Inspection·January 25, 2024

F 0554 overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 2 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 ensure that the call light device was within reach for one resident (R114). This failure has the potential to affect one resident out of a sample size of 41 residents. Residents Affected - Few Findings Include: R114 has a diagnosis of but not limited to Urinary Tract Infection, Paroxysmal Atrial Fibrillation, Depression, and Abnormalities of Gait. R114 has a Brief Interview of Mental Status score of 99. R114's Minimum Data Set, dated [DATE] documents Impairment on both sides for lower extremity. On 1/22/2024 at 10:58am surveyor observed R114 sitting in a chair that was across from his bed where the call light would not reach. Surveyor inquired if R114 could reach the call light and R114 said no. On 1/22/2024 at 11:01am V3 (RN) stated it (call light device) is here, but I don't think he (R114) can reach it and R114 does understand the purpose and how to use the call light. On 1/24/2024 at 1:25pm V2 (DON) stated the call light device should be anywhere the patient is and within their reach and the purpose of the call light device is for the resident to communicate their needs to staff. Care Plan focus: fall related to weakness, poor safety awareness dated 1/17/2024 documents place call bell/light within easy reach. Facility's policy: Answering the Call Light with a last reviewed date of 1/2017 documents, in part, when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 3 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure that four residents (R5 R6, R7, and R28) who depend on staff assistance for their ADL (Activities of Daily Living) care received shaving. This failure affected four of 41 residents reviewed for ADL care and shaving. Residents Affected - Some Findings include: On 01/22/24 at 10:30 am, R5 was observed in R5's room in bed awake and alert with facial hair to R5's lip and chin. When R5 was asked regarding R5 being shaved at the facility, R5 stated, They (referring to staff) don't trust me with a razor, so they give me a razor whenever they are up to it. When R5 was asked regarding if R5 wanted to be shaved R5 stated, Well yes, if I (R5) had a razor. On 01/22/24 at 10:35 am, R28 was observed in R28's room in bed awake and alert with facial hair (beard) to R28's lip and chin. When R28 was asked regarding R28 being shaved at the facility, R28 stated, I (R28) do not know how long it's been since I've been shaved. They (referring to the staff) shave me whenever they feel like shaving me (R28). On 01/22/24 at 10:38 am, R7 was observed in R7's room in bed awake and alert ungroomed with facial hair unshaved. When R7 was asked regarding R7 being shaved at the facility, R7 stated, I (R7 have to wait for them (referring to staff) to shave me. On 01/22/24 at 10:52 am, R6 was observed in R6's room in bed awake and alert with facial hair (mustache) to R6's upper lip area. When R6 was asked regarding R6 being shaved at the facility, R6 stated, I (R6) am shaved when they (referring to staff) are able to do it. On 01/24/24 at 9:32 am, R5 was observed in room in bed awake and alert with facial hair to R5's lip and chin still visible. This observation was brought to V9 (Certified Nursing Assistant, CNA) and V9 stated, Yes, she (R5) needs to be shaved. I (V9) will do it today. When V9 was asked regarding shaving residents, V9 stated that the CNA's are responsible for shaving the residents at the facility as needed. V9 stated that it is important to shave the residents at the facility for the resident's dignity. On 01/24/24 at 9:40 am, R28 was observed in R28's room in bed awake and alert with facial hair (beard) to R28's lip and chin still visible. This observation was brought to V24 (CNA) and V24 stated, Yes, she (R28) needs shaving. When V24 was asked regarding shaving the residents at the facility, V24 stated that the CNA's are responsible for shaving the resident as needed. V24 stated that it is important to shave the residents at the facility to improve the resident's hygiene. On 01/24/24 at 9:42 am, R6 was observed in R6's room in bed awake and alert with facial hair (mustache) to R6's upper lip area still visible. This observation was brought to V7 (CNA) and V7 stated that the residents are shaved in the resident's beauty shop. V7 was asked the importance of ensuring the residents are shaved and V7 stated that V7 did not understand what the surveyor was asking. On 01/24/24 at 9:45 am, R7 was observed in R7's room in bed awake and alert ungroomed with facial hair still visible. This observation was brought to V24 (CNA) and V24 stated, He (R7) needs shaving. I (V24) will shave him today. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 4 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 01/24/24 at 9:46 am, V18 (Registered Nurse, RN) stated that the CNA's are responsible for shaving the residents. V18 explained that CNAs shave the residents whenever the residents get a shower and as needed. V18 stated that it is important for the residents to be shaved for the resident's self-esteem and dignity. On 01/24/24 at 9:54 am, V2 (Director of Nursing, DON) stated that shaving is done by the CNA's or nurses. V2 stated that shaving should be done at least weekly and as needed. V2 stated the importance of the residents being shaved is for infection control. V2 stated that it is important for the residents to be shaved for the resident's appearance and for the resident to follow the resident's normal routine. R5's Minimum Data Set (MDS) dated [DATE] shows that R5 requires setup or clean up assistance for personal hygiene. R5's has a Brief Interview for Mental Status (BIMS) score of 14 which indicates that R5 is cognitively intact. R5 has a diagnosis which includes but not limited to memory deficit following cerebral, hemiplegia and hemiparesis, chronic obstructive pulmonary, age-related osteoporosis, chronic kidney disease, essential hypertension, and vitamin D deficiency. R5's care plan dated 09/04/2022 documents, in part: Focus: R5 has Activities of Daily Living (ADL) and self-care performance deficit related to (r/t) activity intolerance and impaired mobility stroke . personal hygiene requires set up assistance. R6's MDS dated [DATE] shows that R6 requires partial/moderate assistance for personal hygiene. R6's BIMS shows that R6 has a BIMS score of 14 which indicates that R6 is cognitively intact. R6 has a diagnosis which includes but not limited to hypertensive heart disease, hyperlipidemia, lymphedema, unilateral primary osteoarthritis, spinal stenosis, dementia, and presence of urogenital. R6's care plan dated 09/10/22 documents, in part: Focus: R6 has impaired ADL and mobility self-care performance related to muscle weakness. Interventions: Evaluate resident ability to perform ADL/IADL (Activities of Daily Living/Instrumental Activities of Daily Living) . Provide assistance with ADL's/IADL as needed . Set-up items for personal hygiene. Allow R6 to complete as much as possible. Assist as needed. R7's MDS dated [DATE] shows that R7 requires partial/moderate assistance with personal hygiene. R7 has a BIMS score of 15 which indicates that R7 is cognitively intact. R7 has a diagnosis which includes but not limited to intervertebral disorder, major depressive disorder, mild cognitive impairment, personal history of traumatic, malignant neoplasm of prostate, abnormal posture, and history of falling. R7's care plan dated 12/06/23 documents, in part: Focus: R7 has a self-care deficit: Bathing, dressing, feeding related to weakness, confusion and unsteadiness . Interventions: Evaluate residents' ability to perform ADL/IADLs . ADLs as much as possible, bed mobility, transfer, walking, dressing, grooming and AROM (Active Range of Motion). R28's MDS dated [DATE] shows that R28 requires supervision or touching assistance. R28 has a BIMS score of 15 which indicates that R28 is cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 5 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R28 has a diagnosis which includes but not limited to: hemiplegia and hemiparesis, paroxysmal atrial fibrillation, non-rheumatic aortic, type 2 diabetes mellitus, coronary angioplasty, chronic kidney disease, anemia, weakness, need for assistance and anxiety. R28's care plan dated 01/16/24 documents, in part: Focus: R28 has an ADL self-care performance deficit and impaired physical mobility due to weakness related to leg ulcers and multiple chronic illnesses including history of hemiplegia and hemiparesis due to CVA (Cerebral Vascular Accident). The facility's document dated 08/2021 and titled Supportive Activities of Daily Living (ADLs) documents, in part: Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Policy Interpretation and Implementation: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADL) do not diminish unless the circumstances of their clinical condition (s) demonstrate that diminishing ADL are unavoidable. 