Inspection·December 9, 2022

F 0558 keep the call light within resident's reach. Level of Harm - Minimal harm or potential for actual harm Facility Policy: Call light effective 11/28/2012, revision on 2/2/2018 Residents Affected - Few Purpose: To respond to resident's requests and needs in a timely and courteous manner. Guidelines: Resident call light will be answered in timely manner. 1. All residents that can use a call light shall always have the nurse call light system available and within easy accessibility to the resident at the bedside or other reasonable accessible location. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide privacy to residents when providing care/procedure/medication. This deficiency affects two (R11 and R30) of three residents in the sample of 18 reviewed for privacy. Residents Affected - Few Findings include: On 12/6/22 at 9:35 AM, V6 Hospice RN observed performing assessment and vital signs on R30 in the dining room with 18 residents, one CNA and one housekeeping staff. On 12/6/22 at 9:45 AM V6 Hospice Nurse stated that she is from a hospice service and has been coming for one month to see R30. She stated that she always assesses and takes vitals of R30 in the dining room. She stated she assess the residents where they are sitting and this is how she was taught during her orientation. When surveyor asked her if she should provide privacy when assessing residents and taking vital signs, she said, I guess so. On 12/6/22 at 10:08 AM, surveyor informed V5 RN Supervisor of observation made with V6 Hospice Nurse to R30. She stated she should do the assessment and vital signs in the resident's room to provide privacy. It should not be done in the dining room where there are residents present. Surveyor requested policy on Resident's Privacy from V5. On 12/6/22 at 1:21 PM, V10 RN administered oral medication to R11. V10 did not close the curtain to provide privacy from R11's two roommates (R13 and R163). R163 wheeled himself into the room. At 1:27 PM, V10 administered Nebulizer treatment to R11 without closing R11's curtain to provide privacy from his roommates (R13, R14 and R163). On 12/7/22 at 11:03 AM, Follow up request for facility's policy on privacy as requested yesterday. V12 Nurse consultant stated that they don't have a policy on Resident's Privacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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 maintain personal hygiene for one of six residents (R262) observed for activities of daily living (ADLs) in the sample of 18 residents. Residents Affected - Few Finding Include: On 12/6/2022 at 10:45 AM, surveyor observed R262 sitting in 2nd floor dining room with V19 - CNA (Certified Nurse's Aide) assigned to R262. R262's shirt, mouth and chin were stained with food particles from breakfast food that morning. V19 stated R262's shirt should have been changed and his mouth/chin cleaned after breakfast. On 12/6/2022 at 11:00 AM, surveyor observed R262 with V7 RN (Registered Nurse) assigned to R262. R262 was still wearing the shirt with stained food particles and his mouth and chin not cleaned. V7 stated that V19 should have taken R262 to his room, cleaned him up and put a clean shirt on him. On 12/7/2022 at 2:30 PM, V12 (Nurse Consultant) stated that V7 should have cleaned R262 up and put on a clean shirt. R262 is a [AGE] year-old admitted on [DATE] with a diagnoses of Dementia, Psychotic disturbance, Mood disturbance, Anxiety, altered mental status, other abnormalities of gait and mobility. R262's care plan indicated that R262 has an ADL self-care performance deficit related to altered mental status. Facility Policy: Activities of Daily Living (ADLS) Grooming: Maintaining Personal Hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow manufacturer's recommendations when using low air loss mattress (LAL) for a resident who has a Stage 3 pressure ulcer. This failure affects one (R35) of three residents in the sample of 18 reviewed for Pressure Ulcer management. Residents Affected - Few Findings include: R35 was admitted on [DATE] with diagnoses of Stage 3 Pressure ulcer, Parkinson's disease, Dementia, and Osteoarthritis. R35's physician order sheet indicates a low air loss mattress and a wound treatment Sacrum-Alginate and dry dressing twice daily. R35's physician wound report dated 11/21/22 indicated R35 has an unstageable