Health inspection·January 16, 2025

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the resident is able to demonstrate how to administer the medication, and physically if able to open and close the medication container. Self-administration Review result should be relayed to the doctor, that the resident can take medication; and get an order from the doctor to self-administer. It should be care planned. On 01/15/2025 at 12:00pm, this surveyor handed V2 the 2 self-Administration Reviews of R13 and inquired if there are other assessments completed between 9/2021 and 01/2025. V2 stated no, these are the only 2 assessments completed for him (R13). There was no other assessment besides the assessment in 09/2021 and 01/14/2025. This surveyor handed the facility policy which indicated assessment should be done at least 2 times a year. V2 stated I cannot answer that question. I started in 02/2024. I cannot speak for the assessments in between. On 01/15/2025 at 12:03pm, inquired about the importance of completing the self-administration review, getting a doctor's order to self-administer, and to care plan the self-administration of medication. V2 stated for the safety of the resident doing the self-administration of medication and for the safety of other residents. R13's (Active Order as Of: 01/13/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) age-related cataract and depression. Of note, R13's 5-paged Order summary report was reviewed with no order for nasal spray and no order to self-administer nasal spray. R13's (01/13/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 07. Indicating R13's mental status as severely impaired. R13's (09/28/2021 and 01/14/2025) Self-administration Reviews documented that R13 may proceed with training program and self-administer medications. Of note, facility was not able to provide R13's Self-administration Review between 09/28/2021 and 01/14/2025. R13's (Target Date: 12/27/2022) Care plan documented, in part has medication at bedside. Will comply with facility policy. Of note, no revision was made from the target date through 01/15/2025. R13's (Date Initiated: 01/15/2025) care plan documented, in part 1/14/25 (R13) has medication at bedside per MD orders. Of note, R13's Active Order as of 01/13/2025 did not include order to may self-administer. R66's (Active Order as Of:01/13/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) asthma and dementia. Order Summary: Albuterol Sulfate HFA Aerosol solution 1 puff inhale orally. Of note, R66's 8-paged Order Summary Report did not include an order to self-administer a medication. R66's (01/01/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating that R66's mental status as moderately impaired. R66's (Revision on 01/15/2025) care plan documented, in part Respiratory risk r/t (related to) Asthma. Risk will be minimized. Administer inhalers. Of note, R66's 23-paged care plan was reviewed with no care plan to may self-administer a medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 2 of 40 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 01/16/2025 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 0554 Level of Harm - Minimal harm or potential for actual harm R84's (Active Order as Of: 01/13/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) chronic obstructive pulmonary disease, emphysema and chronic respiratory failure. Order Summary: Ventolin HFA inhalation aerosol solution 2 inhalation orally every 4hours as needed for shortness of breath related to chronic respiratory failure with hypoxia. Of note, R84's 6-paged Order Summary Report did not include an order to may self-administer a medication. Residents Affected - Some R84's (11/14/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R84's mental status as cognitively intact. R84's (08/12/2024) care plan documented, in part at respiratory risk r/t (related to) COPD, emphysema, chronic respiratory failure. Risks will be minimized with nursing and medical interventions. Administer inhalers. Of note, R84's 25-paged careplan was reviewed with no care plan to self-administer a medication. The (undated) Residents' Rights for People in Long-Term care facilities documented, in part As a long-term care resident in Illinois, you are guaranteed certain right, protections and privileges according to State and federal laws. If your care plan team and your doctor say that you are able to do so. The (undated) Self-Administration of medications procedure documented, in part Purpose: Residents have the right to self-administer their medications if they have the cognitive, physical, and visual ability and the interdisciplinary team has determined the practice is safe for the resident. To provide procedures for determining if the resident can safely self-administer and store medications in their room. Procedure: 1. Residents who requested to self-administer drugs will be assessed thereafter, to determine if the practice is safe. 2. The assessment results will be discussed with the attending physician and obtained to self-administer, if appropriate. 9. Residents who self-administer shall be monitored at least semi-annually by licensed nursing personnel. 10. If after making the assessment the team feels the resident is unable to carry out the responsibility of self-administration, the interdisciplinary team may withdraw this right and defer responsibility to the facility. 12. A careplan indicates the resident's self-administering of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 3 of 40 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 01/16/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a home-like environment by not replacing missing window coverings which affected one resident (R51) reviewed in the total sample of 64 residents. Findings include: On 1/13/25 at 11:20 AM, R51 observed sitting in black recliner-type chair in room, close to windows on the outside facing wall. The sun coming in the room from one (left window when looking at the outside facing wall) of the 2 windows is hitting R51 in the eyes when R51 is sitting forward in the chair. This surveyor observed hanging vertical blinds on both windows with missing vertical blinds on both windows. The left window (when facing windows) has approximated 6 inch gaps in between 5 vertical blind panels and there is no roll down curtain hanging from the brackets at the top of the window frame. The right window (when looking at the outside facing wall) has missing vertical blind panels, but there is a roll down curtain hanging and is closed blocking the sun. The right window is directly above R51's bed. When asked about the sun coming into R51's view with no full window blinds or window covering for this left sided window, R51 stated that R51 would like some shades and sees that the vertical blind panels are missing. R51 stated, Do I have to pay for those? On 1/14/25 at 10:05 AM, this surveyor conducted a brief environmental tour with V32 (Maintenance Director). This surveyor observed that R51's vertical blinds remain missing on the left facing window with no roll down curtain behind the missing vertical blinds. When asked about the missing vertical blinds, V32 (Maintenance Director) stated that a former resident who lived in the room a few months ago pulled the vertical blinds down. V32 stated, I (V32) was supposed to replace them. V32 confirmed with this surveyor that there is no roller blind hanging behind the missing vertical blinds in the left facing window. When asked R51's preference (who is standing/walking in the room) of having a cover over the window for R51's choice, R51 said, Yes. I want that. V32 stated that V32 has a few roller blinds downstairs and that V32 needs to hang R51's roller blind. When asked when is V32 doing rounds to check the conditions of resident blinds/window coverings, V32 stated that V32 does rounds every day, 2 to 3 times a day, and that V32 performed resident rounds on 1/13/25. This surveyor informed V32 of 1/13/25 and 1/14/25 observations of R51's missing window coverings. When asked the importance of having a window blind or covering for R51 to close or open, V32 stated that it would be a home-like environment for R51. R51's admission Record documents, in part, diagnoses of type 2 diabetes mellitus, seizures, dementia, anxiety disorders and history of falling. R51's Minimum Data Set (MDS), dated [DATE], documents, in part, that R51's Brief Interview for Mental Status (BIMS) score is 8 which indicates that R51 has moderate cognitive impairment. Facility (undated) policy titled Environmental Services Schedule documents, in part, . Daily: . Daily: . Check window and privacy curtains for tears or excessive/dirt/replace or wash. Facility (undated) policy titled Resident Rights documents, in part, Policy: Employees shall offer all residents privacy and treat all residents with respect, kindness and dignity. To provide an environment of care that supports a positive self image. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 4 of 40 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 01/16/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete include the resident's right to: . ee. The right to an environment that preserves dignity and contributes to a positive self image. Facility Job Description titled Maintenance Director documents, in part, Job Summary: The Maintenance Director is responsible for the day-to-day activities of the Maintenance Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility and maintained in a clean, safe and comfortable manner. As the Maintenance Director you are delegated the administrative authority, responsibility, and accountability necessary to carry out your assigned duties. Essential Duties and Responsibilities: Include the following, other duties may be assigned . 2. Maintains the building in good repair . 12. Maintains the building and grounds in compliance with Federal, State, local and Joint Commissions laws and standards. Event ID: Facility ID: 146062 If continuation sheet Page 5 of 40 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 01/16/2025 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 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 Based upon observation, interview, and record review the facility failed to ensure that ADL (Activities of Daily Living) care was provided to three of 64 dependent residents (R11, R37, R56) in the sample. Residents Affected - Few Findings include: 1) R11's diagnoses include dementia, benign lipomatous neoplasm, encounter for palliative care, hemiplegia and hemiparesis affecting the left side. R11's (8/31/20) care plan states resident has a self-care deficit and requires assistance with ADL's. Intervention: provide assistance with all ADL's as required per the residents need dependence: personal hygiene. On 1/13/25 at 11:30am, V17 (Chaplain) affirmed that R11 speaks Spanish and agreed to translate interview. R11's hair was long, unkempt, and appeared greasy. R11's beard and nails were also long. Surveyor inquired if R11 prefers the long hair and unshaven appearance V17 stated He said that he shave himself and affirmed (R11) is confused. Surveyor inquired about the appearance of R11's nails V17 responded They look a little long. Surveyor inquired if R11 usually appears disheveled (as he does today) V17 stated Not really. 