2. A Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 6 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 observations, interviews, and record reviews, the facility failed to ensure residents lying on a low air loss mattress were not over layered with sheets, incontinence briefs and/or pads for 2 residents (R9 and R41); and failed to ensure the low air loss mattress was set based on the resident weight for 1 resident (R23). These failures affected 3 (R9, R23, and R41) residents reviewed for prevention of pressure injury/ulcer in the total sample of 41 residents. Residents Affected - Few Findings include: On 01/22/24 at 10:14am, R23 was lying on low air loss mattress. The setting was at 300 pounds. This observation was pointed out to V5 (Registered Nurse). V5 stated the setting is at 300lbs; the setting of the low air loss mattress is based on the resident's weight. I (V5) don't know why its set like that. On 01/23/2024 at 2:36pm, V37 (Treatment Nurse) stated the low air loss mattress is used to prevent pressure injury. The setting is always based on the resident's weight. We (facility) need to have the correct firmness of the mattress because if it is too firm, it will act as a regular mattress, defeating the purpose of the low air loss mattress. We (facility) definitely cannot make the setting 100lbs higher than the resident's weight. It will be too firm and may cause pressure injury. On 01/23/2024 at 2:41pm, V37 stated for resident using a low air loss mattress, there should be a flat sheet and a draw sheet. We don't recommend the use of a blanket as draw sheet because it is too thick and defeats the purpose of the low air loss mattress. If a resident is wearing an incontinence brief, we don't recommend the use of an incontinence pad; both cannot be used. Ideally, not recommending that because it is putting too much layers, which defeats the purpose of the low air loss mattress. A flat sheet, a draw sheet and incontinence brief or pad is okay. Use of fitted sheet on low air loss mattress prevents the low air loss mattress from inflating properly hence defeating the purpose of the low air loss mattress. R23's (Active Order As Of: 01/23/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Alzheimer's disease, adult failure to thrive, and heart failure. R23's (12/03/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-term Memory OK. 1 Memory problem. C0800. Long-term Memory OK. 1. Memory problem. Section M. Skin Conditions. M0150. Risk of Pressure Ulcers/Injuries. Yes. M1200. Skin and Ulcer/ Injury Treatments. B. Pressure reducing device for bed. R23's (01/22/2024) weights and Vitals summary documented, in part 01/22/2024 weight 100 lbs. R23's (12/16/2023) Care Plan documented, in part Focus: is at risk for skin breakdown r/t (related to impaired bed mobility, incontinence, poor nutrition transfer and self-care deficit. Goal: The resident will maintain or develop clean and intact skin. Interventions: Maintain pressure relief mattress (LAL mattress). The (undated) Mattress Operation Manual documented, in part General. The system is designed for prevention, treatment, and management of pressure ulcers. the pump is a smart pump simple to operate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 7 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 and easy to use, constantly providing pressure redistribution and support patients. The system is intended to reduce the incidence of pressure ulcers while optimizing patient comfort. Pump Unit. Press minus or plus button to select the correct patient weight. Weight/Pressure set up. Users can adjust the air mattress to a desired firmness according to the patient's weight or the suggestion from a health care professional. The (undated) facility provided document 'Can you put a fitted sheet on a low air loss mattress? documented, in part Fitted sheets should not be used over low air loss mattress because they compress the air cell and restrict air flow. Thin knit or jersey material flat sheets should be used instead. The (6/28/23, 12/16/23, 1/19/24) In-Services Skin Care Preventions documented, in part Use of low air loss mattress. Use only flat sheet on top of mattress. No fitted sheet. PSI (pressure per square inch) setting must be adjusted to resident's weight. R41 has an admission diagnosis of but not limited to dementia, atherosclerotic heart disease, vitamin B12 deficiency, vitamin D deficiency and hyperlipidemia. R41's functional status for mobility requires substantial/maximal assistance to roll left and right, sit to lying, and sit to stand. On 1/22/24 at 11:30 am, R41 was lying on an air loss mattress with multiple layers between R41 and the low air loss mattress. The layers observed under R41 consisted of a flat sheet, a flat sheet folded multiple times for a draw sheet that was positioned under R41's lower back and buttock, and an incontinent brief. On 1/22/24 at 11:40 am, V18 RN (Registered Nurse) stated that it should only be one layer on an air loss mattress. R41's (1/10/24) Skin and wound evaluation form documented in part, stage 2: Partial-thickness skin loss with exposed dermis, location left gluteus. Wound measurement area 1.5 cm (Centimeter), length 1.0 