Health inspection·April 25, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but reported the family said it was a long time. V2 reported call lights need to be answered as soon as they are put on and gave an average time frame of 5 to 10 minutes on when staff answer call lights. On 04/24/25 at 10:54 AM, V15 (CNA) reported V15 did not care for R15 so V15 was unaware of the refrigerator being taken in V15's room. V15 reported another R82 had a refrigerator placed in the room last week. V15 confirmed staff is responsible to clean the refrigerators and date/label food. V15 stated nurses, CNAs, and the dietary manager check the refrigerator at least a couple times per week. V15 denied any management telling staff that residents were not allowed to have personal refrigerators in their rooms anymore. On 04/24/25 at 11:05 AM, the surveyor observed a personal refrigerator in R82's room. The surveyor then saw V15 in the hall and V15 said, Yes. I told you she had a fridge in her room. On 4/24/25 at 3:57PM, V37 (Director of Customer Experience) stated an in-service was completed on 2/10/25 for call light response time. V37 reported it was discussed the importance of answering the call lights as soon as possible so residents' needs are being taken care of. V37 stated V37 has gotten complaints from residents or family's within the last six months about call light wait time. V37 reported the complaint time is for waits that are more than two or three minutes. V37 could not give an exact time family's reported waiting for a response. On 4/25/25 at 12:15PM V1 stated the facility began removing personal fridges from resident rooms about a week ago due to safety concerns of dementia residents going into fridges and taking items that are not on their diet. V1 reported some residents still have personal fridges in their room because the facility is still getting around to taking them out. V1 reported angel rounds are done daily by staff and anything in the room that should not be there should be removed and reported as soon as possible. V1 stated R82's refrigerator has not been removed yet because the facility has not educated the family yet. There is no documentation of education that was provided to R15 or V36 on the facility's new protocol of not allowing personal refrigerators in the resident rooms. An in-service dated 2/10/25 documents the topic of education as all staff are to ensure that call lights are answered in a timely manner. CNAs and nurses were the staff educated in this in-service. The policy titled, Call Light Response, dated 1/10/24 documents, General: To provide the staff with guidance on responding to residents' requests and needs. Protocol: .6. Answer the patient or resident's call as soon as possible. The policy titled, Personal Food, dated 01/2024 documents, General: To provide guidance regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Responsible Party: Nursing Staff, Social Services, Administration, Housekeeping, Nutritional Services Guideline: .3. Facility staff will assist the resident in accessing and consuming the food, if the resident is not able to do so on his or her own. The Illinois Long-Term Care Residents' Rights for People in Long-Term Care Facilities dated 11/2018 documents, Your rights to dignity and respect- You have a right to make your own choices. Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source .You may be informed, in advance, of changes to the plan of care .You may keep and use your own (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 2 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0550 property. Level of Harm - Minimal harm or potential for actual harm The Contract Between Resident and Facility documents, .C. Resident's Rights and Obligations .4. No food, liquids, or medicines will be brought into the Facility without permission of the Administrator or nurse in charge. Food must be in sealed containers .11. The Resident is free to decorate his/her Room as he/she wishes, provided that the Resident complies with the safety rules of the facility. The Resident may not make any structural or physical changes to his/her Room, unless expressly approved in writing by the Facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 3 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow their Call Light Response policy, by not placing the call light within reach. This affected one of three residents (R321) reviewed for accessible call lights. Residents Affected - Few Finding Include: On 4/22/25 at 12:00pm to 12:08PM, R321 heard yelling Someone Please Help me. Observed R321 in his room, up on a Geri chair, on right side of the bed, foot side area. Call Light on bed, in upper head part of the bed, not within reach of R321. R321 was asking to be put back to bed and voiced out that he is looking for his dentures. On 4/22/25 at 12:10PM, confirmed with V4 (CNA/Restorative Aide) that R321's call light is not within R321's reach. V4 moved and placed the call light closer to R321, and within his reach. On 4/25/24 at 9:00AM, V2 (DON) stated that staff should place the call light within resident's reach. If coming from dialysis, the person placing him in the room should make sure that the call light is within the resident's reach, so they can call for assistance. Call light response policy with a revision date of 3/17/25, reads in part: To provide the staff with guidance on responding to residents' requests and needs. Ensure the call light is always within resident's reach. When the patient or resident is in bed or confined to a bed or chair, provide the call light within easy reach of the patient or resident. Answer the patient or resident's call as soon as possible. Listen to the patients/resident request. Do what the resident as of you, if permitted, if you are uncertain whether a request can be fulfilled or cannot fulfill the patient/resident's request, ask for assistance. If assistance is needed when you enter the room, summon help to the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 4 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to preserve one resident's privacy and dignity and obtain informed consent from the resident and resident's POA (power of attorney) to reside in a semi-private room in which the roommate has constant video monitoring. This failure affected two resident (R71, R77) out of three reviewed for privacy in a sample of 37. Residents Affected - Few Findings include: On 4/22/25 at 10:00 AM, signage was observed on R71 and R77's room doorway noting video monitoring is occurring. On 4/25/25 at 8:30 AM, V1 (administrator) stated that consent is obtained if a roommate is placed in a room with video monitoring. On 4/25/25 at 9:10 AM, V17 (social services) stated that R77's BIMS (brief interview of mental status) is 9 or 10 out of 15. V17 stated that R77 can make her needs known. V17 was questioned regarding reason R77's signature and date do not match from the original document in R77's EMR (electronic medical record) and the copy given to this surveyor. V17 stated that she gave this surveyor the original document of the consent and did not want to ask for the original back so she had the resident sign a new consent form and placed in R77's EMR yesterday. When questioned reason this consent was not uploaded into R77's EMR on 9/23/24, V17 replied that this document does not have to be in the EMR. When questioned reason R71's consent was uploaded into R71's EMR, V17 did not respond. V17 stated that this consent form for R77's roommate having a video monitor in room is not related to healthcare and therefore did not need informed consent from R77's POA (power of attorney for healthcare). V17 stated that she spoke with R77's POA in August 2024 and obtained verbal consent for video monitoring. R77's medical record, dated 7/23/24, V17 noted R77 is up for a quarterly review. R77 has a POA in place. R77 has family involvement. R77 is not able to make her own decisions. Her BIMS score is 9 out of 15, moderate impairment. R77's medical record, dated 8/23/24 at 4:35 PM, V17 noted V17 left voicemail message for R77's POA regarding room change. R77's medical record does not note any documentation by V17 between 8/23/24's note and 1/7/25's note. