Inspection·December 14, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm 12/12/23 at 1:50PM, V16 (Restorative Nurse) provided a list of residents who are receiving restorative treatments at the facility and R86 was not in the list. When presented with this observation, V16 said that the list comes from general nursing assessment and medical doctors' quarterly assessment, when therapy discharge a resident, they are usually placed on restorative care and the list is given to them. Residents are supposed to get up at least twice a week especially on Tuesdays and Thursdays when there is no dialysis. Residents Affected - Some On 12/11/23 at 10:35AM, R89 and R98 were both observed alert and oriented lying in bed, dressed in medical gowns. R89 and R98 shared concerns of not being able to attend activities despite their desire to do so. R89 is [AGE] years old and was admitted to the facility 3/15/23 with diagnoses that included Multiple Sclerosis and hemiplegia of the left side. R98 is [AGE] year-old admitted to the facility 3/27/23 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction. According to the electronic health record, R89 and R98 are dependent on staff to carryout activities of daily living. During resident screening conducted on 12/11/23, R89 and R98 (roommates) shared concerns regarding Activities of Daily living in the facility. At 10:35AM, R89 said to Surveyor that they would like to get up out of the bed and couldn't remember when the last time they were up. R89 said that it would be nice if I could get dressed and sit up in the chair when receiving family and visitors. R89 said that they were dependent on staff to get up and dressed due to weakness of the left side and deformity of the left hand and wrist. R98 was also interviewed, and shared the same concerns, and added that when they first came to the facility, they were working with therapy to walk and exercise, but when therapy stopped, staff did not spend the time to dress and help them to the wheelchair. Surveyor noted two wheelchairs and a rolling walker inside the attached washroom. V16 Restorative Nurse was interviewed 12/12/23 at 2:00PM and said that one of the biggest concerns received from residents is not being able to get up to the wheelchair regularly for those who are not independent. V16 said, the restorative department was working on a schedule to get residents up at minimum two days out of the week but acknowledged that residents should be able to get up on request as well. Care plans were reviewed for Activities of Daily Living. R89's care plan initiated 3/15/23, revised 10/4/23 states R89 demonstrated a self-care deficit and should receive assistance by nursing staff, Assist with daily hygiene, grooming, dressing, oral care and eating as needed; Uses assistive/adaptive equipment: wheelchair. R98's care plan was initiated 4/5/23, revised 7/13/23 states, nursing staff should assist with necessary ADL needs and use of wheelchair and walker. During this survey, R89 and R98 were observed lying in bed for two days and concerns were relayed to V2 Director of Nursing and V16 Restorative Nurse. On 12/11/23 at 10:55AM, R28 was observed to be in bed in their room. R28 said I have expressed concern to the staff that I am always in bed and would like to get out of bed more often. They told me they would get me out of bed on Tuesdays and Thursdays but last week I was only out of bed one day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 2 of 13 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 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 On 12/12/23 at 12:10PM, R28 was observed to be in bed. R28 said they have not gotten me out of bed today and it is Tuesday. I was hoping to get out of bed today. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 3 of 13 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 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 0679 Provide activities to meet all resident's needs. 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 residents were able to engage in the Activity Program upon request and failed to assess for recreation and activity needs upon admission. This failure affected two (R89 and R98) of 44 residents reviewed for activities. Residents Affected - Few Findings include: During resident screening, R89 and R98 (roommates) were interviewed regarding care they were receiving in the facility. On 12/11/23 at 10:35AM, R89 and R98 were both observed alert and oriented lying in bed, dressed in medical gowns. R89 and R98 shared concerns of not being able to attend activities despite their desire to do so. R89 is [AGE] years old and was admitted to the facility 3/15/23 with diagnoses that included Multiple Sclerosis and hemiplegia of the left side. R98 is [AGE] year-old admitted to the facility 3/27/23 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction. During resident observation and interview, R89 pointed to the wall and said, the staff comes in every month and places an activity calendar on the wall, but no one comes to take us. I would like to go to activities, but it seems like nobody cares enough to get us. I don't even know where activities are held. R98 expressed the same concerns, saying that all they do is sit in the room and watch television and talk to each other because there is nothing else they can do. During survey observations on 12/11/23 and 12/12/23, R89 and R98 did not attend any in house activities, nor were they provided with any activity materials. V28 Activity Director was interviewed on 12/12/23 at 11:02AM and said, as a staff member who was newer to the facility (since September 2023), they noticed