Health inspection·March 21, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm 2) R58's EMR (Electronic Medical Record) showed R58 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, heart failure, dementia, and muscle weakness. R58's MDS dated [DATE], showed R58 had moderate cognitive impairment and needed substantial assistance with bathing and personal hygiene. Residents Affected - Few On March 18, 2024, at 10:38 AM, R58 was lying in bed, taking a nap, with long facial hair present. On March 19, 2024, at 9:05 AM, with V20 (CNA-Certified Nurse Aide) present, R58 remained with long facial hair, in need of shaving and R58 requested to be shaved. On March 20, 2024, at 9:20 AM, with V17 (LPN-Licensed Practical Nurse) present, R58 remained with long facial hair, in need of shaving and again R58 requested to be shaved. R58's care plan initiated on November 14, 2023, showed R58 needed assistance of 1 staff with dressing and hygiene ADL (Activities of Daily Living) task. The facility was unable to provide documentation that R58 had received a shower, which included shaving, during the month of March 2024. On March 20, 2024, at 10:05 AM, V2 (DON) stated it is the expectation for staff to complete documentation on the shower sheet form when a shower or bed bath is given or when the resident refuses a shower or bath. V2 stated residents are scheduled for showers twice a week and the expectation of grooming facial hair should be included during the shower or when needed. V2 stated she did not have documentation of shower sheets for either R40 or R58. The facility's policy Activities of Daily Living (ADL's) dated November 2022, showed the Purpose .to preserve ADL function, promote independence, and increase self-esteem and dignity .and Bathing .washing and drying the body, including full body sponge bath and Grooming .maintaining personal hygiene .combing and/or styling hair, face and hands, brushing teeth, shaving or applying makeup, oral hygiene, self-manicure (safety awareness with nail care) and/or application of deodorant or powder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 2 of 13 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow manufacturer's instructions for a pressure reducing/relieving mattress. This applies to 2 of 7 residents (R15, R87) reviewed for pressure ulcers in the sample of 21. Residents Affected - Few The findings include: 1.R15's EMR (electronic medical records) showed R15 was admitted on [DATE] with diagnoses including cognitive communication deficit, other reduced mobility, pressure ulcer of sacral region, stage 2. R15's care plan revised on February 11, 2024 included R15 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to impaired cognition, impaired communication, incontinence of bladder, incontinence of bowel, impaired mobility status, impaired nutritional status, comorbidities, cancer, failure to thrive. Interventions for the same included pressure reducing/relieving mattress as needed. R15's weights and vitals section in EMR showed R15 was 89.2 pounds on March 1, 2024. On March 18, 2024 at 10:57 AM, V19 (Licensed Practical Nurse) stated she is unsure if R15 has pressure sore on sacral area. V19 added, She has a dressing. The wound nurse does the treatments. On March 19, 2024 at 10:34 AM, R15 was lying in a low bed had a pressure relieving mattress. The control knob was switched ON at low pressure and had the label for Proactive Medical Products with weight dial set at 320 lbs. for weight in pounds. When asked, R15's nurse V3 (Registered Nurse) stated she is not aware of what the settings should be. V3 stated, The housekeeping does the setting for the air pressure on the mattress. On March 19, 2024 at 10:37 AM, V2 (Director of Nursing) was shown the above setting on R15's air mattress. V2 stated, V12 (House Keeping Director) puts it (control setting) on. I am not sure if V11 (Wound Care Nurse) lets him (V12) know about the setting. V2 added she will refer to the manufacture's guidelines for the same. On March 19, 2024 at 10:39 AM and 11:18 AM, V11 stated, I check it (mattress) sometimes to see if the pressure is low or high but never do any adjustments. I don't know anything about the setting. She (R15) had a pressure sore on admission but currently it is healed. Currently I do protective treatment on her sacral area. On March 19, 2024 at 10:42 AM, the control knob for the weight dial on R15's pressure relieving mattress was noted changed to 350 lbs. for weight in lbs. V12 stated he adjusted it a few minutes earlier to make sure there is enough air in the mattress. V12 added he thinks the adjustments are related to the weight but is not sure. Proactive Medical Product's operation manual instructions for the pressure redistribution mattress showed as follows: Step 6. Determine the patient's weight and set the control knob to the weight setting on the control unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 3 of 13 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. R87's EMR showed R87 was admitted on [DATE] with diagnoses including