Health inspection·April 4, 2024

F 0550 with Dysplasia, and Alzheimer's Disease. Level of Harm - Minimal harm or potential for actual harm R44's care plan dated 10/20/2023 reads in part, Eating/Swallowing Program: Put resident in an upright position while sitting in (geriatric) chair during meals. Assist with opening condiments, monitor intake, and encourage resident to bring his head slightly forward and feed self, using verbal cueing during meal. Provide assistance with extensive assist of 1 staff. Residents Affected - Some On 04/01/24 at 12:55 PM observed V31 (CNA) during lunch time. V31 was standing while assisting R44 with feeding. On 04/03/24 at 12:30 PM observed V25 (Registered Nurse) observed during lunch time. V25 was feeding R44 while standing up, feeding quickly, rushing R44 to swallow food. 5. R71 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Dementia, Anemia, Dysphagia, Anorexia, and History of Falling. R71's care plan dated 05/15/2023 reads in part, Provide necessary assistance with PO intake. On 04/01/24 at 01:00 PM observed V33 (CNA) assisting with lunch meal. V33 was standing while assisting R37 and R71 with feeding, feeding both residents simultaneously. On 04/03/24 at 12:40 PM interviewed V34 (Certified Nursing Assistant) who stated in summary: It's important to sit down and feed resident in sitting position to have face to face interaction. Also, sitting down allows you to ask if they like the food or not. I think it's also a rule to sit down while providing feeding assistance. On 04/03/24 at 03:23 PM interviewed V4 (Assistant Director of Nursing) who stated in summary: Staff providing feeding assistance to residents should be sitting down during entire mealtime. One of the reasons for providing feeding assistance while sitting down is to maintain eye contact, interaction, and safety, to make sure resident can swallow. It also makes residents feel more comfortable. The facility Contract between Resident and Facility. Attachment E: Statement of Residents Right (no date) reads in part, The right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy, and choice and to be treated with consideration and respect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 2 of 15 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 04/04/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 properly administer physician ordered continuous oxygen to an immunocompromised resident dependent on supplemental oxygen and monitor oxygen saturation level for 1 (R290) of 1 resident reviewed for oxygen therapy in sample of 41. Residents Affected - Few Findings include: R290 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Hemiplegia and Hemiparesis, Progressive Leukoencephalopathy, HIV, Cytomegaloviral Disease, Acute Flaccid Myelitis, and Dependence on Supplemental Oxygen. R290's care plan dated 03/28/2024 reads in part, Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. R290's Physician orders dated 03/28/2024 reads in part, Oxygen at 3LPM via N/C continuous every shift for Pneumocystosis. On 04/01/2024 at 01:28 PM observed R290 laying supine in the bed. Nasal Cannula observed to be laying around R290's neck, not inserted into R290's nostrils, not delivering oxygen. R290 noticed to be diaphoretic breathing at an increased rate. On 04/01/24 at 01:31 PM V25 (Registered Nurse/RN) entered R290's room. Surveyor pointed to R290's nasal cannula and asked if this is an accurate nasal cannula placement, wrapped around R290's neck, V25 denied and placed nasal cannula's prongs in R290's nostrils. Surveyor proceeded to interview V25 who stated in summary: R290's nasal cannula is off but when I came in earlier, around 10:00 AM, the nasal cannula was on. Surveyor asked how is R290's oxygen saturation monitored and whether it is important to monitor it for residents depending on continuous oxygen therapy. V25 stated: R290's oxygen saturation level is checked once per shift with vital signs. R290 is a critical care resident, so we have to monitor her oxygen saturation. R290 also has some abnormal breathing, so chest x-ray was done yesterday, and we are currently waiting for the x-ray results. Surveyor clarified if a resident has acute respiratory issue, should oxygen saturation level be monitored even closer, V25 agreed. On 04/01/2024 at 1:40 PM V25 (RN) left R290's room, obtained oxygen saturation measuring device, measure R290's oxygen saturation at 94%. Per 290's electronic medical record, last oxygen saturation level checked on 03/29/2024 noted to be at 96%. No documented oxygen saturation level found between 03/29/2024 and 04/01/2024. On 04/01/24 at 01:45 PM V25 (RN) stated: I will notify R290's nurse practitioner about the decreased oxygen saturation level. On 04/01/2024 at 2:00 PM interviewed V4 (Assistant Director of Nursing/ADON) who stated in summary: I think we should have order set for oxygen level monitoring for residents on continuous oxygen therapy. Residents