Health inspection·August 14, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's policy dated 03/07/2023 and titled Catheter Care documents, in part: Policy: It is the policy of the facility that each resident residing in the facility with a urinary catheter will receive catheter care every shift and as needed. Procedure: General Guidelines: 10. Maintain drainage bag inside of a privacy bag on the bed frame whenever possible. 2. R4's admission diagnoses include but not limited to obstructive and reflux uropathy, hydronephrosis with renal and urethral calculous obstruction, benign prostatic hyperplasia of lower urinary tract and urine retention. R4 Minimal Data Set documents in part, Section C. Brief Interview of Mental Status (BIMS) score of 14 indicating R4 is cognitively intact. Section H. Appliances: A. Indwelling catheter Yes. On 8/11/24 at 10:47 am, R4's indwelling catheter drainage bag was hanging on the bed frame facing the entrance of the doorway in a clear plastic bag not in a privacy bag. R4's POS (Physician Order Set) documents in part, Catheter (Foley Catheter) size 16 FR (French) with balloon of 10 ml (Milliliter) for urinary retention. R4's Care plan documents in part, Focus: R4 has an Indwelling Catheter due to Obstructive Uropathy. On 8/11/24 at 10:49 am, V11 RN (Registered Nurse) stated that the urinary bag should be covered in a blue bag. I (V11) do not remember the name of the bag, to promote dignity and privacy for the resident. On 8/13/24 at 1:30 pm, V3 RN stated that a privacy bag should be on the urinary drainage bag. The urinary drainage bag should be covered to promote residents' dignity and privacy. Facility policy titled Catheter Care dated 3/7/23, documented in part, Purpose: To prevent infection and maintain resident comfort and dignity. General Guidelines: 10. Maintained drainage bag inside of a privacy bag on bed frame whenever possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 2 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide ADL (Activity of Daily Living) care for one dependent resident (R23) to maintain personal hygiene and dignity. This failure affected one resident (R23) out of a sample size of 34. Residents Affected - Few Finding include: R23 has a diagnosis of but not limited to Multiple Sclerosis, Type 2 Diabetes Mellitus, Chronic Diastolic Heart Failure, Hypertensive Heart Disease with Heart Failure and Muscle Weakness. Progress noted dated 8/12/2024 at 3:51pm by V26 (Director of Social Services) documents R23 has a Brief Interview of Mental Status score of 06. On 8/11/2024 at 10:56am surveyor observed R23's fingernails on her right hand to have a black substance under the nails. Surveyor also observed R23 scratching her head several times while interviewing R23. On 8/11/2024 at 11:17am stated that her fingernails are dirty because she has not had her hair washed in at least a month and she has been scratching her head and scalp. R23 said, Of course I would like a shower, my hair washed, and fingernails cleaned and that the itchy scalp annoys the hell out of her. On 8/11/2024 at 2:49pm V7 (Registered Nurse-RN) stated that residents receive showers at least twice a week and as needed by the CNA's. On 8/12/2024 at 10:23am V27 (RN) stated showers are offered at least once a week and if a resident refuses a shower then they will get a bed bath and hair washing depends on the resident. On 8/12/2024 at 1:41pm V3 (RN/Nursing Supervisor) stated nail care, is the responsibility of the CNA and can be provided on shower days and as needed. V3 stated that it is expected that resident fingernails are cleaned and there is no visible dirt underneath the fingernails. R23's Minimum Data Set (MDS) dated [DATE] documents, in part, Personal Hygiene: the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands: Partial/Moderate assistance. ADL (Activities of Daily Living) policy with an effective date of 5/05/2023 documents, in part, residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL's and residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain grooming and personal hygiene. Undated Job Description titled Certified Nursing Assistant documents, in part, the primary purpose of the job position is to provide each of the assigned resident with routine activities of daily living and provides and assists personal care assistance to assigned residents as directed (bathing, grooming/hygiene). Undated policy titled Resident Rights and Dignity documents, in part, each resident shall be cared (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 3 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm for in a manner that promotes and enhances quality of life, dignity and 1. resident shall be treated with dignity and respect at all times, 2. Treated with Dignity means a resident will be assisted in maintaining and enhancing his or her self esteem or self-worth and 3. Resident will be groomed as they wish to be groomed (hairstyles, nails). