Health inspection·August 9, 2024

F 0694 Level of Harm - Minimal harm or potential for actual harm should be dated. The purpose for dating the IV insertion site is to keep track of when it was inserted. The site is changed within 96 hours unless they need it before. If the site is not changed within 96 hours there is a potential risk for infection (phlebitis). Surveyor informed V5 that R64 IV site was inserted on 07/29/24, was not dated and remained in place on Residents Affected - Few Policy Titled Intravenous/Intra-arterial Access Devices-Guidelines for Care reviewed 01/18 document in part: Purpose: The purpose of this policy is to provide guidelines for the nursing staff on the care of IV (Intravenous) therapy. Peripheral insertion: 4. Replacement schedule site: Adults: 96 hours if no signs/symptoms of infection. 4.2. Replacement Schedule and Administration Set: Change at 96 hours. Replacement and Relocation of Device. 1. Peripheral venous catheters: In adults, replace catheter and rotate site every 96 hours. Replace catheters inserted under emergency basis and insert a new catheter at a different site within 48 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 2 of 8 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 08/09/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow their respiratory infection control practices policy by not storing Continuous positive airway pressure mask in a closable bag for one [163] resident reviewed in a sample of 20. Residents Affected - Few Findings Include: R163's clinical record indicates in part, R163 was admitted with transient cerebral ischemic attack, obstructive sleep apnea, morbid obesity, bradycardia, chronic diastolic heart failure, facial weakness, atrial fibrillation, monoplegia of upper limb affecting left side, hypertensive heart disease, osteoarthritis, mitral insufficiency, and lymphedema. R163's Respiratory Orders: Non-Invasive Ventilation at bedtime [Continuous positive airway pressure-CPAP]. On 08/06/24 10:45 AM, surveyor observed R163's C-PAP mask hanging off the side of the machine. On 8/6/24 at 10:55 AM, V3 [Licensed Practical Nurse] stated, Respiratory therapist take care of the C-PAP device and set up. The C-PAP mask always hang off the side of the device. On 8/6/24 at 11:00 AM V2 [Director of Nursing] stated, I do not know if the C-PAP mask should be kept in a storage bag, I will call the respiratory therapist for verification. On 8/6/24 at 11: 14 AM, V7 [Respiratory Manager] stated, The C-PAP mask, when not in use, should always be kept in a storage bag to prevent potential contamination and infections from transferring to the patient. Policy document in part Respiratory Infection Control Practices dated 1/23. -Equipment and materials. All respiratory care equipment and supplies should be cleaned, packaged, labeled, dated, and sterilized. -After each treatment, the equipment should be stored in a closable plastic patient setup bad at the bedside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 3 of 8 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 08/09/2024 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 as evidenced by a.) food not properly labeled, and b.) food not properly stored. These deficient practices have the potential to affect all 20 residents receiving food prepared for the nursing skilled facility. Findings include: On 8/6/24 at 10:33 AM, during initial kitchen tour with V8 (Dietary Cook), the following items were found in walk-in freezer [#11]: [1] Open box of blue berry muffins no open or expiration date. [2] Breakfast cart #1 with raw thawed bacon with wax paper covering only the top of the bacon without date open or use by date. A metal container of pureed pancakes and metal container pureed sausage with a label date of 8/1/24. [3] Breakfast cart#2 with raw thawed bacon, and raw thawed breakfast sausage covered only the top with wax paper, without date on food or cart. [4] A metal container on the shelf of pureed noodles dated 8/1/24. Walk -In Cooler [ #13]: [5] Opened roast beef thawed without date. [6] Open 1/2 Ground beef roll without date. [7] 4 rolls of pork loin thawed, without date. Freezer [# 14] [8] Open, expose box of enchiladas, without covering and no date. [9] Open, expose box of turkey sausage, without covering and no date. [10] Open exposed box of Tilapia dated 3/27/24. [11] Metal container of taco pork dated 6/20/24. Freezer [19]: [12] Fast food restaurant plastic coffee cup with straw, and brown substance opened on the shelf. [13] Box breaded cod fish open and exposed, without date. Dry storage Room: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 4 of 8 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 08/09/2024 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 [14] 2- bottles of honey dated 8/3/23. Level of Harm - Minimal harm or potential for actual harm On 8/6/24 at 10:56 AM, V8 stated, All food items, once removed from the box, the items need to be dated. The food items should have a label with an open date and expiration date. If dietary staff prepare food, not knowing how long the food has been open, it could cause a food born illness. Residents Affected - Many On 8/8/24 at 11:48 AM, V9 [Chef] stated, I oversee the kitchen operations while the food service supervisor is out on leave. I been working here as a chef for ten years. All food items stored in the cooler and freezer should have an open and discard date wrote on the packaging and covered at all times to decrease the risk of food borne illness. The cup of coffee belongs to an employee, and personal food items should not be stored in the walk-in cooler to prevent cross contamination. Serving residents food that does not have an open or discard date could potentially cause a food borne illness. Policy: Documents in part Food Storage dated 6/1/25. -This policy outlines