like R290, would require vital signs, including oxygen saturation, check at least once every shift. I worked with R290 yesterday, and heard some wheezing when I assessed her, so chest (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 3 of 15 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 04/04/2024 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 0695 x-ray was ordered. R290 definitely needs oxygen monitoring. Level of Harm - Minimal harm or potential for actual harm On 04/03/24 at 10:55 AM interviewed V26 (Physician Assistant) who stated in summary: Resident requiring continuous oxygen therapy mostly require at least once a shift oxygen saturation level check. Residents Affected - Few On 04/03/24 at 03:23 PM interviewed V4 (ADON) who stated in summary: Nurses and CNAs are expected to follow physician's order. It's important because it is quality of care of the resident. Physician place orders based on assessment, testing, and expertise, to come up with way to care for a resident. Nurses and CNA may have suggestions that they can communicate to a medical doctor; however, it is the doctor who makes sure all appropriate orders are carried out. R290's chest x-ray report dated 04/01/2024 reads in part, Findings: The lungs demonstrate patchy right-sided pneumonia. Oxygen Therapy policy not provided by V1 (Administrator) upon surveyor's request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 4 of 15 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 04/04/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate nutrition, and follow dietary order for 2 (R18, R44) of 5 reviewed for nutrition in the sample of 41. Findings include: 1. R18 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Hemiplegia and Hemiparesis, Major Depressive Disorder, Malignant Neoplasm of Brain Aphasia, and Dysphasia. R18's physician order dated 02/29/2024 reads in part, General Diet. Mechanical Soft texture, Regular/Thin Consistency. R18's care plan dated 11/14/2023 reads in part, Encourage The resident's family members to bring in favorite food items from home or favorite restaurant items: [NAME] John's sandwich, sausage w/ onion pizza, pork sandwich. Give to dietary to ensure correct texture. R18's Nutrition Progress Note dated 03/04/2024 shows R18's current body weight at 92.2 lbs, BMI 15.8 (underweight) and 20.7% weight loss in 5 months. On 04/02/24 at 10:30 AM observed R18 observed, laying in the bed, appears emaciated. On 04/02/24 at 10:30 AM interviewed V27 (Licensed Practical Nurse/Wound Care Nurse) who stated in summary: The family brings R18 sandwiches. R18 is on mechanical diet, so we educated them, but they disregard our recommendations. R18 also needs assistance with feeding. On 04/02/24 at 12:38 PM observed R18's lunch tray placed and can of soda on the bedside table, in front of the R18, R18 asleep in the bed. R18' meal ticket reads in part, Mechanical Soft Diet, Thin Liquids. On 04/02/24 at 12:40 PM Surveyor V28 (Certified Nursing Assistant/CNA) come into R18's room. V28 offered lunch tray but R18 refused. V28 reached to R18's personal refrigerator and placed sandwich on the bedside table. R18 proceeded to eat the sandwich while V28 assisted with drinking soda and intermittently feeding supplemental frozen dessert. R18 able to feed self, eating sandwich and coughing periodically, observed having difficulty swallowing. Surveyor interviewed V28 who stated in summary: R18' family lives out of state, they order sandwiches from there and sandwiches get delivered to the facility. On 04/02/2024 at 01:15 PM Surveyor interviewed V29 (Registered Nurse) who stated in summary: R18's family says it's better for him to eat sandwich rather than nothing. But they don't see R18, so maybe it's hard for them to understand. R18 calls the family, tells them what he wants to eat, they order it, and it gets delivered to the facility. I educated the family that sandwiches are dangerous for him, and we have to assist him throughout the feeding, and we don't have enough staff to do that, but they don't understand that. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 5 of 15 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 04/04/2024 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 0803 On 04/03/24 at 11:15 AM Surveyor interviewed V30 (Dietitian) who stated in summary: Level of Harm - Minimal harm or potential for actual harm R18 is on mechanical diet. Sandwiches provided by the family would not be appropriate as part of mechanical diet. Mechanical soft diet consists of sandwiches with soft lunch meat, no raw vegetables, and soft bread but and I don't know what's on the sandwiches that he eats on daily basis. Residents Affected - Few On 04/03/24 at 11:50 AM Surveyor interviewed V7 (Dietary Manager) who stated in summary: R18 is on pureed food. Sandwiches provided by the family are not mechanically altered, so R18 can choke. If the sandwiches were delivered to me, and I could mechanically alter them, and make it safe for R18 to eat, but I wasn't aware that R18 eats sandwiches. 