Health inspection·October 20, 2023

F 0550 the 2nd unit dining room. Level of Harm - Minimal harm or potential for actual harm On 10/17/23 at 11:54 AM, observed V12 pick up R42's utensil, place utensil into R42's food and brought utensil to R42's mouth and R42 accepted the food from the utensil. V12 then put R42's utensil down on the table and turned toward R68, away from R42. R42 made no attempt to feed herself. Residents Affected - Some On 10/17/23 at 11:56 AM, observed V12 pick up R68's utensil, place utensil into R68's food and brought utensil to R68's mouth. Observed R68 accept the food. R68 made no attempt to feed self. V12 then put R68's utensil down on the table and turned toward R42, away from R68. On 0/17/23 at 11:57 AM, observed V12 pick up R42's utensil, place utensil into R42's food and brought utensil to R42's mouth. Observed R42 accept the food from the utensil. V12 then put R42's utensil down on the table and picked up R42's water glass and brought it to R42's mouth. Afterwards, V12 turned back toward R68, away from R42. On 10/17/23 at 11:58 AM, observed V12 pick up R68's utensil, place utensil into R68's food and brought utensil to R68's mouth. Observed R68 accept the food. V12 then put R68's utensil down on the table and turned toward R42, away from R68. R68 made no attempt to feed herself. On 10/17/23 at 12:02 PM, observed V12 pick up R42's utensil, place utensil into R42's food and brought utensil to R42's mouth. Observed R42 accept the food. V12 then put R42's utensil down on the table and turned toward R68, away from R42. R42 made no attempt to feed herself. On 10/17/23 at 12:03 PM, observed V12 pick up R68's utensil, place utensil into R68's food and brought utensil to R68's mouth. Observed R68 accept the food. V12 then put R68's utensil down on the table and turned toward R42, away from R68. On 10/17/23 at 12:04 PM, observed V12 pick up R42's utensil, place utensil into R42's food and brought utensil to R42's mouth. Observed R42 accept the food. V12 then put R42's utensil down on the table and turned toward R68, away from R42. On 10/17/23 at 12:05 PM, observed V12 pick up R68's utensil, place utensil into R68's food and brought utensil to R68's mouth. Observed R68 accept the food. V12 then put R68's utensil down on the table and turned toward R42, away from R68. On 10/17/23 at 12:06 PM, observed V12 pick up R42's utensil, place utensil into R42's food and brought utensil to R42's mouth. Observed R42 accept the food. V12 then put R42's utensil down on the table and turned toward R68, away from R42. This process of V12 giving R42 and then R68 a bite of food back and forth continued until 12:25 PM. Surveyor did not observe R42 or R68 make any attempt to feed themselves during this time period. On 10/18/23 at 11:29 AM, V19 (Food Server) stated that the meal tickets are organized and distributed by room number, not by table in the unit dining room. On 10/18/23 at 12:26 PM, in the 2nd unit dining room observed V6 (Licensed Practical Nurse) standing over R8 while feeding R8 food. Did not observed R8 make any attempt to feed herself. On 10/18/23 at 12:28 PM, when V6 saw surveyor watching V6 standing while feeding R8, V6 quickly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 2 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 - Some turned around and pulled a chair over from the wall to the table, sat down in the chair and continued to feed R8 again. On 10/18/23 at 3:35 PM, V16 (Registered Dietitian) stated the staff should be sitting down when feeding a resident, not standing. V16 stated it is a dignity and safety issue. The resident who is dependent on staff for feeding needs the staff members full attention. Staff should be feeding one resident at a time at eye level so that they can be monitored closely for choking or swallowing issues. V16 stated if a staff member is getting pulled away then they are not providing their full attention, and this would be doing a disservice to the resident. On 10/19/23 at 8:35 AM, V17 (Restorative Nurse) stated that residents who require feeding should be fed one at a time and staff should be sitting down next the resident, at eye level, not standing. V17 stated this is because of safety and dignity. V17 stated, I wouldn't want anybody standing over me when I was being fed and that this could be viewed as intimidating to a resident, which could make a resident fearful. R8's diagnosis included but not limited to Dementia, Dysphagia, Muscle Weakness. R8's MDS (Minimum Data Set) undated indicates