paraplegia, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, oropharyngeal phase. R87's quarterly MDS (Minimum Data Set) assessment dated [DATE], showed R87 was cognitively intact. R87's care plan revised on September 12, 2023, included R87 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to immobility, admitted with pressure injury to sacrum, tube feeding, respiratory trach, incontinence, advancing age. Interventions for the same included pressure reducing/relieving mattress as needed. R87's weights and vitals section in EMR showed R87 was 126.0 pounds on March 1, 2024. On March 18, 2024 at 9:10 AM, R87 was seated up in a wheelchair and stated she had had a wound on her sacral area, and she gets dressing change every morning by V11. R87 was not sure if the wound was still present. On March 19, 2024 at 10:29 AM, R87 was lying in bed had a pressure relieving mattress showing the control unit labeled Drive with power switch switched on. The pressure adjust knob was set at 350 firm setting. R87 stated, I have had this (pressure) mattress ever since I have been here since last August. Nobody ever adjusts it. They don't even look at it. On March 19, 2024 at 10:38 AM, V2 was also shown the above setting on R87's air mattress. V2 added she will refer to the manufacture's guidelines for the same. On March 19, 2024 at 11:18 AM, V11 stated R87 had a stage 3 pressure sore on here sacral area, and it is currently healed. V11 added she does routine preventive treatments on the area to prevent it from reopening. Drive operation's manual instructions for alternating pressure low air loss mattress showed as follows: Step 6. Determine the patient's weight and set the control knob to the weight setting on the control unit. On March 19, 2024 at 12:23 PM, V2 stated per operations instructions shown both in the Proactive Medical Products and Drive manuals, the setting for the pressure relieving mattress is based on (patient) weight. On March 21, at 10:02 AM, V26 (Drive Representative) stated it is recommended the control knob is set to the patient's weight as if its set too low the mattress will be soft and if set too high the mattress will be too firm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 4 of 13 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide specialized cup for drinking for residents that were at risk for aspiration with dysphagia and could not use straws. This applies to 2 of 3 residents (R18, R87) observed for dining in the sample of 21. The findings include: R87's face sheet included diagnoses of dysphagia, oropharyngeal phase, paraplegia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R87's quarterly MDS (minimum data set) dated December 19, 2023, showed R87 was cognitively intact. R87's POS (Physician Order Sheet) showed diet order of General diet, Mechanical Soft texture, Regular Thin Liquids consistency, chop vegetables, gravy added to meat. No straw during TL (thin liquid) related to dysphagia, oropharyngeal phase. On March 18, 2024 at 04:23 PM, R87 in bed with tube feeding running. On R87's bedside table, there was a straw in a cup of brownish tinged water with a bottle of 16.7 oz/ounces soda placed next to it. R87 stated, I just drank my soda with a straw. The water is from the ice that melted. It was also noted there were multiple straws in a cup on the nightstand. V19 (Licensed Practical Nurse) who was in the area, was not sure if R87 is able to use straws with liquids. On checking the diet order that showed, no straw during TL. V19 did not know what TL abbreviation meant. Nursing progress note dated March 18, 2024 17:06 (5:06 PM) included, Came to the room and noted straw in resident's cup of water. Made resident aware that she is not to use straw when drinking as it can make her cough and possibly aspirate. Resident verbalized understanding and allowed this writer to remove the straw and the unopened ones at bedside. On March 19, 2024 at 2:51 PM, V4 (Speech Language Pathologist) stated she just picked R87 back up on her case load. V4 stated she had previously recommended no straw for R87 as R87 demonstrates high risk for aspiration as she has dysphagia. V4 added larger volumes of liquids can be ingested with straws and cause higher risk for aspiration. V4's Discharge summary dated [DATE] included as follows: To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: chin tuck. general swallow techniques/precautions, rate modifications, no straws . 