Health inspection·January 17, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's Dignity policy dated 12/24 shows each resident shall be care for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy showed; residents should be always treated with dignity and respect, residents will be assisted in maintaining and enhancing his/her self-esteem and self-worth, residents' private space will be always respected, staff shall promote, maintain, and protect residents' privacy including bodily privacy during assistance with personal care and during treatment procedures. Event ID: Facility ID: 145358 If continuation sheet Page 2 of 12 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 01/17/2025 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The clinical records of R37 showed that diagnoses included cirrhosis of the liver, hemiplegia, type 2 diabetes, urinary tract infection, cardiac diseases, and hepatic encephalopathy. The current Minimum Data Set, dated 12/18//2024 indicated that R37 is cognitively moderately intact. R37 was transferred and admitted to the hospital on [DATE] for high level ammonia. The progress report review for R37 showed R37 was transferred to the hospital on [DATE], 06/09/2024,10/11/2024, and 01/13/2025 related to comorbid conditions and complications. The R33's clinical records lacked the documentation of providing in writing R37 or representative the notification of discharge with the reason for transfer/discharge to the hospital and sending a copy to the ombudsman. Based on interview and record review, the facility failed to provide written notice of reason for transfer to resident and/or their representative before resident transferred to hospital and failed to send a copy of transfer notice to the Ombudsman. This applies to 3 residents (R62, R69, and R37) reviewed for hospital transfers in a sample of 25. The findings include: 1. R62's Face sheet shows an admission date of 11/5/24. R62's nursing progress note dated 1/8/25 at 15:33 shows R62 was transferred and admitted to hospital with diagnosis of pneumonia and acute cystitis. There is no documentation of written notice of transfer being provided to resident or their representative, or the Ombudsman. 2. R69's Face sheet shows an admission date of 8/4/23. R69's nursing progress note dated 1/14/25 at 11:34 AM shows R69 was transferred to hospital for gastrostomy and jejunostomy tube evaluation. There is no documentation of written notice of transfer being provided to resident or their representative, or the Ombudsman. On 1/15/25 at 3:50 PM, V1 (Administrator) said the facility does not notify the resident or their representative, or the Ombudsman in writing of reason for resident transfer to hospital. On 1/16/25 at 1:17 PM, V2 (Don/Director of Nursing) said she did not know the resident and/or resident representative and the Ombudsman were supposed to be notified in writing of reason for resident transfers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 3 of 12 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 01/17/2025 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The clinical records of R37 showed that diagnoses included cirrhosis of the liver, hemiplegia, type 2 diabetes, urinary tract infection, cardiac diseases, and hepatic encephalopathy. The current Minimum Data Set, dated 12/18//2024 indicated that R37 is cognitively moderately intact. R37 was transferred and admitted to the hospital on [DATE] for high level ammonia. The progress report review for R37 showed R37 was transferred to the hospital on [DATE], 06/09/2024,10/11/2024, and 01/13/2025 related to comorbid conditions and complications. The R33's clinical records lacked the documentation of providing R37 or representative and the Ombudsman with written notice to be aware of a facility's bed-hold and reserve bed payment policy to R37 before and to the Ombudsman upon transfer to a hospital. Based on interview and record review, the facility failed to provide written bed hold policy to resident and/or their representative prior to resident transfer to hospital. This applies to 3 residents (R62, R69, and R37) reviewed for hospital transfers in a sample of 25. The findings include: 1. R62's Face sheet shows an admission date of 11/5/24. R62's nursing progress note dated 1/8/25 at 15:33 shows R62 was transferred and admitted to hospital with diagnosis of pneumonia and acute cystitis. There is no documentation of bed hold policy being provided to resident prior to transfer to hospital. 2. R69's Face sheet shows an admission date of 8/4/23. R69's nursing progress note dated 1/14/25 at 11:34 AM shows R69 was transferred to hospital for gastrostomy and jejunostomy tube evaluation. There is no documentation of bed hold policy being provided to resident prior to transfer to hospital. On 1/15/25 at 3:50 PM, V1 (Administrator) said the facility does not have any documentation of bed hold notices being provided to residents prior to their transfers to hospital. On 1/16/25 at 1:17 PM, V2 (DON/Director of Nursing) said the residents are not provided written documentation of bed hold policy, including reserve bed payment, upon their transfers to the hospital because she did not know the facility was supposed to be providing it. The facility's policy titled, Bed Hold Policy last revised July 2024 states, Federal Standards: Federal regulations require each facility provide written information to the resident and/or legal representative that specifies the duration of the bed hold policy under the Medicaid state plan during which the resident is permitted to return and resume residence in the facility. This notice shall be provided during the admission period and at the time of a transfer to notify the resident and/or representative concerning bed hold rights and promote appropriate return to the facility .Purpose: To ensure the residents are informed of the bed hold and reserve bed payment policy before and upon transfer to a hospital . