Health inspection·December 5, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observation, interview, and record review, the facility failed to honor R196's decision to observe a vegan diet. Residents Affected - Few This applies to 1 of 1 residents (R196) reviewed for self determination in the sample 35. The findings include: MDS (Minimum Data Set), dated September 5, 2024, shows R196's cognition was intact. POS (Physician Order Sheet), printed December 4, 2024, shows R196's diagnoses included major depressive disorder, suicidal ideation, and personal history of suicidal behavior. The POS shows R196's diet order, ordered November 28, 2023, shows General diet, Regular texture, Regular consistency. The POS shows, Allergies: Dairy Products. On December 4, 2024 at 10:10 PM with V1 (Administrator) present, R196 stated she was upset she was made to drink milk because she had no other protein sources in the diet served to her by the facility. R196 stated she chose to be vegan over 20 years prior, and was vegan when she was admitted to the facility a year ago. R196 stated in March of 2024, she spoke with V6 (Corporate Dietitian) via teleconference with V1 (Administrator) present in V1's office. R196 stated they discussed vegan protein options to be served to R196 because R196 was not receiving enough protein at meals. R196 stated she was told by V1 and V6 they would provide veggie burgers, but R196 never received them. R196 stated she was told the facility bought beans in large bulk packages and could not purchase smaller amounts only for one resident. V1 stated V1 did not remember that conversation. R196 stated the night prior, two nurses entered her room and insisted she could take a (lactose free) pill so that she could consume dairy products. R196 stated she felt unheard, powerless, and like the staff were patronizing her. R196 stated she told the nurses she was not only lactose intolerant, but that she had a cow's milk allergy, and the rash on the back of her neck was the result of consuming cow's milk in addition to her nasal congestion. R196 stated she felt like she was forced to drink the cow's milk because she was not receiving any adequate protein sources in her diet. R196 told V1 she had reactions to cows milk as a child and was told by her doctor to eliminate it because it was causing rashes, congestion, and other symptoms. On December 2, 2024 at 11:30 AM, R196 had a (lactose free) milk sitting on the dresser in room, and stated she has to drink the (lactose free) milk at the facility because otherwise she would not have any other sources of protein. R196 stated she also needed to eat cheese at the facility for a protein source because the facility does not provide an alternate source of protein at meals. R196 demonstrated a rash on back of neck and stated it was caused by consuming milk products to which she is allergic, and the result was a rash like the rash on the neck. R196 stated she was also lactose intolerant, so the facility gave her lactose free milk. On December 2, 2024 at 12:33 PM, R196 received her lunch tray which consisted of plain noodles, 1 serving approximately 1/2 cup of green beans, bowl of lettuce with tomato, and a 1 piece frosted cake. R196 stated, This is typical. No protein. I used to be dairy free, but I can't be here because I wouldn't get any proteins. I drink (lactose free milk), but I break out into a rash behind my neck because I am allergic to milk. R196 pulled back the hair on her neck to show a rash of approximately two inches in diameter. R196 stated she does not want to eat animal products for moral/ethical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 2 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reasons due to her love for animals. R196 stated stated she has high cholesterol and when she eats a plant-based diet, her high cholesterol resolves. R196 stated when she stops eating dairy her rashes also resolve. Stated she has talked to V6 (Corporate Dietitian) and V7 (Dietary Manager) and filled out her menus based on what was available on the regular menu and the substitution menu. R196 stated she was told the doctor had to order a vegetarian diet and the food service was unable to serve beans in one portion for a resident because the packages are too big to be opened for one person. R196's lunch tray ticket showed she was provided a Regular diet with allergies to Lactose. The tray ticket showed notes which included Double Veg, Side Salad, Vegetarian and apple juice and large salad of the day with French dressing was written on the tray ticket. Attached to the tray ticket was a list of substitutions which included, Deli meat and Cheese, Tuna Salad, Egg Salad, Grilled Cheese, Peanut Butter and Jelly, Vegetable of the Day, Large Salad of the Day, Small Salad of the Day, Cottage Cheese with Fruit, and Bread. The substitution ticket included a hand written note of Potato salad on side, Apple Juice and the Large Salad of the Day was chosen. On December 3, 2024 at 12:05 PM, R196 brought her lunch tray back to her room, which had iceberg lettuce covering a lunch plate, with 4 slivers of tomato and 5 slivers of peeled cucumber on the iceberg lettuce. The lunch tray had French dressing, apple juice, approximately one cup of cooked spinach, and two cookies on the tray. R196's lunch tray ticket, dated December 3, 2024, showed R196 requested a large salad with French dressing, potato salad, and apple juice for lunch. The tray ticket shows R196 allergies included Lactose. R196 stated it was typical to receive a lunch with no protein items, not receive the food items she requested (such as the potato salad), and receive items she did not request such as the cooked spinach. R196 had a shelf stable carton of lactose free milk on her dresser and stated she received that carton at breakfast on December 3, 2024. R196 stated she was told by the facility that they only purchase beans in bulk and were unable to open a bulk package for only one resident who requested beans. R196 stated at one time, she was offered vegetarian burgers, which she agreed to receive, but never received them for meals. Review of R196's clinical record, dated November 