2) R37's diagnoses include dementia, benign prostatic hyperplasia, and encounter for palliative care. R37's care plan includes (10/25/19) Resident has a self-care deficit and requires assistance with ADL's. Interventions: provide assistance with all ADL's as required per the residents need dependence: eating. (5/20/24) Resident is incontinent of bowel and bladder. Interventions: administer appropriate cleansing and peri-care after each incontinent episode. On 1/13/25 at 11:58am, R37 affirmed that his incontinence brief was soiled however was unable to state the time it was last checked and/or changed. V11 (Registered Nurse) removed R37's brief (as requested) and it was moderately saturated with urine. On 1/13/25 at 12:26pm, R37's tray was away from the bed (out of reach) and the plate was covered with a lid. Plastic wrap was also covering the entire plate. Staff were not present at bedside. R37 resides on 2nd floor. On 1/13/25 at 12:48pm, surveyor inquired when the (2nd floor) lunch trays were served. V16 (Restorative Aide) replied I wanna say probably about 11:40 to 11:45am (roughly 1 hour prior). Surveyor inquired who requires feeding assistance on the unit. V16 provided several resident names and stated That will be all I can remember however R37 was excluded. Surveyor inquired if R37 requires feeding assistance. V16 responded He can use assistance depending on what type of day were (staff) having. V16 subsequently entered R37's room and stated, Are we almost finished? Surveyor inquired about concerns with R37's meal left at bedside V16 responded It's a tray that haven't been touched. 3) R56's diagnoses include dementia, obesity, and generalized weakness. R56's (7/7/23) care plan states resident has a self-care deficit and requires assistance with ADL's. Interventions: provide assistance with all ADL's as required per the residents need dependence: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 6 of 40 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 01/16/2025 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 0677 transferring, dressing. Level of Harm - Minimal harm or potential for actual harm On 1/13/25 at 12:20pm, R56 was lying in bed wearing a nightgown (not up and/or dressed). Surveyor inquired about concerns V15 (Family) stated I (V15) want her (R56) diaper changed and them (staff) to make sure that she's up. She's (R56) usually up when I get here but today, I don't know what happened. Surveyor inquired when R56's incontinence brief was last checked and/or changed. R56 did not respond. V15 replied I got here about 11:00, my mom (R56) has Alzheimer's, so she doesn't know when they (staff) changed her. She (R56) has no concept of times or dates. Residents Affected - Few The (4/14) Activities of Daily Living policy includes Purpose; to preserve ADL function, promote independence and increase self-esteem and dignity. Interventions; dressing and grooming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 7 of 40 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 01/16/2025 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 upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that medications were administered and/or documented within regulatory requirements for seven of 64 residents (R30, R34, R43, R46, R48, R57, R169) in the sample. Residents Affected - Some Findings include: On 1/14/25 at 9:46am V26 (LPN/Licensed Practical Nurse) dispensed three of R48's prescribed medications (Azelastine, Divalproex, Levetiracetam) in a medication cup and affirmed that she was going to administer them however they were scheduled for 8:00am administration (1.75 hours prior). Surveyor inquired why R48's 8:00am medications were highlighted red on the EMAR (Electronic Medication Administration Record), V26 replied It's gonna turn red cause you're late with the administration. Surveyor inquired about the regulatory requirement for medication administration, V26 stated It's one hour before or after, you have to give for the time that it said and affirmed its within 1 hour before or 1 hour after the scheduled time. On 1/14/25 at 11:37am, V2 (Director of Nursing) stated I'm (V2) helping her (V26/LPN) out with the med pass however she (V2) was not observed dispensing and/or administering medications. V26 subsequently approached the med cart, accessed the EMAR and 5 residents (R30, R34, R43, R57, R169) were noted to be highlighted red. Surveyor inquired why R30, R34, R43, R57, and R169 were highlighted red on the EMAR, V26 stated Because I haven't checked on it or didn't give em (medications). Surveyor inquired why the 9am medications were not administered yet, V26 responded I'm not as efficient as I should be. On 1/14/25 at 11:44am, V26 (LPN) dispensed R57's prescribed medications (Certivite, Lisinopril, Metformin, Vitamin D3, Fish Oil, Glipizide ER) in a medication cup and affirmed that she was going to administer them however they were scheduled for 9:00am administration (roughly 2.75 hours prior). On 1/14/25 at 10:03am, surveyor inquired about the (2nd floor) 9am medication administration V11 (Registered Nurse) stated I'm done with that for now. Surveyor inquired why R46 was highlighted red on the EMAR if the medication administration was completed, V11 responded These are scheduled for 8 and 9:00 but she refuses all her meds no matter what I try. Surveyor inquired about the regulatory requirement for documenting medication administration and/or refusals, V11 replied Upon passing medication. The (8/15) medication administration policy states medications must be administered in accordance with a physician's order and at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 8 of 40 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 01/16/2025 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to ensure that a residents (R22) low air loss mattress (in use) was functioning properly, failed to obtain PRN (as needed) wound care orders for R37, failed to ensure that R56's (left) buttock treatment orders were transcribed on the TAR (Treatment Administration Record), failed to obtain treatment orders for R56's (right) buttock wound, and failed to follow Physician orders. These failures affected 3 residents (R22, R37, R56) in the sample. Residents Affected - Few Findings include: 1) R37's (12/26/24) POS (Physician Order Sheets) include Hydrocol External Pad (Wound Dressing) apply to sacrum every day shift every Friday for wound care prevention for 1 month (PRN orders were excluded). R37's (2/12/20) care plan states resident is at risk for skin impairment related to bladder incontinence. Interventions: skin checks daily, inform staff Nurse of any concerns. On 1/13/25 at 11:58am, R37 affirmed that his incontinence brief was soiled however was unable to state the time it was last checked and/or changed. V11 (Registered Nurse) removed R37's brief (as requested) that was moderately saturated with urine. Surveyor inquired about R37's sacrum hydrocolloid dressing that was noted to be falling off and adhered to itself, V11 stated This done rolled off, I gotta get a new one. 2) R56's (12/31/24) POS includes Hydrocol External Pad (Wound Dressing) apply to left buttock one time a day every Tuesday, Thursday, Saturday. Apply Hydrocolloid PRN (as needed) for soiled/dislodged dressing. R56's (5/20/24) care plan states resident is incontinent of bowel and bladder. Interventions: observe skin condition during care for open areas. On 1/13/25 at 12:20pm, surveyor inquired about concerns, V15 (Family) stated I (V15) think she (R56) got a little bed sore, she (V19/Wound Nurse) said there was a dressing and antibiotic. Surveyor inquired if R56 has a wound, V14 (Certified Nursing Assistant) stated Yeah, on her butt the Wound Nurse take care of it. V14 removed R56's brief (as requested) and 2 open areas were observed on her buttocks (1 on the right, 1 on the left) however neither area was covered with a dressing. Surveyor inquired if a dressing was present on either of R56's wounds, V14 responded No. On 1/13/25 at 12:33pm, surveyor inquired if (V19/Wound Care Nurse) was working today V2 (Director of Nursing) stated The Wound Nurse is on the floor but were (Nurses) doing wounds and affirmed that (V19) is assigned to work on the 3rd floor [R56 resides on 2nd floor]. On 1/13/25 at 12:35pm, V11 (Registered Nurse) affirmed that she's assigned to R56. Surveyor inquired if R56 has wound care orders V11 accessed R56's electronic TAR (Treatment Administration Record) and affirmed wound care orders were excluded. V11 then accessed R56's Physician Orders (as requested) and affirmed She has Hydrocol to left buttocks Tuesdays, Thursdays, and Saturdays for wound care (right buttock was excluded). Surveyor inquired if R56's wound care orders were on the MAR (Medication Administration Record) V11 responded It's not on the MAR either therefore the facility failed to ensure the Physician Orders were transcribed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 9 of 40 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 01/16/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few R56's (January 2025) printed MAR was subsequently reviewed by surveyor however wound care orders for buttock wounds were excluded. R56's (January 2025) TAR (requested 1/13/25) was not provided by the facility. On 1/15/25 at 10:27am, surveyor inquired where treatment orders are supposed to be entered/transcribed when received. V19 (Wound Care Nurse) stated For the wounds they are entered in the TAR, for any ointments applied more than once they go on the MAR. Surveyor inquired about R56's wounds. V19 responded She (R56) has stage 2 to both the right and left buttock. Surveyor inquired if R56 has treatment orders. V19 replied, Right now its honey alginate covered with bordered gauze [therefore the orders were changed]. Surveyor inquired why R56's Hydrocol orders were not entered in the MAR and/or TAR. V19 stated She (R56) had an order for Hydrocolloid, so it only pops up on the TAR when its scheduled. However R56's wound care orders also include PRN administration for dislodged dressing. Surveyor inquired what staff are required to do if a dressing falls off. V19 responded Notify either the floor Nurse or notify me (V19) if I'm in the building. Surveyor inquired who was responsible for wound care on Monday (1/13/25), V19 replied I was pulled Monday so floor Nurses are, but I believe the Corporate Nurse (referring to V31/Nurse Consultant) was in the building doing some treatments as well. The pressure injury and skin condition assessment policy states care givers are responsible for promptly notifying the Charge Nurse of skin observations. Dressing will be checked daily for placement, cleanliness, and signs and symptoms of infection. Physician ordered treatments shall be initialed by the staff on the treatment administration record after each administration. 