Health inspection·October 8, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few bedside within reach. Call light, bed controller, and TV remote within reach next to resident. R1's emergency room records dated [DATE] denotes in-part patient coming from the nursing home, report from Emergency Medical Service (EMS), noted an unwitnessed cardiac arrest. The patient has an LVAD (Left Ventricular assist device). According to EMS when they arrived Cardiopulmonary Resuscitation (CPR) was in progress. EMS continued CPR. Assessment of the patient HeartMate 3 shows that the patient is on battery backup, that there is no power to this his unit. CPR continued. The patient's HeartMate 3 was connected to power source and began operating. Of note the advance heath care team stated that the patient had been on battery backup for over 300 minutes prior to arrival. On [DATE] at 1:10pm, V13 (emergency room Nurse) stated R1 arrived at the hospital for cardiac arrest, with EMS (Emergency Medical Service.) V13 stated that R1's Left Ventricular Assist Device's, batteries and the backup battery were dead upon arrival to the Emergency Room. V13 explained that the LVAD system is designed to pump blood to the heart because R1 has heart failure. V13 said the batteries should never be allowed to deplete. The event log file for R1's LVAD system denotes in part: the event log captured low voltage advisory and few voltage hazard events on battery power 9/15 at 3:55am through 4:20am, then the patient changed to charged batteries. Also noted a lone low flow event 09/15 at 3:56am with flow noted at 2.0. looked to be patient related as this was associated with elevated Pulsatility Index (PI) values. Further low voltage advisory events on battery power noted 09/16 at 12:59 which progressed into low voltage hazard events 09/16 at 3:28am. Battery power depleted 09/16 at 4:51am which enabled the EBB (emergency backup battery) in the controller and ran the VAD at the low limit of 5200 RPM until the EBB depleted as well on 09/16 at 6:48am, resulting in the VAD turning off. Unable to determine the time the VAD was off due to the timestamp being reset to [DATE] once the power was restored to the VAD. On [DATE] at 2:43pm, V19 Licensed Practical Nurse (LPN) said he was R1's nurse on the 3:00pm to 11:00pm pm shift on [DATE], he was orientating a new nurse V18 (LPN). V19 said he checked R1's LVAD, he (V19) checked the connections, he (V19) checked the batteries, and the aide assessed the vital signs. V19 said this was completed prior to him (V19) discharging an unrelated resident, that resident was discharged around 8:00pm. V19 said both of R1's LVAD's external batteries had three green bars. V19 said he did not change R1's batteries at that time. V19 said he did not change R1's LVAD's batteries during his shift, V19 said he did not plug R1's LVAD to the wall outlet prior to him (V19) leaving his shift. V19 said he left at 11:30pm. V19 said he reported to V3 (RN) the oncoming nurse to monitor R1 because R1 had an LVAD and R1 was an elopement risk. V19 said R1 has cognitive deficits. V19 said V18 completed all of the documentation for R1 because V18 was in orientation. V19 said he did not get training at [NAME] Oak Lawn for LVAD patients. V19 said V18 documented N/A -alarms and system check for LVAD, that was an error, the time is correct. V19 said N/A was for the dressing change, the facility did not have the correct dressing for R1's LVAD, and he (V19) did check the batteries and ensured the drive lines were connected. V19 said he did not complete a system check for R1's LVAD during his shift. V19 said he worked with LVAD patients in the past at another facility and he would complete a system check of the LVAD, V19 describes there's a button on the controller, and you press it, and it will take you through all the systems in the controller. V19 said he did not plug R1's LVAD into the wall outlet because R1 could let him know when he's going to bed, and could request to be plugged in.Facility presents timecard for V19 denoting V19 punched out at 12:45am on [DATE].This supports that V19 had the opportunity to change R1's LVAD external batteries during his shift, V19 remained on duty for 7 hours after he observed R1 LVAD batteries at three bars.On [DATE] at 12:42pm, V18 (LPN) said he was on orientation and V19 was the preceptor, V18 said his shift was on [DATE] on the 3:00pm-11:00pm shift, V18 stated he did not get training at [NAME] Oaklawn (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 2 of 24 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 10/08/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few for LVAD patients. V18 said he observed V19 check R1's LVAD's batteries. V18 said he completed the documentation for R1's care, and he documented N/A for LVAD-alarms and system check, V18 said that was an error, and the N/A documentation was for the dressing change. V18 said the time does reflect when the batteries were checked. V18 said the LVAD is for heart failure.R1's progress notes denotes V18 documented at 5:01pm on [DATE], for the LVAD alarms and system check.The Facility presents a timecard for V18 denoting V18 punched out at 12:45am, on [DATE].This supports that V18 had the opportunity to change R1's LVAD's batteries during his shift, V18 remained on duty for 7 hours after the LVAD batteries was observed at three bars.On [DATE] at 11:13am, V3 (RN) said she was R1's nurse during the night shift (11pm-7:00am) on [DATE], V3 said she was familiar with R1, and she knew who R1 was. V3 said she was prompted to enter R1's room because the medication administration record showed orders to check R1's LVAD. V3 said she checked R1's blood pressure, it was low, but she wasn't concerned because R1's blood pressure usually runs low. V3 omitted checking R1's heart rate, respirations, and temperature. V3 stated that she documented the vital signs in the record. V3 said she hooked R1 up to the small charger (portable power unit/ wall outlet charger) at 3:30am and unhooked R1 at 6:00am. V3 stated that she spoke to R1, R1 even told her not to remove his batteries and to plug the pump into the portable charger. V3 said she knew the batteries were charged because the light was green. V3 described there's a button on the battery that you can be pressed, and it will illuminate. V3 said she has worked with LVAD systems in the past at another facility, but she did not receive training at the [NAME] Oak Lawn nursing home for LVADs. At 3:43pm, during a follow up interview V3 stated she was confused, and she switched R1's batteries out and did not charge R1 batteries by connecting the LVAD to the portable power unit (wall out charger). V3 said she was confused during the first interview. V3 said she switched the batteries out at 3:30am. V3 omitted completing a system check for R1's LVAD, V3 said she did not connect R1's LVAD to the wall outlet to charge during the night. Review of R1's physician order sheet for R1 does not have any orders to check the LVAD at night, as V3 stated that is what prompted her to enter R1's room. V3 stated she completed R1's vital sign assessment, however V3's documentation on the asthma/ COPD record date and time of [DATE] at 6:10am, denotes V3 used vital signs results dated [DATE] at 7:22 am completed by V10 Certified Nursing Assistant (CNA).On [DATE] at 12:12pm, V11 (CNA) said she was the aide for R1 on [DATE] during the night shift, and saw R1 around 10:30pm or 11:00pm, R1 said he wanted a sandwich and R1 got a sandwich from the nurse station and went to his room. V11 said she rounded on R1 during the shift by walking pass his room. V11 said she did not go into R1's room to check on R1, R1 was a resident that wandered, and if he's sleeping you don't wake him. V11 said she thought the Nurse gave R1 some good medicine to sleep all night. V11 said she doesn't check the LVAD because she is not a Nurse.On [DATE] at 2:10pm, V4 (RN) said she was R1's nurse for the morning shift of [DATE], V4 said upon arrival to the unit she did rounds, she (V4) always checked on the residents that have intravenous medications, and she checked on R1. V4 said R1 was okay, she entered his room to check on him, she observed R1's chest rise and fall. V4 said she did not check R1's LVAD because V3 (RN) reported to her that R1 was okay, and that she (V3) charged R1 batteries, and it was full. V4 said she just took V3 (RN) words for fact. V4 said she has not received any training on LVAD system at the [NAME] Oak Lawn. During this interview, V4 was asked to demonstrate how to check the LVAD batteries to determine the capacity, V4 picked up the gray battery, V4 could not identify where the button was located on the battery to determine if the battery was charged or not. V4 was observed to flip the battery over and over, V4 did not identify the button on the front of the battery to check the battery capacity. V4 stated she did not check R1's LVAD system or batteries when rounding on R1 upon the start of the shift on [DATE]. V4 observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 3 of 24 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 10/08/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few on video surveillance, V4 did not enter R1's room as stated during the interview to observe that R1 chest was rising and falling. On [DATE] at 10:01am, V2 (CNA) said she was going to assess R1's vitals and observed R1 with no pulse, V2 said she notified V1, and immediately returned to start CPR on R1.On [DATE] at 11:23am, V7 (RN) stated that she cared for R1 quite often when R1 was on the back wing, on the Med bridge unit. V7 said she worked 16 hours often (first and second shift), and she changed R1 batteries at the beginning of each shift. V7 said there was 5 bars on the battery and when she changed them, the batteries, there would be 2 bars remaining. V7 said R1 often would mess with his LVAD and remove the batteries. V7 said the stationary charger was at R1's bedside on the table within R1's reach. V7 said R1 was verbal, always stated he wanted to go and smoke, and R1 wandered, wanting to go home. V7 said R1 had cognitive deficits. V7 said all the nurses were aware that R1 would remove his batteries, and the unit manager was aware also. V7 said she checked R1 more frequent because of this behavior. V7 said more frequent was about every two hours. V7 described entering the room, checking the batteries capacity and LVAD connections. V7 said she was a cardiac nurse from (hospital name) and she was familiar with the LVAD. V7 said she was off duty when the facility offered the training in [DATE], and when she returned to duty, she received a packet, and someone went over the packet with her. V7 said she doesn't recall who the person was that went over the packet with her.The unit manager was not available for interview during this survey, per V5 (Administrator) she resigned effective immediately on [DATE].On [DATE] at 12:41pm, V6 (Director of Nursing) stated that her expectation is that the Nursing staff follow the facility policy when caring for a resident with LVAD systems. V6 said she expects her staff to complete rounds on the residents initially upon coming on