Inspection·December 11, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R2's room, this surveyor observed a straight knob sticking out from a panel labeled low, medium, high and off. V3 stated that nurses have a special key that they can turn this knob to control the central air heat in the rooms that have it, including R2's room. This surveyor and V3 end this environmental tour on the ground floor observing the boiler room. Two boilers observed and labeled # 1 and # 2 with an additional yellow tank that V3 explained is for domestic water only with the external temperature gauge clearly reading 110 degrees. V3 stated that the boilers (#1 and #2) heat the water, pump and circulate the water through the pipes, and it returns through the system to keep the building warm. When asked how is V3 regulating the temperature of the water within the boiler tanks #1 and #2, V3 stated that V3 will turn on the boiler for 1 to 2 hours because it depends on what the weather is outside. V3 will adjust the tank after 3 pm before V3 goes home from working V3's day shift. On 12/9/24 at 1:15 pm, R2 observed standing in the dining/activity room pulling out the small drawer of a storage dresser and then closing it. V8 (Certified Nursing Assistant, CNA) supervising R2 and stated that R2 is nonverbal and will continually keep moving around but does not talk. R2 was not able to be interviewed by this surveyor. On 12/9/24 at 1:50 pm, V9 (R2's Family Member, Power of Attorney, POA) stated that V9 visited R2 in the facility on 11/28/24 where the facility appeared to feel warmer than normal. V9 stated that on 12/1/24 during another visit to the facility, V9 talked to V7 (Licensed Practical Nurse, LPN) about the excessive heat in R2's room. On 12/9/24 at 3:14 pm, V7 (Licensed Practical Nurse, LPN) stated that V7 works regularly with R2, and R2 is alert, confused, oriented to self and needs frequent redirection. V7 stated that V7 remembers V9 (R2's Family Member, POA) visiting last week and asked V7 why is it so hot in R2's room. V7 stated that V7 informed V9, Unfortunately, it's been like that. Management is doing something about it. V7 stated that V7 opened up R2's window. V7 stated that when V7 came to work the following day, R2's room remained hot with a fan in R2's room, but V7 stated for safety reasons, V7 did not leave R2's fan in the room saying, it could fall on (R2). When asked about V7 using a special key to turn the knob in R2's room to decrease the heat, V7 stated that V7 did not do that and just opened R2's window. V7 stated that V7 did not inform V1 (Administrator) or V3 (Maintenance Director) on 12/1/24 about V9's concern of excessive heat. On 12/10/24 at 12:34 pm, this surveyor reinterviewed V3 after facility policy and air temperature log review. V3 stated that the older thermostats that are on resident rooms and dining room walls are not working, not accurate. They are not connected to the heating sources in the facility. V3 stated that there are no functioning thermostats in the nurse's stations or common areas of the facility. When asked about V3 documenting the air temperatures on the different units (east, center, and west) on each floor, V3 stated that V3 was supposed to put down the room number on the air temperature log that V3 was checking, but V3 did not. V3 stated, I shut off the boiler today at 5 am. If a resident room is too hot during night, they open the window or will use the key to turn down the air flow in rooms. I showed you (surveyor) the boiler room, there is a temperature gauge for the yellow tank and that's for the domestic water. But I didn't know that there's another gauge for the boiler for the heat also. I was on the phone yesterday for 2 hours with the previous maintenance director and they said there's a mark here and a mark here, like a minimum and a maximum, but I don't know which mark is which. I turned the knob to move the gauge lower since it was next to the one mark, and I will test it. This is a trial period. V3 confirmed that V3 turned the knob on the gauge on the boiler yesterday before leaving work. When asked if V3 took air temperature readings today in the facility, V3 stated, No, and now corporate wants me to check it (air temperatures) two times a day. (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 12/11/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 12/10/24 at 1:19 pm, this surveyor performed a tour of the nurse's stations in the facility. No thermometer was observed in the 4th floor nurse's station with V17 (LPN) stating that there is no thermometer in the 4th floor nurses station and that this is the only nurse's station on the floor. One thermostat (name is same as one that V3 stated is not working or accurate) is noted inside the 3rd floor nurse's station. When asked if this is accurate, V18 (LPN) said, I think it's broken. I don't think it's working. They said that something broke. On 12/10/24 at 2:30 pm, V1 (Administrator) stated that the staff can open a window, offer a fan or the nurse can use the special key to turn the dial down in rooms where it's too warm. V1 stated the air temperature is too excessive still, then staff will call (V3). V1 stated that V3 would notify V1 if there are concerns with heat in the facility. V1 stated that V1 did speak with V9 (R2's Family Member/POA) about R2's room being too hot on an unknown date at the end of November to the