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 5 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to include intervention prevent or reduce the risk of skin breakdown. for one of three (R1) residents reviewed for plan of care interventions for skin breakdown, failed to follow their policy to complete a comprehensive skin assessment on one resident (R1) with skin impairments on readmission from the hospital to identify the size and appearance of the wounds or dressings present. This failure affected 1 of 4 residents in a sample of 37 residents reviewed for pressure ulcers. The findings include: 1.R1's diagnosis includes but are not limited to diabetes, Dementia, Anemia, End Stage Renal Disease, Sacral Pressure Ulcer, Dependence on Renal Dialysis. R1 was admitted to Hospice services on 3/15/25. On 4/24/25 V8 presented the surveyor a care plan labeled original dated 2/3/25 for R1 risk for alteration in skin integrity due to risk factors associated with decreased mobility, poor oral intake, history of pressure ulcers, and advanced age. A second care plan labeled updated for R1 identifies heel protectors and low air loss mattress in place dated 4/24/25. On 04/23/25 10:32 AM R1 in bed, on her back, surveyor knocked on door R1 is not verbally or physically responding to the surveyor. On 04/23/25 at 10:33 AM R1 observed in bed, on an air mattress. V8, Wound Nurse, present. V8 wearing protective boots with toes exposed and support to upper calf region. R1 did not verbally respond or move as V8 was touching R1's legs. On 4/23/25 at 3:29PM V8, Wound Nurse, said the wounds on R1's legs were already there when she returned from the hospital on 3/6/25 in the evening. The surveyor asked how the facility ensures prevention interventions are in place for residents at risk for developing skin impairments. V8 replied I check them and make sure everyone with pressure ulcers has interventions in place. V8 said R1 is not able to move. V8 said I don't know how R1 was laying in the facility bed on readmission because she was not here. V8 said R1 was already considered a high risk for skin. V8 said a score of 0-12 is a high risk on the Braden assessment. The surveyor asked for documentation to show interventions she mentioned, like heel protectors were in place for R1. V8 said I have never had to document the interventions, like heel protectors, were used, or frequency of use. The facility Skin Care Prevention policy dated 1/2025 states all residents will receive appropriate care to decrease the risk of skin breakdown. The facility Care Plan dated 1/2023, in part, states purpose to provide the staff with guidance on completion of comprehensive person centered care baseline care planning. Person centered care means that the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. The facility presented a second policy, Comprehensive Care Plan dated 3/17/25 states the care plan will include a focus, measurable goal, and interventions specific to the resident's medical, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 6 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 Residents Affected - Few nursing, mental, and psychosocial needs. The comprehensive care plan should drive the care and services provided for the resident and allow for the highest practicable physical, mental, and psychosocial well-being. R1's diagnosis includes but are not limited to diabetes, Dementia, Anemia, End Stage Renal Disease, Sacral Pressure Ulcer, Dependence on Renal Dialysis. R1 was admitted to Hospice services on 3/15/25. On 04/23/25 10:32 AM R1 in bed, on her back, surveyor knocked on door R1 is not verbally or physically responding to the surveyor. On 04/23/25 at 10:33 AM R1observed in bed, on an air mattress. V8, Wound Nurse, present. V8 uncovered R1's legs and showed the right, outer, lower leg with rectangle white dressing. V8 showed left leg with white dressing to back of lower leg/calf region. V8 wearing protective boots with toes exposed and support to upper calf region. R1 did not verbally respond or move as V8 was touching R1's legs. On 04/23/25 at 10:36 AM V13,LPN, said she didn't have pain signs or symptoms for me. V13 said some people say R1 speaks but she only moans for means to communicate. On 4/23/25 at 2:16PM V12, LPN, said when I readmitted R1, I did my skin assessment. V12 said I saw two scars on each leg. One on her right outer legs and one on her left leg. V12 said there were no open areas. V12 said I would have documented any open or impaired areas, R1 had scars. On 4/23/25 at 3:29PM V8, Wound Nurse, said the wounds on R1's legs were already there when she returned from the hospital on 3/6/25 in the evening. The surveyor asked how the facility ensures prevention interventions are in place for residents at risk for developing skin impairments. V8 replied I check them and make sure everyone with pressure ulcers has interventions in place. V8 said I was made aware R1 had pressure ulcers on her legs when I assessed her on 3/7/25. V8 said R1 was readmitted on [DATE] in the evening and V8 said she did not see R1 on 3/6/25. V8 said when I saw the pressure ulcers I saw scars that are open. V8 said there are no skin pictures from 3/6/25 for R1. V8 said R1 had scabs, which are necrotic, the areas on R1's legs are pressure ulcers. V8 said R1 is not able to move. V8 said I am not sure how R1 would have been laying in the bed while in the hospital. V8 said I don't know how R1 was laying in the facility bed on readmission because she was not here. V8 said R1 was already considered a high risk for skin impairment because she had been seen by the wound doctor for a sacral wound. V8 said a score of 0-12 is a high risk on the Braden assessment. V8 said I believe the admitting nurse did a skin assessment on 3/6/25. The surveyor asked for documentation to show interventions she mentioned, like heel protectors were in place for R1. V8 said I have never had to document the interventions, like heel protectors, were used, or frequency of use. On 4/24/25 at 2:07PM V24, Wound Doctor, said a scab is a thick dry area of the skin. V24 said a scar is different than a scab. V24 said a scar is healed tissue not a dry skin area. V24 said I would think a nurse should know the difference between a scab and a scar. V24 said a pressure ulcer can have a scab in it, but a scab is not the same as a pressure ulcer. V24 said a pressure ulcer can develop in a number of hours. V24 said devlopin a necrotic wound in 15 hours is not impossible. V24 said R1 has pressure ulcers on the left and right lower legs. V24 said I only saw R1 once and debrided one leg because of moderate drainage. Review of R1's Treatment Administration Record (TAR) there is no treatment dated 3/6/25 for R1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 7 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 legs. Level of Harm - Minimal harm or potential for actual harm Progress notes dated 3/6/25 at 5:17PM documents R1's bilateral lower extremities with some healing scars that mirror each other. They are to the lower lateral and front ankle area of both extremities. Bilateral heels are intact. Residents Affected - Few R1's admission Evaluation dated 3/6/25 identifies healing scars on right and left outer ankles. Large deep open area to the sacrum. Other states healing scar to lateral left and right lower legs. On 4/24/25 V8 presented the surveyor a care plan labeled original dated 2/3/25 for R1 risk for alteration in skin integrity due to risk factors associated with decreased mobility, poor oral intake, history of pressure ulcers, and advanced age. A second care plan labeled updated for R1 identifies heel protectors and low air loss mattress in place dated 4/24/25. R1's hospital record dated 2/28/25 states lower left leg. 3/11/25 pressure injury right lower leg. The facility Skin Care Prevention policy dated 1/2025 states all residents will receive appropriate care to decrease the risk of skin breakdown. The facility Skin Management policy dated 1/2025 states an evaluation of the pressure ulcer/injury if no dressing is present. An evaluation of the status of the dressing, if present. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 8 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat elevated blood sugars that were above the resident's baseline before it got to a critical level and the facility failed to put in any interventions for a resident experiencing vomiting and diarrhea to prevent dehydration. This affected two of three (R81, R84) reviewed for nursing quality of care. This failure resulted in R84 being sent to the hospital with a blood sugar level of 521 mg/dL and was diagnosed with uncontrolled diabetes and R81 being sent to the hospital to be treated for severe dehydration after being diagnosed with norovirus. Residents Affected - Few Findings Include: R81 is an [AGE] year old with the following diagnosis: chronic obstructive pulmonary disease, nontraumatic intracerebral hemorrhage, chronic kidney disease, congestive heart failure, and peripheral vascular disease. R81 was at the hospital from [DATE] through the evening of 4/23/25. A Nursing note dated 4/18/25 at 2PM documents the nurse was notified by staff that R81 appeared to be choking. Upon entering the room, the nurse observed emesis and mucous on R81's shirt. The nurse assisted R81 with cleaning up and clearing throat of sputum. The oncoming nurse was made aware in report. A Nursing note dated 4/18/25 at 5:35PM documents the nurse was made aware by the coming nurse that R81 had sputum in the mouth. The nurse still observed sputum coming from R81's mouth. An allergy spray was ordered for R81's nose for seasonal allergies. An order for an antidiarrheal medication was also placed. A Nursing note dated 4/18/25 at 8:57PM documents V37 (Family member) called the nurse to the room because R81 had a very large watery stool. Staff cleaned R81 and administered the antidiarrheal