28, 2023 to December 2, 2024, showed no documentation or a conversation between R196, V1, and V6 in March 2024. Review of R196's clinical record, including dietitian / food service notes, showed no documentation regarding R196's request for vegan food items or alternative protein sources, R196's food preferences, R196's allergy to milk products, or discussion of how to provide alternative sources of nutrients due to the elimination of all dairy and animal products. Review of the facility planned menu spreadsheets showed no vegan diet was planned and served at the facility. Review of Vegetarian (Lactose-Free) menu, provided by V7 on December 3, 2024 during the survey in attempts to begin providing R196 a planned vegan menu, shows R196 was planned to receive eggs at breakfast as well as egg salad and vegetable omelets on the weekly menus in spite of requesting vegan meals. On December 4, 2024 at 11:20 AM, V1 was made aware there were eggs on R196's newly-written vegan menu. V1 stated V6 told V1 vegetarians can have eggs on a vegetarian diet. V1 stated he understood R196 expressed she was clear that she did not want to consume any animal products. On December 3, 2024 at 12:54 PM, V6 (Corporate Dietitian) stated R196 was receiving a regular diet/texture. V6 stated she spoke with R196 when R196 was admitted , and then stated she may have touched based with R196 briefly. V6 stated she was confident the Food Service Manager prior to V7 would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 3 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have talked to R196. V6 stated resident food preferences should be adhered to within reason at the facility and some requests were not reasonable. V6 reviewed R196's clinical record and stated R196 did not have any dietary restrictions, but had a dairy intolerance. V6 then stated R196's intolerance was listed as a dairy allergy in the clinical record, so R196 should not be receiving any dairy products at all, but that she was receiving lactose free milk as an add on to her meal tickets. V6 then stated R196 did not have an official diet order for a vegan diet, and it was only a resident preference. V6 stated R196's tray ticket did show she was to receive double portions of the planned menu vegetables. V6 stated the tray ticket showed she was vegetarian. V6 stated she and R196 never spoke about having a vegetarian diet and, if they had, V6 would make sure she was meeting her protein goals. V6 stated if R196 did not consume dairy, V6 would look at other sources of protein to make sure she was meeting her protein goals. V6 was not sure if the facility offered a pre-planned vegetarian diet. V6 stated she would work with the company that planed the facility menus and the entrees they had to offer to add beans and create a vegan menu for R196. On December 3, 2024 at 1:11 PM, V7 (Food Service Director) stated she had not spoken to R196 in a long time. V7 stated when she did speak with R196, R196 asked for chick peas, but V7 told her the facility did not carry chick peas. On December 3, 2024 at 3:16 PM, V8 (Licensed Practical Nurse) stated she was aware R196 was vegetarian and R196 and V8 discussed the fact that they were both vegetarian. V8 stated R196 had a good appetite and ate all of her meals. On December 4, 2024 at 2:17 PM, V1 (Administrator) stated if a resident wished to adhere to a vegan diet, the facility should accomodate the resident request by providing the resident with a vegan diet. R196's Care plan, initiated November 29, 2023, shows, I have a nutritional problem or potential nutritional problem related to depression. R196's interventions include Provide, serve diet as ordered. Monitor intake and record every meal. The care plan fails to address R196's desire to adhere to a vegan diet at the facility. Review of V7 (Consultant Dietitian) initial admission nutrition assessment, dated November 29, 2023, shows no mention of R196 adhering to a vegan diet at the facility, and no changes to R196's diet were recommended. Review of subsequent nutrition notes in R196's clinical record, dated June 3, 2024 (significant weight loss note), July 2, 2024 (significant weight loss note), August 8, 2024, September 10, 2024 (Significant weight loss note), and November 12, 2024 showed no mention of R196's desire to adhere to a vegan diet or any attempts to discuss R196's diet preferences. Facility procedure Menu Planning and Requirements, dated 2022, shows 2. Menus are planned in advance and are varied for the same day of consecutive weeks. Cycle menus are to be planned for a minimum of one week or based upon specific state regulations 3. Planned menus take into consideration cultural backgrounds and food habits of residents 6. Deviations from the planned menu allow for individual nutrition based on nutritional or medical needs and/or resident requests. These deviations are indicated on a meal card or other communication tool for the serving staff 8. Regular and therapeutic menus are planned by a nutrition professional in accordance to the community's approved diet manual. The planned menus are reviewed and approved by a registered dietitian (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 4 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Facility Food Preferences procedure, dated 2020, shows, Dining Services Department will gather information upon admission to the facility regarding resident food preferences. Procedure: 1. Following admission to the community, and periodically as necessary, the Dining Services Manager, Registered Dietitian, or other designee will interview the resident to determine foods preferred and inform resident about meal services at the community. A form such as a Food Preferences Form may be used to document this information. Information should be appropriately logged in the meal card or preference tally and filled in the Dining Services department and/or the medical record according to facility practice 3.Residents are visited in a timely fashion after admission The goal is to complete the initial interview by the Dining Services Manager or Registered Dietitian within 72 hours of admission . 