beginning of December 2024 and that a room window was opened for the higher heat in R2's room. On 12/10/24 at 3:36 pm, this surveyor showed V1 (Administrator) the air temperature log readings of 80 degrees and higher. V1 stated that V3 did not inform V1 of these air temperature readings of 80 degrees and higher. When asked if V3 is to be following the facility's air temperature policy and procedure, V1 stated, Yes. This surveyor and V1 reviewed the air temperature policy with the facility air temperature range being maintained between 68 and 79 degree F for residents, visitors and staff in facility. V1 stated that the purpose of maintaining these specific air temperature readings per facility policy is to be comfortable, those are comfortable temperatures. On 12/10/24 at 3:12 pm, this surveyor and V3 toured the boiler room again. V3 stated that V3 has adjusted both boilers, #1, and #2. V3 stated, There were no marks on there gauge (on boiler), so I was guessing. V3 showed this surveyor inside a panel where the temperature gauges are for the boilers. On the inside of the door of the panel, written in marker, it reads: Turn clockwise to raise water temperature and lower heat exchange, turn counterclockwise. Two black marks are noted with a small needle (gauge) in the middle that V3 turned the black dial counterclockwise which moved the needle in the middle of the two black marks. When asked V3 about turning the black dial clockwise to warm the boiler water, V3 stated, Yes. V3 stated that V3 called the previous maintenance director yesterday and that's when V3 found out about how to adjust the boiler temperatures. V3 stated that the writing on the inside panel has been there since way before (V3) started. V3 stated that V3 turned the black dial counterclockwise yesterday on 12/9/24 to decrease the facility air before V3 left the facility. When asked if V3 performed air temperatures today (12/10/24), V3 stated that V3 did not. V3 stated that it feels better in the facility, not as warm. When asked how V3 can make this statement without measuring the air temperature, V3 stated, I can feel it. V3 stated that V3 did not inform V1 (Administrator) of the logged temperatures from November and December 2024. V3 stated, If it's 85 degrees, then I (V3) let (V1) know. If it's 81 (degrees), then yes, I am supposed to, but I open up a window. Facility document titled Air temperature documents, in part, columns with dates, initial and temperature readings for ground, 1st, 2nd, 3rd and 4th floors with units on the east, middle and west areas of the facility. At the bottom of each Air temperature log sheet, **Please note actions taken for high or low temperatures on the back of this form. There is no documentation noted on the back of the log sheets reviewed (9/30/24 to 11/29/24 log and 12/2/24 to 12/9/24 log). The following temperatures are documented: 10/29/24: 1st floor center unit with temperature of 80 degrees F. 2nd floor east unit with temperature of 90 degrees F. 2nd floor west unit with temperature of 80 degrees F. 4th floor west unit with (continued on next page) 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 12/11/2024 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 0921 temperature of 80 degrees F. All temperature entries signed by V3. Level of Harm - Minimal harm or potential for actual harm 10/30/24: 1st floor west unit with temperature of 90 degrees F. 3rd floor center unit with temperature of 80 degrees F. All temperature entries signed by V3. Residents Affected - Many 11/5/24: 1st floor center unit with temperature of 80 degrees F. 1st floor west unit with temperature of 80 degrees F. 4th floor center unit with temperature of 80 degrees F. 4th floor west unit with temperature of 80 degrees F. All temperature entries signed by V3. 11/8/24: Ground floor with temperature of 80 degrees. 1st floor center unit with temperature of 80 degrees F. 1st floor west unit with temperature of 82 degrees F. 2nd floor center unit with temperature of 81 degrees F. 2nd floor west unit with temperature of 80 degrees F. 3rd floor center unit with temperature of 80 degrees F. 3rd floor west unit with temperature of 80 degrees F. 4th floor center unit with temperature of 82 degrees F. 4th floor west unit with temperature of 81 degrees F. All temperature entries signed by V3. 11/11/24: 1st floor west unit with temperature of 82 degrees F. 2nd floor east unit with temperature of 81 degrees F. 2nd floor east unit with temperature of 81 degrees F. 2nd floor center unit with temperature of 82 degrees F. 2nd floor west unit with temperature of 81 degrees F. 3rd floor center unit with temperature of 81 degrees F. 3rd floor west unit with temperature of 81 degrees F. 4th floor center unit with temperature of 81 degrees F. 4th floor west unit with temperature of 82 degrees F. All temperature entries signed by V3. 11/19/24: Ground floor with temperature of 80 degrees. 1st floor west unit with temperature of 81 degrees F. 2nd floor east unit with temperature of 80 degrees F. 2nd floor center unit with temperature of 80 degrees F. 2nd floor west unit with temperature of 80 degrees F. 3rd floor center unit with temperature of 80 degrees F. 3rd floor west unit with temperature of 80 degrees F. 4th floor center unit with temperature of 80 degrees F. 4th floor west unit with temperature of 81 degrees F. All temperature entries signed by V3. 