2. R44 is an [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Neurocognitive Disorder with Lewy Body, Psychosis, Depression, Barrett's Esophagus with Dysplasia, and Alzheimer's Disease. R44's physician order dated 06/23/2023 reads in part, Low Potassium Diet. Regular Texture, Regular thin liquids, consistency. Provide 1 plate in front of resident at a time during meals for improved PO intake. R44's care plan dated 10/20/2023 reads in part, I will eat enough nutrients during mealtimes. R44's Nutrition Progress Note dated 04/03/2024 shows R44's current body weight at 142.4 lbs, trending downward. On 04/01/24 at 12:55 PM observed V31 (CNA) feeding R44 with supplemental frozen dessert, no lunch tray offered to R44. Surveyor interviewed V31 (CNA) who stated in summary: R44 only eats ice cream or sweet stuff, she spits out regular meals, so we don't even try to offer it to her. R44 has been doing that for at least 2 months that I have been here. Nurses are aware. R44's meal ticket reads in part, Low Potassium/Thin Liquids/No Yogurt Pureed Diet; Pureed Turkey Tetrazzini, Pureed Parslide Bowtie Noodles, Pureed Buttered Corn, Pureed [NAME] Bread, Margarine, Pureed Apple Pie. On 04/01/24 at 01:09 PM interviewed V25 (Registered Nurse/RN) who stated in summary: R44 only eats ice cream because if we try to feed her other food, she spits it out. R44 only eats sweet treats like apple sauce, ice cream, or oatmeal w/sugar in the morning. When we see she has good apatite, we pour sugar over her plate, so she eats it. R44 has dietary supplements such as house nutrition supplement. R44 only likes to drink supplements but not water. On 04/03/24 at 11:04 AM interviewed V30 (Dietitian) who stated in summary: As of today, R44 does not display significant change in weight but there was gradual weight loss over the last 6 months. R44's diet is low potassium with house supplement three times a day and no yogurt. No yogurt is due to R44's preference. I was not aware that R44 doesn't eat her meals. Staff should document that R44 doesn't consume regular meals. If staff only gives supplemental frozen dessert, that what should be documented. Staff should be offering meal, even if R44 refuses to eat it. Nutritionally speaking, R44 won't be meeting her nutritional needs from consuming supplemental frozen dessert only. No progress note noticed in R44's electronic medical chart showing that R44 eats sweet treats only and not eating regular melas. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 6 of 15 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 04/04/2024 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 0803 On 04/03/24 at 11:43 AM interviewed V7 (Dietary Manager) who stated in summary: Level of Harm - Minimal harm or potential for actual harm I have never heard that R44 refuses all meals. Staff should offer a meal; R44 must be offered a tray. R44 can eat what they prefer but sugary treats would not be a wholesome diet. Staff should not sprinkle sugar over R44's plate to encourage eating. There is no nutritional value in sugar. Residents Affected - Few On 04/03/24 at 12:30 PM R25 (RN) observed feeding R44 during lunch time. R25 standing up, feeding quickly, rushing R44 to swallow. R44 covered mouth periodically; however, after multiple attempts of persistent cuing, R44 consumed supplemental frozen dessert, vanilla shake house supplement, and yogurt, despite no yogurt shown on R44's meal ticket. On 04/03/24 at 03:23 PM interviewed V4 (Assistant Director of Nursing) who stated in summary: Nurses and CNAs are expected to follow physician's order. It's important because it is quality of care of the resident. Physician place orders based on assessment, testing, and expertise, to come up with way to care for a resident. Nurses and CNA may have suggestions that they can communicate to a medical doctor; however, it is the doctor who makes sure all appropriate orders are carried out. The facility Diet Order policy (no date) reads in part, Each resident will have a diet order prescribed by the physician (or Registered Dietitian were allowed by State and Federal Guidelines) and documented in the health record. Diet orders are clearly communicated, using the designated diet order communication form, to Dining Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 7 of 15 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 04/04/2024 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 observations, interviews, and record reviews, the facility failed to: 1. wear a hair restraint to cover a beard while in the kitchen, 2. ensure hand soap was available at the hand washing sink in the kitchen, 3. maintain sanitizing solution buckets at 200 ppm (parts per million) of Quaternary Ammonium solution for sanitizing kitchen surfaces and dishes in the three compartment