medication. Vital signs show s blood pressure of 107/51. V37 was adamant on sending R81 to the hospital after the staff explained interventions could be put in place at the facility. V37 still insisted on sending R81 to the hospital stating something is wrong. A Nursing note dated 4/19/25 documents R81 was admitted to the hospital with a diagnosis of colitis. The Hospital Records dated 4/18/25 document R81 arrived to the emergency department with a chief complaint of low blood pressure. The admitting diagnosis was colitis and altered mental status. R81 presented from the nursing home back from hospice with nausea, vomiting, and diarrhea. Blood pressure is in the high 90s to low 100s. R81 was somnolent and wakes to loud voice and shoulder taps. Per family, R81 has been complaining of abdominal pain and having diarrhea for the last four days. Stool studies are pending, but R81 was put on two oral antibiotics at this time. V37 reported the facility gave R81 an anti-diarrheal medication, but R81 started having profuse and voluminous amounts of diarrhea. Family also reports R81 having violent vomiting as well. R81 is ill appearing. Mucous membranes are dry. Lab levels revealed a BUN level of 37 in creatinine of 1.66. Both of these levels are high, indicating dehydration. Stool studies eventually came back positive for norovirus. R81 received supportive treatment with IV fluids and retuned back to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 9 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm On 4/22/25 at 11:15AM, V37 (Family member) stated the staff do not respond to any changes in condition of residents. V37 stated R81 has had to be sent out to the hospital twice within the last two months where V37 had to ask staff to send R81 out of the hospital because there were changes V37 was concerned about that staff didn't think were serious. Residents Affected - Few On 4/24/25 at 2:31PM, V28 (Nurse) stated V37 was at R81's bedside reporting to staff that R81 was having loose stools. V28 did not know the exact amount of times R81 had an episode of diarrhea but stated V28 was present in the room when R81 had two loose bowel movements. V28 described the bowel movement as liquid diarrhea. V28 reported telling V37 that interventions could be done in the hospital but V37 wanted R81 sent to the hospital because the blood pressure was low. V28 reported the blood pressure was 100s over 50s and confirmed this was a lower blood pressure for R81. V28 stated R81 was on hospice and only to receive comfort care. V28 reported the diarrhea was a new symptoms since starting hospice. V28 stated V28 called and got an order for an anti-diarrhea medication and administered it to R81 but did not do any further testing due to R81 being on hospice. V28 was not aware about any vomiting R81 was having. V28 reported when a resident has a change in condition and assessment needs to be done and vital signs need to be taken. V28 reported if anything is abnormal than the physician must be made aware. V28 stated signs of dehydration would be sunken eyes, dry mouth, low blood pressure, and increase heart rate. V28 defined a change in condition as anything observed that is out of the regular for a resident. V28 reported based on what V37 said R81 had a change in condition, but no aggressive interventions were pursued due to being on hospice. V37 denied R81 showing any signs of dehydration before being sent to the hospital. On 4/24/25 at 2:55PM, V29 (CNA) stated throughout the shift, R81 threw up multiple times and had multiple episodes of diarrhea. V29 reported working with R81 on the 2 PM to 10 PM shift. V29 stated R81 had 2 to 3 episodes of diarrhea before dinner and two more episodes of diarrhea after dinner. V29 reported the quantity of diarrhea was large amounts that caused R81 to need an entire bed change because the diarrhea had leaked all over the bed. V29 was not able to state the amount of time R81 vomited. V29 reported the nurse was also in and out of the room and notified of every episode of diarrhea or vomiting. V29 stated R81 was sent out to the hospital per V37's request. V29 reported that R81 verbalized to V29 that R81 did not feel good and had been quieter. V29 stated R81 is normally very confused and will answer baseline questions, but was struggling to even do that before being sent out. V29 reported signs and symptoms of dehydration are dry mouth. V29 denied R81 having any intake from 2 PM until the time R81 went out around 8 PM. V29 denied being aware if R81 had any other intake earlier in the day. V29 reported R81 kept having spit up in R81's mouth so it was difficult to tell if R81's mouth was dry. On 4/25/25 at 9:36AM, V31 (Attending Physician) stated R81 has a poor baseline health. V31 reported all hospitalizations are driven by V37 even though R81 is on hospice. V31 reported R81 is to receive comfort measures only but V37 still wants R81 to be sent out. V31 defined a change of condition as any change from baseline with paying special attention in any changes to vital signs. V31 stated R81 is on a hospice for a general decline in health and poor quality of life. V31 denied the diarrhea having to do with why R81 was on hospice. V31 stated V31 would expect staff to evaluate a resident and take vital signs and then let the physician know so further testing could be ordered if needed. V31 stated with a diagnosis of norovirus there is no medication that can be given to treat the virus, but comfort measures would have been provided to treat the symptoms. V31 reported it is also not recommended to give any anti-diarrhea medication for this virus as it could make the diarrhea worse. V31 reported comfort measures include treating the nausea and vomiting with medication and hydrating the resident with IV fluids but if they can't stay hydrated with oral intake. V31 stated if comfort measure do not work to keep them stable then they need to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 10 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 be sent to the hospital. Level of Harm - Actual harm On 4/24/25 at 10:52AM, V2 stated anything opposite noted from the original admission assessment is considered a changing condition. V2 reported any change in assessment means a physician needs to be notified so they can be aware and provide additional orders to the nursing staff if needed. V2 stated V37 reported that R81 aspirated. V2 reported once V2 entered the room R81 was coughing and had sputum in the mouth. V2 stated R81 had loose but formed stool at first. V2 stated R81 had another episode of sputum in the mouth and V37 requested to send R81 to the hospital. V2 reported that V2 was only aware of the one episode of diarrhea and no staff notified V2 of any additional episodes of vomiting or diarrhea. V2 stated R81 eats by mouth. V2 reported hospice residents are usually not sent out to the hospital once they're on hospice but V37 has requested to send R81 out to the hospital for an evaluation. V2 stated signs of dehydration would be increase heart rate, low blood pressure, not urinating as much, and dry mouth. Residents Affected - Few Vital signs for 04/2025 document an average blood pressure for R81 of 130-150s/60-70s from 4/12/25-4/17/25. The blood pressure documented on 4/18/25 at 8:28AM was 102/60, at 1:31PM was 102/61, and at 8:11PM 107/51. Normal pressure is around 120/80. The blood pressures documented on 4/18/25 are low for R81. The SBAR Communication Form dated 4/18/25 documents R81 is having a change in condition of loose stools. No additional testing was completed. R81 was sent to the hospital per V37's request. The Transfer Form dated 4/18/25 documents the reason for transfer as diarrhea. R81 remains at baseline mental status of confused but able to follow simple directions. The Care Plan dated 9/4/23 documents R81 has renal insuffiency related to chronic kidney disease stage three. An intervention includes to monitor for sing or symptoms of hypovolemia and monitor vital signs. This care plan also documents R81 is at risk for dehydration or potential fluid deficit related to history of electrolyte correction and poor oral intake. An intervention includes to monitor for signs or dehydration. The policy titled, Change in Resident Condition, dated 01/2025 documents, General: It is policy of the facility, except in a medical emergency, to alert the resident, resident's physician, and resident's responsible party of a change in condition. Policy: Nursing will notify the resident's physician or nurse practitioner when: .b. There is significant change in the resident's physical, mental, or emotional status .e. It is deemed necessary or appropriate in the best interest of the resident. R84 is an [AGE] year old with the following diagnosis: Alzheimer's disease, type 2 diabetes, and acidosis. R84 is not able to communicate due to mental status so no questions were able to be asked by the surveyor about this incident. A Nursing note dated 12/16/24 documents R84 was transferred out to the hospital. A Nursing note dated 12/17/24 documents the nurse