Inspection·January 8, 2025

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R53's (Active Order as Of: 01/06/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) essential hypertension, type 2 diabetes mellitus, and contact dermatitis. Order summary: Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to affected area on Back topically every morning and at bedtime for MAD (Moisture Associated Dermatitis) Fungal Rash Apply Zinc oxide to area then sprinkle powder over area after cleanse with NSS or mild soap/water. Order Date: 08/04/2024. Of note, there was no order to may self-administer this medication. The 8-page 01/06/2025 Order Summary Report was reviewed with no order to may self-administer medication/s. R53's (Active Order as Of: 01/07/2025) Order Summary Report documented, in part Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to affected area on Back topically every morning and at bedtime for MAD Fungal Rash unsupervised self-administration Apply Zinc oxide to area then sprinkle powder over area after cleanse with NSS or mild soap/water. Order Date: 08/04/2024. R53's (11/20/2024) Self-Administration of Medication documented, in part 1. Based on the answers, is it appropriate for the resident to self-administer any medications? B. Yes. 1a. R53's (01/06/2025) care plan documented, in part Focus: able to self-administer medication (Nystatin Powder. Goal: will administer medication appropriately. Interventions: MD ordered (sic) obtained for resident to self-administer. Of note, there was no doctor's order to may self administer this treatment as of 01/06/2025. The (1/2024) Self administration of medications and treatments Documented, in part General: Self administration of medications and treatments are done to prepare a resident for discharge and to help the resident maintain their independence. The decision for self administration is done by the interdisciplinary team. Guideline: 1. Self administration of medications and treatments is determined by an order after determining that the resident is able to self administer. Procedure: 1 if it is determined by a member of the interdisciplinary team, or if the resident requests to self administer, it is documented in the chart and the healthcare provider is called for an order to self administer medications, and keep the medications at bedside. 7. A care plan is for resident who self administer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 2 of 23 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 01/08/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 prevention policy and failed to report abuse to the state survey agency within required time parameters. This failure affects 1 resident (R45) in a sample of 74 residents. Findings include: R45's admission record documents in part the following diagnosis: right-sided hemiplegia, type 2 diabetes mellitus, unspecified dementia without behavioral disturbance, cerebral infarction. R45's minimum data set (11/18/2024) documents in part a brief interview of mental status score of 13, indicating that resident is cognitively intact. On 1/5/2025 at 10:40 AM, R45 was observed lying in bed. Observed bruises to R45's left wrist and inner forearm. R45 stated that the bruises were from the staff handling me (R45) too rough and began to cry. R45 could not name a staff member or a time when this occurred. Additionally, R45 stated that R45's nurse (V40, Registered Nurse) had yelled at him this morning and had threatened him saying if you don't take your fucking medication, I will not help you!. On 1/5/2025 at 10:50 AM, V1 (Administrator) was notified about the allegation of physical abuse (handling roughly) and mental abuse (yelling/threatening). On 1/5/2025 at 11:35 PM, V1 stated that V1 had talked to the resident, and that the bruises were from lab draws. V1 stated that V40 (Registered Nurse) was being suspended pending investigation. Surveyor confirmed with V1 that V1's investigation into the allegation of physical abuse determined that the bruising was from lab draws (uncommon places for blood draws). Record review of the facility's initial report to the state survey agency for the incidence of alleged abuse reported to V1 on 1/5/2024 documents that an allegation of verbal abuse was reported to V1. The allegation of physical abuse (handling roughly) was not included in the initial report. On 1/7/2025 at 12:21 PM, V1 reviewed the initial report that was sent to the facility regarding R45's allegations. V1 affirmed that the physical abuse was not on the report and stated, remember, I told you that the bruises were from blood draws or from the hospital. V1 affirmed that V1 did complete an investigation into the incident and surveyor inquired to why the allegation of physical abuse was not reported to the state survey agency if an investigation was completed. V1 stated, Oh, I thought by telling you (surveyor) that would be enough. V1 affirmed that V1 would document the details of the investigation and submit the investigation to the state survey agency. Facility policy titled, ABUSE POLICY AND PREVENTION PROGRAM (dated 10/2022) documents in part, .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish to a resident . 1. Initial reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee shall notify Department of Public Health's regional office immediately by telephone or fax. Public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 3 of 23 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 01/08/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRR) was completed prior to resident's admission for one resident R137. This failure affects 1 (R137) resident in a sample of 74. Residents Affected - Few Findings include: R137 has a diagnosis of but not limited to Hemiplegia and Hemiparesis, Aphasia, Vascular Dementia, Bipolar Disorder, Major Depressive Disorder and Weakness. R137 has a Brief Interview of Mental Status score of 08. R137's admission date is 12/07/2021. On 1/05/2025 surveyor could not find in the facility's electronic records a PASRR for R137. On 1/6/2025 at 12:20pm V41 (admission Coordinator) stated that R137 was admitted prior to the start of the Maximus program and his information was not submitted to the program. V41 also stated that staff will be coming out soon to complete the Level ll determination than the care plan will be updated with their recommendations. On 01/06/25 at 1:49 pm V41 stated that they did not have a PASRR for R137 and that they (facility) initiated a new PASRR after the start of the survey on 1/5/2025. PAS screening with a review date of 1/2024 documents, in part, in accordance with Illinois regulatory standards and recommended practices, this organization requests Level 1 (one) and Level 2 (two, where applicable) Pre-admission Screening