Inspection·October 8, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of the assessment. Each department has a section they are responsible for. Surveyor inquired if V8 is responsible for checking the care plan after each department completes their section, V8 responded Yes. The (1/2023) baseline care plan policy states the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will be developed within 48 hours of the resident admission into the facility. The baseline care plan will include at a minimum the following necessary information to properly care for a resident. Activities of Daily Living needs. Supervision needs. The baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her current needs. Event ID: Facility ID: 145983 If continuation sheet Page 2 of 10 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 145983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya on 87th 2940 West 87th Street Chicago, IL 60652 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that care requirements are documented in the plan of care, failed to implement care plan interventions, and failed to provide timely ADL (Activities of Daily Living Care) to one of three dependent residents (R1) reviewed for quality of care. Residents Affected - Few Findings include: On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that a facility resident is often found soaked due to not being changed overnight. R1's (9/27/24) functional assessment affirms resident is dependent on staff for sit to stand, chair/bed to chair transfer, and toilet transfer. Dressing requires substantial/maximal assistance. R1's (9/23/24) care plan includes self-care deficit/impaired mobility, Intervention: provide peri-care after each incontinent episode. Elimination: assistance and instruction are given as required. [dressing assistance is excluded]. R1's (9/27/24) BIMS (Brief Interview Mental Status) determined a score of 9 (moderate impairment). On 10/2/24 at 9:49am, R1 was observed lying in bed and wearing a gown. Surveyor inquired why R1 was admitted to the facility, R1 stated I couldn't walk, and my blood pressure was low. I went to the hospital, and they told me I had a stroke. R1 affirmed that she now has left sided weakness and requires physical therapy. Surveyor inquired if R1 uses the toilet R1 responded I have a diaper on, I haven't been changed this morning at all. When I call them (staff) they take their time. Surveyor inquired when R1 was last checked or changed R1 responded It was probably after dinner and affirmed that she was not changed during the night. On 10/2/24 at 10:18am, surveyor inquired if R1's incontinence brief was changed this morning, V3 (Certified Nursing Assistant) stated I'm gonna get to her however failed to answer the question therefore surveyor requested to inspect R1's brief. V3 subsequently removed R1's brief and it was saturated with urine. Surveyor inquired about concerns with the appearance of R1's brief, V3 responded That she wet, that she's soiled? She's a heavy wetter. Surveyor inquired again if R1's brief was changed this morning, V3 replied This the first round, I'm still getting people up for dialysis and all kinda stuff. Surveyor inquired when V3's shift started, V3 stated 6:00 [over 4 hours prior]. Surveyor inquired about the required frequency for checking and/or changing incontinent residents, V3 responded I think it's every two hours. Surveyor inquired why R1 was lying in bed (after 10am), R1 responded They'll (staff) get me up when I go to therapy. The ADL policy (reviewed 5/2024) includes responsible party: all Nursing Personnel. Dressing: residents are given instructions and assistance as required. Elimination: assistance and instruction are given as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 3 of 10 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 145983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya on 87th 2940 West 87th Street Chicago, IL 60652 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to follow policy procedures, failed monitor blood glucose levels, failed to ensure that medication administration records include actual times for administration, failed to follow physician orders, and/or failed to ensure that medications/supplements were administered and documented within regulatory requirements for nine of thirteen residents (R1, R3, R5, R6, R7, R8, R9, R10) in the sample. The facility also failed to ensure that (R2's) Humalog was ordered and administered before meals, this failure resulted in R2's frequent blood glucose levels above 200. On 9/2/24, R2's blood glucose level was 399 (critical high). Residents Affected - Few Findings include: On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that medications are not administered at the facility as ordered and there's no set