Inspection·December 31, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (Wednesday), indicating R2's dressing was not changed per physician's order.R2's Treatment Administration Record, dated October 2025 and December 2025, documents, in part, PICC (Peripherally Inserted Central Catheters) lines/Midlines: Measure (specify arm/type of line) circumference upon admit and weekly with dressing changes every night shift every Sun for IV (intravenous). Document in Progress notes. Upon review, nursing staff initials are missing for the dates 10/12/25, 10/19/25, 11/07/25, and 11/21/25. Additionally, R2's progress notes contain no documentation indicating that the PICC line dressing was changed on these dates, indicating that the dressing change was not completed in accordance with the physician's order.R3's face sheet documents diagnoses that include but are not limited to renal dialysis, end stage renal disease, and disorder of muscle.R3's BIMS (brief interview mental status) score, dated 10/03/25, is 15 which indicates R3 is cognitively intact.R3's active physician order, dated 11/24/25, documents, in part, LEFT SHIN: cleanse with wound cleanser. apply collagen to the wound bed. skin prep peri wound and cover with calcium alginate and bordered gauze daily and PRN. every day shift for Venous ulcer.R3's care plan, dated 8/19/25, documents, in part, (R3) was admitted to the facility for a skilled stay requiring physician ordered, medically necessary services including direct therapy services, skilled nursing care, management and evaluation of the patient care plan, observation and assessment of the patient's condition and/or teaching and training activities related to the reason for stay or in preparation to transition to a lesser care environment. He requires skilled services related to primary diagnosis of hypertensive heart and kidney disease with ESRD (end stage renal disease), with interventions that document, in part, Provide skin treatments per MD (medical doctor) order. Follow plan of care for skin management. Provide therapy per MD (medical doctor) orders.R3's Treatment Administration Record, dated September 2025, documents, in part, Wound care: Left lateral arm everyday shift Cleanse area with normal saline and pat dry. Apply honey and calcium alginate and cover with dry dressing. -D/C Date- 09/08/2025 1247; Wound: Left lower extremity everyday shift Cleanse area and pat dry. Apply calcium alginate to wound bed and cover island dressing. Wrap with ace bandage. -D/C Date- 11/03/2025 1543. Upon review, nursing staff initials were missing on 9/01/25 and 9/04/25, indicating that the dressing change was not completed in accordance with the physician's order.R3's Treatment Administration Record, dated October 2025 and December 2025, documents, in part, Wound: Left lower extremity everyday shift Cleanse area and pat dry. Apply calcium alginate to wound bed and cover island dressing. Wrap with ace bandage. -D/C Date11/03/2025. Upon review, nursing staff initials are missing on 10/01/25, 10/03/25, 12/04/25, 12/14/25, and 12/24/25, indicating that the dressing change was not completed in accordance with the physician's order.R4's face sheet documents diagnoses that include but are not limited to renal dialysis, end stage renal disease, and cellulitis of right lower limb.R4's BIMS (brief interview mental status) score, dated 12/22/25, is 13 which indicates R4 is cognitively intact.R4's care plan, dated 7/31/25, documents, in part, (R4) was admitted to the facility for a skilled stay requiring physician ordered, medically necessary services including direct therapy services, skilled nursing care, management and evaluation of the patient care plan, observation and assessment of the patient's condition and/or teaching and training activities related to the reason for stay or in preparation to transition to a lesser care environment, with interventions that document, in part, Provide skin treatments per MD order. Follow plan of care for skin management. Provide therapy per MD orders.R4's physician order, order date 11/13/25, documents, in part, LEFT AMPUTATION FOOT: Apply 0.125% Dakins moist gauze to the wound bed. gently pack the moist gauze into the area of depth of the lateral aspect of the wound. cover with ABD pad and wrap with kerlix. change dressing daily and PRN. every day shift for SURGICAL WOUND. R4's Treatment Administration Record, dated October 2025 and December 2025, documents, in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 2 of 4 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 12/31/2025 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 - Minimal harm or potential for actual harm Residents Affected - Some part, Left Lower Leg / Betadine every day shift Cleanse with normal saline. Pat dry with gauze. Apply treatment and leave open to air. -D/C Date-12/24/2025 and Right Lower Leg / Betadine every day+ shift Cleanse with normal saline. Pat dry with gauze. Apply treatment and leave open to air. -D/C Date12/24/2025. Upon review, nursing staff initials were missing on 10/03/25, 12/04/25, and 12/14/25, indicating that the dressing change was not completed in accordance with the physician's order.On 12/29/25 at 2:00pm, V5 (Wound Care Nurse) said, On admission of a resident, either way the nurse's do a head to toe assessment. Probably wouldn't change the dressing until the next day to be seen by a doctor or wound care nurse, unless there are specific orders to do so. Especially, if it's a surgical incision. It all depends on the orders with the doctors. A lot of the surgeons don't want the dressing removed. Upon review of R1's TAR (Treatment Administration Record) with V5, V5 said, I'm not sure why a nurse didn't sign off that the dressing was changed on those days (10/02/25, 10/03/25, and 10/04/25). I came in on the sixth (10/06/25). I'm pretty new here. V5 affirmed that dressing care is dependent on physician orders and acknowledged that dressings are required to be signed off on the Treatment Administration Record to indicate the treatment was completed. On 12/30/25 at 12:42pm, upon review of R1, R2, R3, and R4's TARs (Treatment Administration Record) with V2 (Director of Nursing/DON), V2 said, I cannot locate any documentation showing the dressings were changed. The number one rule is that if it's not signed, it's not done. V2 affirmed that the nurses should be signing the TARs after completion of changing resident's dressings. On 12/30/25 at 1:55pm, V10 (Infection Preventionist) said, IP said, PICC (peripherally inserted central catheter) line dressing are changed every 7 days. The purpose is to monitor the site, prevent any further infections. The purpose for changing wound dressing as ordered is to prevent further infection, prevent further wound damaging and prevent worsening of the wounds.Record review of facility policy titled Skin Management: Monitoring of Wounds and Documentation, dated 5/2025, documents, in part, It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. With each dressing change or at least weekly, an evaluation should be documented. At a minimum, documentation should include the date observed and: Location and staging; Size, depth, and the presence of any undermining or tunneling; Exudate, if present; Pain; Wound bed description; and Description of wound edges.Record review of facility policy titled Physician Orders, dated 5/01/25, documents, in part, Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet in PCC (PointClickCare) and the Medication Administration Record (MAR) or Treatment Administrative Record (TAR). The following steps are initiated to complete documentation: a. Clarify the order; b. Enter the orders with administration schedule in PCC and transit to pharmacy; c. If order is replacing a previous order, d/c previous order in PCC.Record review of facility policy titled, Infection Control Program- General, dated 2/2025, (Name of Facility) is committed to ensuring that all appropriate infection and control measures are in place as determined by State and Federal Regulations as well as CDC (Center for Disease Control) recommendations and guidance. The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility.Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Your facility must provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 3 of 4 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 12/31/2025 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 - Minimal harm or potential for actual harm services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145758 If continuation sheet Page 4 of 4