Inspection·December 17, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's (11/7/24) functional assessment affirms partial/moderate assistance is required for eating and toileting hygiene. R2's (5/21/24) care plan states resident has a self-care deficit and requires extensive assistance with most ADL's. Intervention: provide assistance with all ADL's as required per the residents need dependence: eating and personal hygiene. Resident is incontinent of bowel and bladder. Interventions: administer appropriate cleansing and peri care after each incontinent episode. On 12/9/24 at 2:18pm, R2 was lying in bed requesting water (repeatedly) in Spanish however none was available in the room. V4 (RN) subsequently provided water, R2 drank the entire cup of water immediately. A reasonable person who was experiencing extreme thirst would consistently yell out for water and then engorge themselves after it was received. The front of R2's incontinence brief had a blue line present (indicating the brief was wet). V6 (CNA) removed R2's brief (as requested) and it was soiled with urine. On 12/11/24 at 10:09am, surveyor inquired about the requirement for checking and/or changing incontinent residents V2 (Director of Nursing) stated The CNAS every 2-hour round, so they supposed to be doing they rounds every 2 hours. The (4/14) Activities of Daily Living policy includes but not limited to the following interventions: bathing, grooming (maintaining personal hygiene including shaving, manicure) however incontinence care was excluded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 2 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure they have a policy for scheduling/rescheduling appointments, failed to ensure that reported concerns were resolved and failed to re-schedule a Neurology appointment for one of three residents (R1) in the sample. Residents Affected - Few Findings include: The (12/9/24) facility census includes 117 residents. R1's diagnoses include Multiple Sclerosis. R1's (11/11/24) progress notes state Resident out for appointment for Neurology clinic. On 12/11/24 at approximately 11am, surveyor requested R1's (11/11/24) Neurology Consultation. V2 (Director of Nursing) stated I (V2) did see in the documentation on November 11, but she (R1) was complaining that she's hungry, so she didn't go to the appointment. On 12/11/24 at 1:32pm, surveyor inquired if R1 and/or family reported care concerns. V16 (Minimum Data Set Coordinator) stated Her daughter (V3/Family) worries about (R1's) Neurology appointments but they're not getting done. I tell the DON (Director of Nursing) about her (V3's) concerns and that she wants a Neurology appointment but nothings being done and affirmed that reported concerns are documented. R1's (11/18/24) concern form states administration not communicating with (daughter) about resident's care. No responses from Social Service. Action: concerns were shared with Nursing as majority of concerns involve Nursing and Medical Care. Effort was made to writer for care plan at the time she requested. She did not answer, called the next day, and claimed staff never called. Recommendations: family conference. Final Disposition: unresolved. Nursing to call and follow-up on medical concerns. On 12/11/24 at 2:34pm, surveyor inquired about R1's (11/18/24) concern form. V17 (Social Service Director) stated It was following up after a care plan meeting because she (referring to V3) didn't pick up. She called the next day asking why she wasn't called but we (staff) did explain that we called, and a message was left she (V3) said she didn't receive it. Surveyor inquired about R1's reported concerns. V17 responded They were medically based I had asked for Nursing, the DON to follow-up on the medical concern. Surveyor inquired if V2 (DON) followed-up on R1's reported concerns. V17 replied I (V17) wouldn't be aware if she (V2) did or not, I wouldn't know. I know everything was presented to her. The concern form was written out and she received a copy. Surveyor inquired why R1's (11/18/24) concern form states 'Unresolved V17 stated I try to answer within 72 hours, but I had not gotten confirmation that the DON followed-up and affirmed that V2 is also responsible for completing the form. On 12/11/24 at 2:02pm, V15 (Admissions Director) affirmed that she schedules transportation for resident appointments. Surveyor inquired if R1's Neurology appointment was re-scheduled. V15 stated I (V15) would know if there was a re-scheduled appointment. If they (staff) scheduled it, I would see it on the home page on in Healthcare Software. I have not seen a recent appointment for the Neurologist, no. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 3 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 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 On 12/16/24 at 1:00pm, V1 (Administrator) affirmed (via email) We don't have the policy for rescheduling /scheduling. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 4 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on observation, interview, and record review the facility failed to ensure that sufficient Wound Care Nurses are available to meet resident needs, failed to provide timely incontinence care, failed to administer prescribed treatments, failed to ensure that staff are aware of required LALM (Low Air Loss Mattress) settings and failed to ensure that the LALM was on the correct setting for three of three residents (R1, R2, R3) reviewed for pressure ulcers. These failures resulted in R1 sustaining a (facility acquired) sacrum pressure ulcer with tailbone exposure/fracture and radiographic suggestion of osteomyelitis, R2 sustained a stage 3 (facility acquired) pressure ulcer, and R3 sustained a stage 3 (facility acquired) pressure ulcer. Residents Affected - Few Findings include: The (12/3/24) facility pressure ulcer log affirms R1, R2 and R3 sustained (facility acquired) sacrum pressure ulcers. 1) R1's diagnoses include dementia, multiple sclerosis, neuromuscular dysfunction of bladder, type 2 diabetes mellitus, (Stage 4) pressure ulcer of sacral region, hemiplegia, and hemiparesis. R1's (11/21/24) functional assessment affirms resident requires substantial/maximal assistance with rolling left and right. R1's (11/21/24) risk assessment for potential skin integrity impairment determined a score of 13 (moderate risk). R1's (12/3/24) skin alteration assessment includes (facility acquired) sacrum (stage 2) pressure injury 1.3 x 1.3 x 0.3cm (centimeters). R1's (9/24/24) care plan states resident has an alteration in skin integrity and is at risk for additional and/or worsening skin integrity issues related to incontinence and impaired mobility. Intervention: Air loss mattress. R1's (1/8/24) POS (Physician Order Sheets) include pressure reduction mattress. R1's (12/5/24) weight was 133.6 pounds. On 12/9/24 at 2:03pm, R1 was in bed and the LALM was set on alternate #5. Surveyor inquired when R1 was placed in the wheelchair. V5 (CNA/Certified Nursing Assistant) stated A little bit after 10am (roughly 4 hours prior). V5 subsequently removed R1's incontinence brief (as requested) a large bowel movement was adhered to the skin between the buttocks and lower back. Surveyor inquired what was on R1's skin V4 (CNA) replied Poop. Bowel movement was also present on R1's sacrum dressing dated 12/7 (two days prior). R1's (November 2024) TAR (Treatment Administration Record) includes the following physician orders: apply to sacrum Balsam Peru Castor Oil daily however 9 (see nurses note) is documented for 11/3, 11/9, 11/15, 11/16, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/26 and 11/27 entries. R1's (11/3, 11/9, 11/15, 11/16, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/26 and 11/27 2024) progress notes exclude wound care documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 5 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few On 12/11/24 at 1:12pm, surveyor inquired what a #5 setting indicates on the LALM. V11 (Wound Care Nurse) stated I don't know, I don't know what weight that is. We got 2 of them (LALM) that don't got no weight on it and it may be the in between setting. I came back from maternity leave mid-November and I haven't checked them since I got back. Surveyor inquired about R1's sacrum wound and current treatments. V11 responded Currently she has collagen to the site. Her wound looks really good, its open in just a little area. It's healing very well. We have it (Collagen) scheduled every other day unless its PRN (as needed). R1's (12/13/24) CT (Computed Tomography) Pelvis (obtained 2 days later) states indication: worsening deep sacral wound. Check for soft tissue infection and underlying osteomyelitis. Findings: there is no skin or subcutaneous tissue over the distal vertebral column where the sacrum transitions to the coccyx. There is associated focal sacrococcygeal sclerosis and fracture of the distal bone concerning for osteomyelitis. Impression: penetrating 4.7 x 4.8cm skin and soft tissue defect (ulcer) exposes the tailbone beginning where the sacrum transitions to the coccyx, complicated by radiographic suggestion of osteomyelitis. On 12/16/24 at 2:18pm, surveyor inquired about potential harm to a resident if wound treatments are not administered as ordered. V18 (Medical Director) stated Its gonna get worse and worse. Surveyor inquired about potential harm to a resident with bone exposure. V18 responded osteomyelitis and sepsis. 