Health inspection·June 16, 2023

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to facilitate their guidelines for residents' leaving the facility against medical advice for one of three residents (R285) reviewed for discharge in a sample 19. Residents Affected - Few Findings include: On 06/14/2023 at 9:30AM during record review of Beneficiary Notification, R285 was noted with last covered day of Medicare Part A services on 1/16/2023. Progress note dated 1/17/2023 reads R285 is discharged home with daughter at 9:20AM. Progress notes and assessments from 12/26/2022 to 1/17/2023 reviewed and no documentation of any discharge planning, education about the risks of going against medical advice or R285 going against medical advice (AMA) noted. Care Conference dated 1/6/2023 indicated R285 asked about assisted living for the future and that she will stay in the facility for short term care. Order Summary Report dated 06/14/2023 reviewed and no discharge order was noted. Physical Therapy Discharge summary dated [DATE] indicated discharge reason is unexpected transfer to home and discharge, recommendations are discharge to home and continue home health. On 06/14/2023 at 10:44AM, V19 (Director of Korean Services) stated that on the day R285 was discharged she was surprised because R285 never mentioned anything about discharge to her. She also said that other staff never mentioned anything about R285's desire to be discharged . She also mentioned that R285 asked during the care conference about future residence in assisted living but never inquired about it again. She also added that she is not aware if R285 signed AMA. She also mentioned that no home health was set up for R285. On 06/14/2023 at 10:46AM, V7 (Registered Nurse) said that during R285's stay in the facility, she had been hearing R285 mentioning to her daughter that she wants to go home but not sure what was going on with her discharge planning. On 06/14/2023 at 10:48 AM, V18 (Director of Rehab) stated that R285 was observed packing her things with her daughter like getting ready to leave. She said that the daughter said R285 is going home. She said that therapy did not recommend for R285 to go home for safety concerns, so it is like she went home AMA. On 06/14/2023 at 02:44 PM, V2 (Director of Nursing) stated that R285 was discharged home with daughter on 01/17/2023 and it was not recommended by the therapy, so it is considered AMA. She said she is not aware of any AMA form signed. She reviewed the orders and unable to locate any discharge order. On 06/14/2023 at 3:12PM, V3 (Assistant Director of Nursing) stated that she notified V26 (Attending Physician) that R285 was going home with family and V26 acknowledged but did not give an order to discharge R285. Facility Policies: Title: Discharge Planning Guidelines Effective Date: 10/27/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 2 of 8 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 145999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Niles 6601 West Touhy Avenue Niles, IL 60714 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 0660 Discharge Planning begins at admission and is based on the resident's assessment and goals of care, desire to be discharged , and the resident's capacity for discharge. Level of Harm - Minimal harm or potential for actual harm Title: AMA Discharge Guidelines - (Against Medical Advice) Residents Affected - Few Revisions: 5/8/23 Policy: It is the policy of the Facility to acknowledge the right of the resident to sign him/herself out of the facility without consent of or an order from the attending physician providing that the resident has the decisional capacity to do so. If it has been determined that the resident is able to make his/her own decisions and chooses to exercise this right, he/she will be discharged from the Facility Against Medical Advice (AMA) Procedure: 1. If the resident has made their desire to discharge against medical advice known, the following should be attempted prior to the resident leaving the facility: a. Discharge planning must identify the discharge destination, and ensure it meets the resident's health and safety needs, as well as preferences. If the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and must: i. Discuss with the resident, (and/or his or her representative, if applicable) and document implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location. ii. Document that other, more suitable options of locations that are equipped to meet the needs of the resident were presented and discussed. iii. Document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings. 7. Any resident or legal representative choosing to discharge or be discharge without the consent of or an order from the attending physician is expected to sign the AMA form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 3 of 8 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 145999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Niles 