pressure injury on the coccyx area since 5/13/2022 which is a stage 3 pressure injury since 8/16/22. The wound is currently as Stage III pressure ulcer on coccyx area. The wound measures 4cm x 2 cmx 0.1cm. There is a large amount of serous drainage noted. There is large (65 to 100%) pink granulation within the wound bed. The peri wound skin appearance exhibited maceration. Wound progress: worsening. On 12/6/22 at 10:46 AM, V5 RN Supervisor/Wound Coordinator and V9 Certified Nurse Assistant (CNA) observed repositioning R35 to her left side to perform wound care to R35's sacral area. Surveyor observed fitted sheet covering the LAL mattress with multiple layers of folded linen on top of the mattress. There was no wound dressing found. V9 CNA stated that she removed it when she provided incontinent care with R35 earlier. V5 RN stated that R35 has a stage 3 pressure ulcer, with moderate serous sanguineous drainage, pinkish red tissue with maceration on surrounding wound. She cleansed the wound with wound cleanser and applied calcium alginate and covered with a dry dressing. After wound dressing completed, surveyor informed V5 RN of observation. V5 stated that R35 should not have a fitted sheet covering her LAL mattress and should not have multiple layers of folded linen underneath R35 as stated in the manufacturer's recommendation. V9 CNA stated that she is not aware that R35 should not have a fitted sheet and folded linen underneath her. V9 added that no one told her. On 12/6/22 at 1:30 PM, R35 observed with fitted sheet over the LAL mattress and folded linen. V5 RN Supervisor presented in-service form dated 11/29/21 indicated that air loss mattress is used for prevention and treatment of pressure wounds and is suited for immobilized residents with lack of sensory perception or immobile. No fitted sheets should be used because they compress the air cells and restrict air flow. On 12/7/22 at 11:03 PM V12 Nurse Consultant stated that they don't have a policy on usage of low air loss mattresses. Facility unable to provide policy on low air loss mattress. Facility's policy on Pressure ulcer prevention indicates: Purpose: To prevent and treat pressure sores/pressure injury (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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 Guidelines: Level of Harm - Minimal harm or potential for actual harm 9. Pressure reducing (foam) mattresses are used for all resident unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow its policy on fall prevention management by failure to provide adequate supervision to prevent falls to residents who have history of multiple falls, failure to complete fall assessments after each fall incident, and failure to update fall safety care plan with new interventions after each fall incident to prevent future falls. This failure affects two (R162 and R262) of three residents in the sample of 18 reviewed for fall prevention management. Findings include: 1. R162 re-admitted on [DATE] with diagnoses listed in part not limited to history of falling, Surgical aftercare following surgery on the nervous system, Schizoaffective disorder, Epilepsy, Borderline intellectual function. R162's admission fall assessment completed on 11/14/22 indicated at risk for falls. R162's fall care plan indicates that she is at high risk for falls related to confusion, unaware of safety needs and history of falls on 11/16/22 and 12/1/22. R162 had no new care plan interventions documented after fall incidents. R162 had a mandibular fracture related to falling. R162 had a mandibular closed reduction on 11/18/22. Review R162's fall incident report to IDPH dated 11/16/22 indicated unwitnessed fall. R162 was observed lying on the floor mat in supine position next to her low bed during rounds. She was last seen by V7 RN around 11 AM and the CNA checked on her around 11:20 AM, R162 was lying in her bed. V7 did a head-to-toe assessment and vital signs with no apparent injury noted. R162 was wearing a neck collar, stable at baseline. No respiratory distress, no pain, range of motion/ROM normal on upper and lower extremities. R162's primary care physician ordered to send her to the hospital for further evaluation related to usage of Coumadin. R162's family was notified. R162 was admitted for observation. A computerized tomography/CT of maxilla facial showed left mandibular