2) R2's diagnoses include dementia, type 2 diabetes mellitus, and stage 3 chronic kidney disease. R2's (11/7/24) functional assessment affirms resident requires partial/moderate assistance with rolling left and right. R2's (11/7/24) risk assessment for potential skin integrity impairment determined a score of 16 (low risk). R2's (12/3/24) initial skin alteration assessment includes (facility acquired) sacrum (stage 3) pressure injury 3.2 x 5.8 x 0.2cm. What is the probable or known cause of the skin alteration? pressure and incontinence. R2's (5/11/24) care plan states resident is at increased risk for alteration in skin integrity related to peripheral vascular disease, diabetes mellitus and incontinence. Interventions: precautions for prevention of Pressure Ulcers will be completed: good peri care. R2's POS includes (2/5/24) pressure reduction mattress. On 12/9/24 at 2:18pm, R2 was lying atop of a LALM, and the setting was on 160 (pounds). Surveyor inquired about the settings on R2's LALM V4 (RN/Registered Nurse) stated I don't deal with this. I think who deals with this is restorative if I'm not mistaken. R2's incontinence brief had a blue line present (indicating the brief was wet). V6 (CNA) removed R2's brief (as requested) and it was soiled with urine. On 12/11/24 at 1:18pm, surveyor inquired if R2 weighs 160# (lbs). V11 (Wound Care Nurse) stated I don't think so then reviewed R2's electronic medical records and affirmed It's 123.4 (pounds) on 12/6/24. Surveyor inquired what R2's mattress is supposed to be set on. V11 responded I don't know. I'm not sure what the setting's supposed to be. Surveyor inquired about R2's current sacrum treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 6 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few V11 replied He gets Medihoney to the sacrum. Surveyor inquired who's responsible for dressing changes. V11 stated I do them every time I'm here and sign them off. Today I'm working on the floor, so the Nurses are responsible for wound care and affirmed that she's the only Wound Care Nurse employed by the facility. R2's (December 2024) TAR includes the following physician orders: apply to sacrum Medihoney and cover with bordered foam daily however the treatment was not documented on 12/8 (the entry is blank). 3) R3's diagnoses include type 2 diabetes mellitus. R3's (9/1024) functional assessment affirms R3 requires substantial/maximal assistance for rolling left and right. R3's (9/10/24) risk assessment for potential skin integrity impairment determined a score of 14 (moderate risk). R3's (2/2/24) care plan states resident has potential/actual impairment to skin integrity. Intervention: Keep skin clean and dry. R3's (10/31/24) initial skin alteration assessment includes (facility acquired) sacrum (stage 3) pressure injury. 1.0 x 1.0 x 0.5cm. R3's (10/19/20) POS includes pressure reduction mattress. On 12/9/24 at 1:49pm, R3 was lying atop of a LALM. Surveyor inquired about the settings on R3's LALM V4 (RN) replied I am not too familiar with the air settings. V5 (CNA) affirmed that R3's LALM setting was on #8 (350 pounds) however R3 appeared to be less than half that weight. [R3's 12/6/24 weight was 138.0 pounds therefore the LALM was on the incorrect setting]. Surveyor inquired when R3's incontinence brief was last checked and/or changed V5 responded. Around lunch, she may be wet. V5 removed R3's brief (as requested) and affirmed it was soiled with urine. On 12/11/24 at 1:09pm, surveyor inquired who's responsible for the facility LALM settings. V11 (Wound Care Nurse) stated I set them, and I go around maybe once a month to check on them. Surveyor inquired why R3's LALM was set on #8 (on 12/9/24). V11 responded I can't answer that cause I'm not really sure why that was set on 8. It should not have