Health inspection·October 7, 2022

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 observation, interview, and record review, the facility failed to develop an individualized care plan to address a resident's pain and use of anticoagulation medication. This applies to 2 of 15 (R65 and R66) residents residing at the facility. Findings include: 1. R66 is [AGE] years old with medical diagnosis Leukocystosis, Choledocholithiasis. R66 and has current order for the following medications: Acetaminophen 650 MG as needed every 6 hours for mild pain and fever Acetaminophen - Codeine 300-30 MG 1 tablet as needed for moderate pain. On 10/04/2022 at 12:54 PM, while passing by R66's room, R66 was heard moaning with an interval of 2 to 5 seconds. Upon entering R66's room, R66 was asked if he was in pain, but was not able to verbalize. R66 was found grimacing, and his right hand was on his stomach. V8 (Registered Nurse) stated R66 is taking antibiotic for his GI (Gastrointestinal) infection, and R66 was NPO (nothing by mouth) because he was scheduled today for testing. On 10/05/2022 at 1:36 PM, V7 (Minimum Data Set Coordinator) stated, (R66) has an infection and medical diagnosis that led him to pain. When a resident has medical diagnosis of pain., assessment and monitoring must be done. On 10/06/2022 at 10:28 AM, V7 said, Not all shifts performed pain assessment with (R66). Per staff, (R66) moans a lot. Yes, (R66) cannot express himself with words if he has pain. And I agree, given his medical diagnosis he must be in pain. He (R66) has sepsis. V7 was asked after review of R66 most current complete care plan; pain was not included. V7 said, Pain should have been included in the care plan. I will modify (R66's) care plan to include pain. 2. R65 is [AGE] years old, with the following medication for anticoagulant: Warfarin (Coumadin) 5 MG to take by mouth nightly and Enoxaparin Sodium (Lovenox) injection 40 MG every 24 hours. R65 most recent complete care plan was reviewed. There was no care plan for anticoagulant medication. On 10/05/2022 at 1:36 PM, V7 (Minimum Data Set Coordinator) stated, I missed it. There should be a Page 1 of 14 145548 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

F 0656 care plan for anticoagulant because of the risk for bleeding. Yes, (R65) currently takes 2 anticoagulant medications. And there must be a care plan for that. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145548 Page 2 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 assess a resident's pain level every shift, to manage a resident's pain. This applies to one of 15 residents (R66) who was reviewed for pain management. Residents Affected - Few Findings include: R66 is [AGE] years old with medical diagnosis Leukocystosis, Choledocholithiasis. R66 and has current order for the following medications: Acetaminophen 650 MG as needed every 6 hours for mild pain and fever Acetaminophen - Codeine 300-30 MG 1 tablet as needed for moderate pain. On 10/04/2022 at 12:54 PM, while passing by R66's room, R66 was heard moaning with an interval of 2 to 5 seconds. Upon entering R66's room, R66 was asked if he was in pain, but was not able to verbalize. R66 was found grimacing, and his right hand was on his stomach. V8 (Registered Nurse) stated R66 is taking antibiotic for his GI (Gastrointestinal) infection, and R66 is NPO (nothing by mouth) because he is scheduled today for testing. On 10/05/2022 at 1:36 PM, V7 (Minimum Data Set Coordinator) stated, (R66) has an infection and medical diagnosis that led him to pain. When a resident has medical diagnosis of pain, assessment and monitoring must be done. On 10/06/2022 at 10:17 AM. V1 (Chief Nurse Officer) said, Assessment needs to be done more than daily. In fact, it should be done every shift to determine if patient has pain. There are also non-verbal cues of pain, that includes grimacing. For that instance, we give pain medication. At 10:28 AM, V7 said, Not all shifts performed pain assessment with (R66). Per staff, (R66) moans a lot. Yes, (R66) cannot express himself with words if he has pain. And I agree, given his medical diagnosis, he must be in pain. He (R66) has sepsis. R66 has no care planned for pain. R66 does not have pain assessment done per shift, and no notes related to pain were written related to pain. R66's clinical record, dated 10/4/2022, documents resident has occasional moan/groan, speech, negative, disapproving quality. Per V7, staff did document as 0 (zero) for pain, but no further assessment was done. Facility policy on Pain Management, dated as revised 3/2022, In part reads: This policy will provide guidelines for the assessment, interventions and an effective management of pain. Under procedure, all residents/patients have their comfort and pain level assessed on admission. Assessment includes as follows: Assessment of the resident's/patient's present pain level, history, past pain treatments and effectiveness. Determining intensity, location, duration, radiation, pattern of pain and effects the pain has on ADL's and quality of life. Use resident's/patient's own words whenever possible to describe pain. Emotional, physical, and behavioral manifestations may be used to determine pain level if the resident/patient is unable to communicate verbally. Under reassessment and documentation, Reassessment of all residents/patients will be done and documented. Documentation should be charted in the pain assessment and reassessment portion of the nurse's notes and flow sheets as indicated. 