severe cognitive impairment with BIMS (Brief Interview for Mental Status) 3/15. R42's diagnosis included but not limited to Muscle Weakness, Dementia, Acute Respiratory Failure with Hypoxia, Muscle Wasting/Atrophy, Anxiety. R42's MDS (Minimum Data Set) undated indicates severe cognitive impairment with BIMS (Brief Interview for Mental Status) 6/15. R68's diagnosis included but not limited to Malaise, Weakness, Muscle Wasting and Atrophy, Alzheimer's Disease. R68's MDS (Minimum Data Set) undated indicates severe cognitive impairment with BIMS (Brief Interview for Mental Status) 0/15. Facility policy titled Promoting/Maintaining Resident Dignity During Mealtimes dated 03/23/23 documents in part it is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life. Guidelines include feed only one resident at a time and all staff will be seated, if possible, while feeding a resident. Facility policy titled Facility Responsibilities - Resident Rights dated 02/10/23 document in part the resident has the right to a dignified existence and the facility will treat each resident with respect and dignity, and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 3 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 label/date 3 (R25, R32, R56) of 3 residents oxygen tubing, failed to properly store 2 (R32, R56) of 2 residents oxygen tubing and 1 (R32) nebulizer set up to prevent contamination, failed to change R56's oxygen humidifier bottle, and failed to have an oxygen in use signage posted for 1 (R42) resident reviewed for oxygen therapy in a sample of 18. Residents Affected - Some Findings Include: R32 has diagnosis not limited to Acquired Absence of Bilateral Breasts and Nipples, Acute and Chronic Respiratory Failure with Hypercapnia, Acute Embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity, Bilateral, Acute Myocardial Infarction, Anxiety Disorder, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Emphysema, Moderate Persistent Asthma, Peripheral Vascular Disease, Shortness of Breath, Solitary Pulmonary Nodule and Tachycardia. R32 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R32 physician order document in part: O2 (oxygen) at 4L (liters) per NC (nasal cannula) Dx: (diagnosis) COPD (Chronic Obstructive Pulmonary Disease). Ipratropium 0.5 mg (milligrams)-albuterol 3 mg (2.5 mg base)/3 mL (milliliters) nebulization soln. (solution) 1 Time Daily. Care Plan document in part: R32 was recently admitted to the hospital due to shortness of breath and diagnosed with acute on chronic hypoxemic respiratory failure. R32 now presents with a functional deficit in ADLs (activities of daily living) and mobility she also has the following dx: Emphysema. Intervention: Oxygen as ordered by physician. On 10/17/23 at 10:37 AM R32 was observed sitting in a chair at the bedside asleep with oxygen in use set on the at 4 liters per nasal cannula on the oxygen concentrator. The oxygen humidity bottle was dated 10/14/23, oxygen tubing was observed undated. Two-portable oxygen tanks were observed in the oxygen tank stand with the oxygen tubing hanging over the oxygen tank stand unlabeled and not stored in a bag with the connector end of the oxygen tubing on the floor. The nebulizer set up was observed on top of the nebulizer machine not stored in a bag. On 10/17/23 at 11:34 AM V3 (Registered Nurse) entered R32 room with the surveyor. V3 stated the oxygen tubing is changed once a week. There is no label on R32's oxygen tubing. The oxygen tubing that is on the portable oxygen tanks should be in a plastic bag. Since it is on the floor it is now contaminated. I will throw it away. The nebulizer is usually put in a bag. On 10/19/23 at 09:50 AM V2 (Director of Nursing/Infection Preventionist) stated my expectations for a resident with oxygen are that the staff should have the red oxygen label on the resident's door. The oxygen tubing, nebulizer and the humidity bottle should be labeled and there should be a bag attached to the oxygen concentrator for storage of the oxygen tubing when the oxygen is not in use. The purpose of labeling is to know when the oxygen tubing and nebulizer setup was opened and need to be replaced. The humidity bottle should be changed weekly or when needed. The oxygen tubing and the nebulizer set ups are to be change weekly. If the oxygen tubing touches the floor, it should be discarded immediately and replaced. If the oxygen tubing and nebulizer setups are not stored in the bag there is a risk for contamination. Policy: Titled Oxygen Administration revised 03/23 document in part: Policy: Oxygen is administered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 4 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to residents who need it, consistent with their comprehensive person-centered care plans, goals, and preferences. 