some challenges in the Activity Department that were currently being addressed. For instance, V28 noticed that most residents were not fully engaged in the activity program and some of the activities offered were not specific to the Resident's needs. V28 said that needs would be determined with an activity assessment that would be completed after meeting and speaking with the Residents individually upon admission and quarterly. V28 also recognized that Residents such as R89 and R98 who were on the subacute rehabilitation unit did not participate in activities as often as those on the long term care unit, pointing out that it may be due to the placement of the activity room, and staff being encouraged to bring them to the room. Activity assessments were requested for R89 and R98 and the facility provided the only assessments available that were signed and dated 12/13/23. Facility Activities Policy revised 11/1/23 states in part: Policy: It is the policy of this facility to provide an activity program to the residents which is appropriate to their needs and interests and capacity to participate and benefit. Activities are designed to stimulate physical and mental capabilities in order to obtain the optimal social, physical and emotional state. Individual resident activities will be planned in accordance with any limitations set by the attending physician. Standards: 4. Activity programming will include daily activities including weekends and at least (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 4 of 13 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 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 0679 two evenings per week. Variations in the schedule may be made by the Resident Level of Harm - Minimal harm or potential for actual harm Council, which may be reevaluated at least every six (6) months. 6. Activity programming shall include but not be limited to: Residents Affected - Few a. Small and large group social activities b. Activities specifically suited for residents unable to leave their rooms c. Indoor and outdoor activities d. Activities await the facility (when feasible) e. Religious programs, including attendance at local churches f. Opportunities for resident and family involvement in planning and implementation of activities g. Creative activities, arts, crafts, music and other creative programs h. Educational programs 1. Physical exercise programs j. Individual programs provided on a one-to-one basis k. Activities which promote community/facility interaction I. Activities suited for residents with cognitive impairments 7. Programming will be designed to meet, in accordance with the comprehensive assessments, the interests and the physical, mental and psychosocial well-being of each resident. 9. Services shall be provided to assure both ambulatory and non-ambulatory residents have access to activities, both inside and outside the facility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 5 of 13 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 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 - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interviews, and record reviews, the facility failed to follow manufacturer's guidelines for dating a multidose vial when opened. This deficiency has the potential to affect all 109 residents currently residing in the facility. Findings include: Per resident census dated 12/11/23, there were 109 residents in the facility. On 12/11/23 at 11:35 AM during inspection of the three medication rooms in the facility, the following were observed: Rosewood East: three vials of opened of Tubersol Tuberculin Purified Protein Derivative (Mantoux) Multi dose vial 5TU/0.1ml (tuberculin units per 0.1 milliliter) Intradermal were opened but not dated. V10 (Registered Nurse, RN) was asked if there is a need to put a date on the vial when opened. V10 stated, I am not sure if we have to date it or not. Rosewood West: One multidose vial of Tubersol Tuberculin Purified Protein Derivative (Mantoux) was also opened but not dated. Per V11 (RN), It should have been dated when opened. Regency: One multidose vial of Tubersol Tuberculin Purified Protein Derivative (Mantoux) was opened but not dated. V4 (Licensed Practical Nurse, LPN) was asked if Tubersol vial need to be dated when opened. V4 verbalized, We are supposed to date it, it expires in 30 days. On 12/12/23 at 1:37 PM, V2 (Director of Nursing) was interviewed regarding dating of Tubersol Tuberculin multidose vial. V2 replied, Multidose vials like Tubersol should be dated when opened. Because it expires within 28 days when opened. Its potency will be compromised. Facility's policy titled; Medication Storage in the Facility dated 1/2023 stated in part but not limited to the following: General: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, pr staff members lawfully authorized to administer medications. Tubersol Tuberculin package insert documented in part but not limited to the following: Storage: A vial of Tubersol which has been entered and in use for 30 days should be discarded Do not use after expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 6 of 13 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow their menu and failed to provide appropriate and approved menu changes and substitutions. This failure has the potential to affect 108 residents who are currently receiving meals and dietary services in the facility. Findings include: Per facility's Diet Type Report dated 12/12/23 shows that one resident on NPO (Nothing per Oral). Per facility census dated 12/11/23, shows 109 residents currently residing in the facility. Diet spreadsheet