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 4 of 12 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 01/17/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 assess and provide necessary treatments and services for skin impairment, which caused a resident severe itching and discomfort. This applies to 1 of 3 (R33) reviewed for skin impairment in a sample of 25. Residents Affected - Few Findings Include: R33 is an [AGE] year-old female with diagnoses including chronic respiratory problems with hypoxia dependent on supplemental oxygen, acute kidney disease, cerebral infarction, a chronic obstructive pulmonary disease with polyneuropathy, depression, and anxiety disorder. Minimum Data Set, dated [DATE] showed R33 was cognitively moderately intact and required one person to assist with activities of daily living (ADL), transfers, and bed mobility. On 01/14/2025, R33 was in her room scratching both arms. Redness, scratch marks, dry skin, and scabs were observed on both arms and the right chest area. R33 was interviewable and said the itching has been happening for at least a month and the staff knows about it. R33 said she doesn't know whether her skin conditions and itching could be due to her medication, food, or bedding. R33 said the continuous itching is annoying. R33 said V14 (Certified Nursing Assistant) showered her last week, and because of her itching, V14 checked her bedding and changed her linens to ensure there were no issues with her bedding. On 01/15/2025 at 12:45 PM, V14 (Certified Nursing Assistant) said R33 has had rash and itching issues for a while and she provided a shower to the resident on 01/06/2025. V14 completed the form titled, CNA skin attention form and notified the nurse (V13) on duty about R33's known skin condition. The writer asked V14 to assist R33 in showing her entire body for the skin conditions and noted R33 also has rashes on her back and right buttocks with itching and scratch marks in addition to her arms and chest. On 01/15/2025 at 1:00 PM, V15 (Certified Nursing Assistant) said he was new and over the weekend he noticed skin issues with R33 during his hygiene care and notified the V13 (Licensed Practical Nurse). On 01/16/2025 at 10:00 AM, V13 (Licensed Practice Nurse) said she should have assessed R33 for her skin conditions and notified the physician for further evaluation and treatment. On 01/16/2025 at 11:45 AM and 1:30 PM, V6 (Infection Preventionist) and V2 (Director of Nursing), respectively, said the nurse should be checking the CNA skin attention form, assessing the residents, signing off on the form, and notifying the wound care nurse and the physician for evaluation and treatment. A review of CNA skin attention dated 01/06/2024 showed V14 marked as a known skin condition, and the nurse evaluation was not completed. The facility policy, titled Wound Care, revised dated 11/2023 under assessment, in part, stated that the nurse should review the nurse's aide's completed shower sheet form for the impairment, the shower sheet should be given to the designee for follow-up, and the Director of Nursing should review the shower sheet weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 5 of 12 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 01/17/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide restorative therapy services as care planned. This applies to 1 resident (R68) reviewed for restorative services in a sample of 25. The findings include: R68's Face Sheet shows he was admitted to the facility on [DATE] and has the following diagnoses: need for assistance with personal care, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, muscle weakness (generalized), unsteadiness on feet, history of falling, and difficulty walking. R68's POS (Physician Order Sheet) shows order entered on 8/8/23 that resident may participate in restorative services. R68's MDS (Minimum Data Set) dated 12/14/24 shows his cognition is intact and he requires substantial/maximal assistance to roll right and left in bed. R68's Care Plan last revised on 11/30/22 shows he has a self-care deficit (Activities of Daily Living/Mobility) related to generalized weakness, left hemiparesis/hemiplegia, impaired balance, limited range of motion, multiple comorbidities, left knee pain, and physical limitations. Care Plan goal states resident will improve/maintain highest level of function with participation in therapies and/or restorative programs through next review. R68's Care Plan dated 1/12/23 shows he would benefit from participation in Bed Mobility Restorative Nursing Program due to impaired mobility, physical limitations, decrease in strength, endurance, balance and lack of coordination, and at risk for fall related to: stroke with hemiplegia and hemiparesis affecting left dominant side, generalized weakness, and cognitive impairment. Care Plan interventions state R68 was placed on ADL Bed Mobility restorative nursing program and document restorative minutes in point of care for each individual task, documenting time spent working with resident on each program on your shift. Additional Care Plan also dated 1/12/23 