schedule for when medications are given. In addition, blood glucose and blood pressure are not being monitored at the facility. R2's diagnoses include type II diabetes mellitus and metabolic encephalopathy. R2's POS (Physician Order Sheets) include (4/2/24) blood glucose check before meals. (4/7/24) Humalog (Insulin) per sliding scale one time a day. R2's (September 2024) MAR (Medication Administration Record) affirms blood glucose level was above 200 on 9/1, 9/2, 9/3, 9/6, 9/8, 9/9, 9/11, 9/12, 9/13, 9/14, 9/16, 9/17, 9/18, 9/19, 9/22, 9/23, 9/25, 9/26, 9/27, and 9/29 [20 days]. R2's (9/2/24) 11:00am blood sugar was 399. On 10/8/24 at 12:12 pm, surveyor inquired if blood glucose checks are ordered before meals and a resident is prescribed Humalog how often should the Humalog be administered V11 (Medical Director) stated Usually whenever they check the blood sugar, it depends on how the physicians order it. Usually, we check the blood sugar before meals and try to cover that. Surveyor inquired if prescribing Humalog only once a day is appropriate for a resident with blood glucose levels frequently above 200 V11 responded It can be that way depending on the patient. We might need to adjust the dose or the frequency, it depends on the patient. Surveyor inquired about Humalog insulin V11 replied It's not a long acting one, it doesn't last a long time. Surveyor inquired about potential harm to a resident with a blood sugar of 399 that's not treated, V11 stated If it's a one time reading probably nothing but if it's a persistent reading over a couple weeks, it can start causing dehydration or frequent urination. Long term non-controlled diabetes can affect the kidneys. R1's diagnoses include type II diabetes mellitus. R1's (9/27/24) BIMS (Brief Interview Mental Status) determined a score of 9 (moderate impairment). On 10/2/24 at 9:49am, surveyor inquired if medications are received (at the facility) as ordered R1 stated I don't know. On 10/2/24 at 2:50pm, surveyor inquired about medication administration concerns at the facility V6 (Family) stated When my mother (R1) got there, they (facility) didn't have her medication. The Nurse said the medication wasn't there. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 4 of 10 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 145983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya on 87th 2940 West 87th Street Chicago, IL 60652 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 R1 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm R1's POS (Physician Order Sheets) include the following medications with (9/20/24) start date: Atorvastatin Calcium 80mg (milligrams) at bedtime, Gabapentin300mg three times daily, Metformin (Hypoglycemic) 500mg twice daily, Metoprolol Succinate ER (Extended Release) 25mg at bedtime, Pantoprazole Sodium 40mg twice daily, and Sacubitril Valsartan 24-26mg twice daily. [Blood Glucose orders are excluded however hypoglycemic medication is prescribed]. Residents Affected - Few R1's MAR (Medication Administration Record) affirms the following medications (scheduled for 9/20/24 administration) were marked 9 (see Nurse notes): Atorvastatin Calcium, Gabapentin Metformin, Metoprolol Succinate ER, Pantoprazole Sodium, and and Sacubitril Valsartan. In addition, several of R1's medications were noted to be scheduled for morning, afternoon, or evening therefore not specified times - as warranted. R1's (9/20/24) Nursing Progress Notes affirm at 4:23pm resident was received for admission. (11:41-11:43pm) EMAR (Electronic Medication Administration Record): pharmacy to deliver Metformin, Pantoprazole Sodium, Atorvastatin Calcium, Gabapentin, and Metoprolol Succinate ER [R1 was admitted roughly 7 hours prior]. On 10/7/24 at 12:49pm, surveyor inquired about the requirements for receiving medication orders V2 (Director of Nursing) stated In that order you have to have the name of the medication, the milligrams or the dosage, how often it's to be given, it needs to be verified with the doctor and have a diagnosis. The schedule depends on what the doctor orders, if it's ordered daily, usually daily is scheduled for 9am. Surveyor requested the actual times for R1's medication administration V2 reviewed R1's (September 2024) MAR and responded It says for Atorvastatin bedtime, I don't actually see a time on there, it just says bedtime. Metoprolol just says given at bedtime. Metformin it says give by mouth 2 times a day, it says morning and evening. Pantoprazole it says morning and evening, it's not giving a specific time. Surveyor inquired about the regulatory requirement for medication administration, V2 replied It should be given a time, so if its 9:00 we have a hour before and a hour after to administer the medication. Surveyor inquired if staff should be monitoring