Inspection·September 8, 2023

F 0687 Provide appropriate foot care. 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 provide foot care and treatment to resident who is totally dependent. The facility also failed to carry out and implement a podiatrist recommendation order. This deficiency affects one (R43) of three residents in the sample of 19 reviewed for foot care. Residents Affected - Few Findings include: On 9/6/23 at 10:10AM observed R43's feet with V2 DON (Director of Nursing) and V12 Nurse Practitioner Wound Care (NPWC). Left foot has dark discoloration scab on great toe. Toenails has dark discoloration, long and thick. The entire foot is dry and scaly. Right foot has dark discoloration thick long toenails. The second toe over [NAME] over great toe. The entire right foot is dry and scaly. V12 NPWC said R43 need to be seen by podiatrist. On 9/6/23 at 10:28AM, review of R43's medical records with V5 Resident Assessment/Care plan Coordinator. R43 was admitted on [DATE] with diagnosis listed in part but not limited to Quadriplegia, Muscle wasting and atrophy. V5 said that R43 is totally dependent with ADLs (Activity with Daily living). R43's Quarterly Minimal Date Assessment (MDS)/Resident assessment dated [DATE] indicated he is totally dependent with ADLs and Transfers. Section G: Functional Status: 1. ADL self-performance coding- 4 Total dependence; 2. ADL support provided- 3 Two+(plus) persons physical assist. No care plan addressing his needs for foot care. On 9/7/23 at 10:30AM, V1 Administrator said they don't have a policy on Podiatrist care and referral. On 9/7/23 at 11:02AM, V1 Administrator presented copy of Podiatrist notes dated 6/9/23 which indicated: This [AGE] year-old male present with calluses, toenails that are difficult to cut and skin is dry and flaky. Orthopedic Exam: Contracted digit feet bilateral, arthritis feet bilateral. Difficulty in walking, muscle weakness. Treatment: Manual debridement by use of nail clippers to debride all fungal nails to decrease pain and risk as required by medical necessity. Podiatric professional is needed to avoid possible infection. Xerosis treatment: Feet bilateral- Full exam performed. Removed skin flakes. Applied Aquaphor ointment to bilateral lower legs and feet. Recommended the use of skin protectant daily (Aquaphor or Vitamin A and D ointment) or coconut oil to bilateral lower legs and feet. Patient to see again in 2 months. R43's podiatrist notes reviewed with V1. Informed that podiatrist recommendation was not carried out and implemented by the facility. On 9/7/23 at 11:30AM, V2 DON said that after the podiatrist treated the resident, he will talk to the floor nurse about his treatment plan. The floor nurse should carry out and implement treatment ordered. Facility's policy on Foot Care indicates: Purposes: To provide comfort and prevent infection of the feet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 If continuation sheet Page 2 of 9 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 09/08/2023 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 0692 Provide enough food/fluids to maintain a resident's health. 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 monitor and record fluid intake of resident who is on push fluids as ordered due to dehydration. This deficiency affects one (R63) of three residents in the sample of 19 reviewed for ensuring proper Hydration. Residents Affected - Few Findings include: On 9/5/23 at 9:03AM, observed R63 in the dining room in recliner chair. V8 LPN (Licensed Practical Nurse) said R63 is totally dependent with ADLs (Activity with daily living) and transfers. On 9/6/23 at 10:28AM, review of R63's medical records with V5 Resident Assessment/Care plan Coordinator. R63 was admitted on [DATE] with diagnosis listed in part but not limited to Traumatic hemorrhage of Cerebrum with loss of consciousness, and Dysphagia. Physician order sheet (POS) indicates he is on pureed texture, honey consistency diet. Push fluids every shift ordered on 9/1/23. No documentation found for monitoring of fluid intake. V8 said there is no documentation in R63's chart of monitoring and recording of his fluid intake. V8 said for residents with orders of push fluid, the nurses and CNAs should monitor and record the fluid intake. R63's Nurse Practitioner Cardiologist consultation dated 9/1/23 indicated: Plan: 5. AKI (Acute Kidney Injury): Recent creatinine level elevated-1.8, BUN (Blood Urea Nitrogen) elevated-42 possibly due to dehydration. Recommending push fluids. Avoid nephrotoxins. We will monitor BMP (Basic Metabolic Profile). Requested for policy on Push Fluids. On 9/6/23 at 2:00PM, R63's blood test (BMP) dated 9/6/23 results indicated: Creatinine elevated -2.0, BUN elevated- 42. Nurse Practitioner notified by staff with new orders: fluid every shift, Sodium Chloride Intravenous solution 0.45% (Sodium Chloride) use 50ml intravenously every shift for dehydration order to give 1000ml 50ml/hr. On 9/7/23 at 9:30AM, V2 DON (Director of Nursing) said they don't have a policy on Push Fluids. V2 said the nurses and CNAs should monitor and record R63's fluid intake. Facility is unable to provide policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 If continuation sheet Page 3 of 9 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 09/08/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 obtain physician's order for oxygen and tracheotomy care management for a resident who has tracheostomy capped and using oxygen via nasal cannula. The facility failed to ensure that there is water in the humidifier bottle. This deficiency affects