documents prior to the individual's arrival at the facility and the screening material should be reviewed as a component of the assessment process and treatment suggestions/recommendations should be identified and appropriately addressed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 4 of 23 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 01/08/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review the baseline care plan with the resident/resident's representative and failed to provide a copy of the baseline care plan to the resident/resident's representative. This failure affects 1 resident (R398) in a sample of 74. Findings include: Record review of R398's face sheet documents in part the following diagnosis: gout, type 2 diabetes mellitus, end stage renal disease, chronic obstructive pulmonary disease, Alzheimer's disease, heart failure. Record review of R398's minimum data set (dated 1/7/2024) documents in part a brief interview of mental status (BIMS) summary score of 11, indicating resident is cognitively impaired. On 1/5/2025 at 11:42 AM, V39 (R398's family member) stated that V39 was upset because we don't really know what's going on. V39 clarified, stating that V39 and R398 were confused about R398's plan of care. R398 and V39 affirmed that R398 has not been provided a copy of R398's baseline care plan or invited to participate in the development of R398's plan of care. V39 stated that R398 was admitted on [DATE]. Record review of R398's progress notes does not indicate that R398's care plan had been reviewed with R398 or V39. Additionally, no documentation was noted of the care plan being given to R398 or V39. On 1/6/2025 at 11:45 AM, V2 (Director of Nursing) stated that baseline care plan meetings are conducted with the family when it is convenient for them and should be offered within the first 5 days of being admitted . V2 reviewed progress notes and progress notes document that a care plan meeting was offered on 1/6/2025 and scheduled for 1/7/2025. V2 stated that the facility does not document giving a copy of the baseline care plan to residents so they do not have any documentation that R398 got R398's plan of care. Facility policy titled, Baseline Care Plan dated 1/2023, documents in part, .The baseline care plan will be developed within 48 hours of the residents admission into the facility . The facility will provide the resident AND their representative with a summary of the baseline care plan . [NAME] facilities will provide a copy of the following as a summary of the baseline care plan to the resident and the resident's representative within 5 days of admission to a [NAME] facility . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 5 of 23 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 01/08/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to provide a person center care plan focus PASRR (Pre-admission Screening and Resident Reviews) for one resident (R137). Residents Affected - Few Findings include: R137 has a diagnosis of but not limited to Hemiplegia and Hemiparesis, Aphasia, Vascular Dementia, Bipolar Disorder, Major Depressive Disorder and Weakness. R137 has a Brief Interview of Mental Status score of 08. R137's admission date is 12/07/2021. R137's Order Summary Report with active orders as of 1/6/2025 documents, in part, Escitalopram Oxalate oral tablet 5mg daily (Major Depressive Disorder) and Quetiapine Fumarate oral tablet 3 times a day for Bipolar Disorder. R137's Level I PASRR (Pre-admission Screening and Resident Review) dated 1/5/2025, documents, in part, diagnosis of Major Depression and Bipolar disorder and PASRR Level 1 Determination: Refer for Level ll onsite. R137's care plan focus-PASRR Level 2 dated 1/5/2025 documents, in part, R137 has been screened by an agency and determined to have persistent mental illness and require LT (long Term Care) placement. Level 2 screening recommendation. On 1/6/2025 at 12:20pm V41 (admission Coordinator) stated that R137 was admitted prior to the start of the Maximus program and his information was not submitted to the program. V41 also stated that staff will be coming out soon to complete the Level 2 determination than the care plan will be updated with their recommendations. V41 stated care plan was not implemented prior to the start of the survey because R137 was admitted prior to the start of the Maximus program and his information was never submitted. On 1/08/2025 at 3:47pm via email V4 (Social Service Director) stated yes, PASRR should be completed prior to admission and the care plan is updated once the Level 2 screening is completed. On 1/8/2025 at 3:54pm via email V2 (Director of Nursing) stated do not have a policy specific for updating the care plan for PASRR. Comprehensive care plan policy dated 1/2023 documents, in part, the care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental, and psychological needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 6 of 23 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 01/08/2025 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 on observation, interview and record review the facility failed to provide ADL care (Activities of Daily Living) to two dependent residents (R137, R176) to maintain grooming and personal hygiene. This failure affected two residents (R137, R176) in a sample of 74 residents. Residents Affected - Few Findings include: R137 has a diagnosis of but not limited to Hemiplegia and Hemiparesis, Aphasia, Vascular Dementia, and Weakness. R137 has a Brief Interview of Mental Status score of 08. R176 has a diagnosis of but not limited to Myopathies, Dysphagia, Hypo-Osmolality and Hyponatremia, Glaucoma, Hypertension, Lack of Coordination and Megaloblastic Anemia. R176 has a Brief Interview of Mental Status score of 15. R176's admission date 7/15/2024. R176 census documents that she has been in her current room (307-1) since 11/06/2024. On 1/05/2025 at 11:02am surveyor observed R176 with facial hair, and long fingernails on both hands. On 1/05/2025 at 11:05am R176 stated that she had not had a shower since she's been on this floor, and they (facility staff) offered to shave the hair off her face once, but they never came back to cut it. R176 stated that staff will give her a bed bath, but she has never been in the shower since arriving to this floor. R176 said she would like for it to be cut and her nails to be trimmed. R176 stated that it makes her feel hairy and that this is the most hair she has ever had on her face. On 1/5/2025 at 11:32am surveyor observed R137's first three fingers on his right hand to be cut but his 4th and 5th fingers the fingernails were long and digging into his hand. On 1/5/2025 at 11:33am R137 showed me his 4th and 5th fingernails and nodded yes when asked if he would like for