Health inspection·September 1, 2023

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 policy to ensure two residents (R11, R15) of five residents reviewed were free of physical restrains in sample of 14 residents. Residents Affected - Few Findings include: 1. R15 is an [AGE] year-old individual with a BIMS (Brief interview of Metal Status) score of 12/15, indicating R15's cognation is moderately impaired. R15's Patient care flow documents: Care interventions: Provide a safe, barrier-free environment that promotes activity. R15's functional status documents R15 needs extensive assistance with bed mobility, transfer, dressing and toilet use, one-person physical assist, and R15 needs limited assistance with walk in room and corridor. R15 uses a walker and is not steady, only able to stabilize with staff assistance. R15 is frequently incontinent of bladder. On 08/29/23 at 11:46 am, R15 was observed sitting in bed with all four side rails up. R15's bed was inclined at about 90 degrees, and R15 said she just finished lunch. R15 said she cannot get out of bed because the four bedrails are up, and she has to call staff to come assist when she needs to get out of bed. 2. R11 is a [AGE] year-old individual with a BIMS (Brief interview of Metal Status) score of 0/15, indicating R11's cognation is severely impaired. R11's patient care flow documents: Care interventions: Provide a safe, barrier-free environment that promotes activity. R11's functional status documents R11 needs extensive assistance with bed mobility, transfer, dressing and toilet use, two or more-person physical assist and helper does all effort. No assistive devices are listed for R11. R11 is always incontinent of bladder and bowel. On 08/29/23 at 12:16 pm, R11 was observed in bed inclined at a 90 degrees angle, eating lunch. V11(Registered Nurse-RN) was observed feeding R11 lunch. R11 was observed with scabs on his forearms, and sheen on his legs and arms. V11 said R11 gets the scabs from hitting the bed as he(R11) tries to get out of bed by himself, and R11 cannot get out of bed without assistance; R11 is at risk of falls. V11 said the four bedrails up because R11 keeps trying to get out of bed constantly, and bangs himself on the side rails. V11 said all four bed rails when pulled up can be considered a form of restraint, because it makes it difficult for the resident to get out of bed. On 08/29/2023 at 1:55pm, V2(Director of Nursing-DON) said the facility uses bed rails to help with turning/repositioning, and to give residents clues for the space they can use. V2 said bedrails are used for resident safety, but it is not ok to have all four bedrails up, and at least one side rail should be down. V2 further commented that four bedrails when pulled up can be seen as a form of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 2 of 12 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 145548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community First Medical Center 5645 West Addison Street Chicago, IL 60634 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few restraints, because it is restricting resident movement and how the resident can get out of bed, and their ability to get out of bed without help. On 8/31/223 at 10:10am, V2 stated, I think the manufacture's guide say all four bedrails can be up because there is a small gap between the upper and lower rails, therefore the resident can get out of bed if they want to, through the small gap. V2 further stated it is what she has heard other staff members, who have been to the facility for long, say. Surveyor asked V2 for the manufacture's guidelines that V2 was referring to. V2 said she was waiting for the manufacture to send her the guidelines. The document/guidelines were not received at the time of the survey exit. V2 said R11 and R15 do not have orders for four bedrails to be up, and are they are not care planed for use of four bed rails. V2 checked R11 and R15's Assessment for environmental and medical device safety, and stated both residents were recommended to use a bed alarm and bed in low position for safety. V2 said there was nowhere where four bedrails were recommended or ordered by physician as a safety precaution for both R11 and R15. Facility policy titled Utilization of Restrains and Seclusion, dated March 2022, documents: Restraint. Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely, or a drug, or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and not a standard treatment or dosage for the patient's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 3 of 12 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 145548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community First Medical Center 5645 West Addison Street Chicago, IL 60634 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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based observation, interview, and record review, the facility failed to provide person-centered care plans for 4 out of 5 residents (R5, R8, R9, and R158) for a total of 14 residents reviewed for plan of care. Residents Affected - Some Findings include: On 08/29/2023, the plans of care of R5, R8, R9, and R158 were reviewed. R5 was seen earlier at 11:47 am, with foam protector on both heels, with pressure ulcer on left heel and redness on sacrum. R5's care plan does not indicate any pressure ulcer or redness. R5 also takes anti-psychotic medication, and care plan does not address possible adverse effect of medication. R8 has an order for wound care daily on posterior ear, and foam padding to nasal cavity, but does not have care plan specific