Health inspection·May 26, 2023

F 0677 At 12:30 PM, R28 remained lying on back leaning to the left side. Level of Harm - Minimal harm or potential for actual harm At 12:41 PM, R28 was asleep in bed lying on backside and leaning to left side. Head of the bed was down less than 45 degrees. No positioning pillows. Residents Affected - Few On 05/24/2023 at 9:45 AM, V10 stated R28 cannot turn from side to side independently. V10 stated R28 needs one assist for bed mobility. When asked what interventions the facility has in place to prevent pressure ulcers, V10 stated to turn and reposition R28 every two hours. Facility's Pressure Ulcer Prevention and Treatment, last revised 03/03/2023, documents in part: Reposition resident per care plan using pressure relieving devices (i.e., low air loss mattress, pillows, etc.) to prevent bony prominences from rubbing as applicable. Facility's Feeding policy, last revised 11/27/2022, documents in part: For a bedbound patient, elevate the head of the bed upright to 90 degrees (unless contraindicated). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 2 of 10 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 05/26/2023 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 0692 Provide enough food/fluids to maintain a resident's health. 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 provide enteral feedings as prescribed by physician for 1 (R40) of 3 residents reviewed for nutrition in a total sample of 22. Residents Affected - Few Findings include: On 05/24/23 at 10:10 AM, surveyor observed tube feeding IsoSource 1.5 formula in plastic bag with R40's tube feeding infusing at 50 milliliters/hour (ml/hr.) and tube feeding formula bag labeled with R40's name, room number, date 05/23/23, time 7:00 PM, total volume 1000 milliliters, rate 50 milliliters/hour. V22 (R40's Family Member) stated a member of R40's family is at the facility daily from morning to early evening and that R40's tube feeding is routinely turned off at 12 noon so that R40 can receive therapy downstairs. On 05/24/23 at 10:52 AM, V5 (7-3 Registered Nurse/RN) stated R40 receives tube feedings and nothing by mouth. V5 stated V5 turns off and removes R40's tube feeding at 12 noon so R40 can participate in physical therapy downstairs. V5 stated R40's tube feeding is off between 12 noon and restarted at approximately 6:00 or 7:00 PM by the 3-11 shift nurse. V5 stated V5 does not restart R40's tube feeding during the rest of V5's 7-3 shift once V5 turns it off at 12 noon. On 05/24/23 at 11:58 AM, surveyor observed R40 in R40's room with tube feeding unhooked and no tube feeding longer infusing. Tube feeding formula bag was no longer hanging on infusion pole or in R40's room. On 05/24/23 at 3:39 PM, V18 (3-11 Registered Nurse/RN) stated R40's tube feeding is turned on at 7:00 PM every day. V18 stated V18 was working on 05/23/23 and V18 turned on R40's tube feeding at 7:00 PM. V18 stated V18 writes the time the tube feeding administration was started on the tube feed label along with R40's name, room number, rate of infusion, total volume, date, and V18's initials. On 05/24/23 at 4:03 PM, V13 (Registered Dietitian) state based on the estimated nutritional needs that the Registered Dietitian calculates a tube feeding order is recommended which would include the rate and total volume of tube feeding the resident would need to receive to meet those calorie and protein needs. V13 stated the RD recommendation for R40 was IsoSource 1.5 at 50 milliliters/hour for a total volume of 1000 milliliter/day which would provide 1500 calories, 68 grams protein. V13 stated R40 was diagnosed with protein calorie malnutrition in the hospital and a Registered Dietitian on 05/03/23 conferred with this diagnosis of protein calorie malnutrition based on R40's loss of body fat and moderate muscle mass loss. V13 stated R40's care plan goal is for R40 to gradual gain weight to desired body mass index to 23. R40 stated R40 receives nothing by mouth and receives all nutrition via a feeding tube. V13 stated the goal is for R40 to receive 1500 calories per day and if R40's tube feeding was run continuously for 20 hours at 50 milliliter/hour this would provide 1000 milliliters and then the resident would be off the tube feeding for a total of four hours daily. V13 stated if R40 is not receiving any tube feeding between 12 PM-7 PM this would be a total of seven hours off the tube feeding instead of four hours which would mean R40 is not receiving a total of 1000 milliliters, providing 1500 calories per day as recommended. V13 stated if R40 was not receiving the calories and protein recommended then this could cause weight loss, impaired wound healing, and lack of energy to participate in physical therapy. On 05/25/23 at 10:05 AM, V2 (Director of Nursing/DON) stated the nurse should be following the tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 3 of 10 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 05/26/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few feed order as prescribed by the physician. V2 stated R40's tube feeding start time