Health inspection·January 16, 2025

F 0761 INSULINS* *HIGH ALERT DRUG* Level of Harm - Minimal harm or potential for actual harm R22's active physician order dated 05/02/2024 reads in part Humalog Kwikpen 100 UNIT/ML Solution pen-injector, INJECT SUB-Q THREE TIMES DAILY PER SS: 200-250=2 UNITS, 251-300=4 UNITS, 301-350=6 UNITS, 351-400=8 UNITS, *HIGH ALERT DRUG* (DX: DM) Residents Affected - Some R24's active physician order dated 12/16/2023 reads in part Fiasp FlexTouch 100 UNIT/ML Solution pen-injector, INJECT SUB-Q BEFORE MEALS PER SS: 151-200=2 UNITS, 201-250=4 UNITS, 251-300=6 UNITS, [PHONE NUMBER]=8 UNITS, 351-400=10 UNITS, CALL MD IF <150 OR >400 *CHART & ROTATE SITE* *HIGH ALERT DRUG* (TI) R131's active physician order dated 12/30/2023 reads in part Lantus Solostar 100 UNIT/ML Solution pen-injector, INJECT 40 UNITS SUB-Q DAILY AT BEDTIME *CHART & ROTATE SITE* *DO NOT MIX WITH ANY OTHER INSULINS* 01/14/2025 at 12:10PM Surveyor reviewed Medication Cart (Middle) with V21 (Licensed Practical Nurse/LPN) and observed R148's and R410's Lantus Solo Insulin Pen 100 unit/mL with no open date as directed by protocol noted on medication, and not stored in the appropriate facility/medication refrigerator. V21(LPN) stated insulin pens were sent from pharmacy but not sure when they were received. V21(LPN) stated she wasn't sure how long the pens were in the medication cart. V21 stated in summary, Insulin Pens are good for 28 days and need to be labeled with an open and expiration date. Original bag from pharmacy noted with residents' personal information, medication name, dosage, and storage instructions. Prescription bags are clearly labeled from pharmacy with a blue sticker store in fridge until opened. On 01/14/2025 at 12:40PM Surveyor reviewed Medication Cart (North) with V22(Registered Nurse/RN) and observed R131s', R24s' Lantus Solo Insulin Pen 100 unit/mL and R22s' Lantus Solo Insulin Pen 100 unit/mL and Humalog Kwikpen 100 UNIT/ML with no open date, and not stored in the appropriate facility/medication refrigerator. V22(RN) stated pharmacy sent the insulin pens but wasn't sure how long they had been stored in the medication cart. V22 stated insulin pens are good for 30 days and should be labeled with an open and expiration date. Prescription bags for R22, R24, and R131 contain a blue label stating store in fridge until opened. Surveyor interviewed V2 (Director of Nursing/Regional) who stated in the summary, it is important for the nurses to ensure both open and expiration dates are noted on the labels for insulin pens, in order to know how long they're good for and maintain efficacy. V2(DON) stated unopened insulin pens should be stored in the appropriate facility/medication fridge until needed. V2(DON) stated insulin pens should be stored in privacy bags and dated 28 days after opening so the medication can be discarded per manufacture's expiration date. V2(DON) stated she started an in-service on Insulin Storage. V2 stated the purpose of the medication in-service is to make sure nursing staff understands proper storage and labeling. Record review for medication protocol detailed that pharmacy policy 3.5: Refrigerated Products dated 07/2024 reads in part Medications required by the FDA to be stored in a refrigerator may be subject to special handling, storage, and record keeping: 2. Upon delivery, the nurse will be responsible for storing the medication in the appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 2 of 6 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 145087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453 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 0761 facility/medication refrigerator. Level of Harm - Minimal harm or potential for actual harm 5. Residents Affected - Some Insulin Storage: all unopened insulin should be refrigerated. If unopened insulin is left at room temperature, the date opened would be the date it was sent from the pharmacy located on the prescription label. Expiration date for each insulin product varies, and facilities should refer to the insulin expiration date reference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 3 of 6 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 145087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 1. Label and date opened food in the freezer, 2. Follow their policy on use of hair restraints by staff entering the kitchen without putting on a hair net and failing to use a beard restraint while in the kitchen, 3. Maintain infection control by placing a pair of oven gloves and a package of gravy inside clean and sanitized pots in the food preparation area and clean a whisk used during meal preparation, 4. Follow their policy on use of standardized recipes by not using a