cm, width 1.5cm. R41's care plan documented in part, Focus: R41 has potential/actual impairment to skin integrity related to impaired physical mobility and incontinence .with an intervention of pressure relief mattress. On 1/22/24 at 10:43am, R9 was observed in bed, positioned on her right side, on a Low Air Loss (LAL) mattress. This surveyor observed the following layers of linen under R9's body on the LAL mattress: a flat sheet and a quadruple folded flat sheet. R9 was also wearing an incontinent brief which made a total of 6 layers under R9's body. On 1/22/24 at 11:18am, R9 was in her room being provided care by V18 (Registered Nurse, RN) and V34 (Certified Nursing Assistant, CNA). When V18 was asked how many layers of linen the nursing staff are to place on top of the LAL mattress (linens in between the top of the LAL mattress and the resident), V18 stated that only 1 layer of linen should be placed on top of the LAL mattress. When asked how many layers are on top of R9's LAL mattress, V18 stated that there are 6 layers including the incontinence brief. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 8 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 R9's admission Record documents, in part, R9's diagnoses including but not limited to: Alzheimer's disease, unspecified dementia, osteoporosis, essential (primary) hypertension and abnormal weight loss. R9's Minimum Data Set (MDS), dated [DATE], documents, in part, R9's Brief Interview for Mental Status (BIMS) score is 99, which indicates that R9 was unable to complete the interview. R9's Skin Conditions (section M) documents, in part, that R9's Skin and Ulcer/Injury Treatments include a pressure reducing device for bed. R9's Patient Risk Profile, dated 12/14/23, documents a Braden score of 12 which shows R9 is at high risk for developing a pressure ulcer injury. R9's Care Plan, with initiated on 10/2/22 with last review completed on 12/26/23, documents, in part, a focus of (R9) is at risk for skin breakdown related to impaired bed mobility and incontinence to bladder and bowel with an intervention of Provide alternating pressure mattress. R9's Order Summary Report documents, in part, an active order (dated 2/1/23) for Specialty Mattress: alternating pressure. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 9 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 ensure medication carts are secured and locked while unattended. These failures have the potential to affect 46 residents residing on the second and third floors. Findings include: On 1/23/24 at 9:40am, with V33 (Registered Nurse, RN), during observation of medication pass the following was observed: Multiple employees and residents were seen passing by the medication cart while V33 was preparing medications to administer to R314. V33 stated that the medication cart contains all 21 resident's medications on the second floor. V33 went into R314's room to administer her (R314) medications and left the medication cart in the hallway, unlocked and unattended. While V33 was administering medications to R314, the medication cart was not visible to V33. When asked why the medication cart should be locked when unattended, V33 stated that anyone can come and open the medication cart. On 1/23/24 at 10:20am, with V4 (Registered Nurse, RN), during observation of medication pass the following was observed: Multiple employees and residents were seen passing by the medication cart while V4 was preparing medications to administer to R18. V4 stated that the medication cart contains all 25 resident's medications on the third floor. V4 went into R18's room to administer her (R18) medications and left the medication cart in the hallway, unlocked and unattended. While V4 was administering medications to R18, the medication cart was not visible to V4. When asked why the medication cart should be locked when unattended, V4 stated that the medication cart should have been locked when in the room because his (V4) back was turned away from the medication cart. On 1/23/24 at 2:16pm, V2 (Director of Nursing, DON) stated that medication carts should always be locked when the nurse is not within proximity to the cart. When asked if the medication cart should be locked if a nurse is in a resident's room and the medication cart is outside the resident's room, V2 stated Absolutely. V2 stated that the nurse should lock the medication cart whenever they are not looking at it. Facility presented policy titled, Administering Medications, with revised date of 4/19. This policy states in part: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 10 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 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 accurately log dish