safe food handling and storage practices for the Food and Nutrition Services Department. -Before and during each tray line employees check the items in their coolers for any outdated items. -All food requiring refrigeration must be dated and placed in the refrigerator first upon receipt from the supplier. -All food is dated upon receipt -All tray line food is 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 in the refrigerator. -Food prepared in advance for use the next day, must be labeled with the date of preparation. -Dry storage: The container must be labeled with the contents and the date the original container was received, the date the package was opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 5 of 8 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 08/09/2024 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 Based on observation, interview, and record review the facility failed to a.) maintain infection control standard precautions by removing an IV (intravenous) access timely after discontinuation of the IV antibiotic for 1 (R64) resident, b.) failed to clean and disinfect equipment between 5 (R59, R60, R61, R62, R66) residents use and c.) failed to maintained infection control for 1 (R60) of resident observed during medication administration. Residents Affected - Some Findings Include: R64 has diagnosis not limited to Physical Deconditioning, Fracture of Proximal end of Humerus, Dizziness, Cerebral Vascular Accident, Essential Hypertension, Low Back Pain, Radiculopathy, Spinal Stenosis Lumbar Region, Disc Displacement Lumbar, Lumbar Radiculopathy, Right Hip Pain, Hypoxia, Fall at Home, Chronic Obstructive Pulmonary Disease, Pulmonary Embolism, Shortness of Breath. Report Viewer document in part: Peripheral IV line - Single lumen 07/29/24 0920 cephalic vein (lateral left arm), Left 20 gauge. Placement date/time: 07/29/24 0920. On 08/06/24 at 10:22 AM R64 was observed sitting in a wheelchair at the bedside with a sling to the right arm. A Hep lock (Heparin IV locking device) was observed to the left wrist area with no date and time at the insertion site. On 08/06/24 at 11:26 AM V4 (Registered Nurse) stated we put a label with the date when the hep-lock or peripheral IV is inserted. The IV or hep-lock site is good for four days then at that time the site is changed or removed if the IV therapy is completed. The Surveyor informed V4 (Registered Nurse) that there are two residents that were observed including an unlabeled hep lock for R64. V4 (Registered Nurse) stated I was planning to take them out. It is on my to do list. R64 IV is completed. On 08/06/24 at 11:57 AM the surveyor entered R60 room with V4 (Registered Nurse). R60 was observed sitting in a chair at the bedside. V4 pushed the computer on wheels with the scanner into R60 room to scan R60's name band then V4 administered Hydrocodone-Acetaminophen 5-325 MG (milligram) for right hip pain with a pain scale of 7. On 08/06/24 at 12:02 PM V4 handed R60 the medication cup and while R60 was attempting to take the pill out of the medication cup the Hydrocodone-Acetaminophen 5-325 MG fell on the floor. V4 looked on the floor then located, picked up the Hydrocodone-Acetaminophen 5-325 MG then handed it to R60. V4 said I'm glad I found it. R60 placed the Hydrocodone-Acetaminophen 5-325 MG in her mouth and swallowed it with a sip of water. V4 placed the medication cup on top of the computer with wheels then discarded the medication cup. V4 then exited the room without sanitizing the computer on wheels with the scanner. On 08/06/24 at 12:27 PM the surveyor entered R61 room with V4 (Registered Nurse). R61 room entrance was observed with signage indicating Enhanced Barrier Precautions. R61 was observed lying in bed. V4 pushed the computer on wheels with the scanner into R61 room to scan R61's name band then V4 administered R61 medications. V4 placed the medication cup on top of the computer with wheels then discarded the medication cup. V4 then exited the room without sanitizing the computer on wheels with the scanner. On 08/06/24 at 12:40 PM the surveyor entered R62 room with V4 (Registered Nurse). R62 was observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 6 of 8 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 08/09/2024 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 sitting in a chair at the bedside. R62 room entrance was observed with signage indicating Enhanced Barrier Precautions. V4 placed the medication cup on top of the computer with wheels then discarded the medication cup. V4 pushed the computer on wheels with the scanner into R62 room to scan R62's name band then V4 administered R62 medication. V4 then exited the room without sanitizing the computer on wheels with the scanner. Residents Affected - Some On 08/06/24 at 12:55 PM the surveyor entered R66 room with V4 (Registered Nurse). R66 was observed sitting in a chair at the bedside. R66 room entrance was observed with signage indicating Enhanced Barrier Precautions. V4 pushed the computer on wheels with the scanner into R66 room to scan R66's name band then V4 administered R66 medications. V4 placed the medication cup on top of the computer with wheels then discarded the medication cup. V4 then exited the room without sanitizing the computer on wheels with the scanner. On 08/06/24 at 01:17 PM the surveyor entered R59 room with V4 (Registered Nurse). R59 was observed lying in bed with oxygen at 2 liters per nasal cannula in use. R59 room entrance was observed with signage indicating Enhanced Barrier Precautions. V4 pushed the computer on wheels with the scanner into R59 room to scan R59's name band then V4 administered R59's medications. V4 placed the medication cup on top of the computer with wheels then discarded the medication cup. V4 then exited the room without sanitizing the computer on wheels with