5. a. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. c. Change nebulizer tubing and delivery device weekly and as needed if it becomes soiled or contaminated. d. Keep delivery devices covered in plastic bag when not in use. 6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. 9. Oxygen Equipment includes a selection from the following: c. Oxygen warning signs. 11. Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them. Possible risks humidification systems. On 10/17/23 at 10:40 AM, surveyor and V18 [Licensed Practical Nurse] observed R25's oxygen infusing per nasal canula not labeled, no date, and oxygen humidifier bottle not labeled, no date. On 10/17/23 at 10:42 AM, V18 stated, The oxygen tubing and oxygen humidifier bottle should have a date. The night nurse is responsible to changing and dating the oxygen tubing and humidifier bottle weekly with a date. On 10/17/23 at 12:47 PM, observed oxygen concentrator at R56's bedside. Humidifier bottle was dated 09/11/23 and oxygen nasal cannula tubing was not dated. Nasal cannula oxygen tubing was laying on the floor. There was no container or storage bag observed at R56's bedside or in room. R56 stated that he uses the oxygen every night when he sleeps and that the staff removes the tubing in the morning and turns off the oxygen machine. R56 stated, the tubing is on the floor right now. On 10/17/23 at 12:50 PM, V6 (Licensed Practical Nurse) observed R56's humidification bottle dated 09/11/23 and stated the oxygen tubing and humidification bottle should each be labeled with a date and changed weekly. V6 observed R56's nasal cannula tubing on the floor and stated the oxygen tubing should be in a bag to keep it clean from bacteria and should not be on the floor. V6 stated she would change R56's oxygen tubing and humidification bottle right away. On 10/17/23 at 11:52 AM, observed R42 sitting in unit dining room with oxygen infusing via nasal cannula. On 10/17/23 at 12:55 PM, observed doorway outside of R42's room. There was no oxygen in use sign outside R42's doorway. On 10/17/23 at 12:57 PM, V6 stated a resident who is receiving oxygen should have a sign outside their doorway to their room indicating oxygen is in use. V6 observed outside R42's room and verbalized the R42 did not have an oxygen sign outside R42's room and that there should be a sign because R42 is receiving oxygen. R42's diagnosis included but not limited to Chronic Obstructive Pulmonary Disease (COPD), Muscle Weakness, Dementia, Acute Respiratory Failure with Hypoxia, Muscle Wasting/Atrophy, Anxiety. R42's Physician Order Sheet October 2023 in part documents in part 2-liter oxygen with nasal cannula. R42's active care plan printed 10/17/23 documents in part R42 has oxygen therapy as ordered by physician. R42's MDS (Minimum Data Set) undated indicates severe cognitive impairment with BIMS (Brief (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 5 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 Interview for Mental Status) 06/15 and special treatments include oxygen therapy. Level of Harm - Minimal harm or potential for actual harm R56's diagnosis included but not limited to Shortness of Breath, Muscle Wasting and Atrophy, Muscle Weakness, Heart Failure. Residents Affected - Some R56's Physician Order Sheet October 2023 in part documents in part administer oxygen at 3 liters per nasal cannula for Shortness of Breath. R56's active care plan for oxygen therapy documents in part R42 requires oxygen per nasal cannula PRN and nightly at 3 liters per nasal cannula for shortness of breath and interventions include to change tubing & nasal cannula per policy. R56's MDS (Minimum Data Set) undated indicates moderate cognitive impairment with BIMS (Brief Interview for Mental Status) 09/15 and special treatments include oxygen therapy. Facility policy titled Oxygen Administration dated March 2023 documents in part change oxygen tubing and mask/cannula weekly, keep delivery devices covered in a plastic bag when not in use, oxygen warning signs must be placed on the door of the resident's room, and possible risks and complications include respiratory infections related to contaminated humidification systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 6 