Inspection·July 19, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interviews and record reviews, the facility failed to have an order for a code status for one resident (R153) out of a total sample of 24 residents reviewed for advanced directives. Residents Affected - Few Findings include: On 7/16/2024 at 2:53 PM, R153 stated, wanting to be resuscitated (Full Code) if [R153] had a change in condition. On 7/16/2024 at 2:54 PM, V8 (Nurse) stated R153 is Full Code if there are no DNR (Do Not Resuscitate) papers in the paper chart. If there are no DNR papers in the chart, then V8 will check the computer. V8 stated I think [R153] is Full Code. R153's admission Record does not document a code status under the section Advance Directive. R153's Order Summary Report does not contain an order for a code status. R153's care plan did not contain a code status. R153's admission Summary progress note dated 7/12/2024 8:47 PM documents in part that R153 is Full Code. Surveyor reviewed R153's orders on 7/17/2024 at 10:09 AM and 11:42 AM. R153 remained without an order for a code status. On 7/17/2024 at 12:15 PM, V3 (Director of Nursing) stated staff assess a resident's code status upon admission. Staff will consult with the resident about their wishes and if the resident is not decisional, staff will consult with the hospital or family representative or guardian. The resident's code status will show on their profile in the electronic medical records. Surveyor showed V3 R153's profile on the laptop. No code status listed. V3 stated R153 is supposed to have a code status. Facility's 1/15/13 Policy and Procedure Advance Directives document in part: The facility provides to all residents the right to accept or refuse medical and surgical treatment, and at the resident's option, formulate an advance directive. The resident choice of advance directive will be developed into the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 2 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to electronically transmit MDS (Minimum Data Set) records to CMS system using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 10 (R11, R16, R20, R32, R33, R39, R41, R49, R59, R90) of 10 residents reviewed for resident assessment in a sample of 24. Residents Affected - Some The findings include: On 7/17/24 at 3:10 pm, V28 (MDS Regional Consultant, RN) stated she is covering the facility as there is no full time MDS coordinator currently working in the facility but there is a part time MDS coordinator who comes to the facility on weekends and working remotely on weekdays for few hours. She said the facility is in the process of hiring a full time MDS coordinator. She said facility is following CMS RAI guidelines in completing and transmitting MDS records. V28 said MDS assessment is completed for all residents, it is a snapshot of the resident's condition and how they should be taken care of. MDS includes resident's functional capabilities, it helps staff identify health problems or concerns and care planning decision. MDS should be completed accurately and timely as much as possible and should follow regulatory timeframes. V28 said MDS records should be transmitted 14 days or prior from completion date otherwise it is considered late transmission. She said there could be financial and medical implications if MDS assessment is not completed accurately and timely. Surveyor reviewed MDS records of the following residents with V28: 1. R11 MDS ARD (assessment reference date) 6/13/24 was completed on 6/27/24 and transmitted / accepted on 7/15/24. V28 said transmission date should have been on 7/10/24, it is considered late transmission. 2. R16 MDS ARD 6/7/24 was completed on 6/21/24 and was transmitted / accepted on 7/15/24. V28 said transmission date should have been on 7/4/24, it is considered late transmission. 3. R20 MDS ARD 6/10/24 was completed on 6/24/24 and transmitted / accepted on 7/15/24. V28 said transmission date should have been on 7/7/24, it is considered late transmission. 4. R32 MDS ARD 6/8/24 was completed on 6/22/24 and was transmitted / accepted on 7/15/24. V28 said transmission date should have been on 7/5/24, it is considered late transmission. 5. R33 MDS ARD 6/12/24 was completed on 6/26/24 and was transmitted / accepted on 7/15/24. V28 said transmission date should have been on 7/9/24, it is considered late transmission. 6. R39 MDS ARD 6/6/24 was completed on 6/20/24 and was transmitted or / accepted on 7/15/24. V28 said transmission date should have been on 7/3/24, it is considered late transmission. 7. R41 MDS ARD 6/10/24 was completed on 6/24/24 and was transmitted / accepted on 7/15/24. V28 said transmission date should have been on 7/7/24, it is considered late transmission. 8. R49 MDS ARD 6/7/24 was completed on 6/21/24 and was transmitted or accepted on 7/15/24. V28 said transmission date should have been on 7/4/24, it is considered late transmission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 3 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 0640 Level of Harm - Minimal harm or potential for actual harm 9. R59 MDS ARD 6/6/24 was completed on 6/20/24 and was transmitted or accepted on 7/15/24. V28 said transmission date should have been on 7/3/24, it is considered late transmission. 10. R90 - admission ARD 3/11/24 was completed on 3/17/24 and was transmitted or accepted on 4/12/24. V28 said transmission date should have been on 3/30/24, it is considered late transmission. Residents Affected - Some V28 said facility is keeping the final validation report electronically to verify or confirm that MDS assessment were transmitted and accepted successfully to the national data base. Facility provided final validation report with message documented in part: Record submitted late - the submission date is more than 14days after the completion date for 10 residents (R11, R16, R20, R32, R33, R39, R41, R49, R59, R90). Chapter 2 of the RAI manual dated October 2023 page 2-17 titled RAI OBRA-required Assessment Summary documented in part: Transmission date no later than MDS completion date + 14 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 4 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R51's 6/19/2024 Minimum Data Set Assessment documents in part that R51 was dependent on staff for personal hygiene and upper/lower body dressing. Residents Affected - Few R51's Clinical Census documents in part a hospital leave on 7/09/2024. R51 returned to the facility on 7/15/2024. On 7/16/2024 at 11:21 AM, V29 (R51's family member) stated R51 came back from the hospital last night. V29 stated when [V29] arrived at the facility to check on R51 this morning, R51 was not settled in bed and still had multiple sheets from the hospital and ambulance under R51. V29 stated, calling the facility multiple times last night to speak with the nurse that received R51 