shows R68 would benefit from participation in AROM/AAROM (Active Range of Motion/ Active Assisted Range of Motion) Restorative Nursing Program due to impaired mobility, physical limitations, decrease in strength, endurance, balance and lack of coordination related to: stroke with hemiplegia and hemiparesis affecting left dominant side, and generalized weakness. Care Plan goal shows R68 will be able to participate in AROM/AAROM exercises to all extremities 20x2 reps daily as tolerated through next review date and interventions show R68 was placed on ADL (Activity of Daily Living) AROM/AAROM restorative nursing program and document restorative minutes in point of care for each individual task, documenting time spent working with resident on each program on your shift. R68's Point of Care Task for AROM states R68 will be able to participate in AROM/AAROM exercises to all extremities 20x2 reps daily as tolerated through next review date. Over the past 30 days, facility staff have documented AROM program participation for R68 9 times. There has been no documentation of resident refusal. R68's Point of Care Task for Bed Mobility states R68 will be able to turn from side to side of the bed with limited to extensive assist of one daily as tolerated through next review date. Over the past 30 days, facility staff have documented Bed Mobility participation for R68 9 times. There has been no documentation of resident refusal. On 1/14/25 at 2:26 PM, R68 said he no longer receives restorative nursing services. On 1/16/25 at 11:25 AM, R68 said he does turn side to side in bed when the staff assist him to get changed about 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 6 of 12 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 01/17/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few times a day. R68 said it has been weeks and weeks since restorative therapy has worked with him or has done any range of motion exercises with him. On 1/16/25 at 9:55 AM, V5 (Restorative Nurse) said R68 is on Bed Mobility and AROM Restorative Programs. V5 said the restorative staff is not doing Bed Mobility Program with R68 because he should be turning side to side with incontinence care. V5 said the Restorative staff is doing the AROM Program with R68 3-4 times a week, not daily as it is recommended. V5 said the Restorative staff do not document when they work with R68 in the POC (Point of Care) task as stated in the Care Plan. On 1/16/25 at 1:17 PM, V2 (DON/Director of Nursing) said R68's care plan needs to be followed and Restorative Nursing participation should be documented in the point of care task daily. V2 said restorative nursing programs should be done daily for R68 as they were assessed as needed so R68 can maintain, and not decrease, his abilities with mobility and strength. The facility provided policy titled, Restorative Nursing Program dated 9/14 states, Purpose: The facility promotes restorative nursing to attain or maintain the highest practicable physical, mental, and psychosocial well-being .Restorative Nursing is available seven days a week and is provided for residents with assessed needs according to program criteria. The Restorative Nursing Program is designed to: preserve function, promote optimal improvement, increase independence, self-esteem and dignity, promote safety, and minimize deterioration within the limits of normal aging . Components and Types of Restorative Nursing Programs: . Contracture Prevention and Management- .AAROM and AROM . Mobility ProgramsBed Mobility . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 7 of 12 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 01/17/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. 2. R56's electronic health record showed that R56's has diagnoses including history of UTI (urinary tract infection), anemia, adult failure to thrive, malnutrition, and is under Hospice care at the facility. Residents Affected - Few On 01/16/25 at 10:35 AM V3 and V4 CNAs (Certified Nurses' Assistants) were providing catheter care for R56. R56's urinary catheter was observed with a hard brown substance on the tubing near R56's urethral meatus. V3 with gloved hands grabbed the catheter with her right hand and wiped the catheter tubing towards R56's urethral meatus twice. After V3 was done cleaning R56's perineal area and ureteral catheter, V3 removed her gloves and put on new gloves not cleaning her hands and began cleaning in-between R56's legs, removing a brown substance. Then V3 cleaned R56's rectal area. R56's had 2 open pressure ulcers on her buttocks with dressings on them. After V3 finished cleaning R56's rectal area, V3 removed the dirty brief from under R56 and then changed gloves but did not clean her hands. V3 then put a new brief under R56, then changed gloves again and applied barrier cream to R56's buttocks and thighs again without cleaning her hands. V3 then removed her gloves, put on clean gloves, did not clean her hands, and preceded to attach R56's brief, adjust R56 in her bed, adjust R56's pillow and linen, and adjusted R56's bed, all with uncleaned gloved hands. On 01/16/25 at 12:50 PM V2 DON (Director of Nursing) said staff should always clean/wipe the tubing on the catheter away from the insertion site for infection control to prevent UTIs. V2 said staff should have cleaned their hands after removing their gloves when going from dirty to clean for infection control. The facility's Catheter Care policy dated 11/2023 showed that the guidelines are established to reduce the risk of or prevent