Health inspection·January 22, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have resident-specific and effective interventions in place for a resident with multiple falls while in the facility; failed to ensure care plan interventions are being carried out per the resident's plan of care; and failed to have a fall care plan in place for a resident who was assessed to be at risk of falls. These failures applied to two (R2 and R3) of three residents reviewed for falls, and resulted in R2 sustaining multiple rib fractures after a fall, and R3 sustaining a pelvic fracture as a result of a fall. Findings include: 1. R2 is a [AGE] year-old resident, originally admitted to the facility on [DATE]. R2 has medical diagnoses that include but are not limited to: Parkinson's Disease without dyskinesia, dementia, history of falling, mild cognitive impairment, and longtime use of Aspirin. R2's MDS (Minimum Data Set) assessment, dated 6/21/23, documents R2 requires limited assistance of one person for toilet use and is occasionally incontinent of urine. Review of R2's fall risk assessments from 08/12/23 to current, all document R2 is at risk for falls. Nursing Progress Note, dated 8/27/23, documents R2 is one person assist with ADL's (activities of daily living). Nursing Progress Note, dated 9/13/23, documents R2 is incontinent of bowel & bladder and requires one person assist with ADL's. There are several nursing progress notes that document ,R2 does not use a bed/chair alarm, and R2 forgets to use the call light (these are dated throughout October 2023) Review of R2's medical record shows R2 had the following falls while at the facility: 8/12/23 - fell out of wheelchair in room (no injury) 9/13/23 - fell from bed (no injury) 10/25/23 - fell in room near bedside table (no injury) 11/13/23 - fall on bed, resulting in rib fracture 1/5/24 - fell in room (no injury) R2 had a significant change MDS, completed on 10/17/23, which documents R2 had a BIMS (Brief Interview for Mental Status) score of 5, which indicates severe cognitive impairment and that R2 is frequently incontinent of bowel and bladder. Facility submitted incident report, documenting on 11/13/23, R2 was transferred to local hospital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145984 If continuation sheet Page 2 of 8 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 145984 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden North Shore Rehab & Hcc 5050 West Touhy Avenue Skokie, IL 60077 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 0689 at approximately 12am due to chest pain and per report from, he had fallen onto his bed. Level of Harm - Actual harm Hospital record from 11/13/23 admission, documents R2 sustained displaced fractures of left 7-11 ribs due to a fall. Residents Affected - Few Review of R2's care plan for falls includes interventions for falls, however, R2 was still having falls in the facility. On 01/19/2024 at 2:35pm, V11 (Licensed Practical Nurse/LPN) stated, I sent (R2) to the hospital after a fall back in November because he had rib pain, increased respirations, blood pressure, and chest pain. 911 was called and then the hospital confirmed he had multiple rib fractures. The fall was unwitnessed, and he was in his room. (R2's) normal baseline is alert and oriented x 1. Before the fall, he ambulated better. but now he uses the wheelchair. We watch him all the time. He is always one person assist. On 1/19/24 at 2:12pm, V25 (Certified Nursing Assistant/CNA) stated, (R2) is confused, and he needs help. V25 continued to state that she was not on duty when R2 fell back in November, but she heard he fell a couple weeks ago. V25 stated, I always watch (R2) because I know that he is confused, and he doesn't use the call light. At this time, R2 was found to be lying in bed, and it was noted R2's wheelchair was pulled up next to R2's bed (in between the bed and the wall), and there was no bed alarm in place for R2; bed alarm was on the wheelchair. V25 said, The alarm is not supposed to be here, and the wheelchair is not locked. I'm sorry, I don't know who put him in bed; I just got in and haven't gotten a chance to do my rounds. On 1/21/24 at 3:59pm, V2 (Director of Nursing) stated, We are constantly assisting (R2) and taking him into consideration. He's in the room close to the nurses' station and we encourage him to stay in areas where he can be seen. We weren't sure how to label it (11/13/23 fall), because he didn't have a change of plane. He wouldn't have been able to get himself off the floor. We think that he attempted to self-transfer from the bed and maybe he hit himself with the side rail of the bed. It may have had to do with his ability to self-transfer. V2 stated she was not sure why that intervention (bed alarms) was not added sooner. It is noted bed and chair alarm interventions were added to the care plan after the fall on 01/05/24. 2. R3 is a [AGE] year-old resident, admitted to the facility on [DATE]. R3 has medical diagnoses that include but are not limited to: history of falling, dementia, fracture of right pubis, fracture of right ischium, and unsteadiness on feet. Facility submitted incident report, documenting R3 had an unwitnessed fall on 12/3/23 at approximately 4:20pm on the bathroom floor. R3 was subsequently transferred to the local hospital and per hospital records, was found to have an acute fracture of the right inferior pubic ramus and a mildly comminuted, acute fracture of the right ischial tuberosity. Hospital record also documents R3's son was contacted and stated R3 has frequent falls and worsening weakness recently, has baseline dementia, walks with assistance, but doesn't regularly use walker. Based on facility documentation of investigation, multiple staff reported resident ambulates on his own to the bathroom, without assistance. R3's most recent fall risk assessment prior to falling on 12/3/23 was completed on 9/25/23, and was scored at a 3 - At Risk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145984 If continuation sheet Page 3 of 8 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 145984 