Health inspection·April 10, 2025

F 0880 Interventions: Level of Harm - Minimal harm or potential for actual harm Educate staff/resident/family on enhanced barrier precautions as needed. Residents Affected - Some Gown and glove during high contact resident care activities (such as dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use, wound care (any chronic skin opening) Maintain enhanced barrier precautions for the duration of their stay OR until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. On 04/07/25 at 10:58 AM, R99 was in bed, alert, oriented. R99 has an indwelling urinary catheter in placed, connected to a urinary bag, draining well. A sign at his door stating that he is on enhanced barrier precaution (EBP). On 04/08/25 at 11:42 AM, CNAs V19 and V20 were observed in R99's room providing care without wearing isolation gowns. V19 was assisting R99 in putting on his shirt. V20 was emptying his (R99) urinary bag. Subsequently, V19 and V20 used a mechanical lift device and transferred R99 to his motorized wheelchair. V19 was asked regarding EBP on R99. V19 stated, I'm not sure if he is on EBP, because I don't work here every day. On EBP, we are supposed to wear gloves, gown, and goggles. We have to wash our hands before and after. Signage posted on R99's door: Providers and staff must also: Wear gloves and a gown for the following High-Contact resident care activities. Dressing Transferring Device care or use: central line, urinary catheter, feeding tube, tracheostomy. 3. R51 is a [AGE] year-old, female, admitted in the facility on 09/11/18 with diagnoses of Malignant Neoplasm of Colon, Unspecified; Colostomy Status and Alzheimer's disease, Unspecified. R51 has colostomy bag, intact and in placed. There was no sign at R51's door stating she is on any type of precautions, as observed on 04/06/25, 04/07/25 and 04/08/25. On 04/08/25 at 9:46 AM, V3 (Infection Preventionist) was asked regarding R51. V3 replied, She has colostomy. She should be on enhanced barrier precautions for that. They must have flipped the sign around backwards by accident. Every room does not need a supply bin. I have binders at the nurses' station as well. If the signs get knocked down, staff is supposed to go to the nurse and ask or go to the nurses' station and look at the binder. And there is supposed to be an orange dot to know who is on enhanced precaution. V3 flipped the sign to show that resident is on enhanced barrier precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 04/08/25 at 1:37 PM, V3 was interviewed regarding transmission based and enhanced barrier precautions. V3 verbalized, For transmission-based precautions (TBP) such as contact/droplet precautions, there should be a signage at the door upon entrance; orders need to be placed; isolation bins placed outside the room. Staff needs to wash their hands before and after entering and exiting the rooms; staff and visitors need to wear PPE - gown; gloves and if its droplet - gown, gloves, face shields; N95. For contact isolation - anybody entering the room should wear gown and gloves. So, infection is contained. For enhanced barrier precautions, anybody that is on high contact with resident needs to wear gown and gloves. High contact such as bathing, transferring, feeding, changing linens; administering IV (intravenous); indwelling urinary catheter care; gastrostomy tube care or ADL (activities of daily living) care. On 04/09/25 at 12:46 PM, V2 (Director of Nursing) was also asked regarding infection control in the facility. V2 stated, Staff has to follow all infection control policies and procedures, which includes isolation precautions; TBP; EBP and standard universal precautions. I am a part of providing education on staff regarding infection control. We constantly asking questions on staff regarding what to do for isolation, handwashing, hand hygiene, donning and doffing PPE. We do random audits on staff for hand hygiene, hand washing and PPE. Staff has to make sure outside vendors, visitors that PPE should be worn for isolation rooms. 4. R107 is [AGE] years of age. Current diagnoses include but are not limited to Cerebral Infarction affecting the left side, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Urinary Tract Infection, Obstructive and Reflux Uropathy, and Resistance to Vancomycin. R107's comprehensive assessment section C cognitive patterns dated 2/7/2025 documents a brief interview for mental status score of 15 out of 15 indicating he is cognitively intact. On 04/07/25 at 11:00 AM, this surveyor observed the 400 hallway during screening of residents. There are multiple residents with EBP (Enhanced Barrier Precaution) and TBP (Transmission Based Precaution) signs and PPE Personal Protection Equipment bins in place at the room entrance. On 04/07/25 at 11:32 AM, this surveyor entered R107's room for interview. Upon entrance to the room, there is no signage at the door for R107 indicating contact isolation precautions. There is