5. Resident food preferences are kept on file in the Dining Services Department as a part of the meal card system and used to ensure each resident's needs and desires are met . Event ID: Facility ID: 145830 If continuation sheet Page 5 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 0694 Provide for the safe, appropriate administration of IV fluids 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 implement their policy regarding care and management of implanted central venous catheter to prevent infection. Residents Affected - Few This applies to 1 of 1 (R26) reviewed for central venous catheter in the sample of 35. The findings include: The EMR (Electronic Medical Record) shows that R26, a [AGE] year-old with diagnoses that includes type 2 diabetes mellitus, foot ulcer, osteomyelitis, PVD (peripheral vascular disease), PD (Parkinson's Disease), and Schizophrenia. The MDS (Minimum Data Set) dated November 26,2024 showed that R26's cognition was intact with BIMS (Brief Interview for Mental Status) score of 15/15. The assessment also showed that R26 was identified with no behavior. The POS (Physician Order Sheet) shows a physician order dated December 2,2024 for R26 to have antibiotic medication of Vancomycin HCl Intravenous Solution 2000 MG/400ML (Vancomycin HCl) to be administered intravenously via the implanted central venous catheter. The Vancomycin 2 grams was for R26's sepsis of the foot ulcer. The care plan dated December 2,2024 showed that R26 was placed on Enhance Barrier Precautions during IV (intravenous) medications. On December 2, 2024, at 10:00 A.M., R26 was sitting in his wheelchair in his room. V3 (Infection Control Nurse) was also observed checking R26's central venous catheter. R26's central venous catheter was implanted to his right upper chest. V3 was noted making to fit an end cap to the entry/exit port of lumen central catheter. V3 said that the end cap was missing making the central venous catheter expose and no closed barrier to prevent entry of contaminants. V3 failed to apply the end cap and said she will look for an end cap that will fit and cover the exposed entry port of the lumen catheter. R26 said it must have been removed while I was asleep. V3 left R26's exposed entry port lumen catheter without applying a sterile barrier such as sterile gauze and prevent opportunity of entry for contaminants while V3 was locating an end cap that will fit the lumen catheter. On December 2,2024 at 10:30 A.M., V4 (Registered Nurse, assigned to R26) said that there was no end cap of R26's central venous catheter lumen catheter when V4 came in for her shift at around 7:00 A.M. V4 said she did not apply a sterile gauze to cover the exposed opening of the lumen central catheter. On December 4,2024 at 11:20 AM, together V2 (Director of Nursing), R26's central venous catheter was checked. V2 said that facility finally found an end cap to cover the entry/exit lumen catheter and entry of contaminants. The facility's policy for maintaining central venous catheter dated February 2009 showed: Guidance regarding specific intervals administration sets and tubing will be changed in order to prevent infections associated with IV therapy equipment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 6 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 0694 Level of Harm - Minimal harm or potential for actual harm 5. Change devices that are added to tubing such as extension sets, filters stopcocks, end caps, or any devices when tubing is changed. II. 2. A sterile end cap must be placed on the end of the intermittent tubing in between administrations. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 7 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident assessment was documented upon return to the facility after dialysis. Residents Affected - Few This applies to 1 of 1 (R109) residents reviewed for dialysis services in the sample of 35. R109's EMR (Electronic Medical Record) showed R109 was [AGE] years old and admitted to the facility on [DATE]. R109 had multiple diagnoses including end stage renal disease with dependence on hemodialysis, chronic obstructive pulmonary disease, unspecified asthma, schizophrenia, unspecified, history of falling, and essential hypertension. R109's care plan, dated November 5, 2024, showed R109 receives hemodialysis at the local dialysis center on Monday, Wednesday, and Friday. R109's care plan for dialysis was initiated on November 26, 2019, upon his admission to the facility. Review of R109's progress notes from November 1, 2024, through December 4, 2024, showed there was no documentation of a resident assessment upon return from dialysis. On December 4, 2024, at 1:30 PM,V2 (Director of Nursing/DON) stated documentation of assessment upon return from dialysis the nurse should assess the resident including vital signs and the condition of the fistula site and document the assessment on the MAR (Medication Administration Record). R109 has been receiving hemodialysis since his admission to the facility on November 26, 2019. Review of R109's October 2024 and November 2024 MAR showed there was no documentation of an assessment until November 26, 2024, when it was added to the record to document the assessment after dialysis. V2 stated that is all the documentation there is for R109's after dialysis assessment. The monitoring order for bruit and thrill of the fistula, each shift, was also not added to the record until November 26, 2024. On December 4, 2024, at 12:50 PM, V4 (Registered Nurse/RN) stated R109 has a fistula in his right forearm for dialysis access, and staff should not be taking a blood pressure from the right arm. V4 stated, If I ask the CNA (Certified Nursing Assistant) to take (R109's) blood pressure I would verbally tell the CNA not to take the blood pressure on the right arm, but I don't know what the other nurses do. V4 stated R109 should have a sign in his room so all staff know not to take the blood pressure from R109's right arm. V4 stated she was not sure where to document the after dialysis assessment upon R109's return from dialysis. The facility's policy titled Dialysis Monitoring and Observation, dated February 13, 2018, showed Monitoring .2. Document the presence or absence of the bruit and thrill on the MAR or TAR each shift .Documentation: 1. Obtain V/S (B/P and pulse at a minimum) following dialysis treatment. B/P to be done on the unaffected arm. 2. Assessment of the fistula site for presence or absence of bruit and thrill each shift. 