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 food items were properly labeled, dated, and stored; failed to ensure raw food and cooked/ready to eat foods stored properly on the same storage rack using top-to-bottom system per facility policy; and failed to ensure staff performed appropriate hand hygiene in between handling dirty plate ware and clean plate ware. This deficient practice has the potential to affect all 70 residents receiving food prepared in the facility's kitchen. Findings include: On 10/17/23 at 09:22 AM, V8 (Director of Dining Services) stated all food items stored in the refrigerator are labeled with an open/prepared date and a use by date. V8 stated the kitchen uses an orange sticker to label items which has the following information on it to be filled out: product name, today's date (prepared date), good thru date and staff initials. V8 stated the use by date lets staff know when the product needs to be used by and/or discarded. On 10/17/23 at 09:32 AM, observed in the walk-in refrigerator a container of green beans labeled with orange sticker indicating prepared date 10/12/23, and good thru date 10/15/23. V8 stated the green beans should have been thrown out because it is past the use by date as marked on the label. V8 stated there is the potential to cause a food borne illness for the residents which is why the product should have been thrown out. On 10/17/23 at 9:40 AM, observed two cases of defrosted ground beef patties on the upper shelf in the walk-in refrigerator with a large container of salmon fillets on the lower shelf directly underneath the defrosted ground beef patties. V8 observed the location of the ground patties above the salmon and stated the ground patties should be stored on the lowest shelf, underneath the salmon because the cooking temperature of the fish is lower than the beef. On 10/17/23 at 9:44 AM, observed a portable open shelving rack containing various food items in the walk-in refrigerator. Raw fish was observed in a shelving slot stored over cooked prepared food and on the same portable shelving rack. Raw pork was observed in another shelving slot stored over cooked prepared food. V8 stated raw foods should never be stored above ready to eat prepared food or cooked left over foods because the potential for the dripping of the raw meat could cause cross contamination and food borne illness. On 10/17/23 at 9:55 AM, V8 stated that all items in the dry storage area should be labeled with a delivery date unless there is already an order label containing the delivery date on it. On 10/17/23 at 10:10 AM, observed in dry storage room [ROOM NUMBER]-plastic bottles (7 pounds, 6 ounces each) of Sliced Strawberry Topping, 8-1 gallon containers of mayonnaise, 3-1 gallons of Balsamic Vinaigrette, and 3-1 gallons of Home Ranch Dressing without any delivery dates or label indicating the delivery date. V8 stated the items should have been labeled with a delivery date so the staff would know how to rotate the food in storage using first in, first out. On 10/17/23 at 10:30 AM, observed in reach-in refrigerator near prep area ¾ full container of Fat Free Sour Cream dated with an open date of 10/07/23 with manufacturers best by date printed on the container of 10/14/23. Also, observed in reach-in refrigerator an opened glass jar of apricot (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 7 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 preserves labeled with an open date 06/17 (year not specified) and good thru date 07/17 (year not specified) and container of opened applesauce labeled with open date 08/09/23 and good thru date 08/28/23. V9 (Executive Chef) stated the items should not be used because they have expired and I'll throw it out right now. On 10/18/23 at 9:44 AM, V4 (Kitchen Server) stated that each of the nursing units contain a dishwasher which is used after every meal to wash all the utensils, plates, and glass ware for the residents to use for the next meal. On 10/18/23 at 9:46 AM, observed V4 rinse off resident dirty dishes and then stack the dirty dishes into a rack. At 9:47 AM, V4 placed the rack containing the dirty dishes into the dishwasher and turned dishwasher on. On 10/18/23 at 9:50 AM, without performing hand hygiene after handing the dirty dishes V4 removed a rack now containing clean dishes from dishwasher. On 10/18/23 at 9:51 AM, without performing hand hygiene observed V4 remove dishes one at a time from the rack and stack dishes in a pile on the counter. On 10/18/23 at 10:05 AM, in