145548 Page 3 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to reconcile controlled narcotic medications stored in automated dispensing machines located on the fourth floor of the facility. This failure affected six of six residents (R163, R7, R1, R11, R65, R8) who receive narcotic medications from the 4th floor medication dispensing machine. Findings include: Record review documents that R163, R7, R1, R11, R65, and R8, all have active physician orders to receive controlled substance medication. On 10/05/2022 at 12:00 PM, V13 (Registered Nurse) stated, We don't always sign with two nurses and count the narcotics if narcotics are used, sometimes the pharmacy counts the narcotics. The nurses perform their own individual narcotic count. Two nurses only need to sign for heparin administration. On 10/05/2022 at approximately 3:00 PM, the daily nursing inventory/reconciliation reports and the monthly pharmacy inventory/reconciliation reports for controlled narcotics kept in the automated dispensing machine were requested from V1 (Chief Nursing Officer) by surveyor. On 10/06/2022 at 9:49 AM, V1 (Chief Nursing Officer) stated, The nurses are supposed to perform a daily narcotic count at the end of each shift only if a controlled substance is used during that shift. The pharmacy performs a monthly reconciliation of the narcotic count. About 3 months ago, we recognized that the narcotic reconciliation counts were not being done and there was so many discrepancies with the narcotic count. We developed a task force to address the issue back in June of this year and since then, the nurses have been educated on the need to perform the count on a daily basis and the narcotic count should be getting done now. We revised the policy in June also to reflect the changes made. On 10/06/2022 at approximately 10:00 AM, the daily nursing inventory/reconciliation reports for the past 3 months for controlled narcotics kept in the automated dispensing machine were requested again from V1 (Chief Nursing Officer) by surveyor. On 10/06/2022 at approximately 12:00 PM, facility provided surveyor with the nursing inventory/reconciliation report for all three automated dispensing machines dated 10/06/2022 only. The daily nursing inventory/reconciliation reports for the past 3 months for controlled narcotics were not provided by facility. 145548 Page 4 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

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. Based on observation, interview, and record review, the facility failed to follow its policy on labeling and dating opened insulin medication vials for three of three residents (R162, R64, R63) receiving insulin medications and house stock insulin vials located on the 4 west unit of the facility. Findings include: Facility census, dated 10/04/2022, documents seven residents reside on the 4 [NAME] Unit and eight residents reside on the 4 East Unit. List of residents who are prescribed insulin medication provided to surveyor by V1 lists a total of three residents who are prescribed insulin medication. Review of all resident physician order sheets documents R162, R64, and R63 all have active orders for insulin medication. On 10/04/2022 at 11:17 AM, surveyor observed the following insulin medications inside medication refrigerator for 4 [NAME] Unit located on the 4th floor of the facility: Novolin R insulin 100 units/ml vial Housestock open, with no date indicating when the medication was opened, date written on vial observed as 10/29/2022. Novolin 70/30 insulin 100 units/ml vial Housestock open, with no date indicating when the medication was opened, date written on vial observed as 10/24/2022. Lantus insulin 100 units/ml vial Housestock open, with no date indicating when the medication was opened, date written on vial observed as 10/07/2022. Novolog insulin 100 units/ml vial Housestock open, with no date indicating when the medication was opened, date written on vial observed as 10/14/2022. On 10/04/2022 at 1:17 PM, V11 (Registered Nurse) stated, We only write the expiration dates on the insulin vials. I do not know when the insulin was opened. On 10/05/2022 at 11:51 AM, surveyor observed the following insulin medications inside medication refrigerator for 4 East Unit located on the 4th floor of the facility: Novolin R insulin 100 units/ml vial Housestock open with no date indicating when the medication was opened, date written on vial observed as 10/22/2022. Lantus insulin 100 units/ml vial Housestock open, with no date indicating when the medication was opened, date written on vial observed as 10/19/2022. Novolog insulin 100 units/ml vial Housestock open, with no date indicating when the medication was opened, date written on vial observed as 10/29/2022. On 10/06/2022 at 9:49 AM, V1 (Chief Nursing Officer) stated, For insulin, my understanding is that the vials are labeled with an expiration date or an open date, I'm not sure which one. V1 is shown facility document dated August 2019, titled Medication Administration provided to surveyor by V1. 145548 Page 5 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

