Inspection·August 18, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Corporate Nurse. V30 said that R67's elopement care plan should be updated when he returned to the facility on 7/10/23. Facility's policy on Comprehensive care plan indicates: Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences and services that are to be furnished to attain or maintain the resident's highest practicable physical mental and psychosocial well-being. Guidelines: * The care plan should be revised on an ongoing basis to reflect changes in the resident and the care plan the resident is receiving. Facility's policy on Fall prevention Program indicates: Purpose: To assure the safety of all residents in the facility ,when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality assurance program will monitor the program to assure ongoing effectiveness. Guidelines: *Care plan incorporated: -Interventions are changed with each fall, as appropriate Facility's policy on Code pink-Missing resident/Elopement indicates: Guidelines: 4. Upon return of the resident to the facility, the DON or charge nurse should: Complete a new elopement risk assessment and update plan of care as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 2 of 12 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement its policy on fall prevention and risk for elopement management by failure to provide adequate supervision and monitoring to residents who are at high risk for falls and at high-risk elopement . This deficiency affects all three (R10 , R52 and R67) residents in the sample of 22 reviewed for Resident Safety. Findings include: R67 is admitted on [DATE] with diagnosis listed in part but not limited to Major Depression, Dementia, Schizophrenia. R67's care plan indicated that he is at risk for elopement. R67 is included in the list of residents who are at risk for elopement and on safety checks monitoring every 30 minutes. On 8/15/23 at 8:55am, Observed R67 lying in bed. He admitted that he eloped from the facility last month but would not like to talk about it. On 8/15/23 at 11:05am, V11 Former Employee said that she was suspended for not monitoring and documenting safety monitoring checks every 30 minutes to R67. V11 said that she did not have time to document and supervise because of short of staff on 7/2/23. She said that she has to take care of 24 residents by herself. She said that they have more than 40 residents in the 1st unit and there were only 2 CNAs instead of 3 to 4 CNAs on 7-3 shift. She said that last time she saw R67 was around 1:30 after lunch. She said that R67 usually goes to smoking area after lunch. V11 said that she was told that per surveillance camera R67 left the building via 2nd unit smoking area patio door at 1:36pm. R67 is on monitoring for high risk for elopement every 30 minutes. V11 said that V21 Dietary aide discovered R67 is missing during dinner time around 5:00pm. On 8/15/23 at 10:00am, V1 Administrator said that they discovered R67 missing on 7/2/23 around 3:30pm. R67 usually has his smoking scheduled at 2:30pm. Staff noticed that he did came back from smoking around 3:30pm. The surveillance camera indicated that he left the building from 2nd unit smoking patio before 2:00pm. She said that V17 LPN called her, V2 DON, and Police officer. V1 said on her way to the facility she saw R67 at sitting at the bus station by around 147th and Kedzie. V1 said she called and approached him, but he walked away. V1 said she called police for assistance. The police officer able to convince R67 to get in the police care and transported back to the facility. V1 said R67 was assessed by V17 LPN and no injury was observed. R67 was sent out to the hospital with petition for psych evaluation and was admitted . V1 cannot recall the time that R67 returned to the facility and was sent out to the hospital. Informed V1 that R67's incident report documented by V2 DON indicated that R67 was unable to be located in the building at 5:00pm for dinner and R67's progress notes documented by V17 LPN indicated that R67 was sent to the hospital and was picked up by ambulance at 9:30pm. V1 denied documentation of V2 DON and V17 LPN. V1 said that she does not have written narrative report of investigation done but presented actual elopement procedure checklist dated 7/2/23 at 5:00pm, Quality assurance meeting minutes not dated, and invoice from vendor who repair the disarmed door dated 7/5/23. On 8/16/23 at 10:36am, V10 [NAME] said that she worked double shift on 7/2/23. V10 said that V21 Dietary Aide noticed around 5:00 to 5:30pm that R67 was not in the dining room for dinner. V10 said that V21 went to R67's room but unable to locate. V21 brought his tray to V17 LPN and informed that R67 was not in the dining room and in his room. V10 said that she left the facility around 8pm. V10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 3 of 12 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 0689 heard that the staff able to locate R67 and