can be anytime between 4:00-7:00 PM. V2 stated R40 should be receiving 50 milliliters/hour of IsoSource 1.5 tube feed formula for a total volume of 1000 milliliters per 24-hour period. V2 stated R40's tube feeding infusion is held during activities of daily living and when R40 receives therapy. V2 stated it was V2's expectation that the nurses would turn R40's tube feeding back on back on once R40 returned from therapy to complete the tube feeding bag so R40 receives the full amount of 1000 milliliters as prescribed. V2 stated the nurses should be making sure R40 is receiving the full amount tube feeding formula in the bag. R40 was admitted to the facility on [DATE] and has diagnosis which includes but not limited to: Dysphagia following Cerebral Infarction, Unspecified Protein-Calorie Malnutrition, Encounter for Attention to Gastrostomy, Hypertensive Heart Disease with Heart Failure, Chronic Combined Systolic and Diastolic Heart Failure, Chronic Atrial Fibrillation, Anemia, Polyarthritis, Pneumonia. R40's Order Summary Report dated 05/25/23 documents in part enteral feeding order in the evening for nutrition IsoSource 1.5 to infuse at 50 ml/hr for a total volume of 1000 ml/day. R40's Medication Administration Record dated 05/01/23-05/31/23 document in part, enteral feeding for Nutrition IsoSource 1.5 to infuse at 50 ml/hr for total volume 1000 ml start date 05/03/23 1700. R40's care plan initiated 05/03/23 documents in part, nutritional diagnosis: moderate malnutrition related to chronic illness, impaired skin integrity as evidenced by loss of muscle mass and body fat with weight goal: gradual weight gain, BMI between 23-25, TF as prescribed IsoSource 1.5 at 50 ml/hr for a total of 1000 ml/day. R40's MDS (Minimum Data Set) from 05/01/23 BIMS (Brief Interview for Mental Status) indicates moderately impaired cognition. R40's Comprehensive Nutrition Assessment signed 05/03/23 documents in part, R40 appears to be (have) mild body fat and moderate muscle mass loss diagnosis protein-calorie malnutrition, estimated calorie needs 1440-1680 calories, moderate malnutrition, and recommendation for IsoSource 1.5 to infuse at 50 ml/hr for a total of 1000 ml/day to provide 1500 calories, 68 gm protein. Facility policy titled, Enteral Nutrition Support dated 01/01/21 documents in part, nursing to administer daily enteral nutrition per order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 4 of 10 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 05/26/2023 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 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 policy and procedure for oxygen administration to ensure that oxygen is administered under orders of a physician. This failure has the potential to affect one (R245) of three residents reviewed for respiratory care in a sample of 22. Residents Affected - Few The findings include: R245 admission date was on 5/22/23 with diagnoses not limited to Displaced Intertrochanteric fracture left femur status post intramedullary nail/ORIF (open reduction internal fixation), History of falling, COPD (Chronic Obstructive Pulmonary Disease), Paroxysmal Atrial Fibrillation, Unspecified Dementia without behavioral disturbance, Essential Hypertension, Atherosclerotic heart disease. On 5/23/23 at 10:29 AM, R245 was observed sitting in wheelchair, alert and verbally responsive. R245 stated, I think I was admitted last night. R245 was observed with oxygen inhalation at 2L/min via nasal cannula. At 11:10 AM, V5 (Registered Nurse -RN) was interviewed and stated she (V5) was the assigned nurse to R245. V5 stated that R245 is currently using oxygen at 2L/min related to diagnosis of COPD. On 5/24/23 at 9:46 AM, R245 was observed in bed, on lowest position, alert and verbally responsive. R245 stated she (R245) prefers to be in bed. Observed with O2 inhalation at 2L/min via nasal cannula. On 5/25/23 at 10:53 AM, V2 (Director of Nursing -DON) was interviewed and stated she has been working in the facility for about 2 years. V2 stated that oxygen administration should have a physician order in resident electronic health record. V2 stated that during emergency, nurse can administer oxygen then inform attending doctor. V2 reviewed R245 electronic health record (EHR) and confirmed that there was no physician order for oxygen. V2 stated that the nurse will not be able to know how many liters and method of oxygen administration if there is no physician order. V2 further stated that R245 was using oxygen upon admission per EHR. Reviewed R245 physician order sheet (POS) active orders as of 5/23/2023 with no order for oxygen. R245 admission progress notes dated 5/22/2023 documented in part: Utilizing oxygen: Yes. Oxygen L: 2 LPM Oxygen via nasal cannula. admitted resident via stretcher, accompanied by 2 EMTs (Emergency Medical Technician). With O2 (oxygen) support of 2LPM via NC (nasal cannula). R245 care plan dated 5/25/23 documented in part: R245 has altered respiratory status / difficulty breathing r/t (related to) COPD. Oxygen settings: 2L/min via nasal cannula as ordered by MD. Facility's policy and