that addresses the problem. R9 underwent abdominal surgery that was not part of care plan. R158 has wound care order for her heels that was not care planned. On 8/29/2023 at 1:50 pm, V6 (Minimum Data Set Coordinator / Registered Nurse) stated when doing care plan, the format is to click premade options that will populate right away; the choice she makes in that option. It needs to be itemized after it populates, but failed to itemize. Care plan should be pattern to individual and should be person-centered. RAI (Resident Assessment Instrument) 3.0 Manual, reads: The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 4 of 12 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 145548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community First Medical Center 5645 West Addison Street Chicago, IL 60634 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label all insulin vials and eye drops, and failed to Maintain insulin vials used by multiple residents at dedicated clean medication preparation area. These failures can affect all residents in facility. Finding includes: On [DATE] at 1:29 pm, the facility 2 refrigerators were seen with multiple vials of insulins and a bottle of eye drops. With V18 (Registered Nurse), the first refrigerator has the following insulin vials: Novolog insulin vial (use by date [DATE]) and Novolin R insulin vial (use by date [DATE]), and an eye drop (Lantanoprost/Xalatan 0.005%) without any date as to when it was open or when is not good to use. With V11 (Registered Nurse), the second refrigerator has the following insulin vials: Novolin R insulin vial (use by date [DATE]), Insulin Glargine insulin vial (use by date [DATE]), Novolog insulin vial (use by date [DATE]), and Novolin 70/30 insulin vial (use by date [DATE]). All insulin vials in both refrigerators do not have open date as when the vial was first opened and/or used. Both V18 and V11 stated if multiple residents have the same order of insulin, those residents are using the same vial of insulin. On [DATE] at 10:50 am, V2 (Director of Nursing) stated, Pharmacy delivers those insulin vials to the nurses on the floor. Upon deliver,y insulin vials are unopened, and when it is time for the nurse to use the insulin, it will be labelled when it expires by the nurse who will use the insulin. V2 was asked how to determine if the expiration date is correctly computed for 28 days when all that was written was the do not use by date? V2 said, It was suggested to the pharmacy, but pharmacy instructed nurses to write only when insulin will expire. There are three refrigerators in the unit; only two refrigerators have insulin. At 11:11 am, V20 (Registered Nurse) aspirated 2 units of Novolog insulin, and placed the insulin vial on the surface of an automated medication dispenser near the laptop computer. V20 then went to R15's room. After administering 2 units of Novolog insulin to R15, R15 was transferred by V20 and V11 to the bed side commode. V20 and V11 performed incontinence care to R15 because of bowel movement. After incontinence care, V20 returned to medication room and placed the insulin vial back in the refrigerator where all insulin vials are located. V20 stated, When pharmacy delivers insulin vials on to nurses, it sealed and not opened, and once the nurse opens to use the insulin, it can be used up to 60 to 90 days. If the date of expiration is [DATE], that means insulin was opened on [DATE]. V20 was asked since it is 60 to 90 days, is there a 30-day window when insulin will expire? V20 replied, We follow 90 days from [DATE] to [DATE], or 90 days. On [DATE] at 12:25 pm, V21 (Director of Pharmacy) stated, (Lantanoprost/Xalatan 0.005%) once (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 5 of 12 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 145548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community First Medical Center 5645 West Addison Street Chicago, IL 60634 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 opened, expires in 6 weeks, and best practice is to label eye drops upon opening, because the patient may still use the eye drops after 6 weeks if not labelled. Regarding insulin vials, upon receiving physician order, pharmacy delivers insulin vials to the nurses on the floor. It is the pharmacy who writes expiration date on the vial. Even if insulin is not opened, pharmacy writes expiration date for 28 days. Yes, single insulin vial is used by multiple residents. As long as there is physician's order any patient can receive insulin from the same vial. V21 then stated for insulin vials to have only date of expiration, it cannot be determine if it was initially opened 28 days prior to expiration date. V21 said, You have to understand, I am taking care of the whole hospital, not only extended care. V21 provided drug information for Lantanoprost/Xalatan that reads: Once a bottle is opened for use, it may be stored at room temperature for 6 weeks. V21 also provided Insulin disbursement list for Extended Care. On the list, there are twelve insulin vials that were sent to the unit. Two of the vials expired on [DATE], leaving ten insulin vials left. During review of refrigerators, only six insulin vials were accountedfor, and three of those insulin vials Novolin R insulin vial (use by date [DATE]), Insulin Glargine insulin vial (use by date [DATE]), Novolog insulin vial (use by date [DATE]), were not listed based on expiration date provided by V21. Per CDC Safety Instructions for injection of multi-dose vials, dated as reviewed in [DATE], it reads: Multi-dose vials should be dedicated to a single patient whenever possible. If multi-dose vials must be used for more than one patient, they should only be kept and accessed in a dedicated clean medication preparation area (e.g., nurses station), away from immediate patient treatment areas. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters an immediate patient treatment area, it should be dedicated for single-patient use only. Examples of immediate patient treatment areas include operating and procedure rooms, anesthesia and procedure carts, and patient rooms or bays. If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date. The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 6 of 12 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 145548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community First Medical Center 5645 West Addison Street Chicago, IL 60634 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 proper sanitation and food storage practices by not labeling and storing food appropriately. These deficient practices have the potential to affect all 14 residents receiving food prepared in the facility kitchen. Facility census, dated 08/29/2023, documents a total of 14 residents admitted to the extended care unit/ECU of the facility. Findings include: On 08/29/2023 at 11:32 am during initial kitchen tour with V1 (Chief Quality Officer), V3 (Nutritional Services Supervisor), and V7 (Chief Operating Officer), the following food items were found in the walk-in freezer: 1. Two open boxes of uncovered pork sausage links without an open date labeled. 2. One open package of pepperoni meat without an open date labeled. 3. One open box of Yuca fries without an open date labeled. 4. Two boxes of cheese stuffed shells without an open date labeled. 5. One box of uncovered pork topping meat without an open date labeled. 6. One box of uncovered puffed pastry sheets without an open date labeled. On 08/29/2023 at 11:39 am, V3 stated all food items stored in the freezer should have an open date written on the packaging, and covered/wrapped at all times. Facility Matrix provided by facility documents a total of one resident admitted to the ECU receive enteral tube feedings. On 08/30/2023 at approximately 10:30 am, V2 (Director of Nursing) stated the one resident who receives enteral feedings also receives food by mouth from the facility kitchen. V2 stated there are no residents in the ECU of the facility who are NPO/nothing by mouth. Facility policy, dated 06/01/2022, titled Food Storage- Labels and Dates, Scoop Storage, Rotation of Stock, FIFO, Use of Leftovers documents in part, All food is dated upon receipt and is rotated in the appropriate storage area so that the oldest is used first. All stock is dated upon delivery and is rotated according to the FIFO system. The container must be labeled with the date the food was received (the original date) and the date the package was opened. Wrapping means to cover the item completely and tightly with plastic wrap or foil or place in a container with a lid, attaching a label with the name of the item and the date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 7 of 12 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 145548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community First Medical Center 5645 West Addison Street Chicago, IL 60634 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 Deficiencies at this level require 2 Deficient Practice Statements. Residents Affected - Many A. Based on observation, interview, and record review the facility failed to perform apprpriate hand hygiene after touching multiple high-touched areas to prepare and administer medicines for 2 out of 7 residents (R18 and R16) during medication administration. These failures have the potential to place 2 residents (R18 and R16) at risk of infections. B. Based on observation, interview, and record review, the facility failed to conduct an assessment to identify where Legionella (a bacteria that can cause a serious type of pneumonia (lung infection) called Legionnaires' disease) and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter) could grow and spread; and failed to consistently perform and monitor control measures. These failures have the potential to affect all the residents in the facility. Findings include: A. On 08/31/2023 at 8:10 am, V18 (Registered Nurse) placed gloves on both hands, then took R18's vital signs, first on R18's right upper arm, then on R18's left upper arm, because the blood pressure result was high. After taking vital signs, multiple high-touched areas were in contact with V18's gloves. With the same gloves, V18 prepared medicine for R18, touching all 14 medicines with the same glove. After placing all medicines in the medicine cup, V18 gave R18 her medication, one tablet at a time, by picking each tablet and placing the tablet inside R18's mouth. After medication administration of R18, V18 went to prepare R16's medication, due to complain of headache. V18 was about to start preparing medication when she left R16's room to get the vital signs equipment. V18, upon arrival in R16's room with vital sign machine, changed her gloves. V18 then took R16's vital signs, touching a lot of areas that are considered high-touched areas. Using the same gloves, V18 prepared R16's medications ,by picking and touching each tablet out of the package. On 08/31/2023 at 9:48 am, V18 stated she forgot to change her gloves and perform hand hygiene after touching high-touch areas that lead to contamination of her gloves. At 12:16 pm, V17 (Infection Preventionist) stated best practice is to take off gloves, and then perform hand hygiene