brought back to the facility. Level of Harm - Minimal harm or potential for actual harm On 8/16/23 at 11:02am, V15 LPN said that R67 is at high risk for elopement. R67 had history of attempted to leave the facility twice, last year and recently on 7/2/23. R67 is on safety monitoring checks every 30 minutes. V15 said that she worked on 7//2/23 at 1st unit on 7-3 shift, but she has to leave early around 2:10pm. She endorsed the 1st unit to V22 RN, the nurse assigned to 2nd unit and gave the keys. V15 said that the last time she saw R67 was around 1:30pm after lunch. R67 usually goes to 2nd unit smoking patio to smoke after lunch. Residents Affected - Few On 8/16/23 at 11:21am, V17 LPN said that he worked on 7/2/23 at 3-11 shift and was the assigned nurse for R67. Review with V17 his documentation on R67's progress notes late entry effective date 7/2/23 8:30pm indicated: When writer was aware that resident made an unauthorized exit from the facility, a police report was initiated. 2 police officers came into the facility and a report was made. Within 20 minutes after the police officers left, resident was spotted by the officers and was brought back to the facility. When this writer called the psych doctor to inform him of the unauthorized exit made by the resident, the psych doctor gave an order to petition resident to the hospital whenever he found and brought back to the facility. Complete body assessment done; no injuries noted. Write called hospital emergency room and gave them report. Ambulance called and was given an estimated time of arrival of 60 minutes. 2 ambulance staffs came at 9:30am and resident left on a stretcher to the hospital. V17 LPN said that he received endorsement from V15 LPN (7-3 shift) and made his rounds. V17 said that he noticed that R67 is not in his room, not in the dining room or in smoking area. V17 said that he announced for code pink (resident elopement) at 3:30pm. Informed V17 that surveyor had interviewed with V15 LPN and said that she left early on 7/2/23 at 2:10pm. Then V17 changed his statement that he got the keys from V22 RN from 2nd unit and did not receive any report. On 8/16/23 at 1:54pm, V2 DON said that she did the unauthorized leave/elopement incident report on 7/2/23. Review R67's incident report dated 7/2/23 at 6:06pm indicated: Resident was unable to be located in the building at 5:00pm for dinner. Code pink (resident elopement) called. Staff searched throughout the facility. Unable to locate resident. Notified administrator and police. Notified sister. When resident returned, ordered was obtained to send resident to hospital for further evaluation. Resident was located on Kedzie and 147th street. No injuries observed at time of incident. Agencies/people notified: V23 Psychiatrist notified at 5:27pm, V23 Primary Care Physician notified at 8:32pm, V1 Administrator notified at 5:10pm, V25 local police notified at 5:32pm and V2 DON notified at 5:05pm. V2 DON said that the elopement investigation/root cause analysis is done by V1 Administrator and herself. V2 said that the incident report is usually discussed with IDT team (Administrator, DON, Restorative Nurse, Social Service and Care plan Coordinator) and formulated new intervention to prevent elopement re-occurrence. V2 said that V30 Care plan coordinator will update the elopement care plan after elopement re-occurrence and when R67 returned from the hospital. Surveyor asked V2 DON who will update the elopement risk assessment. V2 said that she cannot answer and has to review the policy. On 8/16/23 at 2:00pm, Review with V2 DON the elopement procedure /actual elopement form for R67 indicated: Date- 7/2/23 Time 5:00pm. V2 said that R67 able to get out from the from the 2nd unit smoking patio because the door was disarmed after the power outage in the building a day before the incident happened. The door was not reset after the power outage. Review R67's safety checks every 30 minutes documentation on 7/2/23. V2 said that V11 Former Employee who worked with R67 did not document safety checks monitoring during her shift from 7am to 3:00pm on 7/2/23. V2 said that V26 CNA (worked on 3-11 shift) documented safety checks monitoring done to R67 from 3:00pm to 8:00pm. V2 said that when resident is on safety check monitoring, she expected the staff to physically monitor the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 4 of 12 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident and document as well. V2 said suspended V11 Former employee for not monitoring and documenting safety check for R67 and reprimanded V26 CNA for documenting task not was not performed. R67 was discovered missing around dinner time, 5pm. V2 is aware that there are only 1 nurse who left at 2:10pm and 2 CNA assigned on 1st unit. Review V26 CNA 's notice of corrective action dated 7/6/23 indicated: the above employee failed to do initial rounds at the beginning of the shift . On 8/17/23 at 10:19am, V2 DON said that Risk for elopement assessment