3) R22 is an [AGE] year old with diagnosis including but not limited to: Unspecified urinary incontinence, type 2 diabetes mellitus, altered mental status, unspecified injury of head and heart disease. On 01/13/25 at 11:15 AM during investigation, R22 was observed in bed with bed beeping. At that time, Surveyor entered R22's room with V2 (DON/ Director of Nursing) and observed R22's air mattress improperly plugged into the wall near R22's bed. On 01/13/25 at 11:15 AM, Surveyor observed R22's air mattress deflated as V2 plugged the mattress back into the outlet. At that time, V2 (DON) said that R22's LALM (Low Air Loss mattress) sometimes is mistakenly unplugged if R22's bed is moved. Surveyor inquired about the purpose of Low Air Loss mattress. On 01/15/25 at 10:20 AM, V19 (Wound care nurse) said that the purpose of LALM is to help relieve pressure from the body. Surveyor asked what could occur if R22's LALM is not used. At that time, V19 said that R22 had an unstageable wound to the sacrum region and that the wound could worsen if a LALM is not in use as ordered. R22's Care plan dated 01/09/25 documents, R22 has an alteration in skin integrity and is as risk for additional worsening of skin integrity related to a pressure wound to the sacrum. R22's Section M- Skin Conditions section of the MDS (Minimum Data Set) dated 10/28/24 documents, a pressure reducing device for bed is used as treatment for skin injury. Facility policy titled Low Air Low Mattress documents, purpose to provide support and pressure relief to pressure ulcers/ injuries while optimizing resident comfort, as well as pain management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 10 of 40 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 01/16/2025 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 - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff were available to provide restorative care, failed to ensure that staff are aware of residents' restorative care needs, and/or failed to ensure that restorative care was provided as directed for four of 64 residents (R26, R49, R55, R86) in the sample. These failures have the potential to affect 104 residents. Findings include: The (1/13/25) census includes 114 residents. On 1/13/25 at 10:52am, surveyor inquired about the current (2nd floor) staffing. V12 (CNA/Certified Nursing Assistant) stated It's 3 CNAs right now and affirmed that 1 of the assigned CNAs is V16 (Restorative Aide) that was pulled to work the floor. On 1/13/25 at 11:15am, surveyor inquired who provides restorative care if V16 (Restorative CNA) was pulled to work on the unit, V16 stated My supervisor (V34/Restorative Nurse) is here however a total of 104 residents require restorative care per (1/15/25) facility [NAME] Report. The (1/15/25) [NAME] report also affirms that 14 residents require restorative devices, 15 residents require PROM (Passive Range of Motion) x 15 minutes 7 days a week, and 89 residents require AROM (Active Range of Motion) x 15 minutes 7 days a week. On 1/13/25 at 11:21am, V14 (CNA) stated The 2nd floor restorative aide (referring to V36) is actually off today. Surveyor inquired if there are only 2 restorative aides employed by the facility, one is off today and the other one (V16) was pulled to work on the unit who's providing restorative care, V14 responded When something like that happens, we make sure bed alarms and devices are in place, were also dressing, getting them up and stuff like that. Surveyor inquired who provides required ROM (Range of Motion). V14 replied, We (CNAs) do it for the most part, we try to incorporate all of that. Surveyor inquired if R55 has any restorative/rehab needs. V14 stated He (R55) does for himself, he doesn't have any however R55's (1/15/25) [NAME] includes the following Nursing Rehab interventions: active ROM to BUE (Bilateral Upper Extremities) and BLE (Bilateral Lower Extremities) with verbal cues x 15 reps 7 days a week. Dressing/grooming: resident to put on upper and lower garments, wash face, hand, comb hair with supervision and verbal cues, 7 days a week 15 minutes a day. R86's diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. On 1/13/25 at 11:41am, surveyor inquired about concerns. R86 stated I need therapy cause its most not work and pointed to his right upper extremity. Surveyor inquired if R86 was able to raise his right arm. R86 affirmed he was unable to do so, then struggled to lift the right arm with his left hand. Surveyor inquired if R86 was able to grasp with his right hand. R86 attempted to make a fist and open his hand however had difficulty doing so. R86's (1/15/25) [NAME] includes the following Nursing Rehab interventions: active ROM to LUE (Left Upper Extremity) and LLE (Left Lower Extremity) with verbal cues x 15 reps 7 days a week 15 minutes a day however PROM (Passive Range of Motion) to the right extremities was excluded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 11 of 40 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 01/16/2025 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 - Many R86's (December 2024-January 2025) documentation survey report affirms PROM to the RUE (Right Upper Extremity) and/or RLE (Right Lower Extremity) was not documented. R26's diagnoses include lack of coordination and abnormalities of gait/mobility. R26's (5/21/23) care plan states resident would benefit from participation in an AROM restorative nursing program. Interventions: active ROM to BUE and BLE with verbal cues x 15 reps 7 days a week 15 minutes a day. R26's (1/15/25) [NAME] includes the following Nursing Rehab interventions AROM to BUE and BLE with verbal cues x 15 reps 7 days a week 15 minutes a day. On 1/13/25 at 12:10pm, surveyor inquired about concerns. R26 stated They (facility) promised me (R26) physical therapy when I came here, I (R26) get a week here and a week there and that's it. Surveyor inquired if restorative care is provided by staff to prevent decline in activities of daily living. R26 responded No. Surveyor inquired if transfer assistance is provided by staff. R26 replied The CNA does that in the morning and in the night but that's all I do. I get in the chair, sit in the chair, and go to bed that's all I do. I know that if I got therapy, I know I could walk by now. Nobody cares if I get help or not. R26's (January 2025) documentation survey report includes AROM to BUE and BLE however on 1/4 and 1/6 N/A (not applicable) was documented. R49's (8/30/23) care plan includes participation in an AROM restorative nursing program. Interventions: the restorative aide and/or unit aide will document the program minutes within the point of care module as indicated per the schedule. R49's (1/15/25) [NAME] includes the following Nursing Rehab interventions AROM to BUE and BLE with verbal cues x 15 reps 7 days a week 15 minutes a day. R49's (January 2025) documentation survey report includes AROM to RUE and RLE however there was no documentation on 1/5 and 1/11 [LUE and LLE are excluded therefore bilateral extremity ROM was not provided as directed]. On 1/15/25 at 12:09pm, surveyor inquired about the facility restorative staff. V34 (Restorative Nurse) stated I have 2 restorative aides (V36's name) and (V16's name) that's it. Surveyor inquired if V34 gets pulled to work on the unit when there's a shortage of staff in the facility, V34 responded Yes, I (V34) actually resigned 2 months ago and got back in the position 2 weeks ago. I get pulled roughly twice a week sometimes 3 times a week and whatever weekend I pick I'm on the floor. When they (facility) want me to get my restorative work done and work the floor it's a lot. Surveyor inquired if the restorative aides are also pulled to work on the unit when there's a shortage of staff in the facility. V34 replied Yes, it's probably more often, it depends on how many call-offs they have. That's why I left because were (restorative staff) all being pulled every week. Surveyor inquired who's providing range of motion for residents requiring services when restorative staff are assigned to other duties V34 replied We try to get the CNAs to do the range of motion, but I don't know if they're actually doing them. The (9/14) restorative nursing policy states; develop an individualized restorative program based on the assessment information and update the resident care plan. Documentation of interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 12 of 40 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 01/16/2025 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 provided must be completed following the interventions on the specific form for each program as indicated on the form. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 13 of 40 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 01/16/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to ensure that the environment was free from hazards for two residents (R44 and R95). This failure has the potential to affect all 39 residents on the third-floor unit. Findings include: On 1/13/25 V10 (Assistant Administrator) presented a facility census of 39 residents on the third-floor unit. On 01/13/25 Surveyor toured the facility's third-floor unit and observed residents ambulating throughout the unit freely. R44's face sheet shows that R44 has a diagnosis which includes but not limited to transient cerebral ischemic attack, encounter for attention to gastrostomy, and dysphagia oral phase. R44's Brief Interview for Mental Status (BIMS) dated 12/11/24 shows that R44 does not have a BIMS score and documents that R44 could not recall which indicates that R44 has some cognitive impairments. During interview with R44, R44 was able to answer yes and no to surveyor questions. R95's face sheet shows that R95 has a diagnosis which includes but not limited pure hypercholesterolemia, Type 2 diabetes mellitus, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. R95's Brief Interview for Mental Status (BIMS) dated 11/25/24 shows that R95 has a BIMS score of 13 which indicates that R95 is cognitively intact. On 01/13/25 at 11:07 am, Surveyor observed a clear cup with a thick, gold liquid on top of R44's sink visible from the hallway while walking pass R44's room. Surveyor questioned R44 regarding the yellow substance and R44 was not able to tell Surveyor what the gold substance in the clear cup on R44's sink was. At 11:09 am, Surveyor brought this observation to V18 (Certified Nursing Assistant, CNA) and V18 stated, I (V18) believe that is soap. I didn't put that there. I believe that's the color of the soap from the shower room pumps. When V18 was asked what could happen if a resident takes the cup with the gold liquid from R44's room and V18 stated, They can drink it and it can be bad for them. On 01/13/25 at 11:12 am, Surveyor observed 3 razors on R95's nightstand visible from the hallway. R95 stated that staff gives R95's razors to shave. When R95 asked how does R95 dispose of razors given to R95, R95 stated that R95 throws the razors in the garbage when R95 is finish using the razors. On 01/14/25 at 10:23 am, Surveyor observed 3 razors remain on R95's nightstand. Surveyor brought this observation to V27 (Licensed Practical Nurse, LPN) and asked V27 the facility's policy for residents having razors. V27 stated, I (V27) don't know the policy. When Surveyor questioned V27 what could happen to razors left in the residents rooms and V27 stated, Another resident can come in the room, use the razor, or use the razor inappropriately. When V27 was asked regarding if residents are allowed to shave themselves and V27 stated, Yes, with supervision and the razor should be discarded in the sharps container once the resident is done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 14 of 40 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 01/16/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 01/15/25 at 9:23 am, V2 (Director of Nursing, DON) was asked regarding chemicals and razors left in residents rooms and V2 stated, Staff should not be placing or leaving chemicals in a cup on sinks in the residents room. Anything can happen. Residents can grab it and drink it. Its like poison. When V2 was asked regarding if soap is a chemical V2 stated, Yes. V2 was asked regarding razors being left at the bedside and V2 stated that if the resident is alert and oriented the resident can have a razor at the bedside and once used the resident should submit the razor to the staff. When V2 was asked should residents who are able to shave themselves be monitored while shaving and V2 stated, The CNA (Certified Nursing Assistant) should be supervising the resident while the resident shaves and then discarding the razor once the resident is done. When V2 was asked what could happen if a resident is not supervised during shaving or if a resident shaves and leaves a razor at the bedside and V2 stated, The resident can accidentally injury themselves or another resident can get it (referring to the razor) and injure their self. The facility's document dated 3/14 and titled Needle Sharps- Handling and Disposal documents, in part: Policy: Safe handling and disposal of needles/sharps will be followed. Policy Interpretation: 1. Caution shall be exercised by all personnel handling use needles or other sharp objects to reduce the possibility of needle sticks injuries and cuts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 15 of 40 