recipe during food preparation for lunch, and 5. Follow their policy on maintaining the proper sanitation level in the three compartment sink. These failures have the potential to affect all 151 residents who receive oral meals from the facility's kitchen. Findings include: On 1/13/24 at 10:28 AM, during review of the freezer noted one clear bag of food with no label or open date. V4 Dietary Manager/DM was inquired of the bag. V4 DM stated, It's potatoes, I'm not sure when it was opened, had to be over the weekend. It should have a use by date on it. On 1/14/25 at 9:24 AM, V7 Dietary Aide is in the kitchen and is not wearing a hair net. V9 Dietary Aide has a moustache and beard and is wearing a surgical mask while in the kitchen. On 1/14/25 at 9:38 AM a large cooking pot hanging on a rack in the food preparation area has two oven gloves sitting inside of the pot. A medium cooking pot hanging on a rack in the food preparation area has a 22.6-ounce (1/2 used) bag of chicken gravy inside of the pot. On 1/14/25 at 9:41 AM, V4 Dietary Manager was inquired of the items found inside the cooking pots. V4 DM stated, It shouldn't be in there. It's contaminating the pots. On 1/14/25 at 10:09 AM, V14 [NAME] put an unmeasured amount of salt, black pepper, and melted butter into two separate metal containers and filled them with water. V14 then placed both containers on the steam table and covered them with lids. V14 [NAME] was inquired of the containers. V14 [NAME] stated, I'm preparing my water for the cheesy mashed potatoes. V14 [NAME] is not using a recipe or measuring spices/ingredients while preparing the cheesy mashed potatoes. V14 was asked which residents would be receiving the cheesy mashed potatoes for lunch? V14 [NAME] stated, Regular, mechanical soft and puree residents except those who can't have cheese. V14 stated I'm making regular and enhanced mashed potatoes. V14 [NAME] was inquired of enhanced mashed potatoes. V14 [NAME] stated, It has whole milk and cheese. On 1/14/25 at 10:19 AM, V14 [NAME] poured 8 ounces of whole milk, an unmeasured amount of melted butter, and water in a pan and put it on the stove. V14 [NAME] opened a large bag of cheese and with a gloved hand put two handfuls of cheese into the pot. V14 [NAME] then poured an unmeasured amount of powdered mashed potatoes into the pot and mixed it with a large whisk. V14 put the whisk into a pitcher of water sitting in the food preparation sink. V14 [NAME] is not using a recipe or measuring utensils to prepare the enhanced mashed potatoes. V14 [NAME] did not wash the large whisk. On 1/14/25 at 10:25 AM, V14 [NAME] put an unmeasured amount of salt, black pepper, melted butter, and water into a metal container and placed it onto the stove. V14 [NAME] added an unmeasured amount of powdered mashed potatoes into the container. V14 [NAME] removed the large whisk from the pitcher (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 4 of 6 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 145087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453 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 - Many of water in the food preparation sink and began to stir the potato mixture. V14 put the whisk into a pitcher of water sitting in the food preparation sink. V14 [NAME] is not using a recipe or measuring utensils to prepare the mashed potatoes. V14 [NAME] did not wash the large whisk. On 1/14/25 at 10:26 AM V14 [NAME] was inquired of his preparation. V14 stated, I'm making plain mashed potatoes. On 1/14/25 at 10:29 AM, V14 put an unmeasured amount of water into a metal container and placed it onto the stove. V14 [NAME] removed the large whisk from the pitcher of water in the food preparation sink, tapped the whisk on the inside of the food preparation sink and used it to stir an unmeasured amount of brown gravy mix into the water on the stove. V14 put the whisk into a pitcher of water sitting in the food preparation sink. V14 [NAME] is not using a recipe or measuring utensils to prepare the gravy. V14 [NAME] did not wash the large whisk. On 1/14/25 at 10:33 AM, V8 Director of Rehab entered the kitchen from the main dining room with a food tray and handed it to a dietary aide. V8 is not wearing a hair net. V8 was inquired of entering the kitchen. V8 stated, Oh, I should have on a hair net, I was just helping out. There are no hair nets available at the kitchen entrance from the main dining room. On 1/14/25 at 10:38 AM, V14 [NAME] was inquired of meal preparation. What should be used to ensure accurate amounts of seasoning or ingredients are used during food preparation? V14 stated, It's the recipe. I failed to use it to know what to put in. How do you know how much seasoning was put into each container while preparing