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 4 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications for one resident (R16) was administered to the resident at the scheduled time. This failure affected one resident (R16) and has the potential to affect all residents in the sample size of 34. Residents Affected - Few Findings include: R16 has a diagnosis of but not limited to End Stage Renal Disease, Insomnia, Depression, Benign Prostatic Hyperplasia, Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension and Acute on Chronic Diastolic Heart Failure. Minimum Data Set (MDS) dated [DATE] does not document a Brief Interview of Mental Status score. R16's Order Summary Report with active orders as of 8/12/2024 does not document an order for self-administration of medication or Bedside Medication Storage. R16's Care plan focus dated 12/13/2022 documents, in part, administer meds as ordered. On 8/11/2024 at 12:20pm surveyor observed 2 clear small medicine cups sitting on a small table on the side of the dresser in R16's room. There was 1 small clear medicine cup that had 10 pills, and the other cup had a box with eye drops. On 8/11/2024 at 12:21pm V28 (R16's Personal Companion) stated she is required to take a picture of the morning medications before they are administered to R16 and yes, these pills are the morning meds. V28 stated that R16 sleeps a lot the day after dialysis and we are required to let him sleep and not disturb him and when R16 wakes up and eats than I will let the nurse know so that they can take his vitals and give him his medicine. On 8/11/2024 at 12:25pm V7 (Registered Nurse-RN) stated R16's daughter has requested that R16 receive his medicine when R16 wakes up. V7 stated that V28 will call me when R16 wakes up so that I can take his vitals and administer his medications. V7 stated that V28 is required to take a picture of the meds when they (R16's medications) are scheduled and the daughter wants the medications pulled when they are scheduled. V7 stated that she signed them out when she left them to the caregiver in R16's room. On 8/12/2024 at 10:23am V27 (RN) stated that if a resident refuses their medicine than we can discard and chart accordingly unless it is still in the allowable timeframe to give the medicine which is one hour before and one hour after the scheduled medication time and that medications should not be left at the bedside. On 8/12/2024 at 10:50am surveyor observed R16's EMAR (Electronic Medication Administration Record) that displayed R16's 9:00am medications in red. On 8/12/2024 at 11:01am V4 (RN) stated that red means the medications are past due. On 8/12/2024 at 5:00pm surveyor reviewed R16's Medication Administration Record (MAR)for 8/11/2024 documents R16 should receive 10 oral medications that are scheduled at 9:00am. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 5 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/13/2024 at about 9:20am surveyor reviewed R16's Medication Administration Audit Report (MAAR) for 8/11/2024 that documents R16's 9:00am blood pressure medication (Midrodrine HCL 10mg TID {three times a day} was administered at 8:13am. On 8/13/2024 at 1:41pm V3 (RN/Nursing Supervisor) stated the expectations are for the nurses to administer medications one hour before and one hour after the scheduled medication time. V3 also stated, If a resident does not have an order to self-administer medications then medications cannot be left at the bedside and medication administration documentation should occur after the medication has been given. V3 stated the initials in the box on the MAR means that the medication was administered, the time on the MAAR is the time the medication was given and in PCC (Point Click Care software) red indicates that the medication is past due or past the scheduled medication time. On 8/14/2024 at 8:30am V29 (Primary Physician) stated Yes, R16 has trouble sleeping and is usually worn out after dialysis so I will give the nurses instructions for R16 not to be disturbed and to give the 9:00am medication after R16 wakes up. V29 also stated there is definitely an understanding with the nurses that if R16 is sleeping that he should not be disturbed and I (V29) will suggest that they wait to give R16 the 9:00am medications. Yes, R16 can still get