Inspection visit

InspectionJune 5, 2025

PAUL HOUSE & HEALTH CR CTRCMS #14576748 citations on this visit

48 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 48 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. On 6/2/25 at 11:15am, R104 was observed in bed with the indwelling urinary catheter drainage bag without privacy bag. The urine bag was hung on the side of the bed visible to anyone walking down the hallway when the door is not closed. On 6/2/25 at 11:18am, R18 was observed in bed with the indwelling urinary catheter drainage bag without privacy bag. The urine bag was hung on the side of the bed visible to anyone walking down the hallway when the door is not closed. On 6/2/25 at 12:05pm, both residents still had the urine bags without privacy bags. V5 (Registered Nurse) was notified and V5 stated that she (V5) would ensure to put the urine bags in privacy bags. Based on observation, interview and record review, the facility failed to ensure the indwelling catheter drainage bag was covered for three residents (R18, R51 and R104) reviewed for dignity in the sample of 55 residents. Findings include: On 06/02/25 at 11:19 am, R51 was observed in bed with indwelling catheter bag hanging on the bottom of R51's bed, visible to the doorway and not covered in a privacy bag. R51 stated that R51 has been at the facility for several months and has never had a privacy bag for R51's indwelling catheter. On 06/02/25 at 11:22 am, V16 (Licensed Practical Nurse, LPN) stated that residents with indwelling catheters should have a privacy bag to cover the residents indwelling catheter. V16 stated that if a residents indwelling catheter bag is not covered then the facility is not protecting the residents privacy. On 06/04/25 at 9:35 am, V2 (Assistant Director of Nursing, ADON) stated that indwelling catheters should be in a privacy bag for the residents dignity. V2 explained if the indwelling catheter should be placed on the side of the bed not visible to the hallway so that no one can see the residents indwelling catheter and to protect the residents dignity. R51's face sheet shows that R51 has a diagnosis which includes but not limited to indwelling and inflammatory reaction due to indwelling urethral catheter, initial encounter, hydronephrosis with ureteral stricture, and benign prostatic hyperplasia with lower urinary tract symptoms. R51's Brief Interview for Mental Status (BIMS) dated 03/24/25 shows a BIMS score for R51 of 15 and indicates that R51 is cognitively intact. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 48 Event ID: 145767 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 06/05/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R51's physician order sheet (POS) show active orders dated 06/03/25 shows that R51 has orders for indwelling catheter care every shift. The facility undated policy titled Dignity documents in part: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered. The facility's undated policy and titled Resident Rights documents, in part Policy Statement: Employees shall treat all resident with kindness, respect, and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 2 of 48 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 06/05/2025 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that the call lights of residents are accessible as stated in the care plans. This failure has the potential to affect 3 residents (R74, R94, and R504) reviewed for accommodation of needs in a sample of 55 residents. Residents Affected - Few Findings include: On 06/02/25 at 11:27am, R74 was observed at the edge of the bed and the surveyor asked R74 to use the call light to ask staff for help. The call light could not be found and R74 did not know where to find the call light. The surveyor went to the Nursing Station and called V5 (RN/Registered Nurse). V5 came and stated I found it. It's here under the bed. Inquired from V5 why the call light should be within reach of the resident; V5 stated to allow the resident to get help and to prevent falling. V5 added that she will remind the CNAs (Certified Nurse Assistants). R74's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Repeated Falls, Vascular Dementia, Unsteadiness on Feet, Abnormalities of Gait and Mobility, Lack of Coordination, Right Foot Drop, Osteoarthritis, and Cognitive Communication Deficit. Care plan dated 3/21/25 states in part that R74 is at risk for falls related to Deconditioning, musculoskeletal impairment, neurological impairment, vascular dementia with anxiety, Interventions states to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Fall Risk Evaluation dated 1/28/25 shows that R74 is at high risk for falls. Basic Interview for Mental Status (BIMS) Score is 12 out of 15 (Mild Cognitive Impairment). Facility's Call Light Policy dated 9/1/22 states in #5: When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. On 6/2/2025 at 12:48pm, R94 was lying in bed with a clean kept appearance. R94's call light was observed on the floor. On 6/2/2025 at 12:51 pm, V12 (Licensed Practical Nurse-(LPN) affirmed R94's call light on the floor next to R94's bed. V12 stated R94 doesn't use the call light so that's why we keep the door open. V12 stated R94 can fall if the call light is not within easy reach. On 6/4/2025 at 3:36pm, V2 (Acting Director of Nursing-(ADON) stated the call light should be within easy reach so that a resident's needs can be met. V2 stated an example is when a resident is in pain and the call light is not in reach, there will be a delay in relieving the resident's pain if the call light is not in easy reach. Facility's undated policy titled Answering Call Light Policy documents in part: When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. On 06/02/25 at 11:00am, R504 was observed, in his (R504) room, sitting on the side of bed with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 3 of 48 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 06/05/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few walker in front of him, and R504's call light was wrapped on the bedside table behind R504 not within reach of R504. Surveyor observed urine on the floor below R504 with his (R504) foot lying in the puddle of urine. R504 stated, It has been over an hour that I (R504) have been waiting for help to get to chair and get cleaned up. A nurse came in, helped me sit on the side of the bed, and said that he (nurse) would be back once he (nurse) could find another nurse to help him (nurse). I'm sorry. This is humiliating. I'm (R504) so embarrassed. No, I (R504) can't reach the call light over there. R504's face sheet documents diagnoses that include but are not limited to need for assistance with personal care; muscle weakness; fall; other abnormalities of gait and mobility; unsteadiness on feet; and periprosthetic fracture around internal prosthetic left hip joint. R504's Brief Interview of Mental Status (BIMS) score, dated 5/16/25, documents, in part, a BIMS score of 15 which indicates R504 is cognitively intact. On 6/2/2025 at 11:05am, V11 (Certified Nurse's Assistant/CNA) stated, My resident's load is heavy because many of them require increased surveillance and two people assistance, and they are always short staffed. I (V11) already waited for over an hour for another CNA to help me (V11) to move the resident from bed to chair. There is only one nurse and one other CNA working this unit. I (V11) will not risk the resident falling by moving him (R504) by himself (V11). No, he (R504) cannot reach the call light over there. On 6/4/25 at 12:01pm, V2 (Assistant Director of Nursing/DON) said, Call lights should be answered immediately. At least go and see what the resident needs. Any staff can help a resident. Physical therapy, social workers. You (staff) do not have to be a nurse. An hour is too much for a resident to get assistance. Right away. Assist them (residents) right away. Waiting for an hour with sitting in urine would probably make a resident mad and sad. Facility policy titled, Activities of Daily Living (ADLs), Supporting, reviewed date 9/01/24, documents, in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently . including . hygiene; . mobility (transfer and ambulation, including walking); elimination (toileting) . Facility policy titled, Answering the Call light, reviewed 9/1/22, documents, in part, . When the resident is in the bed . be sure the call light is within easy reach of the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 4 of 48 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 06/05/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide clean bed and bath linens for residents with the need of assistance with daily hygiene, bathing, or showers. This failure affected two residents (R96, R504) out of three reviewed in the final sample of 55 residents, however, this failure has the potential to affect all 93 residents living in the facility. Findings include: On 6/2/2025 the Census sheet provided by the facility showed 93 residents. On 6/2/2025 at 11:00 AM, observed R504 sitting on the side of the bed, holding a walker. Underneath the bed, observed a fresh urine-like spot on the floor and on the resident's left foot. R504 stated, that it has been over an hour, that someone came in to help to transfer R504 from bed to the chair. R504 could not wait longer and tried to use the urinal, could not reach it in time and had an accident. R504 stated that R504 felt embarrassed, humiliated, and angry and did not have any clean towels or washcloths to use. On 6/2/2025 at 11:05 AM V11 (Certified Nurse's Aide/CNA) stated the resident's wait for help for a long time sometimes because the patient load is heavy because many of the residents require increased surveillance and two people assistance. V11 stated that the facility is always out of towels and washcloths and many times V11 had to use blankets to give residents bed baths. V11 stated that to cover the urine spot until cleaned, blanket must be used, because there are no towels available on the unit. 6/2/2025 at 11:10 AM, in the 2 East Unit's Clean Linen Room, observed no towels or washcloths on the linen carts. On 6/2/2025 at 11:30 AM R96 stated that sometimes the facility runs out of towels and washcloths and pillowcases and must use blankets instead when receiving a shower. R96 receives showers twice a week on Wednesday and Saturday. R96 had to take towels or a pillowcase from a cart when available, because the facility is often short of linens. R96 stated that sometimes she uses her own linens. On 6/3/2025 at 11:45 AM in the Facility's Laundry room observed with V22 (Laundry Aide), Observed on the top of the clean linen folding table, a total of eight towels and eight washcloths. Next to clean linen folding table, observed three full bins of clean linen (blankets, gowns, sheets, chucks,) and one empty linen cart with a pink cover attached to it. Surveyor observed additional room with clean linen storage area, with four carts of clean linen on the carts, covered with pink covers. No additional towels or washcloths observed in the additional clean linen storage room. No towels or washcloths observed in the four working dryer machines or the clean bins. V22 stated that there is a certain amount of linen placed on the linen carts for each unit specifically, and then the carts get distributed to each unit at 7am and again in the evening. The amount of linen varies per unit and is written on a paper form on the bulletin board in the laundry room. Surveyor observed, written in permanent black marker on each unit's linen cart, the amount of linen each unit is dispersed (the same amounts that are written on the paper form on the bulletin board in the laundry room). Evidence shows that the amount of linen that is dispersed to each unit is less than the number of residents on each unit. V22 said, sometimes V22 does not have clean towels and other linens ready, because V22 is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 5 of 48 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 06/05/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the only one laundry aide until 2pm. V22 said, that another laundry aide comes in at 2pm and works until 8pm. V22 does not have enough time or help to wash and sort, fold, and disburse all linen in a timely manner. V22 said, that the reason why the towels and wash cloths are not visible in the laundry room, is that a full cart of fresh linen, was delivered at 7am to each unit and the dirty linen is still being washed. On 6/3/2025 at 11:55 AM Laundry's room bulletin board sign for distribution of linens showed linen placement as follows but not limited to 1 East 13 towels, 15 wash cloths; 2 East morning linen 10 towels, 15 wash cloths, 2 East night linen 6 towels, 10 wash cloths; 2 [NAME] linen Morning 12 towels, 20 washcloths, Night 6 towels, 20 wash cloths. 2 East Unit on 6/3/2025 at 12:07PM, V12 (LPN), stated that current census for the unit is 24 residents. 