fracture. R162 prior to admission was hospitalized due to multiple falls with head injury/cervical injury and bruises noted to chin. R162 returned to the facility on [DATE] with interventions in place to include frequent rounding in place, bed in low position and floor mat in place continued education on use of call light with demonstration. Pain management in place, will refer to therapy for evaluation for bed transfer safety. Care plan will be updated accordingly. R162's hospital record dated 11/18/22 indicated ENT ( Ear, nose & Throat) consultation regarding mandibular condyle fracture: CT was concerning for possible nasal fracture, however there is no evidence on exam of fresh trauma to the nose, so suspect this is an old fracture. Review R162's fall incident dated 12/1/22 indicated unwitnessed fall. R162 was found kneeling beside her bed. Bed in lowest position and call light within reach. R162 unable to state what happened. A head-to-toe assessment completed; no apparent injury noted. R162 was sent out to the hospital for evaluation due to Coumadin usage. R162's family was notified. R162 returned from the hospital. Post fall monitoring and neuro check done as ordered. Floor mat as ordered. On 12/7/22 at 10:24 AM, R162 observed sitting on high back wheelchair in the dining room. R162 is confused and unable to interview. Both V7 RN and V13 CNA are taking care of R162. Both are not aware of R162's recent fall incident on 12/1/22. V7 stated that she was aware of R162's fall incident on 11/16/22 when she was sent out to the hospital. V7 stated she was the nurse working on that day. V13 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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 stated that R162 is total care with ADLs and transfers with 2 person assist. V7 and V13B both stated that R162 is on low bed with floor mat. On 12/7/22 at 10:41am, V14 CNA stated that he heard that R162 rolled out from bed last Thursday (12/1/22). V14 stated that R162 can move side to side in bed and can rollout of bed. Residents Affected - Few On 12/7/22 at 11:53AM, V4 MDS/Care plan coordinator stated that she updates the fall care plan after they have the IDT fall meeting after each resident's fall incident and formulates new interventions based on root cause analysis to prevent future falls. Review of R162's fall incident report and root cause analysis for incidents dated 11/16/22 and 12/1/22 indicates new fall interventions formulated was not updated in care plan. V4 stated that she should update the care plan interventions after each fall incident. V4 stated she added that she did a revision to the care plan today 12/7/22 adding dates of falls in the care plan but no new interventions based on root cause analysis. V4 did not update the care plan after R162's fall incidents. On 12/7/22 at 1:00 PM, V1 Administrator stated that V2 DON (Director of Nursing) is the fall coordinator and out sick for a week. V2 is not available for interview. Surveyor requested fall incident investigation interview competed. V1 and V4 MDS/Care Plan Coordinator stated they don't have the investigation interview done just the root case narrative report done in risk management. On 12/8/22 at 2:54 PM, V4 MDS/Care plan Coordinator stated that they did not complete the Fall risk assessment after R162 fell on [DATE] and 12/1/22. V4 stated that the floor nurse should complete the fall assessment after each fall incident. Facility's policy on fall prevention program indicates: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Guidelines: The Fall prevention program includes the following components: Care plan incorporates: Interventions are changed with each fall, as appropriate. Preventive measures. Facility's policy on Comprehensive care plan indicates: Guidelines: * The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. Standards: * A fall risk assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few * Accident/Incident reports involving falls will be reviewed by the Interdisciplinary team to ensure appropriate care and services were provided and determine possible safety interventions. 