposable brief. Informed observation to both V10 and V13. Both said that a resident on LAL mattress should only have flat sheet over it. There should be no multiple layers of linen over the mattress. On 1/18/24 at 1:30PM, Informed V2 (Director of Nursing/DON) of the above observation. V2 said that a resident on LAL mattress should only have a flat sheet over the mattress. No multiple layers of linen as the manufacturer's recommendation. On 1/18/24 at 2:00PM, V2 (DON) and V16 (Nurse Consultant) said that they don't have policy for using LAL mattress. R42 was initially admitted on [DATE] with diagnosis listed in part but not limited to Stage 3 Pressure ulcer of left heel, Peripheral vascular disease. Active physician orders indicate: Evidenced based practice for chronic wound. Cleanse right heel with normal saline, apply Betadine solution 10% topically every Monday, Wednesday and Friday and as needed for arterial non pressure ulcer. Cleanse left heel with ½ strength (name brand) solution, apply Silvadene, Calcium Alginate and cover with foam dressing to left heel every day shift and as needed. Cleanse with solution, pat dry, apply (name brand ointment) and hydrocolloid dressing to sacral to perineum every Monday, Wednesday, Friday and as needed. Apply (name brand cream) as needed for contamination. Care plan indicates: Actual alteration in skin integrity related to Left heel pressure ulcer, sacral pressure ulcer, Perineum MASD (Moisture Associated Skin Disorder), right heel arterial non pressure ulcer. Is high risk for alteration in skin integrity related to limited mobility, use of anti-coagulants, incontinence. Intervention: Pressure reduction foam mattress or pressure redistribution support (low air or alteration air) in bed. R42's wound report dated 1/12/24 indicated 1. Left heel- Stage 3 pressure ulcer. Date reported 12/29/23. Measurement-3x3.5x01cm. 30% granulation, 50% necrotic/eschar, 20% slough. Moderate serosanguineous. Subcutaneous tissue exposed. Treatment: Cleanse with ½ (name brand solution), apply Silvadene, calcium alginate and cover with foam dressing. 2. Perineum- Diaper dermatitis MASD, Superficial mycosis. Dare reported 12/29/23. 100% less erythema and scales. Undefined margins. Denuded peri wound. Treatment: Cleanse with normal saline twice a day and as needed. Apply Mycolog II. 3. Sacral extends to perineum- Stage 3 pressure ulcer. Date reported 12/29/23. Measurement- 8x7x0.1cm. 40% patchy granulation, 30% necrotic/eschar, 10% slough, 20% epithelization. Undefined margins. Denuded peri wound. Light serosanguineous exudate. Treatment: Cleanse with (solution). Apply (name brand ointment) cover with hydrocolloid dressing. (name brand cream) 0.75% as needed for contamination. 4. Right heel - non pressure arterial. Date reported 12/29/23. Measurement-3x6x0cm. 100% maroon. Dry peri wound. Treatment: Cleanse with normal saline. Apply betadine paint and cover with foam dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145907 If continuation sheet Page 4 of 9 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 145907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Evanston 2520 Gross Point Road Evanston, IL 60201 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 Facility unable to provide policy in using Low air loss mattress. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145907 If continuation sheet Page 5 of 9 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 145907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Evanston 2520 Gross Point Road Evanston, IL 60201 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 observation, interview and record review the facility failed to ensure a resident received the correct oxygen flow as ordered for 1 of 2 residents (R14) reviewed for respiratory care in a sample of 17. Residents Affected - Few Findings include: On 1/17/2024 at 12:05 PM R14 was observed in bed with oxygen via nasal canula set at 5 liters. On 1/17/2024 at 12:07 PM V12 (Registered Nurse) observed with surveyor R14's oxygen infusing at 5 liters. V12 said oxygen should on 2-3 liters. On 1/28/2024 at 11:20 AM V2 (Director of Nursing) said that if resident is using oxygen, it should be in place all the time if continuous and nurse to follow physician's order as far as oxygen setting. A Transfer and Discharge Report indicated R14 has a diagnosis of Dependence on Supplemental Oxygen and Acute Respiratory Failure with Hypoxia. An Order Summary Report indicates R14 has a Physician order dated 11/10/2023 for Respiratory: Oxygen per nasal cannula at 2 liters per minute continuous every shift. A Care Plan dated 11/10/2023 with an intervention of Administer oxygen per Medical Doctor -MD orders. Facility Policy: Oxygen Therapy Devices - Nasal Cannula 09/2020 Policy: Oxygen delivered per nasal cannula, will be used to prevent or reverse hypoxia and improve tissue oxygenation. Procedure: 1.Verify physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145907 If continuation sheet Page 6 of 9 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 145907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Evanston 2520 Gross Point Road Evanston, IL 60201 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to label and date food placed in one of three resident unit refrigerator. This deficiency has the potential to affect 25 residents receiving a general diet. Findings include: On 1/17/24 at 1:31PM, Checked refrigerator in the 3rd floor dining room pantry with V8 (Dietary Aide/DA). Observed sliced turkey pale and dry, placed in small plate not completely covered, not