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden North Shore Rehab & Hcc 5050 West Touhy Avenue Skokie, IL 60077 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 0689 Level of Harm - Actual harm The fall risk assessment completed on 9/25/23 documents R3 is alert & oriented x 3 (mentation) and R3 is regularly continent (no assist to get to the toilet); both of these categories are conflicting with the information documented on the resident's MDS (Minimum Data Set) assessment of approximately the same timeframe. Residents Affected - Few R3's most recent MDS assessment prior to falling on 12/3/23 was completed on 9/28/23, and documents the following: (BIMS) Brief Interview for Mental Status score is 7, which indicates severe cognitive impairment; ADL (Activities of Daily Living) needs include limited assistance, one person assist with bed mobility, transfers, walking in room, and toilet use; R3 is occasionally incontinent of bowel. Review of R3's medical record includes psychiatry note dated 9/26/23, which documents: Chief Complaint/Nature of Presenting Problem: dementia History of Present Illness: F/U with [AGE] year-old patient who has a history of dementia. Patient found in his room, with baseline level of confusion . Facility was asked to provided fall risk care plans for R3, and it is noted the fall care plan provided was not initiated until 12/6/23. Although the care plan has interventions initiated in 2019, there were no recent care plan interventions for all of 2023, prior to R3's fall on 12/3/23. On 01/19/24 at 2:24PM, V10 (Registered Nurse) stated, (R3) used to be independent, but now he needs help of one person assistance. (R3) had another fall on 01/04/24 while I was on duty; he went into the bathroom in the hall. When I heard a loud sound coming from the bathroom, I went to check and found (R3) on the floor. He did not have any injuries with this fall. On 1/21/24 at 3:59pm, V2 (Director of Nursing) stated, (R3) had a hospital stay and then came right back and the care plan was initiated when he came back. Surveyor asked why the fall care plan was not updated all of the prior year, and V2 stated t if he hadn't had a fall prior to that, then his care plan wouldn't have been updated. We don't change the dates of the interventions if they are still applicable. Surveyor asked if the care plan should be updated since the resident has declined or had a change in condition since he first arrived in the facility several years ago, and V2 stated that she does not know, because she was not working here then. The MDS (Minimum Data Set) coordinators update the care plans quarterly. It (fall on 12/3/23) was an unwitnessed fall. He was attending activities in the lower level and then went to the bathroom; he went to the bathroom without asking for assistance. Sometimes he's not compliant with asking for help; he thinks that he is more independent than he is. The discrepancy in the MDS and assessment could be two different people are completing them. Assuming that they are looking at the same information, I would expect them to be the same. We do have trainings and in-services to ensure that staff are on the same page to confirm what they are describing and seeing accurately. Assessments need to be completed correctly so that everyone can be aware of the residents current functioning and need level. Facility provided policy titled, COMPREHENSIVE CARE PLANS, dated 11.2017, reads: Policy Statement An individualized, person-centered comprehensive care plan, including measurable objectives with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145984 If continuation sheet Page 4 of 8 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 145984 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden North Shore Rehab & Hcc 5050 West Touhy Avenue Skokie, IL 60077 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 0689 timetables to meet Resident's physical, psychosocial and functional needs, is developed and implemented for each Resident. Level of Harm - Actual harm PROCEDURE: Residents Affected - Few 1.) In coordination with the Resident and Resident representative, as applicable, the Interdisciplinary team will develop and implement a person centered, comprehensive plan of care. Care plans are comprised of Focus statements, Goals and Interventions. 2.) The Interdisciplinary team includes, but is not limited to: a. The Attending Physician b. A nurse and nurse's aide that have responsibility for the Resident; c. A member of the food and nutrition services staff d. The Resident and Resident representative, if applicable; e. Other appropriate staff or professionals determined by the Resident's needs, preferences, or requests. 3.) The Resident's comprehensive, person-centered care plan will be kept consistent with the Resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. Participate in the care planning process; b. Identify individuals or departments to be included; c. Request meetings; d. Request revisions to the plan of care; e. Provide input into the expected goals and desired outcomes of care; f. Receive the care and services as outlined in the plan of care; g. View the care plan after significant changes are made. 4) Care plan interventions are initiated based on an analysis of information collected throughout the comprehensive assessment process. 5.) The medical record will show evidence of an explanation if the Resident or Resident representative's participation in the development of the plan of care is determined to not be practicable. 