Health inspection·January 24, 2025

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few alcohol use, unspecified with withdrawal and bipolar disorder, current episode depressed, severe, without psychotic features, notes by Medical Practitioner dated 11/04/2024 that indicated R27 has PMHx (past medical history) that includes Hx (history) of ETOH (alcohol) abuse and Bipolar who was recently hospitalized from [DATE] to 11/1/2024 due to alcohol abuse with withdrawal delirium. Review of R27's Progress Notes by Social Service dated 11/06/2024 indicated R27 is being followed up on aggressive behavior towards others/staff and during staff interventions exhibited on 11/05/2024. Review of R27's Progress Notes by Social Service dated 11/08/2024 indicated R27 dx (diagnoses) are bipolar d/o (disorder) unspecified, major depression d/o, cognitive communication deficit, delirium d/o, alcohol abuse unspecified d/o, and other medical conditions. It also indicated that R27 has also displayed behaviors or episodes of anxiety thoughts or actions, aggression towards staffs or during staff interventions, depressive thoughts or mood distress, episodes of cognitive decline or communication deficits, feelings of helplessness/hopelessness, and grieving of loss of control over his community independent lifestyle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146058 If continuation sheet Page 2 of 9 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 146058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Evanston 1300 Oak Avenue Evanston, IL 60201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician's order on oxygen administration and to replace and safely store oxygen nasal cannula for two of two residents (R7, R35) reviewed for respiratory care in a sample of 18. Residents Affected - Few Findings include: 1. On 01/21/2025 at 10:22AM during unit rounds, R7 was lying flat on bed, and R7's oxygen nasal cannula was on the floor and not in a plastic bag. R7's oxygen nasal cannula was also not dated, and the oxygen humidifier indicated a date of 12/15/2024. On 01/21/2025 at 10:50AM during observation with V3 (Registered Nurse), R7's oxygen nasal cannula was not in a plastic bag and was on the floor. Also, R7's oxygen nasal cannula was not dated, and the oxygen humidifier indicated a date of 12/15/2024. V3 picked up R7's oxygen nasal cannula and put it in a bag without changing it. At 11:19AM during record review with V3, R7's oxygen order is to administer oxygen at 2 liters per minute to maintain O2 (oxygen) saturation at 95% or greater every day and night shift for SOB (shortness of breath). At 11:20AM, V3 proceeded to check R7's oxygen level. Between 11:20AM 11:25AM, R7's oxygen level is at 87%. V3 did not administer oxygen to R7. On 01/21/2025 at 10:50AM during interview with V3, V3 stated that R7's oxygen nasal cannula should be placed in a bag after each use. V3 stated that R7's oxygen is to be given only as needed by R7. V3 also stated that R7's humidifier and oxygen nasal cannula should be dated and changed weekly. On 01/24/2025 at 9:44AM during interview with V2 (Acting Director of Nursing), V2 stated that all oxygen humidifiers and nasal cannulas are expected to be changed in a weekly basis for infection control. V2 also stated that the nurses are expected to administer the oxygen to the residents as prescribed by the physician. V2 also stated that if the resident had any change in condition during their shift, the nurses are expected to manage the resident first then inform the attending physician for further management and document it in the resident's chart. Review of R7's Order Summary Report dated 01/22/2025 indicated R7 was admitted at 03/04/2020 with diagnoses of not limited to Chronic Respiratory Failure with Hypoxia, Obstructive Sleep Apnea, Morbid (Severe) Obesity with Alveolar Hypoventilation and Chronic Obstructive Pulmonary Disease (COPD), order to change O2 tubing and humidifier weekly every night shift every Sunday for Infection Control with order date of 08/17/2024, and order for oxygen at 2 liter per minute to maintain O2 (oxygen) saturation at 95% or greater every day and night shift for SOB with order date of 09/08/2024. Review of R7's Care Plan revised 11/21/2024 indicated R7 has COPD, sleep apnea, and hx (history) of resp. (respiratory) failure with interventions including to administer O2 as ordered and to HOB (head of bed) elevated when lying flat as R7 has SOB when lying flat. 2. On 01/21/2025 at 10:25AM during unit rounds, R35's oxygen was at 4 liters per minute, nasal cannula was not dated, and the oxygen humidifier indicated a date of 12/15/2024. On 01/21/2025 at 11:15AM during observation with V3 (Registered Nurse), R35's oxygen was at 4 liters per minute, nasal cannula was not dated, and the oxygen humidifier indicated a date of 12/15/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146058 If continuation sheet Page 3 of 9 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 146058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Evanston 1300 Oak Avenue Evanston, IL 60201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/21/2025 at 11:20AM during interview with V3, V3 stated that R35's humidifier and oxygen nasal cannula should be dated and changed weekly. On 01/24/2025 at 9:44AM during interview with V2 (Acting Director of Nursing), V2 stated that all oxygen humidifiers and nasal cannulas are expected to be changed in a weekly basis for infection control. V2 also stated that the nurses are expected to administer the oxygen to the residents as prescribed by the physician. V2 also stated that if the resident had any change in condition during their shift, the nurses are expected to manage the resident first then inform the attending physician for further management and document it in the resident's chart. Review of R35's Order Summary Report dated 01/23/2025 indicated R35 was admitted on [DATE] with diagnoses of not limited to Acute Respiratory Failure with Hypoxia, Acute on Chronic Systolic (Congestive) Heart Failure and dependence on supplemental oxygen, and order for oxygen at 2 LPM (liters per minute) with order date of 12/06/2024. Review of facility's policy entitled Oxygen Safety/Use reviewed on 01/2024 indicated the following: General: 9. Oxygen tubing will be changed weekly and appropriately stored to prevent contamination when not in use. Chart as nursing order on treatment administration record. Procedure: 2. Turn flow control knob on oxygen unit clockwise until prescribed flow rate is visible in the knob window. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146058 If continuation sheet Page 4 of 9 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 146058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Evanston 1300 Oak Avenue Evanston, IL 60201 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 - Many 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. Based on observation, interview and record review the facility failed to discard expired opened medications from 2nd floor medication room. This failure has the potential to affect all 51 residents residing in the facility. Findings include: On 1/21/24 at 10:00am during medication room inspection on the 2nd floor, surveyor observed an open house stock Tuberculin purified Protein Derivative (TB) (5TU/0.1ml) 5ml (milliliters) vial that was about 75-80% full in the medication fridge on the 2nd floor. The vial had an open date of 9/26/24. During medication cart inspection on the 2nd floor, surveyor also observed a bottle of house stock acetaminophen 500mg (milligrams) with no expiration date. During an interview on 1/21/25 at 10:00am, V4 (Registered Nurse) stated that the opened TB vial should be discarded after 30 days and expired medications should be returned to the return bin for pharmacy to pick it up. Facility policy dated 1/2024 reads, medication storage in the facility. Responsible party: Nursing Procedure: 14. outdated, .drug will be immediately withdrawn from stack by facility. They will be disposed of according to drug disposal procedures and reorder from the pharmacy if a current order exit. Facility's document Medication storage information Best Practices reads. Product: PPD (Tubersol) Storage: Refrigerate Expiration Date: 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146058 If continuation sheet Page 5 of 9 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 146058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Evanston 1300 Oak Avenue Evanston, IL 60201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to follow their 3 compartment sink policy by not submerging used utensils in the quat (Quaternary Ammonium Compounds) solution for 60 seconds and the facility failed to follow the Labeling and Dating Foods (Date Marking) Policy by not ensuring sandwiches were dated. This failure has the potential to affect all residents receiving nutrition from the kitchen. Findings include: 1. On 1-22-25 at 11:05 AM, surveyor observed V13 (Cook) submerge used utensil (scraper) into the 3-compartment sink (water compartment) for approximately 2 seconds. Surveyor observed V13 did not submerge the used utensil for 60 seconds in the quat solution. Surveyor observed V13 place the used utensil back into the workstation and then used it to make pureed stuffing. On 1-23-25 at 9:06 AM, V12 (Dietary Supervisor) said the purpose of submerging items in quat solution for 1 minute and air drying to eliminate any bacteria. On 1-22-25 at 11:20 AM, V13 (Cook) said she did not submerge the utensil in the quat solution for 60 seconds. V13 said she usually sanitizes in the quat solution for 60 seconds but did not do it this time. Three Compartment Sink Policy (no date) documents: Sanitize items in the 3rd sink. Submerge items for at least 60 seconds, or per the manufacturer's guidelines. Washing Procedures dated 2016 documents: 4. After rinsing ware, submerge into sanitizer sink for at least 1 minute. 2. On 1-21-24 at 10:30 AM, surveyor and V12 (Dietary Supervisor) noted 2 individually wrapped Ham and Cheese sandwiches without a label date. V12 immediately pulled the sandwiches and applied a label dated of 1-21-25. On 1-23-25 at 9:06 AM, V12 (Dietary Supervisor) said prepared food is good for 72 hours. V12 said the purpose of labeling food is to know the use by date of the food. Labeling and Dating Foods (Date Marking) Policy (no date) documents: Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food guidelines or by the manufacturers expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146058 If continuation sheet Page 6 of 9 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 146058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Evanston 1300 Oak Avenue Evanston, IL 60201 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to monitor the temperature of the refrigerator unit in resident's room for four of four residents (R2, R3, R13, R16) reviewed for food safety in a sample of 18. Residents Affected - Some Findings include: 1. On 1/21/25 at 10:30am during patient encounter, R3's refrigerator was observed with no temperature log. R3's refrigerator was observed with oranges, blueberries, and nuts. During an interview on 1/21/25 at 10:30am, V6 (Restorative Aide) and V7 (CNA-Certifed Nursing Assistant) all stated that housekeeping checks the resident's refrigerator temperature. During an interview on 1/21/25 at 10:30am, V5 (Housekeeping Director) stated that housekeeping monitor the resident's refrigerator in their rooms. V5 stated that the logs are kept in his office downstairs but was unable to produce any logs as requested. 