from the hospital but did not get a return call. V29 stated the CNA (V30, Certified Nurse Assistant) that was just here just changed [R51]. No one changed [R51] until right now. [V30] just got rid of the sheets that were brought from the hospital. On 7/16/2024 at 11:50 AM, V30 stated I cleaned [R51]. I took the hospital stuff off [R51] and hospital gown off [R51]. V30 stated there were extra sheets and an incontinence pad under R51. On 7/17/2024 at 10:34 AM, V16 (CNA) stated upon a resident arriving to the facility, staff are supposed to introduce themselves to the resident and orient them to their room. Staff are to remove all the ambulance and hospital sheets and dress the resident. Staff are supposed to make sure the resident is comfortable and has everything they need. V16 stated this is done within 10-15 minutes of admission. V16 stated it is not acceptable to leave the resident with the hospital and ambulance transfer sheets overnight. Facility's 11/02/2020 Policy on Resident Rights, Respect & Dignity documents in part that the resident has a right to a dignified existence. Facility's undated Activities of Daily Living (ADLS) policy documents in part: To preserve ADL function, promote independence, and increase self-esteem and dignity. Based on observation, interview and record review, the facility failed to ensure incontinence care was provided in a timely manner for 2 (R10 and R50) residents who needed assistance with toileting; and failed to ensure personal hygiene assistance was provided for 1 resident (R51) after returning from the hospital. This failure affected 3 residents (R10, R50, R51) reviewed for ADL (activities of daily living) care in a sample of 24. The findings include: 1. R10's face sheet showed admission date on 8/4/2023 with diagnoses not limited to Unilateral primary osteoarthritis right knee, Chronic systolic (congestive) heart failure, Hypothyroidism, Personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits, Presence of cardiac pacemaker, Type 2 diabetes mellitus without complications, Other asthma, Muscle wasting and atrophy, Insomnia, Unspecified atrial fibrillation, Hyperlipidemia, Unspecified glaucoma, Carpal tunnel syndrome left upper limb, Unspecified fall, Cellulitis, Cutaneous-vesicostomy status, Unspecified protein-calorie malnutrition, Pain in right knee, Unspecified superficial injury of right knee, Fracture of unspecified part of neck of right femur. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 5 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 07/16/24 at 12:02 pm, R10 Observed lying in bed, alert and verbally responsive, Spanish speaking but can speak simple English. Stated she wanted to be changed. Surveyor conducted incontinence care observation with V10 (Agency Certified Nursing Assistant / CNA), R10 incontinence brief was heavily soiled with urine. Incontinence care provided. V10 said R10 was last changed around 8am. At 12:35 pm, V11 (CNA) Spanish speaking interpreter requested to R10's room. V11 said that R10 stated she was last changed at 5am was not change for 7 hours and she has a lot of urine in her incontinence brief. V11 said that R10 has been calling the staff to be changed but was not attended to. MDS (Minimum Data Set) dated 6/20/2024 showed R10's cognition was intact. She needed supervision / touching assistance with eating; Partial / moderate assistance with oral and personal hygiene, upper body dressing; Dependent with toileting hygiene; Substantial / maximal assistance with shower / bathe self, lower body dressing, chair / bed, and toilet transfer. MDS showed R10 was always incontinent of bowel and bladder. 2. R50's face sheet showed admission date on 4/22/2021 with diagnoses not limited to Chronic systolic (congestive) heart failure, Paranoid personality disorder, Other Alzheimer's disease, Fracture of unspecified part of neck of left femur, Unspecified psychosis not due to a substance or known physiological condition, Acute embolism and thrombosis of other specified veins, Major depressive disorder, Acute posthemorrhagic anemia, Hyperlipidemia, Essential (primary) hypertension, Vitamin D deficiency, Elevated white blood cell count, Anemia, Other pulmonary embolism with acute cor pulmonale, Contusion of left hip, Chronic kidney disease, Aphasia, Unspecified protein-calorie malnutrition, Unspecified fall, Personal history of covid-19, Unspecified dementia. At 12:10 pm, Observed R50 lying in bed, alert with confusion, with strong odor of urine. V10 stated R50 was last changed around 8am. Surveyor requested V10 to check R50. Surveyor observed incontinence care with V10, R50's incontinence brief was soiled with urine. On 7/18/24 at 10:23 AM, V3 (Director of Nursing / DON) said staff is expected to check and change or provide incontinence care to resident at least every 2 hours and as needed. Stated incontinence care should be done timely and promptly to prevent pressure ulcer or skin breakdown. MDS dated [DATE] showed R50's cognition was severely impaired. She needed total assistance / dependent with eating, oral, personal and toileting hygiene, shower / bathe self, upper and lower body dressing, and chair / bed transfer. MDS showed R50 was always incontinent of bowel and bladder. Facility's policy for bowel and bladder incontinence dated 1/20/24 documented in part: to prevent skin breakdown. Facility's policy for perineal care dated 12/2013 documented in part: to cleanse the perineum and to prevent infection and odors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 6 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interviews, and record reviews, the facility failed to re-evaluate the necessity of a resident's (R83) enteral feeding for one out of a total sample of 24 residents reviewed for nutrition. Residents Affected - Few Findings include: R83's admission Record documents in part medical diagnoses of adult failure to thrive (onset 3/05/2024), gastroparesis (onset 12/16/2023), unspecified protein-calorie malnutrition (onset 3/05/2024), and encounter for attention to gastrostomy (onset 3/05/2024). R83's Order Summary Report documents in part orders for Low concentrated sweets (LCS) diet Mechanical Soft texture, Thin Liquid consistency, No Added Salt, pleasure feed only (active since 3/29/2024). R83 also had an order for Enteral tube feeding Glucerna 1.2 at 65 [milliliter/hour] continuous [every] shift (active 6/10/2024) and Enteral tube [flush] 150 [milliliter] [three times] a day including medication administration three times a day for hydration (active 3/29/2024). R83's medications varied between oral and enteral feed administration. On 7/17/2024 at 8:55 AM, R83 received enteral feed of Glucerna 1.2 at 65 milliliters per hour via gastrostomy tube (g-tube). R83 also had empty breakfast tray at bedside. R83 stated, consumed all the meal. R83 stated, doing good