machine temperatures. This failure has the potential to affect all 66 residents who receive oral nutrition in the facility. Residents Affected - Many Findings include: On 1/22/24 at 10:00 am surveyor reviewed the dishwashing temperature log with V26 (Dietary Manager) and observed lunch temperature prefilled with a temperature of 165 (wash) and dinner temperature prefilled with a temperature of 185 (final). Prefilled temperature for 1/23/24 for dinner 165 (wash) and 185 (final). Prefilled temperature for 1/24/24 for dinner 185 (wash) and 185 (final). On 1/22/24 at 10:15 am, Surveyor inquired to V26 (Dietary Director) why is temperatures recorded on the log for lunch and dinner for 1/22/24, 1/23/23; and 1/24/24 for dinner? V26 stated that the log sheet should be filled out after the wash cycle and final rinse is complete. I do not know why it was already filled out. On 1/22/24 at 10:20 am, Surveyor inquired to V29 (Dishwasher), why was lunch and dinner prefilled on the dishwashing temperature log? V29 (Dishwasher) stated, I made a mistake prefilling the temperature log sheet. V29 stated that the dinner temperatures were filled out by the other dishwasher. On 1/22/24 at 3:00 pm, V28 (Dishwasher) stated, I (V28) was trained to put the temperatures on the log sheet because it's always 165. Surveyor inquired to V28 how long has V28 been working in the facility? V28 stated, I've been here for 6 years. I put the temperatures on the sheet for whoever is going to be working. On 1/24/24 at 12:26 pm, V26 (Dietary Director) stated that an in-service was done with staff on recording dish washer temperatures. V26 stated that the staff cannot do a temperature ahead of time because it can compromise the health of the residents if the temperatures is not above 150 degrees. The machine has to run five or six times before it is safe to start washing the dishes. Surveyor inquired to V26 if the wash temperature is always 165, which is documented on the dishwashing temperature log sheet from January 11th to January 22nd for Breakfast, lunch, and dinner? V26 stated that the temperatures are not always 165 and the temperatures should change. Facility Job description (6/2021) titled, Director of Dining Service, documents, in part, Essential Job Functions: Check to make sure that daily cleaning and documentation is being completed as required. Facility Job description (6/2021) titled, Dishwasher, documents, in part, Essential Job Functions: Monitor dishwasher temperatures. Perform daily temperature monitoring and document as required. Facility Policy titled Mechanical Cleaning and Sanitizing, Undated, documents in part, Procedure: High Temperature Dishwashers; Dish machines using hot water for sanitizing may be used if the temperature of the wash water is no less than that specified by the manufacturer, which may vary from 150 degrees Fahrenheit to 165 degrees Fahrenheit, depending on the type of machine and if the final rinse temperature is no less than 180 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 11 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm R42 has a diagnosis of but not limited to Acute and Chronic Respiratory, Bilateral Primary Osteoarthritis, Dysphagia, Oropharyngeal Phase, and Hypertension. R42 has a Brief Interview of Mental Status score of 11. Residents Affected - Few On 1/22/2024 at 10:11am surveyor observed R42 without a temperature log for her personal refrigerator. On 1/22/2024 at 10:51am V4(RN) stated that we do not have logs for personal refrigerators. Based on observations, interviews and record reviews, the facility failed to check and document the temperatures of residents' personal refrigerators daily and failed to maintain an appropriate temperature in a resident's personal refrigerator. These failures affected 3 (R10, R42 and R57) residents reviewed for personal food in the total sample of 41 residents. Findings include: On 01/22/24 at 10:20 AM, there was a refrigerator inside R10's room. This surveyor requested V5 (Registered Nurse) to check the refrigerator. V5 opened the refrigerator and checked the temperature and it stated temperature is 48F. Surveyor requested to check for temperature log, V5 checked for the temperature log and stated there is no temperature log. Inside R10's refrigerator were a tub of yogurt, cartons of milk and juice. On 01/22/24 at 10:36 AM, there was a refrigerator inside R57's room. This surveyor requested V5 to check the refrigerator. V5 stated the temperature is 42F. There are bottles of boost and soda. There is no temperature log. On 01/23/2024 at 3:04pm, V2 (Director of Nursing) stated we have to make sure the resident's food are safe. If the resident's personal refrigerator temperature is above 40F we have to