2. On 12/8/2022 at 2:34 PM, V7 (Registered Nurse) stated that R262 is alert times one. V7 stated that R262 is high risk for falls because he is confused, impulsive, attempts to get up by himself, poor safety awareness, and requires close monitoring. V7 stated that R262 requires one person for transfers, two people if combative. V7 stated that R262 did not display any abnormal behaviors when V14 handed R262 to V20 (Registered Nurse). V7 was in the dining area. V7 heard a loud noise and saw resident on the floor from the dining room. V7 stated that R262 complained of neck pain. V7 stated that V20 said she was by the window and R262 was by the door. V7 stated that she did not inform V20 about R262's confusion and impulsive behavior. V7 stated V14 was taking care of other residents within the vicinity of resident in question. V7 stated that R262's care plan should be updated with new interventions to prevent future falls. On 12/8/202, at 3:01 PM, V4 (MDS Coordinator) stated that R262 is alert times one. V4 stated that R262 has Dementia and poor safety awareness, is impulsive, and unable to redirect due to history of Dementia. V4 stated that R262 is aggressive, confused, and tries to get up by himself and requires close monitoring. V4 stated that she would have given V20 report about the resident's mental status including R262's impulsive behaviors of trying to get up without assistance. R4 stated that there was no staff in the room with the V20 x-ray technician when the x- ray was being taken. R4 stated that V14 was in the dining room feeding other residents. On 12/9/2022 at 2022, V14 CNA (Certified Nurses' Assistant) stated R262 is high risk for falls. R262 is confused, forgetful, and not direct-able. V14 also stated that R262 has poor safety awareness, is impulsive, and will try to get up by himself. V14 state that R262 needs supervision and requires at least two person's for transfer. V7 instructed V14 to take R262 to the room for x-ray. V14 asked V20 (x-ray technician) if R262 should be transferred in bed but V20 said to leave R262 in the chair. V14 left R262 in the room with V20. V14 stated that he was in the hallway outside the door waiting for V20 to finish. V14 stated that he did not inform V20 about R262 mental status. V14 heard a sound and saw the resident on the floor. V14 notified the nurse about the fall, and the nurse called 911. On 12/9/2022 at 10:40 AM, V20 stated on 11/18/2022, she approached V7 for R262 x-ray to be taken. V20 stated that V7 told her that the CNA will bring R262 to his room. V20 stated that V7 did not give her any report regarding R262 impulsive behavior or poor safety awareness. V20 stated that V14 brought R262 in a wheelchair to the room and left the room. V20 stated that after taking the x-ray picture, she took the plate off the patient and turned towards the window to put the plate away. V20 stated she heard a sound and turned and saw R262 on the floor by the door. It was after R262's fall that she overheard the nurses saying that R262 has the habit of sliding off his wheelchair. R20 stated that if she had got report ahead of time about resident's high risk fall behaviors, she would have requested for adequate help to prevent the resident from falling. R262's MDS (ARD 10/6/2022) documents: BIMS = 3, Self-Transfer = Extensive assistance, Support Transfer = 2 persons' physical assist, Self-walking = Extensive assist, Support walking = 2 person's plus physical assist. Surface to surface transfer = Not Steady, Lower extremity = Impairment on both sides, Diagnosis: Non-Alzheimer's Dementia, Anxiety Disorder, Psychotic Disorder (other than schizophrenia), and Lack of Coordination. R262's Fall Risk Assessments (All) document AT RISK for FALL. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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 Fall Incident Report Dated 11/18/2022 document: Level of Harm - Minimal harm or potential for actual harm Resident was in room getting an x-ray done. This writer heard a loud noise coming from resident's room. Proceeded to resident's room and noted resident on the floor flat face down. Resident was voicing pain to his head neck area. Resident was kept comfortable and 911 was activated. Resident was transported to hospital via stretcher, left facility awake and verbal responsive. Residents Affected - Few Care plan initiated 7/29/2022 indicates that R262 is at risk for falls related to confusion and lack of safety awareness secondary to dementia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to properly administer medication to a resident. This deficiency affects one (R11) of 12 residents in