and eating most meals. R83 stated, also ate all of last night's dinner. R83 also went into describing favorite cultural dishes and wishing to have more of those. When asked about the enteral feeding, R83 did not know why [R83] needed the g-tube. On 7/17/2024 at approximately 9:05 AM, V16 (CNA-Certified Nurse Aide) stated, working with R83 during most shifts. V16 stated that R83 has been eating 50% or more of [R83's] meals. V16 stated if R83 likes the food, R83 will eat 100% of the meal. V16 stated R83 has been eating well because R83 wants the g-tube out. Reviewed facility's charting for R83's NUTRITION-Amount Eaten for the last 30 days. Facility failed to chart meal intakes daily and for each meal. Of the charted meal intakes, the majority charted 51% - 100% meal consumed with most of that being 76-100%. R83's 7/14/2024 8:31 PM, Dietary Assessment progress note documents in part significant weight gain of 7.6% in the last three months. It documents in part: [Weights are going back up to previous weights likely [due to] increased appetite. [Tube feeding] was decreased last month. Noted with additional 4 [pound] [weight] gain. R83's comprehensive care plan documents in part a focus related to R83's enteral feeding (last revised 3/06/2024) and potential for alteration in nutrition/hydration (last revised 3/15/2024). Listed goals do not include removing the enteral feeding or g-tube. On 7/17/2024 at 10:59 AM, V18 (Nurse Practitioner) stated, R83's oral intake used to be terrible. V18 stated, that the goal for the enteral feeding was to get R83 back on track. V18 stated, no recent reports of R83 with low appetite. V18 stated, since R83 came back from the hospital, R83 has improved and is eating. V18 stated, now I feel like [R83] is back on track and probably doesn't need it anymore. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 7 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a telephone interview with V19 (R83's Primary Physician) on 7/17/2024 at 11:12 AM, V19 stated, facility did not inform V19 of R83's weight gain or that R83 was eating well. V19 stated, when staff inform [V19] of a resident's nutritional improvement, V19 will usually order a calorie count to obtain objective information to further evaluate need for the g-tube. If the calorie count proves adequate intake, then V19 will order for the g-tube removal. R83's progress notes do not document in part that staff notified V19 of R83's nutritional improvement. R83's orders did not include a calorie count. During a follow-up interview on 7/18/2024 at 9:05 AM, V19 stated, evaluating R83 early that morning. V19 stated R83 looked good overall and R83 talked about missing cultural foods. V19 stated will order a calorie count and was 90% confident that R83's g-tube can be removed. V19 stated if the calorie count was good, the goal was to schedule the g-tube removal next week. Facility's 3/31/2023 Nutritional Intervention Procedure documents in part: It is the policy of the Nursing Department to routinely evaluate resident food and beverage consumption, and to notify the resident of their legal representative, dietary supervisor, dietitian, and physician or resident nutritional problems. The Charge Nurse, or assigned Licensed Nurse, or CNAs shall evaluate and record resident's nutritional intake after each meal and after consumption of nourishments and physician ordered nutritional supplements. A licensed nurse is responsible for assuring staff request and offer dietary substitutions for the resident who consumes less than 50% of the meal and documenting the amount consumed. A licensed nurse is responsible for analyzing resident's nutritional consumption by reviewing the food consumption record, in between meal nourishments, and physician ordered supplements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 8 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure oxygen tubing and bubbler were dated and changed and failed to administer oxygen as ordered for 2 residents (R49 and R71) reviewed for respiratory care in a sample of 24. Residents Affected - Few The findings include: 1. R49's face sheet showed admission date on 7/6/2021 with diagnoses not limited to End stage heart failure, Hypertensive heart disease with heart failure, Chronic obstructive pulmonary disease, Unspecified intestinal obstruction, Other asthma, Type 2 diabetes mellitus without complications, Unspecified abdominal pain, Peripheral vascular disease, Spinal stenosis cervical region, Other chronic pain, Nonrheumatic aortic (valve) stenosis with insufficiency, Unspecified atrial fibrillation, Primary insomnia, Zoster without complications, Unspecified abdominal hernia with obstruction without gangrene, Personal history of Covid-19, Presence of coronary angioplasty implant and graft, Coronary angioplasty status, Acute on chronic systolic (congestive) heart failure. On 07/16/24 at 11:10 AM, R49 Observed lying in bed, alert and verbally responsive. Observed with oxygen at 3L/min, oxygen tubing with no date. Requested V5 (Registered Nurse / RN) to R49's room and stated oxygen tubing should be changed weekly and dated when it was changed. V5 (RN) checked R49's oxygen tubing and stated it was not dated. R49's POS (Physician order sheet) showed order not limited to: Change and Label O2 tubing and humidifier weekly when in use at bedtime every Sat. Oxygen Therapy @ 3 LPM (Liters Per Minute) via nc (nasal cannula) CONTINOUS to maintain saturation > 90%. MDS (Minimum data set) dated 6/7/2024 showed R49's cognition was intact. She needed supervision / touching assistance with eating; Partial / moderate assistance with oral hygiene, upper body dressing; Dependent with toileting and personal hygiene, shower / bathe self, lower body dressing, and chair / bed transfer. 2. R71's face sheet showed admission date on 6/22/2023 with diagnoses not limited to Radiculopathy lumbar region, Dorsalgia, Unspecified osteoarthritis, Hypertensive urgency, Anemia, Unspecified fall, Tachycardia, Nicotine dependence, Acute kidney failure, Insomnia, Difficulty in walking, Fracture of unspecified part of neck of left femur. At 11:23 AM, R71 Observed lying in bed, alert and verbally responsive, oxygen concentrator was on, and regulator indicated at 2L/min. Observed O2 cannula tubing at the side of the bed and was not in place in R71's nares. At 11:35 am, Requested V5 (Registered Nurse / RN) in R71's room. R71's oxygen tubing was not in place. V5 stated she is not sure why the oxygen was not in place as the resident is not assigned to her and V5 was not sure if oxygen order is continuous. At 12:42 pm, Requested V7 (Agency Licensed Practical Nurse / LPN), the assigned nurse, to R71's room. Oxygen cannula tubing was not in place and was at bedside. Oxygen concentrator was on. On 7/18/24 10:23 AM, V3 (Director of Nursing / DON) stated that staff is