procedure for oxygen administration dated 7/1/22 documented in part: PURPOSE: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Procedure: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 5 of 10 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 05/26/2023 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 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 discard expired medications from their medication carts for 3 residents (R9, R29, R30) in 2 out of 2 medication carts reviewed in a sample of 20 residents. Findings include: On 05/23/2023 at 2:21 PM, surveyor reviewed the third-floor medication cart with V10 (Nurse). Observed R9's Atropine Sulfate 1% solution in the drawer. Open date 02/24/2023. Staff did not write a date in the expired section of the label. V10 stated for ophthalmic solutions, they should be discarded after 28 days from open date. Observed R30's Ear Wax Removal Drops 6.5% solution in the drawer. Open date 2/10/2023. No written expired date. V10 stated it should have been discarded 4 weeks after open date. Facility's Medication Storage in the Facility policy, dated March 2021, documents in part: Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed per community policy. On 5/23/23 at 11:32am, first floor medication room and medication cart inspected with V5 (Registered Nurse -RN). Observed R29's Humalog multi dose vial with date opened: 4/21/23; date expired: 5/19/23 was still in the medication cart. V5 stated that expired Humalog vial should be discarded. V5 stated it can potentially cause some adverse effects to the resident if expired medication was given to the resident. 5/25/23 at 10:53 am, V2 (Director of Nursing -DON) was interviewed and stated that she has been working in the facility for 2 years. V2 stated that insulin should be labeled with open and expiration / discard date. V2 stated that Humalog insulin expiration date and be discarded 28 days after opening. V2 stated that potentially can cause some adverse reactions to resident if expired medication was given to resident. V2 stated that expired insulin will not be returned to pharmacy, it will be discarded in the (Tradename) medical collection and waste disposal. R29 physician order sheet (POS) active orders as of 5/24/2023 was reviewed and documented in part: Humalog Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 0; 201 - 249 = 2; 250 - 299 = 4; 300 - 350 = 6 If less than 70 or greater than 400 call MD, subcutaneously three times a day for diabetes mellitus with meals. Hold if not eating. R29 has diagnoses not limited to Type 2 Diabetes Mellitus with hyperglycemia, long term (current) use of insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 6 of 10 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 05/26/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the meal ticket menu for 1 (R22) of 3 residents reviewed for nutrition in a total sample of 20 residents. Findings include: On 5/23/23 at 11:47 AM, R22's eating lunch in her room. R22's meal tray consisted of pureed chicken salad, pureed orzo, pureed ginger soup, pureed cake, and coffee. R22's meal ticket shows R22 was supposed to receive 4 ounces (oz) of pureed roll wheat and 4 oz of pureed peaches. R22's meal ticket also shows that R22 is allergic to milk. R22's physician order sheet shows R22 is on puree texture, thin liquid consistency and lactose free diet. R22's Minimum Data Set (MDS) dated [DATE] shows R22 is cognitively impaired. At 11:53 AM, V17 (Dietary Aide) stated that for dessert residents get cake and no peaches. V17 also stated the kitchen has no pureed roll wheat and pureed peached prepared. At 11:55 AM, V4 (Dining Services Director) stated that residents should receive what's on their meal ticket. On 5/24/23 at 10:22 AM, interviewed V13 (Registered Dietitian) and stated that residents' allergies are indicated on their meal tickets, and staff should provide all foods and beverages listed on the residents' meal tickets. V13 stated that if a resident is allergic to milk and if any sort of menu item has milk in it, a substitution will be provided to the resident. V13 also stated that the cake should not be provided to resident who's allergic to milk. V13 stated R22 is on a lactose-free pureed consistency diet. V13 checked R22's records and V13 stated R22 was supposed to get the pureed wheat roll and pureed peaches on 5/23/23 for lunch. V13 stated that the peaches were R22's alternative for the cake because R22's allergic to lactose. V13 stated that it is very important for the staff to follow the meal ticket because it reflects not only the residents' needs of caloric intake, but also reflects the allergens, reflects the mechanically altered diet, and potential interactions with medication. V13 that residents could have allergic reactions to something, could aspirate, or could lose weight if residents are not provided with their caloric needs. V13 stated that V13 approves the menus, and the meal tickets are paper communication for the nurses and Certified Nursing Aides (CNAs) from the kitchen. The facility's policy titled; Nutritional Menu