6601 West Touhy Avenue Niles, IL 60714 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and ensure that effective interventions were identified and implemented to prevent one resident (R49) of three residents reviewed in a sample of 19 from falling. The facility also failed to ensure that all staff are aware of fall risk status and interventions. This failure resulted R49 falling and suffering an injury to her head that required three staples. Findings include: Review of R49's final incident report dated 6/7/2023 documents resident was found sitting on the floor by her bathroom door. Resident did not know the cause of the fall. Laceration found to the back of the head and resident was sent to the emergency room. R49 was diagnosed with a head laceration and received 3 staples. Review of R49's hospital discharge instructions dated 6/4/2023 document the following: diagnosis: Fall, Injury of head, and Laceration of scalp. Follow up in 10 days to have staples removed. On 6/14/23 at 9:40 AM with V19 (Director of Korean Service) interpreting, R49 states she doesn't remember the circumstances of the fall. Observed 3 staples in the back right side of R49's head. On 06/15/23 03:31 PM V27 (Registered Nurse/RN) states V27 doesn't think she (R49) can comprehend if you tell her something. V27 states that sometimes in the evening R49 gets up once or twice and comes to the nurse's station. V27 states that last week was the last time she saw R49 come from her room to the nurse's station without assistance. V27 states R49's gait is not stable. V27 states, R49 doesn't need to have assistance with ambulation. V27 states R49 does not speak English. V27 states she has not received communication from therapy about their recommendation for R49 assistance while ambulating. V27 states someone should communicate with evening shift the therapy recommendations. On 06/15/23 03:40 PM V21 (Certified Nurse Assistant/CNA) states on 6/4/2023 he was in another resident's room and heard a thump. V21 states, he came out and found R49 on the floor by her bathroom. V21 states R49 is very confused at times. V21 states the more confused R49 is the more she tries to move around. V21 states that R49 walks with supervision, no hand-on assistance. V21 states he is not sure if R49 understands them when they tell her things. V21 states he can redirect R49 and then later she will come out of her room again after redirection. V21 states he only redirects her when she comes out of the room. On 06/15/23 03:52 PM V6 (CNA) states R49 hates to sit. V6 states R49 likes to be out and moving. V6 states R49 was an elopement risk before the 6/4/2023 fall. V6 states she was not aware R49 was a fall risk before the 6/4/2023 fall. V6 states no one ever told her that R49 was a fall risk just an elopement risk and she was not giving R49 any assistance for ambulating before the 6/4/23 fall. V6 states R49 tries to get up to go to restroom or get up when she is hot. V6 states I don't think she really understands us, so they use gestures. V6 states she would gesture for her to use light; however, she never has seen the resident use the call light. V6 states, she doesn't believe R49 understands how to use the call light and is forgetful. V6 states that no one has ever directed her to frequently remind R49 to use her call light or call for help. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 4 of 8 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 145999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Niles 6601 West Touhy Avenue Niles, IL 60714 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 - Actual harm Residents Affected - Few On 06/15/23 10:56 AM V18 (Physical Therapy Director of Rehab) states they started seeing R49 on 5/15/23 after R49's elopement and they are working on balance, strengthening, and cognition for speech, ADL training and toilet transfer. V18 states, R49 was having balance issues. When she stood, she would fall back or sideways. V18 states, the week before the 6/4/23 fall R49 required one person touch assist with ambulation. V18 states they inform nurses what we recommend verbally. V18 states R49 is forgetful. V18 states, R49 would Definitely, forget to do the things we asked her to do. V18 states R49 is not safe ambulating alone as of 5/15/2023 until now. Review of facility's falls log documents five falls since October 2022 for R49. R49 fell on [DATE] (documented left arm fracture per progress notes), 11/25/22, 1/2/23, 4/1/23, and 6/4/2023. Review of fall assessments dated 1/6/23 and 4/1/23 documents resident was at risk for falls. Fall occurrence form dated 1/2/23 documents CNA saw resident falling backwards. Fall occurrence form dated 4/1/23 documents resident trying to transfer herself from chair and slid to the floor. R49's fall risk care plan documents the 1/2/23 fall intervention as follows: Remind patient on asking for assistance, frequent monitoring, and redirection. R49's fall risk care plan