expected to administer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 9 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few oxygen as ordered and change oxygen tubing every week and should be dated. She said if oxygen tubing is not changed it can accumulate molds and cannula can get stiff. She said it is important to follow doctor's order for oxygen administration. V3 said when it is ordered continuous then resident should use it all the time and monitor the resident. R71's POS showed order not limited to: Oxygen Therapy @ 2 LPM via nc (nasal cannula) continuous to maintain saturation > 90% every shift. MDS dated [DATE] showed R71's cognition was moderately impaired. She needed supervision / touching assistance with eating, oral hygiene; Partial / moderate assistance with upper body dressing and personal hygiene; Dependent with toileting hygiene, shower / bathe self and lower body dressing and chair / bed transfer. Facility's policy for oxygen therapy dated 1/1/20 documented in part: MD (medical doctor) order will provide: when to use, how often, liter flow and whether to use cannula or mask. If using cannula gently place the tops of the cannula into the nares. Loop the tubing around each ear and secure with the slide adjustment, which should be under the resident's chin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 10 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interviews and record reviews, the facility failed to ensure that one resident (R79) received medication as ordered out of a total sample of 24 residents. Residents Affected - Few Findings include: R79's admission Record documents in part a diagnosis of major depressive disorder, recurrent, unspecified. R79's Order Summary Report documents in part an order for Wellbutrin SR (Sustained Release) oral tablet 150 milligram by mouth one time a day for depression. Order active on 5/06/2024. R79's care plan contains a focus for R79's use of antidepressant medication (last revised 8/10/2023). However, care plan is not updated to include R79's current antidepressant (Wellbutrin). Intervention for this focus includes to Administer ANTIDEPRESSANT medications as ordered by physician (initiated 8/10/2023). On 7/16/2024 at 11:10 AM, R79 was oriented to person, place, and year. R79 answered questions appropriately. R79 stated facility is not consistently providing medications. R79 stated facility did not provide Wellbutrin for six days a month or two ago. Random days when facility doesn't have Wellbutrin. R79 stated nurses keep telling R79 that the medication is not available. R79's May 2024 Medication Administration Record (MAR) documents in part that staff charted 9 (charting code for 'Other / See Progress Notes) on 5/7-5/11, 5/14, and 5/16-5/18 for Wellbutrin SR. R79's June 2024 MAR documents in part that staff charted 9 on 6/18 and 6/24-6/26. Progress notes from 5/10/2024, 5/17/2024, 5/18/2024 and 6/25/2024 document in part that WellButrin SR was not available, and facility was waiting for pharmacy delivery. No other related progress notes for the rest of the listed dates above. No pharmacy progress notes document in part the reasoning for why pharmacy has not delivered it. No progress notes document in part that staff notified the physician. On 7/16/2024 at 12:04 PM, V8 (Nurse) stated 9 on the MAR means the medication was not available or not here. V8 stated the nurse has to follow-up on why the medication was not available. If it is due to insurance or billing, then the nurse needs to let administration know. V8 also stated that if a medication is running low, the nurse is supposed to order a refill within 4-5 days before it finishes. On 7/18/2024 at 10:09 AM, V17 (Nurse) stated nurses should call for a medication refill when they reach the blue portion of the medication blister packet. V17 showed surveyor R79's Wellbutrin SR blister pack. R79's WellButrin SR blister pack has designated blue area starting at when there are eight pills left in the packet. V17 stated the designated blue portion prompts nurses to reorder the medication to ensure that the medication does not run out for the resident. On 7/18/2024 at 10:33 AM, V3 (Director of Nursing) stated I tell the nurses to order once they get in the blue. Like the first pill in the blue, they need to reorder it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 11 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 Facility's 12/2022 Administration of Medication policy documents in part: Residents shall receive their medications on a timely basis and in accordance with our established policies. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 12 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate of less than 5% during medication administration observations. The facility had four medication errors out of 37 opportunities resulting in a 10.81% medication error rate. Residents Affected - Few Findings include: On 7/16/2024 at 10:19 AM, V7 (Nurse) prepared medications for R9. V7 prepared Amlodipine, Buspirone, Lisinopril, Vitamin C and Vitamin D. At 10:26 AM, V7 stated [V7] needed to prepare MiraLAX (brand name) for R9. V7 pulled out a bottle of Polyethylene glycol 3350 (generic). V7 stated, did not have a spoon in the medication cart. V7 locked up the medication cart and went to the nurses' station. V7 retrieved plastic spoons and returned to medication cart. At 10:27 AM, V7 stated R9 needs one teaspoon of MiraLax. V7 took one spoonful of the Polyethylene Glycol 3350, put it in a clear, plastic cup, and mixed it with water. At 10:30 AM, R9 finished taking the medications and V7 returned to the medication cart to chart. V7 charted administering Aspirin 81 milligram but surveyor did not observe V7 pull the medication during medication prep. On 7/16/2024 at 12:25 PM, R9 stated did not receive Aspirin. On 7/16/2024 at 12:26 PM, V7 stated, administering R9's Aspirin during 10:19 AM medication pass with surveyor. R9's Order Summary Report and Medication Administration Records document in part orders for Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day for pain and MiraLax Oral Powder 17 [Gram]/Scoop (Polyethylene Glycol 3350) Give 1 scoop by mouth two times a day for constipation. On 7/17/2024 at 9:25 AM, V17 (Nurse) stated, for MiraLax, the nurse must use the medication bottle cap to measure the scoop. V17 stated the cap has a specific measure that designates 17 Grams. On 7/17/2024 at 12:20 PM, V3 (Director of Nursing) stated for the multi-dose MiraLax or Polyethylene Glycol 3350, the scoop is one bottle cap. The nurse is not supposed to use a spoon. V3 is not sure how many grams of MiraLax a spoonful is so nurses are not to use it as measurement. V3 also stated that nurses should only chart medications they administered. On 7/17/2024 at 8:35 AM, V15 (Nurse) prepared medications for R83. V15 prepared Venlafaxine Hydrochloride, Calcium Carbonate, Rivastigmine transdermal patch, Thiamine Hydrochloride, and Metformin Hydrochloride. At 8:44 AM, V15 applied the patch to R83's left upper arm and instructed R83 to take the rest of the medications orally. R83's Order Summary Report and Medication Administration Records document in part that Thiamine Hydrochloride and Metformin Hydrochloride were to be administered enterally via gastrostomy tube. On 7/17/2024 at 12:20 PM, V3 (Director of Nursing) stated the five rights of medication administration were the right patient, time, medication, route and dose. Facility's 12/2022 Administration of Medication policy documents in part: Residents shall receive their medications on a timely basis and in accordance with our established policies. Medications must (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 13 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 0759 be administered by the route ordered by the Physician, unless specified route is orally. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 14 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 observations, interviews, and record reviews, the facility failed to refrigerate unopened insulin, discard loose tablets and expired medications, defrost medication refrigerators, and double-lock controlled medications from 2 of 2 medication rooms and 3 of 3 medications carts reviewed during medication storage observations. Findings include: On 7/16/2024 at 9:47 AM, surveyor reviewed the 1-East Team 1 medication cart with V4 (Nurse). In one of the top drawers, there was a bottle of Insulin Aspart 100 unit/milliliter vial for R154. The label on the bottle documents in part Refrigerate until open. V4 stated the vial was unopened. In the drawer with the house stock medications, there was a bottle of One-Daily Multivitamin 200 tabs. Written open date on the bottle was 5/27/2024. The best by date on the bottle was 3/2024. V4 started administering medications from the bottle that morning. At 9:52 AM, V4 stated the night shift nurses are supposed to check the medication carts for expired medications. On 7/16/2024 at 10:02 AM, surveyor reviewed the 2-West medication room with V5 (Nurse). There were two medication refrigerators on top of a counter. There was ice buildup in the freezer with some of the ice falling off onto the medication shelves. V5 stated, did not know who was responsible for maintaining the refrigerators or how often they were defrosted. On 7/16/2024 at 12:34 PM, surveyor reviewed the 2-East medication room with V6 (Nurse). The medication refrigerator was on the floor at the nurses' station. V6 unlocked the padlock to the refrigerator door. Inside there was a clear box with R351's Hydromorphone and Lorazepam. Surveyor was able to remove the box from the refrigerator. The box had a lock, but it was not locked. Surveyor was able to pull the medications out of the box without V6's key. On 7/16/2024 at 12:42 PM, surveyor reviewed the 2-East Team 1 medication cart with V17 (Nurse). In the drawer containing the residents' medication blister packets, there were seven loose tablets outside of their packaging. There were three orange tablets, three white tablets, and one pink tablet. V17 did not know what the tablets were. On 7/17/2024 at 12:20 PM, V3 (Director of Nursing) stated narcotics and controlled medications should be double locked in the fridge. The small box in the fridge should be locked including the pad lock on the fridge. The medication fridge should be defrosted every week or once a week. V3 stated if insulin is not open, it should be in the fridge. On 7/18/2024 at 10:14 AM, surveyor reviewed the 2-West Team 1 medication cart with V31 (Nurse). In the third, large drawer, there were loose pills (one yellow and two white pills) outside of their packaging. V31 did not know what the pills were and discarded them. Facility's 12/31/2022 Medication Storage in the Facility policy documents in part: Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations. All drugs classified as Schedule II of the Controlled Substance Act will be stored under double locks. Medications requiring 'refrigeration' or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator. Outdated, contaminated, or deteriorated drugs and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 15 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 FORM CMS-2567 (02/99) Previous Versions Obsolete those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock. They will be disposed of according to drug disposal procedures, and reordered from the pharmacy if a current order exists. Medication storage areas are kept clean, well lit, and free of clutter. Facility's 11/17 Medication Storage Controlled Medication Storage policy documents in part: Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator. Event ID: Facility ID: 145767 If continuation sheet Page 16 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 ensure food was labeled, dated, and discarded after use by date and failed to ensure equipment has been immersed in the sanitizer sink for a full minute and then air-dried before use. These failures could potentially affect 100 residents who were to receive meals from the kitchen on 7/16/24. The findings include: On 7/16/24 at 9:34 AM, Surveyor toured kitchen with V12 (Dietary Manager), reach-in fridge checked and observed thickened water with open date on 7/3/24. V12 said thickened water is good for 7 days from date it was opened, and it should be discarded. V12 removed the opened thickened water from the fridge and tossed it. Thickened water container label showed after opening, may be kept up to 7 days under refrigeration. V12 said if food item is used beyond used by date there is a risk of making resident get sick, food / drink could be contaminated or spoiled. Surveyor inspected dry food storage room with V12, observed box of tea bags opened with no date labelled. V12 said once food item or product was opened it should be dated, so everybody is aware when it was opened and when to discard it. On 7/17/24 at 10:46 AM, observed pureed food preparation conducted by V13 (Cook) and stated there are 3 food items to be pureed (pasta, meat balls and Italian blended vegetables). Observed V13 puree the pasta using a blender machine. At 10:53 am, Observed V13 cleaned, rinsed the equipment and immersed the container, lid, blade in the sanitizing solution in the 3-compartment sink for less than 20 seconds then he placed the equipment to the drying rack. At 10:55 am, Observed V13 use the equipment (container, blade, and lid) not fully air-dried, water was dripping. V13 put Italian blended vegetables into the container that was not fully air-dried, and water was dripping. V13 blended the vegetables into pureed consistency. At 10:59 am, V13 cleaned and rinsed the equipment. Observed V13 immersed