F 0761 V1 is referred by surveyor to the following statement written in policy: Level of Harm - Minimal harm or potential for actual harm All multi-dose vials of injectables, including all types of insulin, will be dated by the nurse on the day the vial is opened with a beyond use date of 28 days from the day of opening the vial. Residents Affected - Few V1 then stated, So then we are not following our policy on labeling insulin, there is supposed to be an open date and an expiration date written on the vials. We don't follow our policy, it is what it is, we have to fix it. Facility document dated August 2019, titled Medication Administration states in part All multi-dose vials of injectables, including all types of insulin, will be dated by the nurse on the day the vial is opened with a beyond use date of 28 days from the day of opening the vial. 145548 Page 6 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have evidence of rountine testing of the the dish machine sanitizing temperatures and demonstrated the dish machine had proper santizing temperatures, failed to ensure food stored in the dry storage and refrigeration areas were stored in a manner to prevent cross contamination of the food items, failed to ensure an expired food item and each food item was dated while stored in the refrigeration area, failed to ensure can foods have in-out dating tracking, and failed to ensure staff perform hand hygiene when taking food temperatures; These failures have the potential to affect 14 residents in the facility whom recieve an oral diet. Per Facility Census there are 15 total number of residents, with 1 resident on NPO. Findings includes: On 10/04/2022 at 11:40 PM, with V4 (Food Services Supervisor) and V3 (Chief Operating Officer), near the walk-in cooler there are 3 large bins for rice, flour, and sugar that were not dated. On the surface of the lid, was a scooper left on a high touch area. V4 was asked why the scooper was not inside a compartment. V4 said, I know it should be in a compartment. Like the one on a wall to keep it clean. Pointing at the scooper on the wall that was inside a transparent compartment. Inside the walk-in cooler on a cart, there were metal containers of ham, jalapenos, tomatoes and bacon that were not dated. V4 said they forgot, but it should have been dated. Large boxes of eggs were seen on the shelves. 1 box has has a label that reads best used by 8/30/2022. V4 said those eggs were expired, and must be taken out of supply immediately. V3 said they will check out with supplier, but also said inventory must be done in a daily basis, to make sure food supplies are not expired. Inside an open box, a tray of eggs was seen with a broken shell with the egg white and yolk dripping to the crate. On another shelf, 3 bags of bagels were seen without a date. A yogurt on a cylinder plastic packaging had a crack on the bottom and was dripping. V3 said, I will get rid of it, right away. Yes, it should have been checked by staff. Inside walk-in cooler, the fan was dripping due to condensation of its surface, going inside 2 buckets, and some liquid was dripping inside an open plastic covering that had cans of soda. In the dry storage room shelf, 3 large cans of beans were seen with print that reads: Expires [DATE]. V3 stated, I did not keep a log or inventory of the food supply in the dry storage room. Yes, those 3 cans are expired for more than a year. And it should have been taken out of food supply. I do not know when the last time we used these beans. At the dishwasher area, V4 said the dishwasher was temperature-based machine. V4 was asked to present the log that staff was checking if the dishwasher meets the required temperature. V4 said they check it one time a day every lunch, but was not able to present the log when requested. On 10/05/2022 at 11:06 AM, with V4 and V3, at the dishwasher area, V4 presented a log with testing strips attached. A lot of testing strips bars have colored dark blue. The test strip instructions reads: Pass when blue bar turns orange 180 degrees Fahrenheit. V3 stated, I can see that. V4 was asked 145548 Page 7 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many why it was not addressed since test strips instructions does not pass the required temperature? V4 did not answer. V3 stated, Let us just test the machine so that we will know if it will turn orange. Dishwasher machine was tested with a test strip placed in a metal utensil. After running the test strip inside the dishwasher, it remained dark blue. V3 stated, We will run it again. V4 ran the same procedure with the same test strip, and the result was the same. Test strip remained dark blue. V3 was asked to present maintenance log to