documents the 4/1/23 fall intervention as follows: Continue frequent monitoring and frequently reminding resident to ask for help. On 6/15/23 01:19 PM V2 (Director of Nurses) states R49 tries to get up on her own. V2 states that the interdisciplinary team including herself determine interventions after each fall. The facility's Fall Prevention Program policy dated 11/21/17 documents the following: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized, as necessary. Care plan incorporates: Identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 5 of 8 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 145999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Niles 6601 West Touhy Avenue Niles, IL 60714 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the facility failed to avoid prescribing unnecessary psychotropic medications for one resident (R135) of five residents reviewed for unnecessary medications in the sample of 19. Findings include: A Physician's Order by V36 (Psychiatrist) dated 6/9/23 indicates Haloperidol 2 MG (milligrams) Give 2mg by mouth every 8 hours as needed for unspecified psychosis not due to a substance or known physiological condition for 30 days. The order for the antipsychotic is not limited to 14 days. There is no documentation that V36 examined the resident. On 6/15/23 at 3:50 PM V33 (Medical Director) said when an antipsychotic is ordered the physician should document the diagnosis and indication. The risks and benefits should be discussed with the resident if able and the family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 6 of 8 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 145999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Niles 6601 West Touhy Avenue Niles, IL 60714 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 - Many 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 follow their policy and ensure that kitchen staff wore beard hair covers while preparing food. This failure has the potential to affect all residents that receive food from the kitchen. Findings include: On 06/13/23 09:50 AM during initial tour of the kitchen, observed V24 (Cook) busy in food prep area with full reddish mustache and beard about ½ inch long. Observed V25 (Dishwasher) going in and out of kitchen with no hair net or mustache cover on. On 06/13/23 11:01 AM observed V24 (Cook) in kitchen cooking and not wearing a beard or mustache cover. V24 observed stirring 2 big pots that are cooking on the stove. V24 states the contents of the pots are ground meat and broth for chicken. Then observed V24 stirring and putting carrots in a different dish. On 06/13/23 11:10 AM V23 (Dietary Manager) states the cook and dietary aids should be wearing mustache and beard covers while in the kitchen. On 6/25/2023 at 3:10 PM V3 (Infection Preventionist/Assistant Director of Nurses) states in the kitchen staff should were covering over their beard to prevent hair from going into the food. This is a sanitation issue. The facility's Hair restraint policy documents: Guideline: hair restraints shall be worn by all Dining Services staff when in food production areas, dishwashing areas, or when serving food. Procedure: 1. Staff shall wear hair restraints in all food production, dishwashing, and serving areas. 2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 7 of 8 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 145999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Niles 6601 West Touhy Avenue Niles, IL 60714 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 interview and record review, the facility failed to perform preventative maintenance to decrease risk for Legionella growth as outlined in their policy and procedure. This deficiency has the potential to affect all 81 residents in the facility. Residents Affected - Many Findings include: On 06/13/2023 at 2:30PM during record review, Boilers Environment Temperature Logs from January to May 2023 were noted with two-week monitoring for January, February, April and May 2023 and one-week monitoring for March 2023. On 06/13/23 at 3:24 PM, V16 (Maintenance), while with V1 (Administrator), stated that they only check the domestic hot water boiler temperature for 5 days a week for two weeks per month. On 06/14/23 at 2:45PM, V1 (Administrator) reviewed Boilers Environment Temperature Logs from January to May 2023 were noted with two-week monitoring for January, February, April and May 2023 and one-week monitoring for March 2023 and said that it should have been checked five times per week. Facility Policy: Title: Water Management Program for Prevention of Legionella Growth Revisions: 7-19-19 Purpose: To identify and reduce the risk of Legionella growth and spread. Guidelines: Preventative maintenance will be performed as applicable: - Hot water temperatures will be obtained at the domestic hot water boiler and at the mixing valve at least 5 times per week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 8 of 8