sink, 4. maintain sanitizing solution in the low temperature chemical sanitizing dishwasher at 50-100 ppm (parts per million) of Chlorine solution for sanitizing kitchen dishware and utensils, 5. cover, date, and label prepared desserts in the refrigerator, and a bag of fish while stored in the freezer, 6. ensure staff are properly trained how to clean the kitchen, 7. perform hand hygiene prior to putting on gloves to prepare food and maintain infection control, 8. follow the recipe with exact measurements during food preparation, and 9. ensure food handler certificates were renewed for staff in a timely manner. This failure has the potential to affect 87 residents who received oral meals from the facility's kitchen and 23 of the residents who consume the Korean meals. Findings include: On 4/1/24 at 11:06 AM, upon entrance to the kitchen, V8 (Dishwasher) was observed with a full beard standing near the food prep line stacking clean food trays. V8 was not wearing a beard protector. V8 was inquired of not wearing a beard protector. V7 (Dietary Manager) entered the kitchen. V7 was inquired of V8 not wearing a beard protector while handling clean food trays. V7 said, V8 is a dishwasher, but he should have a beard cover on. V7 told V8 to put on a beard protector in English and handed one to him. V7 said, V8 doesn't speak much English. I don't remember his language. I use Google translate to talk to him. On 4/1/24 at 11:10 AM, surveyor approached the hand washing sink to perform hand hygiene. There was no soap in the soap dispenser at the sink. V18 (Cook) said, I used the last bit of soap. V7 (Dietary Manager) was inquired of the person responsible for checking the soap levels for the hand washing sink. V7 said, Everyone should be checking the soap. V7 was inquired of the importance of the soap at the hand washing sink. V7 said, They need the soap for cleanliness, infection control, and proper hygiene. On 4/1/24 at 11:19 AM This surveyor asked V7 (Dietary Manager) to test the sanitation buckets in the food preparation area. V7 was inquired of the sanitation solution used. V7 said, We use Quat (Quaternary) in the buckets. On 4/1/24 at 11:21 AM, V7 dipped the sanitation test strip into the sanitation bucket #1 across from the stove area. The test strip color read at the 100 ppm (parts per million). V7 was inquired of the test strip reading. V7 said, It should be at least 200 (ppm). On 4/1/24 at 11:22 AM, V7 dipped the sanitation test strip into the sanitation bucket #2. The test strip color read at the 0 ppm. V7 was inquired of the test strip reading. V7 said, It should be at least 200 (ppm). I'll have them change these buckets. On 4/1/24 at 11:23 AM, V9 (Dishwasher) was observed washing the cooking pans at the 3-compartment sink. V7 was asked to test the sanitation of the 3-compartment sink. V7 dipped the sanitation test strip into the sink area labeled sanitize. The test strip color read at the 0 ppm. V7 was inquired of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 8 of 15 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 04/04/2024 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 the test strip reading. V7 said, It should be at least 200 (ppm). V7 began adding more sanitizing solution to the sink area. On 4/1/24 at 11:25 AM, V9 (Dishwasher) was inquired of checking the sanitizing solution in the 3-compartment sink. V9 said, I push the button by the sink 3 times. V9 was not able to explain how to check the sanitizing solution in the 3-compartment sink. On 4/1/24 at 11:30 AM, V7 was inquired of testing the sanitation of the single rack dish washing machine and the type of washer it was. V7 said, It uses chlorine. V7 put a sanitation strip on the dish rack and ran it through the dish washing cycle. The sanitation strip read at 25 ppm. V7 was inquired of the strip reading. V7 said, It should probably be around 100. I'll tell maintenance to check it or have them call the supplier. On 4/1/24 at 11:36 AM, review of the refrigerator identified a full cart of desserts uncovered. V7 was inquired of the desserts. V7 said, Those are cups of apple pie for lunch today, they should be covered. On 4/1/24 at 11:40 AM, review of the freezer identified an open bag of Tilapia fish with no open date. V7 was inquired of the bag of fish. V7 said, It's a bag of fish, it should be closed, dated, and labeled. The Korean meal had fish for dinner last night. On 04/01/24 at 12:14 PM, during lunch observation on the second-floor residents are being served lunch on kitchen dishware plates, coffee cups, juice cups, and utensils. The kitchen did not provide disposable dishware due to the dishwashing machine found to be out of acceptable range for the chemical sanitizing concentration. On 4/3/24 at 10:13 AM, V8 (Dishwasher) took the mop over to the dish washing sink sprayer and sprayed water on the mop. V8 wrung out the mop and began mopping the floor. V7 (Dietary Manager) observed V8's