infections in resident with an indwelling catheter. The policy standards show that hand washing shall be performed before and after touching any part of the urinary catheter drainage system, and encrustations on the Foley catheter should be removed from the meatus outward. The facility's Hand Hygiene policy dated 11/8/2022 showed proper and appropriate hand washing hygiene techniques will aid in the prevention of the transmission of infections. The policy showed that staff perform hand hygiene before applying gloves and after removing gloves, after contact with body fluids secretions, mucous membranes, or non-intact skin, after handling items potentially contaminated with body fluids or secretions, and before moving from a contaminated body site to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier or other treatments, and after providing direct resident care. Based on observation, interview, and record review, the facility failed to provide appropriate urinary catheter care to prevent UTI (Urinary Tract Infection). This applies to 2 out of 3 residents (R56, R67) reviewed for urinary catheter care in a sample of 25. The findings include: 1. R67's Face Sheet documents he was admitted to facility on 9/26/2022. R67 has a urinary catheter for diagnosis of neuromuscular dysfunction, BPH (Benign Prostatic Hypertrophy), and Obstructive Uropathy. Currently, R67 has diagnosis of UTI and is on Ceftriaxone Sodium Injection Solution. 1 gram intravenously in the afternoon for UTI for 10 Days. R67 started his antibiotic on 1/13/2025 and will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 8 of 12 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 01/17/2025 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 0690 end on 1/24/2025. Level of Harm - Minimal harm or potential for actual harm On 1/15/2025 at 9:33 AM, during skin check, R67 was noted to have a small amount of bowel movement on his incontinent briefs. V9 (CNA- Certified Nurse Assistant) proceeded to provide incontinence care. R67's urinary catheter was observed to have dried up debris on the tubing close to the base. V9 wiped the urinary catheter tubing by wrapping the tubing with a wet towel and wiping the tubing sideways to remove the debris. While wiping the tubing, V9 did not attempt to hold the catheter steady to avoid pulling on it. V9 did not attempt to wipe the rest of the tubing. V9 continued to provide incontinent care. Residents Affected - Few On 1/16/2025 at 10:02 AM, morning care provided to R67 by V10 (CNA) and V12 (CNA) was observed. V10 provided catheter care. Dried debris were observed on R67's urinary catheter tubing. V10 wiped the urinary catheter tubing towards the body three times. While wiping the tubing, V10 did not attempt to hold the catheter steady to avoid pulling on it. V10 continued providing incontinence care to R67. On 1/16/2025 at 12:51 PM, V2 (Director of Nursing) said urinary catheter tubing should always be wiped away from the body to prevent UTI (Urinary Tract Infection). V2 said staff should attempt to clean the tubing of any dried debris and inform the nurse so the nurse can assess the catheter and change it if needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 9 of 12 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 01/17/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to properly label/date/store food items and scoops, remove expired items, clean walk-in cooler, and wear hair restraint while serving food from facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 1/14/25 documents the total census was 79 residents. On 1/15/25 at 11:29 AM, V1 (Administrator) said there are 3 NPO (Nothing By Mouth) residents; all other residents eat from the facility kitchen. On 1/14/25 starting at 10:16 AM, the facility kitchen was toured in the presence of V16 (Dietary Manager) and the following was found: In walk-in cooler: 1. A large empty silver bin on top shelf under the fan with crusted dirt and dust in it and a dead dusty black house fly. V16 said the bin is kept on the top shelf to catch water dripping off the fan. Surveyor did not observe any water dripping from fan. 2. Medium sized bin labeled gravy with expiration date of 1/6/25. 3. Small sized silver bin of leftover fish fillets with expiration date of 1/13/25. 4. Medium sized clear bin of cut up fruit with no label or date. V16 said they were peaches. 5. Medium sized silver bin of leftover Spanish rice with no label or date. In the kitchen: 6. A medium sized clear bin of powdered mashed potatoes with no date. 7. A 20 gallon large white plastic bucket labeled thickener, not dated and scoop stored inside the thickener. 8. A 20 gallon large white plastic bucket labeled flour, not dated and scoop stored inside the flour. 