before preparing medication to prevent infection from contaminated gloves. V17 stated the policy does not address infection control during medication administration. Hand Hygiene policy, dated 02/2023, reads: The purpose of this policy is to prevent the spread of healthcare acquired infection. Proper hand hygiene is a fundamental infection control intervention to prevent transmission of infections to patients, residents, visitors, and staff. Hand hygiene should be performed before entering a resident room or prior to start of care and before touching the resident surroundings. Findings include: B. On 08/30/23 at 12:23 pm, V23 (Facility manager) said the facility does not test for Legionella because it uses the city water that comes from the city of Chicago. V23 said he was not aware of any requirement for testing water for Legionella. He further commented stagnant water is flushed off weekly, and after flushing it off, it is assumed the water is clean and safe for resident consumption. V23 said the only testing done is water weekly temperatures in patient care areas, and the water is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 8 of 12 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 145548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community First Medical Center 5645 West Addison Street Chicago, IL 60634 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 - Many maintained below 110 degrees Farenheit. V23 said If a resident room is vacant for a long while or over a week, they we go into the room and flash out the water, but we do not test for Legionella. We flush it so that there are no bacteria like Legionella. V23 said the facility flushes the stagnant water because there could be bacteria and/or pathogens are living in the stagnant water, and they flush the water as preventive measure because stagnant water could encourage bacteria. V23 said, We don't test the water, we just assume after flushing the stagnant water, there is no bacteria. V23 said he does not know of any requirement to have the facility water tested for Legionella. On 08/30/23 at 2:14 pm, V17(Infection preventionist -IP) said the water is not tested, and she has not seen any case of Legionella, and if there is a case of Legionella, the results are sent directly to the Department of Health. Facility's policy titled Water Management Plan, dated 2/2023, documents: The laboratory will notify the infection control Practitioner (ICP) of positive test results for waterborne pathogens, however, the policy does not provide what tests are performed and how frequent. To reduce cases of Legionnaires' disease in health care facilities, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare certified healthcare facilities must develop and maintain water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. The directive has an immediate effective date. (https://www.ashrae.org/about/news/2017/cms-issues-directive-requiring-medicare-certified-healthcare-facilities-to-impleme Legionella, the bacterium that causes Legionnaires' disease, .Legionella can pose a health risk when it gets into building water systems. Legionella first must grow (increase in numbers). Then it has to spread through small water droplets (aerosolization) that people can breathe in. (https://www.cdc.gov/legionella/wmp/overview/growth-and-spread.html) Seven key elements of a Legionella water management program are to: Establish a water management program team, describe the building water systems using text and flow diagrams; identify areas where Legionella could grow and spread; decide where control measures should be applied and how to monitor them; establish ways to intervene when control limits are not met; make sure the program is running as designed (verification) and is effective (validation) and document and communicate all the activities. (https://www.cdc.gov/legionella/wmp/overview.html) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 9 of 12 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 145548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community First Medical Center 5645 West Addison Street Chicago, IL 60634 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 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 observation, interview, and record review, the facility failed to follow their policy and procedure by failing to administer/offer the pneumonia vaccine to two (R11, R12) of five residents reviewed in a sample of 14. Residents Affected - Few Findings include: R11 is a [AGE] year-old individual, with a BIMS (Brief interview of Metal Status) score of 0/15, indicating R11's cognation is severely impaired. R11's medical diagnoses includes, but ie not limited to history of paroxysmal A-fib (atrial fibrillation, or abnormal heartbeat), hyperlipidemia, apparent undiagnosed and untreated Parkinson's Disease. R12 is an [AGE] year-old individual, with medical diagnoses not limited to paroxysmal atrial fibrillation, (Irregular heartbeat) high blood pressure, pulmonary embolism, sacral decubitus ulcer, and urinary dysfunction. On 9/29/2023 at 12:08 pm, R12 said no one had told her about the pneumonia vaccine, and not one has provided any information or education about it, and R12 does not know what the vaccine is about. V12 said she would like to know more about the pneumonia vaccine. R12 said she had the COVID-19 vaccines. On 08/31/2023 at 12:00pm, during review of residents' immunization status with V17(Infection Preventionist-RN), R11 and R12 were noted to have not received their pneumonia vaccines. V17 said residents are supposed to be offered and educated