Inspection·January 17, 2024

F 0600 asked if she could come for further interview for her statement. V9 agreed, but resigned later that day. Level of Harm - Actual harm Facility abuse prevention and reporting policy dated 11/28/16 documents: The facility affirms the right of residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. Abuse means any physical or mental injury inflicted in a resident other than by accidental means. Abuse is the willful infliction of injury, intimidation or punishment with resulting pain harm or mental anguish to the resident. Physical abuse is the infliction of injury that occurs other than by accidental means and requires medical attention. physical abuse includes hitting, slapping and controlling behavior through corporal punishment. Verbal abuse may be considered to be a type of mental abuse. Examples include but not limited to: mocking, insulting, ridiculing, yelling or hovering over a resident with the intent to intimidate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 follow their abuse policy by taking a resident's personal food item and sharing with other resident without the resident's consent. This affected one of three (R1) residents reviewed for misappropriation of property. Residents Affected - Few Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis, type II diabetes, muscle wasting, neuromuscular dysfunction of bladder, neurogenic bowel, bipolar disorder, and depressive disorder. R1's Minimum Data Set, dated [DATE] documents a brief interview for mental status score of 15/15 which indicates cognitively intact. On 1/5/24 at 1:00PM, R1 who was alert and oriented at time of interview said he was out at an appointment when his friend dropped off items for him. R1 said when he got to his room V7 (CNA) brought in two bags. One bag had tacos and other bag had shoes. There was nothing else in the bags. R1 talked to V13 (R1's friend) later to thank him for the items and learned he never received cookies, popcorn, and chips. V1 (Administrator) spoke to R1 with V7 who said items were never in the bags and denied getting the items. V7 was terminated. R1 was furious with the situation and said staff should not be taking his things. R1 said he will share pizza and other items with other residents but denies every giving V7 permission to share the items. R1 said he never even knew he received them, so how could he share them. R1's police report dated 10/13/23 documents the following: R1 requesting a theft report. V13 (R1's friend) dropped off food and personal items for R1 on 10/6/23. R1 was not at the facility when items were dropped off. Upon R1 returning R1 called V13 and thanked him for the items. That is when R1 discovered he never received popcorn, chips, and homemade cookies. V13 notified V1 of situation and they will be investigating the problem. Facility replaced bag of chips. After reviewing video footage V1 discovered a staff member (V7 CNA) took the items. V7 ate the popcorn at the start of the following shift she worked. The video showed she passed out the cookies to other residents. When V1 (Administrator) talked to R1 about it on day of complaint, V7 had claimed it wasn't me. V1 had purchased popcorn and cookies to make R1 less angry about incident, but he is still upset. V1 said, V7's employment with facility will be terminated due to her action. R1's facility reportable dated 10/11/23 documents under summary of witnesses/video surveillance: After reviewing video surveillance of the day, the following was able to be viewed: V3 (receptionist) can be seen receiving two bags from V13 (R1 friend). V3 gave the bags to V7 (CNA). V7 can be seen taking the bags towards R1's room and taking something out of the bag and placing it on the linen cart. V7 can be seen later exiting the resident room with two bags placing one bag in the trash can and other on top of the cart. V7 can be seen taking cookies out of the bag and entering resident's room. V7 can be seen taking an item from the linen cart and placing the item in the bag on top of the linen cart. V7 can be seen placing a bag inside the linen cart and later, the next shift, retrieving that same bag and going to the nursing station with it. V7 observed eating at nursing station and giving same bag to another resident. Under summary of interview with R1, dated 10/20/23: R1 was asked if he gave V7 permission to share cookies. R1 said he never knew he had cookies or popcorn before he spoke to V13 (R1's friend). R1 is alert and oriented x three. Under interview with residents: R9 said he received popcorn from V7. Under interviews with staff: during the initial contact 10/11/23 with R1 by V1 (Administrator) V7 was in the room. V7 was asked if she received items and she replied yes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V7 said she fed R1 tacos and placed shoes and chips in the nightstand. V7 went on to say, That was all in the bags and I did not see any popcorn or cookies in the bag. On 10/20/23, V7 said R1 gave her the cookies and popcorn to share with the other residents and did not initially report it because she did not want R1 to get upset. V7 said she does not have a good repour with R1 and he is always mean. Under summary of findings: After interviewing V7, she indicated she did not give R1 the popcorn, it was left at the facility for him. V7 continued to deny ever receiving popcorn in the bags. V7 can be seen giving another resident a brown bag with popcorn. After concluding the investigation, due to resident history of sharing snacks with coresidents, it cannot be determined if R1 asked staff to share items by residents. V13's statement undated documents: I am writing this letter to report theft of R1's food items. I arrived at facility at 4:30 on 10/6/23 to drop off items for R1. R1 was not available, and items were left with V3 (receptionist). V13 said he followed up with R1 on 10/10/23 and R1 thanked V13 for the tacos and shoes. V13 asked, what about the popcorn, chips, and cookies. R1 said he never received those items. Facility abuse prevention and reporting policy dated 11/28/16 documents: The facility affirms the right of residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. Misappropriation of property means the deliberate misplacement, exploitation or wrongful temporary or permanent use of the resident's belongings or money without the resident's consent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to follow their abuse policy by not immediately reporting an allegation of abuse for one resident (R2) for one of ten residents reviewed for abuse. Residents Affected - Few Findings include: On 1/10/24 at 2:33PM, V1 (Administrator) said she did not have or receive any allegations of abuse prior to surveyor reporting abuse. V1 said, Staff should immediately report any allegation of abuse to me immediately. Staff are given my card upon hire with my cell number to call if any concerns. Staff are trained on abuse upon hire, every 6 months and as needed. V1 said she has had two new hires, V8 (Certified nursing assistant, CNA) and V9 (CNA) for the month of January and they have had abuse reviewed with them during orientation. Facility reportable dated 1/9/24 documents: Surveyor reports that during investigation that someone alleged physical abuse toward R2 by V4 (CNA). On 1/9/24 at 12:08PM, V9 (CNA) said V9 did not feel comfortable telling on staff about incident on 1/5/24 because V4 has been working there for so long. V9 said abuse should be reported to V1(Administrator). On 1/9/24 at 11:49AM, V8 (Certified nursing assistant, CNA) was asked why she did not report the incident immediately to supervisor on 1/5/24. V8 said she did not want to get in trouble because V4 had worked at the facility a long time. V8 said she did not want to seem like she was snitching on staff. V8 said she received training on abuse in her paperwork she received. Facility reportable undated documents: V9 (CNA) was asked if she witness anything inappropriate with care standards. V9 stated, yes. V9 stated she did not report since she is a new employee and thought she would report it incorrectly. V9 was asked if she received abuse training upon hiring, V9 stated, yes, from the administrator. Facility abuse prevention and reporting policy dated 11/28/16 documents: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145947 If continuation sheet Page 5 of 5