been. Surveyor inquired if R3 weighs 350 pounds. V11 replied She does not, she's not big at all. Surveyor inquired about R3's current sacrum treatment. V11 stated She (R3) just has betadine to the site. R3's (December 2024) TAR (Treatment Administration Record) includes the following physician orders: apply Betadine to sacrum one time a day however on 12/8/24 the entry is blank. The (8/23) Low Air Loss Mattress policy states low air loss mattresses may be used for residents who are high risk for pressure ulcer/injury development. Operating instructions: turn the pressure adjust knob to set a comfortable pressure level from soft to firm. [required settings including numbers and/or weights are excluded from the policy]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 7 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interview and record review the facility failed to follow policy procedures, failed to ensure that staff were available to provide restorative care, and failed to ensure that restorative care was provided as directed for three of three residents (R1, R2, R3) in the sample. These failures have the potential to affect all 38 residents on the second floor. Findings include: The (12/9/24) facility census includes 117 residents. On 12/9/24 at 1:39pm, surveyor inquired about the current (2nd floor) staffing. V4 (RN/Registered Nurse) stated Today I (V4) have 38 (residents) and two CNAS (Certified Nursing Assistants), one's restorative. On 12/9/24 at 1:49pm, surveyor inquired about the current (2nd floor) staffing. V5 (Certified Nursing Assistant) stated It's only two of us with the Nurse (referring to V4) so we got the whole floor. We got 38 patients. Surveyor inquired which CNA was currently working with V5, V5 responded She's a CNA but she's the Restorative Aide too (referring to V8/Restorative CNA). When it's short, they pull restorative to the floor so there's no restorative going on today because the patients need to be done. R1, R2, and R3 reside on 2nd floor. 1) R1's (9/24/24) care plan states resident would benefit from participation in an AROM (Active Range of Motion) Restorative Nursing Program due to multiple sclerosis. Intervention: The Restorative Aide and/or Unit Aide will complete AROM Programming to BUE (Bilateral Upper Extremities) 1 set x 10 reps. The Restorative Aide and/or Unit Aide will document the program minutes within the Point of Care Module as indicated per the schedule. R1's (12/2024) Nursing Rehab documentation includes AROM to BUE 7 days a week, 15 minutes a day however on 12/7 and 12/9 nothing is documented (entries are blank). 2) R2's (5/21/24) care plan states resident would benefit from participation in an AROM Restorative Nursing Program. Intervention: The Restorative Aide and/or Unit Aide will complete AROM Programming to BUE 1 set x 10 reps. The restorative Aide and/or Unit Aide will document the program minutes within the Point of Care Module as indicated per schedule. R2's (11/2024) Nursing Rehab documentation states Active ROM to BUE 7 days a week, 15 minutes a day however on 11/18 and 11/26 nothing is documented (entries are blank). 3) R3's (10/16/24) care plan states resident would benefit from participation in the (Passive Range of Motion) PROM Restorative Nursing Program as evidenced by generalized weakness. Intervention: The Restorative Aide and/or Unit Aide will complete PROM Programming to the BUE and BLE (Bilateral Lower Extremities). The Restorative Aides and/or Unit Aide will document the program minutes within the Point of Care Module as indicated per the schedule. R3's (12/2024) Nursing Rehab documentation includes Passive ROM to BUE and BLE with assist from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 8 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff 7 days a week 15 minutes a day, 1 set of x 15 reps however on 12/8 the entries are marked N/A (not applicable). On 12/9/24 at 2:45pm, surveyor inquired about the current (1st floor) staffing. V7 (Restorative CNA) stated Mondays are always bad; I actually do restorative and affirmed she was pulled to work on the floor. Surveyor inquired who provided restorative care to the residents today V7 responded Nobody. We have 2 restorative aides in the building and the other restorative aide (referring to V8) was pulled and worked the 2nd floor today. On 12/11/24 at 10:51am, V14 (Restorative Nurse) stated I have 2 restorative aides they work