them to be cut and if the long nails hurt. On 1/5/2025 at 12:19pm V16 (Certified Nursing Assistant) stated that resident receives a shower twice a week and nails are cut and trimmed, and shaves (men and women) are offered as needed. On 1/06/2025 at 9:10am surveyor observed R137's fingernails on his 4th and 5th fingers not to be cut. On 1/6/2025 at 9:12am surveyor observed R176's fingernails to be long and not trimmed. On 1/06/2025 at 9:14am R176 stated that she did receive a shower yesterday and her face shaved but they did not cut her fingernails. On 1/7/2025 at 10:21am surveyor observed R176's fingernails to be long and not trimmed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 7 of 23 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 01/08/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/7/2025 at 10:24am V10 (Restorative Director/Licensed Practical Nurse) stated that R176 did receive her shower and her facial hair shaved, but she did not get a chance to cut her nails. V10 stated that the nurses and CNAs can cut the residents fingernails, but she wanted to do it. On 1/7/2024 at about noon V10 stated that R176's shower days are on Tuesday and Friday and provided shower sheets for R176 that documents showers were given twice a week for December of 2024. On 1/7/2025 at 12:55pm V2 (Director of Nursing) stated showers are offered twice a week and as needed and nail care should be offered and completed when showers are given. Male and female residents should be offered to be shaved as needed, and they should be shaven if they agree to be shaved. Point of Care showers/bathing documentation for 12/07/2024 to 1/072025 does not document any showers were given for R176. R176's care plan focuses for ADL's dated 12/29/2024 documents, in part, R176 requires assist with daily care needs related to generalized weakness and mobility and assist R176 with ADL's. R137's care plan focuses for ADL's dated 12/26/2024 documents, in part, R137 requires assist with daily care needs related to right side hemiplegia and hemiparesis and assist resident with ADL's and maintain clean and trimmed nails. Activities of Daily Living policy with a revision date of 5/2024 documents, in part, a program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning and Hygiene: a. resident self-image is maintained, f. showers or baths are scheduled, and assistance is provided when required and Grooming: c. resident's facial hair should be shaved if necessary and appropriate per personal preference. Nail care policy with a revision date of 1/10/2024 documents, in part, to provide care and maintain hygiene for the resident's nails and nail care is offered and performed on the resident's shower day and as needed. Undated Certified Nursing Assistant job description documents, in part, to provide assigned residents with routine daily nursing care in accordance with established nursing care procedures, give or assist resident with bathing, shave female residents as needed and keep resident's fingernails clean and trimmed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 8 of 23 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 01/08/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the Low Air Loss Mattress were set based on the resident's weight. This failure affected 1 resident (R100) reviewed for pressure ulcer/injury prevention and treatment in a sample of 74 residents. Residents Affected - Few Findings include: R100's diagnoses include but not limited to Alzheimer's, Atherosclerotic Heart Disease, hypertension, and chronic kidney disease. R100's (10/31/24) MDS (Minimal Data Set) documents in part, Section C: Brief Interview of Mental Status (BIMS) score is blank. Section M: Skin Condition 1. Number of Stage 4 pressure ulcer - 1 checked in box. On 1/5/25 at 10:25 am, R100 was lying on a low air loss mattress with a setting at 300. R100's monthly weight report documents in part, November 2024 weight 132.4, December 2024 weight 133.6 and January 2025 weight 132.8. R100's (11/18/24) care plan documented in part, Focus: R100 has a pressure injury R/T (Related/To) self-care deficits impaired mobility and comorbidities DX (Diagnosis)of Alzheimer's, CKD (Chronic Kidney Disease), Covid-19, HTN (Hypertension), Hypoxia, Insomnia, Depression, Psychosis, and weakness. Interventions: Apply pressure redistribution or low air loss therapy pressure redistribution mattress when in bed. The (undated) Protekt Aire 3000/3500/3600 Operation Manual documented, in part, Instructions: Step 6 Determine the patient's weight and set the control knob to that weight setting on the control unit. On 1/7/25 at 12:40 pm, V2 DON (Director of Nursing) stated that the low air loss mattress settings should be based on the resident's weights. On 1/8/25 at 11:25 am, V30 Wound Care Coordinator (WCC) stated that the low air loss mattress settings should be based on the resident's weight. At no time should a low air loss mattress should be set over 300 for R100. It could cause the wound to worsen. Facility job description titled Register Nurse/License Practical Nurse documents in part, Essential Duties: 12. Adhere to all facility and department safety policies and procedures. Facility's job description titled Wound Care Nurse documents in part, 5. Monitor the resident overall condition and provide care as required while maintaining compliance with the facility and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 9 of 23 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 01/08/2025 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 0687 Provide appropriate foot care. 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 provide foot care for one resident (R64) who is dependent on staff for Activities of Daily Living (ADL) care (foot care). This failure affected one resident reviewed for foot care in the total sample of 74 residents. Residents Affected - Few Findings include: R64's Face sheet shows that R64 has diagnosis which include but not limited to pain in right knee, rheumatoid arthritis, generalized osteoarthritis, and essential hypertension. R64's Brief Interview for Mental Status (BIMS) dated 11/25/24 shows that R64 has a BIMS score of 12 which indicates that R64 has moderate cognitive impairment. On 01/06/25 at 11:18 am, Surveyor observed R64 in bed awake and alert. Surveyor observed R64's right and left foot toenails, long, thick, and ridged (ungroomed, in need of foot care). Surveyor also observed R64's right great toe and second toenails with a white dry substance, and white tissue paper adhered to R64's right great toe and 2nd toe. R64 stated, They hurt (referring to R64's right great toe and right second toenails). R64 then stated, I (R64) put baking soda on it a while ago and wrapped it with tissue to make it feel better. On 