2 East Unit's Linen Room on 6/3/2025 at 12:08 PM, observed NO towels or washcloths on linen carts. On 6/3/2025 at 12:10 PM V13 (Certified Nurse's Aide/CNA), stated that since the new management took over, there has been many changes in laundry practices. V13 stated at 7am V13 removed four washcloths and two towels from the delivered linen cart and the other aide took the rest, which was about the same number of towels and washcloths. V13 affirmed that the facility is often short on linens, especially towels and washcloths and that since the new changes in laundry staff (now only one person working), it got worse. V13 must often call for more linens, sometimes must leave the unit and go to the laundry room and try to obtain more linens. V13 also stated that a few times, when V13 went to obtain more linens from the laundry room, the laundry room did not have the linens needed. On 6/3/2025 at 14:34 PM, V1 (Administrator) stated that there should be clean linen observed and available on every unit. V1 wasn't aware of not having towels or washcloths available. Observed two linen carts brought up by the maintenance personnel by the conference room. One cart was half empty with clean linen, including five towels and four washcloths, the second cart had only sheets, blankets, and gown on it, halfway full. When asked about the number of available towels and washcloths for residents on the clean linen carts coming from laundry, V1 stated that the amount gets refilled as needed, the laundry aide delivers more linen to the units, when needed. On 6/4/2025 at 11:19 AM V1 (Administrator) stated, that, the bulletin board signs used for stocking the linen carts in the laundry room, were made prior V1's start at the facility. V1 was not aware that the linen carts were stocked with the limited number of towels and other linens as shown on the bulletin board signs in the laundry room. V1 stated that each resident should be provided two towels and two washcloths. V1 provided document that listed linen inventory summary as of 6/4/2025. On 6/4/2025 at 12:10 PM V2 (Assistant Director of Nursing/ADON) stated that to provide a resident with a bed bath, a minimum of four bath towels and four washcloths are necessary to use. There should be a separate washcloth used for face and arms and resident's chest and lower extremities. V2 stated that the linen gets delivered in the morning, but there is not enough to give bed baths for all the residents. On 6/4/2025 at 14:20 PM V24 (Maintenance Director), stated that when more linen is need, the staff should call the maintenance, or the laundry and the linen would be brought up to the unit. V24 also stated that often the linen gets discarded to trash bins and therefore some linen gets locked in the storage room. V24 was not aware of no towels and washcloths not available on 6/2/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 6 of 48 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 06/05/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm On 6/4/2025 at 15:00 PM V1 affirmed that according to the inventory document provided, the facility does not have enough towels to provide minimum of two towels for 93 residents. Facility's Linen Inventory Document provided by facility dated 6/4/2025 showed in part 120 towels in circulation and 60 towels in storage, which equals to a total of 180 towels in the building. Residents Affected - Many R96's Minimum Data Sheet (MDS) dated [DATE], in Section C- Cognitive Patterns documents Brief Interview for Mental Status (BIMS) Summary Score of 12 which indicates moderate cognitive impairment. R96's Diagnosis included but not limited to palliative care, interstitial pulmonary disease, chronic obstructive pulmonary disease, chronic respiratory failure, anxiety disorder, hypothyroidism. R96's Care Plan Report (POC) initiated on 5/28/2025, showed in part that R96 is on hospice care and the staff should meet R96's comfort needs and provide support and comfort care (pg. 3 of POC). POC also showed in part that R96's palliative care status prioritizes comfort. (pg. 7 of POC) R504's Minimum Data Sheet (MDS) dated [DATE], in Section C- Cognitive Patterns documents Brief Interview for Mental Status (BIMS) Summary Score of 15 which indicates intact cognitive function. R504's Diagnosis included but not limited to history of unsteadiness on feet, acute thrombosis of veins, falls, aftercare following joint replacement surgery, presence of left artificial hip joint, major depressive disorder, benign prostatic hyperplasia R504's Care Plan Report (POC) initiated on 5/24/2025, showed in part that R504 had surgery on left hip and needs assistance in hygiene when there is an episode of incontinence, needs assistance to toilet in the morning, before or after meals, before bed and as needed, provide peri care, Activities of Daily Living (ADL's) self-care deficit. (pg4, 5, 7,11) Facility's Laundry Aide Job Description documents in part, that the laundry aide is responsible for ensuring that all resident linens and facility laundry are properly cleaned, sanitized, folded, and returned in a timely and efficient manner. Facility's Certified Nursing Assistant (CNA) Job Description documents in part, that the CNA is responsible for providing resident care and support all activities of daily living and ensures the health, welfare, and safety of all residents. The document also states in part, that CNA should aid in all activities of daily living including but not limited to personal hygiene by giving bedpans, urinals, baths, backrubs, shampoos, and shaves, assisting with showers and baths; provide for resident comfort by utilizing resources and material. Facility's Assistant of Director of Nursing (ADON) Job Description documents in part, that the one of the purposes of ADON is to direct the day-to-day functions of the Nursing Department and ensure that the highest degree of quality care is always maintained. Facility's Administrator Job Description documents in part, that some of essential duties and responsibilities expectations are to plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board, to develop and implement strategies to improve the quality of care of the residents. Administrator ensures that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 7 of 48 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 06/05/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Facility's Policy titled Resident Rights, documents in part that federal and state laws guarantee certain basic rights to all residents of this facility. These rights include but not limited resident's right to: be treated with respect, kindness, and dignity. Facility's Policy titled Homelike Environment presented 6/5/2025, revised 9/1/2024, showed in part that residents are provided with a safe, clean, comfortable, and homelike environment. The facility staff and management should maximize, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics including but not limited to clean, sanitary, and orderly environment; clean bed and bath linens that are in good condition. Illinois Long-Term Care Ombudsman Program Resident's rights booklet, dated 11/18, states in part that the facility must be safe, clean, comfortable, and homelike. The residents should receive the services and/or items included in the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 8 of 48 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 06/05/2025 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 transmit a minimum data set (MDS) assessment within required timeframes. This failure affects 1 resident (R354) in a sample of 55. Residents Affected - Few Findings include: Review of R354's minimum data set (assessment reference date 4/7/2025) documents in part that the assessment was signed as complete as of 4/16/2025. No documentation could be found within R354's electronic health record. Review of R354's electronic health record does not document that R354's minimum data set (assessment reference date 4/7/2025) was transmitted to CMS. Review of R354's validation report related to the minimum data set (assessment reference date 4/7/2025) documents in part that the assessment was transmitted to CMS on 6/3/2025. On 6/4/2025 at 10:43 AM, V19 (Registered Nurse, MDS Coordinator) stated that the assessment was completed on 4/16/2025 and should have been transmitted within 14 days of completion. V19 explained that when the MDS was requested by the survey team, V19 noticed it was not submitted to CMS, which is why it was submitted yesterday (6/3/2025). V19 stated, it (the transmission of the assessment) must have gotten missed, I forgot to check. V19 affirmed that a purpose of transmitting the MDS to CMS is to track quality data for residents and for the facility's financial reimbursement. Facility policy titled, MDS Completion and Submission Timeframes (reviewed 9.2.24) documents in part, Policy Statement Our facility will conduct and submit resident assessments in accordance with currrent federal and state submission timeframes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 9 of 48 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 06/05/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plan meetings were conducted and failed to ensure residents/resident's family members participated in the development of the comprehensive care plan. This failure affects 4 residents (R49, R65, R83, and R354) out of a sample of 55. Findings include: R65's minimum data set (5/16/2025) documents in part a brief interview of mental status summary score of 12, indicating that R65 has moderate cognitive impairment. On 6/2/2025 at 11:09 AM, R65 stated that R65 was not familiar with R65's plan of care and denied ever receiving a copy of R65's care plan. R65 denied that R65 has attended a plan of care meeting. R65 stated, I would want to go if there were meetings about me like that. R65's progress notes indicate that on 4/26/22, R65's was scheduled for a care plan meeting on 5/4/22. No further documentation of care plan meetings or care plan participation was observed in R65's medical record. R49's minimum data set (5/7/2025) documents in part a brief interview of mental status summary score of 9, indicating that R49 has moderate cognitive impairment. On 6/2/2025 at 11:33 AM, R49 denied knowledge of what a care plan was and denied that R49 had ever attended a plan of care meeting. R49 stated, Well, yeah, of course I would want to go to a care plan meeting if they were having them. I really don't remember ever having one. Review of R49's progress notes does not document any care plan meeting participation or resident input in development of R49's plan of care. R354's minimum data set (4/6/2025) documents in part that R354's cognition was unable to be assessed due to being rarely/never understood. On 6/2/2025 at 11:40 AM, V29 (R354's Family Member) stated that R354 is on hospice services and has difficulty communicating/impaired cognition. V29 could not recall the last time R354 had a care plan meeting. Review of R354's progress notes documents in part that R354's last care plan meeting was held on 10/5/2023 prior to discharge. R354 was readmitted on [DATE] and no care plan meeting documentation or participation was noted in the medical record. R83's minimum data set (5/9/25) documents in part a brief interview of mental status summary score of 15, indicating that R83 is cognitively intact. On 6/2/2025 at 11:50 AM, R83 explained that R83 has a lot going on right now with a lot of different health issues and wants to be discharged to a lower level of care (such as supportive living or a community apartment) but doesn't know where we (the facility) are at with that. R83 stated that R83 has not had a care plan meeting but would like to be invited to participate if the facility was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 10 of 48 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 06/05/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm conducting them. R83 stated that R83 never got a copy of R83's care plan since being a resident of the facility. Review of R83's progress notes does not document any care plan meeting participation or resident input in development of R83's plan of care. Residents Affected - Some On 6/4/2025 at 10:43 AM, V19 (Registered Nurse, MDS Coordinator) stated that residents get care plan meetings quarterly and with significant changes. V19 affirmed that social services and nursing conducts the care plan meetings in accordance to the minimum data set (MDS) schedule, quarterly, annually and with any signficant change, about a week after the MDS. V19 denied that members of the dietary department or certified nursing assistants participate in the development of a resident's plan of care and that the nurse usually covers all that (dietary/certified nursing assistant). V19 affirmed that residents have the right to participate in the development of their plan of care. On 6/4/2025 at 1:51 PM, V35 (Social Services Director) stated that V35 could not find any documentation that indicates that R49, R83, and R65 received care plan meetings. V35 affirmed that the last documentation that R354 had a care plan meeting was in 10/2023. V35 affirmed that the care plan meetings are conducted quarterly for residents. No further documentation was provided prior to the exit of the survey. Facility policy titled Care Planning - Interdisciplinary Team (undated), . 3. The resident, the resident's family and/or the residents legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 4. Every effort will be made to schedule care plan meetings at the best time of day for the resident and family 5. The mechanics of how the interdisciplinary team meets is responsibilities in the development of the interdisciplinary care plan (e.g. face-to-face, teleconference, written communication, etc.) is at the discretion of the care planning committee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 11 of 48 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 06/05/2025 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 - Actual harm Based on observations, interviews, and record reviews, the facility failed to ensure that one (R504) resident who depends on staff assistance for ADL (Activities of Daily Living) care was provided incontinence care and transfer assistance in a timely manner, demonstrating inadequate care in a sample of 55 residents. This failure resulted in R504 suffering psychosocial harm stating feelings of humiliation and embarrassment. Residents Affected - Few Findings include: On 06/02/25 at 11:00am, R504 was observed, in his (R504) room, sitting on the side of bed with a walker in front of him, and R504's call light was wrapped on the bedside table behind R504 not within reach of R504. Surveyor observed urine on the floor below R504 with his (R504) foot lying in the puddle of urine. R504 stated, It has been over an hour that I (R504) have been waiting for help to get to chair and get cleaned up. A nurse came in, helped me sit on the side of the bed, and said that he (nurse) would be back once he (nurse) could find another nurse to help him (nurse). I'm sorry. This is humiliating. I'm (R504) so embarrassed. R504's face sheet documents diagnoses that include but are not limited to need for assistance with personal care; muscle weakness; fall; other abnormalities of gait and mobility; unsteadiness on feet; and periprosthetic fracture around internal prosthetic left hip joint. R504's Brief Interview of Mental Status (BIMS) score, dated 5/16/25, documents, in part, a BIMS score of 15 which indicates R504 is cognitively intact. On 6/2/2025 at 11:05am, V11 (Certified Nurse's Assistant/CNA) stated, My resident's load is heavy because many of them require increased surveillance and two people assistance, and they are always short staffed. I (V11) already waited for over an hour for another CNA to help me (V11) to move the resident from bed to chair. There is