Inspection·May 1, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R3 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: cerebral infarct, anemia, aortic aneurysm, aortic dissection, aortic valve replacement, tracheostomy, gastrostomy, diabetes, and pressure ulcer. The care plan initiated on 4/23/2025 states, that R3 has ADL self-care performance deficit and decreased functional ability related to fall risk, limited mobility, recent hospitalization, shortness of breath, stroke, weakness/deconditioning, tracheostomy status, anoxic encephalopathy. Interventions read: Assist resident with oral care daily as needed. Assist with personal hygiene as needed. On 4/30/2025 at 11:00 AM V11(Family Member) said, I come to the facility every day to visit my brother and the care is good, but mouth care is a problem, and his teeth are very dirty. V11 opened R3's mouth and showed the surveyor R3's teeth condition, stating look to see for yourself how yellow and crusted his teeth are. On 4/30/2025 at 4:10 PM V2 (Director of Nursing) said, the nursing assistant is responsible for oral care unless a medicated mouthwash is used. Oral care is done every shift or as needed by nursing assistants and residents who require assistance. I expect the staff to provide oral care to prevent build-up and dry-crusted secretion on lips and gums. The facility will work on adding residents to the dentist list. Facility provided policy titled, Oral Care (dated 09/2020), which includes: Procedure: Note: Offer oral care hygiene before breakfast and bedtime. 6. Inspect mouth and gum FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145998 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 145998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Des Plaines Rehab & Hc 1221 East Golf Road Des Plaines, IL 60016 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 review, the facility failed to follow facility-enhanced barrier precautions during tracheostomy care and suctioning, failed to change gloves during suctioning and used soiled gloves to start a sterile procedure, and failed to use a sterile technique when using the sterile catheter. This failure affected one (R1) of three residents reviewed for infection control. Residents Affected - Few Findings include: R2 is a [AGE] year-old resident with diagnoses including but not limited to: metabolic encephalopathy, respiratory failure, spinal cord injury, diabetes, quadriplegia, gastrostomy, and tracheostomy. R2 was admitted to the facility on [DATE]. On 4/30/2025 at 1045 AM Observed V5 (Respiratory Therapist) providing tracheostomy and suctioning care to R2. V5 touched the suctioning tubing hanging around the canister on the wall removed the yanker suction tube with yellow secretion opened to air and removed the sterile suction tubing from the opened sterile package proceeded to connect it to the wall suction tube. V5 used a nondominant hand to remove the tracheostomy oxygen collar and suctioned R2 with the dominant hand, during the procedure the suction tube touched the gown and R2's hand. After suction was completed, there was a moderate amount of secretion outside the tracheostomy on the drain gauze, V5 grabbed the yanker tubing from the bag behind the bed and suctioned R2 and did not change the drain gauze. V5 said, R2 is having a lot of secretions requiring suctioning every two hours and I will be back to change later. V5 did not use a gown to suction R2 and did not change gloves during the process or hand hygiene. V5 stated that it was a clean procedure and did not use a gown because it was a quick procedure. V5 said I was expected to do it when the enhanced barriers precaution was placed on the door and R2 had a tracheostomy. On 4/30/2025 at 2:29 PM V4 (Director of Respiratory Therapy) said, I expect the staff is taking care of a tracheostomy it is considered a clean procedure but during suctioning, if the respiratory therapist used a sterile suction kit, I expect the respiratory therapist to use a sterile technique using the dominant hand and the non-dominant hand to use clean technique and change gloves, hand washing when gloves were dirty. V5 was expected to be using enhanced barriers precaution per facility protocol during suctioning and tracheostomy care. V5 was expected to dispose of the opened suction tubing hanging around the suction canister with secretion before suctioning R2. On 4/30/2025 at 4:10 PM, V2 (Director of Nursing) said, I am the infection control preventionist for the facility. I expect the staff to use enhanced barriers precaution per facility protocol during tracheostomy and suctioning. The respiratory therapist should have changed his gloves when V5 moved from dirty to clean and washed his hands. Suction supplies opened in use should be kept in the bag. On 4/30/2025 at 4:15 PM, V1 (Administrator) said, I expect the staff to use enhanced barrier precautions per facility protocol during tracheostomy, suctioning, and respiratory procedures, and I will work with V2 to educate the staff. Facility provided policy titled, Suctioning Tracheostomy (dated 09/2020), which includes: 8. Remove soiled tracheostomy dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145998 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 145998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Des Plaines Rehab & Hc 1221 East Golf Road Des Plaines, IL 60016 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 9. Remove exam gloves and wash hands. Level of Harm - Minimal harm or potential for actual harm 10. Open dressings, sterile basins, and other supplies using a clean technique. Residents Affected - Few 11. Pour 50% hydrogen peroxide & 50% NS (per MD orders) into one sterile basin and sterile saline/normal saline into the other sterile basin, using aseptic technique .10. Put on a face shield or goggles and mask (if indicated). Put on sterile gloves. The dominant hand will manipulate the catheter and must remain sterile. The non-dominant hand is considered clean rather than sterile and will control the suction valve (y port) on the catheter. Facility policy titled, Enhanced Barrier Precaution (dated 12/2024) reads: POLICY: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. As well as to prevent multi-drug resistant organism acquisition of those with an increased risk of acquiring MDROs including residents with a chronic wound or an indwelling medical device. 2. Residents that have indwelling medical devices, regardless of MDRO status, will be on EBP. a. Some examples may include central vascular line (including hemodialysis catheter), urinary catheter, feeding tube, tracheostomy, and ventilator (excludes peripheral IVs). Facility policy titled, Hand Hygiene (date 10/2024), reads: c. When caring for a resident, when moving from a soiled body site to a clean body site of the same resident. d. After touching a resident or the resident ' s immediate environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145998 If continuation sheet Page 4 of 4