called the hospital to inquire on the status of R84. R84 was admitted with uncontrolled diabetes and altered mental status. The Blood Sugar Summary for 12/2024 documents R82 has a blood sugar range of 143-246 mg/dL from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 11 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few 12/1/24 through 12/13/24. A normal blood sugar is 60-100 mg/dL. On 12/14/24 at 8:47AM, the blood sugar was 399 mg/dL. On 12/15/24 at 9:00AM, the blood sugar was 304 mg/dL. On 12/16/24 at 11:39AM, the blood sugar was 178 mg/dL. On 12/16/24 at 5:30PM, the blood sugar was 521 mg/dL. The Transfer Form dated 12/16/24 documents R84 was sent to hospital for abnormal vital signs with the most recent blood glucose being 521 mg/dL. A Nurse Practitioner note dated 12/26/24 documents R84 readmitted to the facility on [DATE] after a hospitalization where R84 was diagnosed with lethargy and metabolic encephalopathy. Blood sugars are now controlled. On 4/24/25 at 3:30PM V30 (Nurse) stated V30 define a change in condition as anything that is out of the baseline for a resident's physical status or behaviors. V30 reported each resident has their own baseline and if anything is out of the ordinary, then an assessment must be completed to try to see what is going on. V30 reported there are parameters for certain laboratory levels, and vital signs so the physician can be made aware of what is going on with the resident. V30 reported even if the vital signs or laboratory levels are still within perimeter than the physician still needs to be notified if there is a change. V30 stated nurses need to use their judgment to decide when a resident is having a change of condition. V30 stated the physician needs to be made aware of a change in condition to see if any additional orders need to be put in place so whatever is going on can be managed in the facility. V30 reported that all changes in condition need to be documented and when the physician was notified. V30 stated if a change in condition is not addressed when it is first noted by the nurse, then a situation and the patient's health could decline. On 4/25/25 at 5:03PM, V38 (Former Nurse) stated V38 cared for R84 during the evening shift. V38 reported residents were receiving insulin need to have blood sugars checked before meals and bedtime. V38 could not remember the exact number of R84's blood sugar but knew it was over 500 and considered a critical level. V38 denied being aware that R84 was having a change in condition of elevated blood sugars in the 300s before the blood sugar hit 500. V38 stated once the blood sugars got to the level of 300 then a physician should have been notified because R84 normally did not have blood sugars in the 300s. V38 reported R84 was only ordered a long acting insulin at that time and not on a sliding scale insulin which could have provided additional insulin for R84. V38 reported R84 is not able to speak due to mental status so it was not possible to ask how R84 was feeling. V38 stated by notifying the physician when the blood sugars were in the 300s R84 could have possibly been treated at the facility and not had to go out to the hospital for uncontrolled diabetes. On 4/25/25 at 9:36AM, V31 (Attending Physician) stated a parameter on when to notify a physician should be put in place for a resident who is receiving blood sugar checks. V39 reported basic protocol usually does not have staff notify a physician of elevated blood sugar until the blood sugar is over 400. V31 stated if the blood sugar has become more elevated than usual than an order for extra insulin or labs could be put in place to assess any additional causes of why the blood sugar might be elevated. V31 reported a blood sugar of over 500 indicates a resident is in diabetic keto acidosis (DKA). V31 stated it is caused due to a lack of insulin in the blood and needs to be treated at a hospital once it gets to the level of DKA. On 4/25/25 at 10:52AM, V2 stated if a resident is having blood sugars that are elevated into the 300s that is not their normal then a physician should be notified to see if additional orders need to be put in place. V2 reported if the blood sugar is left untreated than the blood sugar will remain elevated or increase. V22 was unable to answer why a physician was not notified of our 84 elevated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 12 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 blood sugar in the 300s before it reached 500. Level of Harm - Actual harm The Physician Order Sheet documents an order for blood sugar checks before meals and at bedtime that was ordered on 10/25/24. There are no parameters for when staff should notify the physician or an elevated blood sugar. R84 was ordered the following medications for diabetes before going to the hospital: Gilmepiride oral tablet 2mg daily, Jardiance oral tablet 25mg daily, Metformin oral tablet 1000mg, and Lantus Subcutaneous 100 unit/mL for 8units once a day. After the hospitalization in 12/2024, an order was placed for Humalog insulin 100 unit/mL on a sliding scale based on blood sugar checks. Residents Affected - Few The Medication Administration Record dated 12/2024 documents R84 received the medication as ordered for diabetes mellitus. The Care Plan dated 10/25/24 documents R84 is at risk for hypo/hyperglycemia related to diabetes mellitus. R84 receives routine insulin and PO medication for glycemic control. R84 was recently hospitalized with diabetic ketoacidosis. Interventions include: accuchecks as ordered and monitor/document/report to the physician as needed for signs and symptoms of hyperglycemia. The policy titled, Diabetes Management, dated 01/2025 documents, General: To provide guidelines for the management of diabetic residents. Guideline: .3. Diabetics who require blood glucose monitoring due to insulin use should have parameters for when the physician should be notified and how insulin should be adjusted. The policy titled, Blood Glucose Monitoring, dated 3/2025 documents, General: To provide guideline for managing blood glucose. Guideline: Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 13 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and records the facility failed to follow their policy to complete a comprehensive skin assessment on one resident with skin impairments on readmission from the hospital to identify the size and appearance of the wounds or dressings present, failed to ensue effective interventions were in place, and failed to ensure low air loss mattress was used per manufactures recommendations. This affected two of four residents (R1, R325) reviewed for pressures sore preventions and effective interventions. Residents Affected - Few The findings include: 1. R1's diagnosis includes but are not limited to diabetes, Dementia, Anemia, End Stage Renal Disease, Sacral Pressure Ulcer, Dependence on Renal Dialysis. R1 was admitted to Hospice services on 3/15/25. On 4/24/25 V8 presented the surveyor a care plan labeled original dated 2/3/25 for R1 risk for alteration in skin integrity due to risk factors associated with decreased mobility, poor oral intake, history of pressure ulcers, and advanced age. A second care plan labeled updated for R1 identifies heel protectors and low air loss mattress in place dated 4/24/25. 04/23/25 10:32 AM R1 in bed, on her back, surveyor knocked on door R1 is not verbally or physically responding to the surveyor. On 04/23/25 at 10:33 AM R1 observed in bed, on an air mattress. V8, Wound Nurse, present. R1 wearing protective boots with toes exposed and support to upper calf region. R1 did not verbally respond or move as V8 was touching R1's legs. On 4/23/25 at 3:29PM V8, Wound Nurse, said the wounds on R1's legs were already there when she returned from the hospital on 3/6/25 in the evening. The surveyor asked how the facility ensures prevention interventions are in place for residents at risk for developing skin impairments. V8 replied I check them and make sure everyone with pressure ulcers has interventions in place. V8 said R1 is not able to move. V8 said I don't know how R1 was laying in the facility bed on readmission because she was not here. V8 said R1 was already considered a high risk for skin. V8 said a score of 0-12 is a high risk on the Braden assessment. The surveyor asked for documentation to show interventions she mentioned, like heel protectors were in place for R1. V8 said I have never had to document the interventions, like heel protectors, were used, or frequency of use. The facility Skin Care Prevention policy dated 1/2025 states all residents will receive appropriate care to decrease the risk of skin breakdown. The facility Care Plan dated 1/2023, in part, states purpose to provide the staff with guidance on completion of comprehensive person centered care baseline care planning. Person centered care means that the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. The facility presented a second policy, Comprehensive Care Plan dated 3/17/25 states the care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental, and