Monday through Friday unless it's their weekend to work. Surveyor inquired why both restorative aides were pulled to work the floor on Monday (12/9/24) V14 responded I wasn't here Monday, so I don't know what happened. Surveyor inquired how many facility residents are receiving restorative care V14 replied Everyone is in some type of restorative program. Surveyor inquired what a blank space on the Nursing Rehab documentation indicates. V14 stated It wasn't documented and whatever ain't documented wasn't done. The (9/14/24) Restorative Nursing Program states the facility promotes restorative nursing to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Restorative Nursing is available seven days a week and is provided for residents with assessed needs according to program criteria. The Restorative Nursing Program is designed to: preserve function, promote optimal improvement, increase independence, self-esteem and dignity, promote safety, minimize deterioration within the limits of normal aging and/or recognized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 9 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 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 Residents Affected - Few 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 follow policy procedures, failed to transcribe Physician Orders, failed to ensure that indwelling urinary catheter treatments are on the TAR (Treatment Administration) record, and failed to monitor/record/report abnormal urine findings to the Physician for one of three residents (R1) in the sample reviewed for bowel/bladder incontinence. Findings include: R1's diagnoses include neuromuscular dysfunction of bladder. R1's (9/24/24) care plan states resident has an indwelling catheter related to skin breakdown. Interventions: monitor/record/report to Medical Doctor signs/symptoms of UTI (Urinary Tract Infection). R1's POS (Physician Order Sheets) include (5/15/24) Change urinary drainage bag monthly on the 15th and as needed. (8/19/24) Change (Indwelling Urinary) catheter as needed for blockage, leaking, or malfunctioning. (8/23/24) Clean urethra catheter site daily and as needed. R1's (November-December 2024) TAR excludes catheter treatment and/or clean urethra orders. R1's (November-December 2024) MAR (Medication Administration Record) states catheter care: change (indwelling urinary) catheter as needed for blockage, leaking or malfunction as needed [change urinary drainage bag monthly and clean catheter urethra site were excluded]. On 12/9/24 at 2:03pm, R1's indwelling urinary catheter tubing was coated with a white, purulent substance and the urine was notably cloudy. Surveyor inquired about the appearance of R1's catheter V4 (Registered Nurse/RN) stated There's sediment. Surveyor inquired about the appearance of R1's urine V5 (Certified Nursing Assistant) responded Cloudiness. Surveyor inquired when R1's catheter bag was last changed V5 replied I don't know when, I don't know if they have certain days to change that or what. On 12/9/24 at 2:26pm, surveyor inquired when R1's indwelling urinary catheter was inserted and/or urine drainage bag was changed. V4 (RN) reviewed R1's TAR and stated, This is just telling us about the treatment she has, it doesn't give me anything about the (Brand Name) catheter bag change. Surveyor inquired about the required frequency for changing urine drainage bags. V5 responded When I was working in another area, we used to change it every 7 days so I would say weekly. R1's (12/9/24) progress notes exclude abnormal urine findings and Physician notification. On 12/11/24 at 10:11am, surveyor inquired about the requirement for changing urinary drainage bags V2 (Director of Nursing) stated I would have to look at our policy to see how often its being changed. Surveyor inquired about the standard Nursing practice for changing urinary drainage bags. V2 responded The Nursing standard to change the whole (Name Brand) catheter if I'm not mistaken, it's a week. Surveyor inquired where catheter care orders should be transcribed. V2 replied It's under the order tab it depends. So, with our catheter if you look under our orders some of them will pop up on the MAR (Medication Administration Record). Anything else would be other, it just stays in the order it doesn't transcribe in the MAR or the TAR it just stays under other. Surveyor inquired if concerns (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 