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 01/16/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based upon observation, interview, and record review the facility failed to follow policy procedures, and failed to ensure that gastrostomy tube (g-tube) feedings were labeled for one of three residents (R11) reviewed for tube feeding. Findings include: On 1/13/25 at 11:30am, R11's g-tube feeding was infusing however the bag was not labeled with resident's name, type of feeding, date, and/or time the infusion started (as required). On 1/13/25 at 12:40pm, surveyor inquired about R11's g-tube feeding V11 (Registered Nurse) stated He gets Jevity 55cc's per hour. I (V11) hung that bag this morning, but I didn't have no sticker or didn't put no date on that. The (6/14) gastrostomy feeding policy states label container with resident's name, name of formula, concentration flow rate, date, and time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 16 of 40 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 01/16/2025 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 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 (nasal cannula tubing); and failed to properly contain oxygen equipment (nasal cannula tubing). These failures affected two residents (R3 and R109) reviewed for oxygen equipment, in a total sample of 64 residents. Residents Affected - Few Findings include: R3's face sheet shows that R3 has a diagnosis which includes but not limited to chronic obstructive pulmonary disease (COPD), and asthma. R3's Brief Interview for Mental Status (BIMS) dated 12/22/25 shows that R3 has a BIMS score of 13 which indicates that R3 is cognitively intact. R109's face sheet shows that R109 has a diagnosis which includes but not limited to obesity and cardiac arrhythmia. R109's Brief Interview for Mental Status (BIMS) dated 12/19/25 shows that R109 has a BIMS score of 14 which indicates that R109 is cognitively intact. On 01/13/25 at 11:13 am, R109 was observed in bed awake, alert, and oriented. Surveyor observed R109 with a concentrator next to the bedside with the oxygen tubing (nasal cannula) hanging across the top of the oxygen concentrator, touching the floor, uncontained and, undated. When surveyor asked R109 how does R109 store R109's oxygen tubing when not in use. R109 stated, I (R109) just put it over there (referring to placing R109's oxygen tubing across R109's oxygen concentrator touching the floor). When R109 was asked regarding storing R109's oxygen tubing in a bag when not in use R109 stated, (I (R109) never had a bag. On 01/13/25 at 11:59 am, R3 was observed in R3's room. Surveyor observed R3's room with a concentrator at the bedside that had oxygen tubing (nasal cannula) hanging across R3's bed with the oxygen tubing touch the floor, dated 06/06/25 and uncontained. When surveyor asked R3 how R3 stores R3's oxygen tubing when not in use R3 stated, I (R3) just put it across the bed. When R3 was asked regarding storing R3's oxygen tubing in a bag when not in use R3 stated, (I (R3) don't have a bag for it. On 01/13/25 at 2:02 pm, R3's oxygen tubing observation was brought to V22 (Licensed Practical Nurse, LPN) and V22 stated, It shouldn't be like that (referring to R3's oxygen tubing hanging across R3's bed onto the floor). It should be in a plastic bag. When V22 was asked regarding the importance of storing oxygen tubing in a bag when not in use V22 stated, For infection control. On 01/15/24 at 9:30 am, V2 (Director of Nursing, DON) was asked regarding how oxygen equipment (nasal cannula tubing) is stored when not in use and V2 stated that oxygen tubing in the residents room should be placed in a bag so that the oxygen tubing is not touching the floor. When V2 asked what can happen if a residents oxygen equipment is not placed in a bag when not in use and V2 stated, If it touch the floor it can be contaminated, and bacteria can be introduced into the resident if the resident put the tubing back into their nose. R3's Physicians Order Sheet (POS) dated 6/08/2024 shows that R3 has orders for: Oxygen 2-4 LPM-NC (liter per minute) (nasal cannula) as needed q (every) shift for SOB (shortness of breath) rto (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 17 of 40 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 01/16/2025 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 0695 (related to) COPD. May titrate for comfort. Level of Harm - Minimal harm or potential for actual harm R109's Physicians Order Sheet (POS) dated 6/08/2024 shows that R109 has orders for: Oxygen via nasal cannula up to 3L (liter) as needed for shortness of breath. Residents Affected - Few The facility policy dated 8/14 and titled Oxygen Equipment documents, in part: Objective: To administer oxygen in conditions in which infection control is maintained . Procedure: 4. Oxygen tubing/nebulizer masks will be changed and dated weekly and prn (as needed). 5. Oxygen tubing/nebulizer masks will be covered when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 18 of 40 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 01/16/2025 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and, record review the facility failed to obtain a physicians order for a resident (R3) who requires dialysis. This failure affected one resident in the sample of 64 residents. Residents Affected - Few Findings include: R3's face sheet shows that R3 was admitted to the facility on [DATE] and has a diagnosis which includes but not limited to dependence on renal dialysis, chronic kidney disease stage 5, and renal sclerosis. R3's Brief Interview for Mental Status (BIMS) dated 12/22/25 shows that R3 has a BIMS score of 13 which indicates that R3 is cognitively intact. On 01/14/25 upon review of R3's Active Physician Order Sheet no physicians orders for R3 to receive hemodialysis. On 01/15/25 at 9:51 am, V2 (Director of Nursing, DON) stated that when a resident is admitted to the facility it is the admitting nurses responsibility to carry out and verify orders for residents from the sending facility including orders for residents who require receiving dialysis. V2 explained that the facility receives residents dialysis orders with the residents hospital transfer orders. V2 further explained that the residents dialysis orders should be verified and carried out with the residents physician upon the residents admission to the facility. V2 also explained that residents who require dialysis should have orders regarding how often the resident receives dialysis, where they will receive the dialysis, and the dialysis port location. V2 stated that R3 is a resident who receives dialysis on Tuesday, Thursday, and Saturday's at the facility. When V2 was asked regarding what can happen if a resident who requires dialysis does not have physicians orders to receive dialysis and V2 stated, A lot of things can happen. They can miss their dialysis and deteriorate. R3 should have had dialysis orders. It was missed. The facility undated document titled Dialysis Patients shows R3 received dialysis on Tue (Tuesday), Thur (Thursday), Sat (Saturday). The facility document dated 04/14 and titled Dialysis Hemo: AV (Arteriovenous Fistula) fistula or Graft Care documents, in part: Purpose: To prevent infection and monitor patency of AV fistula or graft for hemodialysis. Procedure: 1. Verify Physician's order. The facility documents titled Dialysis Communication Report shows that R3 received dialysis on 12/19/24, 12/26/24, 12/28/24, 01/02/25, 01/04/25, 01/07/25, 01/11/25, and 01/14/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 19 of 40 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 01/16/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon 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, failed to implement the emergency staffing policy and failed to ensure that sufficient nursing staff were available to meet the needs for 15 of 64 residents (R11, R15, R26, R30, R34, R37, R43, R46, R48, R49, R55, R56, R57, R86, R169) in the sample. These failures have the potential to affect 114 residents. Findings include: On 12/17/24, the facility was cited by IDPH (Illinois Department of Public Health) for insufficient Nursing staff. The (1/13/25) census includes 114 residents. On 1/13/25 at 10:48am, surveyor inquired about the current (2nd floor) staffing, V11 (RN/Registered Nurse) stated, I have 3 CNAs (Certified Nursing Assistants) sometimes we have 4 and affirmed there are 40 residents currently residing on the unit. On 1/13/25 at 10:52am, surveyor inquired about the current (2nd floor) staffing, V12 (CNA) stated It's 3 CNAs right now, it's 3 to 4 sometimes but usually we have 3. V12 affirmed that one of the assigned CNAs is a restorative aide (referring to V16) that was pulled to work the floor. Surveyor inquired who provides restorative care if V16 (Restorative CNA) was pulled from her duties, V12 responded When she (V16) gets pulled there's nobody else that could help. Surveyor inquired if 3 CNAs is adequate staffing considering acuity of the residents. V12 responded I think we could get one more. R49 resides on 2nd floor. On 1/13/25 at 11:04am, R49's personal refrigerator temperature was last documented on the (daily) refrigerator temperature log on 1/7/25 (6 days prior). A thick build-up of ice was also noted on R49's freezer. R15 resides on 2nd floor. On 1/13/25 at 11:06am, R15's personal refrigerator contained perishable items including juice and cheese however the refrigerator temperature was noted to be 76F (Fahrenheit). R15's personal refrigerator temperature was last documented on the log on 1/7/25 (6 days prior). On 1/13/25 at 11:08am, surveyor inquired who's responsible for monitoring personal refrigerator temperatures V13 (Housekeeping) stated, I do. Surveyor inquired when R15's personal refrigerator temperature was last documented V13 responded 7 (and affirmed it was 1/7/25) surveyor inquired what today's date is V13 replied It's um 13. Surveyor inquired about the current temperature of R15's refrigerator V13 replied This um 80. Surveyor inquired what the refrigerator temperature range should be V13 stated It think it's this 40, no? and pointed to the thermometer (- 40F). Surveyor inquired if the items in R15's refrigerator were cold V13 picked up the juice and responded, Not too much, [NAME] its warm. On 1/13/25 at 11:12am, surveyor inquired when R49's personal refrigerator temperature was last documented V13 stated This is the same thing, 7 and affirmed it was 1/7/25. Surveyor relayed concerns with ice buildup observed in R49's refrigerator and inquired who this concern should be reported to V13 responded Manager. Surveyor inquired if the ice buildup in R49's refrigerator was reported to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 20 of 40 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 01/16/2025 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 Manager V13 replied This is the families and affirmed it was not. Level of Harm - Minimal harm or potential for actual harm The (1/19) food storage - outside sources policy states in part; Nursing staff will be responsible for checking resident personal refrigerator (daily) for proper labeling, temperature recording and storage. Facility staff will monitor resident personal refrigerators for food and beverage disposal needs for safety. All refrigerators in use in the facility have an internal thermometer to monitor temperature. All refrigerators have their internal temps recorded (daily). Any refrigerators found to have an internal temperature that is outside of the accepted safe parameters of temperature will be immediately addressed by maintenance and will be taken out of service if the internal temperature cannot be corrected within a reasonable time frame to maintain food safety. Any affected food/beverages will be discarded. Residents Affected - Many On 1/13/25 at 