6.) The comprehensive person-centered care plan will: a. Reflect treatment goals, timetables and objectives in measurable outcomes; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145984 If continuation sheet Page 5 of 8 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 145984 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden North Shore Rehab & Hcc 5050 West Touhy Avenue Skokie, IL 60077 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 0689 b. Describe the services that are to be provided to attain or maintain the highest practical physical, mental and psychosocial well-being; Level of Harm - Actual harm c. Describe services that would be provided to attain the above, but the Resident refuses; Residents Affected - Few d. Describe specialized services to be provided based on PASARR recommendations; e. Include the Resident's goals for progress, reflect the Resident's expressed wishes regarding care and treatment goals, including discharge planning; f. Identify the professional services that are responsible for interventions; 7.) The comprehensive, person-centered plan of care is developed within 7 days of the completion of the required comprehensive MDS. 8.) Assessment of the Resident is ongoing and care plans are revised based on the Resident condition, preferences, treatments and goals change. 9.) After the initial comprehensive, person-centered plan of care is developed, formal care plan reviews will be held in conjunction with the MDS schedule and shall be no longer than 92 days apart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145984 If continuation sheet Page 6 of 8 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 145984 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden North Shore Rehab & Hcc 5050 West Touhy Avenue Skokie, IL 60077 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 interview and record review, the facility failed to follow their policy Management of resident with confirmed or suspected Covid-19 infection or identified as a close contact by not testing one resident after 24 hours (R8) after the roommate tested positive for Covid-19, and by allowing a staff member to come to work with sore throat, who tested positive for Covid-19 after working with direct patient contact. These failures have the potential to affect all residents living in the facility. Residents Affected - Many Findings include: R7 is an [AGE] year-old female admitted on [DATE], with medical diagnosis that include and are not limited to: hemiplegia and hemiparesis, hypertension, and dementia. On 1-17-2024 at 9:13pm, R7 tested positive for Covid-19 at a local emergency room; V1 (Administrator) and V2 (Director of Nursing) informed. On 1-19-2024 at 9:20am, V1 (Administrator) said, Our census is 65 patients with one positive Covid-19 patient (acquired in the facility); currently (R7) is in a private room on isolation. (R7) tested positive on 1-17-2024. We are monitoring the other residents for any signs and symptoms; we are not doing any broad approach testing. We did not test the roommate because (R8) does not have any symptoms. On 1-19-24 at 9:30am, V2 (Director of Nursing) said, We are not to do any tests on any resident unless the patient presents with any Covid-19 respiratory sign and symptoms. The nurse consultant is the Infection Preventionist. On 1-19-2024 at 1:50pm, V9 (Dietary/ Dining Room Aide) said, I am responsible to do the distribution of the trays in the dining room, another person plates the food and I take the tray and set it up for the patient in the dinner table. I work the first shift; I passed the breakfast and lunch trays on the second floor. On 12-31-2023, I came to work with a sore throat, I was not able to sleep the night prior. I make sure to serve the breakfast and the discomfort was getting worse and worse; at about 10:00am, I asked the nurse to please give me the rapid Covid-19 test, and the results were positive. On 1-19-24 at 3:40pm, V2 (Director of Nursing) said, We have not done any Covid-19 tracking and tracing, we are only monitoring for signs and symptoms. We do not take any broad approach of testing any other residents. The staff members know that if they are sick they need to call the facility report to the supervisor; if they have Covid-19 signs and symptoms they need to make sure to test themselves. If they need to be tested, they can come and we can do the test at the facility if they are negative and they are well enough to work, they can work, if they are positive, they need to make sure to go home and quarantine for 10 days before they are able to return to work. My expectation is that no one that is sick or have a sore throat comes to work, if they have any signs and symptoms, they need to be off work. On 1-20-2024 at 12:10pm, VI6 (Medical Doctor) said, No staff member should report to work if they are sick with any signs and symptoms of Covid-19. Residents that are positive for Covid-19 need to be closely monitor and the facility needs to follow the CDC recommendations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145984 If continuation sheet Page 7 of 8 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 145984 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden North Shore Rehab & Hcc 5050 West Touhy Avenue Skokie, IL 60077 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 1-20-2024 at 1:00pm, V23 (Infection Preventionist/ Corporate Consultant) said, The Director of Nursing (V2) and me are responsible for the tracking and monitoring of the infections. I need to make sure that Infection control policy is followed, if a patient is positive for Covid-19 we isolate for 10 days and monitor the other for signs and symptoms, take vitals; High exposure- Roommate- will be tested within 24, 48 hours and the fifth day. We did not do any tracing for (R7) since the patient is a long-term care and does not go out of the facility. I do not know why (R8) was not tested yesterday after she was directly exposed by (R7) (roommate). On 1-20-2024 at 1:00pm, V23 (Infection Preventionist/ Corporate Consultant) said, My expectation is that anyone with symptoms do not allow to work, the employee is to test at home if they are having any signs and symptoms of Covid-19 and they should not be in direct contact with the residents in the facility. Policy titled: Management of resident with confirmed or suspected Covid-19 infection or identified as a close contact, dated: 1-5-2024, reads: the facility will manage residents with confirmed or suspected Covid-19 infection in accordance with recommendations from CDC. Resident identified as close contact: testing is recommended immediately and if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145984 If continuation sheet Page 8 of 8