Health inspection·July 29, 2022

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Potential for minimal harm Based on observation, interview and record review the facility failed to prevent the potential for cross contamination when using blood glucose supplies. This deficient practice has a potential to affect 4 of 4 (R24, R26, R34, R39) residents reviewed for blood glucose monitoring. The facility also failed to clean the insulin pen stopper prior to applying the needle for 2 of 2 (R34, R39) review during medication administration in a sample of 12. Residents Affected - Some Findings Include: R24 has diagnosis not limited to Type 2 Diabetes Mellitus, Chronic Kidney Disease, Bipolar Disorder, Major Depressive, Dementia and Anxiety Disorder. Care Plan document in part: R24 has Diabetes Mellitus. Fingerstick blood sugars as ordered. R24 Physician Order dated 12/18/21 document in part: Blood Glucose Test Strip (Glucose Blood) Inject 1 stick subcutaneously three times a day. R26 has diagnoses not limited to Type 2 Diabetes Mellitus with Foot Ulcer, Hypertensive Heart and Chronic Kidney Disease with Heart Failure. Care Plan document in part: R26 has Diabetes Mellitus. R26 Physician Order dated 07/18/22 document in part: Blood Glucose Test QID (four times a day). R34 has diagnoses not limited to Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy, Unspecified Dementia and Depression. Care Plan document in part: R34 has Diabetes Mellitus. R34 Physician Order dated 10/26/21 document in part: Blood Glucose Test Strip (Glucose Blood) Inject 1 stick subcutaneously before meals and at bedtime. Novolog Flex pen inject 5 units subcutaneously Twice a day. Order date 04/29/22. R39 has diagnoses not limited to Type 2 Diabetes Mellitus and Hypertensive Heart and Chronic Kidney Disease with Heart Failure. Care Plan document in part: R39 has Diabetes Mellitus. Administer diabetic medication as ordered. o Conduct blood sugar testing as ordered. R39 Physician Order dated 12/14/21 document in part: Humalog Solution 100 UNIT/ML (Milliliter) per sliding scale. (Insulin Lispro) Inject subcutaneously three times a day. Physician Order dated 12/14/21 Blood Glucose Test Strip (Glucose Blood) Inject 1 strip subcutaneously one time a day On 07/26/22 at 12:50 PM, V4 (Registered Nurse/RN) removed R39 Insulin Kwik Pen from the medication cart, removed it from the storage bag, took the Insulin Pen out of the storage bag, removed the cap then applied the needle to the pen without wiping the stopper with an alcohol wipe. On 07/26/22 at 01:04 PM, V4 (RN) placed 3 lancets, alcohol wipes, glucometer and blood glucose test (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 2 of 6 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 145637 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Joseph Village of Chicago 4021 West Belmont Chicago, IL 60641 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 - Potential for minimal harm strip container on a white Styrofoam tray then entered R26 room, placed the Styrofoam tray on R26 bed side table, applied gloves, wiped R26 finger with an alcohol wipe, used 1 lancet to prick R26 finger, picked up the container of blood glucose strips, removed a strip, placed the blood glucose container back on the white Styrofoam tray, checked the blood glucose with the glucometer, placed the glucometer back on the Styrofoam then exited R26 room. Residents Affected - Some On 07/26/22 at 01:07, PM V4 (RN) returned to the medication cart, placed the Styrofoam tray on top of the medication cart, cleaned the glucometer, placed the 2 lancets, alcohol wipes and test strip container on a clean Styrofoam tray then placed the tray in the medication cart drawer. On 07/26/22 at 01:11 PM, V4 removed R34 Insulin Flex pen from the medication cart, removed the Insulin Flex pen from the storage bag, removed the cap from Flex pen then applied a needle to the insulin pen without cleaning the Flex pen stopper with an alcohol wipe. On 07/26/22 at 12:15 PM, V4 (RN) stated I should clean the insulin pen with alcohol to make sure it is clean because it just has the cap on it and is not sterile. There are four residents on the XX floor that have glucose monitoring, R24, R26, R34 and R39. I take the Styrofoam tray with the glucose monitoring supplies (lancets, alcohol wipes, glucose strips) and glucometer into the resident's room. By taking the glucose monitoring supplies into multiple resident rooms there is a potential for cross contamination. On 07/27/22 at 04:25 PM, V1 (Administrator) stated we do not have an insulin Flex pen/Kwik pen Policy. I will check with corporate about the policy for the insulin pen. On 07/28/22 at 11:02PM, V2 (Nursing Supervisor Clinical Service) stated before the needle is applied to the insulin pen the stopper should be rubbed with an alcohol swab for aseptic technique. The stopper could have accumulated a bacterial film. Cleaning the stopper is to make sure it is clean and do not transmit bacteria to the patient. Only the blood glucose equipment that is needed should be taken into the resident's room. No equipment should come back out of the resident's room except for the glucometer. This is to minimize any bacteria or contamination and we do not want to introduce any germs a resident may have into the facility. There is a potential for cross contamination. On 07/28/22 at 02:08 PM, V1 (Administrator) stated the alcohol swab thing for the insulin pen, the nurse was