11:15am, surveyor inquired about the current (2nd floor) staffing. V16 (Restorative CNA) stated, It's two plus me and affirmed there is one nurse assigned. Surveyor inquired who provides restorative care if V16 (Restorative CNA) was pulled to work on the unit, V16 stated My supervisor (V34/Restorative Nurse) is here however a total of 104 residents require restorative care and 14 residents require restorative devices per (1/15/25) facility [NAME] Report. On 1/13/25 at 11:21am, surveyor inquired about the current (2nd floor) staffing. V14 (CNA) stated We have 3 CNAs. Surveyor inquired if 3 CNAs is adequate staffing considering acuity of the residents, V14 responded I would say adequate staffing would be 4. We had 4 but it's not consistent and unforeseen circumstances happen. Surveyor inquired if the facility uses agency staff, V14 replied No, not for once did I see agency here in the past year that I've been here. Surveyor inquired why V16 (Restorative Aide) was pulled to work on 2nd floor, V14 stated The 3rd person had an emergency and had to leave that's why the restorative (referring to V16) came. The 2nd floor restorative aide is actually off today. Surveyor inquired if there are only 2 restorative aides employed by the facility, one is off today and the other one (V16) was pulled to work on the unit who's providing restorative care. V14 responded When something like that happens, we (CNAs) make sure bed alarms and devices are in place, were also dressing, getting them up and stuff like that. Surveyor inquired who provides required ROM (Range of Motion) V14 replied We (CNAs) do it for the most part, we try to incorporate all of that. R55 resides on 2nd floor. Surveyor inquired if R55 has any restorative/rehab needs V14 stated He (R55) does for himself, he doesn't have any and affirmed he (R55) cares for himself however R55's (1/15/25) [NAME] includes the following Nursing Rehab interventions: active ROM (Range of Motion) to BUE (Bilateral Upper Extremities) and BLE (Bilateral Lower Extremities) with verbal cues x 15 reps 7 days a week. Dressing/grooming: resident to put on upper and lower garments, wash face, hand, comb hair (with supervision and verbal cues), 7 days a week 15 minutes a day. The (4/14) Activities of Daily Living policy includes Purpose; to preserve ADL function, promote independence and increase self-esteem and dignity. Interventions; dressing and grooming. R11 resides on 2nd floor. On 1/13/25 at 11:30am, V17 (Chaplain) affirmed that R11 speaks Spanish and agreed to translate interview. R11's hair was long, unkempt, and appeared greasy. R11's beard and nails were also long. Surveyor inquired if R11 prefers the long hair and unshaven appearance. V17 stated He (R11) said that he shave himself and affirmed (R11) is confused. Surveyor inquired about the appearance of R11's nails. V17 responded They look a little long. Surveyor inquired if R11 usually appears disheveled (as he does today). V17 stated Not really. R11's g-tube (gastrostomy) feeding was infusing however the bag was not labeled with type of feeding, date and/or time the infusion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 21 of 40 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 01/16/2025 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 started (as required). Level of Harm - Minimal harm or potential for actual harm On 1/13/25 at 12:40pm, surveyor inquired about R11's (unlabeled) g-tube feeding V11 (Registered Nurse) stated He gets Jevity 55cc's (cubic centimeters) per hour. I (V11) hung that bag this morning, but I didn't have no sticker or didn't put no date on that. Residents Affected - Many The (6/14) gastrostomy feeding policy states label container with resident's name, name of formula, concentration flow rate, date, and time. R86 resides on 2nd floor. On 1/13/25 at 11:41am, surveyor inquired about concerns. R86 stated I need therapy cause its most not work and pointed to his right upper extremity. Surveyor inquired if R86 was able to raise his right arm. R86 affirmed he was unable to do so, then struggled to lift the right arm with his left hand. Surveyor inquired if R86 was able to grasp with his right hand, R86 attempted to make a fist and open his hand however had difficulty doing so. R86's (1/15/25) [NAME] includes the following Nursing Rehab interventions: active ROM to LUE (Left Upper Extremity) and LLE (Left Lower Extremity) however PROM (Passive Range of Motion) to the right extremities was excluded. [R86's diagnoses include hemiplegia and hemiparesis affecting the right side]. R86's (December 2024-January 2025) documentation survey report affirms PROM to the RUE and/or RLE was not documented. The (9/14) restorative nursing policy states; develop an individualized restorative program based on the assessment information and update the resident care plan. Documentation of interventions provided must be completed following the interventions on the specific form for each program as indicated on the form. R37 resides on 2nd floor. On 1/13/25 at 11:58am, R37 affirmed that his incontinence brief was soiled however was unable to state the time it was last checked and/or changed (due to Dementia diagnosis). V11 (RN) removed R37's brief (as requested) and it was moderately saturated with urine. Surveyor inquired about R37's sacrum hydrocolloid dressing that was noted to be falling off and adhered to itself. V11 stated This done rolled off, I gotta get a new one. Surveyor inquired if the facility uses agency staff. V11 responded If it was agency here we (facility) would be packed with staff, I see now why they (facility) can't keep anybody here this floor is kinda skilled and affirmed that her assigned workload (40 residents) is heavy for 1 Nurse. On 1/13/25 at 12:26pm, R37's lunch tray was noted to be placed in the room (out of reach) and the meal was covered with a lid. R37 affirmed that he was unable to reach the tray at this time. [R37's 10/25/19 care plan states resident has a self-care deficit and requires assistance with ADL's (Activities of Daily Living) interventions: provide assistance with eating]. On 1/13/25 at 12:48pm, surveyor inquired when the (2nd floor) lunch trays were served V16 (Restorative Aide) replied I wanna say probably about 11:40 to 11:45am (roughly 1 hour prior). Surveyor inquired who requires feeding assistance on the unit V16 provided several resident names and stated That will be all I can remember however R37 was excluded. Surveyor inquired if R37 requires feeding assistance V16 responded He can use assistance depending on what type of day were (staff) having. V16 subsequently entered R37's room and stated, Are we almost finished? Surveyor inquired about concerns with R37's meal left at bedside. V16 responded It's a tray that haven't been touched. The pressure injury and skin condition assessment policy states care givers are responsible for promptly notifying the Charge Nurse of skin observations. Dressing will be checked daily for placement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 22 of 40 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 01/16/2025 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 R26 resides on 2nd floor. On 1/13/25 at 12:10pm, surveyor inquired about concerns. R26 stated They (facility) promised me (R26) physical therapy when I came here, I (R26) get a week here and a week there and that's it. Surveyor inquired if restorative care is provided by staff to prevent decline in activities of daily living. R26 responded No. Surveyor inquired if transfer assistance is provided by staff. R26 replied The CNA does that in the morning and in the night but that's all I do. I get in the chair, sit in the chair, and go to bed that's all I do. I know that if I got therapy, I know I could walk by now. Nobody cares if I get help or not. [R26's January 2025 documentation survey report includes AROM (Active Range of Motion) to BUE (Bilateral Upper Extremity) and BLE (Bilateral Lower Extremity) however on 1/4 and 1/6 N/A (not applicable) was documented]. R26's personal refrigerator contained perishable items including creamer, cheese, and a protein shake however the refrigerator temperature was noted to be out of range (above 40F). Surveyor inquired about the current temperature of R26's refrigerator. V14 (CNA) inspected the thermometer and stated, I would say 45 therefore out of range. R56 resides on 2nd floor. On 1/13/25 at 12:20pm, R56 was lying in bed wearing a nightgown (not up and/or dressed). Surveyor inquired about concerns. V15 (Family) stated I (V15) want her (R56) diaper changed and them (staff) to make sure that she's up. She's (R56) usually up when I get here but today, I don't know what happened. Surveyor inquired when R56's incontinence brief was last checked and/or changed R56 did not respond. V15 responded I got here about 11:00, my mom (R56) has Alzheimer's, so she doesn't know when they changed her. She (R56) has no concept of times or dates. I think she got a little bed sore, she (V19/Wound Nurse) said there was a dressing and antibiotic. Surveyor inquired if R56 has a wound, V14 (CNA) replied Yeah, on her butt the Wound Nurse take care of it. V14 removed R56's brief (as requested) and 2 open areas were observed on her buttock(s) however neither area was covered with a dressing. Surveyor inquired if a dressing was present on R56's wounds V14 stated No. On 1/13/25 at 12:33pm, surveyor inquired if (V19/Wound Care Nurse) was working today. V2 (Director of Nursing) stated The Wound Nurse is on the floor but were (Nurses) doing wounds and affirmed (V19) is assigned to work on the 3rd floor [The facility employs only one Wound Care Nurse]. On 1/13/25 at 12:35pm, V11 (RN) affirmed that she's assigned to R56. Surveyor inquired if R56 has wound care orders. V11 accessed R56's electronic TAR (Treatment Administration Record) and affirmed that wound care orders were excluded. V11 then accessed R56's Physician Orders (as requested) and stated She has Hydrocol to left buttocks Tuesdays, Thursdays, and Saturdays for wound care however the right buttock was excluded. Surveyor inquired if R56's wound care orders were on the MAR (Medication Administration Record). V11 responded It's not on the MAR either therefore the facility failed to ensure the Physician Orders were transcribed. On 1/14/25 at 9:46am V26 (LPN/Licensed Practical Nurse) dispensed three of R48's prescribed medications (Azelastine, Divalproex, Levetiracetam) in a medication cup and affirmed that she was going to administer them however they were scheduled for 8:00am administration (1.75 hours prior). Surveyor inquired why R48's 8:00am medications were highlighted red on the electronic MAR (Medication Administration Record). V26 replied It's gonna turn red cause you're late with the administration. Surveyor inquired about the regulatory requirement for medication administration. V26 stated It's one hour before or after, you have to give for the time that it said and affirmed its within 1 hour before or 1 hour after the scheduled time. V26 proceeded to dispense R48's 9:00am medications in the medication cup however Cetirizine (scheduled for 9am administration) was not dispensed. Surveyor inquired if R48's Cetirizine was available. V26 searched to no avail and responded, We have none. V26 subsequently administered R48's medications however a total of 4 medication errors occurred at this time (3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 23 of 40 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 01/16/2025 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 were administered late and 1 was unavailable). Level of Harm - Minimal harm or potential for actual harm The (8/15) medication administration policy states medications must be administered in accordance with a physician's order and at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. Documentation