the equipment in the sanitizing solution in the 3-compartment sink for at least 10 seconds. He placed the equipment in the drying rack. At 11:01 am, V13 used the container, blade and lid that were not fully air dried, water was still dripping. He put meat balls with sauce inside the wet container, blade and lid with dripping water. Blended the meat balls into pureed consistency. V13 cleaned the equipment, rinsed and immersed into the sanitizing solution in the 3-compartment sink for less than 10 seconds and placed the equipment (container, lid and blade) to the drying rack. On 7/18/24 at 9:08 am, V12 (Dietary Manager) said they are using Quaternary solution / ammonium compound as a sanitizing solution in the 3 compartment sink and staff is expected to immerse or soaked kitchen equipment such as blender container, lid, blades, pots and pans, etc. for 60 seconds or full minute to kill bacteria or any food particles gotten in the equipment will be removed and 60 seconds immersing could allow time to kill the bacteria and disinfect the equipment. V12 said after immersing the equipment in the sanitizing solution, should be kept on the air-drying rack, turn it over until fully air dried. She said equipment should not be used if it is wet, it should be fully air (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 17 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 dried. She said if equipment such as blender container, blade and lid were not fully air dried and were used there could be moisture / growth and potential contamination could happen. Facility census dated 7/16/24 showed 102 residents. Facility provided list of residents on NPO (nothing by mouth) and showed 2 residents on NPO as of 7/16/24. Residents Affected - Many Facility's policy for labeling and dating foods dated 2010 documented in part: Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality product for the residents and minimize waste. Foods prepared on the premises to be hold cold will be labeled with the date of preparation and time as required for cooling purposes. This food will also be labeled with date to discard or use by. The discard / use by date will be a maximum of 6 days after preparation. For example, food prepared on June 10th will be labeled to discard on, or use by, June 16th. Commercially processed foods that have been prepared and packaged by a food processing plant will be labeled with the date it is opened. Facility's policy for manual sanitizing in three-compartment sink dated 2017 documented in part: After washing and rinsing utensils and equipment are sanitized in the third sink by immersion. Chemical sanitizing solution used according to manufacturer's instructions. Facility provided manufacturer's procedures for 3 compartment sinks and documented in part: Immersed utensils in sanitizer sink for a full minute. Facility's policy for sanitation and food safety dated 2021 documented in part: Utensils and equipment are air-dried. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 18 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to dispose garbage properly in a contained dumpster; ensure garbage receptacles were covered and keep the dumpster area clean and free of garbage or waste to maintain a sanitary condition and to prevent harborage and feeding of pest. These failures could potentially affect all 102 residents that reside in the facility as of census 7/16/24. Residents Affected - Many The findings include: On 7/16/24 at 10:15 AM, Surveyor inspected dumpster with V12 (Dietary Manager), observed dumpster with recycled items not closed, lid broken and/or bent. Another dumpster, with trash, had a lid not fully closed. V12 stated it was not fully closed because it is full of waste. V12 said the dumpster or garbage bin should be completely closed or covered to prevent flies or insects to come by. Surveyor also observed broken furniture and equipment around the dumpster area and garbage bins with waste inside, not covered. V27 (Maintenance Staff) interviewed and he stated the dumpster lid has bended and it does not close completely. He said another dumpster with trash was not completely closed because it is full of garbage. V27 said the dumpster or garbage should be closed as rodents could go in there and stuff could happen. On 7/18/24 08:56 AM, V26 (Director of Maintenance) said he provides oversight for dumpster or garbage disposal and there is 1 custodian staff (V27) who is responsible for waste management. V26 said dumpster or garbage bins should be completely closed or covered to prevent rodents and insects. The policy for garbage disposal / refuse or waste / dumpster management requested. On 7/16/24, 7/17/24 and 7/18/24 Surveyor made multiple requests for facility's policy regarding garbage disposal / refuse or dumpster management but V1 (Administrator) said there is no policy for such. V1 provided policy for pest control instead. Facility's policy for pest control dated 12/14 documented in part: Garbage and trash are not permitted to accumulate and are removed from the facility per policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 19 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 record reviews, the facility failed to follow their policy to ensure proper infection control guideline practices are followed related to personal protective equipment was not worn prior to entering a contact isolation room for 1 resident (R403), failed to use standard precautions during incontinence care and perform hand washing/hand hygiene for 2 residents (R10, R50), failed to follow their policy to ensure proper infection control guideline practice are followed related to the use of a nasal cannula that was picked up from the floor and was placed in the nostrils of 1 resident (R6) reviewed for infection control in a sample of 24. Residents Affected - Some Findings Include: 1. On 07/17/2024 at 09:45 AM, surveyor observed R403's room had contact isolation sign on her door. On 07/17/2024 at 10:41 AM, V20 (Licensed Practical Nurse) stated that R403 is on isolation for Extended Spectrum Beta-Lactamase (ESBL). On 07/17/2024 at 11:45 AM, surveyor observed V22 (R403's daughter) sitting with R403 on the bed, hugging R403 without wearing any personal protective equipment. V22 stated that she did not know her mother had an infection and required contact isolation precautions. On 07/17/2024 at 11:50 AM, V2 (Director of Nursing) stated that if a resident is on contact isolation, anyone who touches the resident needs to be wearing personal protective equipment, which includes gown and gloves. V2 stated that R403 is on contact isolation for ESBL and that her daughter should be wearing personal protective equipment if she is going to sitting and holding her mother in bed. R403's care plan documents in part: 7/14/24 Meropenem IV Solution as ordered, via Heparin