check if dishwasher machine was being maintained. V3 said, We only ask maintenance to check out equipment if the equipment needs to be repaired. Inside the dry storage room, V4 was asked to identify multiple large cans that were unpacked, including a large can of mushrooms that had no date. V4 said he cannot identify since the can of mushrooms was taken out of the box, and there was no date. V4 said, Yes, I understand what you mean. We need a system of tracking food supplies, because there are foods that do not have expiration dates. On 10/06/2022 At 10:50 AM, V4 checked the temperature of all foods on a steam table to be served on the unit. V4 was not seen to perform hand washing or hand hygiene before checking food temperatures. V3 said, Yes, we have policy for handwashing or hand hygiene. And I understand that (V3) should perform handwash before checking food temperature. Yes, since we just went to see the dumpster and touched a lot of areas. At 11:02 AM, V12 went to check the steamer and said, This is not right, it should not be leaking. I will check on it. May be the gasket needs to be change. Related Facility Policies: Food Storage - Labels and Dates, Scoop Storage, Rotation of Stock, First In First Out (FIFO), Use of Leftovers dated as revised 6/1/2022. In part reads: This policy outlines safe food handling and storage practices of the Food and Nutrition Services Department. Under procedure, checking for outdated products. The Purchasing Assistant on a twice weekly basis checks to make sure that food has been properly rotated and removes any outdated items. Product older that a year are discarded. Dry Goods, all stock dated upon receipt (day received, month, day, year) and then rotated so that the oldest is used first (FIFO). Labeling and Dating, all tray line food prepared for the day of use is stored on a large rolling cart rack and covered with plastic sheet or plastic wrap. The wrap is labeled and dated before being placed into the fridge with day's prep date. Food Supplies - Inventory, Ordering, Receiving, Storage of Food and Supplies and Essential Records Retention dated as revised on 6/1/2022. In part reads: This policy establishes procedure to follow for inventory maintenance, ordering of food and supplies, the delivery, storage of goods, and record-keeping to control to avoid excesses or shortage. Under storage, the purchasing assistant dates and stores all deliveries in their designated area. Under opened, dry items. Any dry food that has been opened but only partially used will be stored in its original container provided the container has cover. If the item cannot be stored in its original container, the food will be stored in a sanitary container with a lid. The container must be labeled with the contents and the date the original container was received, the date packed and was opened and stored in the appropriate areas. No loose scoops will be left in bulk food containers. Scoop will be stored in a covered container and washed completely, daily. Temperature Monitoring - Equipment, Refrigerators, Freezers, Dish Machine dated as revised 6/1/2022. In part reads: To ensure that food products are stored at appropriate temperatures and that dishware is properly clean and sanitized. Under Dish Machine Temperatures, the dish machine temperature will be taken 3 times daily during each use at breakfast, lunch and dinner. The dish machine temperatures are recorded in the Dish Machine Temperature Log Binder prior to processing dishes. If the final 145548 Page 8 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

F 0812 rinse does not meet standard of 180 degrees Fahrenheit, maintenance is called to determine the problem. Level of Harm - Minimal harm or potential for actual harm Hand Washing and Proper Glove Usage dated as revised 6/1/2022. In part reads: To establish protocol for proper handwashing and eliminate transmission of any potentially harmful microorganism. To establish proper disposable glove usage. Under procedure, all employees must wash their hands before they start work and after any of the following occurrences: Before beginning a different task. Touching anything else that may contaminate hands such as un-sanitized equipment, work surface or washcloths. Under glove use in food preparation and handling. Gloves must be worn when handling cooked or ready to eat foods. Residents Affected - Many 145548 Page 9 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to perform hand hygiene for one (R7) resident receiving a wound dressing change, and failed to place a new disinfecting port protector on a needleless intravenous connector for one (R163) resident after accessing the intravenous connector during medication administration. Residents Affected - Few These failures have the potential to affect 2 of 15 (R7, R163) residents residing in the facility. Findings include: 1. On 10/05/2022 at 10:46 AM, V9 (Wound Care Nurse) was inside of R7s' room performing wound care dressing change for R7. V9 observed removing dirty dressing from R7s' sacral wound. V9 did not remove soiled gloves. V9 double-gloved and began performing