the food? V14 stated, I should use measuring cups, but I taste it after it's done. V14 showed this surveyor measuring cups and spoons he removed from the drawers at the food preparation table. V14 [NAME] was inquired of using the whisk. After using a cooking utensil what should be done to ensure it's safe to use again? V14 [NAME] state, I should change the whisk, it needs to be cleaned. It could be contaminated, but I soak it in hot water. On 1/14/25 at 10:46 AM, V9 Dietary Aide has a moustache and beard and is wearing a surgical mask under his chin. He is receiving and removing clean dishes from the dishwashing machine. V9 was inquired of his mask. V9 stated, I don't have to cover my beard in the kitchen, only out in the building because of the residents and visitors. On 1/15/25 at 8:50 AM, V7 Dietary Aide is in the kitchen and is not wearing a hair net. On 1/15/25 at 9:34 AM, V4 Dietary Manager was inquired of hair net usage. V4 stated, Everyone should wear a hair net, so hair doesn't fly into the food. V4 stated anyone with a beard should wear a beard cover because hair can get into the food or anywhere. V4 was inquired of V14 [NAME] meal preparation regarding use of a recipe. V4 stated, V14 should follow a recipe so the meal comes out properly and for the resident's diet. I have measuring cups and spoons. On 1/15/24 at 9:40 AM, V9 Dietary Aide is at the three-compartment sink washing pots and pans. V9 tested the three-compartment sink for the sanitation level. V9 dipped the chemical test strip which indicated 100 ppm (parts per million) of quaternary solution. V4 Dietary Manager was asked what the chemical solution concentration should indicate for proper sanitation. V4 said, It should be 200. Quaternary sanitizer solution concentration range is 200 ppm per the posted manufacturer guidelines above the three-compartment sink. On 01/15/25 02:08 PM, V4 Dietary Manager was inquired of the kitchen infection control policy. V4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 5 of 6 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 145087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453 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 said, We are still looking for one. V4 DM did not provide a policy for infection control. Level of Harm - Minimal harm or potential for actual harm The 2020 Guideline & Procedure Manual Labeling and Dating Foods (Date Marking) policy states in part: Procedure: All foods stored will be properly labeled according to the following guidelines. 3. Date marking for freezer storage food items- once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. Residents Affected - Many The 2020 Guideline & Procedure Manual Hair Restraint policy states in part: Guideline: Hair restraints shall be worn by all dining services staff when in food production areas, dishwashing areas, or when serving food. Procedure: 1. Staff shall wear hair restraints in all food production, dishwashing, and serving areas. 2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. The 2020 Guideline & Procedure Manual Storing Utensils, Tableware, and Equipment policy states in part: Guideline: Employees will store utensils, tableware, and equipment according to the following guidelines. Procedure 1. Cleaned and sanitized utensils and equipment will be stored at least six inches off the floor in a clean, dry location in a way that keeps them from contamination by splash, dust, or other means. 5. Cleaned and sanitized equipment and utensils should be handled in a way that protects them from contamination. The June 2024 [NAME] Healthcare Kitchen Policy Food Safety & Sanitation Standard Recipes policy states in part: Standardized recipes will be available in the kitchen and used for food preparation according to the menu and spreadsheets unless signed off for subs by a dietitian. Procedure: All foods will be prepared using standardized recipes that coincide with the menu cycle spreadsheets. Standardized recipes include number of servings, serving sizes, ingredients, and preparation instructions. The undated facility three compartment sink policy states in part: policy: the facility will clean and sanitize food service equipment, pots and pans, utensils, dishes, and tableware using three compartment sink using the proper procedure. Procedure: 5. Sinks will be prepared as follows: c. Sink three- iv. Add the appropriate amount of sanitizer to the water according to the manufacturer's guidelines: 3. Quaternary Ammonium: 200 PPM (parts per million). Test the water in the sink using the manufacturer's suggested test strips to ensure appropriate concentration s noted above. Record concentration on a Sanitizer Concentration Log. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 6 of 6