10 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 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 Residents Affected - Few with the appearance of R1's catheter and/or urine were reported on 12/9/24. V2 stated Nothing was reported to us as far as something going wrong with her (R1) catheter. On 12/16/24 at 2:15pm, surveyor inquired about the standard of practice for changing urinary drainage bags. V18 (Medical Director) stated At least once a week, and for the catheter once a month. Surveyor inquired what cloudy urine, sediment, and purulent substance (in a catheter bag and/or tubing) are indicative of. V18 responded They can remove the (Brand Name) catheter and change it for a new one. It can be an infection; it can also be dehydration you know if the patient doesn't have enough fluids. I would investigate what the problem is. The (5/14) Urinary Catheter Care policy includes Purpose: to establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Standards: urinary catheter and tubing will be removed and reinserted when any of the following are observed: inability to observed urine contents in the urinary drainage bag or tubing. Observation of gross contamination. Upon Physician' orders. The catheter drainage bag will be marked with the date inserted or when changed. The date of the catheter insertion shall be documented in the Nurse's notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 11 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that Nursing staff arrive on time and/or as scheduled, and failed to ensure that sufficient nursing staff were available to meet the needs for three of three dependent residents (R1, R2, R3) reviewed for ADL (Activities of Daily Living) care. These failures have the potential to affect all 38 residents on the 2nd floor. Findings include: The (12/9/24) facility census includes 117 residents. The (12/9/24) Nursing Daily Staffing Sheet affirms the following: 3 CNAS (Certified Nursing Assistants) called off for day shift. 1 Nurse and 2 CNAS called off for evening shift. The (12/9/24) timecard reports affirm 1 scheduled CNA clocked in at 6:03am, 1 scheduled CNA clocked in at 6:09am, 1 scheduled CNA clocked in at 6:53am, 1 scheduled CNA clocked in at 7:19am and 1 scheduled CNA clocked in at 8:25am (the shift started at 6am) therefore 5 CNAS arrived late. Evening shift starts at 2pm however 1 scheduled CNA clocked in at 2:52pm and 1 scheduled Nurse clocked in at 8:26am therefore both of them arrived late. On 12/9/24 at 1:39pm, surveyor inquired about the current (2nd floor) staffing. V4 (RN/Registered Nurse) stated Today I (V4) have 38 (residents) and two CNAS, one's restorative. I usually have 4 CNAS, they were scheduled, they called off. On 12/9/24 at 1:49pm, surveyor inquired about the current (2nd floor) staffing. V5 (CNA) stated It's only two of us with the Nurse (V4) so we got the whole floor. We got 38 patients. Surveyor inquired which CNA was currently working with V5, V5 responded She's a CNA but she's the Restorative Aide too (referring to V8/Restorative CNA). When it's short, they pull restorative to the floor so there's no restorative going on today because the patients need to be done. Surveyor inquired if showers and/or baths were provided today. V5 replied No, we just make sure they was clean, dry and pulled up. Surveyor inquired how many (2nd floor) residents require total care. V5 stated We have 15 totals and 4 feeders, some of the other patients are assist. 1) R3 was lying in bed. Long white hairs were observed on R3's chin and stubble noted on R3's upper lip. Surveyor inquired what was on R3's chin V5 responded Hair (R3 is female). Surveyor inquired what was on R3's upper lip. V5 replied Hair and a little dry skin. Four (4) fingernails (on R3's right hand) were excessively long, thick, discolored, and severely curved. Surveyor inquired about the appearance of R3's fingernails. V4 (RN) stated This here is all built up (referring to the thickness of R3's nails). Surveyor inquired when R3's incontinence brief was last checked and/or changed. V5 responded Around lunch, she may be wet. V5 removed R3's brief (as requested) and affirmed it was soiled with urine. On 12/9/24 at 2:01pm, R1 and several other residents were observed in the (2nd floor) dining room however there were no staff present. 