labeled, and not dated; three (3) small plates of fruits not labeled and not dated. V8 said that all food inside the refrigerator should be covered, labeled, and dated. On 1/17/24 at 2:00PM, Informed V4 (Dietary manager) of the above observation. V4 said that food inside the refrigerator should be covered, labeled, and dated. Facility's policy on Labeling and dating indicates: Purpose: To reduce the risk of food borne illness. Procedure: 1. Ready to eat time/temperature for safety (TCS) food that is held for less than 24 hours may be labeled with the common name, date, and time it is placed in the refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145907 If continuation sheet Page 7 of 9 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 145907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Evanston 2520 Gross Point Road Evanston, IL 60201 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record the facility staff failed to wear the required PPE (Personal Protective Equipment) and failed to clean the PPE for 2 residents (R26 and R45) of 5 residents reviewed for transmission-based precautions in a sample of 17 residents. Residents Affected - Few Findings include: On 1/17/24 at 12:38 PM V11 (Activity Aide) exited the room of R45. V11 removed the reusable face shield and placed it on the PPE (Personal Protective Equipment) cart. V11 did not clean the reusable face shield. R45 has a positive Covid 19 test result. There are postings indicating contact and droplet precautions for R45. On 1/17/24 at 1:00 PM V2 (Director of Nursing) said that staff are to clean the reusable face shields with the surface wipes after each use before returning them to the cart. On 1/17/24 at 1:10 PM V19 (Maintenance) entered the room of R45 wearing a facemask. V19 was not wearing an N95 mask, face shield, gown, or gloves. V19 said I'm just going to check the ceiling and went into the resident's bathroom. There were signs on R45's door indicating contact and droplet precautions with illustrations of PPE required to enter the room. On 1/19/24 at 10:00 AM V2 (Director of Nursing) said any staff that enter a room with contact and droplet and precautions ordered should wear mask, eye protection, gown, and gloves when entering the room. If the resident is positive for Covid 19 an N95 mask is required. The Order Report Summary for R45 indicates resident in single room isolation for active infection or suspected infection with symptoms, receiving all care within room. Policy: Infection Prevention and Control Manual Transmission-Based Precautions Revised 12/14/2023 Contact Precautions Procedure: 2. All individuals entering the resident's room must use PPE appropriately, including gloves and a gown. Donning PPE upon room entry and doffing before exiting the resident's room is done to contain pathogens. Do not wear the same gown and gloves for more than one person. On 1/17/24 at 12:47PM, Observed V11 (Activity Aide) went inside the R26's room which is contact isolation without donning gloves to serve lunch tray. V11 is wearing surgical mask and gown. Informed V11 of observation made that he did not put gloves when entering contact isolation room. V11 said that he there is no gloves available. V10 (Unit Manager) came and was informed of the above observation made. V10 said that V11 does not need to wear gloves because he will only bring the lunch tray and will not provide direct care. Showed to both V10 and V11 the signage posted at the door entrance indicating of contact isolation requiring hand hygiene, donning mask, gloves, and gown prior entering the room. On 1/17/24 at 12:57PM, Informed V2 (Director of Nursing/Infection Control Coordinator) of the above observation. V2 said that mask, gown, and gloves should be donned prior to entering the contact isolation room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145907 If continuation sheet Page 8 of 9 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 145907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Estates of Evanston 2520 Gross Point Road Evanston, IL 60201 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 0880 R26 is admitted on [DATE] with diagnosis listed in part but not limited to MRSA Level of Harm - Minimal harm or potential for actual harm (Methicillin- Resistant Staphylococcus Aureus) of the wound. Active physician order indicates: Contact isolation precaution due to MRSA of the wound. Care plan indicates: She is on antibiotic therapy with isolation contact precaution due to MRSA of the wound. Intervention: Monitor isolation set up and replenish supplies as needed. Residents Affected - Few Facility's policy on Infection Prevention and Control Manual Transmission-Based Precautions indicates: Contact Precautions policy: The purpose of contact precaution is to prevent transmission of infections that are by direct (e.g., person to person) or indirect contact with the resident or environment. Procedures: 2. All individuals entering the resident's room must use PPE (Personal Protective Equipment) appropriately, including gloves and a gown. Donning PPE upon room entry and doffing before exiting the resident's room is done to contain pathogens. Facility's contact precaution sign adopted from CDC (Centers for Disease Control and Prevention indicates: Contact precautions everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: * Put on gloves before room entry. Discard gloves before room exit. *Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. *Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145907 If continuation sheet Page 9 of 9