Inspection·August 9, 2024

F 0644 - Facility staff, as indicated, will provide information to help Maximus complete the level 2 interview/screen. Level of Harm - Minimal harm or potential for actual harm -A facility representative shall request the complete screening from the referral source. Residents Affected - Few On 08/08/2024 at 1:15 PM, V1 (Administrator) stated that she is responsible for making sure that all residents are added to the Facility Census Report for the Pre-admission Screening and Resident Review (PASARR). V1 states that R14's name was not added to the PASARR Census Report to be referred for a Level II PASARR screening until today on 08/08/2024. R14's Face sheet documents that R14 is a [AGE] year-old male admitted to the facility on [DATE] who has diagnoses not limited to: schizoaffective disorder, schizophrenia, and major depressive disorder. Record review documents that R14 has an initial Level I Pre-admission Screening and Resident Review/PASARR dated 01/25/2000. There is no documentation to show that R14 was screened for a Level II PASARR. Facility policy dated 12/2023, titled Pre-admission Screening and Resident Review (PASRR) documents in part, The facility will expect the appointed screening agency to properly complete the Level 2 if a PASRR condition (SMI/ID) exists. As of March 14, 2022, the Illinois system has changed to the appointed screening agency AssessmentPro (AP) and PathTracker (PT). The facility makes reasonable efforts to make sure the required screening documents are in the AP/PT system prior to admission or shortly after the time of the individual's arrival. The appointed screening agency has given itself authority to complete the Level 2 screens (for persons with severe mental illness and/or an intellectual disability) Facility staff, as indicated, will provide information to help the appointed screening agency complete the Level 2 interview/screen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 2 of 13 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 145648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Nursing Home 2450 North Central Avenue Chicago, IL 60639 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow professional standards of medication administration documentation after administration of medication to prevent medication errors for 19 of 19 (R4, R7, R8, R32, R50, R59, R65, R67, R82, R83, R91, R92, R101, R109, R126, R137, R142, R167, and R172) residents reviewed for medication pass. This failure affected 19 residents whose medications were not documented in a timely manner. Residents Affected - Some Findings include: On 08/07/2024 at 8:25AM, surveyor located on the first floor of the facility with V15 (RN/Registered Nurse). V15 states she has completed her 9:00AM medication pass. V15 stated she began her medication pass at approximately 6:45AM today for resident's 9:00AM scheduled medications. V15 states she is responsible for medication cart #2 on the first floor of the facility. On 08/07/2024 at 9:05AM, surveyor observed that V15 is no longer located at the first-floor nurses' station and the hard chart MAR (medication administration record) for medication cart #2 is no longer on top of medication cart #2. Surveyor inquires to other staff members about the location of the manual/hard chart medication administration record/MAR for V15's assigned residents for medication cart #2. Several staff members then begin to try to locate V15 and the MAR for medication cart #2. On 08/07/2024 at 9:08AM, V15 observed walking down the hall on the first floor of the facility with the hard chart MAR. Surveyor inquires to V15 about why she took the MAR from on top of the medication cart if she was finished performing her 9:00AM medication administration pass. V15 states she took the MAR so that she could sign off for the medication that she administered during her medication pass. V15 states she administered medications to residents but did not sign the MAR. Surveyor inquires to V15 about the protocol and professional standards for documenting administered medications. V15 states medications should be documented immediately after it is administered to the resident. V15 states if medication administration is not documented then it is interpreted that the medication was not administered. On 08/07/2024 at 9:15AM, V2 DON (Director of Nursing/DON) was made aware of surveyor's observations. Surveyor inquires to V2 about professional standards and administering medications. V2 states if administration of medication is not documented, then it was not given. V2 acknowledges if medication administration is not documented, then it is a possibility for a medication error to occur. V2 states the time frame for nurses to administer resident medications is one hour before and one hour after the scheduled administration time. Record review of the MAR for the first-floor medication cart #2 shows that V15 did not sign for medications administered to R4, R7, R8, R32, R50, R59, R65, R67, R82, R83, R91, R92, R101, R109, R126, R137, R142, R167, and R172. Facility policy dated 12/2022, titled Administration of Medication documents in part, 3. Medication may not be prepared in advance and must be administered within one (1) hour of scheduled administration time. 4. Medication must be charted immediately following the administration by the person administering the drugs. The date, time administered, dosage, etc., must be entered in the medical record and signed by the person entering the data. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 3 of 13 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 145648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Nursing Home 2450 North Central Avenue Chicago, IL 60639 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 toenail care for two (R1, R143) residents reviewed for ADL (activities of daily living) care in a total sample of 35 residents reviewed. Residents Affected - Few Findings include: On 08/06/2024 at 11:18AM, R1 observed lying in bed inside of her room without any socks on. Surveyor observed R1's toenails were long and overgrown on both of her feet. R1's toenail on her right great toe and left great toe observed overgrown to approximately ½ inch past the tip of R1's great toes. R1's other toes on both of her feet observed overgrown to approximately ¼ past the tip of R1's toes. R1 states she would like to have her toenails cut because it has been more than two months since she had them cut in the facility. R1's Face sheet documents that R1 was admitted to the facility on [DATE] with diagnoses not limited to: Type 2 diabetes mellitus, schizoaffective disorder, major depressive disorder, anxiety disorder, and mild cognitive impairment. R1's MDS/Minimum Data Set, dated [DATE] documents that R1 has a BIMS/Brief Interview for Mental Status of 13/15, indicating that R1 is cognitively intact. R1s' care plan dated 04/11/2023 documents in part, Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. On 08/06/2024 at 11:20AM, R143 observed lying in her bed inside of her room without any socks on. Surveyor observed R143's toenails were thick, curled, and overgrown. R143's great toe on her right foot observed to be long, overgrown, and curling towards R143's second toe measuring approximately 1 inch in length. R143's toenail on her right second toe observed thick with black discoloration, overgrown and curled over to the left. R143's great toe on her left foot observed long, thick, and overgrown to approximately ¾ inches past the tip of R143's great toe. R143's left second toe observed overgrown and curled over and touching the left side of R143's second toe. R143 states she would like her toenails cut but no one has asked her if she would like them cut. R143 states she is not a diabetic and states she has not had her toenails cut in approximately 6-7 months. R143's Face sheet documents that R143 was admitted to the facility on [DATE] with diagnoses not limited to: major depressive disorder, seizures, Parkinson's Disease, suicidal ideation, hypertensive heart disease, and schizophrenia. R143's MDS/Minimum Data Set, dated [DATE] documents that R143 has a BIMS/Brief Interview for Mental Status of 15/15, indicating that R143 is cognitively intact. R143's care plan dated 03/12/2024 document in part, R143 has Parkinson's disease. At risk for progressive loss of muscle control and self-care deficit. R143 has a fluctuating ADL Self-care deficit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 4 of 13 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 145648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Nursing Home 2450 North Central Avenue Chicago, IL 60639 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 0676 R/T (related to) Disease Process, Impaired balance, and limited ROM (range of motion). Level of Harm - Minimal harm or potential for actual harm On 08/07/2024 at 12:17PM, surveyor located inside of R1 and R143's room with V16 (Licensed Practical Nurse/LPN) and V16 observed R1's toenails and R143's toenails. V16 states R1's toenails and R143's toenails are too long and needs to be cut. V16 states the CNAs/Certified Nursing Assistants at the facility do not perform toenail care and do not cut residents toenails. V16 states the CNAs are responsible for cutting resident fingernails but are not responsible for cutting resident toenails. V16 states if residents need their toenails cut, this task is performed by a podiatrist. V16 states a podiatrist visits the facility every Thursday to perform foot care for the residents. V16 states the CNAs are responsible for informing the nurses if resident's toenails are overgrown and need to see the podiatrist. V16 states she then follows up to place the resident on the list to see the podiatrist. V16 states she is not sure how long it has been since R1 and