the scanner. On 08/06/24 at 01:45 PM Surveyor asked V4 (Registered Nurse) is the computer on wheels with the scanner cleaned and disinfected after each resident's use. V4 responded, I'm supposed to clean it. I tend to try to keep a distance. There is a potential for cross contamination. Surveyor asked V4 what should have been done when V60's Hydrocodone-Acetaminophen 5-325 MG fell on the floor. V4 responded, I should have pulled another one. When asked the reason for pulling another Hydrocodone-Acetaminophen 5-325 MG. V4 responded, when it fell on the floor it was contaminated. On 08/08/24 at 08:45 AM V5 (Infection Preventionist/Employee Health) stated The Computer on Wheels should be wiped down between each resident with disinfectant wipes. There is information on the floor for the disinfectant contact time. The Computer on Wheels should be wiped down with disinfectant wipes to prevent cross contamination and transmission of any organisms. The IV insertion site should be dated. The purpose for dating the IV insertion site is to keep track of when it was inserted. The site is changed within 96 hours unless they need it before. If the site is not changed within 96 hours there is a potential risk for infection (phlebitis). Surveyor informed V5 that R64 IV site was inserted on 07/29/24, was not dated and remained in place on 08/06/24. V10 stated the IV site should have been changed or removed if they don't need it. If the medication is dropped on the floor, the nurse should discard it, check the medication dispenser if they need another dose or contact the pharmacy. The pill should have been discarded because whatever organisms there is an increased risk for transmission of infection or organisms. Policy: Titled Infection Control Policy Policy Title: Cleaning in Patient Care Areas reviewed 08/23 document in part: Purpose: The purpose of this policy is to ensure that staff recognizes their active role and responsibilities and infection control within the hospital environment. Procedure: 1. Environmental and equipment cleaning and disinfecting is the responsibility of all staff. 4. Reusable equipment will be cleaned with a disinfectant wipe. Cleaning of patient care equipment is as follows but not limited to: Clean the following with disinfectant wipes: computers/keyboards. Process - Computer Cleaning Nursing: wipe mobile computer keyboard/mouse and cart with disinfectant wipes every shift and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 7 of 8 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 08/09/2024 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 - Some as needed. Clean the windows of the barcode scanner using alcohol wipes, clean the handles with a disinfectant wipes every shift and as needed. Titled Infection Control Policy Policy Title: Standard Precautions reviewed 02/23 document in part: H. Cleaning of patient care equipment 1. Handle soiled equipment in a manner that prevents exposure or transfer of microorganisms to other patients or the environment. b. All shared equipment must be cleaned between patients using a hospital approved disinfected. Titled Infection Control Policy Policy Title: Transmission Based Precautions reviewed 02/23 document in part: Purpose: The purpose of this policy is to prevent the spread of specific microorganisms among patients, employees, and visitors by using Transmission Based Precautions (in addition to Standard Precautions) as recommended by the Centers for Disease Control and Prevention (CDC). J. Use disposable or dedicated patient care equipment when possible. Equipment that is shared needs to be cleaned and disinfected between patients by hospital approved disinfectant, manufacturers directions to be followed. Titled Infection Control Policy Policy Title: Enhanced Barrier Precautions-Skilled Nursing Facility reviewed 03/24 document in part: Purpose: The purpose of this policy is to implement enhanced barrier precautions (EBP) in addition to standard precautions for the prevention of transmission of multidrug-resistant organisms (MDROs). Enhance barrier precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms in skilled nursing facilities. Enhanced barrier precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for contact precautions. This is because devices and wounds are risk factors that place these residents at higher risk of carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presenting known to be colonized. 5. Disposable or dedicated medical equipment is not required: but any reusable medical equipment should be cleaned and disinfected with an appropriate agent between residents. 10. Enhance barrier precautions should be used for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Titled Intravenous/Intra-arterial Access Devices-Guidelines for Care reviewed 01/18 document in part: Purpose: The purpose of this policy is to provide guidelines for the nursing staff on the care of IV (Intravenous) therapy. Peripheral insertion: 4. Replacement schedule site: Adults: 96 hours if no signs/symptoms of infection. 4.2. Replacement Schedule and Administration Set: Change at 96 hours. Replacement and Relocation of Device. 1. Peripheral venous catheters: In adults, replace catheter and rotate site every 96 hours. Replace catheters inserted under emergency basis and insert a new catheter at a different site within 48 hours. Titled Medication Administration reviewed 08/23 document in part: It is the policy to specify how medications will be managed in a manner which is safe, effective, and efficient for the care of the patients. Purpose: To establish a standard process for safe and accurate administration and documentation of medications in accordance with prescribed orders to provide safe and efficient patient care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145548 If continuation sheet Page 8 of 8