of medication administration is recorded on the Medication Administration Record or Treatment Record and includes the date, time, and initials of the licensed nurse who administered the medication. Residents Affected - Many The (undated) ordering medications policy states medications and related products are ordered from (pharmacy name) on a timely basis. Refill requests should be sent in 72 hours prior to the last dose. On 1/14/25 at 10:03am, surveyor inquired about the (2nd floor) 9am medication administration V11 (Registered Nurse) stated I'm done with that for now. Surveyor inquired why R46 was highlighted red on the electronic MAR if the medication administration was completed. V11 responded These are scheduled for 8 and 9:00 but she (R46) refuses all her meds no matter what I try. Surveyor inquired about the regulatory requirement for documenting medication administration and/or refusals. V11 replied Upon passing medication. V11 affirmed that V8 (Infection Preventionist Nurse) assisted her (V11) this morning with the medication administration. Surveyor inquired why only 1 Nurse is assigned to 2nd floor if assistance is needed with medication administration. V11 stated A lot of times to be honest with you they (facility) just don't want to staff. On 1/14/25 at 10:06am, surveyor inquired about the current (3rd floor) staffing. V27 (LPN/Licensed Practical Nurse) stated I have 3 CNAS, one is the restorative aide. Surveyor inquired if this was adequate staffing considering acuity of the residents V27 responded You should have at least 4 to 5 CNAS and 2 Nurses for 40 residents. Surveyor inquired if 2 Nurses are usually assigned to 3rd floor V27 replied Not usually. Surveyor inquired if the facility uses agency staff V27 stated No. Surveyor inquired when the 9am medication administration is usually completed when only 1 Nurse assigned to 3rd floor. V27 responded Probably like about 10:30 or 11:00, therefore not within regulatory requirements. On 1/14/25 at 11:37am, V2 (Director of Nursing) stated I'm (V2) helping her (V26/LPN) out with the med pass however (V2) was not observed dispensing and/or administering medications at this time. V26 subsequently approached the medication cart, accessed the electronic MAR and 5 residents (R30, R34, R43, R57, R169) were noted to be highlighted red. Surveyor inquired why R30, R34, R43, R57, and R169 (1st floor residents) were highlighted red on the MAR. V26 stated Because I haven't checked on it or didn't give em (medications). Surveyor inquired why the 9am medications were not administered yet V26 responded I'm not as efficient as I should be. On 1/14/25 at 11:44am, R57's 9:00am medications were highlighted red on the EMAR. V26 (LPN) dispensed R57's prescribed medications (Certivite, Lisinopril, Metformin, Vitamin D3, Fish Oil, Glipizide ER) in a medication cup and affirmed that she was going to administer them however they were scheduled for 9:00am administration (roughly 2.75 hours prior). R57's Fenofibrate and Trulicity (also scheduled for 9am administration) were not dispensed. Surveyor inquired about R57's Fenofibrate. V26 stated They missed that one and affirmed the Pharmacy did not send it. Surveyor inquired if R57's Trulicity was available. V26 contacted the Pharmacy and responded They'll (pharmacy) be sending it with the Fenofibrate today. V26 subsequently administered R57's medications however a total of 8 medication errors occurred at this time (6 were administered late and 2 were unavailable). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 24 of 40 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 01/16/2025 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 1/15/25 at 10:27am, surveyor inquired where treatment orders are supposed to be entered/transcribed when received. V19 (Wound Care Nurse) stated For the wounds they are entered in the TAR, for any ointments applied more than once they go on the MAR. Surveyor inquired about R56's wounds. V19 responded She (R56) has stage 2 to both the right and left buttock. Surveyor inquired if R56 has treatment orders V19 replied Right now its honey alginate covered with bordered gauze [therefore the orders were changed]. Surveyor inquired why R56's Hydrocol orders were not entered in the MAR and/or TAR. V19 stated She (R56) had an order for Hydrocolloid, so it only pops up on the TAR when its scheduled however R56's wound care orders also include PRN (as needed) administration for dislodged dressing. Surveyor inquired what staff are required to do if a dressing falls off. V19 responded Notify either the floor Nurse or notify me (V19) if I'm in the building. Surveyor inquired who was responsible for wound care on Monday (1/13/25) V19 replied I was pulled Monday, so floor Nurses but I believe the Corporate Nurse (referring to V31/Nurse Consultant) was in the building doing some treatments as well. Surveyor inquired why V31 administered treatments on 1/13/25. V19 stated She's (V31) a Nurse so when she comes to the building and sees were (facility) short, she assists as needed. Surveyor inquired when V19 was last pulled to work the floor (prior to 1/13/25). V19 responded I know it was sometime last week and affirmed that she (V19) is the only Wound Care Nurse employed by the facility. Surveyor inquired if 3 CNAs (assigned to 3rd floor) is adequate staffing considering acuity of the residents. V19 stated As a previous CNA it's a lot of work. The patients to CNA ratio it's a bit more than, I don't know. Some (residents) need more assistance than others I think I had 39 residents (on 1/13/25) nobody (referring to the residents) does everything for themselves. The (1/13/25) Nursing Daily Staffing Sheet affirms the following: 11 (dayshift) CNAs were scheduled however 1 called off, 1 needs doctor note, and 1 left at 9am. The facility timecard report affirms that 9 out of 9 CNAs (that arrived at the facility) clocked in late (after 6am), 3 of them were roughly 45 minutes late. V16 (Restorative Aide) was also scheduled however her timecard report affirms that she was Tardy clocked in at 8:03am (roughly 2 hours late). 3 Nurses and 1 Nurse Orientee were also on the schedule however V19 (Wound Care Nurse) clocked in at 6:53am (roughly 1 hour late) per timecard report. On 1/15/25 at 11:53am, surveyor inquired if the facility uses agency staff. V35 (Staffing Coordinator) stated I'm not using agency, we don't use agency here. I (V35) did talk to the DON (Director of Nursing) about it. Surveyor inquired about the (1/13/25) dayshift staffing. V35 responded On Monday, we had one CNA call off and then we had to take another CNA off the schedule cause she did not provide a doctor's note until Tuesday and affirmed that one CNA left early (9am). Surveyor inquired who was pulled (1/13/25) from their assigned duties to work on the unit. V35 replied We had (V37's name) the MDS (Minimum Data Set) Nurse, (V19's name) the Wound Care Nurse, and (V16's name) the Restorative Aide work the floor. I tried getting other Nurses to work, I was not able. Mondays and Wednesdays were (facility) short on Nurses, we don't have any. We've been pulling staff for a little bit more than 2 or 3 months, it's been hard. Surveyor inquired if V11 (RN) and V21 (Nurse Orientee) were the only scheduled Nurses (on 1/13/25) if V19 and V37 (from other departments) were pulled to work the floor V35 stated Yes. On 1/15/25 at 12:05pm, V10 (Assistant Administrator) affirmed that the facility has a contract with an external agency however they (facility) are not using agency staff. On 1/15/25 at 12:09pm, surveyor inquired about the facility restorative staff. V34 (Restorative Nurse) stated I (V34) have 2 restorative aides (V36's name) and (V16's name) that's it. Surveyor inquired if V34 gets pulled to work on the unit when there's a shortage of staff in the facility. V34 responded Yes, I (V34) actually resigned 2 months ago and got back in the position 2 weeks ago. I get (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 25 of 40 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 01/16/2025 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 pulled roughly twice a week sometimes 3 times a week and whatever weekend I pick I'm on the floor. When they (facility) want me to get my restorative work done and work the floor it's a lot. Surveyor inquired if the restorative aides are also pulled to work on the unit when there's a facility staff shortage. V34 replied Yes, it's probably more often, it depends on how many call-offs they (facility) have. That's why I left because were (restorative staff) all being pulled every week. Surveyor inquired who's providing range of motion for residents requiring services when restorative staff are assigned to other duties. V34 replied We try to get the CNAs to do the range of motion, but I don't know if they're actually doing them. The (10/20) emergency staffing policy states the use of overtime is approved at all times. Nursing staffing agencies may be employed as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 26 of 40 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 01/16/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that medications were re-ordered timely, and failed to ensure that prescribed medications were available for two of six residents (R48, R57) reviewed for medication administration. Findings include: R48's (1/16/24) POS (Physician Order Sheets) include Cetirizine 5mg (milligrams) daily. On 1/14/25 at 9:46am V26 (LPN/Licensed Practical Nurse) dispensed R48's prescribed medications in a medication cup. However, Cetirizine (scheduled for 9am administration) was not dispensed. Surveyor inquired if R48's Cetirizine was available, V16 searched to no avail and responded, We have none. R57's POS includes (10/22/24) Fenofibrate 54mg daily and Trulicity 1.5mg/0.5ml (milliliters) every Tuesday. On (Tuesday) 1/14/25 at 11:44am, R57's 9:00am medications were highlighted red on the EMAR (Electronic Medication Administration Record) indicating late administration. V26 (LPN) dispensed R57's (9:00am) prescribed medications in a medication cup. However, Fenofibrate and Trulicity (scheduled for 9am administration) were not dispensed. Surveyor inquired about R57's Fenofibrate, V26 stated They missed that one and affirmed the Pharmacy did not send it. Surveyor inquired if R57's Trulicity was available, V26 subsequently contacted the Pharmacy and responded They'll (pharmacy) be sending it with the Fenofibrate today. The (undated) ordering medications policy states medications and related products are ordered from (pharmacy name) on a timely basis. Refill requests should be sent in 72 hours prior to the last dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 27 of 40 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 01/16/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based upon observation, interview, and record review the facility failed to follow policy procedures and failed to maintain a medication error rate below 5%. There were 12 medication errors out of 26 opportunities, resulting in a 46.15% medication error rate. Two of six residents (R48, R57) in the medication administration sample were affected. Residents Affected - Few Findings include: On 1/14/25 at 9:46am V26 (LPN/Licensed Practical Nurse) dispensed three of R48's prescribed medications (Azelastine, Divalproex, Levetiracetam) in a medication cup and affirmed that she was going to administer them however they were scheduled for 8:00am administration (1.75 hours prior). Surveyor inquired why R48's 8:00am medications were highlighted red on the EMAR (Electronic Medication Administration Record). V26 replied It's gonna turn red cause you're late with the administration. Surveyor inquired about the regulatory requirement for medication administration. V26 stated It's one hour before or after, you have to give for the time