dated 12/11/23, shows dessert for lunch meal is fruit cobbler. Diet spreadsheet dated 12/12/23, shows lunch meal should include tossed salad and baked apples. On 12/11/23, observed gelatin with whipped cream being served for lunch meal. On 12/12/23, observed mixed fruit being served for lunch meal. On 12/12/23 at 11:54AM, observed fifteen residents to be eating in main dining room for lunch. Observed thirteen residents in main dining room to not be served. Lunch menu dated 12/12/23 posted in resident area shows dessert listed as 'delicious dessert'. On 12/12/23 at 11:20AM, V12 (Dietary Director) was interviewed regarding substitutions. V12 said it was my understanding that we were allowed to substitute out desserts as needed. V12 said she has not gotten approval for the substitutions she has been making but is aware that the dietitian needs to be signing off on them. Facility policy titled Making Menu Substitutions dated 2022 states in part but not limited to the following: Please be aware that making changes on your menu, whether just a one-time substitution or a permanent menu change, requires approval from your dietitian. A log of substitutions must be kept on file, including what food items were substituted, the date, reason for the substitutions and what new food items were served. This log must be reviewed and signed off by the dietitian. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 7 of 13 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow their policies on food service sanitation and storage by not taking temperatures prior to the start of meal service; failed to ensure the freezer temperature is at 0 degrees or below; failed to place dirty dishes separate from clean dishes; and failed to confirm sanitizer bucket PPM was suitable for use. This failure has the potential to affect all 108 residents who are currently receiving meals and dietary services in the facility. Findings include: Per facility's Diet Type Report dated 12/12/23 shows that one resident on NPO (Nothing per Oral). Per facility census dated 12/11/23, shows 109 residents currently residing in the facility. On 12/11/23 at 9:40AM, observations in the kitchen were made with V12 (Dietary Director). Walk-in freezer was noted to be at 11 degrees Fahrenheit. V12 said this freezer has been a concern for a couple months and is not holding appropriate temperature. Administration is aware and they are saying we need to replace something within the freezer. However, nothing has been done yet. Observed one sanitizer bucket on the back sink in the kitchen. V12 said the sanitizer bucket is being shared by the two cooks who are currently preparing lunch. V12 tested the sanitizer bucket with two different strips which did not turn colors, indicating a 0 PPM. V13 (Cook) and V12 attempted to empty and refill the bucket with sanitizer two times and testing the bucket which still indicated a 0 PPM. At 11:40AM, observed V13 getting ready and then start to serve lunch trays. It is to be noted that this surveyor did not observe any staff member taking temperatures prior to the start of lunch service. At 1:00PM, V13 said I took temperatures of the items after they came out of the oven and before they were put on the steam table. I did not take temperatures prior to serving. Observed five dirty baking sheets to be sitting on a shelf with clean dishes. V13 said, the pans are dirty; but the rest of the dishes are clean. V13 said they should not be here if they are dirty. Facility policy titled Clean and Sanitary dated 9/1/21 states in part but not limited to the following: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. All food contact surfaces will be cleaned and sanitized after each use. Facility policy titled Safe Storage of Food dated 9/1/21 states in part but not limited to the following: All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Freezer temperatures will be maintained at a temperature of 0 degrees Fahrenheit or below. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 8 of 13 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 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 A. Based on interviews and record reviews, the facility failed to follow its policy on water management program related to prevention of Legionella organism in the water system by not treating positive testing sites and not immediately obtaining treatment recommendations. This deficiency has the potential to affect the 109 residents currently residing in the facility. Residents Affected - Many B. Based on observation, interview, and record review, the facility failed to ensure that staff practice appropriate hand hygiene as outlined in their medication administration policy and failed to ensure that staff appropriately dispose sharps in a sharp disposal container. This failure affected two (R39 and R79) of five residents reviewed for infection control. Findings include: A. Per resident census dated 12/11/23, there were 109 residents in the facility. Facility's Legionella test reports recorded the following: 08/18/23: Internet cafe sink - positive, 0.5 CFU/ml (colony forming unit per milliliter) Regency Shower room - positive, 5.0 CFU/ml Kitchen ice machine - positive, 0.5 CFU/ml Species found: Legionella feeleii 11/02/23: Internet cafe - positive, 0.5 CFU/ml, species found - Legionella feeleii There were no other documented test results before and after August 2023 and November 2023. On 12/13/23 at 11:12 AM, V9 (Maintenance Director) was asked regarding Legionella organism found in the facility's water system on 08/18/23 and 11/02/23. V9 stated, I told V22 (Outgoing Administrator) about the Legionella results. I