only one nurse and one other CNA working this unit. I (V11) will not risk the resident falling by moving him (R504) by himself (V11). On 6/4/25 at 12:01pm, V2 (Assistant Director of Nursing/DON) said, Any staff can help a resident. Physical therapy, social workers. You (staff) do not have to be a nurse. An hour is too much for a resident to get assistance. Right away. Assist them (residents) right away. Waiting for an hour with sitting in urine would probably make a resident mad and sad. Facility policy titled, Activities of Daily Living (ADLs), Supporting, reviewed date 9/01/24, documents, in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently . including . hygiene; . mobility (transfer and ambulation, including walking); elimination (toileting) . Facility policy titled, Answering the Call light, reviewed date9/1/22, documents, in part, . When the resident is in the bed . be sure the call light is within easy reach of the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 12 of 48 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 06/05/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow physician orders for obtaining resident weights for a resident with known weight loss and congestive heart failure. This failure affects 1 resident (R80) in a sample of 55. Residents Affected - Few Findings include: R80's face sheet documents in part a diagnosis of hypertensive heart disease and heart failure. R80's care plan identifies that R80 has a history of weight loss and is on diuretic medications that may cause weight fluctuations. R80's physician orders documents in part an active order (4/24/25) for Heart Failure Order Set- Weight every morning; Call MD if gain wt (weight) of 2 lbs (pounds)/1day and 5 lbs/1 week. one time a day every Tue and Thu Review of R80's weights for 5/2025 documents in part that R80's weight was collected on 5/5/2025. R80's weight was not documented again until 5/21/2025 (16 days later). On 6/4/2025 at 11:16 AM, V2 (Assistant Director of Nursing) affirmed that V2 is familiar with R80. V2 stated that R80 has a history of weight loss and heart failure. V2 reviewed R80's physician order for weights and affirmed that the order reads both every day and on Tuesdays and Thursdays. V2 stated, I think it is supposed to be done on Tuesdays and Thursdays. V2 reviewed R80's weights and affirmed that the weights were not completed per the physician order and no weights were obtained between 5/6/2025 and 5/20/2025. V2 stated the purpose of the obtaining daily weights for a heart failure patient is to ensure and monitor for exacerbations which can be identified by frequent weighing of the patient. No further weights for R80 during the date range of 5/5/2025-5/21/25 were provided prior to the exit of the survey. Facility policy titled, Weight Assessment and Intervention (undated) documents in part, The multidisciplinary team will strive to prevent, monitor and intervene for undesireable weight loss for our residents . 2. Weights will be recorded in each unit's weight record chart or notebeek and in the individuals medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 13 of 48 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 06/05/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm On 6/3/25 at 11:05am, R74 was observed in the room sitting in the wheelchair without a cushion to relieve pressure. Again, on 6/3/25 at 12:02pm, R74 was observed still in the same wheelchair without a cushion. At this time, V5(RN/Registered Nurse) was called to see R74. V5 stated that a cushion is needed to prevent pressure ulcer and that she (V5) will get a cushion for R74's wheelchair. Residents Affected - Few R74's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Vascular Dementia, Unsteadiness on Feet, Abnormalities of Gait and Mobility, Lack of Coordination, Right Foot Drop, Osteoarthritis, and Cognitive Communication Deficit. Care plan dated 10/4/24 states in part that R74 has actual impairment to skin integrity. MDS (Minimum Data Status) dated 4/11/25 states that R74 uses wheelchair, and that R74 is at risk of developing pressure ulcer. Basic Interview for Mental Status (BIMS) Score is 12 out of 15(Mild Cognitive Impairment). Facility's policy on Pressure ulcer prevention states in part: Support Surfaces and Pressure Redistribution: 1.Select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice. Device-Related Pressure Injuries: 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device. 2. Monitor regularly for comfort and signs of pressure-related injury. 3. For prevention measures associated with specific devices, consult current clinical practice guidelines. Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress was set appropriately for 1 resident (R66), failed to ensure the low air loss mattresses were not layered with multiple layers for 2 (R52 and R66) residents; and failed to ensure a resident's wheelchair has cushion for 1 (R74) resident. These failures affected 3 (R52, R66, and R74) residents reviewed for pressure ulcer prevention and treatment in the total sample of 55 residents. Findings include: On 06/02/25 at 11:10 AM, R52 was lying on a low air loss mattress. This surveyor requested V6 (Agency Licensed Practice Nurse) to check how many layers were between the low air loss mattress and R52. With assistance from V7 (Certified Nursing Assistant) V6 counted the layers and stated he (R52) was using an incontinence brief, there's a blanket that's twice folded making 4 layers of blanket plus (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 14 of 48 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 06/05/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm the flat sheet. V6 stated we usually use the flat sheet and incontinence brief. V7 stated we use the blanket in case, the incontinence brief leaks. On 06/02/25 at 11:18 AM, V6 stated he (R52) is being changed every 2 hours. There is no purpose of placing the folded blanket underneath him. Residents Affected - Few On 06/02/25 at 11:48 AM, R66 was lying on low air loss mattress. The low air loss mattress setting was between 320lbs and 400lbs. V6 stated the pointer (of the dial) is close to 320. I would say the low air loss mattress is set at 340lbs. This surveyor requested V6 to check how many layers between R66 and the low air loss mattress. V6 stated she has a flat sheet that is twice folded making it 4 layers, there is another flat sheet, and she is using incontinence brief. Total of 6 layers. On 06/04/2025 at 9:41am, V2 (Assistant Director Of Nursing) stated the setting of the low air loss mattress should be based on the resident's weight. It will not work as it should if setting is higher than the resident's weight because it will be hard like a board and defeats the purpose of the low air loss mattress. The resident should be layered with just a flat sheet and incontinence brief. For the same reason, multiple layers defeats the purpose of the low air loss mattress. R52's (Active Order as Of: 06/02/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) muscle waiting and atrophy, severe protein-calorie malnutrition, and hemiplegia and hemiparesis. Order summary. low air loss mattress. Active. Order Date: 01/16/2025. R52's (04/10/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem C1000. Cognitive Skills for daily decision making: 3 severely impaired. Section M - skin conditions. M1200. Skin and Ulcer/Injury Treatments. B. Pressure reducing device for bed. R52's (05/22/2025) care plan documented, in part is at risk for alteration in skin integrity due to total incontinence of bowel and bladder and impaired mobility. Will not develop any skin integrity issues. low air loss mattress check. Provide and maintain an air pressure redistribution mattress to protect the resident's skin integrity while in bed. R66's (Active Order as Of: 06/02/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) gastrostomy status, dysphagia and cognitive social or emotional deficit following cerebral infarction. Order Summary. Utilize air loss mattress. Order Date: 02/21/2025. R66's (printed on: 06/02/2025) Weight and Vitals summary documented that R66 weighed 170.8lbs on 05/06/2025. R66's (05/03/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06. Indicating R66's mental status as severely impaired. Section M - Skin Conditions. M0100. Determination of Pressure Ulcer/Injury Risk. A. Resident has a pressure ulcer/injury. M0150. Risk of Pressure Ulcers/Injuries. 1. Yes. M0210. Unhealed Pressure Ulcers/Injuries. 1. Yes. M1200. Skin and Ulcer/Injury Treatments. B. Pressure reducing device for bed. R66's (Target Date: 05/05/2025) care plan documented, in part is at moderate risk of alteration in skin integrity. Provide preventive measure including preventive mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 15 of 48 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 06/05/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm The (undated) Proactive medical products Operation Manual documented, in part INSTALLATION INSTRUCTIONS. Step 2. You may place a thin cotton sheet over the quilted mattress top cover. OPERATING INSTRUCTION. Step 5. Patients can directly lie of the mattress or cover with a sheet and tuck loosely to increase the comfort of the patient. Step 6. Determine the patient's weight and set the control knob to that weight setting on the control unit. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 16 of 48 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 06/05/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the containers of the piston syringe were labeled with the dates these were changed for 3 (R24, R55, and R66) residents and failed to ensure the containers of the distilled water used for flushing the g-tubes (gastrostomy tubes) were labeled with open date for 2 (R55 and R66) residents. These failures affected 3 (R24, R55, and R66) residents reviewed for tube feedings in the total sample of 55 residents. Findings include: On 06/02/25 at 11:48 AM, R66 had a G-Tube feeding on going with Jevity 1.5 rate of 50cc/hour. This surveyor requested V6 (Agency Licensed Practice Nurse) to check for the label on the container of the piston syringe. V6 stated it is not labeled. V6 stated the container should be labeled to know how old the piston syringe is for infection control. On 06/02/2025 at 11:49am, there was a gallon of [NAME] Choice distilled water at R66's nightstand. V6 stated we use it for flushing her g-tube. This surveyor requested V6 to check for the open date. V6 stated it is not labeled with the date it was opened. It should be labeled with the date it was opened so we know when this was opened. On 06/03/2025 at 12:59pm, V21 (Regional Nurse Consultant/Infection Preventionist) stated the piston syringe should be labeled with the date it was provided to know when it should be replaced. Inquiring about labeling and dating of gallon of distilled water use for flushing g-tube. V21 stated the expectation is anything that is opened should be labeled with the date it was opened for infection control. On 06/04/2025 at 9:43am, V2 (Assistant Director Of Nursing) stated we use piston syringe for med pass and with use, there'll be an accumulation of thick substance on the piston syringe. It is expected of staff to change the piston syringe daily and to label the container with the date it was changed so we know when it was changed for infection control. R66's (Active Order as Of: 06/02/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) gastrostomy status, dysphagia and cognitive social or emotional deficit following cerebral infarction. Enteral Feed Order. Every shift Enteral tube flush with water 300ml (milliliters) every 4 hours. Order Date: 01/31/2025. Enteral Feed Order every shift Jevity 1.5 at 50ml/hr 12hours. Order Date: 02/24/2025. R66's (05/03/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06. Indicating R66's mental status as severely impaired. Section K. Swallowing/Nutritional Status. K0520. B. Feeding tube. 3. While a resident. R66's (01/13/2025) care plan documented, in part is on G-tube due to dysphagia and is at risk for aspiration. Administer G-tube feeding/flushes as ordered. Change tubing and flushing syringe every 24H (hours) at bedtime. The (undated) enteral Feedings - Safety Precautions documented, in part Purpose: To ensure the safe administration of enteral nutrition. Preparation. 2. The facility will remain current in and follow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 17 of 48 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 06/05/2025 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 accepted best practices in enteral nutrition. Preventing contamination. 