Inspection·April 3, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility, V9 did not document resident's blood sugar because the order said to monitor, she does not know the protocol when the order is to monitor but per V9, going forward, she will be documenting the blood sugar. Care plan for R1 dated 12/10/2024 states, the resident has Diabetes Mellitus. Interventions include Fasting Serum Blood Sugar as ordered by doctor, Monitor/document/report to MD PRN s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait, etc. On 4/1/2025 at 3:26PM, V7 (LPN) said that she is familiar with R1; the day he was sent out to the hospital, V7 came in on 3 to 11PM shift and the outgoing nurse told her that R1 might be going out to the hospital because he was not feeling well. V7 said that she assessed the resident and noted that he was not himself. V7 said that family member was in the room and had already called the ambulance because they wanted the resident to go to a specific hospital. V7 said that she thinks she took vitals on R1 and even checked his blood sugar and thinks that she documented it. Surveyor informed V7 that there was no documentation of any vitals or blood sugar level for the resident and she said, well I don't know what happened. R2 is [AGE] years old and was originally admitted to the facility on [DATE]. R2's face sheet listed the following medical diagnosis among others: Dysphagia following cerebral infarction, type 2 diabetes, hypertensive heart and chronic heart disease, essential primary hypertension, systemic lupus erythematous, acquired absence of right leg, unspecified viral hepatitis C, etc. Review of physician orders showed the following: Blood Glucose Fingerstick Monitoring BID at breakfast & dinner. Call MD if BS is under 70___ or over _250__. two times a day for diabetic monitoring. Order date 10/25/2024. Last vital sign documented for R2 was on 2/25/2025 prior to the one documented by V8 on 3/5/2025. Last blood sugar documented was on 2/25/2025 prior to the one documented on 3/6/2025 before resident was sent out to the hospital. On 3/5/2025 at 13:04, V9 (LPN) documented the following: During med pass writer heard congestion during breathing in the resident, writer contacted Primary doctor to alert of s/s, order for Geri-tussin DM 10ML three times a day for 10 days PO (by mouth), cont. to monitor. V9 did not document any assessment or vital signs for R2 after she made this observation. On 4/2/2025 at 11:41AM, V9 (LPN) said that she assessed R2 and took vital signs, she thought she documented it in R2's record. On 4/12025 at 3:12PM, V2 (DON) said that nurses are supposed to check blood sugar and vital signs as ordered and it should be documented in the MAR or in the vitals section of the medical record. Job description for registered nurse and licensed practical nurse document (undated) states in part: The basic functions: under the direction of the physician is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, resident nursing care, staff performance and adherence by staff members to facility policies and procedures. Essential duties: 3. Administer prescribed medications and treatments according to policy and procedure, evaluate treatment effectiveness on a continuing basis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 2 of 6 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 145758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Glenwood 19330 South Cottage Grove Glenwood, IL 60425 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 0658 Level of Harm - Minimal harm or potential for actual harm 9. Recognize significant changes in the condition of residents and take necessary action. 10. Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in facility's policies and procedures. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 3 of 6 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 145758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Glenwood 19330 South Cottage Grove Glenwood, IL 60425 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that staff administer prescribed PRN (as needed) blood pressure medication for a resident; failed to assess and document vital signs for a resident with a change in condition; and failed to monitor and document a resident's blood sugar as ordered. This failure affected one (R2) of three residents reviewed for nursing care and resulted in R2 becoming unresponsive while at the facility and required hospitalization and treatment that included intubation and being admitted to the intensive care unit (ICU) for treatment of septic shock and healthcare associated pneumonia. Residents Affected - Few Findings include: R2 is [AGE] years old and was originally admitted to the facility on [DATE], face sheet listed the following