01/06/24 at 12:26 pm, V22 (Social Service) was asked regarding residents being seen by the podiatrist at the facility and V22 stated that the podiatrist visits the facility weekly, monthly and as needed (depending on the schedule) and that the nurses and Certified Nursing Assistants (CNAs) are responsible for letting the social service department know the residents who need to be seen by the podiatrist. V22 also stated that the podiatrist last visited the facility in November and that V22 will check to see when the next time the podiatrist will visit the facility. On 01/07/25 at 9:02 am, Surveyor observed R64 remain in bed awake, alert with R64's right and left foot toenails, long, thick, and ridged (ungroomed, in need of foot care). R64's right great toe and second toenails long, thick, with a white dry substance, and white tissue paper remained adhered to R64's right great toe and 2nd toenails. R64 stated, They hurt (referring to R64's right great toe and right second toenail bed) but I put toothpaste on them today and wrapped them with tissue to sooth them. When R64 was asked if staff provides foot care to R64, R64 stated I can do some things for myself, but I need some help. Since I got here they (referring to R64's right and left feet toenails) have gotten worse. They grew so long they hurt. No one has provided me (R64) foot care. When R64 was asked if R64 would like foot care to R64's bilateral feet, R64 stated, Yes. On 01/07/25 at 9:04 am, Surveyor brought this observation to V23 (Registered Nurse, RN) and V23 stated, I assume that is some sort of paste on R64's feet. I am unaware of her (R64) in need of any foot treatments. V23 explained that Certified Nursing Assistants, CNAs are responsible for providing foot care during Activities of daily living (ADL) care daily and as needed as well as reporting any foot issues to the nurse. V23 also explained that if V23 observes any issues with a residents foot, V23 will notify the residents physician for treatment orders and recommend the resident to be seen by the podiatrist. V23 stated that V23 is not aware of how often the podiatrist visits the facility and if a resident requires foot care nursing will treat the resident until the resident is able to be seen by the podiatrist. V23 also stated that V23 would call R64's physician for orders to treat R64's feet until R64 is seen by the podiatrist at the facility. When V23 was asked regarding what could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 10 of 23 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 01/08/2025 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 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few happen if a resident goes without foot care, V23 stated that the resident could possibly develop a foot infection. On 01/07/25 at 9:40 am, V2 (Director of Nursing, DON) was asked regarding providing residents foot care at the facility and V2 stated that CNAs are responsible for providing foot care to the residents and reporting any abnormalities to the nurse. When V2 was asked what could happen if a resident who depends on staff for foot care does not receive foot care, V2 stated, The resident can develop a odor, wound, sores, and a possible infection. R64's Minimum Data Set (MDS) dated [DATE] shows that R64 requires partial/moderate assistance with personal hygiene. R64's Physician Order Sheet (POS) dated January 2025 does not indicate that R64 has orders for R64's foot care. The facility's undated document titled Podiatrist List presented by V22 (Social Service) shows a list of resident to be seen by the Podiatrist next visit at the facility and does not show R64 scheduled to be seen by the podiatrist. The facility's email document dated 12/01/24 presented by V22 shows a list of residents seen by the podiatrist last visit at the facility and does not show R64 was seen by the podiatrist at the facility. The facility document dated 01/2024 and titled Foot Care documents, in part: General: Foot care is given to promote cleanliness, prevent infection, control odor, provide comfort, monitor for skin breakdown, and promote healing. Guidelines: Foot care is provided routinely with the bath and prn (as needed). 2. During the bath examine the feet for any open areas, redness, bruises, odor, or color change. 3. Make sure to clean feet in and around toenails and between toes. 9. If resident needs further foot care, notify the nurse so an assessment of the foot can be completed and documented. Notify the physician or nurse practitioner for any further orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 11 of 23 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 01/08/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to ensure that the environment was free from hazards. This failure has the potential to affect all 46 residents on the first-floor unit. Residents Affected - Some Findings include: On 01/05/25 V2 (Director of Nursing, DON) presented a facility census of 46 residents on the first-floor unit. On 01/05/25 at 11:00 am, Surveyor toured the first-floor unit and observed three oxygen cylinder tanks across from the first-floor nursing station, free standing and not in a holder. On 01/05/25 at 11:04 am, Surveyor brought this observation to V20 (Registered Nurse, RN, Weekend Supervisor) and V20 stated that when oxygen is not in use it should be stored downstairs in the oxygen room. Surveyor and V23 observed one of the three oxygen tanks, full, with 2000 psi (pounds per square inch) and two oxygen tanks with 1000 psi. When V20 was asked regarding what can happen if an oxygen cylinder tank is free standing and not in a holder, V20 stated that oxygen tanks should be in a holder because they can tip over and explode. On 01/07/25 at 9:41 am, V2 (Director of Nursing, DON) was asked regarding storage of oxygen cylinder tanks and V2 stated, Oxygen cylinders should be stored in a holder at all times so that the oxygen cylinder will not fall, cause friction, and set on fire. The facility policy dated 01/2024 and titled Oxygen Safety/Use documents, in part: Policy: Oxygen sources will be provided that ensures ready access and safe distribution of oxygen to patients/residents. The facility policy dated 01/2023 and titled Oxygen Cylinder documents, in part: General: standards for safe handling of cylinder gases are set by the National Fire protection Association (NFPA) and regulated by the Compressed Gas Association (CGA). Administrative authorities shall ensure that these standards and others that apply are met . Storage of Oxygen Cylinders: Store in designated area. Oxygen cylinders must be protected from mechanical shock, falling objects, etcetera (etc.). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 12 of 23 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 01/08/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Few On 01/05/25 at 11:26 AM, R132 was lying on her bed. R132 was receiving oxygen through a concentrator via a nasal canula (oxygen tubing). The oxygen tubing was dated 12/23/24. On 01/05/25 at 11:30 AM, V12 (Licensed Practice Nurse) was requested to check the date on R132's oxygen tubing. V12 stated the date on the oxygen tubing is 12/23/2024. Oxygen tubing should be changed weekly. Her (R132) tubing was not changed weekly. The purpose of changing the oxygen tubing weekly is to prevent infection. On 01/06/2025 at 10:16am, V2 (Director of Nursing) stated it is expected of the nursing staff to change the oxygen tubing weekly to prevent any bacteria into the tubing. It also should be labeled with the date it was changed to know when the tubing was changed. R32's (Active Order as Of: 01/06/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) Chronic Obstructive Pulmonary Disease (COPD) and asthma. Order Summary: Oxygen (O2) @ 2Liters prn (as needed) maintain SpO2 greater than 92%. Order date: 06/20/2024. Change O2 tubing weekly every night shift every Sun(day) for infection control. Order Date: 01/05/2025. R132's (10/02/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 8. Indicating R132's mental status as moderately impaired. Section O. Special Treatments. Respiratory Treatments. C1. Oxygen therapy: b. while a resident. R132's (04/12/2024) care plan documented, in part has oxygen therapy r/t (related to) diagnosis of COPD. Will have no sign and symptoms of poor oxygenation absorption. Administer oxygen per physician's order. The (1/ 2024) Oxygen Safety/Use documented, in part Oxygen sources will be provided that ensures ready access and safe distribution of oxygen to patients/residents. General. 9. Oxygen tubing will be changed weekly. Based on observation, interview and record review, the facility failed to label and date oxygen equipment (nebulizer mask); failed to change oxygen tubing (nasal cannula tubing) per facility policy; and failed to properly contain oxygen equipment (nebulizer mask). These failures affected two residents (R132 and R349) reviewed for oxygen equipment, in a total sample of 74 residents. Findings include: R349's face sheet shows that R349 has a diagnosis which includes but not limited hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, acute congestive heart failure, and hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease. R349's Brief Interview for Mental Status (BIMS) dated 01/02/25 (in progress) shows that R349 has a BIMS score of 15 which indicates that R15 is cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 13 of 23 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 01/08/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm On 01/05/25 at 11:05 am, R349 was observed in bed awake, alert, and oriented. Surveyor observed R349 with a nebulizer mask undated and uncontained on R349's nightstand. When R349 was asked when the last time R349 used R349's nebulizer machine and mask, R349 stated that R349 used R349's nebulizer mask yesterday. When R349 was asked regarding how R349 nebulizer mask is stored when not in use, R349 stated, I (R349) just through it on the dresser. Residents Affected - Few On 01/05/25 at 12:48 pm, this observation was brought to the attention of V23 (Registered Nurse, RN) and V23 stated, I (V23) imagine that mask was given to him (R349) yesterday. I don't see a date. It should be dated with a date. When V23 was asked how R349's nebulizer mask is stored when not in use, V23 stated, Not on the table (referring to R349's nightstand). It should be in a bag. When V23 was asked regarding the importance of the nebulizer mask being labeled with a date and stored in a bag when not in use, V23 stated, For infection control. On 01/07/25 at 9:41 am, V2 (Director of Nursing, DON) was asked regarding labeling, dating, and storing oxygen equipment (nebulizer mask) when not in use, V2 stated that the nebulizer mask should be labeled with a date and with the residents room number. V2 also stated that the nebulizer mask should be in a bag when not in use. When V2 was asked regarding the importance of labeling the nebulizer mask and storing the nebulizer mask in a bag when not in use, V2 stated, To decrease infection. R349's Physicians Order Sheet (POS) dated 12/29/2024 shows that R349 has orders for: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg (milligram)/3 ML (milliliter) 0.083% (Albuterol Sulfate), 1 vial inhale orally three times a day for Shortness of breath. The facility policy dated 01/2024 and titled Oxygen Safety/Use documents, in part: Policy: Oxygen sources will be provided that ensures ready access and safe distribution of oxygen to patients/residents. General: 9 . Oxygen tubing will be changed weekly and appropriately stored to prevent contamination when not in use. The facility policy dated 01/2024 and titled Equipment Change Schedule documents, in part: Equipment will be changed following established scheduled to prevent cross contamination. The facility policy dated 01/2024 and titled Oxygen Safety Use documents, in part: 9. Oxygen tubing will be changed weekly and appropriately stored to prevent contamination when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 14 of 23 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 01/08/2025 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the posted nursing staffing information was accurate and failed to ensure the posted staffing information included all required data. This failure affects all 190 residents residing within the facility. Residents Affected - Many Findings include: Record review of facility census documentation indicates that 189 residents reside within the facility. On 1/5/2025 at 9:50 AM, observed posted nursing staffing information near the front door of the facility. The posted nursing staffing information was dated for 1/3/2025 (incorrect date) and did not have the facility's name, or current census numbers. No other staffing information (other sheets) were noted to be dated 1/5/25 behind the 1/3/2025 staffing posting. On 1/6/2025 at 1:31 PM, V38 (Staffing Coordinator) affirmed that V38 is responsible for updating the staffing information and that the receptionist is responsible for updating it on the weekend. V38 stated that the staffing information for the weekend is located behind the staffing posting and the receptionist just pulls it from the top to reflect current staffing. V38 could not give a reason why the staffing information was not posted. V38 provided a copy of the staffing information that should have been posted for 1/5/2025. V38 reviewed the staffing posting with this surveyor and affirmed that the census information was left blank and the name of the