for the shift, and then every few hours after that. V6 said initially she was under the impression that V3 did complete rounds on R1 but after reviewing the facility surveillance she learned that V3 did not enter R1's room from 1:00am to the time she left duty. V6 said her expectation is that staff complete vital assessments on the residents, check the LVAD system to ensure the system is functioning and the batteries are full, and to change the batteries. V6 said she does not have any documentation that the staff received LVAD training in [DATE]. V6 said R1's family was upset by his death and had concerns about the LVAD system. V6 said she is learning during this survey that staff did not receive training for the LVAD.On [DATE] at 11:44am, V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. V17 said she received her training in February or March of 2025, she was not sure. V17 said the staff received LVAD training hosted by the (hospital name LVAD contact person). V17 said the webinar was held in the conference room, and other nursing staff was responsible to review the webinar while at the Nurse's station on the Med bridge unit. V17 said all the LVAD patients are assigned to the Med-bridge unit. V17 said the staff had the LVAD binder during the webinar. V17 said the policy/protocol/practice is for staff to use the binder located at the nurse's station for reference. V17 said staff should familiarize themselves with the patient that has the LVAD and familiarize themselves with the machine. V17 said staff is made aware of the patient with an LVAD during nurse-to-nurse report at the start of the shift. V17 said the staff should ensure that the batteries are charged by using the buttons and using the controller. V17 said if the light is green, it is ok, and staff should proceed with routine care. Staff should monitor the blood pressure, ensure orders are in place, complete daily weights, be attentive by being alert to alarms from the monitor. V17 said if the alarm sounds staff should go to the patient, look at the monitor, check what alarms has triggered, the lights would appear, silence the alarm by clicking the blinking light, this allows the nurse to check the connections from patient to the monitor, once connections are checked the Nurse should push the button again. If the alarm remains off the Nurse can proceed with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 4 of 24 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 10/08/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few routine care. If the alarm continues contact the Tech from the LVAD company to receive further instructions. V17 said at night the resident's LVAD should be plugged into the wall outlet. V17 said during an emergency, if a resident is found unresponsive the Nurse should check the LVAD connections, batteries and check if the LVAD is running, V17 said the Nurse should replace the batteries if the batteries are not charged. V17 said she does not know how to run a system check on the LVAD, V17 said she has never seen R1's LVAD system, she has never entered R1's room to observe R1's LVAD system. V17 said she is not competent in LVAD training, policy/procedures. V17 said she recommends that herself and the nursing staff have hands on training with the LVAD system. V17 said there is not a stop order in place for admitting LVAD patients. V17 said she did not inform the Nursing staff that she was the LVAD preceptor because she did not feel competent in her role as the preceptor. V17 said she informed the Director of Nursing of this today. V17 said resident rounds should be conducted every two hours, staff should go inside the room, assess the patient, check for breathing, look for rise and fall in chest, observe for changes in condition, changes in breathing, check if resident is perspiring excessively, these signs could indicate a change in condition. V17 said she was aware that R1 was admitted with and LVAD in [DATE].On [DATE] at 12:57pm, V15 (Medical Doctor/ Medical Director) said R1 was planning to discharge home, R1 had heart failure with some functioning capacity, V15 stated that if the batteries to R1's LVAD was depleted it would exacerbate R1's death. V15 stated that there should be at least one Nurse on duty that is trained on the LVAD. V15 said the facility did not inform him of the occurrence. On [DATE] around the start of 5:25-5:30pm review of facility video surveillance with assist from V5 (Administrator), V5 made the surveyor aware that the time stamp was incorrect, and that the video was one hour behind. Video surveillance for the Med bridge unit was reviewed from 1:00am until 7:02am (V3 was observed to leave the unit with her bag). V3 did not enter R1's room between the hours of 1:00am to 7:02am. V3 was observed on the video sitting at the nurse's station, using V3's personal phone, blowing kisses while on the phone, laughing, observed rocking back and forth in a chair at the nurse station, walking down the hall waving her hands in the air, V3 was observed walking down the hall with her phone in her hand. V3 was also observed at the medication cart while on her phone. V3 observed to adjust the phone ensuring to prop the phone up while she was at the medication cart. Video shows V3 entering a room on the right-hand side of the hall (front facing the bistro). V5 zoomed into the video, there was three black hand sanitizer pumps on the wall, V3 entered the room between the second and third hand sanitizer pump. Immediately after video observation, during a tour with V5 to identify what room V3 entered, the room was identified as room number seven. That was not R1's room that V3 entered. V3 was observed to enter a room on the left-hand side of the hall, and rooms on the back unit. V3 observed to handle medications that was dropped off by pharmacy. V3 observed talking to V9 (LPN) at the nurse station several times. V3 observed to remove her white jacket and leave the unit and return. Video surveillance shows V4 (RN) entering the unit, V4 was observed to fully enter multiple rooms on the left-hand side and when V4 got to R1's room, V4 poked her head in the door frame briefly. V4 did not enter R1's room (this was identified by the placement of the black hand sanitizer pumps on the wall). Review of R1's asthma/ COPD assessment completed by V3 (RN) with effective date of [DATE] at 6:10am, it is denoted that R1 was alert, required head of bed to be elevated, shortness of breath or trouble breath when lying down, most recent pulse, 63- regular, dated [DATE] at 7:02am. Respiration 15, dated [DATE] at 7:22am. Blood pressure 88/64 dated [DATE] at 7:22am. Auscultation clear bilaterally.Review of R1's vital sign assessment log, the above vital signs was completed by V10 (CNA) on [DATE] at 7:22am and not V3.Review of R1's baseline care plan with V6, R1 did not have any goals and interventions listed for the LVAD.Review of R1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 5 of 24 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 10/08/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few comprehensive care plan with V6, R1 did not have a comprehensive plan of care developed with goals and interventions for the LVAD.Review of R1's physician order sheet, order dated [DATE]; check LVAD two times a day for LVAD alarms and system checks.Review of R1's Medication Administration Record for the LVAD order, it is denoted that R1's LVAD was being checked at 9:00am and 5:00pm.There are no orders, for checking the alarms and system during the night shift. There is no plan of care for monitoring, assessing, and managing R1's LVAD at night.Facility policy/ procedures/ protocol for Ventricular Assist Device SAR/LTAC Training, denotes in-part, how to contact VAD team, heart failure, a ventricular assist device (VAD) is a continuous flow pump implanted to assist a failing native heart by taking blood from the left ventricle. Flowing through the pump into the outflow graft to the ascending aorta. VAD reduce the need of the native heart to pump vigorously to eject blood via the aortic valve, thereby reducing workload and oxygen demands of the native heart. General component; pump, driveline, controller and power x2. Driveline-Electrical line that communicates between the pump and the controller, LIFELINE- DO NOT CUT, DO NOT DISCONNECT FROM SYSTEM CONTROLLER OR THE PUMP WILL STOP!!!! Must ALWAYS be covered with sterile occlusive dressing. Battery power- Batteries can last from 8-17 hours depending on type of VAD, press button on battery to tell how much charge is left, change batteries if down to two lights (50%), always bring all batteries/wall power with patient if being transported/transferred. Every VAD patient must have back-up equipment due to the possibility of malfunction/equipment damage!! Back-up equipment includes extra system controller, extra Batteries clips (HM 2/3), Cell Phone to call hospital contact. Heart Ware Power Sources- one battery is expected to last 7-8 hours, Each, battery drains individually, once one battery drains to less than 25% it automatically switches to the other battery, Batteries are intended for daytime use, the AC adapter will always be the primary source of power if connected, Patients are to always sleep connected to AC adapter and one fully charged battery. While in the hospital the AC adapter should always be plugged into the red outlets. Power module/ mobile power unit aka wall power, patient always sleep on the wall power, assures continuous power, must be plugged into 2-prong grounded outlet (use red outlets if available) amplifies alarms of systems controller with heartmate 2 or 3. Patient will have either mobile power unit (small box only for home use) or power module (big box). In case of a power outage switch to batteries immediately. Keep power modules plugged in at all times to keep the internal battery charged. Batteries HeartMate 3 last 10-17 hours (batteries drain simultaneously). Monitoring battery power- change to fully charged batteries or plug into wall power if power gets to 2 green bars! Switch Power Sources one at a time never double disconnect power sources. Nursing care of VAD patient- patient assessment check vital signs and VAD parameters every shift, controller and power module self-test to be performed every morning, daily weights in the morning. Weights should be consistently with clothing/equipment, contact VAD team of weigh increase greater than 5 pounds in one week. Strict intake and output. Assess driveline site every shift- make sure anchor devices is in place, perform sterile dressing changes as ordered (call VAD team with any abnormalities). Blood pressures (BP)- an automatic blood pressure cuff may not work and the preferred way to check a BP is using the doppler method. Viewing pump and systems perimeters-press display button - pump speed, press display button twice- pump flow in liters per minute, press display button three times- Pulsatility index, press display button four times-power in [NAME] , press display button five times- charge status of the backup battery in the system controller-1.charged-2.charging-3.fault, press display button six times, blank screen indicates the screen is off, which is normal. Driveline dressing. Facility Abuse policy and prevention program dated 10/22 denotes in-part this facility affirms the right of all residents to be free from abuse neglect exploitation misappropriation of property deprivation of goods (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 6 of 24 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 10/08/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and services by staff or mistreatment. This facility therefore prohibits abuse neglect exploitation and misappropriation of property and mistreatment of residents. In order to do so the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that it has within its control to prevent occurrence of abuse neglect exploitation misappropriation of property deprivation of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse neglect exploitation misappropriation of property and mistreatment by anyone including but not limited to facilities app or the residents' consultants' volunteers' staff from other agencies providing services to the individual family members or legal guardians friends or any other individuals. Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm pain or mental anguish neglect means a facility's failure to provide or willful withholding of adequate medical care mental health treatment psychiatric rehabilitation personal care or assistance with activities of daily living that is necessary to avoid physical harm mental anguish or mental illness of a resident including deprivation of goods and services by staff. 3.Orientation and training of employees; during orientation of new employees, the facility will cover at least the following topics, sensitivity to the residents and resident's needs, what constitute abuse, neglect, exploitation, and misappropriation of resident's property. 4.Establishing a resident sensitive environment the facility desires to prevent abuse neglect exploitation mistreatment deprivation of goods and services by staff and mistreatment of residents' property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following resident assessment as part of the resident's life history on the admission assessment comprehensive care plan and NMDS assessments staff will identify residents with increased vulnerability for abuse neglect exploitation his treatment history of trauma or misappropriation of residence property who have needs triggers and behaviors that may lead to conflict. Through the care plan processing staff will identify any problems goals and approaches which will reduce the chance of abuse neglect exploitation mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Staff supervision supervisors will monitor the ability of the staff to meet the needs of residents including that assigned staff have knowledge of individual residents' care needs. Situations such as inappropriate language and sensitive handling or impersonal care will be corrected as they occur incidents that do not meet the definition of abuse neglect exploitation misappropriation of property or mistreatment will be handled through counseling training and if necessary or repeated the facility progressive disciplinary action. In summary there were multiple staff on duty on [DATE] and [DATE] (night shift) that could have checked, changed and ensured that R1's LVAD batteries had adequate voltage to run the pump thereby circulating blood to R1's heart. The facility policy/procedures/protocol reflects to change the batteries at 50% capacity, the policy does not mention to wait for an alarm to sound before addressing, checking and changing the batteries.The Facility Assessment Tool dated [DATE] denotes in-part our resident profile, diseases/conditions, physical and cognitive disabilities- categories-heart/circulatory system, congestive heart failure. Decisions regarding caring for residents with conditions not listed above, facility resources including but not limited to staff skill sets and material resources. Mandatory in-services related to specific diagnoses or equipment, involvement of Medical Director, corporate resources. Services and care the facility offers based on our residents' needs, resident support needs, other special needs, dialysis, hospice, ostomy care, tracheostomy care, bariatric care, palliative care, end of life care, LVAD. Provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 7 of 24 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 10/08/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete person-centered/directed care: Psycho/social/spiritual support: Identify hazards and risks for residents. Training topics, competencies: general staff-Abuse, Neglect and Exploitation. Nurses- Left Ventricular Assist Device. On [DATE] at 2:40pm, facility presented policy titled ‘Left Ventricular Assist Device' dated 01/2025, review date 09/2025 denoting general: to provide guidance on the care of resident with LVAD. Responsible party Nursing staff, when a resident is admitted with in LVAD it will be noted in the medical record. Nurse will enter orders for LVAD care and monitoring based on discharge instructions from hospital or from LVAD clinical directly. All prothrombin time/international normalized ratio PT/ INR results, changes in resident condition, and equipment concerns will be directed to the LVAD clinic to which the resident is assigned. Nursing staff will check to ensure that the battery backup is charged. Facility LVAD training for nurses will be completed through LVAD clinic.This policy was not present when request was made to review the LVAD policy, procedures, and or protocol on [DATE], [DATE] and [DATE].The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy:1. Regional Director of Operations in-serviced the Administrator regarding the facility's Abuse/Neglect Policy and Procedure on [DATE] including neglect. The Administrator is the abuse coordinator and is responsible for ensuring all residents including R1 are free from neglect. The neglect on [DATE] was not reported to the Illinois Department of Public Health and an investigation was not sent until [DATE]. The nurse was the identified staff member that was the alleged perpetrator of neglect towards R1. The nurse was immediately suspended pending investigation. The nurse was terminated from the facility after the investigation was completed due to her failure to provide a clear and accurate report regarding the incident during her shift on [DATE]. The facility in-serviced the facility staff on the neglect/abuse policy and properly rounding and checking on residents at least every 2 hours starting on [DATE] 2. The nurse did not check on or complete vitals on R1 during her 11pm-7am shift on [DATE]. The nurse failed to check the LVAD battery of R1 during her shift on [DATE]. The Director of Nursing and Nurse Managers conducted in-services starting [DATE] regarding LVADs and properly checking for batteries and alarms. The nurse failed to ensure the LVAD was connected to the wall outlet to ensure proper levels of the battery. The Director of Nursing and Nurse Managers conducted LVAD training with licensed staff on [DATE] through [DATE] that included to ensure LVADs are connected to the wall outlet at night to ensure that battery [TRUNCATED] Event ID: Facility ID: 145087 If continuation sheet Page 8 of 24 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 10/08/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their baseline care plan policy and develop an individualized baseline plan of care to include physician orders for a left ventricular assist device for a resident, This affected one of two residents (R2) reviewed for care plans and LVAD. R2 was admitted to the facility on [DATE], R2 face sheet shows diagnosis of chronic systolic congestive heart failure, atrial fibrillation, and presence of heart assist device. R2 facility census shows admission date 09/12/2025 and discharge date [DATE].R2 progress notes show R2 sent to hospital for change in condition on 09/15/2025.R2 third eye heath note dated 09/13/2025 at 10:09am denotes in-part patient name-R2. Initial stabilization visit, [AGE] year-old male admitted from the hospital after hypoglycemic event with sepsis currently on Bactrim DS twice a day for two more days past medical history of hypertension diabetes mellitus. Patient was admitted to the facility today and is awaiting full H and P (history and physical) and review by primary team. The nurse consulted third eye health to assess the patient to review discharge medication and orders and to ensure safe transition of care. Review of available paperwork and consultation with patient nurse was completed to identify high risk medication while awaiting evaluation by primary team. Physical exam findings per nurse and video observation physical exam medication review hospital discharge orders reviewed and updated as appropriate condition is stable medication review medication orders reviewed clarifications made see orders medication orders review no clarifications made patient is at risk for polypharmacy recommend that primary team review medications and eliminate unnecessary medications antibiotics diabetes repeated falls. Does the patient have any acute symptoms or any additional conditions that were addressed? today no. Orders available documentation review orders and medications approved until patient is evaluated by primary team obtain and review current relevant hospital documentation and orders with primary team when available start house start probiotics for 10 days twice a day. Fall precautions per facility policy. Point of care glucose checks three times a day before meals and at bedtime. Notify a clinician of any change in condition. Disposition: of stay at facility. Audio and video with patient and nurse present. Statement of medical necessity- yes. Sign date September 13, 2025 9:05 AM, provider V28.R2 initial stabilization visit completed by the provider, does not address the plan of care for R2's LVAD. Review of R2 physician order sheet for September 2025 there are no orders noted for R2 LVAD, no orders for VAD parameters every shift, no orders for controller and power module self-test to be performed every morning. 