2. R18's face sheet included diagnoses of dysphagia, oropharyngeal phase, communicating hydrocephalus, other cerebral palsy, adult failure to thrive, abnormal weight loss, mild protein-calorie malnutrition. R18's POS included diet order of General diet, Mechanical Soft texture, Regular Thin Liquids consistency, Thin Liquids in Provale cup only; Whole milk all meals related to other cerebral palsy. On March 19, 2024 at 12:14 PM, R18 received a meal tray in the dining room with thickened water in a cup and an 8 oz carton of whole milk (regular consistency). Diet card showed, thin liquid Provale cup. V16 (CNA/Certified Nursing Assistant) who was passing out trays stated that previously a blue (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 5 of 13 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cup used to be sent up on the tray by dietary but recently she has not seen it. V14 (Dietary Aide) who had brought up the tray cart stated the residents take it to their rooms and the dietary does not have any more Provale cups. On March 19, 2024 at 2:57 PM, V4 stated R18 was also on her caseload. V4 stated that on her last recommendations on February 22, 2023 she recommended R18 should have thick liquids but can have thin liquids with Provale cup only. V4's discharge recommendations dated February 22, 2023 showed liquids Provale cup during TL intake to decrease signs and symptoms of aspiration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 6 of 13 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician. There were 26 medication opportunities with 8 errors, resulting in an 30.77% medication error rate. This applies to 3 of 3 residents (R33, R80, R87) reviewed in the sample of 21. Residents Affected - Few The findings included: 1. R33's EMR (Electronic Medical Record) showed R33 was admitted to the facility on [DATE] with diagnoses that included muscular dystrophy, acute and chronic and chronic respiratory failure with hypoxia, pneumonia, chronic bronchitis, heart failure, olecranon bursitis left elbow, and hypertension. On [DATE] at 9:15 AM, V17 (LPN/Licensed Practical Nurse) prepared R33's morning medications. R33 was given: 1. Norco 5/325 mg (milligrams). Give one tablet. 2. Vitamin D 500 mg. Give one tablet. 3. Vitamin C 500 mg. Give one tablet. 4. Divalproex 125 mg. Give one tablet. 5. Iron 325 mg. Give one tablet. 6. Furosemide 20 mg. Give one tablet. 7. Hydroxyzine HCL (Hydrochloric Acid) 25 mg. Give one tablet. 8. Duloxetine HCL 30 mg. Give three tablets. 9. Potassium Chloride 10 meq. (milliequivalents) ER (Extended Release). Give one tablet. 10. Folic Acid 400 mcg (microgram). Give two tablets. 11. Multivitamin. Give one tablet. 12. Vitamin B-complex. Give one tablet. 13. Probiotic one pill (was not counted as an opportunity) After all medications were placed into a medication cup. V17 was asked to count the number of pills in the cup. V17 counted and said there were 16 pills in the medication cup. On [DATE] at 1:00 PM, medication reconciliation showed three medications were missed during the morning medication pass. 1. Capsaicin External Cream 0.025% apply to effected area (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 7 of 13 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 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 0759 2. Fluticasone Salmeterol inhaler, give 1 puff every 12 hours Level of Harm - Minimal harm or potential for actual harm 3. Metoprolol 12.5 mg, in morning and at bedtime Residents Affected - Few R33's POS (Physician Order Set) showed the following three medications were to be administered every morning: 1. Capsaicin External Cream 0.025% (Capsaicin) apply to effected area topically two times a day for pain. 2. Fluticasone-Salmeterol inhalation aerosol powder breath activated 250-50 mcg/act (micrograms/One puff orally every 12 hours for wheezing. 3. Metoprolol Tartrate Tablet, give 12.5 mg (milligrams) by mouth every morning and at bedtime for beta blocker. On [DATE] at 1:14 PM, V17 (LPN) said she gave R33 her Fluticasone Salmeterol inhaler and rubbed the Capsaicin cream on R33's elbows after the surveyor left but was unsure of the time. V17 said she gave the Metoprolol during the surveyor's observation of her medication pass. V17 was asked if she remembered counting the pills in her medication cup and she said yes there were 16 pills. Surveyor said 16 was what was written down and matched the number in her medication cup. Had the Metoprolol been given, there would have been 17 pills in the cup. 2. R80's EMR (Electronic Medical Record) showed R80 was admitted to the facility on [DATE] with diagnoses that included congested heart failure, cardiomegaly, and hypertensive heart and chronic kidney disease with heart failure. On [DATE] at 8:30 AM, V3 (RN/Registered Nurse) prepared R80's morning medications. R80 was given: 1. Vitamin C - 500 mg. Give one tablet. 2. Aspirin 81 mg, chewable. Give one tablet. 3. Bumetanide 2 mg. Give one tablet. 4. Escitalopram 20 mg. Give one tablet. 5. Iron 325 mg. Give one tablet. 6. Farxiga 5 mg. Give one tablet. 7. Glimepiride 1 mg. Give one tablet. 8. Loratadine 10 mg. Give one tablet 9. Spironolactone 25 mg. Give one tablet. 10. Multiple vitamins. Give one tablet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 8 of 13 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 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 0759 11. Pantoprazole 40 mg. Give one tablet. Level of Harm - Minimal harm or potential for actual harm After all medications were placed into a medication cup. V3 was asked to count the number of pills in the cup. V3 counted and said there were 11 pills in the medication cup. Residents Affected - Few On [DATE] at 12:55 PM, medication reconciliation of R80's morning medications showed one medication had been missed. 