a sample of 18 observed for medication administration. Findings include: On 12/6/22 at 1:16 PM V10 RN prepared Benzonatate capsule 200mg 1 capsule medication for R11. V10 with gloves on, pricked the capsule with unused insulin needle and squeezed it into the apple sauce and mixed it. V10 stated that R11 has difficulty swallowing, he is on pureed diet with nectar thick liquids. At 1:21 PM, V10 RN gave the medication orally with nectar thick water using a spoon. On 12/6/22 at 4:15 PM, V5 Supervisor informed of observation made with V10 RN when she administered Benzonatate capsule with R11. V5 stated that she should not have pricked the capsule with a needle. V11 stated that she should place the capsule in apple sauce and wait until it melted or become softer before giving it to resident. On 12/7/22 at 2:17 PM, V12 Nurse Consultant stated that it is not acceptable to prick the capsule and squeeze it into apple sauce. V12 stated they don't have a policy on medication administration for residents who have difficulty swallowing. On 12/8/22 at 9:30 AM, V16 Pharmacist stated that the Benzonatate capsule is used to relieve cough. He stated that the capsule should not be pricked, and the contents squeezed into the apple sauce. The efficiency of the medication cannot be delivered in its therapeutic effect. There is an alternate form the facility can use if the resident has difficulty swallowing. The facility should call the pharmacy for recommendation. Facility unable to provide policy on Medication administration to resident who has difficulty swallowing oral medication such as capsule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement its policy in monitoring resident receiving psychotropic medications for medication side effects (Abnormal Involuntary Movement Scale/AIMS) . This deficiency affects all 4 (R21, R30, R35 and R39) residents in a sample of 18 reviewed for psychotropic medication usage. Findings include: R21 was admitted on [DATE] with diagnoses listed in part not limited to Dementia/Alzheimer's, Psychosis, Communication deficit, Gait abnormality, Multiple site arthritis, Atrial fibrillation, Heart failure. R21's physician order sheet indicates: Haldol Solution give 0.5mg topically in gel form apply to upper back twice daily and Lorazepam intensol concentrate 2mg/ml give 0.5mg by mouth every 4 hours as needed for anxiety. R30 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses listed in part not limited to Alzheimer's disease, Fibromyalgia, Restlessness, and agitation. R30's physician order sheet indicates: Seroquel tablet 25mg 1 tab by mouth one time a day, Seroquel 50mg 1 tab by mouth one time a day, Escitalopram oxalate 10mg 1 tab by mouth one time a day and Trazadone HCL 100mg 1 tab by mouth at bedtime. R35 was admitted on [DATE] with diagnoses listed in part not limited to Dementia, Psychotic disorder, Anxiety disorder, Major depression, Insomnia, Parkinson's disease, Lack of coordination, Gait abnormality and posture. R35's physician order sheet indicates: Clozaril 25mg 1 tab by mouth in the morning, Clozaril 75mg 1 tab by mouth in the evening and Sertraline HCL 50mg 1 tab by mouth one time a day. R39 is admitted on [DATE] with diagnosis listed in part not limited to Alzheimer's disease late onset, Psychosis, Major depressive disorder, Other specified mental disorder due to known physiological condition, Gait abnormality. R30's physician order sheet indicates: Olanzapine 2.5mg 1 tab by mouth one time a day. On 12/6/22 at 9:39 AM, V7 Registered Nurse (RN) stated that R21, R30, R35 and R39 are on psychotropic medications. All residents were observed in the dining room. On 12/7/22 at 2:30 PM V1 Administrator and V12 Nurse Consultant informed that R21, R35 and R39's last AIMS assessment was completed 4/2/22 and R30 does not have an admission AIMS assessment. All residents are on psychotropic medications. On 12/8/22 at 9:45 AM surveyor reviewed AIMS assessment records the following residents with V4 MDS/Care plan coordinator: R35, R21, R39 and R30. R35, R21 and R39's last AIMs assessment was competed on 4/2/22. No AIMS assessment was done on R30. V4 stated that V2 Director of Nursing/DON is responsible for completing the AIMS assessments for residents on psychotropic medications upon admission and quarterly. V4 stated that the former Director of Nursing (DON) did the last AIMS assessments 