psychosocial needs. The comprehensive care plan should drive the care and services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 14 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 Level of Harm - Minimal harm or potential for actual harm provided for the resident and allow for the highest practicable physical, mental, and psychosocial well-being. R1's diagnosis includes but are not limited to diabetes, Dementia, Anemia, End Stage Renal Disease, Sacral Pressure Residents Affected - Few Ulcer, Dependence on Renal Dialysis. R1 was admitted to Hospice services on 3/15/25. On04/23/25 10:32 AM R1 in bed, on her back, surveyor knocked on door R1 is not verbally or physically responding to the surveyor. On 04/23/25 at 10:33 AM R1observed in bed, on an air mattress. V8, Wound Nurse, present. V8 uncovered R1's legs and showed the right, outer, lower leg with rectangle white dressing. V8 showed left leg with white dressing to back of lower leg/calf region. V8 wearing protective boots with toes exposed and support to upper calf region. R1 did not verbally respond or move as V8 was touching R1's legs. On 04/23/25 at 10:36 AM V13, LPN, said she didn't have pain signs or symptoms for me. V13 said some people say R1 speaks but she only moans for means to communicate. On 4/23/25 at 2:16PM V12, LPN, said when I readmitted R1, I did my skin assessment. V12 said I saw two scars on each leg. One on her right outer legs and one on her left leg. V12 said there were no open areas. V12 said I would have documented any open or impaired areas, R1 had scars. On 4/23/25 at 3:29PM V8, Wound Nurse, said the wounds on R1's legs were already there when she returned from the hospital on 3/6/25 in the evening. The surveyor asked how the facility ensures prevention interventions are in place for residents at risk for developing skin impairments. V8 replied I check them and make sure everyone with pressure ulcers has interventions in place. V8 said I was made aware R1 had pressure ulcers on her legs when I assessed her on 3/7/25. V8 said R1 was readmitted on [DATE] in the evening and V8 said she did not see R1 on 3/6/25. V8 said when I saw the pressure ulcers I saw scars that are open. V8 said there are no skin pictures from 3/6/25 for R1. V8 said R1 had scabs, which are necrotic, the areas on R1's legs are pressure ulcers. V8 said R1 is not able to move. V8 said I am not sure how R1 would have been laying in the bed while in the hospital. V8 said I don't know how R1 was laying in the facility bed on readmission because she was not here. V8 said R1 was already considered a high risk for skin impairment because she had been seen by the wound doctor for a sacral wound. V8 said a score of 0-12 is a high risk on the Braden assessment. V8 said I believe the admitting nurse did a skin assessment on 3/6/25. The surveyor asked for documentation to show interventions she mentioned, like heel protectors were in place for R1. V8 said I have never had to document the interventions, like heel protectors, were used, or frequency of use. On 4/24/25 at 2:07PM V24, Wound Doctor, said a scab is a thick dry area of the skin. V24 said a scar is different than a scab. V24 said a scar is healed tissue not a dry skin area. V24 said I would think a nurse should know the difference between a scab and a scar. V24 said a pressure ulcer can have a scab in it, but a scab is not the same as a pressure ulcer. V24 said a pressure ulcer can develop in a number of hours. V24 said devlopin a necrotic wound in 15 hours is not impossible. V24 said R1 has pressure ulcers on the left and right lower legs. V24 said I only saw R1 once and debrided one leg because of moderate drainage. Review of R1's Treatment Administration Record (TAR) there is no treatment dated 3/6/25 for R1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 15 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 legs. Level of Harm - Minimal harm or potential for actual harm Progress notes dated 3/6/25 at 5:17PM documents R1's bilateral lower extremities with some healing scars that mirror each other. They are to the lower lateral and front ankle area of both extremities. Bilateral heels are intact. Residents Affected - Few R1's admission Evaluation dated 3/6/25 identifies healing scars on right and left outer ankles. Large deep open area to the sacrum. Other states healing scar to lateral left and right lower legs. On 4/24/25 V8 presented the surveyor a care plan labeled original dated 2/3/25 for R1 risk for alteration in skin integrity due to risk factors associated with decreased mobility, poor oral intake, history of pressure ulcers, and advanced age. A second care plan labeled updated for R1 identifies heel protectors and low air loss mattress in place dated 4/24/25. R1's hospital record dated 2/28/25 states lower left leg. 3/11/25 pressure injury right lower leg. The facility Skin Care Prevention policy dated 1/2025 states all residents will receive appropriate care to decrease the risk of skin breakdown. The facility Skin Management policy dated 1/2025 states an evaluation of the pressure ulcer/injury if no dressing is present. An evaluation of the status of the dressing, if present. 2. R325 admitted in the facility on 4/15/25. On 4/22/25 at 1030AM, observed R325 in bed, asleep and on Low air loss Mattress. Weight setting is on 220, Alternate. Weight record reviewed and R325 weighed 134.6 lbs (pounds) on 4/16/25. Braden Scale for Predicting Pressure Sore dated 4/16/25 R325 scored 12, High Risk. R325 has care plan for potential and is at risk for alteration in skin integrity due to risk factors associated with Alzheimer's, Dementia, immobility, and nutrition. Pressure ulcer to the sacrum. On 4/24/25 at 9:35AM, V8 (Wound nurse) stated that We set the low air loss mattress closest to the weight of the resident. R325 is admitted with stage 3 in coccyx. We placed her on low air loss mattress upon admission due to the stage 3 pressure sore. We do in services; and have nurses and CNA checks the low air loss mattress machine to make sure that it is in the right setting and to make sure it is closer to their current weight. Mattress Use Policy with a review date of 1/2024 reads in part: To provide a statement on the types of mattresses that are standard in the facility. The standard for all mattresses on the beds will be pressure reducing. At the discretion of the Wound Care Team, Nurse, DON or ADON the resident may be changed to a pressure relieving mattress. Information regarding the mattresses is based on the manufacture's literature. Proactive medical products Operational Manual, reads in part: Intended use: pump and mattress is intended to reduce the incidence of pressure ulcers while optimizing patient as prescribed by a physician. Pressure set up: users can adjust the pressure level of the air mattress to a desired firmness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 16 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 by themselves or according to the suggestions from a health care professional. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 17 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observations, interviews, and record reviews, the facility failed to obtain and document a diagnosis in the physician orders for an indwelling catheter for one resident (R70) out of three reviewed for indwelling catheters in a sample of 37. Findings include: On 4/22/25 at 10:00 AM, R70 was observed to have an indwelling catheter. On 4/25/25 at 8:30 AM, V2 DON (director of nursing) stated that a diagnosis should be documented on the physician order to indicate reason why an indwelling catheter is in place. R70's POS (physician order sheet), dated 3/24/25, notes Indwelling Catheter: _18_Fr,_10cc balloon size for a Diagnosis of _---_. There is no documentation in R70's current POS provided to this surveyor noting reason for indwelling catheter. This facility's physician orders policy, reviewed 3/17/25, notes the elements of an order includes, but not limited to, orders specify the diagnosis or indication for. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 18 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to document accurate meal intakes. This affected two of three residents (R12 and R51) reviewed for nutrition in a sample of 37. Residents Affected - Few Findings include: On 4/24/25 at 1:00PM, R12 and R51 were observed in the dining room eating lunch. R12 consumed 25% of meal. R51 consumed 25% of meal. On 4/24/25 at 9:37 AM, V35 RD (registered dietitian) stated that R12 has been losing weight. V35 stated that recently R12's oral intake has decreased. V35 stated that R12 was started on weekly weights to monitor. V35 stated that last week R12 was started on a medication to stimulate R12's appetite and nutrition monitoring currently being followed weekly by the the interdisciplinary team. V35 stated that yesterday V35 saw R51 and observed that R51 was not eating much. V35 stated that yesterday R51 was placed on weekly nutrition monitoring by the interdisciplinary team. V35 stated that staff should be monitoring and documenting the amount eaten at each meal. On 4/24/25 at 1:00 PM, V22 CNA (certified nurse aide) stated that the CNAs are expected to chart amount eaten for each resident after each meal. On 4/24/25 at 1:05 PM, V23 CNA stated that the CNAs are expected to chart amount eaten for each resident after each meal. V23 stated that CNAs are responsible for picking up all meal trays. V23 stated that if resident doesn't eat or eats very little, she will let the nurse know so the nurse will follow up with resident. V23 stated that if she observes a resident not eating, she will assist with feeding resident, encourage resident to eat, and/or offer an alternative meal choice. On 4/24/25 at 3:15 PM, V34 RN (registered nurse) stated that the CNAs are responsible for documenting the amount eaten for each resident for each meal served. V34 stated that V34 will notify the resident's physician after two consecutive meals not eaten or very little eaten. V34 stated that V34 monitors residents' weights monthly and reviews for any weight changes. On 4/25/25 at 8:56 AM, V31 (attending physician) stated that the nurse can let him know if a resident is not eating. V31 stated that if he is working in his office and the nurse calls to inform him a resident lost 5 pounds, his response is what do you want me to do. V31 stated that at the time of his face-to-face visits he looks at the big picture, reviews laboratory testing and weights. V31 stated that he was aware of R51's weight loss. V31 stated that in July 2022, R51 weighed 68 pounds. V31 stated that at the time of his face-to-face visits he looks at the big picture and R51 has gained weight. On 4/25/25 at V2 DON (director of nursing) stated that she is unable to provide amount of each meal eaten for the past three months for R12 and R51. R12: R12's medical record notes the following weights: 10/3/24, R12 weighed 181 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 19 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0692 12/4/24, R12 weighed 173 pounds Level of Harm - Minimal harm or potential for actual harm There is no documented weight for January 2025. 2/5/25, R12 weighed 166.4 pounds. Residents Affected - Few 3/5/25, R12 weighed 164.2 pounds. 4/8/25, R12 weighed 149.2 pounds. 4/24/25, R12 weighed 146.6 pounds. R12's POC (point of care) charting, dated 4/24/25, notes R12 consumed 76-100% of lunch meal. R12's amount eaten documentation for the past 30 days, 89 opportunities, 71 meal opportunities were documented. On 4/17/25, V35 noted weight warning: weight 147 pounds, body mass index 26. R12 with -7.5% change [ 11.7% , 19.4 ] and -10.0% change [ 17.9% , 32.0 ]. Significant weight loss x 3 and x 6 months noted; R12's weight overall going down and continues to trend down despite interventions with nutrition supplement and wound healing supplement. Mirtazapine started on 4/15 to stimulate appetite and prevent further weight loss. On 3/26/25, V35 RD (registered dietitian) noted weight warning: weight 154 pounds, body mass index 27.3. R12 with -5.0% change [ 6.2% , 10.2 ] and -10.0% change [ 14.9% , 27.0 ]. R12 is receiving nutrition supplement three times a day. Intake 0-75% varied oral intakes noted. R12 was last seen by V35 on 7/8/24. R51: R51's medical record notes the following weights: 10/3/24, R51 weighed 93 pounds. 11/4/24, R51 weighed 88 pounds. 12/4/24, R51 weighed 81 pounds. 1/2/25, R51 weighed 80 pounds. 4/16/25, R51 weighed 80 pounds. R51's amount eaten documentation for the past 30 days, 89 opportunities, 66 meal opportunities were documented. This facility's weight management policy, reviewed 02/2025, notes weekly weights will be done with a significant change of condition or food intake decline that has persisted for more than one week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 20 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their physician services policy and ensure the attending physician conducted face-to-face visits within the first 30 days of admission/re-admission and/or at least once every 60 days. This affected two of three (R12, R51) residents reviewed for care managed by a physician in a sample of 37. Residents Affected - Few Findings include: On 4/25/25 at 8:56 AM, V31 (attending physician) stated that he is present in this facility several times a week. V31 stated that he focuses more on the residents on 2 South nursing unit because this is the acute unit. V31 stated that V31 documents his face-to-face visits with residents in each resident's electronic medical record. R12: R12's medical record notes R12 was admitted to this facility on 5/4/23. R12's medical record notes V33 (attending physician) had face-to-face visit with R12 on 5/24/23. There are no other documented face-to-face visits found in R12's medical record. R12's medical record notes R12 was hospitalized [DATE] - 10/15/24 and 3/7/25 - 3/12/25. R51: R51's medical record notes R51 was admitted to this facility on 7/8/2022. R51's medical record notes V31 face-to-face visits with R51 on 2/24/25, 3/27/24, and 6/15/22. There are no other documented face to face visits found in R51's medical record. This facility's physician services policy, reviewed 1/2025, notes the physician must see the resident at a minimum of every 30 days for a Medicare resident and every 60 days for all other residents. When the physician visits a resident, a progress note will be placed in the medical record. The physician is responsible for reviewing the treatment plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 21 of 31 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 146053 B. Wing (X3) DATE SURVEY COMPLETED A. Building 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 assist a resident with a degenerative eye disease in obtaining transportation to an outside retinal specialist appointment. This affected one of one (R27) residents review for transportation in a total sample of 37. Residents Affected - Few Findings Include: R27 is an [AGE] year old with the following diagnosis: macular degeneration. On 4/22/25 at 10:22AM, R27 stated R27 had an appointment for an eye appointment the first week of April but had to cancel it because the cost of transportation was $270. R27 denied being offered to see the in-house eye doctor. R27 reported R27 would be willing to see the in-house eye doctor because R27 wants to preserve R27's vision for as long as possible. On 4/24/25 at 12:15PM,V18 (Health Information Management Director/Appointment Scheduler/Transportation) stated V18 had an appointment on 4/8. V18 reported R27 is now a private pay patient so R27 needs to now pay for transportation to outside appointment. V18 stated social services called a family member to about R27 refusing to paying for transportation. V18 reported the cost of the transportation was over $200 for round trip. V18 stated V18 called one company for a med car, but R27 refused to pay. V18 reported V18 explained to her about this before the appointment about one week before. V18 reported the appointment was a different doctor R27 wanted to go to in Chicago and was so expensive for this reason. V18 stated Elite and Trace were contracted with the facility for transportation at the time of this appointment. V18 stated V18 only contacted Trace for a medicar. She had an option for family to take her or for an in-house eye doctor to see her but V18 did not offer that to R27. V18 denied documenting any education R27 was provided about being responsible to pay for transportation and denied documenting any other alternative transportation for R27. On 4/24/25 at 12:32PM, V17 (Memory Care Coordinator) stated V17 recalled there was an appointment scheduled for R27 was supposed to go to but didn't because it was an out of pocket expense. V17 didn't know if the appointment was rescheduled. V17 stated R27 does have visual impairment but was unaware of what the diagnosis are. V17 reported V17 didn't offer R27 to see any other specialists after R27 declined to pay for the most recent appointment. When asked why it was that option wasn't offered to R27, V17 said, I just didn't offer it. V17 denied looking into any alternative transportation methods for R27 to get to the appointment. On 4/25/25 at 12:15PM, V1 (Administrator) stated R27 is private pay and the facility does not need to provide any alternate transportation if a resident refuses to pay. The Ophthalmologist Patient Encounter notes dated 1/14/25 documents R27 has puckering of the right macula. Care plan should see a retinal specialist on 4/14/25 for posterior segment encounter. The Physician Order Sheet documents an order for R27 to see a retinal specialist per the recommendations from the ophthalmologist. This order was placed on 1/17/25. There are no notes documenting when education was provided to R27 about R27 being responsible for the transportation to the appointment. There is also no documentation that R27 was offered any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 22 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0745 alternative solutions for transportation to the retinal specialist appointment. Level of Harm - Minimal harm or potential for actual harm The Care Plan dated 11/28/24 documents R27 has impaired vision as evidenced by macular degeneration and receives routine eye drops. An intervention includes arrange for consult as needed for ophthalmologist and optometrist. Residents Affected - Few The policy titled, Appointments and Transportation, dated 2/9/23 documents, General: When a resident has an appointment outside of the facility, the staff will make the transportation arrangements, unless the responsible party chooses to make the arrangements themselves. Procedure: 4. If the family is not making transportation arrangements, the Unit Clerk, HIM (Health Information Manager), or designee will call the transportation company (Medicare, ambulance, etc.) to set up date and time of pick up. The pickup time should be at least one our prior to the appointment. 