R143 has been assessed and had foot care by the podiatrist. Residents Affected - Few On 08/08/2024 at 11:52AM, V2 (DON/Director of Nursing) states a podiatrist comes to the facility every Thursday to provide foot care to the residents in the facility. V2 states the podiatrist is made aware of which residents to visit/assess because there is a binder that is kept on the first floor of the facility. V2 states the CNAs or the nurses place resident names in the binder if they need to be seen/assessed by the podiatrist. V2 states when the podiatrist arrives in the facility, he looks inside the binder to determine which residents needs to be assessed. V2 states she expects for residents to have their toenails cut by the podiatrist in the facility at least once every month. Facility policy dated 05/02/2010, titled Nail Care documents in part, Procedure: 13. Residents toenails/diabetic resident's toenails will only be cut by a podiatrist. Facility policy dated 03/31/2003, titled Activities of Daily Living (ADL) documents in part, ProceduresHygiene a. Resident's self-image is maintained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 5 of 13 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 145648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Nursing Home 2450 North Central Avenue Chicago, IL 60639 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and records review, the facility failed to address behaviors which could endanger one (R92) health of eight residents reviewed in a sample of 35. Findings include: R92 current face sheet documents R92 is an [AGE] year-old individual with medical diagnoses that include but not limited to: unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, unspecified, unspecified osteoarthritis, unspecified site. R92's Brief Interview for Mental Status (BIMS) dated July 5, 2024, as 3/15, indicating R92 has severe cognitive impairment. R92's Functional Abilities documents R92 id dependent on eating, oral hygiene, toileting/bathe self, upper/lower body dressing, putting on/off footwear, personal hygiene and need 0r needs maximal/substantial assistance rolling left and right. On 08/06/2024 at 12:40pm, surveyor observed R92 in his room lying in bed, with bed flat and in low position. R92 was observed chewing on something in his mouth. On 08/06/2024 at 12:42pm, surveyor asked V5(Certified Nursing Assistant-CNA) to go to R92's with surveyor. Surveyor and V5 observed R92 chewing something in his mouth that was light blue and white in color. V5 asked R92 what was in his (R92) mouth, R92 did not answer. V5 asked R92 to take out what was in his (R92) mouth. R92 continued to chew on the item, refusing to take it out. V5 told R92 if he took out the stuff R92 was chewing, V5 would give R92 a chocolate candy bar. R92 spit the item R92 was eating into V5's hand and V5 gave R92 a mini chocolate bar. V5 stated the stuff R92 was chewing was a piece of R92's incontinence wear, and R92 like to tear his incontinence wear and eat it. V5 stated R92 likes to eat inedible items and staff have to constantly ask him not to. V5 stated she did not know what diet R92 is on. On 08/06/2024 at 12:53pm, V6(Registered Nurse-RN/floor charge nurse) stated R92 should not be eating his plastic incontinent brief because it is not food and can affect R92's digestive/gastrointestinal system. V6 further stated R92 should have the cloth incontinence pads to prevent R92 from reaping/ tearing his plastic incontinence wear and eating it because it can cause R92 to choke on the plastic incontinent brief. V6 stated V5 did not notify her R92 was eating/chewing on his incontinent brief. On 08/06/2024 at 1:05pm, V7(Registered Nurse/Supervisor) stated residents should be monitored and residents should not be eating their incontinent briefs because it is a choke hazard. V7 further stated staff should not give their food items to residents because some residents have dietary restrictions and risk for aspiration. V7 stated R92 eating a piece of his incontinent brief is a behavioral issue and R92 needs to be monitored and assessed. V7 stated V5 should not have given R92 a chocolate bar but should have asked R92 to remove what R92 was eating and notify R92's nurse for assistance and assessment, because R92 could have had more items in his mouth and adding the cholate bar could have cause R92 to choke. V7 stated he will take R92's vitals and notify R92's physician. On 08/08/2024 at 11:02am, V2(Director of Nursing-DON) stated the nursing staff monitor residents and if a CNA (Certified Nursing Assistant) notices a behavior of a resident that is not baseline or a behavior that can put a resident in danger, the CNA should report it to the nurse taking care of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 6 of 13 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 145648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Nursing Home 2450 North Central Avenue