Inspection·August 19, 2024

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 personal hygiene and incontinent care was provided for two residents R2 and R3 who rely on staff assistance with ADLs (Activity of Daily living). This failure affected R2 and R3 who were not rendered incontinent care in a timely manner, and this has the potential to affect all the 20 residents residing on the 4th floor. Residents Affected - Few Findings include: On 08/14/24 at 10:50am, R2 observed in bed all covered up. R2 asked whether the surveyor will help in cleaning R2 up because R2 is wet and had stool although R2 was trying not to let it out for a long time. R2 stated I also a have migraine headache and it's hurting bad since during the night. V4 LPN was made aware and V4 stated the CNA's (Certified Nurse's Aides) are busy and have not gotten to R2 yet but V4 will get another (CNA) to help. At 10:58am, V5 (CNA) assigned to R2 stated she has been busy taking care of other resident and has not assisted R2 in incontinent care. When the surveyor asked when the last time R2 was checked for incontinence, V5 stated at around 7:30am but R2 did not say R2 was wet. V5 stated that rounds are made every two hours, and the incontinence rounds are done at the same time. V4 and V5 were observed turning R2 on the right side, R2 was noted wet to the cloth incontinent pad and with a bowel movement. V4 then stated anyway R2 is new to the facility, and we (facility) do not leave any resident lying in bed. We will get R2 up. V4 stated R2 should have been changed but they (CNA's) are busy. During this observation R3 was in bed in an adjacent room shouting for help. From the room doorway, surveyer observed R3 shouting and with dry brownish substance all over their fingers, hair, linens, side rails, side table, food tray and plates and foul strong urine and stool odor from the room. R3 was asking for help from the surveyor saying, please help me. The visitor for R3 who stated she was a friend from R3's church asked the surveyor and V4 whether there was staff who could have helped in cleaning R3 up, stating no one should be left like this. V4 stated they (CNAs) were all busy at this time and I (V4) will attend to R3 later. When asked in V4's professional opinion what can happen to a resident left in urine and stool without incontinent care in a timely manner, V4 stated that the resident can have skin impairment when left longer in the urine or stool. R2's medical record admission showed that R2 was a new admit of 08/12/24 with diagnosis that includes but not limited to Non-displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing, Aftercare following joint replacement surgery, presence of left artificial hip joint, history of falling, generalized anxiety disorder, presence of artificial hip joint, Alzheimer's disease and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R3's medical record admission record showed that R3 was admitted on [DATE] with diagnosis that includes but not limited to displaced bicondylar fracture of right tibia, subsequent encounter for closed fracture with routine healing, repeated falls, bilateral primary osteoarthritis of knee, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified glaucoma, and right knee pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 2 of 5 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 08/19/2024 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 - Few R3's medical record MDS (Minimum Data Set) facility assessment tool section GG documented that R3 is dependent on staff for personal hygiene, coded self-care: Toileting hygiene coded 01 dependent on staff, shower/bathe self-coded 01 dependent. Personal hygiene coded as 02 substantial/maximal assistance indicating that helper does more than half the effort. Transfer from chair to bed and bed to chair coded as 01 dependent indicating that helper does all the effort. Eating coded as 02 substantial/minimal assistance indicating that helper does more than half the effort. R3's plan of care for ADL's (Activities of Daily Living) initiated date 06/22/24 documented that R3 has an ADL self-care/mobility performance (functional abilities) deficit. Listed interventions include but not limited to toilet hygiene and toilet transfer with documentation that R3 usual performance is dependent (staff). The facility policy on Incontinence care with revised date 1/16/18 documented that the purpose is to prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines documented that incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode. Listed procedure includes assisting resident to a comfortable position and placed call light in reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 3 of 5 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 08/19/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to ensure that the medication cart and treatment carts were locked when not in use and when not in visual proximity of the nurse to prevent tampering and accidental hazard. This failure has the potential to affect all the resident on the 1st, 2nd and 3rd floor of the facility. Findings include: On 08/14/24 at 11:24am, the 3rd floor medication cart was noted unlocked and not within the visual proximity of the V7 RN (Registered Nurse).cAt 11:25pm, V7 stated that the facility protocol/ policy is that the medication cart should be locked when not in use or when the nurse is not around to see the cart. At 11:35am, the nurse's station door was noted left wide open with a medication left unlocked and no nurse in attendance in the nursing station. When the surveyor brought this observation to V9's LPN (Licensed Practical Nurse) attention and asked about the facility policy/protocol on medication storage and medication cart, V9 stated that the medication should be stored in a locked medication cart. V9 stated I (V9) just went to answer the call light because the CNA (Certified Nurse's Aide) assigned to this side of the floor was on lunch break. V9 stated, I should have locked the cart for safety, so no one could get into it (referring to the medication cart). At 11:50am, the 1st floor nurse's station treatment cart was noted unlocked and not within the view of the nurse. When this observation was brought to V12's (RN) attention and shown the unlocked cart, V12 stated it is a treatment cart and it should be locked when not in use. V12 stated because he was not the treatment nurse, he did not notice that the cart was left unlocked. Both the surveyor and V12 opened the cart and V12 stated there were treatment medications in here and it should be locked to prevent patient and others from taking medication from the cart because only authorized persons should be opening the medication carts. At 12:20pm, V2 DON (Director of Nurses) stated that the medication cart and the treatment carts are to be locked when not within eyesight of the nurses. V2 stated the nurse's station door does not have any locks on them so when the medication cart is in the nurse's station they should be locked. V2 stated some of the nurses are new graduates and more in-services must be done to ensure that they understand the effects it might have on the resident's safety. V2 stated they follow their pharmacy policy on medication storage. The facility policy for Storage of medication with no revision date documented in part that medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures listed includes but not limited to medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 4 of 5 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 08/19/2024 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 observation, interview, and record review the facility failed to follow current standards of infection control practices on use of gloves. This failure has the potential to affect all the 24-resident residing on the 3rd floor of the facility. Residents Affected - Some Findings include: On 08/14/24 at 11:22am, V7 RN (Registered Nurse) was observed on the 3rd floor walking around with gloved hands. V7 stated I was just trying to get to the nurse's station so I (V7) can take them off and wash my hands. When asked about the facility policy/protocol for infection prevention and control, V7 stated gloves are not to be worn in the hallways, I (V7) should have removed them after I (V7) used it. At 11:36am, surveyor noted R6 walk out of the isolation room and without hand hygiene went straight to the clean cart with supplies in the hallway touching the supplies and taking out supplies. When V9 LPN (Licensed Practical Nurse) was made aware of the observation. V9 stated that the clean cart is usually placed near the nurse's station. V9 stated R6 is on contact precaution isolation for MRSA in the right wound and should not be touching the general supplies for infection prevention and control. V9 stated R6 needs to be supervised. At 12:21pm, when V2 (Director of Nursing) was made aware of this observation and asked about the use of gloves policy and protocol. V2 stated that gloves should not be worn in the hallways, they should be changed after use, used gloves should be discarded at the door of the room when used and that resident in isolation contact should not be going into the clean linen cart / supplies cart. I (V2) will have to in-service on that. The facility policy on Proper Hand Washing and Glove use with no revised date documented under guidelines that all employees will use proper glove usage in accordance with State and Federal sanitation guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 5 of 5