3. Assessment of the dialysis catheter site for any signs of drainage and condition of the dressing to the site every shift. 4. Document and notify the physician of any signs or symptoms of complications observed during the assessment such as bleeding, swelling, infection, redness, and warmth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 8 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medications were obtained from the pharmacy in a timely manner to prevent residents from missing medication doses as ordered by the physician. This applies to 1 of 1 resident (R412) reviewed for pharmacy services in the sample of 35. The findings include: The EMR (Electronic Medical Record) showed R412 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, polycystic ovarian syndrome, Lyme disease, insomnia, and anxiety disorder. On December 2, 2024, at 10:18 AM, R412 said she was admitted to the facility on [DATE]. R412 continued to say she had not received her pregabalin since she was admitted to the facility. On December 3, 2024, at 12:25 PM, V9 (LPN/Licensed Practical Nurse) said the facility did not have R412's pregabalin, and V9 did not administer R412's pregabalin morning dose. V9 said medications are usually delivered within 24 hours of a resident being admitted , but R412's pregabalin was never delivered. V9 continued to say she would follow up with the facility's pharmacy right now. On December 3, 2024, at 12:44 PM, V9 said she contacted the facility's pharmacy and was told a prescription needed to be submitted by the physician for R412's pregabalin to be delivered. V9 said she would contact the physician. On December 5, 2024, at 11:25 AM, V17 (Pharmacy Technician) said R412's pregabalin was first delivered on December 4, 2024, at 4:30 AM. V17 said there were no other deliveries of R412's pregabalin. R412's November 2024 MAR (Medication Administration Record) showed R412 was to start receiving pregabalin on November 28, 2024, at 9:00 AM. Multiple nursing progress notes in the EMR, dated November 28, 29, and 30, 2024, and December 1, 2, and 3, 2024, showed R412's pregabalin was not available and not administered on those days. On December 4, 2024, at 11:47 AM, V2 (DON/Director of Nursing) said the facility should receive resident medications within 24 hours of the resident being admitted to the facility. V2 continued to say R412's pregabalin delivery should have been addressed as soon as the nurses saw the medication was unavailable. V2 said the nurses should have contacted pharmacy prior to December 3, 2024, to inquire about R412's pregabalin. The facility's policy titled Receiving Controlled Substances, dated August 2020, showed, Policy: Medications classified by the Drug Enforcement Administration as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and recordkeeping requirements by the facility in accordance with federal and state laws and regulations. Procedures: 1. The Director of Nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized, licensed nursing and pharmacy personnel have access to controlled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 9 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 substances. 2. Controlled substances prescribed for a specific resident are delivered to the facility only if a valid prescription has been received by the pharmacy prior to dispensing . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 10 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of interview and record review, the facility failed to ensure the the pharmacy was completing monthly MRR (Medication Regimen Review) for residents residing in the facility. The facility failed to provide documentation that showed residents identified as having irregularities on their monthly MRR were addressed by the physician. This applies to 4 of 5 residents (R54, R64, R70, R122) reviewed for monthly MRR (Medication Regimen Review) in the sample of 35. The findings include: 1. R54's EMR (Electronic Medical Record) showed R54 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disorder, dysphasia, unspecified mental disorder due to a physiological condition, altered mental status, schizoaffective disorder, schizophrenia, anxiety, and major depressive disorder. R54's MDS (Minimum Data Set), dated October 16, 2024, showed R54 had severe cognitive impairment. R54's Psych notes and Pharmacy notes were reviewed. R54's MRR (Medication Regimen Review) for February 2024 was completed between February 1, 2024 and February 22, 2024. There was a recommendation that showed R54 was taking Carvedilol 12.5 mg (for altered mental status, unspecified). The recommendation showed altered mental status was not an FDA (Food and Drug Administration) indication for this medication. V2 (Director of Nursing/DON) provided documentation that showed the appropriate indication for this medication was changed to secondary hypertension on October 14, 2024. R54 was missing his monthly MRR for April 2024. On December 3, 2024, at 11:38 AM, a list of residents identified for unnecessary medications was provided to V15 (Psychotropic Nurse) requesting the monthly MRRs and any irregularities and/or recommendations from January 2024 to present. On December 3, 2024, at 3:49 PM, V15 provided routine visit psychiatry progress notes and said what MRRs he gave us are all they for for each of the residents requested. On December 3, 2024, at 3:59 PM, V1 (Administrator) said they had changed to a new pharmacy in either August or October. V1 said the previous provider used to send emails with the MRRs. V1 said he will provide this information to the team in the morning ( December 4, 2024). On December 4, 2024, at 10:16 AM, V2 (DON/Director of Nursing) and V15 (Psychotropic Nurse) were asked again for MRRs and any irregularities/ recommendations that were made. Request was made for the emails V1 said he had received from the previous pharmacy provider. V2 and V15 said what they have provided what MRR and irregularity/recommendation records they have for the residents requested. R54's MRR (Medication Regimen Review) for February 2024 was completed between February 1, 2024 and February 22, 2024. There was a recommendation that showed R54 was taking Carvedilol 12.5 mg (for altered mental status, unspecified). The recommendation showed altered mental status was not an FDA (Food and Drug Administration) indication for this medication. V2 (DON) provided documentation that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 11 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some showed the appropriate indication for this medication was changed on October 14, 2024. R54 was missing his monthly MRR for April 2024. 