about pneumonia vaccine upon admission. V17 said, It's important to offer the residents pneumonia vaccine to prevent residents from getting sick with pneumonia. Most residents admitted to the facility are 55 years and older, and it's important to offer them the pneumonia vaccine to prevent them from getting pneumonia, because residents might have other comorbidities and getting the pneumonia vaccine may prevent them from getting sick. V17 said R11 was admitted to the facility on [DATE], and R11's power of attorney-POA/family member agreed for R11 to get the pneumonia vaccine on 8/16/2023, but it has not been given to date. V17 said, If there was a reason for the vaccine was not to be given, it should have been documented. There is no documentation R12 was offered or educated on pneumonia vaccine upon admission, and the vaccine was offered today after surveyor inquired about it. Facility Immunization policy, dated January, titled Vaccine Protocol-Pneumococcal and Influenza documents: -Pneumococcal vaccine 1. Upon admission, all acute care patients are assessed for eligibility by the admitting nurse for immunization based on the following criteria: a) age [AGE] or older 2. if the criteria are met, the admitting nurse continues the assessment to determine if any reason not to give the vaccine is present. 5. When that vaccine is indicated and there is no reason not to give the vaccine, the admitting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 10 of 12 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 145548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community First Medical Center 5645 West Addison Street Chicago, IL 60634 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 0883 nurse will order the vaccine or contact the physician for an order for the vaccine 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: 145548 If continuation sheet Page 11 of 12 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 145548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community First Medical Center 5645 West Addison Street Chicago, IL 60634 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, intervies, and record review, the facility failed to follow policies in ensuring call lights are functioning and can be used for 3 out of 3 residents (R158, R10, and R8) out of a total sample of 14 residents reviewed for access to staff by using call lights. Residents Affected - Few Findings include: On 08/29/2023 at 12:15 pm, R158 was seen in her bed, alert and verbally responsive. R158 was using nasal cannula for oxygen. During conversation, R158 could barely talk, due to difficulty of breathing. R158 was asked how she let staff know that she needs help. R158 pointed to the call light on the table at the side of the bed. R158 pressed the call light multiple times, but the light at the top of the door outside of the room on the hallway did not work. V19 (Assistant Coordinator for Activity) was passing by in the hallway, went inside R158's room, and checked the call light socket that was hanging and barely attached to the wall. The call light did not have reset button on the wall. In order to turn it off, V19 needed to insert his fingers in the hole where there were many wires. V19 tried many times, and it still did not work. At 01:02 pm, R10 was sitting in her chair, alert and able to express her thoughts well during conversation. R10 stated she wants to go back to bed, but nobody came when she called. In front of R10, was two call lights; each had two buttons. One button was used to call facility staff, and the other was for the television. R10 pushed the call light near to her, and it did not work. The light on the upper right of R10's door did not light up. V11 (Registered Nurse) came and checked the call light near R10; V11 pressed the button, but it did not work. V11 stated staff needs to make sure the call light is working; in case of emergency residents can call. At 1:11 pm, R8 had two call lights on the bedside. One call light ias not working and does not have a reset button on the wall. V11 had to insert his finger inside the hole with wires. On 08/30/2023 at 9:07 am, V22 (Maintenance Staff) checked the rooms of R158, R10, and R8; all were seen with the same issues. V22 stated a lot of call lights need to be fixed, and a lot of call lights were sent out for repair, but were not fixed. The Call light wall socket had no reset button to press; just a hole with lot of wires. V22 inserted his finger to press in order to reset the call light. V22 was asked if it was safe to insert his finger with all those wires. V22 just laughed and said, I am OK. On 08/30/2023 at 12:42 pm, toured with V7 (Chief Operating Officer) and V23 (Manager Facility Services). V23 stated there is preventive maintenance done monthly, but V23 did not elaborate when asked multiple times about the call light status in the Extended Care Unit. V23 stated nursing staff should inform the Maintenance Department by writing a ticket, so that it can be repaired. V7 stated the facility must ensure before a resident admission that the call light is working. Call Light policy, dated 01/2023, reads: The purpose of this policy is to provide a safe environment for the patients. Every member of the healthcare team will contribute to the resident (patient) experience by acknowledging our patients needs by responding to call light. Facility protocol is to check that call lights are properly functioning before a resident (patient) admits into the room. Call light that malfunction should be repair as soon as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 12 of 12