action. V7 was inquired of the correct procedure to mop the floor. V7 said, V8's supposed to use the bucket and the cleaning solution to mop the floor. V8 does not to appear to know the mopping procedure. V7 attempted to demonstrate how to use the mop and bucket to V8. On 4/3/24 at 10:39 AM, V17 (Cook) is preparing the Omu rice and cucumber salad for the Korean lunch. V17 cleaned the food preparation table with a red kitchen towel she wet with water at the food preparation sink. She threw her gloves into the garbage. She went over to the food preparation sink and rinsed her hands with water. V17 then picked up another red kitchen towel and dried her hands off with the towel and placed it onto the food preparation table. V17 did not perform hand hygiene at the handwashing sink and put the used kitchen towel she dried her hands on onto the food preparation table while preparing a meal failing to maintain infection control. On 4/3/24 at 10:43 AM V17 (Cook) is using a disposable plastic spoon to measure spices. V17 left the spoon in one spice container and continued preparing the dish. Then removed the spoon and used it to dispense a different spice from another container. V17 is not using appropriate measuring spoons to measure spices for the recipe. V17 is using the same spoon to dispense spices from two different containers. On 4/3/24 at 10:47 AM, V17 removed gloves from her hands, then picked up the red kitchen towel on the food preparation table and wiped her hands with it. V17 set the towel back on the food preparation table and put on a new pair of gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 9 of 15 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 04/04/2024 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 On 4/3/24 at 10:50 AM, V17 removed gloves from her hands, went over to the food preparation sink, and rinsed her hands with water. V17 picked up the red kitchen towel on the food preparation table and wiped her hands with it. V17 set the towel back on the food preparation table and put on a new pair of gloves. V17 began touching multiple surfaces then went to the food preparation sink and picked up cucumbers from a colander rinsing them with water. V17 did not perform hand hygiene at the handwashing sink and put the used kitchen towel she dried her hands on onto the food preparation table while preparing a meal failing to maintain infection control. On 4/3/24 at 11:14 AM, V23 (Social Services) assisted V17 (Cook) with Korean translation during interview with surveyor regarding food preparation concerns. What is the food preparation sink should be used for? V17 responded and V23 translated and said, Preparing and washing food. Is it appropriate to rinse or wash your hands in the food preparation sink? V17 responded and V23 translated and said, When I came in to work, I used the hand wash sink and washed my hands. When I rinsed the vegetables, I took off my gloves and rinsed my hands. No, I shouldn't wash them here, I should use the hand wash sink. Is it appropriate to use the kitchen towel to dry your hands and put the towel back on the food preparation table? V17 responded and V23 translated and said, I tried to dry my hands. I know I shouldn't use the towel, No. How should spices be measured appropriately? V17 responded and V23 translated and said, I used a spoon. V17 picked up a plastic spoon from under the food preparation table storage area to show this surveyor. V17 did not know she was to use measuring spoons to measure the spices for the recipe. Is it appropriate to leave a spoon inside a spice container? V17 responded and V23 translated and said, I was making two dishes, but I needed the same spices, so I put it in their temporarily. When gloves are removed from your hands what should be done? V17 responded and V23 translated and said, If something contaminates the gloves, I should wash my hands in the hand wash sink. V7 (Dietary Manager) is present during V17's interview and was inquired of V17's food preparation concerns. V7 said, V17 knows to use the hand washing sink and not to use the towels for her hands. She shouldn't put the towel on the table, it's for infection control. She knows to put it in the bin. V17 is supposed to use measuring spoons to measure the spices. On 04/03/24 at 11:45 AM, review of the food service certificates found 5 staff with expired certificates. V19 Cook, V20 Cook, V21 Cook, V22 Dietary Aide, and V18 Cook. V7 (Dietary Manager) was inquired. V7 said, Yes, I know some of them are expired. On 04/03/24 at 12:58 PM, V7 (Dietary Manager) was inquired why disposable dishware wasn't provided for the lunch meal on 4/1/24 when the dishwasher chemical sanitizing solution read 25 ppm. V7 said, No reason. We did use it for dinner. When was the dishwasher serviced? V7 said, It was done Tuesday (4/2/24) by an outside company. The Dining RD Guideline & Procedure Manual 2020 Hair Restraints Policy states in part: Guideline: Hair restraints shall be worn by all dining services staff when in food production, dishwashing, and serving areas. 