5. If the family will not be accompanying the resident, the Unit Clerk, HIM Director, or designee will inform the DON to determine if an escort is needed for the resident .9. If the resident is unable to keep the appointment, it is the Unit Clerk, HIM Director, or designee's responsibility to cancel the appointment and reschedule it at the earliest time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 23 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to follow their policy and complete quarterly psychotropic assessments and assess for or attempt a Gradual Dose Reduction for one resident on an antidepressant. This failure affected one of one (R47) resident in a sample of 37 reviewed for psychotropic medication. The findings include: R1 admitted to the facility on [DATE] with hospitalization and readmissions to the facility since. R1's diagnosis include but are not limited to Multiple Sclerosis and Depression. On 4/24/25 at 12:17PM V3, Assistant Director of Nursing, said she monitors the psychotropic program. V3 said Gradual Drug Reductions (GDR) are attempted or addressed quarterly or if something is going on. V3 said in the electronic charting system there is a Psychotropic Medication Assessment Form for residents on psychotropics, including antidepressants. V3 said the assessment should be assessed quarterly. At 1:23PM V3 said I didn't see one (Psychotropic Assessment) for R47, she should have one. V3 said target behaviors are monitored and documented on the residents' Medication Administration Record (MAR). R47's Order Summary Report December 2024 thru April 2025 identifies R47 receiving Duloxetine 20mg. R47's April 2025 MAR does not include target behaviors for depression. During the survey no progress notes were presented stating a GDR was attempted or that it is not appropriate for R47. R47's care plan includes use of Duloxetine used for Depression. Interventions do not include psychotropic quarterly assessment for GDR or documentation of why GDR is not appropriate. Facility Psychotropic Medication Program policy dated 1/2024 states the purpose is to promote the safe and effective use of psychotropics medications. To ensure the lowest dose of medication is used, for the shortest time frame. Upon admission and Quarterly each resident will have psychotropic medications reviewed utilizing the Psychotropic Medication Assessment Form. This form will identify the time period the resident has been taking the medication, the diagnosis for the medication, behaviors associated with the need for the medication, and non-pharmalogical interventions. Behaviors associated with medications .non-pharmalogical interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 24 of 31 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 146053 B. Wing (X3) DATE SURVEY COMPLETED A. Building 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to give prednisolone acetate ophthalmic suspension 1% (steroid eye drop) and Midodrine 5mg tablet (medication that increases blood pressure) as prescribed. This affected two of six resident (R320, R27) reviewed for medication administration in a total sample of 37. Residents Affected - Few Findings Include: R329 is a [AGE] year old with the following diagnosis: hematuria. On 4/23/25 at 8:37AM, V25 (Nurse) took R320's blood pressure and it was 83/39 (low). On 4/23/25 at 9AM, V25 administered all morning medication except Midodrine 5mg tablet. V25 stated medication should be stocked in the pyxis by pharmacy or ordered by the nurse when the medication is low within three to four pills left. V25 reported pharmacy will deliver the medication automatically when it is due to be delivered. V25 called the pharmacy at 9:05AM to ordered the missing medication. V25 stated the medications can be delivered an hour before or an hour after the scheduled time. V25 reported if the medication is given after 10AM and it is scheduled at 9AM then it is late. On 4/23/25 as the surveyor was exiting the room from the medication pass at 11:52AM, V2 (DON) approached the surveyor and stated R320 received the Midodrine that was delivered by pharmacy. The surveyor then walked back over to 2North and verified with V25 that the Midodrine 5mg table was given. V25 showed the surveyor the pharmacy delivery slip and stated the medication was given at 10:59AM. V25 reported taking another blood pressure before the medication was given and the blood pressure was 101/59. A Nursing note dated 04/23/25 at 8:29AM documents the nurse observed the midodrine 5 mg was missing from the cycle med roll. Upon checking the pyxis, the medication was still unavailable at this time. The nurse called the pharmacy and will be delivered in a couple hours. The physician was notified of the missing dose. A Nursing noted dated 4/23/25 at 11:24AM documents the pharmacy delivered the midodrine for R320. The nurse called the physician and was given the ordered to give the medication. Medication was administered upon rechecking the medication. The Physician Order Sheet documents R320 has an ordered for Midodrine (medication to increase blood pressure) 5mg 1 tablet by mouth two times a day ordered on 4/7/25. The Medication Administration Record dated 04/2025 documents the 9AM dose was not given at the scheduled time but an additional dose was ordered 9AM and administered. R27 is an [AGE] year old with the following diagnosis: macular degeneration. On 4/22/25 at 10:22AM, R27 reported R27 gets eye drops four times a day to relieve pressure in R27's eyes because R27 has macular degeneration. R27 stated R27 did not receive the scheduled 9AM yet and was feeling increased pressure in the eyes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 25 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/22/25 at 10:46AM, the surveyor asked V32 (Nurse) if R27 has received the 9AM dose of eye drops this morning and V32 denied administering the eye drops. V32 reported the eye drops were not given because R27 was in the dining room eating breakfast and medications cannot be administered in the dining room. V32 stated medications can be given an hour before or up to an hour after the scheduled. V32 reported R27 left the dining room around 10 or 10:30AM. V32 stated the eye drops still have not been given yet because V32 has been passing other resident medications. V32 stated since the next dose is due at 12PM, V32 will skip the 9AM dose and administer the 12Pm dose around 11AM. V32 reported R27 gets this medication to bring down the swelling in R27's eyes. The Physician Order Sheet documents prednisolone acetate ophthalmic suspension 1% eye drops are ordered 1 drop in each eye four times a day. That ordered was placed on 12/9/24. The Medication Administration Record (MAR) dated 04/2025 documents the eye drops are ordered to be given at 9AM, 12PM, 5PM, and 9PM. On 4/22/25, the MAR documents the eye drops were not given at the 9AM dose. The Care Plan dated 11/28/24 documents R27 has impaired vision as evidenced by macular degeneration and receives routine eye drops. The policy titled, Medication Administration, dated 01/2024 documents, General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: .6. Check medication administration record prior to administering medication for the right medication, dose, route, patient/resident and time .26. If medication is ordered, but not present, check to see if it was misplaced then call the pharmacy to obtain the medication. If available, obtain it from the contingency or convenience box. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 26 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to remove an expired medication from a medication cart, failed to store two bottles of a medication in a refrigerator that has instructions to store the medication between 36-48 degrees Fahrenheit, and failed to dispose of a controlled medication after it was discontinued during the review for medication storage in a total sample of 37. Findings Include: R3 is a [AGE] year old with the following diagnosis: congestive heart failure and metabolic encephalopathy and on hospice. R38 is a [AGE] year old with the following diagnosis: senile degeneration of the brain and arteriovenous malformation of the digestive system. On 4/23/25 at 9:10AM, the Oak Wing Medication cart on the 2 North unit was reviewed by with V26 (Nurse). During the review, a 12 count card of ferrous sulfate 325mg tablets were in the medication cart with an expiration date of 03/2025. V26 stated medications should be removed from the cart as soon as they expired so there is no chance they will be used. V26 reported it is the nurse's responsibility to check the cart at the beginning of the shift before the morning medication pass to ensure everything is in good standing. V26 denied checking the cart for expired medications before the morning medication pass. V26 stated the medication expired on the last day of the month in March. V26 then took the medication out of the medication cart. On 04/23/25 at 9:50AM, the Peony/Lavender medication cart on 2 South was reviewed with V27 (LPN). Three oral liquid Lorazepam bottles were noted in the narcotic box in the medication cart. All the boxes were labeled that the medication must be stored in the refrigerator. When asked why the medication was not stored in the refrigerator, V27 stated the medication only needs to be stored in the refrigerator until it is opened then it can be stored in the narcotic box. The surveyor pointed out the sticker to V27 on each box which indicated the medication should be refrigerated and V27 said, I don't know anything about that. V27 then asked V3 (ADON) that was walking by where the oral liquid Lorazepam should be stored and V3 looked at the bottle. V3 stated the medication should be stored in the refrigerator based on the sticker on the medication box. On 4/23/25 as the surveyor was exiting the room from a medication pass at 11:52AM, V2 (DON) approached the surveyor and stated staff are also currently being in-serviced on medication and storage in regards to properly storing the oral liquid Lorazepam. V2 confirmed the medication should be stored in the refrigerator and the nurses should be looking at the medication boxes to verify how a medication is stored. V3 reported medications that no longer have active orders need to be disposed of within the same day it is discontinued. The Medication Administration Record dated 04/2025 documents R3 has an order for Lorazepam Oral Concentrate 2 mg/mL (1mb by mouth) as needed. The medication was administered on 4/22/25. The Physician Order Sheet for R38 documents Lorazepam Oral Concentrate was discontinued on 1/21/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 27 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The policy stated, Medication Storage in the Facility, dated 01/2025 documents, General: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Responsible Party: Nursing Procedure: .11. Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator. Medications requiring storage 'in a cool place' are refrigerated unless otherwise directed on the label .14. Outdated, contamined, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures and reordered from the pharmacy if a current order exists. The Medication Drug Insert Sheet for Lorazepam Oral Concentrate documents this medication needs to be stored at a cold temperature. Refrigerate at 2 degrees Celsius to 8 degrees Celsius (36 degrees Fahrenheit to 46 degrees Fahrenheit). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 28 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 - Some 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. Based on observations, interviews, and records reviewed the facility failed to follow the menu served to the residents. This failure affected 7 of 7 (R3, R9, R18, R84, R101, R103, and R105) residents receiving pureed diets in a sample of 37 residents. The findings include: On 4/22/25 the Menu listed to be served oven roasted Turkey with Gravy, Sweet Potatoes, Brussel Sprouts, Dinner Roll, Chilled Peaches, and Beverages. On 04/22/25 at 12:00pm the surveyor observing tray service in the kitchen. The surveyor observed the pureed meals served did not receive a bread or roll item on their plate. V9, Cook, said the residents on pureed diet do not have a roll. V10, Dietary Aid, said I can't give them rolls, they puree. On 4/22/25 at 12:03pm V11, Dietary Manager, said we don't do puree bread, we haven't in a long time. V11 said we don't have the bread puree mix. V11 said we have the recipes for the puree bread. Recipe for Pureed Buttered Dinner Roll: ingredients dinner roll, margarine, solids - melted, milk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 29 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 observation, interview, and record review, the facility failed to follow their transmission based precautions policy by two staff not wearing a gown or gloves in a contact isolation room for one resident (R320) reviewed for infection control in a total sample of 37. Residents Affected - Few Findings Include: R329 is a [AGE] year old with the following diagnosis: hematuria. On 4/22/25 at 12:20PM, PPE (Personal Protective Equipment) cart/drawer present by R320's room, signage for Contact Isolation posted at resident's door. V6 (CNA) entered contact isolation room with meal tray. Did not put on PPE. V6 only used surgical mask, and no gloves and no gown, no handwashing observed prior to entering the room. Touched items in the bed side table and placed phone from beside cabinet to overhead table, as per resident's request. Also assisted resident in cutting meal. V6 exited the room and used hand sanitizer. V6 stated that the R320 is new resident, I do not know what kind of isolation R320 is in. V6 also confirmed that V6 did not put PPE at the time V6 entered the R320's room. On 4/23/25, V25 (Nurse) entered the room at 8:27AM wearing only a pair of gloves. The sign outside the room indicated R320 was on Contact isolation precautions. V25 took R320's blood pressure. V25 removed the gloves and put them in the garbage can in the room. V25 exited the room to prepare the medication after using hand sanitizer. V25 entered the room again after putting on a new pair of gloves without wearing a gown to administer the medication. On 4/23/25 at 9AM, the surveyor pointed out the Contact isolation sign outside of R320's room to V25. V25 stated R320 was on Enhanced Barrier Precautions and not on Contact isolation. V25 reported staff had put up the wrong sign outside of the room. The surveyor then let V25 review the chart to verify if R320 was on Enhanced Barrier Precautions or Transmission Based Precautions, but V25 was unable to give a definite answer to what precautions R320 was currently on. V25 stated if a resident is on contact isolation precautions a gown and gloves must be put on before entering the room to prevent the spread of an infection to other residents in the facility. On 04/23/25 11:43 AM, V7 (infection prevention nurse) stated that currently there are two residents on contact isolation which one was R320. V7 stated that staff are expected to don gown, mask, and gloves prior to entering an isolation room. V7 stated that enhanced barrier precautions (EBP) is to protect the resident with wounds, G-tubes, indwelling catheters and prevent the spread of infection. V7 stated that staff are expected to don gown and gloves when providing direct resident care. The Physician order Sheet documents an order for contact isolation for ESBL/VRE infection in the urine dated 4/17/25. An Infectious Disease Nurse Practitioner note dated 4/18/25 documents R320 is positive for an E. Coli ESBL urinary tract infection and a enterococcus faecium VRE urinary tract infection. R320 is on two antibiotics currently treating both bacteria in the urinary tract infection. Plan is to continue antibiotics as ordered, repeat urinalysis post antibiotics course and contact precautions for ESBL and VRE in the urine until cleared. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 30 of 31 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 146053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464 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 - Few The Medication Administration Record dated 04/2025 documents R320 had a urinary catheter from 4/8/25 upon admission but the catheter was discontinued on 4/13/25. The Care Plan dated 4/8/25 documents R320 is incontinent of bowel and bladder and requires staff assistance with incontinence care to maintain a clean and dry state. There is no care plan addressing R320 being on contact isolation. The policy titled, Transmission based Precautions, dated 02/2025 documents, General: Transmission based precautions are a second tier of basic infection control and are to be use in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which precautions are needed to prevent infection transmission. Responsible Party: All staff Policy: Contactgloves are required upon entry to the room, must be removed before exiting, and followed by hand hygiene; and gowns are required when providing direct patient care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146053 If continuation sheet Page 31 of 31