R7s' wound dressing change with sterile and clean supplies. V9 did not perform hand hygiene prior to performing R7s' wound dressing using sterile and clean supplies. During R7s' wound dressing change, V9 was also observed donning and doffing gloves, without performing hand hygiene in between glove changes. On 10/05/2022 at 11:35 AM, V9 stated No, I did not perform hand hygiene after removing R7s' old wound dressing; I was supposed to perform hand hygiene. I use the double-glove technique for my protection and to prevent having to continuously use hand sanitizer. The number one way to prevent the spread of infection is performing hand hygiene. On 10/05/2022 at 2:20 PM, V2 (Director of Nursing/DON) stated Double gloving is not considered a substitute that replaces hand hygiene; it is not a standard of practice and I would encourage hand hygiene in between glove changes. Yes, the number one way to prevent the spread of infection is performing hand hygiene. Facility document dated February 2020, titled Hand Hygiene documents in part Hand hygiene is required for the following: 2. Upon removing sterile or non-sterile gloves 3. When moving from a contaminated body site to a clean body site when doing patient care. 2. On 10/05/2022 at 9:11 AM, during the medication administration pass, V10 (Registered Nurse) was observed removing R163s' disinfecting port protector on R163s' needleless intravenous connector. V10 placed disinfecting port protector, with sponge side down, onto R163s' bare bedside table. V10 was observed administering R163s' prescribed IV medications. After V10 administered R163s' intravenous medication, V10 picked up the same disinfecting port protector that was placed on R163s' bare bedside table, and placed it back onto R163s' needleless intravenous connector. On 10/05/2022 at 9:35 AM, V10 stated, The green disinfecting caps have alcohol in it, so it cleans the connector once its placed back on the connectors. The green disinfecting cap should only be changed once daily, its does not have to be disposed and changed after it's taken off of the intravenous connectors. On 10/05/2022 at 2:20 PM, V2 (DON) stated, The green disinfecting caps should be changed immediately after being contaminated, and if it touches any resident surface area. Once disinfecting caps are removed, there is a risk for infection when the intravenous port is exposed. On 10/06/2022 at 9:49 AM, V1 (Chief Nursing Officer) stated, We also recognized that we do not have 145548 Page 10 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a policy pertaining to disinfecting port protectors although we utilize them here at the facility. V1 hands surveyor a document and stated, These are the brand type connectors that we use here at the facility. Surveyor observed that the undated document was titled in part Disinfecting Port Protectors How to use. V1 stated, As of yesterday (10/05/2022), we are in the process of developing a policy for using the disinfecting port protectors. As of yesterday (10/05/2022), the nurses have also been educated to wipe the intravenous connector with alcohol for at least 10 seconds when accessing the connector until we can get a policy developed for the port protectors. From my understanding, the port protectors have alcohol inside of the cap for disinfecting purposes but V10 should have discarded the port protector if it was placed on the contaminated surface. (V10) could have also used an alcohol pad to scrub the connector for at least 10 seconds, or placed a new disinfecting cap on the connector. This was not brought to our attention until yesterday (10/05/2022). Undated document titled in part Disinfecting Port Protectors How to use provided to surveyor by V1 states Always place a new disinfecting cap on needleless connector after each use. Dispose of the disinfecting cap after every use. 145548 Page 11 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 follow their Pneumonia/Flu Vaccine policy to ensure residents received education regarding the benefits of influenza and/or pneumococcal immunization. This applies to 5 of 15 residents (R113, R62, R8, R63) residing in the facility. Residents Affected - Some Findings include: On 10/05/2022 at 11:10 AM, surveyor, with V2(Director of Nursing-DON) and V5 (Director of Infection Control and Employee Health), reviewed residents immunization records. R113, R62, R8, R63 medical records document the following: R113's medical records documented R113 was offered pneumococcal vaccine on 9/29/2022, and R113 refused. No documentation of education provided. R113 refused Flu vaccine, no documentation of education provided. R62 refused flu and pneumonia vaccines on 9/26/2022; No documentation of education provided. R8 refused flu and pneumonia vaccines on 9/13/2022; No documentation of education provided. R63 medical records document R63 last received flu vaccine on 2/25/2022; No documentation flu vaccine was Offered this flu season; No education provided. On 11/05/2022 at 11:16AM, V2 said, We ask the patient if they want vaccine. If they refuse, we document the refusal. We should be providing education. It's