2.R122's EMR (Electronic Medical Record) showed R122 was admitted to the facility on [DATE], with multiple diagnoses including, toxic encephalopathy, type 2 diabetes, bipolar disorder, unspecified dementia, long term use of insulin, neuromuscular dysfunction of the bladder and hyperlipidemia, unspecified. Review of R122's medication regimen review notes showed the review did not occur monthly. R122 medication regimen review did not occur in the months of February 2024 and April 2024. In addition, R122 had a notation on the pharmacy recommendations for the regimen review dated September 17, 2024, that irregularities were noted, see recommendation. The completion of this recommendation was unable to be validated. After multiple requests on December 3, and 4, 2024, to V15 (Psychotropic Nurse), V2 (DON) and V1 (Administrator), the facility failed to provide documentation of pharmacy recommendation or the follow up. 3. R64's EMR showed R64 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, unspecified mood disorder, other asthma, essential hypertension, chronic pulmonary edema, cellulitis of the left lower limb, venous insufficiency, chronic, peripheral, anxiety disorder, overactive bladder, and morbid obesity(severe) with alveolar hypoventilation. R64's records show R64 did not have a medication regimen review monthly. R64's record showed R64 was not reviewed during the months of February 2024, and April 2024. 4. R70's EMR showed R70 was [AGE] years old and had been admitted to the facility on [DATE]. R70 was admitted with multiple diagnoses including schizoaffective disorder, bipolar disorder, other abnormalities of gait and mobility, generalized anxiety disorder, abnormal posture, and chronic peripheral venous insufficiency. R70's records show R70 did not have a medication regimen review completed monthly. R70's record showed R70 was not reviewed during the months of February 2024 and April 2024. On December 4, 2024, at 3:00 PM, V2 (DON) stated the consulting pharmacist completes the medication regimen review monthly and emails the recommendations and reviews to V2, and V1. V2 stated the recommendations are to be followed up and the records retained. The facility policy titled Consultant Pharmacist Services Provider Requirements, dated August 2020, showed Policy .The facility ensures regular and reliable consultant pharmacist services are provided to residents 6. Specific activities that the consultant pharmacist performs may include, but are not limited to: a. Reviewing the medication regimen (medication regimen review) of each resident at least monthly, or more frequently under certain conditions .incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review, and documenting the review and findings in the resident's medical record or in a readily retrievable format if utilizing electronic documentation 7a .The facility has a process to ensure that the findings are acted upon. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 12 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 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 prepare and follow a vegan and dairy free diet for a resident who adhered to a vegan diet and who was allergic to dairy. Residents Affected - Few This applied 1 of 1 (R196) reviewed for vegan diet menus in the sample of 35. The findings include: POS (Physician Order Sheet), printed December 4, 2024, shows R196's diagnoses included major depressive disorder, suicidal ideations, and personal history of suicidal behavior. The POS shows R196's diet order, ordered 11/28/23, shows General diet, Regular texture, Regular consistency. The POS shows, Allergies: Dairy Products. On December 4, 2024 at 10:10 PM with V1 (Administrator) present, R196 stated she was upset she was made to drink milk because she had no other protein sources in the diet served to her by the facility. R196 stated she chose to be vegan over 20 years prior, and was vegan when she was admitted to the facility a year ago. R196 stated in March of 2024, she spoke with V6 (Corporate Dietitian) via teleconference with V1 (Administrator) present in V1's office. R196 stated they discussed vegan protein options to be served to R196 because R196 was not receiving enough protein at meals. R196 stated she was told by V1 and V6 they would provide veggie burgers, but R196 never received them. R196 stated the night prior, two nurses entered her room and insisted she could take a lactaid pill so that she could consume dairy products. R196 stated she told the nurses she was not only lactose intolerant, but that she had a cow's milk allergy, and the rash on the back of her neck was the result of consuming cow's milk in addition to her nasal congestion. R196 stated she felt like she was forced to drink the cow's milk because she was not receiving any adequate protein sources in her diet. R196 told V1 she had reactions to cows milk as a child and was told by her doctor to eliminate it because it was causing rashes, congestion, and other symptoms. On December 2, 2024 at 11:30 AM, R196 had a (lactose free) milk sitting on the dresser in room and stated she has to drink the (lactose free) milk at the facility because otherwise she would not have any other sources of protein. R196 stated she also needed to eat cheese at the facility for a protein source because the facility does not