2) On 12/9/24 at 2:03pm, surveyor inquired when R1 was placed in the wheelchair. V5 (CNA) stated A little bit after 10am (roughly 4 hours prior). V5 subsequently removed R1's incontinence brief (as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 12 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm requested) a large bowel movement was adhered to the skin between the buttocks and lower back. Surveyor inquired what was on R1's skin. V5 responded Poop. R1's indwelling urinary catheter tubing was coated with a white, purulent substance and the urine was notably cloudy. Surveyor inquired about the appearance of R1's catheter. V4 (RN) replied There's sediment. Surveyor inquired about the appearance of R1's urine V5 (CNA) stated Cloudiness. Residents Affected - Many On 12/9/24 at 2:26pm, surveyor inquired when R1's indwelling urinary catheter was inserted and/or urine drainage bag was changed V4 (RN) reviewed R1's TAR (Treatment Administration Record) and stated, This is just telling us about the treatment she (R1) has, it doesn't give me anything about the (Brand Name) catheter bag change. Surveyor inquired about the required frequency for changing urine drainage bags V5 responded When I was working in another area, we used to change it every 7 days so I would say weekly. R1's progress notes (reviewed 12/11/24) exclude 12/9/24 abnormal catheter/urine findings, urine drainage bag change, and Physician notification. 3) R2 resides on 2nd floor. On 12/9/24 at 2:18pm, R2 was lying in bed requesting water (repeatedly) in Spanish however none was available in the room. V4 (RN) subsequently provided water, R2 drank the entire cup of water immediately. The front of R2's incontinence brief had a blue line present (indicating the brief was wet). V6 (CNA) removed R2's brief (as requested) and it was soiled with urine. Surveyor inquired about the current (2nd floor) evening shift staffing. V6 stated So far we are 2 but we are expecting I think 3, but so far only 2 are on the floor (the shift started at 2pm.). Surveyor inquired if 2 staff assigned to 2nd floor was adequate staffing considering the acuity of each resident V6 responded No, it's not and most of the time we are full. On 12/9/24 at 2:45pm, surveyor inquired about the current (1st floor) staffing. V7 (Restorative CNA) stated One Nurse is assigned to the floor and we have 3 CNAS scheduled for today, normally it's 4 (CNAS) on evenings. It's normally 5 CNAS on days and we had 3 (CNAS) this morning. Mondays are always bad; I actually do restorative and affirmed she was pulled to work on the floor. Surveyor inquired who provided restorative care to the residents today. V7 responded Nobody. We have 2 restorative aides in the building and the other restorative aide (referring to V8) was pulled and worked the 2nd floor today. I'm here until 10pm, I'm always doing doubles. Surveyor inquired if 3 CNAS assigned to 1st floor was adequate staffing. V7 replied This floor needs more. Surveyor inquired how many residents reside on 1st floor. V7 stated I think maybe 39 or 40. Surveyor inquired about the acuity of the 1st floor residents. V7 responded The section I worked this morning, I would say I had at least 3 totals and with that I probably had 5 limited to extensive assist. Surveyor inquired how many 1st floor residents require feeding assistance. V7 replied 2 and we have 2 that we cue for feeding. On 12/9/24 at 2:51pm, surveyor inquired about the current (1st floor) staffing. V9 (RN) stated Some are called in. So, it's only 3 CNAS and me but for this floor it should be at least 4 CNAS. We have Dementia and also Parkinson residents, so this is a heavy unit. On 12/9/24 at 2:55pm, surveyor inquired about the current (1st floor) CNA staffing. V10 (CNA) stated Sometimes we 3 sometimes we 2. Surveyor inquired if 3 CNAS assigned to 1st floor was adequate considering the acuity of the residents. V10 responded It's not, sometimes we were 2 CNAS. We got 10 fall risk and a lot of people with this kind of condition (referring to a resident in the hallway that appeared confused, would not sit down and/or follow staff re-direction). We always have problem with the DON (Director of Nursing) not schedule enough people. I work night shift, but they call me, so I come in early because they don't have no staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 13 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 12/9/24 at approximately 3:15pm, surveyor inquired if a DON or ADON (Assistant Director of Nursing) were in the