blood sugars if residents are receiving hypoglycemic medication, V2 stated If they (residents) are on anything for diabetes, we (staff) should call and get orders for checking blood sugars once or twice a day. On 10/8/24 at 12:19pm, surveyor inquired about potential harm to a resident receiving oral hypoglycemics if blood sugars are not monitored, V11 (Medical Director) replied Potential harm is they can get all sorts of high or low blood sugars, this can cause coma. On 10/2/24 at 10:29am, surveyor stated that medication administration will be monitored this morning V4 (Registered Nurse) responded Actually, I'm done for now unless you want to see the 12:00. V4 accessed the EMAR (Electronic Medication Administration Record) as requested however R3's name was highlighted red (indicating late administration). Surveyor inquired why R3's name was highlighted red V4 replied Right now I (V4) need to see about getting the medicine from the c (convenience) box. The Metoprolol (ER) 25 milligrams, its scheduled for 9:00 but we got 1 hour after and 1 hour before to give it. Surveyor inquired why R3's Metoprolol (scheduled for 9am administration) was not administered V4 stated I believe that was a new order. [R3's POS affirms Metoprolol ER 25 milligrams was prescribed 7/26/24 therefore not a new order]. Surveyor inquired what time it is V4 responded It's after 10:00. On 10/2/24 at 11:34am, V5 (Licensed Practical Nurse) was observed passing R4's AM medications per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 5 of 10 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 145983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya on 87th 2940 West 87th Street Chicago, IL 60652 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few EMAR [actual time of administration was excluded}. Surveyor inquired if all V5's assigned residents received their AM medications today V5 stated Yes. Surveyor inquired what residents highlighted red on the EMAR indicates V5 responded The red? this means late. Surveyor inquired why R5, R6, R7, R8, R9 and R10 were highlighted red on the EMAR V5 responded These are done I just haven't signed em out yet. V5 reviewed the EMAR with surveyor and affirmed that R5's supplement (scheduled for 10am administration) was not documented. Surveyor inquired if R6's scheduled Haldol, Morphine, and Lorazepam were administered this morning V5 replied The 9am Morphine is the only one I gave. Surveyor inquired when prescribed medications are not given (as scheduled) what's the requirement V5 stated When I (V5) don't give em, I just put the reason why I didn't give it however nothing was documented for R6's Haldol and Lorazepam (scheduled for 10am administration). R7's (10/2/24) 7:30am blood sugar and Humalog administration were not documented. Surveyor inquired why R7 did not receive Humalog this morning V5 responded When we checked his blood sugar it was like 110 however appeared unsure. Surveyor inquired if R7's (10/2/24) 7:30am blood sugar was documented in the EMAR V5 affirmed it was not. Surveyor inquired if R7's blood sugar was documented on paper V5 stated No. R7's MAR (received after interview) affirms 10/2/24 7:30am blood sugar result states N/A (not applicable). Surveyor inquired if R8 received 9am medications this morning V5 stated Yes, I haven't signed em out yet. Surveyor requested to inspect R8's medications V5 removed R8's medications from the cart (which are labeled individually - including date and time) however the 10/2/24 medications (scheduled for 9am administration) remained in the packages. V5 stated Oh no, his (R8's) I (V5) didn't get to yet. I thought I did his, this is the 2nd (October 2nd). Surveyor inquired if R9 received Nifedipine ER (Antihypertensive) scheduled for AM administration, V5 responded I didn't give it yet. Surveyor inquired if R10 received Sacubitril Valsartan (Antihypertensive) scheduled for AM administration, V5 replied I didn't give that one yet because I didn't check his blood pressure for today. The medication administration policy (reviewed 1/2024) states verify that the medication is being administered at the proper time. If the medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. Vital signs are taken as required prior to medications and documented on MAR. The diabetes management policy (reviewed 1/2024) states residents with a diagnosis of diabetes will be managed per physician orders. Physician's orders for diabetic management may include but are not limited to specialized diet, oral medications, insulin injections, and blood glucose monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 6 of 10 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 145983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya on 87th 2940 West 87th Street Chicago, IL 60652 