09/30/2025 V6 presents the admission evaluation, stating that the baseline care plan is included in the admission evaluation, V6 said there are no specific plan of care for R2's LVAD. During a follow-up interview on 10/3/25 at 4:46pm V6 (Director of Nursing) said she is now the LVAD preceptor for LVAD's, she is working with V5 (Administrator) to establish an order set for patients with an LVAD. R2 admission evaluation dated 09/12/2025, completed by the Nurse denotes in-part disease conditions contributing to admission- heart failure, devices- other- LVAD. Cardiovascular, ventricular assist device- yes is checked. Review of the baseline plan of care included in the admission evaluation, there are no goals or interventions noted specifically for the LVAD, there are no orders for checking/monitoring the alarms, system, or batteries. Review of R2 comprehensive plan of care with V12 (MDS coordinator), V12 stated that she edited/ revised the care plan during this survey on 09/18/2025 to include the LVAD, V12 stated she knew the surveyor was reviewing for LVAD's. V12 was asked, what's the specific goals and interventions for the patient with the LVAD, V12 said the floor nurse are supposed develop a plan of care for baseline care needs upon admission within 24 hours, and the MDS team will review the comprehensive plan of care after. V12 did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 9 of 24 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 10/08/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few give a response of what the baseline care needs are for a resident with an LVAD. V12 said she should not edit a resident record after they have discharged from the facility. On 09/24/2025 at 11:44am V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. Staff should monitor the blood pressure, ensure orders are in place, complete daily weights, be attentive by being alert to alarms from the monitor. V17 omitted what orders should be in-place for a patient with an LVAD.Facility policy titled baseline care plan dated 01/2023 last revision date 01/2025 denotes in-part to provide The staff with guidance on completion of comprehensive person-centered care baseline care planning. The facility will develop and implement A baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will be developed within 48 hours of residence admission into the facility. The baseline care plan will include at a minimum of the following necessary information to properly care for a resident elopement risk fall risk supervision needs behavior interventions activities of daily living needs initial goals based on admission orders physician orders dietary orders therapy services social services pass our recommendations if applicable. Person centered care means that the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. The baseline care plan must reflect the residence's stated goals and objectives and include interventions that address his or her current needs it must be based on admission orders and information about the resident available from the transferring provider and discussions with the resident and resident representative if applicable. Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs it should also reflect changes to approaches as necessary resulting from significant changes in conditions or needs occurring prior to the development of the comprehensive care plan.Facility policy titled physician services dated 01/2023 review date of 01/2025 denotes in-part to outline the responsibility of the physician to the resident ad determine the alternative contact if the physician cannot be reached. The physician is responsible for completing the admitting history and physical within 72 hours of admission. The physician is responsible for reviewing the treatment plan, signing all orders in the medical record, as well as completing the medical record upon discharge. When an attending physician designates an on-call physician to cover in his or her absence (who is not currently permitted to provide care, treatment and services at the facility) the medical director and the attending physician determines that on the call physician can perform the required, treatment and services. Facility policy/ procedures/ protocol for Ventricular Assist Device SAR/LTAC Training, denotes in-part, how to contact VAD team, heart failure, a ventricular assist device (VAD) is a continuous flow pump implanted to assist a failing native heart by taking blood from the left ventricle flowing through the pump into the outflow graft to the ascending aorta. Nursing care of VAD patient- patient assessment check vital signs and VAD parameters every shift, controller and power module self-test to be performed every morning, daily weights in the morning. Weights should be consistently with clothing/equipment, contact VAD team of weigh increase greater than 5 pounds in one week. Strict intake and output. Assess driveline site every shiftmake sure anchor devices is in place, perform sterile dressing changes as ordered (call VAD team with any abnormalities).On 10/3/2025 at 2:40pm facility presented policy titled ‘Left Ventricular Assist Device' dated 01/2025, review date 09/2025 denoting general: to provide guidance on the care of resident with LVAD. Responsible party Nursing staff, when a resident is admitted with in LVAD it will be noted in the medical record. Nurse will enter orders for LVAD care and monitoring based on discharge instructions from hospital or from LVAD clinical directly. All PT/ INR results, changes in resident condition, and equipment concerns will be directed to the LVAD clinic to which the resident is assigned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 10 of 24 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 10/08/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Nursing staff will check to ensure that the battery backup is charged. Facility LVAD training for nurses will be completed through LVAD clinic.This policy was not presented when request was made to review the LVAD policy, procedures, and or protocol on 09/17/2025, 09/19/25 and 09/23/2025. During this survey the surveyor was not able to identify what the specific orders should be in-place for a resident with an LVAD. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 11 of 24 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 10/08/2025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review the facility failed to follow professional standards of care for residents requiring LVAD (Left Ventricular Assist Device). This affected two of two residents reviewed for LVAD. This failure resulted in the facility failure to assess and monitor the battery level for R1 LVAD and failure to intervene when the batteries depleted and failed to ensure R2 had physician orders in place in the medical record. 1.R1 face sheet diagnosis of encounter for surgical after care following the circulatory system, unsteadiness on feet, type 2 diabetes mellitus, ventricular tachycardia, presence of heart assist device, cognitive communication deficits, COPD, acute and chronic congestive systolic heart failure. R1 MDS dated [DATE] shows BIMS score of 11 (cognitive deficits)Skin intact, drive line insertion site LLQ (left lower quadrant) with anchor on RLQ (right lower quadrant, scattered bruising, drive line dressing change M, W, F (Monday, Wednesday, Fridays). LVAD (left ventricular assist device) needs to be checked BID (twice a day). R1 emergency room records dated [DATE] denotes in-part patient coming from the nursing home report from EMS noted an unwitnessed cardiac arrest. The patient has an LVAD (Left Ventricular assist device). According to EMS when they arrived CPR was in progress EMS continued CPR. Assessment of the patient heartmate shows that the patient is on battery back up that there is no power to this his unit. CPR continued. The patient heartmate was connected to power source and began operating. Of note the advance heath care team stated that the patient had been on battery backup for over 300 minutes prior to arrival. [DATE] at 1:10pm V13 (emergency room Nurse) stated R1 arrived at the hospital for cardiac arrest, with EMS (emergency medical service.) V13 stated that R1 Left Ventricular Assist Device, batteries and the backup battery was dead upon arrival to the emergency room. V13 explained that the LVAD system is designed to pump blood to the heart because R1 has heart failure. V13 said the batteries should never be allowed deplete. The event log file for R1'S LVAD system denotes in part the event log captured low voltage advisory and few voltage hazard events on battery power 9/15 at 3:55am through 4:20am then the patient changed to charged batteries. Also noted a lone low flow event 09/15 at 3:56am with flow noted at 2.0. Looked to be patient related as this was associated with elevated PI values. Further low voltage advisory events on battery power noted 09/16 at 12:59 which progressed into low voltage hazard events 09/16 at 3:28am. Battery power depleted 09/16 at 4:51am which enabled the EBB (emergency backup battery) in the controller and ran the VAD at the low limit of 5200 RPM until the EBB depleted as well on 09/16 at 6:48am resulting in the VAD turning off. Unable to determine the time the VAD was off due to the timestamp being reset to [DATE] once the power was restored to the VAD.On [DATE] at 2:43pm V19 (LPN) said he was R1's nurse on the 3:00pm -11:00pm pm shift on [DATE], he was orientating a new nurse V18 (LPN). V19 said he checked R1 LVAD, he checked the connections, he checked the batteries, and the aide assessed the vital signs. V19 said this was completed prior to him discharging an unrelated resident, that resident was discharged around 8:00pm. V19 said both of R1 LVAD external batteries had three green bars. V19 said he did not change R1 batteries at that time. V19 said he did not change R1 LVAD batteries during his shift, V19 said he did not plug R1 LVAD to the wall outlet prior to him leaving his shift. V19 said he left at 11:30pm. V19 said he reported to V3 (RN) the oncoming nurse to monitor R1 because R1 had an LVAD and R1 was an elopement risk. V19 said R1 has cognitive deficits. V19 said V18 completed all of the documentation for R1 because V18 was in orientation. V19 said he did not get training at [NAME] Oak Lawn for LVAD patients. V19 said V18 documented N/A -alarms and system check for LVAD, that was an error, the time is correct. V19 said N/A was for the dressing change, the facility did not have the correct dressing for R1 LVAD, and he did check the batteries and ensured the drive Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 12 of 24 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 10/08/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lines was connected. V19 said he did not complete a system check for R1 LVAD during his shift. V19 said he worked with LVAD patients in the past at another facility and he would complete a system check of the LVAD, V19 describes there's a button on the controller, and you press it, and it will take you through all the system in the controller. V19 said he did not plug R1 LVAD into the wall outlet because R1 could let him know when he's going to bed, and could request to be plugged in. Facility presents timecard for V19 denoting V19 punched out at 12:45am on [DATE].This supports that V19 had the opportunity to change R1's LVAD external batteries during his shift, V19 remained on duty for 7 hours after he observed R1 LVAD batteries at three bars. [DATE] at 12:42pm V18 (LPN) said he was on orientation and V19 was the preceptor, V18 said his shift was on [DATE] on the 3:00pm- 11:00pm shift, V18 he did not get training at [NAME] Oak Lawn for LVAD patients. V18 said he observed V19 check R1 LVAD batteries. V18 said he completed the documentation for R1 care, and he documented N/A for LVAD-alarms and system check, V18 said that was an error, and the N/a documentation was for the dressing change. V18 said the time does reflect when the batteries were checked. V18 said the LVAD is heart failure. R1 progress notes denotes V18 documented at 5:01pm on [DATE] for