Health inspection·April 5, 2023

F 0689 R1's initial nursing assessment dated [DATE], shows R1 had 15 sutures to the forehead and 10 steri-strips applied to the back of his left hand. Level of Harm - Actual harm Residents Affected - Few On April 4, 2023, at 10:31 AM, V3 (Nurse) said on March 15, 2023, before dinner, she was pushing R1 in his wheelchair to the dining room when he put his legs on the ground, causing him to fall forward onto the floor. V3 said R1's wheelchair did not have footrests on them. V3 said R1 had increased confusion all day and was being worked up for an infection. V3 said when R1 has an infection, he becomes very confused and is unable to follow commands. V3 said on March 15, 2023, she had told R1 to keep his feet up, but he suddenly put his feet down. On April 4, 2023, at 10:58 AM, V4 (Activity Aide) said she was a 1:1 sitter with R1 as he was very confused and was not redirectable. V4 said on March 15, 2023, V3 came to R1's room to get him to come to the dining hall for dinner and began pushing him to the dining room. V4 said as V3 was pushing him to the dining hall, R1 suddenly put his feet down and went flying out of the wheelchair. V4 said he did not have footrests on his wheelchair. On April 4, 2023, at 11:12 AM, V5 (CNA/Certified Nurse Assistant) said residents should have footrests on their wheelchair if staff are transporting them. V5 said if they do not have footrests, they can fall out of their chair or injure their feet. V5 also said R1 is not himself when he has an infection and requires more assistance with activities of daily living. On April 4, 2023, at 1:05 PM, V2 (DON/Director of Nursing) said V3 (Nurse) had called him on March 15, 2023, at 4:05 PM to assist when R1 fell. V2 said R1 needed to go to the hospital because the laceration was too deep to be taken care of by the facility. V2 said earlier that day around midnight, R1 had fallen out of his bed and the facility staff called the doctor to request labs to work him up for an infection. V2 said R1 was not himself and had behaviors. V2 said on March 15, 2023, the activity aide was assigned to his room because he was experiencing agitation. V2 said V3 should have done an assessment on him to know what his mental status was prior to wheeling him to the dining hall. On April 4, 2023, at 3:32 PM, V11 (NP/Nurse Practitioner) said the fall was the reason he had the laceration and went to the hospital. R1's progress note dated March 14, 2023, at 7:26 PM shows the following: [Power of Attorney] notified staff that [R1] has hallucinated both yesterday and today in addition to an extended crying episode. Requested [urinalysis] be collected due to past histories of [urinary tract infections]. R1's progress note dated March 15, 2023, at 12:34 AM shows the following: Resident laying on the floor. Upon entering the resident's room, writer noted resident to be laying on the floor beside his bed with his blankets. R1's progress note dated March 15, 2023, at 12:42 AM shows the following: [Registered Nurse] notes no injury but does state over the past 3 days has been more confused than usual. 2. On April 4, 2023, at 11:42 AM, R2 was in the dining hall without footrests on her wheelchair. At 3:45 PM, R2 was in her room in her wheelchair without footrests. R2 was self-propelling in her wheelchair using her arms only, while her legs touched the ground while transporting. R2 said she does not really use her legs to transport herself and could not remember her last fall. On April 4, 2023, at 12:02 PM, V8 (CNA/Certified Nurse Assistant) said R2 should have footrests on her wheelchair, but she did not have time to put them on this morning. The facility's accident log documents R2 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146183 If continuation sheet Page 2 of 3 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 146183 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Courts of Shorewood 700 West Black Road Shorewood, IL 60404 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 fall from her wheelchair on January 11, 2023 and sustained a skin tear to the right elbow. Level of Harm - Actual harm The EMR shows R2 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis, dementia, polyosteoarthritis, lymphedema, and peripheral vascular disease. Residents Affected - Few R2's MDS dated [DATE], shows R2 has severe cognitive impairment, and requires extensive assistance from one facility staff for locomoting on and off the unit, and personal hygiene. R2 requires extensive assistance from two facility staff members for bed mobility, transferring, dressing, and toileting. R2's Functional Abilities and Goals assessment dated [DATE], documents R2 requires partial/moderate assistance to travel 50 feet in her wheelchair. 3. On April 4, 2023, at 12:20 PM, R4 was being pushed in her wheelchair without footrests by V9 (CNA). V9 transported R4 from R4's room to the beauty salon to retrieve a weight, and then back from the beauty salon to the nurse's station. Surveyor noted the distance was about 150 feet in total. V9 said R4 should have had footrests on while she was pushing her because R4 could put her feet down and fall without the footrests in place. The EMR shows R4 was admitted to the facility on [DATE], with multiple diagnoses including dementia, epilepsy, and a history of falling. R4's MDS dated [DATE], shows R4 has moderate cognitive impairment and requires extensive assistance from one facility staff for bed mobility, transferring, locomoting on and off the unit, dressing, toileting, and personal hygiene. On April 4, 2023, at 1:38 PM, V10 (Director of Rehab) said if a resident is being transported by staff, they should have their footrests on their wheelchair. V10 said not having the footrests on the wheelchair while being pushed by staff could cause the resident to fall. V10 said if R1 was confused, R1's wheelchair should have had footrests on them. V10 also said if a resident cannot use their legs to self-propel, they should have footrests on their wheelchair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146183 If continuation sheet Page 3 of 3