Health inspection·November 26, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure that kitchen staff perform proper hand hygiene; failed to label and date dry storage food and left-over prepared foods; and failed to discard foods past their discard date. These failures have the potential to affect 60 residents consuming oral diets from the facility kitchen.Findings include:On 9/29/2025 at 9:39 AM, this surveyor initiated the kitchen tour with V3 (Dietary Director). On 9/29/2025 at 9:45 AM, this surveyor viewed the dry storage room with shelving units containing stored food items in packages, containers and boxes. Orange colored labels with a date are noted attached to most dry food items. V3 stated that the orange sticker is the date of the delivery date of the food item, and V3 shows this surveyor the label machine hanging in the dry storage room with the orange stickers. On 9/29/2025 at 9:47 AM, on the shelving unit in the dry storage room, this surveyor observed 2 boxes of bananas. This surveyor is wearing surgical face mask and can smell the ripe bananas. When asked when the bananas were received, V3 is looking at all sides of one of the boxes of banana, and V3 said There's no date. They (kitchen staff) didn't put a date on it. V3 inspects the other banana box and states that there's no date of when the bananas were delivered, and it should be on the outside of the box. V3 stated, We need one on that box too. This surveyor observing the bananas exposed from the top of the box are yellow with black dots scattered on the bananas. On 9/29/2025 at 9:54 AM, V4 (Cook) joins the initial kitchen tour with this surveyor and V3. On 9/29/2025 at 9:55 AM, this surveyor, V3 and V4 walk into the walk-in cooler. This surveyor observes a clear plastic cover over the food tray cart with no label or date. V3 removes the plastic cover, and this surveyor observes a tray (1/2 full) of pre-cut salmon pieces. When asked when the salmon was prepared or cut, V3 stated I (V3) am not seeing a date on that one. Below the salmon tray, there is deep stainless-steel pan full of chicken meat in a liquid. There's a sticker label on the deep stainless-steel pan of chicken in liquid, with a prepared date of 9/21/25 and a discard by date of 9/24/25. Another food try cart (next to the other cart covered with plastic garbage, clear bag covering the cart, with no label or date. V3 removes this plastic cart cover, and on the top shelf, an opened package of sausage bratwurst (plastic wrapped) is observed with a white printed label with open date of 9/22/25 and a discard by date of 9/25/25. The two trays below the top tray are two trays of cod. One tray is plain cod pieces, and the other tray has cod pieces with a butter spread with dill. No label or date is noted on these two trays of cod. V4 stated that there are no dates on the cod and dill code trays. On 9/30/2025 at 9:45 AM, this surveyor performed follow up kitchen tour with V4 (Cook). This surveyor observed on the same shelves, the same 2 banana boxes with ripe bananas (yellow with large number of black spots on the bananas) noted from the 9/29/25 kitchen tour. V4 stated that the bananas are to be used. When asked for what? V4 stated, One case, I (V4) am going to get rid of and the other one use for smoothies in the Chef demo. V4 said that V4 determines the number of days that the food is good for by looking at the posted guidelines in the kitchen. V4 and this surveyor walk out of dry storage to the sign that is posted in the kitchen of the Storage Life of Food. V4 stated that it's for +3 days. When asked V4 about the process of when food is delivered from the vendor in reference to labeling and dating, V4 stated that food items are labeled with the label gun, pointing to the label machine by the shelving units in the dry storage room, and the label sticker is placed on the package or container with the date that the food item was received. A third box of bananas (green/yellow color) is observed on the nearby shelf in the dry storage room. V4 stated that that this specific box of bananas came in this morning. When asked where the date delivered is on this banana box, V4 moves the box examining all sides of the box and says the kitchen staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 2 of 8 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 11/26/2025 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 - Some didn't date it with the label gun. When asked V4 to see a date/label on the 2 original boxes of bananas (noted on 9/29/2025). V4 said that V4 is going to bring these banana boxes out to the prep table to view them. V4 attempts to lift one box of bananas off the shelf is struggling to hold the box. V3 enters the dry storage room and takes the box of bananas from V4 and walks the box of bananas to the prep table in the kitchen. Upon opening one box of bananas, V3 removes a group of bananas bunched together that have the banana peels that have split open and throws them into the garbage. This