2. On 1/21/25 at 10:30am during patient encounter, R16's refrigerator was observed with no temperature log. R16's refrigerator was observed with peanut butter. During and interview on 1/21/25 at 10:30am, V6 (Restorative Aide) and V7 (CNA) all stated that housekeeping checks the resident's refrigerator temperature. During an interview on 1/21/25 at 10:30am, V5 (Housekeeping Director) stated that housekeeping monitors the resident's refrigerator in their rooms. V5 stated that the logs are kept in his office downstairs but was unable to produce as requested. 3. On 01/21/2025 at 10:23AM during unit rounds, R2's refrigerator did not have temperature log and R2's refrigerator temperature was at 48 degrees Fahrenheit (F). On 01/21/2025 at 10:52AM during observation with V3 (Registered Nurse), V3 was unable to locate R2's refrigerator temperature log and R2's refrigerator temperature was at 48 degrees Fahrenheit. R2's refrigerator had an unlabeled and undated cup with black fluid in it and a bottle of soda. On 01/21/2025 at 10:52AM during interview with V3, V3 stated that R2's refrigerator temperature should be checked daily. On 01/22/2025 at 9:30AM during interview with V1 (Administrator), V1 stated that all the refrigerator temperature logs are in V5's (Maintenance Director) office because sometimes the residents lose it. V1 also stated that R2's refrigerator temperature should be checked daily and the food item in R2's refrigerator should be dated and labeled. V1 also stated that all resident refrigerators should be cleaned by housekeeping daily. Facility unable to provide R2's refrigerator temperature log. 4. On 01/21/2025 at 10:44AM during unit rounds, R13's refrigerator did not have temperature log and R13's refrigerator temperature was at 14 degrees Fahrenheit (F). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146058 If continuation sheet Page 7 of 9 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 146058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Evanston 1300 Oak Avenue Evanston, IL 60201 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 0813 Level of Harm - Minimal harm or potential for actual harm On 01/21/2025 at 10:48AM during observation with V3 (Registered Nurse), V3 was unable to locate R13's refrigerator temperature log and R13's refrigerator temperature was at 14 degrees Fahrenheit. R13's refrigerator had 3 boxes of 2% milk with sell by date of 01/14/2025, 1 box of 2% milk with sell by date of 01/07/2025, one unlabeled and undated cup with white viscous liquid inside, and unlabeled and undated food item wrapped in a paper towel. Residents Affected - Some On 01/21/2025 at 10:52AM during interview with V3, V3 stated that R13's refrigerator temperature should be checked daily. On 01/22/2025 at 9:30AM during interview with V1 (Administrator), V1 stated that all the refrigerator temperature logs are in V5's (Housekeeping Director) office because sometimes the residents lose it. V1 also stated that R13's refrigerator temperature should be checked daily, and the food items in R13's refrigerator should be dated and labeled. V1 also stated that all resident refrigerators should be cleaned by housekeeping daily. Facility unable to provide R13's refrigerator temperature log. The facility's policy entitled Refrigerator and Resident Appliance Maintenance Service revised on 08/19/2024 documents: Policy Statement: It is the policy of this facility to provide maintenance services for refrigerator units in resident rooms, common areas/dining rooms and nurses station. Procedures: 1. The maintenance department or the facility designee is responsible for maintaining that resident appliance, e.g. refrigerators are safe, clean and operable at all times. a. Refrigerator in resident room 2. The facility will perform the following refrigerator checks: c. Temperature is maintained below 41F and above 32F using a thermometer with +-3 degrees temperature variance. d. Proper labeling, storage and disposition of food items. e. Ensure proper dating and disposition of outdated food items including food brought by family and resident from the outside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146058 If continuation sheet Page 8 of 9 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 146058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Evanston 1300 Oak Avenue Evanston, IL 60201 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 transmission-based practices for one of three residents (R204) reviewed for infection control in a sample of 18. Residents Affected - Few Findings include: On 01/21/2025 at 10:55AM during unit rounds, V18 (Nurse Practitioner) was going out of R204's room with isolation gown on. R204's room has sign that reads Droplet Precaution. On 01/21/2025 at 10:58AM during interview with V18, V18 stated that she left R204's room with isolation gown on but she should have removed it before coming out or R204's room. On 01/23/2025 at 12:40PM during interview with V2 (Acting Director of Nursing), V2 stated that all personal protective equipment should be removed inside the resident's room. V2 stated that R204's room should have both contact and droplet precaution sign. Review of R204's Order Summary Report documents an admission date of 01/17/2025, diagnoses of not limited to influenza due to identified novel influenza A virus with other respiratory manifestations and order of contact/droplet isolation dx (diagnosis) positive influenza A with order date of 01/17/2025 (discontinued on 1/23/25). Review of R204's laboratory results dated [DATE] indicated Influenzae A detected. Review of facility document entitled How to Safely Remove Personal Protective Equipment (PPE) Example 1 indicated to remove all PPE before exiting the patient room except a respirator if worn. Review of facility document entitled How to Safely Remove Personal Protective Equipment (PPE) Example 2 indicated to remove all PPE before exiting the patient room except a respirator if worn. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146058 If continuation sheet Page 9 of 9