important to educate the residents who refuse vaccine on the importance of the vaccines because vaccines are the first line of defense to prevent communicable diseases. V2 said, If we do not educate them, they could lose an opportunity to get protection. V2 said, Residents who came to us have a weak immunity and getting the flu and pneumonia vaccines can protect them from getting those diseases. V2 said, This is a learning moment for us, we need to educate our residents. On 10/05/2022 at 11:21 AM, V5(Director of Infection Control and Employee Health) said immunizations are given to prevent the spread disease in the community and in the facility. Residents are protected by immunizations, and immunizations protect residents from getting severely sick. V5 said, We should evaluate and teach the resident on the importance of vaccination so they can make informed decisions. Facility Vaccine Protocol-Pneumococcal and Influenza policy dated January/2021 documents in part; A. Pneumococcal Vaccine 1. Upon admission, all acute care patients are assessed for eligibility by the admitting nurse for immunization based on the following criteria: 145548 Page 12 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

F 0883 a. Level of Harm - Minimal harm or potential for actual harm [NAME] 65 or older b. Residents Affected - Some Age 6-64 with CHF, COPD, diabetes, nephritic syndrome, ESRD, HIV or Asplenia c. Age 19-64 with asthma B. Influenza Vaccine (October though March) 2. Upon admission, all acute care patients are assessed for eligibility by the admitting nurse for immunization based on the following criteria: a. Age 6 months or older. The staff nurse will provide the CDC required information sheet (VIS)and assure that the patient verbalizes understanding. The nurse will document the edition and edition date of the VIS provided. 145548 Page 13 of 14 145548 10/07/2022 Community First Medical Center 5645 West Addison Street Chicago, IL 60634

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record reivew, the facility failed to maintain kitchen equipment in working order. This has the potenital to affect 14 of 15 residents receiving meals from the facility's kitchen. Residents Affected - Many Findings include: On 10/05/2022 at 11:06 AM, with V4 (Nutrition Services Manager) and V3 (Chief Operating Officer), near the 3-compartment sink was a steamer machine that was leaking fluids on the door to the floor. V3 stated, Yes, I can see it leaks a lot on the floor. And staff needs to map the floor (pointing at the mop). V3 was asked because the floor is constantly wet, does it post a risk for kitchen staff to slide and fall? V3 said, I know what you mean, that is why staff needs to map the floor every time. At the dishwasher area, V4 presented a log with testing strips are attached. A lot of testing strips bars have colored dark blue. The test strip instructions that reads: Pass when blue bar turns orange 180 degrees Fahrenheit. V3 stated, I can see that. V4 was asked why it was not addressed since test strips instructions does not pass the required temperature? V4 did not answer. V3 stated, Let us just test the machine so that we will know if it will turn orange. Dishwasher machine was tested with a test strip placed in a metal utensil. After running the test strip inside the dishwasher, it remained dark blue. V3 stated, We will run it again. V4 ran the same procedure with the same test strip, and the result was the same. Test strip remained dark blue. V3 was asked to present maintenance log to check if dishwasher machine was being maintained. V3 said, We only ask maintenance to check out equipment if the equipment needs to be repaired. On 10/06/2022 at 10:32 AM, with V4 and V5 (Director of Infecttion Control), the same steamer that was found leaking, was still leaking and making the floor wet. V4 said, We are wiping it often. I know staff can slip on the floor that is wet. V3 came and was informed. Then we went to the office V12 (Maintenance Manager) who said, Kitchen equipment was not maintained in a scheduled basis. And that he only comes to check on the equipment if a ticket was given to him for repair. V3 said, It would be a good idea to create a schedule like on a monthly basis for maintenance schedule. Facility policy on Preventative and Corrective Maintenance Work Orders dated as revised 3/2021. In part reads: Under purpose, it is the policy of the facility that preventative and corrective maintenance work orders will be prioritized to ensure that life safety and systems and human safety are the priorities of the facility, while effectively steward facility resources. The purpose of this policy provides an understanding of the process of providing maintenance service and how department staff will be dispatched to complete work orders. Under preventative/predictive maintenance. Scheduled maintenance to provide inspection, testing and routine service to allow equipment or systems to continue to work properly. Under procedure, all preventive maintenance will be performed at the specified times and documented appropriately. 145548 Page 14 of 14