the 5:00pm dose because his body accommodates and he can still get that 5:00pm dose. Undated policy titled Medication Management Self Administration of Medicines documents, in part, staff shall identify and give it to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage. Medication Administration policy with an effective date of 10/25/2014 documents, in part, medications are administered as prescribed in accordance with good nursing principles and practices, Administration: 2. Medications are administered in accordance with written orders of the prescriber, and Documentation (including electronic): D. The individual who administers medication dose records the administration on the resident's MAR directly after the medication is given. Undated Job Description titled Staff Nurse, documents, in part, the primary role of this employee is to provide direct nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and ensures that resident's medications are administered, in accordance with standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 6 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to ensure that the urinary drainage bag was hanging below the bladder. This failure affected one resident (R4) reviewed in a sample of 34. Residents Affected - Few Findings include: R4's admission diagnoses of Obstructive and reflux uropathy, hydronephrosis with renal and urethral calculous obstruction, fall, benign prostatic hyperplasia of lower urinary tract and urine retention. On 8/11/24 at 10:47 am, R4's was sitting in a chair in the room. R4's indwelling catheter drainage bag was hanging on the bed frame above the level of the bladder. R4 Minimal Data Set documents in part, Section C. Brief Interview of Mental Status (BIMS) score of 14. R4 is cognitively intact. Section H. Appliances: A. Indwelling catheter Yes. R4s POS documents Catheter (Foley Catheter) size 16 FR (French) with balloon of 10 ml (Milliliter) for urinary retention. R4's Care plan documents in part, Focus: I have Indwelling Catheter due to Obstructive Uropathy. On 8/11/24 at 10:49 am, V11 RN (Registered Nurse) stated that the urinary bag should be below the groin level for drainage and gravity. If the urinary bag is above the groin level, it could cause back flow that could cause an UTI (Urinary Tract Infection). On 8/13/24 at 1:30 pm, V3 RN stated that the urinary drainage bag should be place low to allow drainage by gravity. It should be lower than the point of insertion. If it is not below the insertion site it could cause improper drainage, back flow of urine, discomfort, and possible urinary retention. Facility policy titled Catheter Care dated 3/7/23, documented in part, Purpose: To prevent infection and maintain resident comfort and dignity. General Guidelines: 2. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 7 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 and date oxygen equipment (oxygen tubing and nebulizer mask); and failed to properly contain oxygen equipment (nebulizer mask) per the facility policy. These failures affected one residents (R33) reviewed for oxygen equipment, in a total sample of 34 residents. Residents Affected - Few Findings include: R33's face sheet shows that R33 has a diagnosis which includes but not limited neuromuscular dysfunction of bladder, acute and chronic respiratory failure with hypoxia, pressure ulcer of the sacral region stage 4, and Alzheimer's disease. R33's Brief Interview for Mental Status (BIMS) dated 07/30/24 does not document a BIMS score for R33 and indicates that R33 has memory problems. R33 was not able to answer questions asked by surveyor. 08/11/24 at 10:35 am, R33 was observed in bed resting with 3 liters (L) nasal canular (NC) of oxygen administering, R33's oxygen tubing undated, and R33's nebulizer mask undated and uncontained. On 08/11/24 at 12:49 pm, this observation was brought to the attention of V3 (Registered Nurse, RN, Nursing Supervisor) and V3 stated that oxygen tubing should be changed once a week on the night shift. V3 also stated that nebulizer mask should be labeled with a date and bagged when not in use. When R3 was asked regarding the importance of labeling the oxygen tubing and ensuring that the nebulizer mask was placed in a bag when not in use V3 stated, For sterility, cleanliness and for infection prevention. R33's Physicians Order Sheet (POS) dated 10/08/2022 shows that R33 has orders to Change oxygen humidifier bottle and nasal canular once weekly every night shift and PRN (as needed). Label with date and nurse initials. The facility's document dated 01/01/2020 and titled Respiratory Care- Prevention of