the LVAD alarms and system check. Facility presents timecard for V18 denoting V18 punched out at 12:45am on [DATE].This supports that V18 had the opportunity to change R1's LVAD batteries during his shift, V18 remained on duty for 7 hours after the LVAD batteries was observed at three bars. On [DATE] at 11:13am V3 (RN) said she was R1's nurse during the night shift (11pm-7:00am) of [DATE], V3 said she was familiar with R1, and she knew who R1 was. V3 said she was prompted to enter R1 room because the medication administration record showed orders to check R1's LVAD. V3 said she checked R1's blood pressure, it was low, but she wasn't concerns because R1 blood pressure usually runs low. V3 omitted checking R1 heart rate, respirations, and temperature. V3 stated that she documented the vital signs in the record. V3 said she hooked R1 up to the small charger (portable power unit/ wall outlet charger) at 3:30am and unhooked R1 at 6:00am. V3 stated that she spoke to R1, R1 even told her not to remove his batteries and to plug the pump into the portable charger. V3 said she knew the batteries was charged because the light was green. V3 described there's a button on the battery that you can be press and it will illuminate. V3 said she has worked with LVAD systems in the past at another facility, but she did not receive training at the [NAME] Oak Lawn nursing home for LVAD. During a follow up interview V3 stated she was confused and she switched R1's batteries out and did not charge R1 batteries by connecting the LVAD to the portable power unit (wall out charger). V3 said she was confused during the first interview. V3 said she switched the batteries out at 3:30am. V3 omitted completing a system check for R1's LVAD, V3 said she did not connect R1 LVAD to the wall outlet to charge during the night. Review of R1 physician order sheet R1 does not have any orders to check the LVAD at night, as V3 stated that is what prompted her to enter R1's room. V3 stated she completed R1 vital sign assessment, however V3 documentation on the asthma/ COPD record date and time of [DATE] at 6:10am, denotes V3 used vital signs results dated [DATE] at 7:22 am completed by V10 (CNA). [DATE] at 12:12pm V11 (CNA) said she was the aide for R1 on [DATE] during the night shift, V11 said saw R1 around 10:30pm or 11:00pm, R1 said he wanted a sandwich and R1 got a sandwich from the nurse station and went to his room. V11 said she round on R1 during the shift by walking pass his room. V11 said she did not go into R1 room to check on R1, R1 was a resident that wandered, and if he's sleeping you don't wake him. V11 said she thought the Nurse gave R1 some good medicine to sleep all night. V11 said she don't check the LVAD because she is not a Nurse.On [DATE] at 2:10pm V4 (RN) said she was R1's nurse for the morning shift of [DATE], V4 said upon arrival to the unit she did rounds, she always checked on the residents that have intravenous medications, and she checked on R1. V4 said R1 was okay, she entered his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 13 of 24 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 10/08/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room to check on him, she observes R1 chest rise and fall. V4 said she did not check R1's LVAD because the V3 reported to her that R1 was okay, and that she (V3) charged R1 batteries, and it was full. V4 said she just took V3 words for fact. V4 said she has not received any training on LVAD system at the [NAME] Oak Lawn. During this interview V4 was asked to demonstrate how to check the LVAD batteries to determine the capacity, V4 picked up the gray battery, V4 could not identify where the button was located on the battery to determine if the battery was full or not. V4 was observed to flip the battery over and over, V4 did not identify the button on the front of the battery to check the battery capacity. V4 stated she did not check R1's LVAD system when rounding on R1 upon the start of the shift. V4 observed on video surveillance, V4 did not enter R1's room as stated during the interview to observe that R1 chest was rising and falling. [DATE] at 10:01am V2 (CNA) said she was going to assess R1 vitals and observed R1 with no pulse, V2 said she notified V1, and immediately returned to start CPR on R1. [DATE] at 11:23am V7 (RN) stated that she cared for R1 quite often when R1 was on back wing on the Med bridge unit, V7 said she worked 16 hours often (first and second shift), and she changed R1 batteries at the beginning of each shift. V7 said there was 5 bars on the battery and when she changed them the batteries, there would be 2 bars remaining. V7 said R1 often would mess with his LVAD and remove the batteries. V7 said the stationary charger was at R1's bedside on the table within R1 reach. V7 said R1 was verbal, always stated he wanted to go and smoke, and R1 wandered, wanting to go home. V7 said R1 had cognitive deficits. V7 said all the nurse was aware that R1 would remove his batteries, and the unit manager was aware also. V7 said she checked R1 more frequent because of this behavior. V7 said more frequent was about every two hours. V7 described entering the room, checking the batteries capacity and LVAD connections. V7 said she was a cardiac nurse from (hospital name) and she was familiar with the LVAD. V7 said she was off duty when the facility offered the training in [DATE], and when she returned to duty, she received a packet, and someone went over the packet with her. V7 said she don't recall who the person was that went over the packet with her. On [DATE] at 12:41pm V6 (Director of Nursing) stated that her expectation is that the Nursing staff follow the facility policy when caring for a resident with a LVAD systems. V6 said she expects her staff to complete rounds on the residents initially upon coming on for the shift, and then every few hours after that. V6 said initially she was under the impression that V3 did complete rounds on R1 but after reviewing the facility surveillance she learned that V3 did not enter R1's room from 1:00am to the time she left duty. V6 said her expectation is that staff complete vital assessment on the residents, check the LVAD system to ensure system is functioning and the batteries are full, and to change the batteries. On [DATE] at 11:44am V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. V17 said she received her training in February or March of 2025, she was not sure. V17 said the staff received LVAD training hosted by the (hospital name LVAD contact person). V17 said the webinar was held in the conference room, and other nursing staff was responsible to review the webinar while at the Nurse station on the Med bridge unit. V17 said all the LVAD patient are assigned to the Med-bridge unit. V17 said the staff had the LVAD binder during the webinar. V17 said the policy/protocol/practice is for staff to use the binder located at the nurse station for reference. V17 said staff should familiarize themselves with the patient that has the LVAD and familiarize themselves with the machine. V17 said staff is made aware of the patient with an LVAD during nurse-to-nurse report at the start of the shift. V17 said the staff should ensure that the batteries are charged by using the buttons and using the controller. V17 said if the light is green, it is ok, and staff should proceed with routine care. Staff should monitor the blood pressure, ensure orders are in place, complete daily weights, be attentive by being alert to alarms from the monitor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 14 of 24 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 10/08/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V17 said if the alarm sound staff should go to the patient, look at the monitor, check what alarms has triggered, the lights would appear, silence the alarm by clicking the blinking light, this allows the nurse to check the connections from patient to the monitor, once connections are checked Nurse should push the button again. If the alarm remains off the Nurse can proceed with routine care. If the alarm continues contact the Tech from the LVAD company to receive further instructions. V17 said at night the resident LVAD should be plugged into the wall outlet. V17 said during an emergency, if a resident is found unresponsive the Nurse should check the LVAD connections, batteries and check if the LVAD is running, V17 said the Nurse should replace the batteries if the batteries are not charged. V17 said she does not know how to run a system check on the LVAD, V17 said she has never seen R1 LVAD system, she has never entered R1 room to observed R1 LVAD system. V17 said she is not competent in LVAD training, policy/procedures. V17 said she recommends that herself and the nursing staff have hands on training with the LVAD system. V17 said there is not a stop order in place for admitting LVAD patients. V17 said she did not inform the Nursing staff that she was the LVAD preceptor because she did not feel competent in her role as the preceptor. V17 said she inform the Director of Nursing of this today. V17 said resident rounds should be conducted every two hours, staff should go inside the room, assess the patient, check for breathing, look for rise and fall in chest, observed for changes in condition, changes in breathing, check if resident is perspiring excessively, these signs could indicate a change in condition. V17 said she aware that R1 was admitted with and LVAD in [DATE]XXX[DATE] at 2:17pm V15 (Medical Doctor/ Medical Director) said R1 was planning to discharge home, R1 had heart failure with some functioning capacity, V15 stated that if the batteries to R1 LVAD was depleted it would exacerbate R1 death. V15 stated that there should be at least one Nurse on duty that is trained on the LVAD. V15 said the facility did not inform him of the occurrence. [DATE] at 5:25-530pm review of facility video surveillance with assist from V5 (Administrator), V5 made surveyor aware that the time stamp was incorrect, and that the video was one hour behind. Video surveillance for the med bridge unit was reviewed from 1:00am until 7:02am (V3 was observed to leave the unit with her bag). V3 did not enter R1's room between the hours of 1:00am to 7:02am. V3 was observed on the video sitting at the nurse station, using personal phone, blowing kisses while on the phone, laughing, observed rocking back and forth in a chair at the nurse station, walking down the hall waving her hands in the air, V3 was observed walking down the hall with her phone in hand. V3 was also observed at the medication cart while on her phone. V3 observed to adjust the phone ensuring to prop the phone up while she was at the medication cart. Video shows V3 entering a room on the right-hand side of the hall (front facing the bistro). V5 zoomed into the video, there was three black hand sanitizer pumps on the wall, V3 entered the room between the second and third hand sanitizer pump. Immediately after video observation, during a tour with V5 to identify what room V3 entered, the room was identified as room number seven. That was not R1's room that V3 entered. V3 was observed to enter a room