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 - Many 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 upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that prescribed medications are available for two of three residents (R1, R3) reviewed for pharmacy services, failed to ensure that the location of medication in the convenience box is accurate, and failed to ensure that staff utilize the convenience box when medications are unavailable in the medication cart or not received from pharmacy. These failures have the potential to affect 191 residents. Findings include: On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that a resident has not been receiving prescribed medications and the facility blames the pharmacy for medication issues. The (10/2/24) facility census includes 191 residents. On 10/2/24 at 2:50pm, surveyor inquired about medication administration concerns at the facility V6 (Family) stated When my mother (R1) got there, they (facility) didn't have her medication. The Nurse said the medication wasn't there. R1 was admitted to the facility on [DATE]. R1's POS (Physician Order Sheets) include the following medications with (9/20/24) start date: Atorvastatin Calcium 80mg (milligrams), Gabapentin300mg, Metformin 500mg, Metoprolol Succinate ER (Extended Release) 25mg, Pantoprazole Sodium 40mg, and Sacubitril Valsartan 24-26mg. R1's (9/20/24) MAR (Medication Administration Record) affirms the following medications were marked 9 (see Nurse notes): Atorvastatin Calcium, Gabapentin, Metformin, Metoprolol Succinate ER, Pantoprazole Sodium, and and Sacubitril Valsartan [therefore none of which were documented administered]. R1's (9/20/24) Nursing Progress Notes state pharmacy to deliver the following medications: Atorvastatin Calcium, Gabapentin, Metformin, Metoprolol Succinate ER, Pantoprazole Sodium, and Sacubitril Valsartan. On 10/3/24 at 3:15pm, surveyor inquired about the facility protocol for acquiring medications for new admissions V2 (Director of Nursing) stated After you get the medications verified, we (Nurses) usually get the medications from the (brand name convenience box). The facility convenience box log includes the following medications which were prescribed for R1: Gabapentin 300mg, Metformin 500mg, Metoprolol Succinate ER 25mg, Pantoprazole 40mg however none of which were administered [Sacubitril Valsartan was excluded from the list therefore unavailable]. R3's (7/26/24) POS includes Metoprolol Succinate ER daily. On 10/2/24 at 10:29am, surveyor inquired why R3's name was highlighted red on the Electronic Medication Administration Record (indicating late administration) V4 (Registered Nurse) responded Right now, I need to see about getting the medicine from the c (convenience) box. The Metoprolol (ER) 25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 7 of 10 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 145983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya on 87th 2940 West 87th Street Chicago, IL 60652 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 milligrams, its scheduled for 9:00 am. Level of Harm - Minimal harm or potential for actual harm On 10/2/24 at 10:42am, V4 accessed the (brand name convenience box) which states Metoprolol 25mg ER is in box #7 - in the cabinet. V4 subsequently removed box #7 from the cabinet, searched for Metoprolol Succinate ER (to no avail) and affirmed It's not in there. Residents Affected - Many R3's (8/1/24) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 10/2/24 at 10:48am, surveyor inquired if R3 received her Metoprolol Succinate ER this morning R3 stated He (Nurse) didn't bring it in yet, he said he had to get it out of the cabinet. The (undated) ordering medications policy states medications and related products are ordered from (pharmacy name) on a timely basis. New medication order requests can be faxed to the pharmacy's main fax number, sent via electronic health records, EHR (Electronic Health Records) system, electronically prescribed by the prescriber, and/or called in by the appropriate personnel according to State laws and regulations. Refill requests should be sent in 72 hours prior to the last dose. The medication administration policy (reviewed 1/2024) states if medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain it from the contingency or convenience box. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 8 of 10 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 145983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya on 87th 2940 West 87th Street Chicago, IL 60652 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to ensure that five of thirteen residents (R1, R3, R8, R9, R10) in the sample remained free of significant medication errors. Residents Affected - Some Findings include: On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that medications (including antihypertensive and hypoglycemic) are not administered at the facility as ordered. R1's (9/27/24) BIMS (Brief Interview Mental Status) determined a score of 9 (moderate impairment). On 10/2/24 at 9:49am, surveyor inquired if prescribed medications are received as ordered R1 stated I don't know. On 10/2/24 at 2:50pm, surveyor inquired about facility concerns V6 (Family) stated When my mother (R1) got there (facility) they (staff) didn't have her medication. The Nurse said the medication wasn't there. R1 was admitted [DATE] with hypertensive heart disease and type II diabetes mellitus. R1's POS (Physician Order Sheets) include but not limited to the following significant medications with (9/20/24) start date: Metformin 500mg/milligrams (Hypoglycemic), Metoprolol Succinate ER 25mg (Antihypertensive) 25mg, and Sacubitril Valsartan 24-26mg (treats heart failure). R1's (9/20/24) MAR (Medication Administration Record) affirms Metformin, Metoprolol Succinate ER, and Sacubitril Valsartan were marked 9 (see Nurse notes). R1's (9/20/24) Nursing Progress Notes state pharmacy to deliver the following medications: Metformin, Metoprolol Succinate ER, and Sacubitril Valsartan. On 10/3/24 at 3:15pm, surveyor inquired about the facility protocol for acquiring medications for new admissions, V2 (Director of Nursing) stated After you get the medications verified, we (Nurses) usually get the medications from the (brand name convenience box). The facility convenience box log includes Metformin 500mg and Metoprolol Succinate ER 25mg however on 9/20/24 neither of which were administered to R1 [Sacubitril Valsartan was excluded from the list therefore unavailable]. R3's diagnoses include heart failure and hypertension. R3's (7/26/24) POS includes Metoprolol Succinate ER daily for hypertension. On 10/2/24 at 10:29am, surveyor inquired if R3 received Metoprolol Succinate ER today as ordered V4 (Registered Nurse) stated Right now I (V4) need to see about getting the medicine from the c (convenience) box. The Metoprolol (ER) 25 milligrams, its scheduled for 9:00 but we got 1 hour after and 1 hour before to give it. Surveyor inquired what time it is V4 responded It's after 10:00 therefore not administered within regulatory requirements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 9 of 10 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 145983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya on 87th 2940 West 87th Street Chicago, IL 60652 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/2/24 at 10:42am, V4 accessed the convenience box, searched for Metoprolol Succinate ER (to no avail) and affirmed It's not in there. R3's (8/1/24) BIMS determined a score of 14 (cognition intact). On 10/2/24 at 10:48am, surveyor inquired if R3 received her blood pressure medication this morning R3 stated He (Nurse) didn't bring it in yet, he said he had to get it out of the cabinet. On 10/2/24 at 11:34am, surveyor inquired what residents highlighted red on the EMAR (Electronic Medication Administration Record) indicates V5 (Licensed Practical Nurse) stated The red? this means late. Surveyor inquired why R8, R9 and R10 were highlighted red on the EMAR V5 responded These are done I just haven't signed them out yet. V5 reviewed the EMAR with surveyor at this time. Surveyor inquired if R8 received medications today (scheduled for 9am administration) V5 stated Yes, I haven't signed them out yet. Surveyor requested to inspect R8's medications at this time. V5 removed R8's medications from the cart (which are labeled individually - including date and time) however the 10/2/24 (9am) medications including Clopidogrel Bisulfate (Antiplatelet) and Levetiracatam (Anticonvulsant) remained in the packages. V5 stated Oh no, his (R8's) I (V5) didn't get to yet. I thought I did his, this is the 2nd (October 2nd). Surveyor inquired if R9 received Nifedipine ER (Antihypertensive) scheduled for AM administration, V5 responded I didn't give it yet. Surveyor inquired if R10 received Sacubitril Valsartan scheduled for AM administration, V5 replied I didn't give that one yet. On 10/7/24 at 12:49pm, surveyor inquired about the regulatory requirement for administering medications, V2 (Director of Nursing) stated It should be given in time, so if its 9:00 we have a hour before and a hour after to administer the medication. The medication administration policy (reviewed 1/2024) states all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Check the medication administration record prior to administering medication for the right medication, dose, route, patient/resident, and time. Verify that the medication is being administered at the proper time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 10 of 10