surveyor views inside the open garbage can to see the banana peels split open, exposing the banana flesh inside and the banana peels filled with black spots. V3 confirmed again that the banana box was not labeled or dated. On 9/30/2025 at 10:27 AM, V4 stated that V4 is getting ready to prepare the puree sloppy joe sandwich over a bun and that V4 has 15 ounces of milk simmering on the stove to heat up for this puree preparation. Two mixing blenders are noted on the prep table, and V4 is walking around kitchen to obtain pans and utensils for the puree preparation process.On 9/30/2025 at 10:28:33 to 10:28:37 AM (less than 20 seconds), V4 washes V4's hands at the kitchen hand washing station and places gloves on. V4 next places 5 bread buns into the shallow pans, opening each of the five buns, so the five tops and five bottoms are open faced in the pans. V4 retrieves the heated milk and at the prep station, V4 is using a one-ounce ladle and spoons heated milk over the 10 open buns. V4 stated that the milk absorbs and softens the buns prior to the blending. V4 is observed touching the open-faced buns that are soaked with milk to ensure by touch that they are wet. V4 completed spooning all of the heated milk and stated that more milk is needed, but V4 will have to heat it up first. V4 removed V4's gloves. On 9/30/2025 at 10:34:40 to 10:34:45 AM (less than 20 seconds), V4 washes V4's hands at the kitchen hand washing station. V4 then talking to V21 (Registered Dietitian, RD) in the kitchen about heating more milk to continue the puree process.On 9/30/2025 at 10:36:53 to 10:37:05 AM (less than 20 seconds), V4 washes V4's hands and dons gloves. V4 observed at prep station, plugging up blenders in preparation for the puree process while waiting for clean blender container.On 9/30/2025 at 10:43 AM, V4 walks (while wearing gloves) to the stove on the opposite side of the prep table to check the milk heating on the stove. V4 then discards gloves and washes V4's hands from 10:43:57 to 10:44:05 AM (less than 20 seconds). V4 dons new gloves and begins to ladle more milk onto the open-faced buns in the pans to ensure that they are soaked wet. On 9/30/2025 at 10:46 AM, V4 wiped the prep table with the sanitization towel with V4's gloved hands and then removes gloves. V4 washed hands from 10:46:35 to 10:46:50 AM (less than 20 seconds). On 9/30/2025 at 10:52:02 to 10:52:15 AM (less than 20 seconds), V4 washed hands then dons gloves. V4 scoops the sloppy joe meat on the bottoms of the milk-soaked buns and places the milk-soaked bun tops on top of the sloppy joe meat to make the five sandwiches. V4 ladles the sloppy joe sandwiches in the blender to a smooth puree texture. V4 then pours and scoops the pureed sloppy joe sandwich mixture into a stainless-steel pan, places a cover on the pan, and places in the stand up, warming oven.On 9/30/2025 at 11:06 AM, V4 stated that when V4 enters the kitchen and in between tasks, V4 will wash V4's hands. V4 stated that the hand washing process is wetting hands, adding soap, rubbing together for 20 seconds, rinsing with water and dry with towel and turn off the water with the towel. V4 stated that the purpose of handwashing is to keep hands clean and helps prevent cross contamination. This surveyor informed V4 of the observations of V4 washing hands in kitchen several times for under 20 seconds. V4 questioned how surveyor tracked the seconds, and this surveyor showed V4 the stopwatch used by surveyor with the counting seconds that were clearly visible. On 9/30/2025 at 11:29 AM, temperatures of food items being obtained for lunch service with V4 and this surveyor reading 192 degrees Fahrenheit for the same pureed sloppy joe sandwiches in the pan. On 11/24/2025 at 10:32 AM, during a follow up visit to the kitchen, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 3 of 8 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 11/26/2025 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 - Some V4 (Cook) and surveyor performed a brief tour follow up tour of the dry storage room and viewed a box of bananas, yellow with slightly green color of banana peels, on the shelf with a label sticker indicating received on 11/24/25 and to discard on 11/27/25 (3 days).On 11/25/2025 at 10:48 AM, V22 (Assistant Dietary Director) stated that V3 (Dietary Director) cannot be reached via phone, and V22 is the assistant dietary director. V22 stated that hand washing must be done by kitchen staff every time they change a task, come from the bathroom, or touch door handles or knobs. V22 stated that the purpose of hand hygiene is cleanliness and won't cross contaminate or spread germs. V22 stated that the process of hand washing by kitchen staff is as follows: wet hands with water, apply soap and lather, wash hands for 20 seconds (sing a song for 20 seconds), rinse hands with water, dry with towel discard, and then turn off handle with towel. V22 stated that the purpose of washing hands for the entire 20 seconds is so kitchen