did flush. The company did not give any recommendations. I just did what I need to do. When I first started, I don't have any directions on testing. I was told to make sure it is negative for Legionella and do flushing if it is positive. I don't know if I'm supposed to test other areas for Legionella. V9 was asked on how he perform water testing. V9 verbalized, I ordered test bottles, once I received those, I put water samples and mail it to laboratory for testing. I get the results and if it is positive, I flush the water daily. I pick one area randomly when I do the test. I don't know any procedures on how to deal with Legionella. On 12/13/23 at 1:50 PM, V22 (Outgoing Administrator) was also asked regarding positive results of Legionella in the facility water system. V22 replied, As Administrator, I oversee the water management with V9 and Regional Operations Manager. V9 is supposed to report with water issues. I believe I was notified of the water report last August 2023. The issue was referred to Regional Operations Manager. I don't specifically remember exactly, we did flush, monitoring and retesting. I don't recall if I was notified that a retesting was done. Facility was asked to present documentation for retesting after August 2023 and October 2023, but none was submitted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 9 of 13 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 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 Residents Affected - Many Facility's Work History Report dated 07/08/23 to 12/09/23 documented flushing at areas of concern. Flush log dated November to December, with no year indicated, documented daily flushing of the Internet café. On 12/13/23 at 10:23 AM, V2 (Director of Nursing) and V3 (Infection Control Preventionist) were asked regarding awareness of positive Legionella in the water system last August and October 2023. V3 stated, I have never been informed of any issues with water checks related to Legionella. We do monitor patients but not specific for Legionella. I have not received any training regarding Legionella. V2 also verbalized, This year, I was not notified of any issues with Legionella. I am not part of the water management team. On 12/13/23 at 2:25 PM, V23 (Director of Water Safety and Management, Laboratory) was interviewed regarding detection of Legionella organism in facility's water system. V23 stated, There was a final report last 08/18/23 that Regency Shower room had 5CFU/ml of Legionella felleii; ice machine in the kitchen had 0.5 CFU/ml and 0.5 CFU/ml, and in the Internet cafe. I was not contacted regarding recommendations for this 08/18/23 report. The October report had 0.5 CFU/ml. Laboratory did the report, I was not contacted. There were no recommendations last October 2023. I was not contacted at all but yesterday, V24 (Vice President of Operations, Facility) called, and I gave recommendations. I was told about October and November reports and advised her (V24) to clean and disinfect the fixtures. I was not notified about Internet cafe. I recommended flushing, disinfect in a 1:10 bleach solution for 2 hours, one time only; reinstall the fixture and flush for 5 minutes. If the outlets are not used on a weekly basis, hot water flush for 5 minutes weekly. To consider re-sampling after the reinstallation of the fixture. V24 (Vice President of Operations, Facility) was asked on 12/14/23 at 10:02 AM regarding facility's water issue on Legionella organism. V24 verbalized, Any water management issues are handled by facility Administrator and Maintenance Director. I was made aware recently, only this week about Legionella concern in the facility's water system. I just assisted them making sure all the information is updated, that V9 (Maintenance Director) has the same recommendation from the contractor. On 12/13/23 at 11:43 AM, V25 (Director of Water Management, State of Illinois) was asked regarding facility's issue on Legionella and water management. V25 stated, It is concerning because it was at multiple testing sites. If it was just one site that was positive, then it wouldn't be as concerning. They should be doing more investigating to find out the source. Typically speaking, environmental positives would require increased surveillance. Normal procedure is usually for the water management company to provide actions for response that the facility should take. It's very common for Legionella to grow back so you have to do active monitoring of the site even after treatment has been carried out. You would allow for at least two weeks after treatment to test the same fixture. If they are testing positive in the bathroom sink, then they should definitely be testing other sinks and especially showers in that site, if the plumbing is shared. We look at the areas where the Legionella bacteria can be aerosolized and those, especially with hot water, that contain Legionella makes the water aerosolized and makes it more susceptible to breathing in the Legionella. I would agree that the same site should be re-tested if they were positive and the other fixtures and showers with the same plumbing. They should also look at the access risk. They should be looking at high risk fixtures with showers and hot water - jetted tubs and showers are the highest risk fixtures. The water is being re-circulated, and water can sit in the jet lines and can aerosolize the bacteria. If it was just the one sink, then flushing might be okay but since there are three positives at the same time, then it's concerning because that would indicate a problem with their system. They need to further investigate the cause of the issue with