1. Metoprolol 25 mg, take one tablet twice a day for PVCs (Premature Ventricular Contractions). On [DATE] at 1:21 PM, V3 (RN) said she held R80's blood pressure medication (Metoprolol) because V80's blood pressure was low. V3 said her blood pressure was 100/71. When asked what the parameters were to hold the medication, V3 said there weren't any physician ordered parameters, but that she held the medication because her systolic blood pressure (top number) was less than 110. 3) On [DATE], at 5:05 PM, V5 (RN) prepared and administered R87's scheduled medications via gastrostomy tube. V5 prepared the following medication: 1. Cholestyramine powder 4 gm (gram) 1 packet mixed with 200 ml. (milliliter) of water 2. Atorvastatin 40 mg.(milligram) 1 tablet crushed into powder and mixed with 200 ml. water 3. Xarelto 2.5 mg. 1 tablet crushed into powder and mixed with 200 ml. water 4. Metoprolol tartrate 100 mg. 1 tablet crushed and mixed with 200 ml. water V5 turned off the jejunostomy tube feeding that was infusing through the same port and flushed the gastrostomy tube port with 30 ml of water. V5 then administered each medication including the 200 ml. of water with each medication, by gravity bolus and did not flush the tube between medications. V5 then flushed the gastrostomy tube with an additional 175 ml. of water. On [DATE], at 3:57 PM, V2 stated when doing a medication pass the nurse should hand sanitize, have MAR (Medication Administration Record) available, check order, check medication against the physician order, place the medication into a medication cup, make sure house stock is not expired. V2 stated staff should check vital signs, explain to resident what they are going to do, explain what medications are to be given, perform hand hygiene after, and document on the MAR. V2 explained a nurse should never hold a medication without talking to the physician or nurse practitioner and the nurse also needs to know the reason the medication was ordered. V2 stated she had already spoken with V3 (RN/Registered Nurse) regarding the medication V3 held that was a blood pressure medication, but it was ordered for PVCs (Premature Ventricular Contractions) and V3 had no parameters to hold it. V2 stated when administering medications by G-tube (Gastrostomy) the nurse needs to check G-tube placement by listening for air when administering an air bolus, check residuals, crush medications one at time, take crushed pill and add it to 5-10 cc of water, flush 30 cc of water prior to administering any medications, administer the medication and flush with 10 cc of water in between, repeat this process with each medication until all medications are given and then flush with 30 cc of water. V2 stated, using 200 ml with one medication during administration is way too much water, to then repeat 200 ml with 3 other medications for a total of 800 ml, and then administered a flush of 175 ml for a total of 975 ML at one time is unheard of and should not be done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 9 of 13 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 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 0759 Level of Harm - Minimal harm or potential for actual harm The facility's Policy and Procedure Administering Medications last issued on [DATE] showed Purpose: To ensure safe and effective administration of a medication in accordance with physician orders and state and federal guidelines. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 10 of 13 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to store medications in accordance with manufacturer guidelines. This applies to 5 of 5 (R9, R11, R13, R35 and R39) residents in a sample of 21. The findings include: On March 19, 2024, at 9:50 AM, the 2nd floor south medication cart was reviewed, with V7 (LPN) and V6 (ADON Assistant Director of Nursing) with the following observations: R9's Trelegy ellipta (100 mcg/62.5 mcg/25 mcg) inhaler was dated as being opened on 12/6, was in the drawer of the medication cart. R11's Breo ellipta (200/25) inhaler was dated as being opened 12/23, and in the drawer of the medication cart. R13 unopened vial of Lispro insulin had a label on the box, refrigerate if not opened was in the drawer of the medication cart. R35's unopened vial of Aspart insulin had a label on the box, refrigerate if not opened was in the drawer of the medication cart. R39's unopened vial of Lispro insulin had a label on the box, refrigerate if not opened was in the drawer of the medication cart. V7 removed the 3 unopened insulin vials and stated they should not be in the medication cart, they are supposed to be in the refrigerator. V6 reviewed the Medication Expiration Dates document provided by the pharmacy dated January of 2022, and stated R11's Breo Ellipta inhaler expires 42 days after opening and should be removed from the cart and reordered from pharmacy. On March 19, 2024, at 12:30 PM, V6 provided