medical diagnosis among others: Dysphagia following cerebral infarction, type 2 diabetes, hypertensive heart and chronic heart disease, essential primary hypertension, systemic lupus erythematous, acquired absence of right leg, unspecified viral hepatitis C, etc. Hospital record dated 3/6/2025 states in part, patient brought in ALS per Emergency Medical Service (EMS). EMS called uncontrolled blood pressure, upon arrival at nursing home EMS states unresponsive and diaphoretic with shallow respirations. The same hospital record documented in part, [AGE] year-old male with past medical history of diabetes, CKD, hypertension .presents to the emergency department from nursing home via EMS for evaluation after he became unresponsive. Reportedly, his blood pressure was uncontrolled earlier, (unclear if it was low or high) and then he became unresponsive and diaphoretic with shallow respirations. Patient was intubated on 3/6/2025 at 6:01am, lab revealed positive RSV, chest x-ray with possible pneumonia, clinical impression septic shock and health care associated pneumonia. Review of physician orders showed the following: clonidine HCl Tablet 0.1 MG Give 1 tablet by mouth three times a day for antihypertensive. Hydralazine HCl Tablet 10 MG Give 10 milligram by mouth every 6 hours as needed for Elevated blood pressure. Give for SBP over 160 and DBP over 100. Blood Glucose Fingerstick Monitoring BID at breakfast & dinner. Call MD if BS is under 70___ or over _250__. two times a day for diabetic monitoring. Order date 10/25/2024. Medication administration record for the month of March 2025 showed that R2 received only one dose of the ordered PRN (as needed) hydralazine on 3/6/2025 at 0100. Last vital [NAME] documented for R2 was on 2/25/2025 prior to the one documented by V8 on 3/5/2025. Last blood sugar documented was on 2/25/2025 prior to the 3/6/2025. Per record review, R2 was observed with poor appetite for breakfast and lunch and diminished lung sounds with rumbling upon auscultation as documented in progress note dated 3/3/2025at 15:08. Medical doctor was notified and an order for respiratory panel and chest x-ray was obtained. 3/32025 at 15:10, respiratory panel was collected and placed in the soiled utility refrigerator. Laboratory result dated 3/4/32025 stated that R2's lab was canceled due to an unlabeled specimen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 4 of 6 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 145758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Glenwood 19330 South Cottage Grove Glenwood, IL 60425 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 0684 There was no follow up documentation to the collected sample, no assessment or vital signs documented for the resident the rest of 3/3/2024 and all three shifts on 3/4/2025. Level of Harm - Actual harm Residents Affected - Few Laboratory result dated 3/4/32025 stated that R2's lab was canceled due to an unlabeled sample. Repeat lab result dated 3/5/2025, reported at 20:18 showed that R2 tested positive for RSV. 3/5/2025 at 13:04, V9 (LPN) documented the following: During med pass writer heard congestion during breathing in the resident, writer contacted Primary doctor to alert of s/s, order for Geri-tussin DM 10ML three times a day for 10 days PO (by mouth), cont. to monitor. V9 did not document any assessment or vital signs for R2 after she made this observation. On 4/2/2025 at 11:41AM, V9 (LPN) said that said that she assessed R2 and noted that he was having a respiratory issue and coughing, there was an outbreak of RSV in the facility, so she called the doctor and received an order for cough syrup. V9 said that R2 should have gone out the same day but she followed the order. Care plan initiated 12/25/2022 states that R2 have altered cardiovascular status r/t CHF, Hypertension, and heart disease. Interventions include assess for shortness of breath and cyanosis every shift as needed, monitor vital signs, notify MD of significant abnormalities, monitor/document/report PRN any changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight, monitor/document/report PRN any s/sx of CAD: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refill, color/warmth of extremities. On 3/5/2025 19:07:20, V8 (RN) documented the following Writer observed that the resident refused to communicate with him when asked a question, he looks confused, refuses to take his medication and dinner. V/S (vital signs) BP.166/85. P.98. T.97.8. SPO2 87. writer assists with 2 liters of oxygen, will continue to monitor. On 4/1/2025 at 4:05PM, V8 (RN) said that he is familiar with R2, when he came to work on 3/5/2025, the outgoing nurse told him to monitor resident's respiration; V8 continued passing medications and decided to check his lab results. V8 