address it with maintenance whether or not the refrigerator is functioning. Adjustment has to be made so the temperature is within the range. The expectation is to have the temperature within the acceptable range for the safety of the resident. Nursing should check the temperature and expired food items in the refrigerator daily. R10's (Active Order As Of: 01/23/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypertensive heart disease. R10's (11/24/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R10's mental status as cognitively intact. R57's (Active Order As Of: 01/22/2024) Order Summary Report documented, in part diagnoses (include but not limited to) COPD (chronic obstructive pulmonary disease) and unsteadiness on feet and need for assistance with personal care. R57's (10/22/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-term Memory OK. 1 Memory problem. C0800. Long-term Memory OK. 1. Memory problem. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 12 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The (01/23/2024) Food Safety Requirement Policy and Procedure documented, in part It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all foods including those brought to residents by family and other visitors. Educate and inform. 8. Perishable food such as meat, poultry, fish and dairy products must be frozen or refrigerated immediately after receipt. 12. All refrigerators will be at/or below 41 degrees F (Fahrenheit). Refrigeration. A. a potential cause of foodborne illness is improper storage of PHF/TCS (Potentially Hazardous Food/Time/Temperature Control for Safety Food) food. Refrigerators including those in resident rooms must be in good repair and keep foods at or below 41 degrees F. b. Document the temperature of external and internal refrigerator gauge. Refrigerators must be 41 degrees or less. Event ID: Facility ID: 145591 If continuation sheet Page 13 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 observations, interviews, and record reviews, the facility failed to ensure staff donned and doffed appropriate PPE (personal protective equipment) prior to entering and before exiting Droplet and Contact Precaution rooms in an effort to prevent the spread of infectious microorganism including COVID-19. This failure affected 2 (R4 and R30) residents reviewed for communicable disease and have the potential to affect all 25 residents on the 3rd floor. Residents Affected - Some Findings include: The (01/22/2024) facility census documented that there were 25 residents on 3rd floor. On 01/22/2024 at 1:04pm, there was a sign posted by R30's door Droplet & Contact Precautions. V6 (Housekeeping) was wearing a surgical mask and gloves. V6 entered R30's room without donning gown and Face shield, wiped R30's bathroom; exited R30's room without doffing the gloves, got the mop from the housekeeping cart and reentered R30's room without changing gloves, and without donning gown, N95 mask and Face shield. V6 mopped R30's bathroom and floor; exited R30's room without doffing gloves, placed mop head in the bucket. These observations were pointed out to V4 (Registered Nurse). V4 stated he (V6) is supposed to wear proper PPE before entering (R30)'s room because R30 is still on isolation. He (V6) should be donning N95, gown and Face shield and take these off upon exit of the room to avoid or minimize the spread of virus; trying to contain the virus. This surveyor inquired about appropriate use of PPE (personal protective equipment). V6 stated I (V6) don't speak English. On 01/22/2024 at 1:17pm, there was a sign posted by R4's door Droplet & contact Precautions. V6 donned gloves and donned N95 mask on top of a regular mask, took a piece of paper towel from the housekeeping cart and entered R4's room without donning gown and Face shield. At this time, V8 (Registered Nurse) came, and this surveyor pointed out to V8 that V6 entered R4's room without donning appropriate PPE. V8 stated he (V6) should have gown, Face shield, hair restraint and socks. He (V6) should not be wearing the N95 on top of a regular mask. On 01/22/2024 at 1:20pm, V4 (Registered Nurse) stated today is her (R30) 10th day on isolation and she (R30) is off isolation tomorrow. On 01/23/24 11:28 AM, V14 (Infection Preventionist) stated it is expected of staff to wear proper PPE when entering a resident room on covid isolation. Staff should don N95 mask, Face shield, gown and gloves. Before exiting, staff should remove gloves, gown, and the N95 mask replaced with surgical mask. As for the Face shield, it has to be disinfected with Microkill. The importance of donning and doffing of PPE appropriately is to minimize the spread of Covid-19. It also protects the staff and other