building (to request documentation). V1 (Administrator) stated The ADON worked last night so she's not here and affirmed that the DON was at the facility this morning however went home around 9:00am. On 12/11/24 at 10:09am, surveyor inquired about the requirement for checking and/or changing incontinent residents. V2 (Director of Nursing) stated The CNAS every 2-hour round, so they supposed to be doing they rounds every 2 hours. On 12/11/24 at 10:17am, surveyor inquired if the facility uses Agency Nurses and CNAS. V2 (Director of Nursing) stated No. Surveyor inquired what the facility implements when scheduled staff call off. V2 responded Were trying to get other staff to come in. We usually have staff that come in, it depends on what time we have a call off. We usually will find people to come pick up. Surveyor inquired if the facility has a staff shortage. V2 replied Not necessarily. Surveyor inquired what Not necessarily means. V2 stated That means with staff calling off. Our scheduler never starts with 1 or 2 CNAS but calling off is something that we can't prevent. Surveyor inquired why the facility is not using Agency Nursing Staff (as stated in the facility policy). V2 responded I can't answer that question, you would have to ask Corporate they're the one that approve that. Surveyor inquired if use of Agency staff was approved by Corporate V2 replied No. On 12/11/24 at 10:51am, V14 (Restorative Nurse) stated I have 2 restorative aides they work Monday through Friday unless it's their weekend to work. Surveyor inquired why both restorative aides were pulled to work the floor on Monday (12/9/24) V14 responded I wasn't here Monday, so I don't know what happened. Surveyor inquired how many facility residents are receiving restorative care V14 replied Everyone is in some type of restorative program. On 12/11/24 at 11:57am, surveyor inquired how many Nurses and CNAS are required for staffing (day shift) at the facility. V13 (Staffing Coordinator) stated We have 1 Nurse for each floor so, 3 Nurses and at least 9 CNAS in total. The main thing is that we have 3 aides per floor. If we are shorter than 3, we pull restorative aides to cover the floors. Surveyor inquired how many Nurses and CNAS are required for staffing evening shift at the facility. V13 responded It's the same because sometimes we don't have enough staff. When we don't have enough staff, we make sure managers go upstairs and help out to pass trays and stuff like that. Surveyor inquired why 12 CNAS were scheduled for day shift (on prior days -per the December 2024 schedule) if only 9 are allegedly required. V13 replied It should be 4 per floor (12 total) if I got the staff, I usually add them in. Surveyor inquired about the (12/9/24) facility staffing. V13 replied We had a few call offs if I'm not mistaken it was like 3 or 4 on day shift. When I got here (at 6:30am) I started making phone calls, if they don't pick up, I send out group text alerts. If they're available, they'll come in and affirmed that (V7) and (V8) were pulled to work on the floor. [The 12/9/24 schedule affirms that 3 staff also called off on evenings]. Surveyor inquired why Agency staff were not contacted (12/9/24) V13 stated Agency um, I don't do Agencies that's HR (Human Resource) I don't communicate with them (Agencies). Surveyor inquired if V13 contacted HR (12/9/24) due to staff shortage V13 responded No, I did not. Surveyor inquired if the facility uses Agency staff. V13 replied Not that I know of. On 12/11/24 at 1:18pm, V11 (Wound Care Nurse) affirmed that she's the only wound care staff employed by the facility and stated, Today I'm working on the floor, so the Nurses are responsible for wound care. On 12/10/24 at 9:51am, V12 (Assistant Administrator) stated We don't have a staffing policy. We (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 14 of 15 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 only have an emergency staffing policy. Level of Harm - Minimal harm or potential for actual harm The (10/20) Emergency Staffing policy includes: Policy: to provide continuity of care and ensure all services are provided according to regulations at all times. The use of overtime is approved at all times. Nursing Management is to work units as necessary. Nursing staffing agencies may be employed as necessary. Offer shifts to staff from sister facilities. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 15 of 15