nervous and made a mistake. An in-service was given to the nurse and staff. There is no insulin pen policy. In Service document titled Proper Technique in Giving Insulin Injection (Sanitation) dated 07/26/22 and 07/27/22 was reviewed. Policy: Titled Blood Glucose Monitoring, Long - Term Care reviewed 11/18/21 document in part: Single - use, auto disabling fingerstick devices should also be used to prevent the spread of bloodborne pathogens. Implementation: Gather and prepare the necessary equipment and supplies. To collect a sample from the resident's fingertip, position a single - use auto disabling lancet on the resident's fingertip. Contaminated blood glucose monitoring equipment increases the risk of transmitting infections cause by bloodborne pathogens, such as hepatitis B, Hepatitis C, and human immunodeficiency viruses. Titled Medication Administration - Specific Procedures revised 01/15 document in part: Proper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 3 of 6 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 145637 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Joseph Village of Chicago 4021 West Belmont Chicago, IL 60641 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 medication administration techniques should be used regardless of who administers the medication. Subcutaneous Administration: 1) Swab vial stopper with alcohol wipe. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 4 of 6 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 145637 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Joseph Village of Chicago 4021 West Belmont Chicago, IL 60641 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 interview and record review, the facility failed to follow their immunization policy by not providing pneumonia vaccines to three (R141, R2, R38) out six residents reviewed for immunizations in a sample of 12 residents. Also, the facility failed to provide the influenza vaccine to one (R21) out six residents reviewed for immunizations in a sample of 12 residents. Residents Affected - Some Findings Include: On 07/27/2022 at 10:44 AM, immunization information for the pneumonia and influenza vaccines were requested for R141, R2, R38, and R21 from V1 (Executive Director) and V2 (Nursing Supervisor Clinical Services). On 07/29/2022 at 12:41 PM, V1 stated he was unable to locate the pneumonia information for R141, R2, R38. On 07/29/2022 at 02:29 PM, V1 provided an influenza consent for R21 dated 07/29/2022. R21's influenza consent for the 2021-2022 flu season was not provided by the facility. On 07/29/2022 at 12:41 PM, V1 (Executive Director) stated, all residents are offered the pneumonia vaccine upon admission. There should be documentation of refusal and education. All residents are offered the influenza vaccine during flu season and there should be documentation and education. Review of the entire electronic medical records (EMR) of the four (R141, R2, R38, R21) residents residing in the facility during the survey revealed there was no information that addressed the current pneumonia vaccination status for R141, R2, and R38, and there was no information that addressed the 2021-2022 influenza vaccine status for R21. The review included, but was not limited to, physician orders, resident/resident representative consents for influenza and pneumonia immunization, immunization tab and medication administration record (MAR). R141 was admitted to the facility on [DATE], with diagnoses not limited to, Other Intraarticular Fracture of Lower End of Right Radius, Subsequent Encounter for Closed Fracture with Routine Healing. Review of R141's medical record showed no pneumonia consent or refusal documentation. R2 was admitted to the facility on [DATE], with a diagnosis not limited to, Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. Review of R2's medical record showed no pneumonia consent or refusal documentation. R21 was admitted to the facility on [DATE], with a diagnosis not limited to, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Review of R21's medical record showed no Influenza consent or refusal documentation for the 2021-2022 flu season. R38 was admitted to the facility on [DATE], with a diagnosis not limited to, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Review of R38's medical record showed no pneumonia consent or refusal documentation. Facility policy titled, Immunization Program, reads: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 5 of 6 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 145637 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Joseph Village of Chicago 4021 West Belmont Chicago, IL 60641 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Franciscan Ministries offers, as available, immunizations against seasonal influenza, other novel/pandemic influenza and pneumococcal pneumonia to all residents and associates. The time frame for immunizations against seasonal influenza is generally considered to be from October 1st of each year through March 31st of the following year. In certain circumstances, and with certain viruses, the season may be extended to an earlier or later date. A pneumococcal immunization will be offered to residents upon admission unless medically contraindicated. The type and sequencing of pneumococcal immunizations will depend on the resident's age, the type of prior pneumococcal immunization and in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 6 of 6