that it said and affirmed its within 1 hour before or 1 hour after the scheduled time. V26 proceeded to dispense R48's 9:00am medications in the medication cup however Cetirizine was not dispensed. Surveyor inquired if R48's Cetirizine was available. V26 searched to no avail and responded, We have none. V26 subsequently administered R48's medications however a total of 4 medication errors occurred at this time (3 were administered late and 1 was unavailable). On 1/14/25 at 11:44am, R57's 9:00am medications were highlighted red on the EMAR. V26 (LPN) dispensed R57's prescribed medications (Certivite, Lisinopril, Metformin, Vitamin D3, Fish Oil, Glipizide ER) in a medication cup and affirmed that she was going to administer them however they were scheduled for 9:00am administration (roughly 2.75 hours prior). R57's Fenofibrate and Trulicity (also scheduled for 9am administration) were not dispensed. Surveyor inquired about R57's Fenofibrate. V26 stated They missed that one and affirmed the Pharmacy did not send it. Surveyor inquired if R57's Trulicity was available. V26 contacted the Pharmacy and responded They'll (pharmacy) be sending it with the Fenofibrate today. V26 subsequently administered R57's medications however a total of 8 medication errors occurred at this time (6 were administered late and 2 were unavailable). The (8/15) medication administration policy states medications must be administered in accordance with a physician's order and at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 28 of 40 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 01/16/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that two of six residents (R48, R57) reviewed for medication administration remained free from significant medication errors. Residents Affected - Few Findings include: R48's diagnoses include unspecified convulsions and Parkinson's disease. R48's (1/16/24) Physician Orders include Divalproex 250mg (milligrams) twice a day related to unspecified convulsions and Levetiracetam 750mg twice a day related to Parkinson's disease. On 1/14/25 at 9:46am V26 (LPN/Licensed Practical Nurse) dispensed R48's Divalproex (Anticonvulsant) and Levetiracetam (Anticonvulsant) in a medication cup and affirmed that she was going to administer them however they were scheduled for 8:00am administration (1.75 hours prior). Surveyor inquired why R48's Divalproex and Levetiracetam were highlighted red on the EMAR (Electronic Medication Administration Record). V26 replied It's gonna turn red cause you're late with the administration. Surveyor inquired about the regulatory requirement for medication administration. V26 stated It's one hour before or after, you have to give for the time that it said and affirmed its within 1 hour before or 1 hour after the scheduled time. R57's diagnoses include type II diabetes mellitus and hypertension. R57's (10/22/24) Physician Orders include Lisinopril 20mg daily for hypertension, Metformin 1000mg daily for type II diabetes mellitus, Trulicity (Hypoglycemic) 1.5mg/0.5ml (milliliters) every Tuesday for type II diabetes mellitus, and Glipizide ER 5mg daily for type II diabetes mellitus. On 1/14/25 at 11:00am, R57's blood sugar was 341. On 1/14/25 at 11:44am, R57's 9:00am medications were highlighted red on the EMAR. V26 (LPN) dispensed R57's Lisinopril (Antihypertensive), Metformin (Hypoglycemic), Glipizide ER (Hypoglycemic) in a medication cup and affirmed that she was going to administer them however they were scheduled for 9:00am administration (roughly 2.75 hours prior). R57's Trulicity (also scheduled for 9am administration) was not dispensed. Surveyor inquired if R57's Trulicity was available. V26 contacted the Pharmacy and responded They'll (pharmacy) be sending it with the Fenofibrate today. The (8/15) medication administration policy states medications must be administered in accordance with a physician's order and at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. Documentation of medication administration is recorded on the Medication Administration Record or Treatment Record and includes the date, time, and initials of the licensed nurse who administered the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 29 of 40 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 01/16/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure controlled medication for two residents (R8 and R103) were securely locked in the medication room refrigerator; failed to ensure that insulin and eye medication for four residents (R14, R20, R51 and R113) had open and expiration dates; and failed to ensure that expired insulin for one resident (R113) was removed from the medication cart. This failure has the potential to affect all residents that reside on the first floor and four residents on the third floor (R14, R20, R51 and R113). Findings include: R8 is a [AGE] year old with diagnosis including but not limited to: Acute kidney failure, unspecified dementia, unspecified protein-calorie malnutrition and encounter for palliative care. R103 is an [AGE] year old with diagnosis including but not limited to: Unspecified dementia, malignant neoplasm of colon, senile degeneration of brain and personal history of transient ischemic attack. R14 is a [AGE] year old with diagnosis including but not limited to: other specified diabetes mellitus with diabetic chronic kidney disease, mild protein-calorie malnutrition, type 2 diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction. R20 is a [AGE] year old with diagnosis including but not limited to: Unspecified glaucoma, unspecified cataract, tinea pedis, type 2 diabetes without complications, and essential hypertension. R51 is an [AGE] year old with diagnosis including but not limited to: Type 2 diabetes mellitus without complications, hyperlipidemia, essential hypertension and other specified anxiety disorders. R113 is a [AGE] year old with diagnosis including but not limited to: Type 2 diabetes mellitus with hyperglycemia, chronic kidney disease, essential hypertension and hypokalemia. On [DATE] at 12:40 PM during investigation, Surveyor and V21 (LPN/ Licensed Practical Nurse) audited the third floor medication room. On [DATE] at 12:43 PM, Surveyor noted an unlocked medication refrigerator with controlled medication stored inside for residents R8 and R103. At that time, Surveyor observed the following: Lorazepam 2MG/ML (milligrams/milliliter) and Morphine sulfate 20 MG/5ML with R8's name on them; and Lorazepam 2MG/ML and Morphine sulfate 20 MG/5ML with R103's name on them. Surveyor asked if the medication refrigerator should be locked. On [DATE] at 12:43 PM, V21 (LPN) said that controlled medication should be double-locked for safety and that the medication refrigerator should be locked as well as the medication room door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 30 of 40 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 01/16/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm On [DATE] at 12:45 PM, Surveyor audited the first floor medication cart (One west) with V2 (Director of Nursing) At that time, Surveyor noted several insulin pens with no open or expiration dates on them, eye medication with no date and an expired insulin pen. Residents Affected - Some On [DATE] at 12:45 PM, Surveyor observed the following: An opened insulin medication pen with R51's name on it but no open or expiration date labeled on it; an opened insulin medication pen with R14's name on it but no opened or expiration date on it; an opened eye medication solution with R20's name on it but no opened or expiration date on it; two opened insulin medication pens with R113's name on it but not open or expiration date labeled on them and one opened insulin medication pen with an expiration date of [DATE]. Surveyor inquired about expired insulin on a medication cart. On [DATE] at 12:50 PM, V2 (DON/ Director of Nursing) said that expired medication should be removed from all medication carts so that it not mistakenly administered to a resident. Surveyor inquired about the purpose of labeling insulin and eye medication with an open and/or expiration date. On [DATE] at 12:52 PM, V26 (LPN) said that the purpose of labeling insulin and eye medication with a date is so date the nurse would know when the medication expires. On [DATE] at 2:30 PM, V10 (Assistant Administrator) said that the facility did not have a policy regarding the storage of controlled substances. On [DATE] at 2:15 PM, V2 (DON) said that the purpose of labeling insulins and eye drops is to ensure patient safety by knowing when the medication expires after opening. Surveyor inquired about the expectations regarding storage of controlled substances. On [DATE] at 2:15 PM, V2 (DON) said that controlled substances should be double-locked for safety. R8's active orders as of [DATE] documents, Lorazepam 2MG/ ML and Morphine sulfate 20 MG/ 5ML. R103's active orders as of [DATE] documents, Lorazepam 2MG/ ML and Morphine sulfate 20 MG/ 5ML. R14's active orders as of [DATE] documents, Insulin lispro 100 unit/ML. R20's active orders as of [DATE] documents, Latanoprost ophthalmic solution 0.005%. R51's active orders of [DATE] documents, Insulin glargine 300 unit/ML. R113's active orders of [DATE] documents, Insulin glargine 100 unit/ML and Insulin lispro 200 unit/ ML. Facility policy titled Labeling/ Dating Meds documents, the following medications must be dated when first opened: Insulin; all liquids (including inhalers). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 31 of 40 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 01/16/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to ensure staff performed hand hygiene when entering the kitchen, failed to ensure food storage temperatures were monitored, failed to ensure staff hair was fully covered, failed to label food upon opening, failed to ensure the solution used for the sanitation sink was checked, failed to ensure the kitchen drain was not clogged, and failed to ensure paint on the kitchen ceiling was not disintegrating in an effort to prevent foodborne illness. These failures have the potential to affect all 111 residents receiving oral nutrition at the facility. Findings include: The (01/13/2025) facility census was 114. The (01/14/2025) email correspondence with V10 (Assistant Administrator) documented that there were 3 residents not taking oral nutrition at the facility. On 01/13/2025 at 9:28am, V3 (Administrator in Training) was inside the Kitchen. This surveyor inquired with V3 where the hand washing facility is in the kitchen. V3 stated I don't know. This surveyor inquired if V3 washed his hands when he entered the kitchen. V3 stated no, I am training. On 01/13/2025 at 9:30am during the initial tour of the Kitchen with V4 (Dietary Supervisor), observed the following: 1. The (01/2025) reach-in/walk-in coolers labeled #1 and labeled #2 temp(erature) logs had no entries on day 1/12/25 PM Temperature. 2. The (01/2025) chest freezer inside the Kitchen had no entry on PM temperature day 1/12/2025. 3. The (01/2025) Reach in freezer labeled #1 inside the Kitchen Storage room Temp log had no entries on PM temperature on days 01/11/25 and 01/13/2025. 