on the left-hand side of the hall, and rooms on the back unit. V3 observed to handle medications that was dropped off by pharmacy. V3 observed talking to V9 (LPN) at the nurse station several times. V3 observed to remove her white jacket and leave the unit and return. Video surveillance shows V4 (RN) entering the unit, V4 was observed to fully enter multiple rooms on the left-hand side and when V4 got to R1's room, V4 poked her head in the door frame briefly. V4 did not enter R1's room (this was identified by the placement of the black hand sanitizer pumps on the wall). Review of R1's asthma/ COPD assessment completed by V3 (RN) with effective date of [DATE] at 6:10am it is denoted that R1 was alert, required head of bed to be elevated, shortness of breath or trouble breath when lying down, most recent pulse, 63- regular, dated [DATE]at 7:02am. Respiration 15 dated [DATE] at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 15 of 24 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 10/08/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 7:22am. Blood pressure 88/64 dated [DATE] at 7:22am. Auscultation clear bilaterally. Review of R1's vital sign assessment log, the above vital signs was completed by V10 (CNA) on [DATE] at 7:22am and not V3. Review of R1's baseline care plan with V6, R1 did not have any goals and interventions listed for the LVAD. Review of R1's comprehensive care plan with V6, R1 did not have a comprehensive plan of care developed with goals and interventions for the LVAD. Review of R1's physician order sheet, order dated [DATE]; check LVAD two times a day for LVAD alarms and system checks.Review of R1's Medication Administration Record for the LVAD order, it is denoted that R1 LVAD was being checked at 9:00am and 5:00pm. There are no orders, for checking the alarms and system during the night shift. There is no plan of care for monitoring, assessing, and managing R1's LVAD at night. Facility policy/ procedures/ protocol for Ventricular Assist Device SAR/LTAC Training, denotes in-part, how to contact VAD team, heart failure, a ventricular assist device (VAD) is a continuous flow pump implanted to assist a failing native heart by taking blood from the left ventricle. Flowing through the pump into the outflow graft to the ascending aorta. VAD reduce the need of the native heart to pump vigorously to eject blood via the aortic valve, thereby reducing workload and oxygen demands of the native heart. General component; pump, driveline, controller and power x2. Driveline-Electrical line that communicates between the pump and the controller, LIFELINE- DO NOT CUT, DO NOT DISCONNECT FROM SYSTEM CONTROLLER OR THE PUMP WILL STOP!!!! Must ALWAYS be covered with sterile occlusive dressing. Battery power- Batteries can last from 8-17 hours depending on type of VAD, press button on battery to tell how much charge is left, change batteries if down to two lights (50%), always bring all batteries/wall power with patient if being transported/transferred. Every VAD patient must have back-up equipment due to the possibility of malfunction/equipment damage!! Back-up equipment includes extra system controller, extra Batteries clips (HM 2/3), Cell Phone to call hospital contact. Heart Ware Power Sources- one battery is expected to last 7-8 hours, Each, battery drains individually, once one battery drains to less than 25% it automatically switches to the other battery, Batteries are intended for daytime use, the AC adapter will always be the primary source of power if connected, Patients are to always sleep connected to AC adapter and one fully charged battery. While in the hospital the AC adapter should always be plugged into the red outlets. Power module/ mobile power unit aka wall power, patient always sleep on the wall power, assures continuous power, must be plugged into 2-prong grounded outlet (use red outlets if available) amplifies alarms of systems controller with heartmate 2 or 3. Patient will have either mobile power unit (small box only for home use) or power module (big box). In case of a power outage switch to batteries immediately. Keep power modules plugged in at all times to keep the internal battery charged. Batteries heartmate 3 last 10-17 hours (batteries drain simultaneously). Monitoring battery power- change to fully charged batteries or plug into wall power if power gets to 2 green bars! Switch Power Sources one at a time never double disconnect power sources. Nursing care of VAD patient- patient assessment check vital signs and VAD parameters every shift, controller and power module self-test to be performed every morning, daily weights in the morning. Weights should be consistently with clothing/equipment, contact VAD team of weigh increase greater than 5 pounds in one week. Strict intake and output. Assess driveline site every shift- make sure anchor devices is in place, perform sterile dressing changes as ordered (call VAD team with any abnormalities). Blood pressures (BP)an automatic blood pressure cuff may not work and the preferred way to check a BP is using the doppler method. Viewing pump and systems perimeters-press display button - pump speed, press display button twice- pump flow in liters per minute, press display button three times- pulsatility index, press display button four times-power in [NAME] , press display button five times- charge status of the backup battery in the system (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 16 of 24 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 10/08/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few controller-1.charged-2.charging-3.fault, press display button six times, blank screen indicates the screen is off, which is normal. Driveline dressing. Facility Abuse policy and prevention program dated 10/22 denotes in-part this facility affirms the right of all residents to be free from abuse neglect exploitation misappropriation of property deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse neglect exploitation and misappropriation of property and mistreatment of residents. In order to do so the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that it has within its control to prevent occurrence of abuse neglect exploitation misappropriation of property deprivation of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse neglect exploitation misappropriation of property and mistreatment by anyone including but not limited to facilities app or the residents' consultants' volunteers' staff from other agencies providing services to the individual family members or legal guardians friends or any other individuals. Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm pain or mental anguish neglect means a facility's failure to provide or willful withholding of adequate medical care mental health treatment psychiatric rehabilitation personal care or assistance with activities of daily living that is necessary to avoid physical harm mental anguish or mental illness of a resident including deprivation of goods and services by staff. 3.Orientation and training of employees; during orientation of new employees, the facility will cover at least the following topics, sensitivity to the residents and resident's needs, what constitute abuse, neglect, exploitation, and misappropriation of resident's property. 4.Establishing a resident sensitive environment the facility desires to prevent abuse neglect exploitation mistreatment deprivation of goods and services by staff and mistreatment of residents' property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following resident assessment as part of the resident's life history on the admission assessment comprehensive care plan and NMDS assessments staff will identify residents with increased vulnerability for abuse neglect exploitation his treatment history of trauma or misappropriation of residence property who have needs triggers and behaviors that may lead to conflict. Through the care plan processing staff will identify any problems goals and approaches which will reduce the chance of abuse neglect exploitation mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Staff supervision supervisors will monitor the ability of the staff to meet the needs of residents including that assigned staff have knowledge of individual residents' care needs. Situations such as inappropriate language and sensitive handling or impersonal care will be corrected as they occur incidents that do not meet the definition of abuse neglect exploitation misappropriation of property or mistreatment will be handled through counseling training and if necessary or repeated the facility progressive disciplinary action. In summary there were multiple staff on duty on [DATE] and [DATE] (night shift) that could have checked, changed and ensured that R1's LVAD batteries had adequate voltage to run the pump thereby circulating blood to R1's heart. The facility policy/procedures/protocol reflects to change the batteries at 50% capacity, the policy does not mention to wait for an alarm to sound before addressing, checking and changing the batteries. The Facility Assessment Tool dated [DATE] denotes in-part our resident profile, diseases/conditions, physical and cognitive disabilities- categories-heart/circulatory system, congestive heart failure. Decisions regarding caring for residents with conditions not listed above, facility resources including but not limited to staff skill sets and material (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 17 of 24 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 10/08/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resources. Mandatory in-services related to specific diagnoses or equipment, involvement of Medical Director, corporate resources. Services and care the facility offers based on our residents' needs, resident support needs, other special needs, dialysis, hospice, ostomy care, tracheostomy care, bariatric care, palliative care, end of life care, LVAD. Provide person-centered/directed care: Psycho/social/spiritual support: Identify hazards and risks for residents. Training topics, competencies: general staff-Abuse, Neglect and Exploitation. Nurses- Left Ventricular Assist Device. On [DATE] at 2:40pm facility presented policy titled ‘Left Ventricular Assist Device' dated 01/2025, review date 09/2025 denoting general: to provide guidance on the care of resident with LVAD. Responsible party Nursing staff, Nursing staff will check to ensure that the battery backup is charged. Facility LVAD training for nurses will be completed through LVAD clinic.This policy was not presented when request was made to review the LVAD policy, procedures, and or protocol on [DATE], [DATE] and [DATE].2. R2 was admitted to the facility on [DATE], R1 face sheet shows diagnosis of chronic systolic congestive heart failure, atrial fibrillation, and presence of heart assist device. R2's facility census shows admission date [DATE] and discharge date [DATE].R2's progress notes show R2 sent to hospital for change in condition on [DATE].R2's third eye heath note dated [DATE] at 10:09am denotes in-part patient name-R1. Initial stabilization visit, [AGE] year-old male admitted