11/25/24: Ground floor with temperature of 80 degrees. 1st floor center unit with temperature of 81 degrees F. 1st floor west unit with temperature of 80 degrees F. 2nd floor east unit with temperature of 80 degrees F. 2nd floor center unit with temperature of 80 degrees F. 3rd floor center unit with temperature of 80 degrees F. 3rd floor west unit with temperature of 81 degrees F. 4th floor center unit with temperature of 81 degrees F. 4th floor west unit with temperature of 80 degrees F. All temperature entries signed by V3. 11/29/24: 1st floor center unit with temperature of 81 degrees F. 1st floor west unit with temperature of 81 degrees F. 2nd floor east unit with temperature of 81 degrees F. 2nd floor center unit with temperature of 80 degrees F. 2nd floor west unit with temperature of 81 degrees F. 3rd floor center unit with temperature of 80 degrees F. 3rd floor west unit with temperature of 80 degrees F. 4th floor center unit with temperature of 81 degrees F. 4th floor west unit with temperature of 80 degrees F. All temperature entries signed by V3. 12/2/24: Ground floor with temperature of 80 degrees. 1st floor center unit with temperature of 81 degrees F. 1st floor west unit with temperature of 81 degrees F. 2nd floor east unit with temperature of 82 degrees F. 2nd floor center unit with temperature of 83 degrees F. 2nd floor west unit with temperature of 82 degrees F. 3rd floor center unit with temperature of 81 degrees F. 3rd floor west unit with temperature of 82 degrees F. 4th floor center unit with temperature of 82 degrees F. 4th (continued on next page) 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 12/11/2024 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 0921 floor west unit with temperature of 83 degrees F. All temperature entries signed by V3. Level of Harm - Minimal harm or potential for actual harm 12/5/24: Ground floor with temperature of 84 degrees. 1st floor center unit with temperature of 84 degrees F. 1st floor west unit with temperature of 83 degrees F. 2nd floor east unit with temperature of 84 degrees F. 2nd floor center unit with temperature of 83 degrees F. 2nd floor west unit with temperature of 84 degrees F. 3rd floor center unit with temperature of 83 degrees F. 3rd floor west unit with temperature of 82 degrees F. 4th floor center unit with temperature of 83 degrees F. 4th floor west unit with temperature of 83 degrees F. All temperature entries signed by V3. Residents Affected - Many 12/9/24: Ground floor with temperature of 84 degrees. 1st floor center unit with temperature of 84 degrees F. 1st floor west unit with temperature of 85 degrees F. 2nd floor east unit with temperature of 85 degrees F. 2nd floor center unit with temperature of 83 degrees F. 2nd floor west unit with temperature of 832 degrees F. 3rd floor center unit with temperature of 84 degrees F. 3rd floor west unit with temperature of 84 degrees F. 4th floor center unit with temperature of 83 degrees F. 4th floor west unit with temperature of 84 degrees F. All temperature entries signed by V3. Facility document titled Daily Census and dated printed on 12/9/24 at 9:54 am documents, in part, that 82 residents reside in the facility. On 12/11/24 at 2:29 pm, V3 stated that V3 performed a recheck of air temperatures in the facility on 12/11/24 in the morning with the maximum reading today is 78 degrees, and V3 documenting the air temperatures on a new facility temperature log with resident room numbers and common areas. Facility policy Indoor Space Temperature-Resident Rooms; Common Areas and dated June 2024 documents, in part, All nursing facilities must maintain a temperature of not less than 68 degrees Fahrenheit or more than 79 degrees Fahrenheit in the winter months . These temperatures would have been always maintained, and in all areas of the building accessible to residents, employees, and visitors, except for the kitchen and laundry room. Every facility should also have centralized wall thermometers at every nurse's station and common area that will show both the room temperature and relative humidity. These can be purchased at any home improvement store or bought through our purchasing department. Heating Season: The heating season generally is from mid-October to mid-May. Heat will be provided to maintain interior temperatures at an appropriate range of 68 to 78 degrees during normal occupied hours. In implementing this policy, Facilities seeks to ensure that all heated spaces are as close to 71 degrees as possible. In practical terms, this means temperatures may be in the 71-75-degree range. Temperatures may be allowed to drop to as cold as 68 F . Temperature readings are taken at the thermostats that are placed throughout the facility. Facility job description titled Maintenance Director and dated 5/2/2017 documents, in part, Position Title: Maintenance Director. Reports To: Administrator. Summary: The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current, federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner. Essential Duties and Responsibilities: Plan, develop, organize, implement, evaluate, and direct the Maintenance Department, it's programs and activities . Ensure that supplies, equipment, etc. (and other things) are maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to the Administrator . Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145591 If continuation sheet Page 5 of 5