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 10 of 15 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 (X3) DATE SURVEY COMPLETED A. Building 04/04/2024 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 The Dining RD Guideline & Procedure Manual 2020 Sanitizing and Disinfectant Solutions Policy states in part: Guideline: Employees shall refer to the manufacturer guidelines for the proper use of sanitizer and disinfectant solutions. Residents Affected - Many Procedure: 1. The employee will prepare sanitizer solution or disinfectant solution in accordance with manufacture guidelines. 2. If a dispensing system is used, appropriate concentration level will be tested at least daily. 3. If a solution must be prepared, guidelines for preparation will be posted or available to staff. The staff member will prepare the solution in accordance with posted or available instructions and test with a test tape/strip before use. 5. Bleach solution should be at a concentration of greater than or equal to 50 to 100 ppm or in accordance with label instructions for other types of sanitizers. 6. This solution can be used for sanitizing equipment and food contact surfaces. All rags used for sanitizing must be kept submerged in sanitizing solution when not in use. The Dining RD Guideline & Procedure Manual 2020 Cleaning Instructions: Floors states in part: Guideline: Floors will be kept clean and sanitary, washed daily or as needed. Procedure 2. Floors will be washed daily, using hot water and detergent: a. Fill designated mop bucket with hot water and detergent. b. Place wet floor signs around the selected area to be mopped. c. Dip mop into detergent solution, and mop one section of the floor at a time. d. If the floor is exceedingly dirty, allow solution to sit prior to mopping. e. Mop in a figure eight motion, apply pressure on the top of the mop. f. Allow the floor to air dry. The Dining RD Guideline & Procedure Manual 2020 Food Storage (Dry, Refrigerated, and Frozen) Policy states in part: Guidelines: Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 11 of 15 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 04/04/2024 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 All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. See dated marking guidelines in this section for exceptions to dating individual dry storage food items. The Dining RD Guideline & Procedure Manual 2020 Labeling and Dating Foods (Date Marking) Policy states in part: Guidelines: All foods stored will be properly labeled according to the following guidelines. Procedure: 3. Date marking for freezer storage food items. Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. The Dining RD Guideline & Procedure Manual 2020 Proper Hand Washing and Glove Use Policy states in part: Guidelines: All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines. Procedure: 6. Hands are washed before donning gloves and after removing gloves. 7. Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment. 9. When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash, and re-glove. The Dining RD Guideline & Procedure Manual 2020 Dishwashing: Machine Operation Policy states in part: Guideline: The dining services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. Procedure: 1. All dishwashing machine should be operated according to manufacturer recommendations. Tableware, utensils, pots, and pans should be cleaned and sanitized in either a high temperature dish washing machine that uses hot water, or a chemical sanitizing dish washing machine that uses a chemical sanitizing solution. 4. If the machine is found to be out of the acceptable range for either final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes. Empty dish washing machine, check nozzles and empty bottom screen and restart the dish washing machine. 5. After trouble shooting, if the dish washing machine is not functioning, the employee should contact the dining services manager or maintenance or outside vendor per facility guidelines to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 12 of 15 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 04/04/2024 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 coordinate repair. The dish washing machine should be labeled out of service and not utilized until the dish washing machine is repaired. Level of Harm - Minimal harm or potential for actual harm The Dining RD Guideline & Procedure Manual 2020 Standardized Recipes Policy states in part: Residents Affected - Many Guidelines: Standardized Recipes will be used for all menu items, including pureed and therapeutic diets. Procedure: 1. Each standardized recipe will include the following: d. measurement and/or weight of ingredients. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 13 of 15 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 04/04/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow standard infection control practices by not washing hands and not changing gloves while performing dressing change for 1 (R41) of 1 resident reviewed for pressure injury in the sample of 41. This failure may affect 10 resident who currently require dressing changes. Residents Affected - Some Findings include: On 04/04/2024 at 11:30 AM V1 (Administrator) provided list of residents who require dressing changes, the list contains of 10 residents. R41 is an [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Paraplegia, Osteoporosis, Vascular Dementia, Hypothyroidism, Hypotension, and hypertension. According to R41's MDS (Minimum Data Set) section M dated 02/29/2024, R41 has one or more unhealed pressure ulcers/injuries. R41's care plan dated 10/19/2020 reads in part, Follow facility protocols for treatment of injury. R41's physician order dated 03/28/2024 reads in part, Left Lateral Leg: Cleanse wound with NSS (normal saline solution), Apply calcium alginate with silver topical, cover with layers of gauze, wrap with (brand name of gauze wrap) and secure with tape 3x per week. On 04/02/24 at 10:31 AM interviewed V27 (Licensed Practical Nurse/Wound Care Nurse) who stated in summary: R41 has left outer ankle pressure ulcer that's Stage 4 now, he acquired it on 12/24/2023. Recently, R41 developed infection in that wound that required antibiotic therapy. Order for wound care includes calcium alginate with silver, gauze, and (brand name of gauze wrap). The dressing is changed 3 times a week. We utilized an offloading device, but they were ineffective, so now we just use a pillow to elevate his legs. The wound has been stable. R41 also has an unstageable left calf pressure ulcer that was acquired in the facility as well. One of the offloading devices that was supposed to help with ankle wound, caused calf wound. On 04/03/24 at 12:44 PM observed R41 sitting up in the bed, set up to eat lunch. Pillow placed underneath his knees, heals resting directly on the bed mattress. Surveyor approached V35 (Licensed Practical Nurse/LPN) to inquire about R41 pillow placement, R35 stated in summary: I am the float nurse today, so I go between both facility units. The pillow should prevent R41's legs from crossing and his heels resting on the mattress. R41 moves a lot, so the pillow is not the best for him. We tried offloading device but R41 removes it too. On 04/03/2024 at 1:00 PM Surveyor asked V35 (LPN) to see R41's pressure injuries. V35 brought wound care cart into the room and prepared wound care supplies. V35 proceeded then to undressing R41's wound without performing hand hygiene, only donning gloves. V35 measured both wounds, applied treatment consisting of cleaning both wounds with wound cleanser, applying dressing containing calcium alginate with silver, putting gauze over it, taping gauze to the skin, and wrapping both wounds with (brand name of gauze wrap). V35 did not change gloves nor performed any sort of hand hygiene throughout (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 14 of 15 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 04/04/2024 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 dressing change procedure for both wounds. Level of Harm - Minimal harm or potential for actual harm On 04/03/24 at 03:23 PM interviewed V4 (Assistant Director of Nursing) who stated in summary: Wound care, including dressing changes, are usually scheduled three a week. V27 (Wound care nurse/LPN) does it or me if V27 is not available. Floor nurses can help but it's V27's and my primary responsibility. Floor nurses are allowed to do wound care on acutely acquired wounds or when dressing gets soiled. Nurses are expected to follow physician orders, infection prevention, and resident rights while performing wound care. Infection prevention includes washing hands and wearing and changing gloves. Wound care cart should always stay outside of the residents' room. Before initiating dressing change, nurse should perform hand hygiene and put on gloves. They can then remove old dressing followed by removing gloves, performing hand hygiene, and placing new gloves on. Next, nurse should clean the wound, perform hand hygiene, and put new gloves on. Finally, nurse and can finish with a dressing change, and when done, they should perform hand hygiene. If at any point during wound care or dressing change, nurse touches contaminated area, they should perform additional hand hygiene and glove change. Residents Affected - Some The facility Infection Prevention and Control Program policy dated 11/28/2017 reads in part, To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. All facility personnel shall adhere to the Infection Control Program in the performance of their daily assignments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145999 If continuation sheet Page 15 of 15