lock related to Urinary Tract Infection (ESBL/E. Coli). On Contact Isolation. Facility's Transmission Based Precautions policy (6/2023) documents in part: The purpose of the guideline is to summarize best practices for the use of transmission based precautions in SNFs and to assist with decision-making regarding the placement of residents with organisms of concern. Contact Precautions: wear a gown and gloves for all interactions with the patient or potentially contaminated areas in the patient's environment. Donning personal protective equipment (PPE) upon room entry and discarding it before exiting the patient room. 2. On 7/16/24 at 12:02 pm, R10 Observed lying in bed, alert and verbally responsive, Spanish speaking but can speak simple English. R10 requested to be changed. Surveyor conducted incontinence care observation with V10 (Agency Certified Nursing Assistant / CNA). R10's incontinence brief was heavily soiled with urine. V10 used a wet wash cloth in wiping R10's genitalia and the same washcloth in cleaning the buttocks. V10 used the same gloves for the entire procedure of providing incontinence care. V10 did not wipe dry R10's genitalia or buttocks. V10 did not perform hand washing before and after incontinence care procedure. V10 then proceeded with putting on new disposable gloves and took care of R10's roommate (R50). At 12:10 pm, Observed R50 lying in bed, alert with confusion, with strong odor of urine. Incontinence care observation conducted with V10 (Agency CNA). R50's incontinence brief was soiled with urine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 20 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 V10 put on disposable gloves and did not wash her hands before starting care. V10 observed wiping R50's genitalia with a wet wash cloth and then used the same washcloth to wipe R50's buttocks. V10 did not wipe dry R50's genitalia or buttocks. V10 did not perform proper hand washing before and after care. V10 did not bring washbasin, soap, and water to provide incontinence or perineal care to the 2 residents (R10 and R50). On 7/18/24 10:23 AM, V2 (Director of Nursing / DON) stated staff is expected to bring wash basin with soap and water and should have at least 2-3 wash cloth one for front (genitalia) and another washcloth to cleanse the buttocks and 3rd towel to dry the resident. She said staff is expected to perform proper hand hygiene / hand washing before and after care to prevent cross contamination or for infection control. Facility's policy and procedure for perineal care dated 12/2013 documented in part: To cleanse the perineum and prevent infection. Wash hands and put on disposable gloves. Wash perineal area with soap and water or perineal cleanser. After cleansing is complete, rinse if necessary, and then dry the resident by patting skin gently with a clean bath towel. Remove gloves and wash hands. Facility's policy for handwashing dated 12/31/21 documented in part: Proper handwashing technique is used for the prevention of transmission of infectious diseases. All personnel working in the long-term care facility are required to wash their hands before and after resident contact, before and after performing any procedure. 3. On 07/17/24 at 10:22 AM, surveyor and V23 (Certified Nursing Aide/CNA) entered R6's room. R6's oxygen nasal cannula was on the floor. Surveyor observed V23 pick up the nasal cannula from the floor and then placed the nasal cannula into R6's nostrils. V23 was asked why V23 applied the nasal cannula that was picked up from the floor into R6's nostrils? V23 stated she is sorry and that she should have sanitized the nasal cannula or replaced the nasal cannula. V23 was asked what could be the potential effect of what she did by not sanitizing the nasal cannula? V23 stated, the nasal cannula is contaminated, and it could cause infection for R6. V23 then replaced the dirty cannula with a new cannula. On 07/17/24 at 12:03 PM, V25 (Assistant Director of Nursing/ADON) stated when staff observe a nasal cannula on the floor, the nasal cannula should be replaced with a new cannula. V25 stated, applying into R6's nostrils a dirty cannula that was picked up from the floor put R6 at risk for respiratory infection. On 07/17/24 at 12:25 PM, V24 (Licensed Practical Nurse/LPN) stated R6 is on continuous oxygen at 3Liters per nasal cannula. V24 stated the nasal cannula should not be on the floor, but R6 tends to remove the nasal cannula. V24 stated once staff observed the nasal cannula on the floor, such cannula is dirty and contaminated. So, the dirty cannula should not be placed back on R6's nostrils but be discarded and replaced with a new cannula. V24 stated, placing a contaminated nasal cannula on R6 could lead to respiratory infection. The facility policy on infection prevention and control program dated 10/24/22, documents in part: Ensure the facility establishes and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 21 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 Based on record review and interviews the facility failed to offer, educate, and document the benefits and risks of Influenza and Pneumococcal vaccines to 4 (R80, R401, R403, R404) of 5 residents reviewed for vaccinations. Residents Affected - Some Findings include: Per residents' vaccination record, R80, R401, R403, and R404 did not receive any of the following vaccines (influenza and pneumococcal ). Surveyor requested for all documentation related to vaccination including immunization record, consent forms, documentation of education and other documents that residents were offered and educated on before refusal. V2 (Director of Nursing / Infection Preventionist) was not able to provide any consent forms, and there was no documentation that any resident or representative of resident was educated and the reason for refusal. R401's consent for Influenza and Pneumonia vaccine documents in part: Yes to receiving influenza and pneumonia vaccine. R401's immunization record does not document any administration of vaccine. On 07/18/2024 at 10:24 PM, V2 (Director of Nursing / Infection Preventionist) reviewing electronic health records and said, I cannot find any documentation that specific education was given, or if resident was able to understand education. V2 stated that if it's not in the resident's electronic health record, then the consent and education should be in their physical chart. Surveyor followed V2 to first floor nurses station to review resident's chart. Surveyor observed V2 look through R80, R401, R403 and R404's chart and could not find any immunization record, consent form or education provided for influenza and pneumococcal immunization. V2 stated, that she understands that residents can benefit from vaccination, and it is important to let them know what their options are. V2 stated I will check for any documentation. On 