from the hospital after hypoglycemic event with sepsis currently on Bactrim DS twice a day for two more days past medical history of hypertension diabetes mellitus. Patient was admitted to the facility today and is awaiting full H and P (history and physical) and review by primary team. The nurse consulted third eye health to assess the patient to review discharge medication and orders and to ensure safe transition of care. Review of available paperwork and consultation with patient nurse was completed to identify high risk medication while awaiting evaluation by primary team. Physical exam findings per nurse and video observation physical exam medication review hospital discharge orders reviewed and updated as appropriate condition is stable medication review medication orders reviewed clarifications made see orders medication orders review no clarifications made patient is at risk for polypharmacy recommend that primary team review medications and eliminate unnecessary medications antibiotics diabetes repeated falls. Does the patient have any acute symptoms or any additional conditions that were addressed? today no. Orders available documentation review orders and medications approved until patient is evaluated by primary team obtain and review current relevant hospital documentation and orders with primary team when available start house start probiotics for 10 days twice a day. Fall precautions per facility policy. Point of care glucose checks three times a day before meals and at bedtime. Notify a clinician of any change in condition. Disposition: of stay at facility. Audio and video with patient and nurse present. Statement of medical necessity- yes. Sign date [DATE], 9:05 AM, provider V28.R2's initial stabilization visit completed by the provider, does not address the plan of care for R2's LVAD. Review of R2's physician order sheet for [DATE] there are no orders noted for R2 LVAD, no orders for VAD parameters every shift, no orders for controller and power module self-test to be performed every morning. [DATE] V6 (Director of Nursing) presents the admission evaluation, stating that the baseline care plan is included in the admission evaluation, V6 said there are no specific plan of care for R2's LVAD. During a follow-up interview on [DATE] at 4:46pm V6 (Director of Nursing) said she is now the LVAD preceptor for LVAD's, she is working with V5 (Administrator) to establish an order set for patients with an LVAD. R2 admission evaluation dated [DATE], completed by the Nurse denotes in-part disease conditions contributing to admission- heart failure, devices- other- LVAD. Cardiovascular, ventricular assist device- yes is checked. Review of the baseline plan of care included in the admission evaluation, there are no goals or interventions noted specifically for the LVAD, there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 18 of 24 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 10/08/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete are no orders for checking/monitoring the alarms, system, or batteries. Review of R2's comprehensive plan of care with V12 (MDS coordinator), V12 stated that she edited/ revised the care plan during this survey on [DATE] to include the LVAD, V12 stated she knew the surveyor was reviewing for LVAD's. V12 was asked, what's the specific goals and interventions for the patient with the LVAD, V12 said the floor nurse are supposed develop a plan of care for baseline care needs upon admission within 24 hours, and the MDS team will review the comprehensive plan of care after. V12 did not give a response of what the baseline care needs are for a resident with an LVAD. V12 said she should not edit a resident record after they have discharged from the facility. On [DATE] at 11:44am V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. Staff should monitor the blood pressure, ensure orders are in place, complete daily weights, be attentive by being alert to alarms from the monitor. V17 omitted what orders should be in-place for a patient with an LVAD.Facility policy titled baseline care plan dated 1/2023 last revision date 01/2025 denotes in-part to provide the staff with guidance on completion of comprehensive person-centered care baseline care planning. The facility will develop and implement A baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will be developed within 48 hours of residence admission into the facility. The baseline care plan will include at a minimum of the following necessary information to properly care for a resident elopement risk fall risk supervision needs behavior interventions activities of daily living needs initial goals based on admission orders physician orders dietary orders therapy services social services pass our recommendations if applicable. Person centered care means that the facility focuses on the resident as the center [TRUNCATED] Event ID: Facility ID: 145087 If continuation sheet Page 19 of 24 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 10/08/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to provide appropriate, person-centered care and treatment to ensure the highest practicable physical, mental, and psychosocial well-being of 1 of 1 resident's (R1) reviewed with a Left Ventricular Assist Device (LVAD), who was found unresponsive. The facility failed to follow its own emergency response protocol, resulting in a failure to identify that R1's LVAD system had stopped functioning due to depleted batteries, contributing to cardiac arrest and subsequent death.The Immediate Jeopardy which began on [DATE] when the facility failed to follow their policy/practice/protocol to check the Left Ventricular Assist Device for functioning, if the device is running during an emergency when a resident R1 was observed unresponsive contributing to cardiac arrest and subsequent death. V5 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 3:13pm The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R1's face sheet diagnoses of encounter for surgical after care following the Circulatory System, unsteadiness on feet, Type 2 Diabetes Mellitus, Ventricular Tachycardia, presence of heart assist device, Cognitive Communication Deficits, COPD, Acute and Chronic Congestive Systolic Heart Failure. R1's MDS dated [DATE] shows BIMS score of 11 (Cognitive Deficits). Physician order sheet shows orders for full code. R1's progress note dated [DATE] denotes in-part, [AGE] year-old male arrived at facility skin intact, drive line insertion site Left Lower Quadrant (LLQ) with anchor on Right Lower (RLQ) Quadrant, scattered bruising, drive line dressing change Monday-Wednesday-Friday (M, W, F). LVAD needs to be checked twice a day (BID). Registered Nurse spoke with LVAD nurse (name) giving numbers in case of needing to be contacted, (phone number listed) during office hours, after hours or emergency number (phone number listed). Resident very pleasant and cooperative, cell phone, shoes, clothes, LVAD batteries (6), LVAD battery charger, LVAD wall power unit, battery holders (4) all at bedside within reach. R1's emergency room records dated [DATE] denotes in-part patient coming from the nursing home report from EMS noted an unwitnessed cardiac arrest. The patient has an LVAD (Left Ventricular Assist Device). According to EMS when they arrived CPR was in progress EMS continued CPR. Assessment of the patient HeartMate 3 shows that the patient is on battery backup that there is no power to this his unit. CPR continued. The patient HeartMate 3 was connected to power source and began operating. Of note the advance heath care team stated that the patient had been on battery backup for over 300 minutes prior to arrival. On [DATE] at 1:10pm, V13 (emergency room Nurse) stated R1 arrived at the hospital in cardiac arrest, with Emergency Medical Service (EMS). V13 stated that R1 Left Ventricular Assist Device, batteries and the backup battery were dead upon arrival to the emergency room. V13 explained that the LVAD system is designed to pump blood to the heart because R1 has heart failure. V13 said the batteries should never be allowed to deplete. The event log file for R1's LVAD system denotes in part battery power depleted 09/16 at 4:51am which enabled the EBB (emergency backup battery) in the controller and ran the VAD at the low limit of 5200 RPM until the EBB depleted as well on 09/16 at 6:48am resulting in the VAD turning off. Unable to determine the time the VAD was off due to the timestamp being reset to [DATE] once the power was restored to the VAD. On [DATE] at 10:01am, V2 (CNA) said she was going to assess R1's vitals and observed R1 with no pulse, V2 said she notified V1 (LPN), and immediately returned to start CPR on R1. V2 said she remember getting tired when doing chest compressions and she switched out with V1. V2 said when they were in the room, she heard someone say that the LVAD was not plugged up and some said that's okay as long as the batteries Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 20 of 24 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 10/08/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few are attached. V2 said she doesn't know the name of the person because she is fairly new to the facility. V2 said she did not check the LVAD, and she did not check the batteries. V2 said she has not had any training for emergency response to a patient with an LVAD.On [DATE] at 4:09p.m, V1 (LPN) said she was made aware by V2 that R1 was not responding, V1 said she got V4, (RN) attention, and they rushed into the room. V1 said she assisted with chest compressions and bagging R1 when V2 got tired. V1 said she did not check R1, LVAD for function, she did not check the batteries. V1 said V9 (LPN), V4 (RN), V20 (LPN), and V21 (LPN) all responded to the code blue for R1. V1 said she did not receive training on emergency response to a patient with an LVAD.On [DATE] at 2:10pm, V4 (RN) said she was R1's nurse for the morning shift of [DATE], V4 said when she heard the code blue she ran to get the crash cart, V4 said she did not assist with CPR efforts for R1, the other Nurses did CPR. V4 said she did not check the LVAD for functioning when she returned with the crash cart, she did not check the batteries. V4 said she left the room to see if the papers were being printed, V4 said she was not printing them, V9 (LPN) was printing. V4 said she was checking to ensure they were being printed. V4 said she was there when the medics took R1 to the hospital for further evaluation. V4 said she heard the medics say, R1 had a pulse and got R1 out fast. V4 said she did not receive training on emergency response to a patient with an LVAD at the [NAME] Oak Lawn.On [DATE] at 1:33pm, V9 (LPN) said she immediately called 911 when she heard code blue. V9 said she observed a nurse doing CPR, one nurse was writing, and one was doing vitals. V9 said she did not check R1's LVAD for functioning and she did not check the batteries. V9 said she went to print papers for R1's transfer to the hospital. V9 said she did not receive training on emergency response to a patient with an LVAD at the [NAME] Oak Lawn.On [DATE] at 1:48pm, V20 (LPN) said she heard the code