one (R43) of one resident in the sample of 19 reviewed for Respiratory care. Residents Affected - Few Findings include: On 9/5/23 at 10:38AM, R43 observed lying in bed with oxygen at 3.5 LPM (Liters per minute) via NC (Nasal Cannula) connected to oxygen concentrator with V8 LPN (Licensed Practical Nurse). Noted emptied and dried humidifier bottle. Oxygen tubing is not dated. V8 said that she forgot to check this morning when she made her rounds. V8 said there should be water in the humidified bottle to prevent nasal dryness. No manual resuscitator at bedside. R43 has capped tracheostomy. On 9/6/23 at 10:58AM, review of R43's medical records with V5 Resident Assessment/Care Plan Coordinator. R43 was re-admitted on [DATE] with diagnosis listed in part but not limited to Acute Respiratory Failure, Quadriplegia, Paralysis of Vocal Cords, and larynx. No order of oxygen via nasal cannula and tracheostomy care management on the POS (Physician Order Sheet). V5 said there should be an order of oxygen in his POS and tracheostomy care management. The oxygen tubing should be dated and changed weekly. The nurse should check the level of water in the humidity bottle. On 9/6/23 at 1:01PM Informed V2 DON (Director of Nursing) of above concerns. V2 said tracheostomy care should be performed every shift. There should be an order for oxygen usage and tracheostomy care management. The nurse should check the water level in the humidifier. The oxygen tubing and humidifier bottle should be changed weekly and dated. Facility's policy on Oxygen Concentrator indicates: Purpose: To provide oxygen for therapeutic use by utilizing a concentrator that converts ambient air to a higher concentration of level of oxygen. It is commonly used to provide oxygen therapy. Oxygen concentrators are the least expensive, more convenient, and safe options to compressed oxygen in metal tanks. Equipment needed: 3) Humidifier device 4) Nasal Cannula Procedure: 1) Verify and understand the physician's order. 2) Know the flow rate and duration of use. 8) If prescribed, attach the humidifier bottle to the oxygen outlet connection, and ensure there is water in the bottle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 If continuation sheet Page 4 of 9 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 09/08/2023 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 0695 Daily Maintenance: Level of Harm - Minimal harm or potential for actual harm 1) Check the water level in the humidity bottle. Change the bottle as needed or every 7 days. Facility's policy on Tracheostomy Care indicates: Residents Affected - Few Policy: Tracheostomy care should be performed once per shift or as often as required to maintain patency of the airway and minimize the risk of infection. Tracheostomy tube cuffs will be continuously deflated unless otherwise ordered by the physician. When the tracheostomy tube is fenestrated, the inner cannula is to be in place during suctioning or manually ventilating. Depending upon the physician's order/feeding policy, the inner cannula should be in during feeding and for thirty minutes afterwards. A replacement tracheostomy tube is to be always kept at bedside, clearly visible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 If continuation sheet Page 5 of 9 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 09/08/2023 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 safe and secure storage including proper temperature control of medications. The facility also failed to remove the opened and expired medication in the medication cabinet. These failures have the potential to affect all residents taking medication who reside in the facility. Findings include: On [DATE] at 10:03AM, second floor medication room checked with V8 LPN (License Practical Nurse). Observed medication refrigerator unlocked. V8 said that she did not leave it unlocked. She did not check this morning the refrigerator when she came in to work. The night shift usually checks the refrigerator temperature daily. The following medications found inside the refrigerator: Morphine sulfate oral solution 100mg/5ml, rectal suppositories and (2) Tuberculin (Aplisol) vials. V8 read refrigerator temperature at 32F. V8 does not know what the normal ranges for medication refrigerator temperature is. Review of the daily refrigerator temperature log binder [DATE] incomplete daily monitoring log found inside the binder. No monitoring log for this month of September. Checked medications house stock supplies in the cabinet. Found opened, not dated, and expired Antacid medication (Geri-lanta) 12 fluid ounces expired [DATE]. V8 said she does not know who placed the opened and expired medication inside the cabinet with house stock medications. V8 said expired medication should be returned to pharmacy. She took the medication and placed in the bag labeled return to pharmacy. V8 called V2 DON (Director of Nursing). On [DATE] at 10:25AM, informed V2 DON of above observations. V2 said that nurses should lock the medication refrigerator, monitor, and record the medication refrigerator temperature daily and return the expired medication to the pharmacy. On [DATE] at 12:47PM, first floor medication room checked with V9 RN (Registered Nurse). Observed medication refrigerator unlocked. V9 said that he did not check the medication refrigerator this morning when he came to work. V9 said that the night shift is the one who checks the medication refrigerator. The following medications found inside the refrigerator: (2) morphine sulfate oral solution, (2) lorazepam oral solution, (8) pen insulins, (2) Tuberculin (Aplisol) vials, (6) eye solutions and rectal suppositories. V9 read the temperature inside the refrigerator at 31F. Noted normal refrigerator temperature ranges posted outside the refrigerator is at 36 to 46F. V9 said he cannot find the refrigerator temperature monitoring binder. V9 said the night shift is the one monitoring the daily refrigerator temperature. V9 said the medication refrigerator temperature monitoring binder should be in the medication room. V9 called V2 DON. On [DATE] at 12:59PM, Informed V2 DON of above observations. V2 tried to look for the medication refrigerator temperature monitoring binder but was unable to locate it in the med room. V2 said that the medication refrigerator temperature should be monitored daily, and the binder should be in the medication room. The Refrigerator temperature should be at 36 to 46 F. On [DATE] at 2:44PM, V2 DON presented first floor medication refrigerator temperature daily monitoring binder for 2023. Reviewed monitoring log with V2. Noted missing monitoring log for month of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 If continuation sheet Page 6 of 9 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 09/08/2023 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 August, June, May, April, Incomplete log for month of July, March, February, and January. V2 said she will give in-services to her nurses regarding completion of daily medication refrigeration temperature monitoring log, securing/locking medication refrigerator and returning expired medication to pharmacy. Facility's policy on Medication Storage Revised date [DATE] indicates: Residents Affected - Few Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes, and needles. Guidelines: 3. General storage procedures: Facility should store Schedule II Controlled Substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment 3.2 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier. 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: 36F to 46F or 2C to 8C 12. Controlled substance storage: 12.2 After receiving controlled substance and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area and double locked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 If continuation sheet Page 7 of 9 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 09/08/2023 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 Based on observation, interview and record review the facility failed to remove gloves and perform hand hygiene before exiting the isolation room. This deficiency affects one (R43) of one resident in the sample of 19 reviewed for Infection control on isolation precaution. Residents Affected - Few Findings include: On 9/5/23 at 10:40AM, observed V8 LPN (Licensed Practical Nurse) came out from R43's isolation room with gloves on, tried to open the medication room and then she went back to the isolation room. R43 is on isolation set up, droplet contact precaution posted outside the door. R43 has capped tracheostomy and suprapubic catheter. On 9/5/23 at 10:45AM informed V8 LPN of above observation. V8 said that she was putting water in the humidifier oxygen of R43. V8 said she removed the isolation gown but forgot to remove her gloves and wash her hands before she left the isolation room. V8 said that R43 is on isolation precaution. R43 is currently on antibiotic (Bactrim DS) for Urinary Tract Infection. R43 has history of ESBL in wound. On 9/5/23 at 11:00AM, informed V2 DON (Director of Nursing) of above observation. V2 said staff should remove personal protective equipment such as gown, mask, gloves and perform hand hygiene when leaving the isolation room. Facility's policy on Hand Hygiene/Handwashing 1/10/2018 indicates: Definition: Hand Hygiene means cleaning your hands by using either hand washing (washing hands with soap and water), antiseptic hand wash, pr antiseptic hand rub ( i,e alcohol -based hand sanitizer including foam or gel) Guidelines: Example of When to perform hand hygiene (either alcohol-based hand sanitizer or handwashing): *After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient *After glove removal Facility's poster for isolation room indicates: Before leaving the isolation room, please make sure to: 1. Remove gloves 2. Remove Gown 3. Exit room 4. Perform hand hygiene using hand sanitizer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 If continuation sheet Page 8 of 9 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 09/08/2023 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 Facility's policy on Infection Precaution Guidelines 5/15/23 indicates: Level of Harm - Minimal harm or potential for actual harm Guidelines: It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility using isolation precaution. Residents Affected - Few Transmission-Based Precaution will be employed for known or suspected infections for which the route of the transmission/prevention is known. The transmission-based categories are the following: *Contact *Droplet Points to remember: *Hand washing (Hand hygiene) is the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact and after contact with resident belongings and equipment. Alcohol based hand rub may be used if hands are not visibly soiled. *All personal protective equipment (disposable, isolation gowns, mask, gloves, etc.) should be used once and discarded in either the trash or used linen receptacle before you leave the room Precaution signs will be utilized to alert staff and visitors to see the nurse for instructions prior to entering room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145658 If continuation sheet Page 9 of 9