Chicago, IL 60639 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident. V2 stated R92 should not have been eating an incontinent brief because it is not edible and can cause GI(Gastrointestinal) problems. V2 stated V5(CNA)should not have given R92 a chocolate bar in exchange of the piece of incontinent brief R92 was eating. V2 stated V5 have asked R92 to remove the plastic piece of incontinent brief that R92 was eating, then R92 should have called the nurse because there could have been more pieces of the plastic incontinent brief left in R92's mouth. V2 further stated R92 is on an altered thick liquid diet, and he(R92) should have not been given the chocolate bar because of risk of aspiration and choking. R92's care plan dated 08/10/2020 documents R92 is on a mechanically altered diet with Thickened Liquids related to dysphagia, and goals dated 07/18/2024 documents R92 will remain free of S/s(signs/symptoms) of aspiration. Facility policy titled Accident/Incident dated 5/14 documents: -An employee who witnesses an accident/incident involving a resident, employee, or visitor to the director of the department in which the accident/incident occurred as soon as practicable, regardless of how minor that accident/incident may appear to be. -The charge nurse must be informed of each accident/incident as soon as practicable after occurrence so that medical attention can be provided to the accident/incident victim. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 7 of 13 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 145648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Nursing Home 2450 North Central Avenue Chicago, IL 60639 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure controlled substances were counted and documented, at the beginning and end of each shift for 2 out of 16 shifts. This failure has the potential to affect 45 residents. Findings include: On 08/06/2024 at 12:21PM, surveyor located on the fourth floor of the facility with V14 (LPN/Licensed Practical Nurse). V14 was responsible for the 4th floor medication cart. V14 states that she performed a narcotic drug count but did not sign the sheet. Surveyor observed that V14's signature was missing for 08/06/2024 on the Shift Change Accountability Record for Controlled Substances 7am-3pm oncoming shift. Surveyor also observed that the Shift Change Accountability Record for Controlled Substances for the 4th floor medication cart had missing signatures for the 7am-3pm oncoming and off going shift on 08/02/2024. Observation of the Shift Change Accountability Record for Controlled Substances for the month of August 2024 for the 4th floor medication cart indicated for 2 shifts in August 2024, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 08/02/2024, 1st shift (7am-3pm) On 08/06/2024, 1st shift (7am-3pm) On 08/08/2024 at 11:52AM, V2 (Director of Nursing/DON) states every shift the off going and oncoming nurses should count the narcotics together to ensure an accurate count. V2 states if the oncoming nurse is late, then the off going should count with another nurse or call the supervisor to perform a narcotic count. V2 states if the controlled substances are not counted, then there is a possibility for drug diversion, which would have to be investigated. Facility policy dated 04/11/2023 titled Controlled Substances documents in part, Purpose: 1. To ensure that schedule II substances are labeled, handled and accounted for in accordance with the Controlled Substance Act. 8. Change of shift counts will be conducted by authorized nursing personnel to reconcile drug availability. Facility Census dated 08/06/2024 documents that 45 residents reside on the 4th floor of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 8 of 13 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 145648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Nursing Home 2450 North Central Avenue Chicago, IL 60639 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 - Some 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 a.) ensure medications were locked and secured while unattended and b.) remove and discard expired house stock medication in three of six medication carts reviewed for medication labeling and storage. These failures have the potential to affect 40 residents residing in the facility. Findings Include: On 08/06/2024 at 1:55PM, surveyor located on the second floor of the facility. V13 (Licensed Practical Nurse) observed leaving medication cart (identified as medication cart #2) unlocked and unattended. V13 states that residents can potentially get access to the medications if the cart is left unlocked and unattended. V13 states there is potential for the residents to overdose, or residents can self-administer another resident's medication and it would be a medication error. On 08/07/2024 at approximately 9:00AM, surveyor located on the first floor of the facility with V15 (Registered Nurse/RN). Surveyor observed a house stock medication (identified as Vitamin B6) available for resident use inside of the first floor medication cart (identified as medication cart #2). Vitamin B6 medication observed with an expiration date labeled 07/2024. V15 states she does not check the medication cart for expired medications. V15 states that the house stock medication should not be stored in the medication cart and should have been discarded once it expired. Facility census documents that a total of 21 residents receive medication from medication cart #2 on the second floor of the facility. Facility census documents that a total of 19 residents receive medication from medication cart #2 on the first floor of the facility. Facility policy dated 12/31/2022, titled Medication Storage in the Facility documents in part, 3. Medication rooms, carts, and medication supplies are locked or attended by person with authorized access .14. Outdated, contaminated, or deteriorated drugs . will be immediately withdrawn from stock. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 9 of 13 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 145648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Nursing Home 2450 North Central Avenue Chicago, IL 60639 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 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 review of records, facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness for all the residents in the facility. Residents Affected - Many Findings include: 08/07/24 10:04 AM, surveyor observed V9 (Head cook) pureeing veal patty. After pureeing the veal patty, V9 asked V8 to wash the blender pitcher and the rubber spatula. V8 washed the blender pitcher and rubber spatula in the washer container, and then moved the pitcher and spatula to the rinse container and then the sanitizing compartment. The blender pitcher and spatula were moved to the sanitizing compartment at 10:17 AM. Another Kitchen aide moved the blender pitcher and spatula to the table at 10:19 AM. At 10:20 AM, V9 (cook) used the blender pitcher and spatula to puree the pasta. There was still sanitizer dripping in blender pitcher and spatula. V8 stated that you have to wait for the blender pitcher to dry completely before using it to puree another dish otherwise that could contaminate the food. Facility's Manual sanitizing in three-compartment sink policy (undated) documents in part: After washing and rinsing utensils and equipment are sanitized in the third sink by immersion in either hot water for thirty seconds or chemical sanitizing solution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 10 of 13 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 145648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Nursing Home 2450 North Central Avenue Chicago, IL 60639 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 observations, interviews, and review of records the facility failed to ensure urinary catheter bag of 1 resident (R478) maintains in sterile position not in contact on the floor as per policy. The facility failed to ensure linens that are being folded do not touch the floor and to maintain clean and sanitary condition of blower equipment that circulates air in the clean linen room per their policy. The facility failed to document in their infection prevention policies and procedures that review date done at least annually. These failures have the following effects: Potential to affect 1 resident (R478) prevention of urinary tract infection (UTI) to reoccur. Potential to contaminate and affect all 180 residents that uses linens in the facility. Potential to affect all 180 residents in implementing policies and procedure that are outdated and not currently in accordance with national standard. Residents Affected - Many Findings include: On 08/06/2024 at 11:54 AM, R478 was seen sleeping on the bed with urinary catheter connected and catheter bag lying flat on the floor. V2 (Director of Nursing) made aware and stated that urinary catheter bag should not be in contact on the floor without any barrier. And to inform staff that the urinary bag needs to be place not in contact with the floor to avoid contamination. R478 progress notes by V20 (Registered Nurse) dated 7/18/2024 and 7/19/2024, documents: R478 was receiving antibiotic therapy Linezolid 600 MG for urinary tract infection (UTI) with symptoms of hematuria or blood in the urine. Urinary Catheter Care policy dated 12/31/2023, reads: Catheter care is performed appropriately to prevent complications caused by the presence of an indwelling urethral catheter. Under procedure, urinary catheter maintains a sterile, continuously closed drainage system. Per CDC (Center of Disease Control and Prevention) on catheter associated urinary tract infection basics dated 4/15/2024, reads: A catheter-associated urinary tract infection (CAUTI) occurs when germs enter