facility was not located on the staffing posting. On 1/6/2025 at 2:41 PM, V1 (Administrator) stated, We do not have a policy for the daily staffing form because it is a regulatory requirement that the facility has to adhere to to ensure quality of care in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 15 of 23 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 01/08/2025 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to follow policy of reconciling controlled substances at the end of the shift. This failure has a potential to affect all 3 residents (R116, R144, and R172) receiving controlled substances on the 2nd floor. Findings include: Facility presented Shift Change Accountability Record for Controlled Substances dated January 2025 on the 2nd floor medication cart containing medications and controlled substances for rooms 201 to 218 which was missing a signature to verify a controlled substance count was conducted during the 3rd shift to shift change on 1/5/2025. Facility presented a list of residents recorded on the Shift Change Accountability Record For Controlled Substances on the 2nd floor receiving controlled substance medication which includes R172, R116 and R144. On 1/6/2025 at 10:45 am, observed 2nd floor medication cart missing narcotic count on 3rd shift dated 1/5/2025. V29, Licensed Practical Nurse (LPN), stated that the narcotic count is done shift to shift by the oncoming and outgoing nurse. On 1/7/25 at 11:00 AM, V35, Licensed Practical Nurse (LPN), stated that they are stored in a narcotic box under a double lock. V35 stated that on her shift she counts with the 3pm-11pm shift, when she comes to work, and when she leaves, she counts with the 11p-7a shift. V35 stated that the narcotic count is recorded in the book on the blue page and if she is counting medication narcotics with the nurse that results in a discrepancy, it is reported to the Director of Nursing (V2). On 1/7/2025 at 12:30 pm, V2, (Director of Nursing) stated that the controlled substances are stored in a locked medication cart that contains an affixed lock box designated to securely store narcotics and that the nurses are responsible for making sure all narcotic reconciliation or count is accurate and all narcotic medication is accounted for shift to shift. V2 stated that each care has a binder stored on every medication cart that contains the Shift Change Accountability Record For Controlled Substances for which is used for recording the accuracy of shift to shift narcotic count. The facilities Controlled Substances Policy documents in part, All schedule II substances (and other schedules if facility policy so dictates) will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses and Both nurses will sign the Shift/Shift Controlled Substance Count Sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 16 of 23 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 01/08/2025 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on interview and record review, the facility failed to provide snacks to the facility's residents when the duration between meals (dinner and breakfast) exceeded 14 hours. This failure affects all 190 residents that reside within the facility. Findings include: Record review of facility census documentation indicates that 189 residents reside within the facility. Record review of facility mealtimes documents in part, first floor meal times (7:30 AM, 11:30 AM, and 4:45 PM), second floor meal times (7:45 AM, 11:30 AM, and 5:00 PM), and third floor meal times (7:45 AM, 11:30 AM, and 5:00 PM). This indicates that the mealtimes are greater than 14 hours. On 1/6/2025 at 10:42 AM, during the resident council meeting, all residents present unanimously affirmed that the facility does not serve snacks and that they would want snacks if they were available. R114 stated that if the facility does have snacks, there is never enough for all the residents. On 1/7/2025 at 10:40 AM, V1 (Administrator) stated that snacks are served nightly to all the floors. Surveyor requested documentation from V1 that snacks were being administered to the residents. V1 replied that V6 (Dietary Manager) would have the documentation regarding snacks. On 1/7/2025 at 1:20 PM, V6 provided a document titled SNACKS that had 11 resident names listed on it (facility census is 190). V6 stated, those are the residents that get snacks at night. They get a peanut butter and jelly sandwich, a juice and a cookie. Surveyor reviewed mealtimes with V6 and confirmed there is 14 hours and 45 minutes between dinner and breakfast for the facility. Surveyor inquired how long can the duration of meals be in a facility before snacks needed to be administered to all residents, and V6 replied 14 and a half hours. V6 stated, we used to give snacks to all the residents every night, but a lot of times they didn't eat them and it was a waste, so we stopped. V6 explained that it's the dietary departments job to make the snacks and nursing has to pass them out. On 1/7/2025 at 1:39 PM, V2 (Director of Nursing) stated that the expectation is that the nursing department distributes snacks to any residents that want them or request them. Surveyor reviewed the document titled SNACKS with V2 and was unfamiliar with the document. V2 stated, all resident should be offered snacks if they want them. On 1/7/2025 at 2:39 PM, surveyor requested a policy for snack administration. V1 (Administrator) replied, .we are in compliance and not required to offer a snack based on our mealtimes offered. We have 14 hours between meals and we are in the regulation. Breakfast is at 7:30am started and dinner is at 4:30pm . This statement indicates there is 15 hours in-between meals. No policy for snack administration was received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 17 of 23 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 01/08/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to properly label, date and store prepared food items and store unthawed meats, to complete daily temperature logs to prevent the spread of foodborne illnesses. This failure has the potential to affect all residents receiving oral nutrition. Findings include: On 1/5/2025 surveyor observed the temperature logs for the refrigerator, freezer and cooler missing temperatures (morning and afternoon) for 1/1/2025-1/03/2025 and the afternoon temperatures for 1/05/2025. On 1/5/2025 at 9:18am surveyor observed 5 long steel pans of flavored gelatin (2 raspberry, 2 orange and 1 green) that was not dated and uncovered. On 1/5/2025 at 9:18am V5 (Cook)stated the flavored gelatin was made last night and it should have a date and that it should not have a covering because it would not set right. On 1/5/2025 at 9:22am surveyor observed 2 uncovered black tubs of pork chops, out of