is done upon admission, quarterly, annually, significant change and after each elopement incident. The care plan should be updated after each elopement incident. Informed V2 that R67's elopement risk assessment was completed on 7/18/23 by V18 Medical Record. R67's elopement care plan was not updated when R67 returned from the facility on 7/10/23 after hospitalization following elopement incident. R67's elopement care plan is only updated by V31 Corporate nurse on 8/15/23 when surveyor ask for copy of the care plan. On 8/17/23 at 10:30am, Review 2nd unit smoking patio door repair invoice with V1 Administrator dated 7/5/23 indicated: Description- Troubleshoot power loss at mag-locks. Found transformer unplugged in the med closet. V1 said the housekeeping trying to reset the alarm patio door forgot to plug back the transformer. On 8/17/23 at 11:13am, V30 Care plan coordinator said that elopement care plan is updated when the resident return to the facility. R67 was sent out to the hospital on 7/2/23 after an elopement incident and returned to hospital on 7/10/23. Review R67's elopement care plan with V30. R67's care plan is not updated until 8/15/23 when asked for copy of the care plan. V30 said that it was updated by V31 Corporate Nurse. On 8/15/23 at 9:20am, Observed R10 propels himself on wheelchair. R10 said that he has tremors due to his Parkinson's disease. On 8/16/23 at 11:32am V3 Restorative Nurse said that she is the Fall Coordinator and does the fall investigation with V2 DON. V3 said that the floor nurse will do the fall incident report and fall assessment after each fall. V3 said that her and V2 DON will do the fall investigation/root cause analysis. The fall incident is reviewed by IDT and formulate new intervention after each fall incident to prevent fall re-occurrence. Review R67's medical records with V3. R10 is admitted on [DATE] with diagnosis listed but not limited to Parkinson's disease, Difficulty in walking, Lack of coordination, Abnormality of gait and mobility, Unsteadiness on feet, Weakness, Intervertebral disc degeneration lumbar region. admission fall assessment done indicated he is at high risk for fall. Review R10's fall incidents for 2023 with V3 indicated: 1) 2/5/23- witnessed fall in his room; 2) 2/15/23- unwitnessed fall in the hallway; 3) 2/18/23- unwitnessed fall in his room; 4) 4/12/23- unwitnessed fall in his room; 5) 4/17/23- witnessed fall in his room; 6) 4/19/23- staff assisted/lowered to floor in his room; 7)5/9/23- unwitnessed fall in his room; 8) 6/15/23- unwitnessed fall in is room; 9) 7/16/23- unwitnessed fall in his room. V3 said that R10 has currently 9 fall incidents. Review all fall incidents and care plan updates with V3. Informed V3 that fall incidents occurred on 4/19/23 and 6/15/23 does not have updated fall care plan intervention. Review 7/16/23 fall investigation/root cause analysis presented by V3. Informed V3 that the fall investigation care plan intervention did not mirror the updated care plan intervention. V3 documented on fall investigation dated 7/16/23 indicated that R67 did not use call light for assistance from staff. R67 should be up in the dining room for all meals and activities for closer supervision. Medication regimen review by pharmacist and orient to call light system. R10's care plan intervention written for 7/16/23 indicated only medication regimen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 5 of 12 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 0689 review by pharmacist. Level of Harm - Minimal harm or potential for actual harm Facility's policy on Code pink- Missing Resident/Elopement indicated: Guidelines: Residents Affected - Few 1. All personnel are responsible for reporting a cognitively resident attempting to leave the premises or suspected of missing, to the charge nurse as soon as practical. This includes any resident that did not sign out on pass or did not notify a staff member of his or her leaving. 3. Should an employee discover that a resident is missing from the facility, he or she should: g) The Administrator and Director of Nursing (DON) will evaluate the situation and develop a plan action based on the individual resident. The following steps should occur: 7. Complete incident report and notify state agency according to the reporting guidelines. 8. Complete appropriate notations in the medical record 4. Upon return of the resident to the facility, the Director of Nursing or Charge Nurse should: 7) Complete the incident report, indicating, when resident returned and condition of resident 10) Complete a new elopement risk assessment and update plan of care as appropriate. Facility's policy on Incident and Accidents- Illinois Policy: The incident/accident report is completed for all unexplained bruises or abrasions, all accidents, or incidents where there is injury potential to result injury, allegations or theft and abuse registered by residents, visitors or other, and resident to resident altercations. Procedure: 1. An incident or accident report is to be completed by RN or LPN and is to include: a. Date and time of an incident /accident b. Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered and notification of appropriate parties. 5. All incident/accident reports are reviewed, signed, and investigated by: a. Administrator and b. DON or ADON Facility's policy on Fall prevention Program indicates: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 6 of 12 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 0689 Level of Harm - Minimal harm or potential for actual harm Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality assurance program will monitor the program to assure ongoing effectiveness. Residents Affected - Few Guidelines: *Care plan incorporated: -Interventions are changed with each fall, as appropriate Standards: * Safety interventions will be implemented for each resident identified at risk. *The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and in consistently maintained. *Accident/incident reports involving falls will be reviewed by the IDT team to ensure appropriate care and services were provided and determined possible safety interventions. On 8/17/2023 a care plan with R52 diagnosis indicates that R52 has a history of falling, cognitive social or emotional deficit following a cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, nicotine dependence, cigarettes, lack of coordination. A smoking safety risk assessment dated [DATE] indicates that R52 has a score of 4 the recommendation and outcome indicate that R52 requires supervision only (no assistance) with smoking and R52 is not able to store smoking materials. A fall incident log dated December 2022 indicates R52 had a fall on 12/2/2022 with no injury, 12/5/2022 no injury, 12/16/2022 no injury. A January 2023 incident log indicates R52 fell 1/8/2023 does not indicate an injury or not. A March 2023 incident log indicates R52 had a fall on 3/4/2023 with an injury to the head resulting in a hospital visit, on 3/23/2023 R52 had four falls with no injury, 3/25/2023 a fall no injury. An April 2023 incident log indicates R52 had a fall on 4/22/2023 with the incident type of B-behavior resulting in R52 being transported to the local emergency room hospital for an unwitnessed fall on the smoking patio. A progress note dated 4/22/2023 that R52 had an unwitnessed fall resulting in R52 being sent out to the emergency room hospital the symptoms had been deemed unable to determine. A care-plan dated on 4/22/2023 with an intervention of 2 persons with 1 person smoking monitor for closer supervision. A May 2023 fall on 5/23/2023 fall no injury. A June 2023 incident fall with no injury. A Resident smokers list dated 8/1/2023 indicates R52 is in a Behavior Group Smokes together and uses a smoking apron. On 8/18/2023 at 9:30am V32 (Behavioral Aide) said R52 is a high risk for falls and have a child like mind, he was at the end of the bench in his wheelchair during smoking break, V32 light R52 cigarette and then started lighting the other residents' cigarettes and V32 heard a noise and looked at the end of the bench and R52 was on the ground. V32 said R52 was moved to a smaller group because he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 7 of 12 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 0689 needed closer monitoring it was about 10-12 residents in the smoking group at the time R52 fell he was not having a behavior issue at that time of smoking. 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: 145947 If continuation sheet Page 8 of 12 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow physician order and implement care plan intervention of individual psychotherapy to residents who has diagnosis of psychiatric diagnosis. This deficiency affects all three (R4, R10 and R67) residents in the sample of 22 reviewed for Behavioral Health Services. Findings include: Random rounds made to all three residents (R4, R10 and R67) and did not observe participating in individual or group therapy. Review List of residents for psychotherapy from MPAC health care given by V1 Administrator. All three residents are not listed for the psychotherapy program. R4 is admitted on [DATE] with diagnosis listed in part but not limited to Depression disorders, Dementia, Schizophrenia, Anxiety disorder, Psychotic disorder with delusion due to known physiological condition. Physician order sheet indicated: May attend group or 1:1 psychological service. Care plan indicated: He has been diagnosed with psychiatric diagnosis and may benefit from individual therapy. He will be participating in weekly sessions with MPAC. R10 is admitted on [DATE] with diagnosis listed in part but not limited to Schizophrenia, Depression. Care plan indicated: He has been diagnosed with psychiatric diagnosis and may benefit from individual therapy. He will be participating in weekly session with MPAC. R67 is admitted on [DATE] with diagnosis listed in part but not