9. On 1/15/25 at 11:14 AM, V17 (Cook) was observed serving lunch on the tray line in the kitchen with a hair net only covering the back half of her head. V17's bangs and top front of head were not restrained in hair net. On 1/16/25 at 10:18 AM, V16 (Dietary Manager) said all food items in the kitchen should be labeled and dated for food safety so the staff know when the food expires and when to throw the food away to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 10 of 12 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 01/17/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many prevent serving it and making the residents ill. V16 said the expired food items should be thrown away by the end of the day on the expiration date. V16 said the walk-in cooler should be cleaned twice a day on morning shift and afternoon shift. V16 said this includes cleaning the shelves in the walk-in cooler and sweeping/mopping the floor. V16 said the scoops for the flour and thickener should not be stored inside the food item/bin because it is an infection control contamination risk after staff touch the handle of the scoop and place it back in the bin. V16 said kitchen staff should wear their hair restraints covering all their hair to avoid hair falling into resident food causing contamination. The facility's policy titled, Dietary Personnel- Hygienic Practices and Personal Cleanliness dated 4/14 states, Purpose: To establish standards for employee dress, personal hygiene and hand washing practices. Standards: 2.d. Hairnets, coverings or caps shall be worn at all times in the Dietary Department and applied appropriately to keep hair from contacting exposed food, clean utensils and single service/use items, if unwrapped . The facility's policy titled, Storage of Refrigerated/Frozen Foods last revised 4/26/24 states, Policy: Refrigerator and freezer food items will be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance. Procedure: Refrigerated Foods: Refrigeration units are routinely cleaned and free from garbage and other waste . The facility's policy titled, Date Marking and Labeling last revised 5/27/24 states, Policy: All foods that are stored will be properly dated and labeled to ensure food safety. Procedure: 1. Date marking is an identification system that helps identify the name of the food, when the food was prepared, and when it is to be discarded. 2. When to date mark: b. The food requires refrigeration c. A commercially prepared food item is opened e. When potentially hazardous (PHF/TCS) foods are stored f. When leftovers are stored .3. When to discard: b. The item has expired according to the manufacturer's expiration date c. When foods are mixed together, the date of the oldest food becomes the new discard date for the mixed food . 5. Items should be marked with the name of the item and the discard date. The facility's policy titled, Food Storage dated 6/14 states, Purpose: Protect food from contamination, the ensure wholesomeness, and to prevent the spread of infections and communicable disease . The facility's policy titled, Storage of Dry Foods/Supplies last revised 9/18/23 states, Policy: Dry foods and supplies will be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance. Procedure: .Dry bulk foods are stored in plastic containers with tight containers with tight covers or bins which are easily sanitized. Containers are clearly labeled, and scoops are stored separately in a covered, protected area, which are washed and sanitized at least weekly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 11 of 12 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 01/17/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene. This applies to 2 of 7 residents (R9, R12) reviewed for infection control in the sample of 25. Residents Affected - Few The findings include: 1. On 01/14/25 at 12:38 PM V5 (Restorative Nurse) was observed getting up from feeding R9, moving R45, who was in her wheelchair, closer to the table and then, without cleaning her hands, returned to feeding R9. V5 then got up from feeding R9 and picked up R5's dirty lunch plate and put the plate on the food cart and then went back to R9, and without cleaning her hands first, picked up R9's sandwich off of her plate and fed it to R9. 2. On 01/14/25 at 11:35 AM, V7 and V8 CNAs (Certified Nurses Assistants) were providing incontinence care and a bed bath for R12. V8 with gloved hands picked up the garbage can and moved it closer to V7, then with the same dirty gloved hands went to R12's bedside and began providing care for R12 without removing her gloves and cleaning her hands. V7 had gloves on her hands and after cleaning every body part including face, arms, legs, abdomen, penis and rectal area of R12, V7 would remove her gloves and put on new gloves but would not clean her hands. After V7 was done with the incontinence care and bed bath, V7 with dirty gloved hands and V8 with uncleaned gloved hands put a new brief on R12, put R12's pants and shirt on him, put a lift sling under him, removed the soiled linen from R12's bed, and then transferred R12 from his bed to his wheelchair without removing their gloves, cleaning their hands and putting on clean gloves. On 1/16/25 at 12:50 PM V2 (DON) said staff should be cleaning their hands after removing gloves and before putting on new gloves for infection control and cross contamination. V2 said when staff are going from dirty to clean, they are to remove their gloves, clean their hands, and put on new gloves. V2 said that it is her expectations that staff clean their hands after touching another resident or resident's object for infection control. The facility's Hand hygiene policy dated 11/8/2022 showed proper and appropriate hand washing hygiene techniques will aid in the prevention of the transmission of infections. The policy showed that staff perform hand hygiene before applying gloves and after removing gloves, after contact with body fluids secretions, mucous membranes, or non-intact skin, after handling items potentially contaminated with body fluids or secretions, and before moving from a contaminated body site to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier or other treatments, and after providing direct resident care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145358 If continuation sheet Page 12 of 12