staff will be washing away all the germs or anything that is on the kitchen staffs' hands. When asked if kitchen staff were to wash hands less than 20 seconds and then continues to perform a kitchen staff with preparing food, what could occur, and V22 stated that kitchen staff would carry germs to the next task they are doing in the kitchen. V22 stated that kitchen staff label fresh fruit items when the fruit is delivered (when it came into the facility kitchen), and a discard date is placed on the label. V22 stated that with the discard date is followed, and the discarded food item will be removed from production. V22 stated that the dating the in and out of a food item is an identifier that will ensure that no expired foods still remain stocked in the kitchen for potential use. This surveyor informed V22 that upon kitchen rounds on 11/24/2025, this surveyor viewed a box of bananas in the dry storage labeled with a received date of 11/24/2025 and a discard date of 11/27/2025 (3 days). V22 stated that if a box of bananas that are ripened and are opening are stocked in the kitchen past their discard date, bacteria can grow inside and outside (the bananas), and the smell of these bananas can attract fruit flies. V22 stated that when there are left-over prepared foods that are being stored, the kitchen staff must label and date these left-over prepared foods with a label containing the date and time that the food item was prepared, a discard date and time, and the initials of the kitchen staff member. V22 stated, All, absolutely all left-over prepared food items stored in the kitchen should have the identifying label of when the food was prepared and when it is to be discarded. V22 stated that if the left-over food item is stored in the cold storage past the discard date, we can't serve it, bacteria can grow and other nasty things. That can't happen and we cannot serve it to the elderly or anyone. Facility Cycle Menu, titled 2025 Spring, documents, in part, that the oral diet residents are being served from the Week 4 Menu Spread Sheet. Facility Menu Spread Sheet for Tuesdays on Week 4 (from Cycle Menu) documents, in part, that for the lunch meal for puree diet orders, the hot menu item is sloppy joe sandwich. Facility document titled with the facility's name was provided to the survey team by V1 (Administrator) on 9/29/2025 which documents, in part, that one skilled care resident (R7) is the only resident receiving tube feedings/nothing by mouth.On 11/25/2025 at 9:36 AM, V21 (Registered Dietitian, RD) confirmed that upon initiation of this survey on 9/29/2025, all skilled care residents residing in the facility were receiving oral diets except for R7.Daily Census, dated 9/29/2025, documents, in part, that the total census for skilled care residents is 61. Therefore, 60 residents were receiving oral diets.Facility kitchen policy titled Dry Storage Life of Foods dated January 2024 documents, in part, Use manufacturer's expiration date for product storage. If there is no expiration date on the package, add the time listed here to the date the food is received. The time listed is added to today's date. Expiration/use by dates are guidelines; discard products where the quality is deemed unacceptable. Facility kitchen policy titled Employee Health & Hygiene: 2.2 Hand Washing with creation date of 10/01/2022 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 4 of 8 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 11/26/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete revision date of 10/01/2025 documents, in part, that kitchen staff are to wash their hands when anytime hands become soiled/contaminated, upon entering or returning to the kitchen or other food handling areas, immediately before engaging in food preparation including working with exposed food, clean equipment, utensils, and unwrapped single-service and single-use articles, when switched between working with raw food and working with ready-to-eat food; during food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks, and when changing gloves. Facility kitchen policy titled Food Handling Guidelines (HACCP, Hazard Analysis and Critical Control Points dated (revision) January 2025 documents, in part: Policies: Food is handled using a HACCP process in accordance with regulatory guidelines . Procedures: Contamination Precautions: Food shall be protected against cross-contamination by . appropriately separating raw (potentially hazardous) foods from ready-to-eat food products during storage, preparation . Hands should be scrubbed following appropriate hand washing techniques according to facility policy. Event ID: Facility ID: 145904 If continuation sheet Page 5 of 8 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 11/26/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to perform hand hygiene before and after performing direct care to residents; failed to perform hand hygiene during dining; and failed to conduct proper respiratory etiquette during dining