limited to Major Depressive disorder, Dementia, Schizophrenia. Physician order sheet indicated: May receive psychological/group to reduce psych symptoms. Care plan indicated: He has been diagnosed with psychiatric diagnosis and may benefit from individual therapy. He will be participating in weekly session with MPAC. Review R4, R10 and R67's medical records and unable to found documentation of psychotherapy from MPAC. On 8/17/23 at 10:30am Informed V1 Administrator and V2 DON of unable to locate all three residents' documentation of psychotherapy services from MPAC as indicated in their physician order and care plan. Both said that it was not done. No psychotherapy services were provided. On 8/17/23 at 1:13pm Informed V2 DON of unable to locate all three residents' documentation of psychotherapy services from MPAC as indicated in their physician order and care plan. Both said that it was not done. No psychotherapy services were provided. On 8/18/23 at 12:18pm, V5 Social Service director (SSD) said that she does not know the complete name of the psychotherapy services that they utilize. She does not know what MPAC stands for. Informed of the above concerns to V5. She said that it may possibly contributed of short staff in psychotherapy services. V5 said that initially there are 2 psychotherapist who comes to the building but now only 1 therapist. Asked V2 DON for the MPAC meaning, but she does not know either. V5 said that she will call the psychotherapy services. On 8/18/23 at 12:34pm V5 SSD said that MPAC stands for Midwest Post Acute Healthcare. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 9 of 12 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 0740 Facility's policy on Behavioral Health Services (previously Behavior Management Program) indicates: Level of Harm - Minimal harm or potential for actual harm Purpose: To establish a system for identifying behaviors and implementing appropriate interventions consistent with the individualized plan of care and to ensure that each resident receive appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Residents Affected - Few Services: *Individual, group, and family psychotherapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 10 of 12 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to implement infection control protocol by failure to wear gloves when emptying urinal and removing gloves and perform handwashing after emptying urinal. This deficiency affects two (R16 and R72) of three residents in the sample of 22 reviewed for Infection control. Residents Affected - Few Findings include: On 8/15/23 at 7:46am, Observed V4 Activity Director wearing gloves holding disinfecting spray bottle and transparent garbage bag went resident's room to room in 2nd unit. V4 observed went to R16's room. V4 came out holding uncovered urinal with urine without gloves and going the men's bathroom. V4 said that she will dispose the urine in the bathroom. Surveyor asked if she should wear gloves when disposing urine. V4 said that she forgot to wear gloves, she said that should be wearing gloves when emptying urine from urinal. On 8/15/23 at 7:48am, Observed V9 CNA came out from R72's room wearing gloves on holding uncovered urinal with urine and went to the men's bathroom. From the bathroom she went back to R72's room to put back the urinal and came out to the room walking in the hallway with the same gloves. V9 said that she forgot to remove her gloves and wash her hands. On 8/15/23 at 7:53am, Informed V2 DON (Director of Nursing) of above observation. V3 said that staff should not be wearing gloves in the hallway. The staff should be removing their glove when coming out from the resident rooms. Staff should be wearing gloves when emptying urinal. Hand washing should be performed after removing gloves. Facility's policy on Hand hygiene/Hand washing indicates: Definition: Hand hygiene means cleaning your hands by using either hand washing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub ( i.e. alcohol-based hand sanitizer including foam or gel) Guidelines: Examples of when to perform hand hygiene ( either alcohol based hand sanitizer or handwashing) *After contact with blood , body fluids or excretions, mucous membranes, non-intact skin or wound dressings. Facility's policy on giving and removing urinal indicates: Purpose: To assist the resident with urinary elimination Procedure: 3, Wear gloves if resident is unable to place own urinal 10. Cover urinal to take to soiled utility room or empty in resident's toilet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 11 of 12 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 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Midlothian 3249 West 147th Street Midlothian, IL 60445 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 11. Cleanse urinal and return to bedside unit. Level of Harm - Minimal harm or potential for actual harm 12. Wash hands Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 12 of 12