no hand sanitizer solution in the dispenser at the entrance to R107's room. On 04/07/25 at 11:34 AM, while this surveyor is conducting an interview with R107 in his room, V3 arrived in the room with a contact isolation sign and PPE bin. V3 was inquired of the sign and PPE bin placement. V3 said, R107 is on contact isolation for VRE (Vancomycin Resistant Enterococcus) in his urine, he has a urinary catheter. We just moved his room. The only supplies he needs are gowns, gloves, and hand sanitizer. Little said, It' important for the staff and visitors to know R107 is on contact isolation so the infection isn't spread. On 04/07/25 at 11:38 AM, V16 (Director of Environmental Services) was in the hallway near R107's room. V3 asked V16 to put hand sanitizer into the dispenser at R107's door. V16 left and came back to the room and refilled the hand sanitizer dispenser. 04/07/25 11:40 AM, R107 was inquired of being moved to his current room. R107 said, They moved me here yesterday evening. R107's census documents his room on 04/06/2025 as 401 private room. R107's medical diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 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 0880 include Resistance to Vancomycin present on admission. R107 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of R107's progress notes document the following nurses note: Position: RN-Director of Nursing Created By: V2 Created Date : 4/6/2025 1:24 PM: Writer received call from doctor regarding resident's urine culture results. Order received to place resident on contact isolation for VRE of the urine and to initiate ABT (antibiotic) ampicillin 500mg every 6 hours x 10 days. Orders noted and carried out. Daughter has been notified of infection and made aware of room change. She was thankful for the updates. Writer will update daughter once room change is completed. Residents Affected - Some R107's progress note by V24 (LPN Licensed Practical Nurse) documents: Department: Nursing Position: Licensed Practical Nurse Created Date: 4/6/2025 7:06 PM. Narrative: The resident's daughter called the writer to say that if there is anything I can do not to transfer him for his isolation. And that he is used to his roommate and friend. The writer told her that it is an established protocol that if a resident has some particular infection he/she has to be isolated for some days while on treatment for the infection in order to prevent the spread. The writer told her to call the infectious disease coordinator in the morning for further clarification. R107's physician order dated 04/06/2025 documents Maintain Contact precaution for VRE of the Urine every shift for VRE of the Urine for 10 Days Strict Contact isolation precautions maintained. VRE Vancomycin Resistant Enterococcus is a gram-positive bacteria that is resistant to the antibiotic Vancomycin. VRE infections are a serious threat often occurring in healthcare settings and causing bloodstream infections with high mortality rates. On 4/7/25 at 7:19 PM, R107's order for contact isolation was discontinued by the nurse practitioner. On 4/7/25 at 7:28 PM, V3 contacted R107's physician. V3's progress note documents the following: Department: Nursing Position: RN/LPN Writer update ID NP on resident VRE infection in urine. Resident infection is contained in foley catheter. No c/o urinary discomfort nor pain. Orders carried out to DC contact isolation and place resident on Enhanced barrier precautions related to MDRO (Multiple Drug-Resistant Organism). Daughter and resident made aware and updated on room change. All safety precautions in place. Facility's policy titled Transmission Based Precautions dated 1/1/2023 documented in part but not limited to the following: General: Transmission Based Precautions are a second tier of basic infection control and are to be used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Policy: Set up - contact: sign on door; hand hygiene is required; gloves are required upon entry to room, must be removed before exiting, followed by hand hygiene; gown is required. Facility's policy titled IC - Enhanced Barrier Precautions (EBP) dated 1/2024 stated in part but not limited to the following: General: EBP expand the use of PPE and refer to the use of gown and gloves during high - contact resident care activities that provide opportunities for transfer of MDROs (multidrug resistant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/ or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Policy: EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur but is not necessary in other situations. High contact resident care activities requiring gown and glove use among residents that trigger EBP use include: dressing; transferring; providing hygiene; device care or use: urinary catheter. Citation written by Surveyor: [NAME] with supporting documentation based on observations from [NAME], [NAME] and [NAME]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 5 of 5