the original packaging, sitting on the bottom shelf in the refrigerator. The first tub was sitting on top of the second tub of pork chops uncovered. On 1/05/2025 at 9:32am V6 (Dietary Manager) stated all temperature logs (freezer, refrigerator, cooler) should be dated twice a day. On 1/7/2025 at 11:17am V6 (Dietary Manager) stated meat should be thawed in the refrigerator in a large tub with a lid or plastic on it. Jello is allowed to sit overnight in the refrigerator uncovered and, in the morning, we cover it up and everything that is put in the refrigerator or cooler should be dated. Job description for dietary manager documents, in part, to manage and oversee the daily operations of the dietary department, ensuring that meals are prepared, served, and stored in compliance with dietary guidelines, safety, and sanitation standards, and maintains and enforces food safety regulations and practices for storing, preparing, and serving food. Job description for dietary aide documents, in part, stores food properly. Storage of Refrigerated Foods, with a date of May 20, 2014 documents, in part, Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality, air temperature inside the refrigerator is checked twice daily and food in the refrigerator is covered, labeled and dated with a use by date. Undated policy titled Labeling and Dating documents, in part, foods will be labeled upon delivery to the facility and staff will follow the expiration date guidelines as posted or use by date on the product itself, all foods that are opened are to be wrapped or put in a sealed container for storage to prevent contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 18 of 23 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 01/08/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Undated policy titled Fridge/Freezer (Walker) Temperature Policy documents, in part, to assure food is kept and stored appropriately to prevent foodborne illness and staff will complete temperatures twice daily to assure the walk-in, fridge, and freezers are maintained and in good working condition to maintain food safety temperatures. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 19 of 23 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 01/08/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure staff don appropriate PPE (personal protective equipment) prior to performing ADL (activities of daily living) care to 3 (R100, R139, and R189) residents; and failed to ensure an EBP (enhanced barrier precaution) sign was posted for 2 (R53 and R189) residents on EBP. These failures affected 4 residents (R53, R100, R139, and R189) reviewed for infection control and has the potential to affect all the residents on 2nd floor and 3rd floor. Residents Affected - Some Findings include: The (01/05/2024) facility census documented that there were 71 residents on the 2nd floor and 72 residents on the 3rd floor. On 01/05/25 at 10:35 AM, surveyor inquired about the acuity of the floor, V10 (Restorative Director) stated (R53) and (R189) have an indwelling catheter. On 01/05/25 10:37 AM, there was no EBP sign posted by R189's door. On 01/05/25 at 10:40 AM, this observation was pointed out to V10. V10 stated there is no EBP sign posted by his (R189) room. Anyone who has a gtube, foley, and wound should have an EBP sign posted. Informed V10 that this surveyor needed to speak with the infection preventionist nurse. On 01/05/25 at 10:41am, V13 (Certified Nursing Assistant) and another CNA who was later identified as V14 went inside R189's room with a mechanical lift. Both did not don appropriate PPE. On 01/05/25 at 10:57 AM, R189 was outside of his room well dressed and seated on a geriatric chair. On 01/05/25 at 11:03 AM, inquiring if R189 is on EBP. V13 stated he is not on isolation. He has an (indwelling) catheter that is attached to a leg bag. I (V13) went to his room without donning a gown. I (V13) and another CNA (V14- CNA) transferred him (R189) to the chair with a (mechanical) lift with 2-person assist. She (V14) did not wear a gown, too. This surveyor informed V13 that anyone who has an indwelling catheter is on EBP. V13 stated it would help me a lot to know that I have to wear PPE if there was an EBP sign posted by his (R189) door. On 01/05/25 at 10:42 AM, by R53's room, no EBP sign was posted. V10 stated he (R53) has foley catheter. He should be on EBP, too. On 01/05/25 at 10:48 AM, V10 stated he (R53) has suprapubic catheter. The importance of posting an EBP sign by the resident's door is to let anyone, entering the room, know that he is on EBP and to know what PPE to don because staff or visitor may be dealing with body fluid. We try to prevent infection and protect him (R53). The start of infection could be coming from him and other residents could be infected. On 01/05/25 at 11:05 AM, V11 (LPN/Infection Preventionist) stated residents placed on EBP are residents who have wounds, central line, foley catheter, and colonized from MDROs (multi drug resistant organisms). Basically, residents who have artificial opening on the skin and with wounds. The purpose of placing residents on EBP is to prevent transmission of infection. V11 handed this surveyor the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 20 of 23 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 01/08/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some list of residents on EBP. Upon review, R53 and R189 were not included in the list. This was pointed out to V11. V11 stated they should be on EBP list because they (R53 and R189) have a indwelling catheter. I will update the list. On 01/05/25 at 11:08 AM outside of R189's room, V11 stated there should be an EBP sign posted by the resident's door. The purpose of the sign is to let the staff know what PPE to wear. Staff are expected to wear gown and gloves if they are transferring a resident, staff are expected to wear gown and gloves during transfer of a resident because it is considered a direct care to the resident to prevent any transmission of infection to their clothing and to prevent transmission of infection to the residents and other staff. On 01/05/25 11:11 AM, outside of R53's room, V11 stated he (R53) should have an EBP sign posted as well. On 01/07/2025 at 1:59pm, V2 (Director of Nursing) stated EBP signage should be posted by the resident ' s door on eye level so staff and visitor can see it. R53's (10/01/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating R53's mental status as cognitively intact. Section H. Bladder and Bowel: H0100. Appliances: A- Indwelling catheter. R53's (Active Order as Of: 01/06/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) essential hypertension, obstructive and reflux uropathy (when urine can't flow (either partially or completely) through your