provide an alternate source of protein at meals. On December 2, 2024 at 12:33 PM, R196 received her lunch tray which consisted of plain noodles, 1 serving approximately 1/2 cup of green beans, bowl of lettuce with tomato, and a 1 piece frosted cake. R196 stated, This is typical. No protein. I used to be dairy free, but I can't be here because I wouldn't get any proteins. I drink (lactose free milk), but I break out into a rash behind my neck because I am allergic to milk. R196 stated she does not want to eat animal products for moral/ethical reasons due to her love for animals. R196 stated stated she has high cholesterol and when she eats a plant-based diet, her high cholesterol resolves. R196 stated when she stops eating dairy her rashes also resolve. Stated she has talked to V6 (Corporate Dietitian) and V7 (Dietary Manager), and filled out her menus based on what was available on the regular menu and the substitution menu. R196 stated she was told the doctor had to order a vegetarian diet and the food service was unable to serve beans in one portion for a resident because the packages are too big to be opened for one person. R196's lunch tray ticket showed she was provided a Regular diet with allergies to Lactose. The tray ticket showed notes which included Double Veg, Side Salad, Vegetarian and apple juice and large salad of the day with French dressing was written on the tray ticket. Attached to the tray ticket was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 13 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 - Few list of substitutions which included, Deli meat and Cheese, Tuna Salad, Egg Salad, Grilled Cheese, Peanut Butter and Jelly, Vegetable of the Day, Large Salad of the Day, Small Salad of the Day, Cottage Cheese with Fruit, and Bread. The substitution ticket included a hand written note of Potato salad on side, Apple Juice and the Large Salad of the Day was chosen. On December 3, 2024 at 12:05 PM, R196 brought her lunch tray back to her room which had iceberg lettuce covering a lunch plate with 4 slivers of tomato and 5 slivers of peeled cucumber on the iceberg lettuce. The lunch tray had French dressing, apple juice, approximately one cup of cooked spinach, and two cookies on the tray. R196's lunch tray ticket, dated December 3, 2024, showed R196 requested a large salad with French dressing, potato salad, and apple juice for lunch. The tray ticket shows R196 allergies included Lactose. R196 stated it was typical to receive a lunch with no protein items, not receive the food items she requested (such as the potato salad), and receive items she did not request such as the cooked spinach. R196 had a shelf stable carton of lactose free milk on her dresser and stated she received that carton at breakfast on December 3, 2024. R196 stated she was told by the facility that they only purchase beans in bulk and were unable to open a bulk package for only one resident who requested beans. R196 stated at one time she was offered vegetarian burgers which she agreed to receive but never received them for meals. Review of R196's clinical record, dated November 23, 20233 to December 2, 2024, showed no documentation or a conversation between R196, V1, and V6 in March 2024. Review of R196's clinical record, including dietitian / food service notes, showed no documentation regarding R196's food preferences, R196's request for vegan food items or alternative protein sources, R196's allergy to milk products or discussion of how to provide alternative sources of nutrients due to the elimination of all dairy and animal products. On December 3, 2024 at 12:54 PM, V6 (Corporate Dietitian) stated R196 was receiving a regular diet/texture. V6 stated she spoke with R196 when R196 was admitted , and then stated she may have touched based with R196 briefly. V6 stated she was confident the Food Service Manager prior to V7 would have talked to R196. V6 stated resident food preferences should be adhered to within reason at the facility and some requests were not reasonable. V6 reviewed R196's clinical record and stated R196 did not have any dietary restrictions but had a dairy intolerance. V6 then stated R196's intolerance was listed as a dairy allergy in the clinical record, so R196 should not be receiving any dairy products at all, but that she was receiving lactose free milk as an add on to her meal tickets. V6 then stated R196 did not have an official diet order for a vegan diet, and it was only a resident preference. V6 stated R196's tray ticket did show she was to receive double portions of the planned menu vegetables. V6 stated the tray ticket showed R196 was vegetarian. V6 stated she and R196 never spoke about having a vegetarian diet and, if they had, V6 would make sure she was meeting her protein goals. V6 stated if R196 did not consume dairy, V6 would look at other sources of protein to make sure she was meeting her protein goals. V6 was not sure if the facility offered a pre-planned vegetarian diet. V6 stated she would work with the company that planed the facility menus and the entrees they had to offer to add beans and create a vegan menu for R196. On December 3, 2024 at 1:11 PM, V7 (Food Service Director) stated she had not spoken to R196 in a long time. V7 stated when she did speak with R196, R196 asked for chick peas, but V7 told her the facility did not carry chick peas. On December 4, 2024 at 2:17 PM, V1 (Administrator) stated if a resident wished to adhere to a vegan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 14 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 diet, the facility should accommodate the resident request by providing the resident with a vegan diet. Level of Harm - Minimal harm or potential for actual harm Review of the facility planned menu spreadsheets showed no vegan diet was planned and served at the facility. Residents Affected - Few Review of V7 (Consultant Dietitian) initial admission nutrition assessment, dated November 29, 2023, shows no discussion of which planned menu the facility would follow to meet her diet considerations. Review of subsequent nutrition notes in R196's clinical record, dated June 3, 2024 (significant weight