4/2/22. V4 stated the facility did not have DON for a while and V2 was hired last August 2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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 0758 V2 DON is not available for interview per V1 Administrator. Level of Harm - Minimal harm or potential for actual harm Facility's policy on Psychotropic Medication indicates: Residents Affected - Some Monitoring: Resident on anti-psychotic drug therapy will be monitored for tardive dyskinesia side effects every 6 months through the use of the AIMS scale. Facility's policy on AIMS Side Effect Monitoring indicates: Purpose: Abnormal involuntary movement scale (AIMS) records the occurrence of tardive dyskinesia (TD-a neurological disorder characterized by involuntary movements of face and jaw) of residents receiving psychotropic medications. To assess the presence of movement and non-movement side effects and to follow severity of TD over time. Guidelines: *The examination will be performed either at the time of resident's admission or when medications are initially prescribed. In addition, for residents taking psychotropic medication, AIMS examination procedures will be repeated at intervals of no less than every six (6) months. *Assessment results will be conveyed to attending psychiatrist and NP when abnormal findings or increasing in severity and side effects in noted. *The assessment will include direct observation, strict adherence to the test guidelines and medical record review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure medications in the medication refrigerator are routinely stored under proper temperature control and routinely monitored to ensure drug safety. This deficiency affects one of two medication rooms reviewed for medication storage. Findings include: On 12/6/22 at 10:21 AM, 2nd floor medication room checked with V7 Registered Nurse (RN). Surveyor observed the temperature binder log for the month of December, and it is not completed. Surveyor observed no temperature log from [DATE]st to 5th for the medication refrigerator monitoring. Surveyor observed the medication refrigerator thermometer reading at 32F. V7 RN stated that the normal temperature is from 30 to 40F and that the refrigerator monitoring check is done by night shift daily. Medications inside the refrigerator are the following: (3) bottles of Lorazepam, (2) vials of insulin, (2) bottles of eye drops and (1) Vitamin B12. On 12/6/22 at 10:30 AM, Surveyor Informed V5 RN Supervisor of the above observation. She stated that daily medication refrigerator temperature log is monitored by night shift. She stated that normal refrigerator temperature should be below 40F. On 12/7/22 at 2:30 PM Informed V1 Administrator and V12 Nurse Consultant of the above observation. Facility's policy on Medication storage indicates: Purpose: To ensure proper storage, labeling, and expiration dates of medications, biologicals, syringes, and needles. Guidelines: 3. General storage procedures: 11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. 11. 2 Refrigeration: 36 to 46F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to minimize the risk of infection transmission by not properly storing Continuous Positive Airway Pressure (CPAP) and Nebulizer supplies after use. The facility also failed to implement a policy on Nebulizer treatment during COVID. These failures affected 3 residents (R11, R19, R29) in a total sample of 18 reviewed for infection control. Residents Affected - Few Findings include: 1. On 12-6-22 at 10:21 AM, R29, V10 (Registered Nurse/RN), and surveyor observed R29's CPAP mask and hose open to air on the floor. V10 provided a plastic bag for the CPAP mask and tubing. On 12/07/22 8:34 AM, R29's handheld nebulizer was noted open to air on the lid of the garbage can. This was observed by R29 , surveyor, and V17. On 12-7-22 at 10:52 AM, R19's CPAP mask and tubing was noted hanging on the wall closest to the head of the bed open to air as witnessed by R19, surveyor, and V10 (RN). On 12-7-22 at 10:52 AM, R19 stated staff did not store her mask after use. On 12-6-22 at 10:21 AM, R29 stated the nurse will usually put the mask in a bag. On 12-7-22 10:34 AM, R29 stated the nebulizer machine was placed on the garbage can and she received her nebulizer treatment. The nebulizer was not stored after use. On 12-6-22 at 10:56 AM, V10 (RN) stated