4. Administration set changes: b. Change piston syringe with administration set for enteral feeding and label with date. On 06/02/25 at 10:58 am, R24 was observed in bed awake, alert unable to communicate needs, with a feeding tube in place. Surveyor observed a feeding tube piston syringe at the bedside not labeled with a date. Surveyor brought this observation to V16 (Licensed Practical Nurse, LPN) and V16 stated that the feeding tube piston syringes are changed weekly on Sundays or as needed. V16 further explained that feeding tube piston syringes should be labeled with a date so that staff knows when the syringe needs to be change and the piston syringe does not create bacteria. On 06/04/25 at 9:38 am, V2 (Assistant Director of Nursing, ADON) stated that feeding syringes should be labeled with a date so that nurses know when the feeding syringe were placed. V2 explained if a feeding syringe does not have a date there is potential for infection control. V2 further explained that the feeding tube syringe may sometimes accumulate medication residue and should be changed daily by the floor nurse to avoid bacteria growth. R24's face sheet shows that R24 has a diagnosis which includes but not limited to gastrostomy status, dysphagia following cerebral infarction, moderate protein-calorie malnutrition, and dysphagia oropharyngeal phase. R24's Brief Interview for Mental Status (BIMS) dated 05/03/25 does not show a BIMS score and indicates that R24's memory is ok. R24's physician order sheet (POS) show active orders dated 06/03/25 shows that R24 has orders for Enteral Feed Order every 24 hours Jevity 1.5 at 45 ml (milliliters) hr (hour) times 21 hours (on at 9am and off at 6am). On 6/2/2025 at 11:25 AM surveyor observed in R55's room tube feeding syringe placed on the bedside table, not labeled, or contained. Surveyor also observed next to the syringe an enteral tube feeding adaptor, that was placed loosely on the table, not contained. On the bedside table surveyor observed an open gallon container of distilled water, no open date marked. R55's Order Summary Report dated 6/2/2025, documents diagnosis included but not limited to Gastrostomy status, Dysphagia, following cerebral infarction. R55's Order Summary Report dated 6/2/2025, documents orders for flushing G tube with 5mls of water before ad after each medication administration every shift and free water flush (FWF) 150ml via g-tube every 4 hours for hydration. On 6/4/2025 at 12:10 PM, V2 (Director of Nursing/DON) stated that tube feeding syringe should be contained in the container from the set or a plastic bag and labeled with a date opened. The container and the pistol syringe should be changed daily. The tube feeding adaptor should not be left on the table, it could get thrown away. It should stay with the patient. The distilled water container used for flushing of the tube, should be labeled, or marked with a date when opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 18 of 48 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 06/05/2025 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 Based on observation, interview, and record review, the facility failed to ensure the nasal cannula was labeled with the date changed for 1 (R26) resident; failed to follow the prescribed oxygen flow rate for 2 (R26 and R42) residents; and failed to ensure oxygen was delivered to 1 (R12) resident. These failures affected 3 (R12, R26, and R42) residents reviewed for oxygen therapy in the total sample of 55 residents. Residents Affected - Some Findings include: On 06/02/2025 at 11:41am, R12 was using a nasal cannula, the tubing was connected to a humidifier bottle via an oxygen concentrator. The humidifier bottle was filled with water. No bubbles noted in the humidifier bottle. The concentrator regulator was set at 3liters per minute. This was pointed out to V6 (Agency LPN/Licensed Practical Nurse). V6 stated she (R12) is not assigned to me. V6 checked the humidifier bottle and stated there is no bubbles because the oxygen tubing is not screwed tightly to the humidifier bottle. V6 was then observed unscrewing and screwing the oxygen tubing to the humidifier bottle with multiple attempts until bubbles appeared in the humidifier bottle. V6 stated now it is fixed. No bubbles in the humidifier bottle means no oxygen is delivered to the resident. On 06/04/2025 at 9:45am, V2 (Assistant Director Of Nursing) stated we use humidifier when we administer oxygen via an oxygen concentrator. The humidifier bottle should have bubbles to ensure oxygen is delivered to the resident. if there is no bubbles, it means no oxygen was delivered to the resident. R12's (Active Order as Of: 06/02/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) dependence on supplemental oxygen, COPD (Chronic Obstructive Pulmonary Disease), respiratory failure with hypoxia. Order Summary. Oxygen 3/lnc (liters nasal cannula) continuously. Order Date: 08/26/2024. R12's (03/07/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating R12's mental status as moderately impaired. Section O. - special treatments, Procedures, and Programs. O0110. C1. Oxygen therapy. B. While a resident. R12's (Target Date: 02/09/2025) COPD: The resident has COPD/Acute respiratory failure with hypoxia, on continuous oxygen inhalation 2-3L. via NC (nasal canula). The resident will display optimal breathing patterns daily. The (undated) Oxygen Administration documented, in part Purpose. The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure: 11. Check the humidifying jar they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. On 6/02/25 at 12:06pm, R26 was observed in the day area, across from the nurse's station, sitting up in a wheelchair with oxygen being administered at 2 liters and the oxygen tubing was not labeled. On 6/03/25 at 12:21pm, R26 was again observed in the day area, across from the nurse's station, sitting up in a wheelchair with oxygen being administered at 2 liters and the oxygen tubing was not labeled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 19 of 48 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 06/05/2025 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 R26 was unable to be interviewed due to altered mental status. Level of Harm - Minimal harm or potential for actual harm R26's face sheet documented diagnoses that include but are not limited to chronic obstructive pulmonary disease, emphysema, dependence on supplemental oxygen, and chronic respiratory failure with hypoxia. Residents Affected - Some R26's Brief Interview of Mental Status (BIMS) score, dated 4/2/25, documents, in part, a BIMS score of 00 which indicates R26's cognition is severely impaired. R26's Order Summary Report, dated 6/4/25, documents, in part, Oxygen Continuous 41iters per minute Via Nasal Cannula every shift. Oxygen Tubing: Date tubing and Change Weekly and as needed, every night shift every, Sunday change all tubing and label and date new tubing every week on Sundays. R26's care plan, date revised 3/31/25, documents, in part, Resident has 02 (oxygen) per NC (nasal cannula). On 6/04/25 at 12:01pm, V2 (Assistant Director of Nursing/ADON) said, Oxygen tubing should be changed every week and labeled with a date and time that way we (staff) know when to change it (oxygen tubing). It (oxygen tubing) needs to be changed at least weekly because boogers get in there and for infection control. I (V2) expect the oxygen to be running at the rate the physician ordered it to run. R42's Face Sheet documents a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Asthma, Respiratory Failure with Hypercapnia, Paroxysmal Atrial Fibrillation, Heart Failure, and Congestive Heart Failure. R42's Physician Order Sheet documents an active order for Oxygen at 3 Liters Per Minute Continuously with a start date of 4/24/2025. R42's Minimum Data Set Section O dated 2/21/2025 documents in part, R42 is receiving oxygen therapy. On 06/02/25 11:39 AM, surveyor observed R42's oxygen concentrator set at 4 liter per minute continuously in progress. On 06/02/25 at 11:42 AM, V12, (Licensed Practical Nurse-(LPN) affirmed V42's oxygen concentrator was set at 4 liters per minute continuously in progress. V12 verified R42 has a active physician's order for Oxygen 3 liters per minute continuously via Electronic Health Record. V12 stated nurses should follow the physician's order to prevent a resident from developing hypoxia instead of Hyperoxia. On 6/4/25 at 3:36pm, V2, (Acting Director of Nurses-(ADON) stated the nurses are responsible for assessing resident's oxygen is set according to the doctor's orders. V2 stated, nurses should assess if the residents' oxygen concentrator is set at the correct setting every time the nurse pass medication and when the nurse checks the residents' pulse oxygenation. V2 stated residents can experience retention of Carbon Dioxide, especially for residents with a diagnosis of Chronic Obstructive Pulmonary Disease. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 20 of 48 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 06/05/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based upon observation, interview, and record review the facility failed to ensure that sufficient nursing staff were available to meet the needs for one residents (R504) in the sample of 55 residents. These failures have the potential to affect all 24 residents on 2 East. Findings include: On 6/3/2025 at 12:07PM, V12 (LPN/Licensed Practical Nurse), stated that current census for the 2 East unit is 24 residents. On 06/02/25 at 11:00am, R504 was observed, in his (R504) room, sitting on the side of bed with a walker in front of him, and R504's call light was wrapped on the bedside table behind R504 not within reach of R504. Surveyor observed urine on the floor below R504 with his (R504) foot lying in the puddle of urine. R504 stated, It has been over an hour that I (R504) have been waiting for help to get to chair and get cleaned up. A nurse came in, helped me sit on the side of the bed, and said that he (nurse) would be back once he (nurse) could find another nurse to help him (nurse). I'm sorry. This is humiliating. I'm (R504) so embarrassed. R504's face sheet documents diagnoses that include but are not limited to need for assistance with personal care; muscle weakness; fall; other abnormalities of gait and mobility; unsteadiness on feet; and periprosthetic fracture around internal prosthetic left hip joint. R504's Brief Interview of Mental Status (BIMS) score, dated 5/16/25, documents, in part, a BIMS score of 15 which indicates R504 is cognitively intact. On 6/2/2025 at 11:05am, V11 (Certified Nurse's Assistant/CNA) stated, My resident's load is heavy because many of them require increased surveillance and two people assistance, and they are always short staffed. I (V11) already waited for over an hour for another CNA to help me (V11) to move the resident from bed to chair. There is only one nurse and one other CNA working this unit. I (V11) will not risk the resident falling by moving him (R504) by himself (V11). On 6/3/2025 at 12:10pm, V13 (Certified Nursing Assistant/CNA), worked at the facility for 2 years, stated that since the new management took over, there has been many changes in laundry, supplies, staffing. V13 stated that this morning there are two CNA's working and two nurses on the unit with 24 residents, but it is not the standards. It is because the agency (Illinois Department of Public Health) is in the building. Normally there would be only one nurse. The two aides must work together effectively to help residents as much as they can, but sometimes the residents will have to wait for a long time for help. It might be even longer than an hour of wait on occasion. V13 stated that the work would be much better if there were three aides and two nurses, because the units are spread into three different hallways and sometimes it's hard-to-get help. On 6/4/25 at 12:01pm, V2 (Assistant Director of Nursing/DON) said, 2 East should always have 2 nurses and 2 CNAs for at least am shift (AM: 7:00am to 7:00pm) Sometimes, it is hard to find coverage, especially when there is a call off. Sometimes, we (nurses/CNAs) work short. I (V2) have to fight with the owner to raise the hourly rate to get agency nurses to pick up shifts. Any staff can help a resident. Physical therapy, social workers. You (staff) do not have to be a nurse. An hour is too much for a resident to get assistance. Right away. Assist them (residents) right away. Waiting for an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 21 of 48 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 06/05/2025 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 0725 hour with sitting in urine would probably make a resident mad and sad. Level of Harm - Minimal harm or potential for actual harm Facility documents titled Nursing Staff Schedule, documents, in part: May 1, 2025: 1 LPN and 2 CNAs for am shift. Residents Affected - Some May 2, 2025: 1 LPN and 2 CNAs for am shift. May 3, 2025: 1 LPN and 2 CNAs for am shift. May 4, 2025: 1 LPN and 2 CNAs for am shift. May 5, 2025: 1 LPN and 2 CNAs for am shift. May 6, 2025: 1 LPN and 2 CNAs for am shift. May 8, 2025: 1 LPN and 2 CNAs for am shift. May 9, 2025: 1 LPN and 2 CNAs for am shift. May 10, 2025: 1 LPN and 2 CNAs for am shift. May 11, 2025: 1 LPN and 2 CNAs for am shift. May 12, 2025: 1 LPN and 2 CNAs for am shift. May 13, 2025: 1 LPN and 2 CNAs for am shift. May 14, 2025: 1 LPN and 2 CNAs for am shift. May 15, 2025: 1 LPN and 2 CNAs for am shift. May 16, 2025: 1 LPN and 2 CNAs for am shift. May 17, 2025: 1 LPN and 2 CNAs for am shift. May 18, 2025: 1 LPN and 2 CNAs for am shift. May 19, 2025: 1 LPN and 2 CNAs for am shift. May 20, 2025: 1 LPN and 2 CNAs for am shift. May 22, 2025: 1 LPN and 2 CNAs for am shift. May 23, 2025: 1 LPN and 2 CNAs for am shift. May 25, 2025: 1 LPN and 2 CNAs for am shift. May 26, 2025: 1 LPN and 2 CNAs for am shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 22 of 48 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 06/05/2025 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 0725 May 27, 2025: 1 LPN and 2 CNAs for am shift. Level of Harm - Minimal harm or potential for actual harm May 28, 2025: 1 LPN and 2 CNAs for am shift. May 29, 2025: 1 LPN and 2 CNAs for am shift. Residents Affected - Some May 30, 2025: 1 LPN and 2 CNAs for am shift. May 31, 2025: 1 LPN and 2 CNAs for am shift. Evidence shows that 28 days of 31 days in the month of May 2025, 2 East am shift worked short 1 nurse. Facility policy titled, Staffing, reviewed date 9/01/24, documents, in part, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment . Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Facility policy titled, Activities of Daily Living (ADLs), Supporting, reviewed date 9/01/24, documents, in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently . including . hygiene; . mobility (transfer and ambulation, including walking); elimination (toileting) . Facility policy titled, Answering the Call light, reviewed date9/1/22, documents, in part, . When the resident is in the bed . be sure the call light is within easy reach of the resident . Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike . Facility job description titled, Certified Nursing Assistant, revised date 3/24/16, documents, in part, .is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents .Provides assistance in all activities od daily living including but not limited to; personal hygiene by giving bedpans, urinals, baths, .; assisting with ambulation to the bathroom; assisting with showers and baths. Provide assistance in ambulation and movement including but not limited to; turning, and positioning residents, transferring residents from bed to chair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 23 of 48 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 06/05/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to ensure a Registered Nurse was scheduled for 8 consecutive hours daily, 7 days a week. This failure affected one (R504) resident reviewed for Registered Nurse coverage and has the potential to affect all 93 residents at the facility. Findings include: The (06/02/2025) facility census was 93. The (undated) Residents on IVABT (intravenous antibiotic) in MAY 2025 to present include R504. R504 ' s (printed: 06/05/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) infection and inflammatory reaction due to internal joint prosthesis. Status. Discontinued. Order Summary Cefazolin Sodium injection solution reconstituted 2 grams (GM), use 2000 milligram intravenously every 8 hours for prophylaxis for 7 days. Order Date: 5/24/2025. End Date: 06/01/2025. R504 (Active Order as Of: 06/05/2025) Order Summary Report documented, in part Status: Active. Cefazolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Sodium) Use 2000 mg intravenously, every 8 hours for prophylaxis for 8 Days. Order Date: 05/31/2025. End Date: 06/08/2025. Status: Active. PICC Line: Measure external length of catheter once each week. every day shift every Tue for PICC Line. Order Date: 06/03/2025. End Date: 06/10/2025. R504 ' s (05/28/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R504 ' s mental status as cognitively intact. Section O. Special Treatment, Procedures, and Programs. O0110. H1. IV medications. A. On admission and b. while a resident. H3. Antibiotics. A. On admission. R504 ' s (05/2025) Medication Administration Record documented the following: 5/25/2025 at 21:17 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/26/2025 at 06:28 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/26/2025 at 13:41 V12 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/26/2025 at 23:28 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/27/2025 at 05:32 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/27/2025 at 14:16 V12(Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/27/2025 at 04:06 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/28/2025 at 06:13 V30(Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/28/2025 at 14:15 V12 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 24 of 48 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 06/05/2025 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 0727 5/28/25 at 22:19 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously Level of Harm - Minimal harm or potential for actual harm 5/29/2025 at 05:11 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/29/2025 at 15:20 V31 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously Residents Affected - Many 5/29/2025 at 00:11 V32 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/30/2025 at 05:38 V32 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/30/2025 at 15:46 V33 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/30/2025 at 22:13 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/31/2025 at 22:00 V34 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously On 6/4/2025 review of documents titled, Department Of Financial Regulation Nursing License shows that V12, V30, V31, and V32 all have an active Licensed Practical Nurse (LPN) license which will expire January 31,2027. On 6/4/2025 review of documents titled, Nurses Quick Confirm, Quick Confirm License Verification Report shows that V33 and V34 have an active Licensed Practical Nurse license which will expire January 31, 2027. On 6/3/2025 at 9:36 am, V18 (Nursing Scheduler) stated I have two master schedules for nurses that are color coded, the blue coded schedules consist of mostly registered nurses (RN) and the yellow coded schedules has most of the LPN ' s scheduled. V18 stated currently on yellow coded schedule there are no RN 's scheduled and I (V18) am not sure why but that this is how the schedule has been since I started working on schedules, and if a nurse calls off to the nursing director, I (V18) place a call to the Agency staffing to come in and work the shift. On 06/05/2025 at 1:56pm, V20 (Registered Nurse) stated I have not monitored or supervised a Licensed Practice Nurse administer an IV (intravenous) antibiotic. On 06/05/025 at 2:21pm, V5 (Registered Nurse) stated I only work on 1East. I never work on the other floor. I have never monitored or supervised an LPN hanging an IV antibiotic for him (R504). On 6/3/2025 at 10:11 am, V2 (Assistant Director of Nursing) stated there are no LPNs in the facility that are certified to administer intravenous medications. On 06/04/2025 at 9:47am, V2 stated LPN can administer IV medications in the presence of a Registered Nurse. It is not in the scope of their practice. All our LPNs are not certified to administer IV medications. I know the regulation states that we are supposed to have an RN (Registered Nurse) coverage for 8hours daily, seven days a week. I cannot lie to you; you have a copy of our schedule and there are days we don't have an RN on our schedules. On 06/03/25 9:36 AM V18 Staffing coordinator reported that she schedules staff by teams blue or yellow, and that Licensed practical nurses are staffed on yellow team and on those days Licensed practical nurses are scheduled she does not have Registered nurses scheduled. Staff calls off to assistant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 25 of 48 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 06/05/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm director of nursing and then the assistant director then calls V18 and informs her that she needs a nurse to replace the shift, V18 states she is able to replace the shift quickly because she has prn staff who give their availability and are able to work when called. The facility nursing staff work 12 hour shifts and each unit is staffed as below. Some days there is no RN scheduled Residents Affected - Many 7am-7pm: First floor- two nurses, two nursing assistants Second floor east wing- two nurses, 2 nursing assistants Second floor west wing-two nurses, 3 nursing assistants 7pm-7am: First floor-one nurse, two nursing assistants Second floor east wing- one nurse, 2 nursing assistants Second floor west wing-two nurses, 3 nursing assistants The (05/2025) Facility Nursing Staffing indicated no Registered Nurse working in the units on May 02, 03, 04, 08, 18, 22, 27, and 31. The (06/04/2025) email correspondence with V1 (Administrator) documented, in part It is our expectation that we have RN coverage daily. The (3/25/2016) Registered Nurse (RN) Job Description documented, in part Summary: The RN is responsible for providing direct Nursing care to the residents, evaluations and OR assessments, and to supervise the day-to-day clinical care performed by other nursing staff. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility., and ask may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and responsibilities. Administer clinical care according to the standard of care and in accordance with local, state, federal and facility policies and procedures. The (09/01/2024) Staffing documented, in part Policy Statement. Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation. 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident ' s plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 26 of 48 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 06/05/2025 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 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 observations, interviews, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change; failed to ensure administration of controlled medication was documented; failed to ensure that the medication refrigerator had a temperature log sheets; and failed to ensure that staff do not store personal food items inside the medication refrigerator used for residents medication storage. These failures affected two residents (R99 and R104) and have the potential to affect all 47 residents on the 2 [NAME] unit. Findings include: On 06/02/25 the V1(Administrator) provided a facility census of 47 residents on the 2 [NAME] unit. On 06/02/25 at 11:00 am, during the controlled medication count of R104's Pregabalin 150 mg (milligrams) 150 mg capsule, surveyor and V5 (Registered Nurse, RN) observed 52 tablets left in R104's Medication Dispensing Card however, R104's Controlled Drug Record/Disposition Form's last entry was on 06/01/25 at 5:00 pm and amount of Pregabalin 150 mg was observed with 53 capsules. V5 (Registered Nurse, RN) stated, I (V5) gave one this morning. I did not sign it out yet. V5 stated that narcotic medications should be signed out when given so that the medication count can be accurate. On 06/02/25 at 12:14 pm, during the 2 [NAME] Team 1 cart narcotics count review Surveyor and V14 (Licensed Practical Nurse, LPN) observed the 2 [NAME] Narcotic Accountability sheet not signed for the on-coming nurse for June 1, 2025. V14 (LPN) stated, I don't know who should have signed there. That is not me. At 12:15 pm, Surveyor and V14 observed R99's Briviact Oral Tablet 10 mg (milligram) (Brivaracetam) Give 1 tablet by mouth two times a day for seizures 60 tablets repackaged in increments of ten inside six medication pill sleeves. V14 stated, I didn't do that. That was like that when I came. I'm not sure if we can do that (referring to the repackaging of medications for R99. I don't know who did that. On 06/02/25 at 12:17 pm, Surveyor and V14 (Licensed Practical Nurse, LPN) observed 2 [NAME] with two medication refrigerators inside of the 2 [NAME] Medication room with one medication refrigerator without a temperature log sheet and the other medication refrigerator with the facility's document dated May 2025 and titled Nursing Unit Daily Refrigerator Temperature Log posted. V14 stated that there should be a daily refrigerator log for June 2025 posted for both medication refrigerators so that the medication refrigerator can be monitored for a safe range in temperature for medication storage. V14 stated that if the medication refrigerator is not being monitored medication can possibly be stored at an unsafe temperature range. At 12:18 pm, Surveyor and V14 observed a sandwich package labeled Uncrustables in the freezer section of the 2 [NAME] medication refrigerator without a temperature log. V14 stated, That is the staffs. That should not be in there because it can grow mold and bacteria and harm the residents medication. On 06/03/25 at 10:04 am, V2 (Assistant Director of Nursing, ADON) stated that when a nurse administers a narcotic the narcotic should be signed out immediately upon administration. V2 explained that it is important for narcotic medication to be accurately signed during the narcotics count and when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 27 of 48 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 06/05/2025 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 Residents Affected - Some medications are administered so that double doses are not administered to residents and to ensure the narcotics count is accurate. V2 explained if a narcotic is not signed out there is no evidence that the resident received the medication. V2 further explained that medication should be administered from the medications original packaging. V2 stated that each medication refrigerator should have a refrigerator temperature log sheet to monitor the temperature of the medication and so that the medication will not lose its potency. R99's Physician Order Sheet (POS) dated active orders as of 06/04/25 shows that R99 has orders for Briviact Oral Tablet 10 mg (milligram) give 1 tablet by mouth two times a day for seizures. R99's Controlled Drug/Receipt/Record/Disposition Form dated received on 05/13/25 shows that R99 has Briviact Oral Tablet 10 mg (milligram) BID (twice a day) quantity received 60 tablets. R104's POS dated 05/28/25 shows that R104 has orders for Pregabalin Oral Capsule 150 MG (Pregabalin) *Controlled Drug* Give 1 capsule by mouth two times a day for Pain Take 1 capsule by mouth 2 times daily. The facility's document dated June 2025 and titled Controlled Substance Verification Sheet shows Nurses Station: 2 [NAME] Team with missing signatures for June 1, 2025 on the 7:00 am -7:00 pm on coming shift. The facility's documented dated received 05/29/25 and titled Controlled Drug Record shows that R104 has 53 tablets of Pregabalin 150 mg (milligrams)150 mg capsule left to dispense however, Surveyor and V5 (Registered Nurse, RN) observed R104's medication dispensing card for Pregabalin 150 mg (milligrams)150 mg capsule with 52 tablets left to dispense. The facility's undated policy titled Controlled Substances documents, in part: Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation: .8. 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift . 9. Upon Receipt: . b. Both individuals sign the controlled substance record of receipt . 10. Upon Administration: a. The nurse administering the medication is responsible for recording: (1) name of the resident receiving the medication; (2) name, strength, and dose of the medication; (3) time of administration; (4) method of administration; (5) quantity of the medication remaining; and (6) signature of nurse administering medication . 12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. The facility's undated policy titled Storage of Medications documents, in part: Policy heading: The facility stores all drugs and biological in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 2. Drugs and biological's are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 28 of 48 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 06/05/2025 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 The facility's undated policy titled Labeling of Medications Containers documents, in part: Policy Statement: All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. Policy Interpretation and Implementation: 3. Labels for individual resident medications include all necessary information, such as: a. the resident's name . h. the expiration date when applicable. Residents Affected - Some The facility's undated policy titled Refrigerator and Freezers documents, in part: Policy Statement: The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines . 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 29 of 48 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 06/05/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based upon observation, interview, and record review the facility failed to ensure that one resident (R504) reviewed for medication administration remained free from significant medication errors in a sample of 55 residents. Residents Affected - Few Findings include: On 06/02/25 at 11:00am, R504 was observed, in his (R504) room, sitting on the side of bed with a walker in front of him. Also observed in R504's room, a full bag of IV (intravenous) Cefazolin Solution 2gm (gram) bag, on IV pole with primed tubing, not connected to resident. R504 stated that he (R504) is not sure if he (R504) received the antibiotic in the morning, he (R504) was sleeping. R504 stated that few times the nurses just come to connect IV antibiotic while he (R504) sleeps. Observed IV Access on right upper arm (PICC or Central Line) with gauze sleeve around the site. R504 stated that R504 did not refuse the antibiotic. R504's face sheet documents medical diagnoses that include but are not limited to infection and inflammatory reaction due to unspecified internal joint prosthesis. R504's active physician orders documents, in part, PICC (peripherally inserted central catheter) Line: Observe site for S/S (signs and symptoms) of infection or infiltration every shift for PICC Line; Sterile dressing change to PICC LINE once each week and prn; and Cefazolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Sodium) Use 2000 mg intravenously every 8 hours for prophylaxis for 8 Days. On 6/2/2022 at 12:32 PM, V12 (Licensed Practice Nurse/LPN), stated that R504's dose of Cefazolin Sodium was supposed to be hung at six in the morning. Usually, the outgoing nurse (pm shift) will give report to the ongoing nurse if medication was held. V12 did not receive report handoff this morning and checked R504's EMR (electronic medication record). V12 stated that six am dose was not given and that the reason for not given antibiotic documented. V12 also stated that the antibiotic should be refrigerated, and that the pharmacy would bring it out when called prior administration. At 12:33 PM in resident's room V12 affirmed, that there was a full IV bag of Cefazolin hanging on the IV pole and there was a two pm dose in the refrigerator. V12 stated that the physician should be notified about missed dose of antibiotic and will call and place a progress note in the computer. Upon review of R504's EMR, in regard to R504's IV medication Cefazolin that was due for 6:00am, there was no documentation as to the reason the medication was not given. R504's progress note, dated 6/03/25 at 12:06pm, documents, in part, md (medical doctor) aware of dose missed (Cafazolin ABT) and replied back, no orders now. On 6/4/25 at 10:55am, V21 (Infection Preventionist/IP) said that V21 spoke with R504 and R504 stated to V21 that R504 did not refuse the 6:00am dose of Cefazolin antibiotic. V21 said that V21 has attempted to contact the nurse that should have given R504's antibiotic but has been unable to reach the nurse. V21 affirmed that R504 is receiving to antibiotic prophylactically to prevent infection. Facility policy titled, Administering Medications, reviewed date 9/01/24, documents, in part, Medications are administered in a safe and timely manner, and as prescribed . Staffing schedules are arranged to ensure the medications are administered in accordance with prescriber orders, including any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 30 of 48 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 06/05/2025 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 0760 required time frame. 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 31 of 48 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 06/05/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure foods were stored and labeled according to standards, failed to monitor refrigerator, freezer, and cooler temperatures daily; and failed to maintain dishwashing sanitizing water concentrations. This failure has the potential to affect all 93 residents residing at the facility. Findings include: On 6/2/2025 at 10:03 am, during the initial tour of the kitchen, the following was identifed: the refrigerator, freezer, cooler lacked June temperature logs. May temperature logs were taped to the refrigerator, freezer, and cooler with several missing temperature checks. All foods in the refrigerator, cooler, and freezer lacked open and expiration dates, except potentially hazardous foods in particular; Tuna Fish, [NAME] Slaw Salad Dressing, Cottage Cheese, and Bacon with past due expiration dates. Ice cream freezer lacked monthly temperature tracking sheet. On 6/2/2025 at 10:26 am, surveyor observed Low Fat Cottage Cheese dated 5/15/2025. V3, (Dietary Manager-(DM) stated the date on the Low-Fat Cottage Cheese is the opening date. V3 stated when the dietary department receives a food delivery, the receiving date is applied to each food item. V3 stated, I will throw away the cottage cheese dated 5/15/2025 out. V3 stated residents can get sick from outdated perishable foods. On 6/2/2025 at 10:29 am, surveyor and V3 observed a box of bacon in a plastic bag unsealed and open to air. The bacon contained no open or expiration date. On 6/2/2025 at 10:31am, Surveyor and V3 observed a container labeled Tuna Salad with a date of 5/25/2025. Surveyor and V3 observed a large jar of [NAME] Slaw Salad Dressing with receiving date of 10/30/24. V3 affirmed bacon in plastic bag open to air, tuna salad with written date of 5/25/25, and [NAME] slaw salad dressing with a receiving date of 10/30/2024. V3 stated , I just started here, and I haven't had a chance to inspect the entire kitchen. V3 stated residents can get food poisoning from outdated meat, tuna, and salad dressing. Facility Policy titled Food Receiving and Storage with a revised date of October 2017 documents in part: Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready to eat foods. On 6/4/2025 at 9:44 am, V27, (Cook) conducted a critical control points test on the sanitation bucket 1 at the 3-compartment sink. V27 affirmed the results was 300 ppm. V27 stated the critical control points range is 200ppm. V27 stated when the results is out of range, the dishes aren't clean and is not safe. On 6/4/2025 at 9:51 am, V26, (Dishwasher) performed a critical control points test on the sanitation bucket stored by the dishwashing machine. V26 stated the sanitation bucket is used to sanitize the silverware. V26 performed a critical control points test on the sanitation bucket stored on the dishwasher and the results were 100 ppm. V26 stated the critical control points normal range is 200ppm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 32 of 48 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 06/05/2025 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 to 300ppm. V26 stated the critical control points test is performed on the sanitation buckets to make sure the silverware are clean to prevent residents from getting sick. Facility Policy titled Food Receiving and Storage with a revised date of October 2017 documents in part, Foods shall be received and stored in a manner that complies with safe food handling practices and All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Facility Policy titled Refrigerators and Freezers with a revised date of September 20, 2024 documents in part: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 2. Monthly tracking sheets will include time, temperature, initials, and action taken. The last column will be completed only if temperatures are not acceptable. 3. Food Service supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. Facility Policy titled Preventing Foodborne Illness-Food Handling with a last reviewed date of 9/1/24 documents in part: I. Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. II. This facility recognizes that the critical factors implicated in foodborne illness are: a. Contaminated equipment b. Unsafe food sources III. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 33 of 48 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 06/05/2025 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 With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 34 of 48 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 06/05/2025 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 maintain garbage waste with a closed lid to prevent pest infestation and foul odor. This failure affects all 93 residents residing in the facility. Residents Affected - Many Findings include: Facility's Census dated 6/2/2025 documents 93 residents are residing in the facility. On 6/2/2025 at 11:04am, a garbage can stored near the dry storage room was observed without a lid giving off a foul smell and several small black insects flying around the opening. On 6/2/2025 at 11:06 am, V3, (Dietary Manager-(DM) stated, this has been a problem since I started working here, this is fruit fly central. V3 affirmed the garbage can had a foul odor, did not have a lid on it was filled with garbage and black insects flying in and around the garbage can. V3 stated pest control treated the kitchen for fruit flies 3 weeks ago. Facility Policy titled Waste Disposal with a reviewed date of September 1, 20124 documents in part, All infectious and regulated waste destined for disposal shall be placed in closable leak-proof containers or bags that are color-coded or labeled as herein described. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 35 of 48 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 06/05/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a thorough and accurate facility assessment. This failure has the potential to affect all 93 residents that reside within the facility. Findings include: Record review of facility census documentation provided on 6/2/2025 documents in part that 93 residents reside within the facility. Record review of the document titled Facility Assessment Tool for [NAME] House 6/2024 though 7/2025 documents in part the following: A) no resident/resident family member input in the completion of the facility assessment B) no direct care staff input in the completion of the facility assessment c) no specific staffing needs based on shift and unit D) no plan developed/maintained to maximize recruitment/retention of staff E) no Informed contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care F) Describe your plan to recruit and retain enough medical practitioners (e.g., physicians, nurse practitioners) who are adequately trained and knowledgeable in the care of your residents/patients, including how you will collaborate with them to ensure that the facility has appropriate medical practices for the needs and scope of your population. - This section is left blank G) Describe how the management and staff familiarize themselves with what they should expect from medical practitioners and other healthcare professionals related to standards of care and competencies that are necessary to provide the level and types of support and care needed for your resident population. For example, do you share expectations for providers that see residents in your nursing home on the use of standards, protocols, or other information developed by your medical director? Do you have discussions on what providers and staff expect of each other in terms of the care delivery process and clinical reasoning essential to providing high quality care? - This section is left blank. H) List (or refer to or provide a link to inventory) physical resources for the following categories. Review the resources in the example below and modify as needed. If applicable, describe your processes to ensure adequate supplies and to ensure equipment is maintained to protect and promote the health and safety of residents- This section does not indicate the process to ensure adequate supply, appropriate maintenance, replacement as applicable I) List health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. Consider including a description of a) how the facility will securely transfer health information to a hospital, home health agency, or other providers for any resident transferred or discharged from the facility; b) how downtime procedures are developed and implemented; and c) how the facility ensures that residents and their representative can access their records upon request and obtain copies within required timeframes. - This section is left blank. J) Describe how you evaluate if your infection prevention and control program includes effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, that follow accepted national standards. This section is left blank. K) .The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 36 of 48 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 06/05/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require . On 6/4/2025 at 3:37 PM, V1 (Administrator) affirmed that V1 completed the facility assessment with V21 (Infection Preventionist, Registered Nurse, Nurse Consultant), V2 (Assistant Director of Nursing) and the governing body of the facility. V1 denied that input was obtained by residents and families when completing the facility assessment, and added, other facilities I have worked with have done that. Facility assessment was reviewed with V1 and V1 affirmed that there is no contingency staffing plan or a system for recruitment/retention of the facility within the facility assessment. When asked why sections of the facility assessment was not completed or left blank, V1 replied, it is because those sections are not required. V1 affirmed that the purpose of the facility assessment is to analyze and identify the overall needs of the facility, its staff/residents and to address the identified needs. Event ID: Facility ID: 145767 If continuation sheet Page 37 of 48 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 06/05/2025 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 On 06/02/25 at 11:17 am, R86 was observed in bed awake and alert with feeding tube feeding in place running at 40 ml (milliliter) per hour and wound care dressing to R86's left ischium and sacral region. R86's door did not have an Enhanced Barrier Precaution (EBP) sign on R86's door or wall outside of R86's room. Residents Affected - Many On 06/02/25 at 11:22 am, V16 (Licensed Practical Nurse, LPN) stated that residents with feeding tubes and wounds should have EBP signs on the residents door. V16 stated that if a resident who requires EBP does not have a EBP sign on the residents door then staff will not know to wear Personal Protective Equipment (PPE) (gown and gloves) when providing care to the resident and can transmit bacteria to residents and staff. V16 stated, I (V16) thought she (R86) had a sign on her (R86) door. On 06/03/25 at 12:57 pm, V21 (Infection Preventionist, IP) stated residents tube feedings, indwelling catheters, receiving dialysis and residents with wounds require Enhanced Barrier Precautions (EBP) to prevent the staff from passing Multi Drug Resistant Organisms (MDRO's) and bacteria to other staff and residents. V21 stated that residents who require EBP, the staff should be wearing gown and gloves when performing high contact resident care. R86 has a diagnosis which includes but not limited to gastrostomy status, and dysphagia oropharyngeal phase. R86 has a Brief Interview for Mental Status (BIMS) dated 05/19/25 a BIMS score of 2 which indicates that R86 has some cognitive impairments. R86's Physician Order Sheet shows active orders as of 06/03/25 shows orders for Enhanced Barrier Precautions for wound care. Gloves and gown to be worn during wound care and prolonged contact activity. R86 Enteral Feed Order every 4 hours flush 140 ml Q4 (every four). Enteral Feed Order every shift (enteral) flush feeding tube with 20-30 ml (milliliter) of water before and after medication administration . Site: Left Ischium cleanse with NSS (Normal Saline Solution) apply /cover with Ca+ (calcium alginate) silver, cover with bordered foam dressing as needed for wound care. Site Sacral cleanse with NSS APPLY Bordered foam dressing as needed for wound care. The facility's document dated 06/02/25 shows a list of residents in the facility who require EBP and that R86 requires Enhanced Barrier Precautions at the facility. The facility's undated policy titled Enhanced Barrier Precautions documents in part: Policy Statement: Enhanced Barrier Precautions are used in the care for residents with wounds requiring dressings or indwelling medical devices and successfully admit and care for those residents with XDRO (Multi drug resistant organism, MDRO) or epidemiologically important MDRO . 