while feeding a resident. These failures affected three residents (R1, R5, and R27) in a total sample size of 36, and has the potential to affect all 23 residents that reside on the 3rd floor.Findings include: Residents Affected - Some On 09/29/25 at 11:34am V7 (Certified Nursing Assistant/CNA) performed care (repositioning and fixing under pad) to R1 without performing hand hygiene or donning gloves. V7 then removed soiled napkin from R1's bed and exited the R1's room. V7 observed entering R5's room and placing soiled napkin from R1's room on R5's dresser. V7 observed donning gloves without performing hand hygiene and assisting R5 to the restroom. V7 then observed removing gloves, picking up soiled napkin and walking to dining area. V7 observed placing soiled napkin in a basket then placing ice in a cup from shared ice machine, without performing hand hygiene. On 09/29/25 at 12:03pm V8 (CNA) observed donning gloves without performing hand hygiene and enter R1's room to assist V7 (CNA) in pulling R1 up in bed. On 09/29/25 at 12:06pm V8 (CNA) stated I didn't sanitize my hands before putting the gloves on, but I should have. I was just trying to help out. On 09/29/25 at 12:07pm V7 (CNA) stated that she should have sanitized her hands and donned gloves before caring for R1, but she was moving too fast. V7 stated that she should sanitize her hands before entering and exiting a resident's room. V7 stated that she does not like to sanitize her hands before donning gloves because it makes her hands sticky. V7 stated that she should be sanitizing her hands between residents, but it is so busy and she moves fast. On 11/24/25 at 1:50pm V19 (Minimum Data Set (MDS) Coordinator) stated that hand hygiene is important because it prevents the spread of infection. V19 stated that hand hygiene should be done before entering a resident's room, before leaving a resident's room, and in between tasks. V19 stated that dirty linen should not be taken from one resident's room to another resident's room. V19 stated that the unit's ice machine is for all residents on the unit. V19 stated that if hand hygiene is not performed after care of a resident and the ice machine is then used, then the ice machine is considered contaminated. R1's medical diagnoses include but is not limited to hydronephrosis, bipolar disorder, pneumonia, major depressive disorder, anxiety disorder, peripheral vascular disease, muscle weakness. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 7, indicating R1's cognition is severely impaired. R5's medical diagnoses include but are not limited to bladder neck obstruction, urinary tract infection, type 2 diabetes mellitus, chronic kidney disease, major depressive disorder, generalized anxiety disorder. R5's MDS dated [DATE] has a BIMS score of 12, indicating R5's cognition is moderately impaired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 6 of 8 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 11/26/2025 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 Facility's policy titled Infection Control dated 02/2025 documents 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 infections through identification of infectious agents requiring isolation.Policy Explanation and Compliance Guidelines:.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. B. Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing care to patients in isolation. C. For routine patient care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact. D. Hands shall be washed in accordance with our facility's established hand washing procedure.7. Equipment Protocol:.C. Reusable items potentially contaminated with infectious materials shall be placed in impervious clear plastic bag labeled CONTAMINATED and placed in the soiled utility room for pickup and processing. D. Prior to returning soiled trays and carts for decontamination processing: i. Linen shall be removed and placed in designated linen bags. Facility's policy titled Hand Hygiene dated 02/2025 documents in part, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also know as alcohol-based hand rub (ABHR).Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.3. Alcohol-based hand rub with 60-95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. 