ureter, bladder, or urethra due to some type of obstruction. Instead of flowing from your kidneys to your bladder, urine flows backward, or refluxes, into your kidneys) type 2 diabetes mellitus and contact dermatitis. Order summary: Suprapubic catheter 16Fr Dx: BPH/Obstructive and Reflux Uropathy. Order Date: 01/17/2024. R53's (08/09/2023) care plan documented, in part requires suprapubic catheter r/t (related to) obstructive uropathy. Will be/remain free from catheter-related trauma. Catheter care q (every) shift/PRN (as needed). R53's (12/18/2024) care plan documented, in part Enhanced Barrier Precautions for use of (indwelling) catheter. Goal: will not acquire no MDROs. Interventions: wear gown and gloves as outlined by CDC for patients placed on EBP. R189's (Active Order as Of: 01/06/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) cerebral infarction, obstructive and reflux uropathy, and muscle weakness. Order summary. Indwelling Catheter 16 Fr(ench) for a dx (diagnosis) of obstructive uropathy. Change urinary bag as needed. Order Date: 12/02/2024. Change urinary catheter as needed. Order Date: 12/02/2024. Provide catheter care every shift and as needed. Order Date: 12/02/2024. R189's (12/23/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C1000. Cognitive Skills for daily decision making: 2 = moderately impaired. Section GG. Functional Abilities. Admission. GG0170. Mobility. E. Chair/Bed-to-chair transfer: 01 - Dependent. Section H. Bladder and Bowel. H0100. Appliances. A. indwelling catheter Section O. Special Treatment, Procedures, and Programs. M1. Isolation or quarantine for active infectious disease: b. while a resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 21 of 23 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 01/08/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R189's (11/22/2024) care plan documented, in part requires use of an indwelling catheter r/t (related to) obstructive uropathy. Will remain free of complication and infection of foley catheter placement. Empty catheter bag every shift and as needed. R189's (12/15/2024) care plan documented, in part Enhanced Barrier Precautions for use of (indwelling) catheter. Will acquire no MDRO's within the facility. Wear gown and gloves as outlined by CDC for patients placed on EBP. The (undated) Catheter List indicated that R53 and R189 were on the list. The (01/02/2025) updated EBP list indicated that R53 and R189 were on the list. The (01/07/2025) email correspondence with V2 (Director of Nursing) documented, in part Should there be an EBP sign posted for residents on EBP? If so, where should it be posted? V2 responded It should be posted at eye level by the door. The (undated) Enhanced Barrier Precautions Sign documented, in part Providers and Staff Must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Transferring. The (3/20/2024) Enhanced Barrier Precautions (EBP) documented, in part EBP expand the use of PPE (personal protective equipment) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi drug resistant organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high contact resident care activities is indicated for nursing home residents with indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Policy: EBP requires the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. High contact resident care activities requiring gown and gloves those among residents that trigger EBP use include: transferring. Findings include: R100's diagnoses include but not limited to Alzheimer's, Atherosclerotic heart disease, hypertension, and chronic kidney disease. On 1/5/25 at 10:35 am, observed an Enhance Barrier Precaution (EBP) sign outside of R100's door with no EBP bin outside of R100's room or near the room. V17 LPN (License Practical Nurse) and V18 CNA (Certified Nursing Assistant) observed in R100's room. V18 was rubbing soap on R100's body giving a bed bath to R100 with only gloves and mask on without donning a gown. R139's diagnoses include but not limited to cerebral infarction, chronic obstructive pulmonary disease, malignant neoplasm of prostate, and obstructive and reflux uropathy. R139's Active orders as of 1/6/2025 documents in part, Indwelling Catheter 16 Fr (French) 10 cc (Cubic Centimeter) balloon size for a diagnosis of Obstructive and Reflux Uropathy. Change urinary bag as needed when clinically appropriate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 22 of 23 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 01/08/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R139's MDS (Minimal Data Set) section H-Bladder and Bowel documents in part, Appliances: A. Indwelling Catheter. On 1/6/25 at 9:25 am, observed an EBP sign outside of R139's door with an empty EBP bin outside of R139's room. Observed V26 LPN (License Practical Nurse) in R139's room changing a urine leg bag without donning a gown. Surveyor inquired to V26 (LPN) about the posted EBP sign outside of R139's room, if a gown should have been worn when changing the urine bag? V26 stated, No then looked at the sign and read it then stated, Yes, I should have had a gown on. On 1/7/25 at 11:40 am, V11 (Infection Preventionist, IP, Licensed Practical Nurse, LPN) stated that residents who are on EBP, its to protect the residents who are susceptible to MDRO (Multidrug-Resistant Organism) and infection with residents with Gastrostomy tubes, catheters, indwelling catheters, lines, and wounds are to be placed on precautions. EBP residents should have signage on the resident's door with a PPE (Personal Protective Equipment) bin at the door or hallway for accessibility. When V11 was asked if regarding PPE supplies not being accessible, V11 stated that there is a chance staff will run out of PPE supplies and IP, central supply or a nurse manager should be notified to bring more supplies. V11 stated that it is important for staff to wear proper PPE and have accessible PPE for residents who requires EBP to prevent the potential spread of infection between the staff and the residents. On 1/7/25 at 12:40 pm, V2 DON (Director of Nursing) stated that an EBP sign is a quick sheet for staff to know what to put on before going into the room when providing care to the resident. V2 stated, Staff should have had on PPE when giving a bed bath and changing a urine bag. The reason for EBP signs is provide protection for staff with contamination from resident to resident. Facility's Enhanced Barrier Precautions sign documents in part, Providers and Staff Must: Wear gloves and a gown for the following High-Contact Resident Care Activities; dressing bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting. Device care or use: .urinary catheter . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145983 If continuation sheet Page 23 of 23