the night shift nurse is responsible for storing CPAP supplies in plastic bags. CPAP supplies are stored in a bag to prevent germs. On 12-7-22 at 8:34 AM, V17 (RN) stated Nebulizer supplies should be stored in a plastic bag after use. On 12-7-22 at 12:15 PM, V5 (Infection Control Nurse) stated CPAP supplies should be cleaned before and after use and stored in a plastic bag. It is stored in plastic bag for to keep it clean and protect the resident and staff handling the supplies. V5 stated the Nebulizer and cord should be stored in a plastic bag after use. It is stored in a plastic bag to keep it clean and protect the resident and staff handling the equipment. On 12-8-22 at 10:39 AM, V4 (Minimum Data Set/MDS Office) stated CPAP supplies should be cleaned and stored in a labeled bag. It is stored in a bag for infection control. It should be kept open to air. Handheld Nebulizer should be cleaned and stored (not open to air) for infection control and to prevent contamination. Oxygen and Respiratory Equipment- Changing/Cleaning Policy (reviewed 1-7-19) documents: Purpose: 3. To minimize the risk of infection transmission. Handheld Nebulizer and Mask. A clean plastic bag with a zip loc or draw string will be provided with each new set up and will be marked with the date the setup was changed. 2. R11 re-admitted on [DATE] with diagnoses listed not limited to COVID-19, Muscle wasting and Atrophy, Chronic Obstructive Pulmonary Disease (COPD), Dementia/Alzheimer's, Dysphagia. R11 is on Ipratropium-Albuterol solution 0.5-2.5mg/3ml Nebulizer/inhale orally four times a day for shortness of breath. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 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 145658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palatine 24 South Plum Grove Road Palatine, IL 60067 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 On 12/6/22 at 1:27 PM, V10 Registered Nurse (RN) was observed wearing a facial mask, donning gloves and a gown. V10 was observed administering Ipratropium-Albuterol solution 0.5-2.5mg/3ml Nebulizer treatment to R11. V10 did not draw the curtain around the resident for privacy and Nebulizer Aerosol treatment was given with 3 other residents in the room with their cubicle curtains not closed. V10 stated that she will stay in the room until the medication is completed. Residents Affected - Few On 12/6/22 at 4:15 PM, V5 Supervisor state that when performing the aerosol Nebulizer treatment, the nurse should wear proper Personal Protective Equipment/PPE such as a N95 facial mask, face shield, gown and gloves. The resident should be by himself when administering the Nebulizer treatment. If the resident has roommates, all curtains must be close in each cubicle. The nurse should stay with the resident until the medication treatment is completed. Surveyor notified V5 of observation when V10 RN administered Nebulizer treatment to R11, V5 was advised V10 was observed wearing a surgical facial mask not N95, no face shield/eye protection and the curtains not closed in in R11's room which allowed R11's 4 roommates to observe the administration of the treatment. On 12/7/22 at 12:13pm, V12 Nurse Consultant stated that R162's roommate should be out of the room when he is receiving the Nebulizer treatment. The nurse should wear a N95 and face shield/eye protection, gown and gloves. Facility's policy on General Principles for Nebulizer Treatments during COVID Administering Nebulizer treatments: 1. Ideally, the resident should be in a single room. If no single rooms are available, roommates should be removed from the room if possible before administering the Nebulizer treatment to the resident. If unable to move the roommate, the curtain must be drawn between residents 5. Health care provide (HCP) should be wearing an N95 respirator and eye protection 6. [NAME] an isolation gown and gloves before entering the resident room. Close the door after entering the room. 7. Draw the curtain around the resident 8.Open or crack a window (even a small amount will help circulate air) or place a fan in the window and run it during the treatment. The fan should be facing or blowing outwards. 9. If the resident can hold and self-administer the Nebulizer treatment. The HCP may exit the room during the treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 If continuation sheet Page 16 of 16