6. Additional consideration: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perm hand hygiene prior to donning gloves, and immediately after removing gloves. On 9/29/2025 at 11:42 AM, this surveyor performs dining observation on R27's floor. On 9/29/2025 at 11:48 AM, R27 observed sitting at table in a high back wheelchair. V17 (Restorative Nurse) sat next to R27 and initiated R27's one to one (1:1) feeding of the mechanical soft lunch meal (turkey tetrazzini and vegetables). On 9/29/2025 at 12:12 PM, V17 asking R27 if R27 is finished with the turkey tetrazzini and vegetables (ate approximately 90 % during 1:1 feeding), and R27 stated yes. V17 removes R27's tray, leaving R27's table, and R27 remains at table in wheelchair. On 9/29/2025 at 12:19 PM, V9 (Server) delivers R27 an ice cream sandwich on a small plate. V7 (Certified Nursing Assistant, CNA) sits next to R27 at the dining room table to take over 1:1 feeding for R27. V7 observed coughing into V7's scrub shirt, turning V7's head and bringing the right neck of the scrub shirt up near V7's mouth with V7's right hand. V7 performed no hand hygiene and started feeding R27 the ice cream sandwich (taking spoon to ice cream sandwich and spooning small bites of the ice cream sandwich to feed to R27). V7 feed 2 bites of the ice cream sandwich to R27, then V7 sneezed into V7's right elbow (while sitting next to R27). V7 did not perform hand hygiene. V7 went back to feeding R27 with 3 more bites (on spoon) of the ice cream sandwich. With the last spoonful of ice cream sandwich for R27, V7 is brining the spoonful off the plate, and the ice cream sandwich fell off spoon onto the plate. With V7's bare left hand, V7 touches the ice cream sandwich piece to place it onto the spoon then feeds this ice cream sandwich bite to R27. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 7 of 8 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 11/26/2025 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 R27's admission Record documents, in part, diagnoses of encephalopathy, type 2 diabetes mellitus, dementia, neurocognitive disorder with Lewy Bodies, cognitive communication deficit, chronic ischemic heart disease, Parkinsonism, muscle wasting, hypothyroidism, urinary tract infection, anxiety disorder, difficulty in walking, personal history of malignant neoplasm of skin and encounter for palliative care. R27's Minimum Data Set (MDS), dated [DATE], documents, in part, that R27's Staff Assessment for Mental Status indicates that R27 has problems with short and long term memory, and R27's Cognitive Skills for Daily Decision Making are severely impaired. R27's Functional Abilities for eating indicate that R27 is dependent where staff does all of the effort. R27's Order Summary Report showing active orders as of 11/25/2025 documents, in part, that R27's diet order is mechanical soft texture with regular/thin liquid consistency. R27's Care Plan dated 8/12/2024 documents, in part, a focus of R27 being at risk for weight loss, risk of dehydration, and risk for pressure ulcers with interventions of provide 1:1 feeding assistance and provide necessary assistance at meal time and between meals as needed. On 11/25/2025 at 10:29 AM, V19 (MDS Coordinator) stated that V19 is responsible for covering the nursing department for V2 (Director of Nursing, DON) who is currently on vacation. V19 that staff should step away from the resident if they have to cough or sneeze. V19 stated that the staff needs to perform cough etiquette and cover their mouth and lastly perform hand hygiene. V19 stated that hand hygiene is imperative after staff members cough, so they aren't spreading germs to the resident. V19 stated that cough etiquette entails covering the mouth or nose so that the staff member is not coughing or transmitting germs to someone else or someone else near to them. V19 stated that when a staff member is feeding a resident (1:1), the staff member should not touch the resident's food with the staff member's bare hands because the staff member's hands could have germs on them. V19 stated that staff must prevent the transfer of infection. Facility policy titled Respiratory Hygiene and Cough Etiquette dated November 2024 documents, in part, Policy: All staff will adhere to standard infection control precautions, including respiratory hygiene and cough etiquette, to prevent the spread of respiratory pathogens/infections. Definitions: 'Respiratory hygiene and cough etiquette' refers to a set of practices that staff, residents, and visitors can perform to prevent the spread of respiratory pathogens and infections. Policy Explanation and Compliance Guidelines: 1. The respiratory hygiene and cough etiquette strategy applies to any person with signs of respiratory illness including cough, congestion, rhinorrhea (runny nose), or increased production of respiratory secretions. 1. The elements of respiratory hygiene/cough etiquette include: . d. Hand hygiene (i.e. {that is} handwashing or use of alcohol-based hand rub) after contact with respiratory secretions or contaminated objects. e. Spatial separation (social distancing, maintain a separation of 3 – 6 ft {feet}) . 4. Spatial separation refers to social distancing, maintaining 3 ft – 6 ft, away from the person to reduce exposure. Facility policy titled Hand Hygiene dated February 2025 documents, in part, that for Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed when hands are visibly soiled or when exiting an isolation room, using the restroom, before and after eating and under other conditions listed in, but not limited to, the attached hand hygiene table which indicates after sneezing, coughing, and/or blowing or wiping nose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 8 of 8