Infection documents, in part: Policy: Staff will follow protocol to minimize risk of infection related to respiratory care. Purpose: The purpose of this policy is to guide prevention of infection associated use of respiratory equipment, including oxygen, nebulizer's etc. among residents . Procedure: Infection Prevention Related to Oxygen Administration: Change the oxygen cannulas and tubing every seven (7) days, or per state regulations (whichever is stricter) or as needed, date and label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 8 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to post the daily nursing staffing. This failure has the potential to affect all 59 residents residing in the facility. Residents Affected - Many Findings include: On 8/11/24 at 9:00 am, facility census of 59 residents. On 8/11/24 at 9:00 am, upon entrance to the facility, the facility's daily staff posting was not posted or observed in the lobby. On 8/12/24 at 9:45 am, no facility's daily staff posting or observed in the lobby. On 8/12/24 at 9:45 am, V24 (Receptionist) showed the surveyor the Nursing Department Daily Schedule for 8/12/24 and stated that the daily schedule is the only sheet we have. The daily schedule was behind the receptionist desk, not visible. On 8/13/24 at 11:56 am, V1(Administrator) stated. I (V1) told the DON (Director of Nursing) about the staffing posting and the DON said it was not specific on what they wanted on the posting. I do not know why we got away from doing it. I told the scheduler moving forward what the daily staff posting should look like. We had it posted, just not in the proper format. Surveyor inquired to V1 if behind the reception desk is considered posting and visible, V1 stated, No. V1 stated that the daily schedule was the only thing we had for staffing. Surveyor inquired to V1 if they had knowledge on the regulatory requirements for posting staffing, V1 did not respond to the surveyor question and stated that every facility does it different. Facility Policy titled Daily Staff Posting dated 6/6/24, documents in part, Purpose: The purpose is to provide residents and families with daily staffing hours per shift to ensure proper nursing care is provided in the facility. The (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) State Operations Manual documented, in part §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 9 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 0732 (C) Certified nurse aides. Level of Harm - Minimal harm or potential for actual harm (iv) Resident census. §483.35(g)(2) Posting requirements. Residents Affected - Many (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. GUIDANCE §483.35(g) The facility ' s staffing data document may be a form or spreadsheet, as long as all the required information is displayed clearly and in a visible place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 10 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure that a medication cart was kept locked. This failure has the potential to affect all 15 residents on the 6th floor unit. Findings include: On 08/11/24 facility presented a census of 15 residents on the 6th floor unit. On 08/11/24 at 9:56 am, Surveyor observed the 6th floor medication cart unlocked, unattended, with the third drawer of the medication cart slightly opened, medication cards exposed, and not in view of licensed nurse. Between 9:56 am and 10:01 am, no licensed nurse in view of medication cart. On 08/11/24 at 10:07 am, V4 (Registered Nurse, RN) returned to the 6th floor medication cart and Surveyor brought this observation to V4(RN). V4 stated It (referring to the 6th floor medication cart) should be locked to make sure no one touches it (referring to the 6th floor medication cart). When V4 was asked regarding the importance of ensuring the medication cart is locked when not in use or in visibility of the nurse, V4 stated, So that the medications are safe. If a patient (resident) gets the medications it can be unsafe. They (referring to the residents) can take the medication and either a medication error can occur, or it can cause death. On 08/13/24 at 11:40 am, V3 (Registered Nurse, RN, Nursing Supervisor) stated that medication carts should be locked when not in attendance by the nurse for the safety of the residents and the contents of the cart. V3 also stated that the medication cart should only be accessed by the nursing staff or nursing supervisor on duty. When V3 was asked regarding what could happen if a medication cart is left unlocked and unattended by the nurse on duty, V3 stated that a medication error, loss of medications and