Standards dated 1/1/21 reads in part: Procedure: o Menus are developed to meet the specific needs of the patients and/or residents served including age, demographics, and medical nutritional therapy needs. o Menus include a variety of food choices appropriate for the patient / resident's nutritional status and consistent with his or her clinical care; o Therapeutic and mechanically altered diets are developed per the patient and/or resident needs with input from medical and dining service professionals; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 7 of 10 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 05/26/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm o Menu cycle lengths may vary based on facility needs, however, all patient and/or resident menus are planned in advance; o Menus are evaluated for nutritional adequacy with a focus on providing a balanced plate of proteins, fruits, vegetables, and grains with limited amounts of discretionary calories such as sugars and fat. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 8 of 10 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 05/26/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow their policy and procedure for food and supply storage to ensure food and dairies in the main cooler were discarded after the expiration date. This failure has the potential to affect 42 residents in the facility who are receiving oral diet. Findings include: On 5/23/23 at 9:28 AM, during the initial kitchen tour with V4 (Dining Services Director), the following were found in the main cooler: a container of cooked mushrooms labeled today's date 5/15 and good thru 5/15. V4 stated, I think it's expired already. It needs to be thrown out. Also found 5 half gallons of whole milk labeled with best by dates of May 19. V4 stated, They are expired and should have been thrown out, they should have been thrown out on Friday. V4 stated if residents are served with expired foods, they could potentially get illness. On 5/24/23 at 10:22 AM, interviewed V13 (Registered Dietitian) and stated that expired foods and dairies should be removed and disposed of from the main cooler. V13 stated that foods and dairies with best by and expired dates mean that they need to be discarded either that day or the following day. V13 stated that staff are not supposed to be serving expired foods and dairies. V13 stated residents could potentially get sick and get IBS (Irritable Bowel Syndrome) symptoms such as diarrhea, nausea, and stomachache especially with the expired dairy would be the most common. Facility policy titled, FOOD STORAGE & HANDLING dated 1/4/11 reads in part: PROCEDURE: All manufacturer packaged foods are used or discarded by their used by date which is determined by either their open date or manufacture's use-by date whichever is lesser. FOOD STORAGE TIME Check labels daily and discard outdated food! The facility's roster documents 44 residents in the facility with 2 residents who are NPO (Nothing by Mouth). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 9 of 10 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 05/26/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a sanitary elevated toilet seat for 1 (R95) out of a total sample of 20 residents reviewed for homelike environment. Residents Affected - Few Findings include: On 05/23/2023 at 11:23 AM, R95 returned from therapy. V8 (Physical Therapy Assistant) pushed R95 in a wheelchair back to room. Shortly after, V8 and R95 returned to the nurses' station and headed to the spa room next to the nurses' station. V7 (Certified Nurse Aide), who was sitting at the nurses' station, asked what is wrong. V8 stated R95 did not want to use the raised toilet seat because it was rusted. V7 stated [V7] will call for a new one and replace it. At 11:39 AM, R95 was back in the bedroom. Surveyor entered for interview. R95 was alert and oriented to person, place, and time. R95 stated [R95] did not want to use the raised toilet seat so [R95] asked V8 to take [R95] to use the one in the spa room. R95 pointed to the raised toilet seat in [R95's] bathroom. R95 stated, Would you want to use that thing. Look at it. It's all rusted. Rust on the metal brims under the plastic toilet seat. R95 stated the raised toilet seat was rusted when the staff brought it in a week after admission. On 05/24/2023 at 9:17 AM, R95 stated facility did not replace raised toilet seat. Stated no staff talked to R95 as to why they cannot replace it. At 9:50 AM, V15 (Central Supply) stated housekeeping maintains and cleans the resident's equipment with bleach. V15 stated [V15] did not receive a work order or a request to replace R95's raised toilet seat. V15 stated they have others in storage. V15 stated it was only a matter of retrieving one from storage and cleaning it to replace the rusted raised toilet seat. State Operations Manual Appendix PP for Long Term Care Facilities, Revision 211 - 02/03/2023, documents in part to provide a sanitary and comfortable environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145637 If continuation sheet Page 10 of 10