main kitchen observed V14 (Kitchen Utility Aide) feeding dirty pans into dishwasher, then performing hand hygiene and putting on new pair of gloves before pulling clean pans out of the dishwasher. V14 stated that he has to wash his hands and change gloves in between touching the dirty dishes and before getting the clean dishes from the dishwasher to prevent cross contamination. Facility policy titled Food and Supply Storage dated 1/2022 documents in part, foods past the use by, sell by, best by or enjoy by date should be discarded, products are good through the close of business on the date noted on the label, refer to the Food Storage Chart to determine discard dated for food items, separate cooked and raw foods, store ready-to-eat and cooked food above raw food, if raw animal foods are stored on the same rack, store them in the following order from top of the rack to the bottom of the rack (fish, eggs, whole cut of beef or pork, ground meat and poultry. Facility policy titled Refrigerated Storage Life of Foods dated 1/2022 documents in part unused portions of foods prepared on site use by 3 days, and fruit purees use by one month. Facility document titled Proper Refrigerator and Freezer Storage undated documents in part top-to-bottom storage of different foods in the same refrigerator and shows a picture diagram with cooked and ready-to-eat food stored at the top and raw products below cooked and ready-to-eat food in the following order from top to bottom: whole fish, raw shell eggs, whole meat, pork, ground meat, and poultry. Facility policy titled Hand Hygiene dated 03/20/23 documents in part all staff will perform proper hand hygiene procedures to prevent the spread of infection, and this applies to all staff working in all locations within the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 8 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 ensure dumpsters were covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 70 residents who reside in the facility. Residents Affected - Many Findings include: On 10/17/23 at 10:16 AM, surveyor traveled outside facility to view dumpster area with V9 (Executive Chef). Observed both lids to dumpster wide open and garbage loose inside the dumpster. Also, observed smashed Brussel Sprouts, multiple plastic gloves, milk cartons and other garbage debris on the ground all around the dumpster. V9 stated the dumpster lids should be kept closed to keep animals out and that food and other garbage around the dumpster could attract unwanted visitors which could lead to an infestation. On 10/17/23 at 10:23 AM, V10 (Kitchen Utility Aide) viewed the dumpster and stated that the lids to the dumpster should be closed when not being used. V10 did not know why both lids were wide opened and stated they should be closed to prevent animals from getting inside. On 10/18/23 at 12:43 PM, V15 (Assistant Environmental Services Director) stated the dumpster lids should be kept closed when not in use to keep rodents, and other animals out and there should be no food or other debris on the ground around the dumpster as this could attract rats. V15 stated we don't want that. V15 stated the facility wants to try to eliminate the potential of rodents getting close to the doors to prevent them from getting inside the facility. Facility policy titled Disposal of Garbage and Refuse dated 02/10/23 documents in part, containers and dumpsters shall be kept covered when not being loaded, surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 9 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure staff wore the proper PPE (Personal Protective Equipment) during medication administration for 1 (R27) resident. This failure has the potential to affect 28 residents residing on the third floor. Residents Affected - Some Findings include: R27 has diagnosis not limited to Cerebral Infarction, Cognitive Communication Deficit, Congenital Hiatus Hernia, Dysarthria and Anarthria, Dysphagia, Gastrostomy, Essential (Primary) Hypertension, Gastrointestinal Hemorrhage, Hemiplegia and Hemiparesis Following Nontraumatic Subarachnoid Hemorrhage Affecting Left Non-Dominant Side, Hemorrhage, Iron Deficiency Anemia Secondary To Blood Loss (Chronic), Long Term (Current) Use of Anticoagulants, Major Depressive Disorder, Mixed Hyperlipidemia, Myasthenia Gravis, Cholelithiasis, Lack of Coordination, Pulmonary Embolism, Secondary Gout, Multiple Sites, Parkinson's Disease, Personal History of Transient Ischemic Attack (TIA), Slow Transit Constipation, Type 2 