called the doctor to report a positive RSV result for R2 but the doctor did not answer, V8 faxed the result to the doctor. V8 called the DON (Director of Nursing) to let her know and she advised him to follow up with the doctor. Night shift nurse came and V8 handed over to her, he is not sure what the blood pressure was at that time. Vital sign documented by V8 at 23:57 is as follows: B/P 166/98, Pulse 127, T-97.8 02 sat 94%, no respiratory rate charted. V8 was asked if he gave R2 any PRN (as needed) blood pressure medicine and he said, I did not know that the resident have such medication, I don't really know the resident because I hardly work that set, it was the night nurse that informed me that resident have a PRN hydralazine and I even went with her to pull it. On 3/6/2025 at 03:16, V5 documented the following: Writer observed resident sweating, lethargic, not verbally responsive with labored breathing. Vitals 160/89, Temp.99.0 Pulse 84 on oxygen, BS 90. CO -nurse called EMS. EMS arrived at the facility @ 0301. On 4/1/2025 at 1:08PM, V5 (RN) said that she is familiar with R2 and was the person that sent him to the hospital 3/6/2025. V5 came to work at 11:00PM and was notified by the outgoing nurse that R2 was not feeling well. V5 assessed the resident with the outgoing nurse and noted that his blood pressure was elevated, the outgoing nurse made some calls while V5 stayed with the resident. V5 rechecked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 5 of 6 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 145758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Glenwood 19330 South Cottage Grove Glenwood, IL 60425 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 0684 Level of Harm - Actual harm Residents Affected - Few resident's vitals and his blood pressure got higher, she medicated resident with a PRN blood pressure medicine and Tylenol for elevated temperature. V5 said that resident's blood pressure and temperature came down a little after the medication, but the respiration remains shallow, and resident was unresponsive. V5 said that the physician did not call back until early morning and she informed him that resident was sent to the hospital. V5 added that resident is usually responsive but not that night. Medication administration record for the month of March 2025 showed that R2 received only one dose of the ordered PRN hydralazine on 3/6/2025 at 0100. Last vital [NAME] documented for R2 was on 2/25/2025 prior to the one documented by V8 on 3/5/2025. Last blood sugar documented was on 2/25/2025 prior to the 3/6/2025. On 4/2/2025 at 11:22AM, V10 (Primary Physician) said that R2 was sent to the hospital immediately and his test came back positive for RSV; he was treated and he came back to the facility. Surveyor informed V10 that R2 did not return to the facility and presented the documentation by the nurse that they called with the positive RSV result and V10 did not call back until the morning after the resident has been sent out. V10 then said that he must have mistaken this admission with resident's previous hospital visit, V10 added that he keeps his phone with him all the time and always calls the facility back. If the nurse thinks that something is wrong with a patient and the doctor does not answer then they can call the DON and make the decision to send out the resident; they don't have to wait for the doctor to take an action. On 4/12025 at 3:12PM, V2 (DON) said that nurses are supposed to check blood sugar and vital signs as ordered and it should be documented in the MAR (Medication Administration Record) or in the vitals section of the medical record. On 4/2/2025 at 10:30AM, V2 (DON) said that the protocol to follow when staff cannot reach the physician is to call the medical director, all the nurses are aware of this, if they cannot reach the physician they should continue trying and inform the DON of what is going on. V2 added that the rule of thumb is to reach for the nurse practitioner first, then the attending physician and the medical director if needed. Job description for registered nurse and licensed practical nurse document (undated) states in part: The basic functions: under the direction of the physician is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, resident nursing care, staff performance and adherence by staff members to facility policies and procedures. Essential duties: 3. Administer prescribed medications and treatments according to policy and procedure, evaluate treatment effectiveness on a continuing basis. 9. Recognize significant changes in the condition of residents and take necessary action. 10.Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in facility's policies and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 6 of 6