residents. They are expected to follow the sign by the resident's door and the sign also make's them aware of who are on isolation. He (V6) is assigned to work on 3rd floor. R4's (Active Order As Of: 01/23/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) abnormal finding of lung field and acute respiratory failure with hypoxia. Order Summary: Contact and droplet precautions every shift for Covid-19 for 10 days. Start date: 01/15/2024. End Date: 01/25/2024. R4's (10/29/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Indicating R4's mental status as moderately impaired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 14 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 R4's (1/15/2024) COVID-19 Consent for Testing & Results form documented, in part Result: positive. Level of Harm - Minimal harm or potential for actual harm R4's (01/15/2024) Care Plan documented, in part Focus: (R4) turned COVID+ per Rapid test done on 1/15/24. Goal: will not have severe outcomes like hospitalization or death through the course of illness which may last for several weeks or earlier to some individuals. Interventions: Keep on STRICT ISOLATION (CONTACT / DROPLET) x 10 days (1/15/24 - 1/25/24) Read isolation precaution protocol posted by the resident's room which includes but not limited to: *Wearing full PPE when entering the room - discarding gloves. Residents Affected - Some R30's (Active Order As Of: 01/23/2024) documented, in part Diagnoses: (include but not limited to) personal history of Covid-19 and chronic obstructive pulmonary disease. R30's (12/24/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06. Indicating R30's mental status as severely impaired. R30's (1/12/24) Covid-19 Consent for Testing & Results Form documented, in part Result: Positive. R30's (01/23/2024) Care Plan documented, in part Focus: Resident turned COVID positive on 1/12/24. Goal: will not have severe outcomes like hospitalization or death through the course of illness which may last for several weeks or earlier to some individuals. Interventions: Keep on STRICT ISOLATION (CONTACT / DROPLET) x 10 days (1/12/24 - 1/22/24) Read isolation precaution protocol posted by the resident's room which includes but not limited to: Wearing full PPE when entering the room - discarding gloves. The (1/22/2024) Isolation Tracking documented, in part Name: (R4). Isolation Precaution: Contact and Droplet. Reason: Covid Positive. Start Date: 1/15/2024. Stop Date: 1/25/2024. Name: (R30). Isolation Precaution: Contact and Droplet. Reason: Covid Positive. Start Date: 1/12/2024. Stop Date: 1/22/2024. The (undated) Droplet & Contact Precautions sign documented, in part Staff: Required: Gown & Gloves. Procedure mask with eye protection. The (1/2024) Coronavirus Disease (COVID-19) Infection Prevention and Control Measures documented, in part Policy Statement: This facility follows commended standard and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of COVID-19 within the facility. Policy Interpretation and Implementations. 2. While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including: c. Appropriate use of PPE (personal protective equipment). d. Transmission-based precautions, where indicated. Personal Protective Equipment. Residents with Suspected or Confirmed Covid-19 Infection. HCP (healthcare personnel) who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to Standard precautions including Transmission-Based Precautions and use of NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (goggles or Face shield that covers the front and sides of the face). PPE including N95 should be discarded and new applied between each resident encounter. The (04/2013) Isolation - Categories of Transmission-Based Precautions documented, in part Transmission-based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infection that can be transmitted to others. Contact Precautions. Gloves (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 15 of 16 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 145591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Wesley 1415 West Foster Avenue Chicago, IL 60640 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 Level of Harm - Minimal harm or potential for actual harm and Hand Washing During Contact Precautions. C. Gloves and Handwashing. 1. Wear gloves when entering the room. 3. Remove gloves before leaving the room and perform hand hygiene. Gowns during Contact precautions. D. Gown. 1. Wear disposable gown upon entering. 2. After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces. Droplet Precaution. Mask During Droplet Precautions. C. Mask. 1. Put on mask when entering the room or cubicle. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 16 of 16