the safety of the resident and staff can be compromised. The facility's policy dated 05/01/2018 and tilted Storage of Medications documents, in part: Policy: Medications and biological's are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 11 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R16 has a diagnosis of but not limited to End Stage Renal Disease, Insomnia, Depression, Benign Prostatic Hyperplasia, Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension and Acute on Chronic Diastolic Heart Failure. Residents Affected - Few Minimum Data Set (MDS) dated [DATE] does not document a Brief Interview of Mental Status score. On 8/11/2024 at 12:17pm surveyor observed R16's personal refrigerator freezer with a large amount of ice that had built up inside and outside of the freezer. R16 also has a separate personal freezer that had no temperature log. On 8/12/2024 at 10:00am V14 (Dietary Manager) stated that the dietary aides are responsible for completing the temperature log daily unless there is a private sitter or personal companion, then they (private sitter or personal companion) are responsible. V14 stated that R16 has a personal companion who is responsible for defrosting the freezer. V14 stated that it was her (V14) fault that R16's freezer had no log and that it slipped her mind to bring new temperature log for the resident. Undated policy titled Policies and Procedures Regarding use & Storage of Food Brought to Resident from outside the Facility documents, in part, a temperature log will be kept in front of the refrigerator. Undated policy titled Policies and Procedures Regarding use & Storage of Food Brought to Resident from outside the Facility documents, in part, personal refrigerator temperatures are maintained at 41 degree Fahrenheit or below and refrigerators are cleaned regularly to maintain a safe and sanitary environment for food storage. Based on observation, interview, and record review, the facility failed to ensure a personal freezer has a temperature log and a personal refrigerator has no ice built up for 1 (R16) resident and failed to ensure the personal refrigerator has a temperature log for 1 (R46) resident. These failures affected 2 (R16 and R46) residents reviewed for personal food in the total sample of 34 residents. Findings include: 1. On 08/11/2024 at 10:50am, there was a small refrigerator inside R46's room. There was no temperature log on the front or sides of the refrigerator. R46 stated I (R46) have my (R46) ice cream inside the refrigerator. On 08/11/2024 at 10:54am, V6 (RN Nurse Supervisor) checked R46's personal refrigerator and stated there is one [NAME] chocolate ice cream cup and 4 Blue Ribbon cups inside the freezer. V6 also stated there are no expiration dates written on the cups. V6 checked R46's personal refrigerator for temperature log. V6 stated there is no temperature log for R46 personal refrigerator. On 08/11/2024 at 11:05am, V6 stated honestly, we (facility) don't have a temperature log for his (R46) personal refrigerator. I (V6) have no idea when they put the refrigerator in his (R46) room. On 08/13/2024 at 9:22am, V3 (RN Nursing Supervisor) stated the Dietary Staff should check the personal refrigerator to ensure the food are still viable, the temperature is in operating temperature (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 12 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 0813 between 36F to 46F and to ensure the refrigerator is working properly as it should be. Level of Harm - Minimal harm or potential for actual harm On 08/13/2024 at 10:48am, V3 stated personal refrigerator should be checked daily by the Dietary Staff. Residents Affected - Few R46's (Active Order As Of: 08/12/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) dementia, protein-calorie malnutrition, and hypertension. Dietary- Regular/General diet Regular texture, regular (thin liquid) consistency. Status: Active. Order Date: 08/01/2024. Start Date: 08/01/2024. R46's (05/02/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 14. Indicating R46's mental status as cognitively intact. The (08/13/2024) email correspondence with V3 documented, in part In regard to checking the personal refrigerator temperature daily: The purpose of this task is to ensure that the refrigerator is in proper operating temperature/function. It also a ensures that the contents of the refrigerator are kept at consistent and desirable temperature that ensures food safety. A copy of the (undated) Refrigerator Temperature Log indicated 'Date' from 1 through 31 on the first column and 'Temperature' on the second column. The (undated) Policies and procedures regarding use and storage of food brought to resident from outside the facility documented, in part The following steps must be taken to ensure proper handling of food or beverage. A temperature log will be kept in front of the refrigerator. The (undated) Food brought in by family or visitors personal refrigerators policy documented, in part Policy: Clients may accept food from family or visitors. The health are community provides visitors with information on safe food handling practices. Procedure: Food or beverages brought in by family or visitors may be stored in the client's personal refrigerator. Personal refrigerator temperatures are maintained at 41F or below. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 13 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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** 2. On 08/12/2024 at 9:03am during the Medication Administration task with V16 (Registered Nurse), V16 prepared R13's medications. V16 placed R13's medication cup on the medication tray. Residents Affected - Some On 08/12/2024 at 9:04am, V16 knocked at R13's door and mentioned R13's name, entered R13's room, and placed the medication tray on top of R13's bedside table and administered R13's medications. On 08/12/2024 at 9:07am, V16 placed the medication tray he (V16) used for R13 on top of the 7th floor medication cart without sanitizing the medication tray; opened the electronic health record and documented the medication administration. V16 opened R18's eMAR (electronic Medication Administration Record) and stated R18's medications are to be crushed. On 08/12/2024 at 9:15am, V16 prepared R18's medications. V16 placed R18 medications on the same medication tray he (V16) used for R13. On 08/12/2024 at 9:17am, V16 placed the medication tray that contained R18's medications on the table where R18 was eating and administered R18's medications. On 08/12/2024 at 9:22am, V16 placed the medication tray that he (V16) used for R13 and R18 on top of the medication cart without sanitizing the medication tray; opened R29's eMAR and stated that R29's medications are also crush with nectar thick liquid. On 08/12/2024 at 9:27am, V16 placed 4 med cups on the medication tray he(V16) used for R13 and R18 and counted the medications he (V16) prepared for R29 and stated there are 4 pills I (V16) prepared for (R29). On 08/12/2024 at 9:28am, V16 knocked at R29's door. Entered the room and placed the medication tray, which contained R29's medications, on R29's night stand. V16 administered R29's medications. On 08/12/2024 at 9:32am, V16 placed the medication tray he (V16) used for R13, R18 and R29 without sanitizing the medication tray. This surveyor inquired if V16 still has medications to pass. V16 checked the electronic health record and stated I (V16) still have to pass medications to (R16). V16 opened the medication storage room and brought out Nephro Therapeutic Nutrition 237ml and placed it on the medication tray he (V16) used for R13, R18 and R29. At this point, surveyor inquired how many times V16 sanitized the medication tray between residents. V16 stated I (V16) did not sanitize the medication tray between residents. I (V16) am supposed to sanitize the medication tray between residents with Lysol wipes. I (V16) forgot to sanitize the medication tray. The importance of sanitizing the medication tray between use is to prevent cross contamination. On 08/13/2024 at 9:24am, V3 (RN Nursing Supervisor) stated the medication tray should be sanitized between residents to prevent cross contamination. R13's (08/12/2024) Medication Admin(administration) Audit Report indicated that V16 documented administration of R13's medications at 09:08(am). R18's (08/12/2024) Medication Admin(administration) Audit Report indicated that V16 documented administration of R18's medications at 09:22(am). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 14 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 R29's (08/12/2024) Medication Admin(administration) Audit Report indicated that V16 documented administration of R29's medications at 09:32(am). The (08/13/2024) email correspondence with V3 documented, in part 4. Medication Tray - The expectation of medication tray is to be disinfected after every use between residents. The purpose of this task is to promote infection control and prevent cross contamination and spread of germs between residents. 