2. Enhanced Barrier Precautions is to be implemented in conjunction with Standard Precautions . 4. Evidence Based Precautions will be implemented for residents with wounds that requiring dressing changes (e.g. (example) pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and only when the wound drainage is contained. 5. Evidenced Based Precautions will be implemented for residents with indwelling devices. Based on observation, interview, and record review the facility failed to perform hand hygiene in between residents while passing food trays for 4 residents (R21, R42, R48, and R77); failed to ensure a resident (R86) with an indwelling catheter and wounds was placed on Enhanced Barrier Precautions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 38 of 48 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 06/05/2025 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 (EBP); failed to provide easily accessible areas/supplies to perform proper hand hygiene on 2 East; and failed to properly bag and secure soiled linen that is put down the laundry chute. These failures have the potential to affect R21, R39, R42, R48, R77, R86; all 24 residents residing on 2 East; and all 93 residents residing at the facility reviewed for infection control. Residents Affected - Many Findings include: On 6/02/25, V1 (Administrator) stated that there are total of 93 active residents residing at the facility. On 6/2/2025 at 11:20am, with V11(CNA/Certified Nursing Assistant), during observation of the soiled utility room on 2 East, surveyor and V11 observed a brown substance on the walls of the laundry chute. V11(CNA/Certified Nursing Assistant) stated, that soiled linens get thrown into a laundry chute without being put in a plastic bag. On 6/3/2025 at 10:44am, V21 (Infection Preventionist/IP) stated, Soiled linen gets bagged and sent down a laundry chute in the dirty utility room. All resident's laundry bins should have a bag in them. Soiled linen is bagged and contained to prevent the spread of infection. On 6/3/2025 at 11:47am, while in the Facility's Laundry room with V22 (Laundry Aide), an opened bag of visibly soiled linen was on the floor under the laundry chute with multiple articles of visibly soiled linen on top of the bag not contained. V22 said, The linen should come down the chute in a bag. Sometimes the bag gets caught on this (V22 pointed to a metal piece at the end of the laundry chute) and rips open. Sometimes linen comes down the chute without a bag but most of the time the linen is bagged. Facility policy titled, Departmental (Environmental Services) - Laundry and Linen, reviewed date 9/01/24, documents, in part, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . Consider all soiled linen to be potentially infectious and handle with standard operations . If laundry chutes are used, only closed and leak resistant bags will be put into the chute. Loose items will not be placed in the laundry chute . Facility policy titled, Laundry and bedding, soiled, reviewed date 9/01/24, documents, in part, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control . all used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing .Contaminated laundry is placed in a bag or container at the location where it is used . Facility policy titled, Infection Prevention and Control Program, reviewed date 9/1/24, documents, in part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . instituting measures to avoid complications and dissemination; educating staff and ensuring that they adhere to proper techniques and procedures. On 6/2/2025 at 12:07 p.m, V13, a Certified Nursing Assistant (CNA), was passing residents' lunch trays in the hallway. V13 pulled a lunch tray from the dietary cart and headed toward R77's room. After exiting R77's room, V13 removed her hair from her face while walking down the hallway, then took the lemonade pitcher from the cart and began pouring lemonade into a cup, without using hand sanitizer. There were no hand sanitizer dispensers available in the hallway of the unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 39 of 48 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 06/05/2025 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 V13 then rolled the dietary cart down the hall and removed another lunch tray, and placed it on R42's bedside table. V13 opened food items on R42's tray but exited the room without performing hand hygiene. V13 then took another tray from the cart and proceeded to R48's room, placing the tray on R48's bedside table. Again, V13 removed her hair from her face in the hallway, took another tray from the cart, and handed it to another staff member in the dining room. Residents Affected - Many V13 pushed the dietary cart down the hall without using hand sanitizer. V13, removed R21's from the dietary cart and placed the lunch tray on R21's bedside table. V13 did not practice hand hygiene after delivering the lunch tray to R21. On 6/2/2025 at 12:23pm, V13 stated I wash my hands after I pass the trays. V13 was asked if V13 uses hand sanitizer when passing trays. V13 stated I used hand hygiene. V13 was made aware V13 was observed passing several residents trays without using hand sanitizer. V13 stated hand hygiene is used to prevent infection. On 6/3/2025 at 12:07PM, V12 (Licensed Practical Nurse/LPN), stated that current census for the 2 East unit is 24 residents. On 6/2/2025 at 10:55am, surveyor observed no hand sanitizer: on or in any of the PPE (personal protective equipment) bins outside resident's room, on the walls in the hallway, on the 2 East Unit nurse's station, or in the resident's room. On 6/2/2025 at 11:05am V11 (Certified Nurse's Assistant/CNA) stated that the facility does not provide them with enough hand sanitizers, usually only one bottle placed at the nurse's station and the facility also tends to be out of hand soaps in the resident's bathrooms often. On 6/3/2025 at 10:44 AM, V21 (Infection Preventionist/IP) stated that hand hygiene is an ongoing project, facility has monthly meeting and IP is part of morning clinical huddles. Expectation for staff is to use hand gel sanitizer or soap and water, and wash hands between residents. Hand gel sanitizers should be on the PPE carts, and at nurse's station, and the smaller pocket size bottles should be available for the staff to carry in pockets. V21 said that hand sand sanitizer and hand hygiene stations should be readily accessible for the employees and visitors to prevent the spread of infection. On 6/3/2025 at 12:10pm, V13 (Certified Nurse's Assistant/CNA), stated that the facility does supply hand sanitizer but is only one small bottle per nursing station that is located so far from the end rooms, that the hand washing is harder to do. The facility does not provide hand sanitizers inside the PPE carts nor pocket size for employees to carry with them. On 6/4/2025 at 12:15pm, V2 (Assistant Director of Nursing/ADON) stated that hand sanitizing gel should be provided by the facility when needed, but sometimes when ordered, the supplies are not received. Occasionally the staff will have to purchase hand sanitizing gel themselves in the store nearby. V2 stated that the facility used to carry hand sanitizers on the walls of the facility but were removed due to malfunction and breakage. V2 stated that there is usually one bottle of hand sanitizing gel in the nursing station, and the staff can wash the hands in the washroom. V2 affirmed that sometimes it is very inconvenient to not have the ability to have handwashing supplies nearby and it makes it more challenging for staff to perform hand hygiene if they need to perform care in rooms on the far end of the hallways. V2 stated that the lack of supply could lead to spread in infection due to staff not washing their hands as often. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 40 of 48 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 06/05/2025 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 - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Facility policy titled, Handwashing/Hand Hygiene, reviewed date 9/1/24, documents, in part, Policy statement . to prevent the spread of infection . importance of hand hygiene in preventing the transmission of health-care associated infections . hand hygiene products and supplies (sink, soap, towels, alcohol based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . the following equipment and supplies are necessary for hand hygiene: alcohol-based hand rub containing at least 62% alcohol; . Soap . Event ID: Facility ID: 145767 If continuation sheet Page 41 of 48 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 06/05/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interviews and record reviews, the facility failed to clean the lint screens thoroughly, to provide a safe environment for the residents of the facility. This failure has the potential to affect all 93 residents living at the facility. Findings include: On 6/2/2025 the Census sheet provided by the facility showed 93 residents living in the facility. On 6/3/2025 at 11: 50 AM a tour of facility's Laundry room was completed with V22 (laundry aide) and follow observations were noted: Dryer #1 had copious amount of white fluffy lint on the floor, underneath the filter trap. The filter was bulging and overfilled with lint. Dryer #2 had also overfilled lint trap and some white fluffy lint on the floor underneath the trap. Dryer # 3 was not in use and out of order, but it did contain a full lint trap. Dryer #4 lint filter was overfilled with lint and bulging, and white fuzzy lint was on the floor underneath the lint trap. On 6/3/2025 at 11:55 AM V22 stated, that the lint traps should be cleaned twice on his shift at 11 AM and 2PM and again, when the next laundry aide comes and cleans the traps around 5pm. V22 stated that V22 did not get chance to clean the lint traps today. V22 affirmed that cleaning of the lint traps under the dryers is important, so clothes would dry better and because the trapped lint could be a potential hazard for a fire. 6/4/2025 at 14:20 PM V24 (Maintenance Director), stated that V24 is responsible for maintaining and supervision of laundry machines working properly. The laundry aides are responsible for cleaning the dryer's lint traps and V24 provides education and training for them. V24 stated that the lint traps should be cleaned daily at 11am and 2pm by the day shift and 8pm by the evening shift laundry aide. The cleaning of the lint tramps is important because the accumulation of the lint could potentially cause a fire and put the whole facility and all residents in danger. Also, empty lint trap helps with proficiency and effective drying of laundry. On 6/5/2025 at 11:13 AM V1 (Administrator) in the email stated that all equipment are covered under our maintenance policy as provided. Facility's Laundry Aide Job Description documents in part that, the laundry aide is responsible for ensuring that all resident linens and facility laundry are properly cleaned, sanitized, folded, and returned in a timely and efficient manner. The document shows in part that the aide is responsible for operating washers, dryers, and other laundry equipment according to manufacturer instructions and maintain laundry area cleanliness and report equipment malfunctions. Facility's Administrator Job Description documents in part that Administrator should ensure that all facility personnel, follow established safety regulations such as fire protection/prevention, smoking regulations, infection control etc. Administrator ensures that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such deities/services Facility's policy titled Maintenance Services, revised April 01,2020, showed in part that purpose of maintenance services is to protect the health and safety of residents, visitors, and facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 42 of 48 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 06/05/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm staff. Policy also stated that the maintenance department maintains all areas of the building, grounds, and equipment. The policy further stated in part, that the Director of Maintenance is responsible for conducting regular inspections that may include but are not limited to laundry. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 43 of 48 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 06/05/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain an effective pest control that eliminated black flying insects in the kitchen. This failure has the potential to affect all 93 residents in the facility. Residents Affected - Many Findings include: On 6/2/2025 at 11:04am, a garbage can stored near the dry storage room was observed without a lid giving off a foul smell and several small black insects flying around the opening. On 6/2/2025 at 11:06 am, V3, (Dietary Manager-(DM) stated, this has been a problem since I started working here, this is fruit fly central. V3 affirmed the garbage can had a foul odor, did not have a lid on it was filled with garbage and black insects flying in and around the garbage can. V3 stated pest control treated the kitchen for fruit flies 3 weeks ago. On 6/4/2025 at 12:14 pm, V1 (Administrator) stated the Facility's Maintenance Director is responsible for pest control. V1 stated V1 was not aware of a pest control problem in the kitchen until yesterday when it was brought to his attention by the Dietary Manager. V1 stated V1 provided the pest control reports to the survey team. V1 stated V1 was not aware. V1 stated pest control services are provided to the facility once a week for preventive measures. On 6/4/2025 at 1:26pm V24 (Maintenance Director) stated pest control comes out every 2 weeks or twice a month on a regular basis regardless of if there is a pest control problem within the facility. V24 stated no one has brought it to his attention regarding fruit flies in the kitchen. V24 stated V24 noticed some fruit flies primarily in the dish room but no one has brought it to V24's attention of sightings of fruit flies anywhere else in the building. V24 stated I know that fruit flies are annoying and are a nuisance. V24 stated V24 honestly don't know how long the fruit flies has been a problem here. V24 stated V24 thinks the facility probably needs to be a little more aggressive treating the fruit flies. Facility's Pest Control Service Inspection Report from Sentry Pest Control does not document any treatment for fruit flies, gnats, or any flying black insects on the following preventive service dates: 1/17/2025, 1/23/2025, 2/5/2025, 2/21/2025, 3/6/2025, 3/10/2025, 4/16/2025, 4/30/2025, 5/12/2025, and 5/27/2025. Facility's Policy titled Pest Control with a revision date of April 1, 2020, documents in part, The facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 44 of 48 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 06/05/2025 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 0941 Level of Harm - Minimal harm or potential for actual harm Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on interview and record review, the facility failed to provide communication training to the staff. This failure affects 1 resident (R354) out of 55 residents in the sample. Residents Affected - Few Findings include: Record review of facility census documentation provided on 6/2/2025 documents in part that 93 residents reside within the facility. Review of R354's minimum data set (4/7/25) documents in part that R354's primary language is Chinese and requires an interpreter for communication. On 6/2/2025 at 11:40 AM, V29 (R354's Family Member) stated that R354 has difficulty communicating and that English is not R354's first language. V29 explained that it is hard for the staff to communicate with (R354), so I have to be here-I am here every day as much as I can be. None of them speak the language, we speak Chinese. I am the interpreter to ensure (R354) gets the care (R354) needs. On 6/4/2025 at 10:39 AM, surveyor requested documentation for staff training on communication. On 6/4/2025 at 1:39 PM, V1 (Administrator) provided surveyor with 2 binders labeled In-services 2025 and In-services 2024 and stated, all of our in-services are within that binder, if we in-serviced on it, it would be in there. Record review of in-servicing binders for 2024 and 2025 was completed and no training related to communication was observed completed for staff. On 6/4/2025 at 3:37 PM, V1 (Administrator) affirmed there is no further documentation that the facility can produce related to communication training. V21 (Infection Preventionist, Registered Nurse, Nurse Consultant) stated that V21 is the nurse consultant and provides multi-facility oversight. V21 stated that the facility might have documentation in the director of nursing's office. Surveyor observed V21 and V2 (Assistant Director of Nursing) search the office and V21 stated, we don't have any other documentation. V21 denied that there is a training schedule for required in-services and stated, we are currently working on that. On 6/5/2025 at 10:21 AM, V21 affirmed that there was no further documentation that the facility could produce regarding communication training. V21 explained, Communication training is important so that staff know how to speak with the residents verbally and non-verbally. We have residents and staff with a wide variety of cognitive needs, communication impairments and cultural backgrounds. Communication varies from culture to culture. In some cultures, it is normal for them to talk loudly and more shrill, while other cultures might be offended or scared by their tone. No further documentation was provided related to communication in-services prior to the exit of the survey. Record review of facility assessment (6/24 through 7/25) does not identify a training need for communication training. Record review of job description titled Certified Nursing Assistant documents in part Essential Duties and Responsibilities: . Involved in yearly mandated education according to local, state and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 45 of 48 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 06/05/2025 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 0941 federal laws . 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 46 of 48 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 06/05/2025 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interview and record review, the facility failed to provide QAPI (Quality Assurance Performance Improvement) training to the staff. This failure has the potential to affect all 93 residents that reside within the facility. Findings include: On 6/4/2025 at 10:39 AM, surveyor requested documentation for staff training on QAPI. On 6/4/2025 at 1:39 PM, V1 (Administrator) provided surveyor with 2 binders labeled In-services 2025 and In-services 2024 and stated, all of our in-services are within that binder, if we in-serviced on it, it would be in there. Record review of in-servicing binders for 2024 and 2025 was completed and no training related to QAPI was observed completed for staff. On 6/4/2025 at 3:37 PM, V1 (Administrator) affirmed there is no further documentation that the facility can produce related to QAPI training. V1 stated that direct care staff do not get trained on QAPI but if they have a concern, they can tell their supervisor and they can bring it to the QAPI committee. V1 stated that the direct care staff would not know how to submit things to the QAPI committee because our chain of command is to tell the supervisor. V21 (Infection Preventionist, Registered Nurse, Nurse Consultant) stated that V21 is the nurse consultant and provides multi-facility oversight. V21 stated that the facility might have documentation of QAPI training in the director of nursing's office. Surveyor observed V21 and V2 (Assistant Director of Nursing) search the office and V21 stated, we don't have any other documentation. V21 denied that there is a training schedule for required in-services and stated, we are currently working on that. On 6/5/2025 at 10:21 AM, V21 affirmed that there was no further documentation that the facility could produce regarding QAPI training. V21 explained, The purpose of QAPI is to analyze our facility systems/processes and improve or fix them if appropriate. QAPI is a driving force for improving care and the direct care staff should be involved too. Direct care staff know a lot more about system processes and what is working or what is not working. They would also be responsible for driving the needed change identified within the QAPI committee. No further documentation was provided related to QAPI in-services prior to the exit of the survey. Record review of facility assessment (6/24 through 7/25) does not identify a training need for QAPI training. Record review of job description titled Certified Nursing Assistant documents in part Essential Duties and Responsibilities: . Involved in yearly mandated education according to local, state and federal laws . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 47 of 48 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 06/05/2025 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 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide compliance and ethics training to the staff. This failure affects has the potential to affect all 93 residents that reside within the facility. Residents Affected - Many Findings include: On 6/4/2025 at 10:39 AM, surveyor requested documentation for staff training on compliance and ethics. On 6/4/2025 at 1:39 PM, V1 (Administrator) provided surveyor with 2 binders labeled In-services 2025 and In-services 2024 and stated, all of our in-services are within that binder, if we in-serviced on it, it would be in there. Record review of in-servicing binders for 2024 and 2025 was completed and no training related to compliance/ethics was observed completed for staff. On 6/4/2025 at 3:37 PM, V1 (Administrator) affirmed there is no further documentation that the facility can produce related to compliance or ethics. V1 produced a binder labeled compliance and ethics program and affirmed that the facility does have a compliance and ethics program. V21 (Infection Preventionist, Registered Nurse, Nurse Consultant) stated that V21 is the nurse consultant and provides multi-facility oversight (4 facilities). V21 stated that the facility might have documentation (on ethics or compliance) in the director of nursing's office. Surveyor observed V21 and V2 (Assistant Director of Nursing) search the office and V21 stated, we don't have any other documentation. V21 denied that there is a training schedule for required in-services and stated, we are currently working on that. On 6/5/2025 at 10:21 AM, V21 affirmed that there was no further documentation that the facility could produce regarding compliance/ethics training. V21 explained, In our company, we have a compliance and ethics program for our staff members. Any staff member can call a hotline to our company and report ethical concerns. It could be things like not following regulations or other ethical issues like accepting bribes or tips. It is important because we can become aware of issues that affect the resident's care and staff need to know that they can report ethical issues without fear of retailation. If they don't report it, the issues could continue. No further documentation was provided related to compliance/ethics in-services prior to the exit of the survey. Record review of facility assessment (6/24 through 7/25) does not identify a training need for compliance and ethics training. Record review of job description titled Certified Nursing Assistant documents in part Essential Duties and Responsibilities: . Involved in yearly mandated education according to local, state and federal laws . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145767 If continuation sheet Page 48 of 48

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Citations

48 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0584GeneralS&S Fpotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0640GeneralS&S Dpotential for harm
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
0657GeneralS&S Epotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0677SeriousS&S Gactual harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
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.
0695GeneralS&S Epotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0725GeneralS&S Epotential for harm
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
0727GeneralS&S Fpotential for harm
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0814GeneralS&S Fpotential for harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0838GeneralS&S Fpotential for harm
F838 - Facility assessment
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0921GeneralS&S Fpotential for harm
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
0925GeneralS&S Fpotential for harm
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
0941GeneralS&S Dpotential for harm
F941 - Training Requirements
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
0944GeneralS&S Fpotential for harm
F944 - Quality assurance and performance improvement
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
0946GeneralS&S Fpotential for harm
F946 - Compliance and ethics
Provide training in compliance and ethics.
0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
0131GeneralS&S Epotential for harm
Meet requirements for sections of health care facilities separated by fire resistive construction.
0223GeneralS&S Dpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
0293GeneralS&S Fpotential for harm
Have properly located and lighted "Exit" signs.
0311GeneralS&S Epotential for harm
Have an enclosure around a vertical opening shaft.
0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
0541GeneralS&S Epotential for harm
Install properly constructed and protected linen or trash chutes.
0712GeneralS&S Fpotential for harm
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
0761GeneralS&S Fpotential for harm
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
0781GeneralS&S Epotential for harm
Have restrictions on the use of portable space heaters.
0918GeneralS&S Fpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0920GeneralS&S Epotential for harm
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
0923GeneralS&S Epotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
0926GeneralS&S Fpotential for harm
F926 - Establish policies, in accordance with applicable Federal, State, and
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

FAQ · About this visit

Common questions about this visit

What happened during the June 5, 2025 survey of PAUL HOUSE & HEALTH CR CTR?

This was a inspection survey of PAUL HOUSE & HEALTH CR CTR on June 5, 2025. The surveyor cited 48 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at PAUL HOUSE & HEALTH CR CTR on June 5, 2025?

Yes, 48 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 1, 2026. If you believe any information is inaccurate, report it here.

Inspection·June 5, 2025