loss note), July 2, 2024 (significant weight loss note), August 8, 2024, September 10, 2024 (Significant weight loss note), and November 12, 2024 showed assessment of R196's vegan diet adherence or diary allergy, and no discussion of which planned menu the facility would follow to meet her diet considerations. R196's Care plan, initiated November 29, 2023, shows, I have a nutritional problem or potential nutritional problem related to depression. R196's interventions include Provide, serve diet as ordered. Monitor intake and record every meal. The care plan fails to show a planned menu that will be followed to ensure R196 was able to adhere to her vegan diet and avoid her dairy allergen. Facility procedure Menu Planning and Requirements, dated 2022, shows Menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served (based on age, size, gender, physical activity, and state of health), in accordance with the Dietary Reference intakes/Recommended Dietary Allowances as issued by the Food and Nutrition Board of the National Research Council, of the National Academy of Sciences, unless otherwise contraindicated by medical conditions and needs 2. Menus are planned in advance and are varied for the same day of consecutive weeks. Cycle menus are to be planned for a minimum of one week or based upon specific state regulations 3. Planned menus take into consideration cultural backgrounds and food habits of residents 6. Deviations from the planned menu allow for individual nutrition based on nutritional or medical needs and/or resident requests. These deviations are indicated on a meal card or other communication tool for the serving staff 8. Regular and therapeutic menus are planned by a nutrition professional in accordance to the community's approved diet manual. The planned menus are reviewed and approved by a registered dietitian (D). Facility document Vegetarian Diet, dated 2022, shows, The Vegetarian Diet is for individuals that desire to avoid animal products. This may be based on personal, religious or cultural beliefs With the proper selection of foods, the Vegetarian Diet may meet the current Dietary Reference Intakes/Recommendation Dietary Allowances/Adequate Intakes, Food and Nutrition Board, Institute of Medicine, National Academy of Science, 2011 for individuals ages 31 years and older. Based on the type of vegetarian diet consumed, supplementations with vitamins, especially Vitamin D and Vitamin 12, and minerals, especially iron, zinc, and calcium, may need to be added 2. An individual assessment and diet history is vital to assure that nutrient needs can be met with the Vegetarian diet 4 It is important that enough carbohydrate be consumed for energy, so that protein can be used for maintenance and repair, versus energy needs. This is especially important for individuals following the Vegan or Total Vegetarian Diet. 5. Plant proteins alone can provide adequate amino acids when a variety of plant proteins are eaten throughout the day and there is enough carbohydrate for energy 6. Encourage good sources of iron. Iron in plants is not readily absorbed as that in meats. To increase iron absorption, include foods rich in Vitamin C in the same meal with iron containing foods. 7. Vegans with limited (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 15 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 exposure to sunlight may need Vitamin D supplements. 8. Encourage good sources of zinc: tofu, nuts, seeds, beans, whole grain cereals and eggs Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 16 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to eliminate a known dairy allergen from a resident's diet at the facility. This applies to 1 of 2 residents (R196) reviewed for food allergies in the sample of 35. The findings include: POS (Physician Order Sheet), printed December 4, 2024, shows R196's diagnoses included major depressive disorder, suicidal ideations, and personal history of suicidal behavior. The POS shows R196's diet order, ordered November 11, 2023, shows General diet, Regular texture, Regular consistency. The POS shows, Allergies: Dairy Products. R196's Care plan documents, I am allergic to dairy (Date initiated March 7, 2024). Ensure allergy is noted on MAR (Medication Administration Record), TAR (Treatment Administration Record), tray care and [NAME]. Notify nurse of allergic reaction symptoms, such as shortness of breath, rash, itching, swelling and redness. On December 2, 2024 at 11:30 AM, R196 had (lactose free) milk sitting on the dresser in room, and stated she has to drink the (lactose free) milk at the facility, because otherwise she would not have any other sources of protein. R196 stated she also needed to eat cheese at the facility for a protein source, because the facility does not provide an alternate source of protein at meals. R196 demonstrated a rash on back of neck and stated it was caused by consuming milk products to which she is allergic, and the result was a rash, like the rash on the neck. R196 stated she was also lactose intolerant, so the facility gave her lactose free milk. On December 4, 2024 at 10:10 PM with V1 (Administrator) present, R196 stated she was upset she was made to drink milk because she had no other protein sources in the diet served to her by the facility. R196 stated she felt like she was forced to drink the cow's milk because she was not receiving any adequate protein sources in her vegan diet because she was not provided high quality vegan protein sources. R196 stated in March of 2024, she spoke with V6 (Corporate Dietitian) via teleconference with V1 (Administrator) present in V1's office. R196 stated they discussed vegan protein options to be served to R196 because R196 was not receiving enough protein at meals, but R196 never received the options discussed. V1 stated V1 did not remember that conversation. R196 stated the night prior, two nurses entered her room and insisted she could take a (lactose free) pill so that she could consume dairy products. R196 stated she felt unheard, powerless, and like the staff were patronizing her. R196 stated she told the nurses she was not only lactose intolerant, but