07/18/2024 at 11:00 AM, R404 was seen inside his room alert and able to express thoughts well. R403 stated that he did not receive any information about any vaccines. R404 stated that he doesn't think he received any vaccine. On 07/18/2024 at 11:05 AM, R401 was seen alert and verbally able to express needs. R401 said, I was offered vaccine but, no one came to give it to me. I would like to get all vaccines if it was offered to me. No one explained to me about any vaccine. On 07/18/2024 at 11:15 AM, R403 was seen on her bed and does not respond during interview. R403 cognition is impaired with BIMS (Brief Interview of Mental Status) dated 07/05/2024 score of 8. On 07/18/2024 at 11:30 AM, R80 was seen on her bed and does not respond to question within topic during interview. R80 cognition is impaired, BIMS (Brief Interview of Mental Status) dated 04/25/2024 was not performed due to R80 rarely or never understood. Immunizations (Influenza and Pneumococcal) policy dated 12/2022, reads: To minimize the risk of residents acquiring, transmitting, or experiencing complications from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 22 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 Influenza or Pneumococcal pneumonia, it is the policy of this facility to offer Influenza and Pneumococcal vaccinations to all residents. Under procedure for Influenza Vaccination: Each resident or resident's representative will receive education regarding the benefits and potential side effects of influenza immunization. Each resident will be offered the influenza vaccination between October 1 and March 31, unless the immunization is contraindicated or the resident has already been immunized during this time. Consent for and education about the vaccine must be given each time the vaccine is offered. The resident's medical record will indicate: That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and that the resident either receive the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. Under procedure for Pneumococcal Immunization: Each resident or resident's representative will receive education regarding the benefits and potential side effects of pneumococcal immunization. Pneumococcal vaccine will be offered to all residents upon admission unless they report prior immunization. Facility will make best efforts to validate prior immunization. Consent for and education about the vaccine must be given each time the vaccine is offered. The resident's medical record will indicate: That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either receive the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindications or refusal or they received it before. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 23 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 0887 Level of Harm - Minimal harm or potential for actual harm Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on record review and interviews the facility failed to offer, educate, and document the benefits and risks of the COVID-19 vaccines to 4 (R80, R401, R403, and R404) of 5 residents reviewed for vaccinations. Residents Affected - Some Findings include: Per residents' vaccination record, R80, R401, R403, and R404 did not receive any vaccine (Covid-19). Surveyor requested for all documentation related to vaccination including immunization record, consent forms, documentation of education and other documents that residents were offered and educated before refusal. V2 (Director of Nursing / Infection Preventionist) was not able to provide any consent forms, and no documentation that any resident or representative of resident was educated and the reason for refusal. Reviewed R401, R403, R404 and R80's immunization record. No documentation of administering COVID-19 vaccine. On 07/18/2024 at 10:24 PM, V2 (Director of Nursing / Infection Preventionist) reviewed electronic health records and said, I cannot find any documentation that specific education was given, or if resident was able to understand education. V2 stated, that if it's not in the resident's electronic health record, then the consent and education should be in their physical chart. Surveyor followed V2 to first floor nurses station to review resident's chart. Surveyor observed V2 look through R80, R401, R403 and R404's chart and could not find any immunization record, consent form or education provided for COVID-19 vaccination. V2 stated that she understands that resident can benefit from vaccination, and it is important to let them know what their options are. V2 stated, I will check for any documentation. On 07/18/2024 at 2:00 PM, V2 provided surveyor with the binder of all residents who consented and was offered education for COVID-19 vaccination. R80, R401, 403 and R404's consent form and education was not found by V2 in the binder. On 07/18/2024 at 11:00 AM, R404 was seen inside his room alert and able to express thoughts well. R403 stated that he did not receive any information about any vaccines. R404 stated that he doesn't think he received any vaccine. On 07/18/2024 at 11:05 AM, R401 was seen alert and verbally able to express needs. R401 said, I was offered vaccine but, no one came to give it to me. I would like to get all vaccines if it was offered to me. No one explained to me about any vaccine. On 07/18/2024 at 11:15 AM, R403 was seen on her bed and does not respond during interview. R403 cognition is impaired with BIMS (Brief Interview of Mental Status) dated 07/05/2024 score of 8. On 07/18/2024 at 11:30 AM, R80 was seen on her bed and does not respond to question within topic during interview. R80 cognition is impaired, BIMS (Brief Interview of Mental Status) dated 04/25/2024 was not performed due to R80 rarely or never understood. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 24 of 25 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 145767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paul House & Health Cr Ctr 3800 North California Avenue Chicago, IL 60618 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 0887 Covid - 19 Vaccination Policy dated 12/31/2022, reads: Level of Harm - Minimal harm or potential for actual harm The purpose of this policy is to educate and offer residents the opportunity to receive the COVID-19 vaccine. All residents and their representatives will be provided with education on COVID 19 vaccination per Center of Disease Control. Residents Affected - Some Under Covid - 19 Vaccine procedures, all residents will be offered the COVID-19 vaccine. All residents will receive education materials about the benefits of COVID-19 vaccine and adverse reactions post vaccination. If the resident declines the vaccination, COVID-19 vaccination declination waiver signed by resident or representative declining the vaccine must be obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 25 of 25