3. On 08/12/2024 at 9:39am there was a contact and droplet precautions signs posted by R211's door. There was a trash receptacle, that was slightly open noted with blue color material, outside of R211's room. Beside the trash receptacle was also a PPE (Personal Protective Equipment) bin. Inside the room was V15 (Registered Nurse) wearing gown, gloves, mask, and faceshield. This surveyor walked towards the 6th floor nurse's station and waited for V15. When V15 got on to the nurse's station, this surveyor requested to see the Infection preventionist. On 08/12/2024 at 9:56am, with V3 (RN Nursing Supervisor) this surveyor opened the trash receptacle located outside of R211's room via a foot pedal; inside the receptacle were gowns, gloves and faceshield. V3 stated the trash bin should be inside the room of the resident on contact/droplet precautions to prevent further contamination of the outside of the isolation room. The trash bin should not be beside the PPE bin to prevent contaminating the outside of the PPE bin. R211's (Active Order As Of: 8/13/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Covid-19. Order Summary. Transmission Based Precautions (contact/droplet) for Covid-19 Active 8/11/2024. R211's census list documented that R211 was admitted on [DATE]. R211's (08/11/2024) Care plan documented, in part I am admitted with Covid-19 infection. All services are done inside the room to prevent the spread of infection. R211's (08/09/2024) Printable discharge Form documented, in part Pt (patient) is Covid positive. The (undated) Contact Precautions poster documented, in part Providers and staff must also: Discard gloves before room exit. Discard gown before room exit. The (undated) Droplet Precautions poster documented, in part Everyone must: Remove face protection before room exit. The (08/13/2024) email correspondence with V3 documented, in part 5. Trash Receptacle - The expectation of trash receptacle use for transmission based precautions is that the trash receptacle shall be placed inside the residents room. The purpose of this is to prevent spread of infection and to contain whatever transmissible organism is being isolated. The (05/06/2024) coronavirus documented, in part GENERAL: (Facility) continues to be focused on minimizing the impact of COVID- 19 and other respiratory infections on the residents in the facility, who are at higher risk of severe outcomes due to respiratory viral infections. Important facts: 2. Transmission: COVID- 19 is spread from person to person by respiratory droplets between people who are in close contact with another. While there is not yet evidence for spread from surfaces or objects (fomites) this may also be a possible mechanism of transmission. Procedure. 1. A Contact Droplet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 15 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 Transmission Based Precaution will be put in place when a resident is suspected to have COVID-19 or is tested positive for COVID-19 this means wearing a gown, gloves, face mask, and goggles or face Shields. The facility will post information, like posters and Flyers that remind patients, staff, and visitors to practice good respiratory and hand hygiene. 4. Source control. If used during the care of a resident for which a NIOSH- approved respirator or face mask is indicated for personal protective equipment, they should be removed and discarded after the resident care encounter. Based on observation, interview, and record review the facility failed to ensure two residents (R33 and R56) intravenous site (IV) was labeled with a date; failed to ensure staff sanitize the medication tray after use for two residents (R18 and R29); failed to ensure the trash receptacle for residents on isolation was not outside the resident room and was not side by side with the PPE (Personal Protective Equipment) bin for one resident (R211); and failed to ensure a resident (R211) who was positive for COVID 19 maintain contact/droplet isolation precautions in efforts to prevent the spread of COVID 19; including failure to prevent a resident's (R212) exposure. These failures affected five residents (R18, R29, R33, R56, R212 and R211) and has the potential to affect all 15 residents on the 6th floor unit. Findings include: 1. On 08/11/24 facility presented a census of 15 residents on the 6th floor unit. On 08/11/24 at 10:10 am, R211 was observed sitting in a wheelchair, in R212's room, without wearing a facemask. R212 was also observed not wearing a facemask. On 08/11/24 at 10:31 am, R56 was observed in bed awake, alert with an IV site to R56's right hand that was not labeled with a date. R56 stated that R56 has had R56's right hand IV site for a while. On 08/11/24 at 10:34 am, R33 was observed in bed, not alert with an IV site to R33's left arm that was not labeled with