the urinary tract through a urinary catheter and cause infection. They are one of the most common types of healthcare associated infections but are preventable and treatable. On 08/06/2024 at 12:41 PM, at the clean utility area (separate room from laundry room) V21 (Housekeeping) was seen folding white long linen touching the floor. V21 stated that she just folded a sheet and comforter. V21 was requested to fold another sheet which she took from inside the gray cylindrical plastic container. V21 folded again and same thing happened around one-third 1/3 of the linen touched the floor. After which V21 folded another linen the third time and still touched the floor. After the 3rd time V21 folded linens that all touched the floor, V21 was asked if it is proper facility procedure to fold linen while touching the floor. V21 replied that since she cleaned the floor (pointing to the floor area in front of her feet) it is okay. V19 (former head of Housekeeping, currently Assistant Administrator) went to the clean utility room and stated that all linen must be folded on the table. V19 stated, That is why we had these table. (Pointing at the table in front of V21). Also on that top of a plastic crate was an orange color air blower. Inside the area of the air blower where air pass through was a lot of lint and dust. V19 stated that the blower is being used if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 11 of 13 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 145648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Nursing Home 2450 North Central Avenue Chicago, IL 60639 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 temperature gets hot. Upon close examination, V19 saw the inside of the air blower and said, Yes, it is all dust inside. V19 stated that she will inform the maintenance to clean the blower. Laundry services policy dated 4/1/2020, reads: To ensure that the facility provides laundry services that meets the needs of the residents. When the facility operates its own laundry, the laundry: Is maintained in a clean and sanitary condition. Laundry services for residents' must be handled in a manner that will not allow contamination of clean linen. On 08/07/2024 at 11:04 AM, V7 (Infection Preventionist/Registered Nurse) presented the following policies and procedures: Personal Protective Equipment (PPE) policy dated 11/2/2022. Handwashing Policy dated 11/22/2022. Antibiotic Stewardship dated 12/15/2018. Immunization Policy (Influenza and Pneumonia) dated 12/2013. Laundry Services Policy dated 4/1/2020. V7 was informed that all of these policies and procedures were outdated and did not indicate that these policies and procedures were reviewed at least annually. V7 stated that moving forward policies and procedures date will be indicated when reviewed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 12 of 13 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 145648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Central Nursing Home 2450 North Central Avenue Chicago, IL 60639 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 review of records and interview the facility failed to determine, offer and document 2 residents (R481, R157) immunization (influenza and pneumococcal) status as per policy. Failed to review policy and procedure related to immunizations. These failures have the potential to affect 2 residents (R481, R157) in minimizing the risk of acquiring, transmitting, or complications from influenza or Pneumococcal pneumonia. Residents Affected - Few Findings include: R481 and R157 were without record of any immunization since admission in the resident electronic record under immunization tab. On 08/07/2024 at 11:04 AM, V7 (Infection Preventionist/Registered Nurse) during review of infection control and prevention related to immunization of residents. V7 stated that immunization of all residents are documented on the immunization tab on the electronic record. V7 stated that he has to look it up on other documentation. R157 who was admitted on [DATE]. V7 stated that again R157's immunization details should have been recorded in the immunization tab in the electronic resident record because R157 was admitted more than two (2) months ago. R481 and R479 also has no record of immunization under immunization tab. V7 submitted a policy for immunizations (Influenza and Pneumococcal) dated as revised 12/2013. V7 was made aware that the date policy was revised was more than 10 years ago. V7 moving forward policy will be review and indicate the date will place when it was reviewed at least annually. Per immunization policy dated 12/2013, it reads: To minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza or Pneumococcal pneumonia, it is the policy of this facility to offer influenza and Pneumococcal vaccination to all residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145648 If continuation sheet Page 13 of 13