documentation from the pharmacy, manufacturer guidelines for R9's Trelegy inhaler that showed the inhaler expires 42 days after opening and stated it should be removed from the cart and reordered from the pharmacy. R9's EMR (Electronic Medical Record) showed R9 had diagnoses of chronic obstructive pulmonary disease and a physician order for Trelegy Ellipta inhalation powder, 1 puff daily initiated on October 23, 2023. R9's March 2024 MAR (Medication Administration Record) showed R9 was administered Trelegy Ellipta daily. R11's EMR showed R11 had a diagnosis of chronic obstructive pulmonary disease and a physician order for Breo Ellipta aerosol powder, 1 puff orally, one time a day, initiated on December 1, 2020. R11's March 2024 MAR showed R11 was administered Breo Ellipta daily. R13's EMR showed R13 had a diagnosis of type 2 diabetes mellitus and a physician order for Lispro (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 11 of 13 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 insulin in accordance with sliding scale, 4 times per day initiated on September 8, 2023. Level of Harm - Minimal harm or potential for actual harm R13's March 2024 MAR showed Lispro insulin was administered multiple times per day. Residents Affected - Some R35's EMR showed R35 had a diagnosis of type 2 diabetes mellitus with neuropathy and a physician order for Aspart insulin 7 units before meals (three times a day) initiated on March 18, 2024. R35's March 2024 MAR showed Aspart insulin was administered 7 times between March 18 and March 21, 2024. R39's EMR showed R39 had a diagnosis of type 2 diabetes mellitus and 2 physician orders for Lispro insulin, Lispro insulin inject 5 units before each meal (three times a day) initiated on January 25, 2024, and Lispro insulin administer in accordance with sliding scale three times per day also initiated on January 25, 2024. R39's March 2024 MAR showed R39 has been administered Lispro insulin three times per day every day. On March 19, 2024, at 9:50 AM V6 (ADON) stated unopened insulin vials should be refrigerated and expired medications should be removed from the medication cart and reordered from the pharmacy. The facility's policy Storage of Medications dated May 1, 2018, showed Temperature . A. Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges and Expiration Dating .G. No expired medication will be administered to a resident .H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 12 of 13 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 145358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arista Healthcare 1136 North Mill Street Naperville, IL 60563 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to serve portions of chicken nuggets and diced pork as shown on the menu spreadsheet. This applies to 8 of 8 residents (R21, R30, R31, R34, R54, R57, R90 and R196) reviewed for dining in the sample of 21. The findings include: During initial tour of the facility kitchen on March 18, 2024 starting at 9:45 AM, V13 (Food Service Manager) stated that since Sunday (March 17, 2024) was St Patrick's day, the lunch menu from Sunday is served for the lunch on Monday. Lunch menu prepared for March 18, 2024, showed Chicken Nuggets, French Fries, Seasoned Mixed Vegetables, sugar cookie. Facility daily menu spreadsheet for week 1 Sunday included Chicken Nuggets (7 each= 3 oz/ounce protein). On March 18, 2024 at 11:32 AM, V13 was platting the lunch meal at the tray line service in the facility kitchen and served 5 pieces of chicken nuggets to each of the residents on Regular diets. Residents observed to receive the same included R21, R30, R34, R57, R90 and R196. On March 18, 2024 at 11:44 AM, when V13 was asked why the residents received only 5 pieces of chicken nuggets when the spread sheet showed 7 pieces, V13 responded, It shows 5 pieces on the box. V13 added that the size of the nuggets varies depending on the kind purchased. On March 19, 2024 at 11:47 AM, during lunch tray line service, V13 used a #10 scoop to serve diced pork to the residents on Renal diets and R31 and R54 received the same. Facility daily menu spreadsheet for week 1 Tuesday showed to serve 4 oz=2 oz protein of no salt added diced pork for Renal diets. On March 19, 2024 at 11:52 AM, when asked, V13 stated that the Renal diets are supposed to receive 4 oz of diced pork, but they (facility) did not have the scoop (#8) to serve the same. On 03/20/24 at 10:33 AM, V22 (Registered Dietitian) stated that 7 pieces of chicken nuggets should have been served to obtain 3 oz of protein [21 grams protein]. V22 added that a #8 scoop should have been used instead of the #10 scoop to get 4 oz serving. Facility Scoop and Ladle Equivalents chart showed that #10=3 1/4 oz and #8 =4 oz. The label on the box for Chicken Chunk Fritters showed that serving size of 5 pieces =17 grams of protein. Resident diets on Physician order sheet showed that R21, R30, R34, R57, R90, R196 were on Regular consistency diets and R31 and R54 were on Renal diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 13 of 13