a date. On 08/11/24 at 12:50 pm, V3 (Registered Nurse, RN, Nursing Supervisor) stated that peripheral IV sites should be labeled with a date so that the nurse knows when the IV was inserted. When V3 was asked regarding the importance of dating peripheral IV sites V3 stated, So staff knows when to change the IV site and dressing ,and to prevent the IV site from getting and infection. On 08/13/24 at 11:36 am, V3 (Registered Nurse, RN, Nursing Supervisor) stated that residents who have a positive COVID 19 status are isolated in a private room and remain alone in the residents room. V3 explained that residents with a positive COVID 19 status will have all the residents services performed alone in the residents room. V3 also explained that residents with positive COVID 19 status should not come out the residents room to socialize in other residents rooms or with other residents. V3 stated if a resident with a positive COVID 19 status leaves out of the room the resident should wear a mask. When V3 was asked regarding the importance of a resident who is positive COVID 19 status is maintained in a Droplet/COVID 19 isolation room V3 stated, To prevent the spread of the disease to staff and other residents and ultimately to protect the residents. R33's face sheet shows that R33 has a diagnosis which includes but not limited neuromuscular dysfunction of bladder, acute and chronic respiratory failure with hypoxia, pressure ulcer of the sacral region stage 4, and Alzheimer's disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 16 of 17 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 R33's Brief Interview for Mental Status (BIMS) dated 07/30/24 does not document a BIMS score for R33 and indicates that R33 has memory problems. R33 was not able to answer questions asked by surveyor. R56's face sheet shows that R56 has a diagnosis which includes but not limited to sepsis due to Escherichia coli, urinary tract infection, type 2 diabetes mellitus with diabetic chronic kidney disease. Residents Affected - Some R56's Brief Interview for Mental Status (BIMS) dated 06/28/24 shows that R56 has a BIMS score of 15 which indicates that R56 is cognitively intact. R211's face sheet shows that R211 was admitted to the facility on [DATE] with diagnosis with include but not limited to COVID 19 onset on admission [DATE]. R211's Brief Interview for Mental Status (BIMS) dated for submission of 08/15/24 shows that R211 has a BIMS score of 15 which indicates that R211 is cognitively intact. R212's face sheet shows that R212 has a diagnosis which includes but not limited to periprosthetic fracture around internal prosthetic left hip joint subsequent encounter, anemia, essential hypertension, and gastro-esophageal reflux disease. R212's Brief Interview for Mental Status (BIMS) dated for submission of 08/15624 shows that R212 has a BIMS score of 14 which indicates that R212 is cognitively intact. R33's POS shows that R33 does not have orders for R33's left arm IV site on 08/11/24. R56 POS dated 07/11/24 documents, in part: Nursing to insert PIV (peripheral intravenous) and manage. R211's Physician Order Sheet (POS) dated 08/11/24 shows that R211 has orders for Transmission Based Precautions (contact/droplet) for COVID 19 every shift active 08/11/24 The facility's document dated 09/01/2016 and titled Peripheral IV Dressing Changes documents, in part: Policy: Peripheral IV dressings will be changed when needed to prevent catheter-related infections associated with contaminated, loosed or soiled catheter-site dressings . Procedure: 7. Label dressing with date, time, and initials. The facility's policy dated 05/06/2024 and titled Coronavirus documents, in part: General: The facility continues to be focused on minimizing the impact of COVID 19 and other respiratory infections on the residents in the facility, who are at higher risks of severe outcomes due to respiratory viral infections . Procedure: 1. Contact -Droplet Transmission Based Precautions will be put in place when a resident is suspected to have COVID 19 or is tested positive for COVID 19. This means wearing a gown, gloves, facemask, and goggles or a face shield. The facility will post information, like posters and flyers that remind patients, staff, and visitors to practice good respiratory and hand hygiene . 5. Management of Residents: I. g. Pending transfer or discharge, place a facemask on the patient and isolate him/her with the door closed. h. Limit transport and movement of the patient/resident outside of the room. Resident should wear a facemask to contain secretions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 17 of 17