Diabetes Mellitus, Dementia and Weakness. On 10/17/23 at 11:17 AM V3 (Registered Nurse) entered R27 room to administer medication. R27 is on Enhanced Barrier Precautions with signage posted on the entry door indicating the required PPE (Personal Protective Equipment) when providing care for R27. On 10/17/23 at 11:21 AM V3 (Registered Nurse) checked placement by auscultation of the tubing to administer the medications. V3 (Registered Nurse) then flushed the tubing with 30 ml of water and administered the medication. On 10/17/23 at 11:27 AM the surveyor asked V3 (Registered Nurse) how much water is used in each medication cup to mix the medication. V3 (Registered Nurse) responded 10 -15 ml. Surveyor asked V3 what type of PPE should be worn since R27 is on Enhanced Barrier Precautions. V3 responded I should have on gloves and a mask, but I did not have the gown on. V3 put on an isolation gown. At 11:29 V3 removed the isolation gown then exited R27 room. On 10/19/23 at 09:50 AM V2 (Director of Nursing/Infection Preventionist) stated My expectations if a resident is on Enhance Barrier Precautions is that the staff do hand hygiene, put on a gown and gloves. R27 has a g (gastric)-tube. If the staff are not putting on a gown when giving medication through the gastric tube to a resident on Enhanced Barrier Precautions, the risk for infection is always there and there is a potential for cross contamination. Policies: Titled Infection Prevention and Control Program revised 03/23/23 document in part: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 2. All staff are responsible for following all policies and procedures related to the program. Titled Personal Protective Equipment revised 03/23 document in part: Policy: This facility promotes use of appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and staff. Personal protective equipment, or PPE, refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing with pathogens (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 10 of 11 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (bacteria/viruses). It includes gloves, gowns, face protection (facemasks, goggles, and face shields), and respiratory protection. Policy Explanation and Compliance Guidelines: 1. All staff who have contact with residents and/or their environment must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or infectious materials are likely. a. Gloves: 4. Indications/considerations for PPE use: iii. Perform hand hygiene before donning gloves and after removal. Gloves are Not a substitute for hand hygiene. b. Gowns: i. Wear gowns to protect arms, exposed body areas, and clothing from contamination with blood, body fluids, and other potentially infectious material. Titled Infection Control revised 03/20/23 document in part: Policy: All staff engaged in direct patient care shall be instructed in correct techniques and be familiar with our facility's established infection control policies and procedures. Purpose: The primary purpose for this policy is to prevent the spread of infection through identification of infectious agents requiring isolation. 4. Staff Referral to Treatment Centers/Services: d. Staff shall use personal protective care equipment (PPE) according to established facility policy governing the use of PPE. 5. Hand Hygiene Protocol: a. All staff shall wash their hands when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty. 7. Equipment protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our procedure governing the cleaning and sterilization of soiled or contaminated equipment. E. Equipment items not sent for decontamination processing shall be washed with a germicidal detergent before being stored for reuse. Titled Enhanced Barrier Precautions revised 03/30/23 document in part: Policy: it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO's). Definitions: Enhanced Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 2. Initiation of Enhanced Barrier Precautions: b. Enhanced barrier precautions will be initiated for residents with any of the following: i. Significant wounds and/or indwelling medical devices (e.g., central lines, midlines, hemodialysis catheters, urinary catheters, pleural drain, feeding tubes etc.). 3. Implementation of Enhanced Barrier Precautions - a. Gowns and gloves will be available upon entering resident's room. 4. High-contact resident care activities include: g. Device care or use: central lines, urinary catheters, feeding tubes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 11 of 11