their system. Some things that they can consider are: Has there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 10 of 13 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 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 Residents Affected - Many been any plumbing work in the facility or with the city? Have they had any water quality issues? Did the public water supply change their practices? Water main breaks/construction? Hydro-flushing has been known to disrupt systems. Have their census levels changed? Because sometimes if there is a unit or rooms that were not being used for a period of time, they could be more susceptible for developing Legionella since the water is sitting there stagnant. If there were fixtures not being utilized for a period of time, that can also contribute to it. Facility's policy titled Water Management Program for Control of Legionella dated 11/30/2023 documented in part but not limited to the following: General: Facility will participate in the Water Management Program described below to prevent the introduction and growth of Legionella in the facility environment. All (name of healthcare company) facilities have been identified as increased risk due to: Patient/residents staying overnight at (name of healthcare company) facilities Treatment of chronic/acute medical problems or weakened immune systems Patient/residents 65 years and over Responsible party: Water Quality Management Team Administrator Maintenance Supervisor Housekeeping/Laundry Supervisor Regional Director of Operations Testing 2. The potable water system at each facility will receive testing for Legionella as required. Four potable water samples will be drawn for each site by the licensed contractor. 3. The Maintenance Supervisor will test the potable water system as required for residual chlorine at no less than four locations using test kit provided. Prescribed locations for monthly testing include: Source water tank (first opportunity downstream from water main) Hot water holding tank A random resident faucet (location to vary and be documented) - Hot water A random resident shower - hand held or fixed shower head (location to vary and be documented) - hot water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 11 of 13 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 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 Routine Flushing Level of Harm - Minimal harm or potential for actual harm Maintenance Supervisor will identify water outlets (showers/tubs/faucets) that are underutilized and flush those outlets as required by running the hot water and the cold water, separately, through those outlets for 5 minutes each to remove any stagnation. Residents Affected - Many Program Monitoring and Documentation 1. The Maintenance Supervisor will fill out the water management log sheets and share to the licensed contractor and place copy in the water management binder. 2. The licensed contractor will view data. 3. Legionella testing of potable water will be done at each facility by the licensed contractor and results are logged and shared with the facility Water Quality Management Team. Positive Cultures and Remedial Action The licensed contractor will make recommendations to the Water Quality Management Team to remedy actions dependent on level of contamination to eliminate Legionella bacteria. Retesting will confirm effectiveness of the treatment. B. 12/11/23 12:35 PM, observed medication administration with V5 (LPN) who was administering insulin to R39. V5 finished administering insulin to resident, removed her gloves and disposed it in a garbage can, walked out of the room without performing any hand hygiene and returned the insulin pen in her medication cart. At 12:40PM, V5 walked into R79's room to check his blood glucose without knocking on the door, checked resident's blood glucose which read 239, removed her gloves and wrapped the used lancet in her gloves, discarded that in the resident's garbage can. V5 left the room and walked to her medication cart without performing any hand hygiene, drew 7 units of insulin in an insulin pen, went back and injected the insulin on the resident, removed her gloves again and walked out of the room without performing any hand hygiene. At 12:55PM, V5 was presented with these observations, and she stated that the used lancet can be disposed in a regular garbage can because it has been used and cannot harm anyone anymore. V5 also added that she did not knock before entering resident's room because she has been here all day and has been going in and out of resident's room, she did not wash her hands because she used gloves. 12/12/23 at 1:37PM, V2 (DON) said that lancets should be disposed in a sharp container not in a regular garbage can, staff are supposed to knock on resident's door no matter how often they entered the room, hand hygiene should be performed before and after administering medications. Medication administration policy presented by V2 (DON) dated 1/2023 states that all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 12 of 13 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 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 Under guideline, the policy states: Level of Harm - Minimal harm or potential for actual harm #3. Hand hygiene must be performed before and after any invasive procedure (i.e., blood glucose monitoring, injections, etc.). #4. Hand hygiene must be performed after touching any inanimate object possibly infected with microorganisms (according to the CDC guidelines on hand washing.) Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145684 If continuation sheet Page 13 of 13