blue announcement, she responded. V20 said she did compressions. V20 said she did not check R1's LVAD for functioning, she did not check the batteries. V20 said she worked with R1 in the past, she was aware that R1 had an LVAD. V20 said she has not received any training/ in-service for LVAD patients at the [NAME] Oak Lawn. V20 said a nurse showed her what to do for R1 when she worked with R1. V20 said she doesn't recall the name of that nurse. V20 said V21 (LPN) did respond to the code blue for R1. V20 said she did not receive training on emergency response to a patient with an LVAD at [NAME] oak lawn.On [DATE] V21 (LPN) said she can't remember if she responded to the code blue for R1.On [DATE] at 12:41pm, V6 (Director of Nursing) stated that her expectation is that the Nursing staff follow the facility policy when caring for a resident with a LVAD systems. V6 said she does not have any documentation that the staff received LVAD training in [DATE]. V6 said R1's family was upset by his death and had concerns about the LVAD system. V6 said she is learning during this survey that staff did not receive training for the LVAD/ LVAD emergency response. V6 said the LVAD should be checked for functioning during a code blue emergency situation.On [DATE] at 11:44am, V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. V17 said she recommends that herself and the nursing staff have hands on training with the LVAD system. V17 said there is not a stop order in place for admitting LVAD patients. V17 said during an emergency response when a resident is found unresponsive and the resident has a LVAD, the nurse should check the LVAD to ensure it is running (making a humming sound), they should check the batteries and if the batteries are not charged, they nurse should quickly change the batteries. V17 said any nurse that respond to the code blue can check the batteries and change them.R1's physician order sheet, order date [DATE] shows orders for full code.R1 does not have an individualized plan of care for the full code status, there is not an individualized plan of care with goals and interventions to implement when and if R1 is found/observed to be unresponsive, there are no plan of care with goals and interventions to implement for the LVAD when and if R1 is found/observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 21 of 24 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 10/08/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete unresponsive.R1's plan of care for R1 what's admitted to the facility for a skilled stay requiring physician ordered medically necessary services, including direct therapy services, skilled nursing care management, and evaluation of the patient care plan observation and assessment of the patient's condition and or teaching and training activities related to the reason for stay or in preparation for transition to a lesser care environment. R1 requires skill services related to primary diagnosis aftercare s/p (status post) LVAD.Facility policy/protocol/ procedures for LVAD Patient Emergency Assessment denotes in-part: call rapid response team or 911. LVAD functioning? Auscultate left lower chest, continuous humming sound equals pump is working. No initiate: ACLS (advance cardiac life support) protocol, controller will probably be alarming: device check: check VAD parameters, controller alarm lights/sounds, continuous tone: urgent. Check power source. Check all cables connections. Change controller if instructed by VAD team. Transport urgently to ER (emergency room).Facility Emergency Response, denotes in-part VAD hazard alarm, call VAD team immediately (number listed) If patient is unresponsive: is VAD running? (listen for hum and check VAD numbers) YES: Treat underlying cause (patient could be unresponsive for other reasons; respiratory, stroke, blood sugar) NO: 1st attempt to get pump running quickly if unable to quickly okay to administer CPR and/or defibrillate. DO NOT disconnect VAD. If patient is responsive: Step 1-Check the connection between the system controller and the LVAD, (driveline), Step 2-Check the connection between the system controller and the batteries or between the system controller and power-based unit. Step 3-If the device still fails to operate and patient is stable, call VAD coordinator: (phone number listed). The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. Regional Nurse Consultant in-serviced the Director of Nursing regarding the facility's Emergency Protocol and Procedure for a resident with an LVAD on [DATE]. The Director of Nursing and Nurse Managers completed education with nurses on the facility's Emergency Protocol and Procedure for a resident with an LVAD. The Director of Nursing and Nurse Managers also completed the education provided by the manufacturer (via Teams) to the facility nurses. 2. The Director of Nursing was in-serviced on [DATE] by the Regional Nurse Consultant regarding emergency response for LVAD system and specialized device care. The Director of Nursing provided education on [DATE] through [DATE] to licensed and unlicensed nursing personnel on emergency response for LVAD system. The emergency response procedure will be placed in the resident care plan and at the bedside. 3. The Director of Nursing and/or Nurse Managers will provide education to current nursing department staff with competency exams when facility admits any specialty care resident specifically LVAD. This process will be included in the new hire onboarding/orientation process. The facility nurses will also receive training competencies at minimum quarterly and as needed for staff caring for residents with specialty care needs.4. The facility has revised its staffing protocols on [DATE] to ensure that at least one staff member trained in LVAD management is always on duty, including during all shifts, weekends, and holidays when there is an LVAD in the facility. The schedule is now maintained to verify proper coverage and trained staff assigned are being routinely audited by DON/designee. 5. The Director of Nursing and/or designee has educated licensed nursing staff on [DATE] on recognizing and appropriately responding to LVAD-related emergencies including prioritization of device functions assessment during a code situation. Mock code drills incorporating LVAD scenarios will be conducted monthly, with documentation and debriefing to reinforce staff knowledge and readiness. Date: [DATE] Event ID: Facility ID: 145087 If continuation sheet Page 22 of 24 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 10/08/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their facility assessment and ensure that staff received in-service and training to provide care and service for residents with a left ventricular assist device. This affected two of two resident reviewed ( R1, R2). 1.R1's face sheet indicates diagnoses of encounter for surgical after care following the circulatory system, unsteadiness on feet, Type 2 Diabetes Mellitus, Ventricular Tachycardia, presence of heart assist device, cognitive communication deficits, COPD, Acute and Chronic Congestive Systolic Heart Failure. R1's MDS dated [DATE] shows BIMS score of 11 (cognitive deficits).2. R2 was admitted to the facility on [DATE], R2 face sheet shows diagnoses of Chronic Systolic Congestive Heart Failure, Atrial Fibrillation, and presence of heart assist device.On 09/17/2025 11:13am V3 (RN) said she did not receive training at the [NAME] Oak Lawn nursing home for LVAD. On 09/17/2025 at 1:33pm V9 (LPN) said she did not received training on emergency response to a patient with an LVAD at the [NAME] Oak Lawn.On 09/17/2025 at 2:10pm V4 (RN) said she V4 said she has not received any training on LVAD system at the [NAME] Oak Lawn. During this interview, V4 was asked to demonstrate how to check the LVAD batteries to determine the capacity, V4 picked up the gray battery, V4 could not identify where the button was located on the battery to determine if the battery was charged. V4 was observed to flip the battery over and over, V4 did not identify the button on the front of the battery to check the battery capacity. V4 stated she did not check R1's LVAD system or batteries when rounding on R1 upon the start of the shift on 9/16/25.On 09/17/2025 at 4:09p.m V1 (LPN) said she did not received training on emergency response to a patient with an LVAD.On 09/18/2025 at 10:01am V2 (CNA) said she has not received any training on LVAD system at the [NAME] Oak Lawn. On 09/18/2025 at 12:41pm V6 (Director of Nursing) stated that her expectation is that the Nursing staff follow the facility policy when caring for a resident with a LVAD systems. V6 said she does not have any documentation that the staff received LVAD training in July 2025. V6 said she is learning during this survey that staff did not received training for the LVAD. On 09/18/2025 at 2:17pm V15 (Medical Doctor/ Medical Director) V15 stated that there should be at least one Nurse on duty that is trained on the LVAD. On 09/19/2025 at 12:12pm V11 (CNA) said she did not get training at the [NAME] Oak Lawn nursing home for LVAD. On 09/24/2025 at 11:44am V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. V17 said all Nursing staff should have training for the LVAD, V17 said she would like the training to consist of return demonstration to allow for hands on training, V17 said watching videos is not enough training to learn about the LVAD. On 09/24/2025 at 2:43pm V19 (LPN) said he did not get training at [NAME] Oak Lawn for LVAD patients. On 09/24/2025 at 12:42pm V18 (LPN) said he, V18 he did not get training at [NAME] Oak Lawn for LVAD patients. On 09/25/2025 V21 (LPN) said she can't remember if she responded to the code blue for R1. V21 said she remember that the training was offered in July, she doesn't recall the participating in the training. On 09/26/2025 at 1:48pm V20 (LPN) said she did not received training on emergency response to a patient with an LVAD at [NAME] oak lawn.The Facility Assessment Tool dated 08/29/2025 denotes in-part our resident profile, diseases/conditions, physical and cognitive disabilities- categories-heart/circulatory system, congestive heart failure. Decisions regarding caring for residents with conditions not listed above, facility resources including but not limited to staff skill sets and material resources. Mandatory in-services related to specific diagnoses or equipment, involvement of Medical Director, corporate resources. Services and care the facility offers based on our residents' needs, resident support needs, other special needs, dialysis, hospice, ostomy care, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 23 of 24 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 10/08/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm tracheostomy care, bariatric care, palliative care, end of life care, LVAD. Provide person-centered/directed care: Psycho/social/spiritual support: Identify hazards and risks for residents. Training topics, competencies: general staff-Abuse, Neglect and Exploitation. Nurses- Left Ventricular Assist Device. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145087 If continuation sheet Page 24 of 24