that she had a cow's milk allergy, and the rash on the back of her neck was the result of consuming cow's milk, in addition to her nasal congestion. R196 told V1 she had reactions to cows milk as a child and was told by her doctor to eliminate it because it was causing rashes, congestion, and other symptoms. On December 2, 2024 at 12:33 PM, R196 received her lunch tray which consisted of plain noodles, 1 serving approximately 1/2 cup of green beans, bowl of lettuce with tomato, and a 1 piece frosted cake. R196 stated, This is typical. No protein. I used to be dairy free, but I can't be here because I wouldn't get any proteins. I drink (lactose free milk), but I break out into a rash behind my neck because I am allergic to milk. R196 pulled back the hair on her neck to show a rash of approximately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 17 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few two inches in diameter. R196 stated when she stops eating dairy her rashes resolve. R196 stated she does not want to eat animal products for moral/ethical reasons due to her love for animals. R196 stated stated she has high cholesterol, and when she eats a plant-based diet, her high cholesterol resolves. Stated she has talked to V6 (Corporate Dietitian) and V7 (Dietary Manager) and filled out her menus based on what was available on the regular menu and the substitution menu. R196's lunch tray ticket showed she was provided a Regular diet with allergies to Lactose. On December 3, 2024 at 12:05 PM, R196 had a shelf stable carton of lactose free milk on her dresser and stated she received that carton at breakfast on December 3, 2024. R196 brought her lunch tray back to her room which had iceberg lettuce covering a lunch plate with 4 slivers of tomato and 5 slivers of peeled cucumber on the iceberg lettuce. R196's lunch tray ticket, dated December 3, 2024, showed R196 allergies included Lactose. R196 stated it was typical to receive a lunch with no protein items. Review of R196's clinical record, dated November 28, 2023 to December 2, 2024, showed no documentation or a conversation between R196, V1, and V6 in March 2024. Review of R196's clinical record, including dietitian / food service notes, showed no documentation regarding R196's dairy allergy. Review of the facility planned menu spreadsheets showed no vegan diets were pre-planned at the facility. The menus showed milk was served at breakfast and dinner at every milk on the General/Regular diets in addition to foods prepared with dairy products. On December 3, 2024 at 12:54 PM, V6 (Corporate Dietitian) stated R196 was receiving a regular diet/texture. V6 stated she spoke with R196 when R196 was admitted , and then stated she may have touched based with R196 briefly. V6 stated she was confident the Food Service Manager prior to V7 would have talked to R196. V6 stated resident food preferences should be adhered to within reason at the facility, and some requests were not reasonable. V6 reviewed R196's clinical record and stated R196 did not have any dietary restrictions, but had a dairy intolerance. V6 then stated R196's intolerance was listed as a dairy allergy in the clinical record, so R196 should not be receiving any dairy products at all, but that she was receiving lactose free milk as an add on to her meal tickets. V6 then stated R196 did not have an official diet order for a vegan diet and it was only a resident preference. V6 stated R196's tray ticket did show she was to receive double portions of the planned menu vegetables. V6 stated the tray ticket showed R196 was vegetarian. V6 stated she and R196 never spoke about having a vegetarian diet and, if they had, V6 would make sure she was meeting her protein goals. V6 stated if R196 did not consume dairy, V6 would look at other sources of protein to make sure she was meeting her protein goals. V6 was not sure if the facility offered a pre-planned vegetarian spread sheet. On December 3, 2024 at 1:11 PM, V7 (Food Service Director) stated she had not spoken to R196 in a long time. V7 stated when she did speak with R196, R196 asked for chick peas, but V7 told her the facility did not carry chick peas. Review of V7 (Consultant Dietitian) initial admission nutrition assessment, dated November 29, 2023, shows no discussion of accommodating R196's dairy allergy. Review of subsequent nutrition notes in R196's clinical record, dated June 3, 2024 (significant weight loss note), July 2, 2024 (significant weight loss note), August 8, 2024, September 10, 2024 (Significant weight loss note), and November 12, 2024 showed assessment of R196's vegan diet adherence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 18 of 19 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 145830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care West Chicago 201 West North Avenue West Chicago, IL 60185 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 0806 or diary allergy, and no discussion of accommodating R196's dairy allergy. Level of Harm - Minimal harm or potential for actual harm Facility document Allergy Diets, dated 2022, shows, Nutrition Adequacy: With proper selection of foods, the Diet for Allergy or Food Intolerance meets the current Dietary Reference Intakes/Recommended Dietary Allowances/Adequate Intakes, Food and Nutrition Board, Institute of Medicine, National Academy of Science, 2011 for individuals ages 31 years and older. Based on the individual's food allergy or specific food intolerance, the diet may need to be individualized and possibly supplemented with vitamins and or minerals . 1. The Diet for Allergy of Food Intolerance is planned using the menu components as outlined in Section 1 Guidelines for Meal Planning. 2. A thorough diet history and assessment, the individualized meal planning is important as persons may vary greatly in the severity and symptoms resulting from a food intolerance or allergy A food intolerance may allow some intake of the offending food. Complete avoidance of the specific offending food is the only way to avoid a reaction for a food allergy Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145830 If continuation sheet Page 19 of 19