4. A gallon of whole milk had no open date. 5. V6 (Dietary Aide) was wearing a chef's beanie. V6 hair was not fully covered. On 01/13/2025 at 9:32am, V4 stated the freezer and cooler temp logs were not complete. My evening person did not put the time and temperature on those days (pointing to the days with missing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 32 of 40 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 01/16/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many entries). The purpose of checking the temperatures is to make sure the food is stored in appropriate temperature. On 01/13/2025 at 9:42am, V4 stated he (V6) is wearing a chef's beanie and the back of his (V6) head was not covered. Our expectation is for the staff to fully cover their hair to prevent the hair getting into the food of our residents to prevent cross contamination of pathogens. On 01/14/2025 at 9:59am, V4 stated the staff are expected to label the milk container with open date and use-by-date to prevent the residents from getting sick and to ensure food items are fresh. On 01/14/2025 at 10:03am, The (01/2025) POTS and PANS Sanitization Log had missing entries on 1/3 Breakfast and Lunch; on 1/6 supper; on 1/9 supper; on 1/10 breakfast, lunch, and supper; and on 1/13 lunch. This was pointed out to V4. V4 stated our policy is to check the sanitize sink of the 3-sink compartment 3 x a day. Staff fill the 'sanitize' sink before breakfast, before lunch, and before dinner. The purpose of checking the solution of the 'sanitize' sink is to ensure the solution is in the correct potency to prevent cross contamination of pathogens. On 01/14/2025 at 12:41pm, V7 (Dietary Aide) started the Low Temp Dish machine. Within a few seconds after V7 started the dish machine, water started to come out from a pipe connected to a tray that was located below the dish machine, from the tray that was located below the dish machine and from the Kitchen drain. A bucket was used to catch the water that was coming out of the tray. This surveyor inquired how long ago the kitchen drain has had a back flow of water. V7 stated it has been like that for 3 years now. It happens when we empty the sink and when we ran the dish machine. On 01/14/2025 at 12:45pm, this surveyor informed V4 that water was coming out of the Kitchen drain. V4 stated the kitchen drain has been clogged since I got here. I started in June of 2024. The Kitchen drain should not be clogged to prevent staff from slipping and falling. It is a hazard to the staff. On 01/14/2025 at 12:56pm, the paint on the kitchen ceiling where the dish machine was located was disintegrating. This was pointed out to V4. V4 stated that is a hazard to the staff and residents. The particles can go inside the staff's nostril and lungs and can potentially affect the residents because this is where we clean the dishes used by residents. On 01/15/2025 at 10:19am with V4, V30 (Cook) donned gloves and poured cooked rice in the blender pitcher. While waiting for the rice to achieve it desired consistency, V30 touched the table and touched his eyeglasses. V30 opened the blender pitcher and added more rice in the pitcher. V4 stated he is not supposed to touch the table and his eyeglasses because it breaks the barrier and can possibly transit pathogens into the food. On 01/15/2025 at 10:23am, this surveyor inquired if staff are required to wash their hands when entering the Kitchen. V4 stated everyone who comes in the Kitchen should be washing their hands because hand washing is the first line of defense against pathogens. On 01/15/2025 at 2:41pm, V38 (Licensed Dietary Nutritionist/Registered Dietary Nutritionist) stated all employees should wash their hands when they enter the kitchen to prevent the transmission of disease. Even if the employee is in training, I still need them to wash their hands. I don't know what they would touch while in the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 33 of 40 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 01/16/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm On 01/15/2025 at 2:50pm, V38 stated staff are expected to monitor the temperature of the freezer and refrigerator to ensure food safety. Staff are expected to keep their hair covered to keep hair from getting into the resident's food to prevent transmission of bacteria and staff are not supposed to touch any surface for sanitation issue when pureeing food. I expect the staff to check the sanitation sink solution prior to use to prevent transmission of disease. Residents Affected - Many The (01/14/2025) email correspondence with V1 (Administrator) documented, in part Kindly provide V4's hire date. V1 responded 6/18/24. The (undated) Maintenance Director Job Description documented, in part The Maintenance Director is responsible for the day to day activities of the Maintenance Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility and maintained in a clean, safe and comfortable manner. Essential Duties. 2. Maintains the building in good repair and free of hazards such as caused by plumbing. The (undated) Handwashing Policy documented, in part Policy: Food and Nutrition service employees will practice safe food handling to prevent foodborne illness. Procedure: food and Nutrition services employees will thoroughly wash their hands and exposed areas of their arms with soap and water in the designated hand-washing sink at the following times: Upon entering the kitchen. The (undated) Hair Restraint/Jewelry/Nail Polish/False eyelashes policy and procedure documented, in part Food and nutrition services employees shall wear hair restraints and beard guards. Hair restraints including hair nets or hats will be worn at all times in the kitchen and food serving areas. The (undated) Storage of Frozen foods documented, in part Policy: Frozen foods are maintained at a temperature level that keeps the frozen foods solid. Procedure: Air temperature inside the freezer is checked and recorded twice daily. The (undated) Labeling and dating of foods documented, in part Policy: to decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date opened and the date the item should be discarded. The (undated) USE of gloves documented, in part Food and Nutrition services employees will practice safe food handling to prevent food borne illness. Procedure: Disposable gloves will be discarded when damaged or soiled. The (undated) PREVENTIVE MAINTENANCE PROGRAM documented, in part To conduct regular environmental tours/safety audits to identify areas of concerns within the facility. Protocol: 3. Preventive Maintenance Program will review the following areas during random rounds. 13. Paint is free from watermarks and peeling. 17. Drains are clean and free of debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 34 of 40 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 01/16/2025 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 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** Based upon observation, interview, and record review the facility failed to ensure that a thermometer was in (R3's) refrigerator, failed to ensure that (R3's) daily temperature log was not pre-signed, failed to ensure that staff are aware of the required refrigerator temperature range, failed to ensure that refrigerated perishable items were maintained below 40F (Fahrenheit), failed to defrost resident refrigerators, and failed to document daily refrigerator temperatures for six of 64 residents (R3, R15, R26, R49, R66, R84) in the sample. Residents Affected - Some Findings include: On 1/13/25 at 11:04am, R49's personal refrigerator temperature was last documented (on the daily refrigerator temperature log) on 1/7/25 (6 days prior). A thick ice build-up (roughly 1 inch) was also observed on R49's freezer. On 1/13/25 at 11:06am, R15's personal refrigerator contained perishable items including juice and cheese however the refrigerator temperature was noted to be 76F. R15's refrigerator temperature was last documented on the daily refrigerator temperature log on 1/7/25 (6 days prior). On 1/13/25 at 11:08am, surveyor inquired who's responsible for monitoring personal refrigerator temperatures, V13 (Housekeeping) stated, I do. Surveyor inquired when R15's personal refrigerator temperature was last documented, V13 responded 7 (and affirmed it was 1/7/25). Surveyor inquired what today's date is, V13 replied It's um 13. Surveyor inquired about the current temperature of R15's refrigerator, V13 replied This um 80. Surveyor inquired what the refrigerator temperature range should be, V13 stated It think it's this 40, no? and pointed to the thermometer (40F). Surveyor inquired if the items in R15's refrigerator were cold, V13 picked up the juice and responded, Not too much, [NAME] its warm. On 1/13/25 at 11:12am, surveyor inquired when R49's personal refrigerator temperature was last documented. V13 stated This is the same thing, 7 and affirmed it was 1/7/25. Surveyor relayed concerns with ice buildup observed in R49's refrigerator and inquired who this concern should be reported to. V13 responded Manager. Surveyor inquired if the ice buildup in R49's refrigerator was reported to the Manager. V13 replied This is the families and affirmed it was not. On 1/13/25 at 12:10pm, R26's personal refrigerator contained perishable items including creamer, cheese, and a protein shake, however the refrigerator temperature was noted to be out of range (above 40F) and a temperature log was not affixed to the refrigerator. In addition, a thick ice build-up (roughly 1 inch) was observed on R26's freezer. Surveyor inquired about the current temperature of R26's refrigerator. V14 (Certified Nursing Assistant) inspected the thermometer and stated, I would say 45. Surveyor inquired what the refrigerator temperature should be. However, V14 was unsure. Surveyor inquired what was on R26's freezer, V14 responded The ice. The (1/19) food storage - outside sources policy states in part; food/beverages brought in may be stored in resident's personal refrigerator. Nursing staff will be responsible for checking resident personal refrigerator daily for proper labeling, temperature recording and storage. Facility staff will monitor resident personal refrigerators for food and beverage disposal needs for safety. All refrigerators in use in the facility have an internal thermometer to monitor temperature. All refrigerators have their internal temps recorded daily. Any refrigerators found to have an internal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 35 of 40 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 01/16/2025 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some temperature that is outside of the accepted safe parameters of temperature will be immediately addressed by maintenance and will be taken out of service if the internal temperature cannot be corrected within a reasonable time frame to maintain food safety. Any affected food/beverages will be discarded. On 01/13/25 11:08 AM inside R66's room, this surveyor requested V12 (Certified Nursing Assistant) to check R66's refrigerator. V12 stated there are 5 cartons of 2% milk, 8 small tubs of butter and the refrigerator log is thru January 7th only. Maintenance checks the temperature. I don't know how often they check it. On 01/13/25 11:11 AM, there was a small refrigerator inside R84's room. Inside the refrigerator were 6 bottles of Ensure, 4 packs of 2%milk a half gallon of yogurt cool and a half gallon of whole milk. There was a daily temperature log stuck on the side of the refrigerator. The log was for 2024. On 01/13/2025 at 11:19am, this observation was pointed out to V11 (Registered Nurse). V11 stated there was no temperature being logged after 12/07/2024. R66's (Active Order as Of:01/13/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) asthma and dementia. R66's (01/01/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating that R66's mental status as moderately impaired. R66's (2025) Daily Refrigeration Temperature Monitoring log indicated temperature was checked from January 1 thru January 7 only. R84's (Active Order as Of: 01/13/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) chronic obstructive pulmonary disease, emphysema and chronic respiratory failure. R84's (11/14/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R84's mental status as cognitively intact. R84's (2024) Daily Refrigeration Temperature Monitoring Log documented the refrigerator was checked from August 17 thru [DATE] only. Of note, R84 has no log for the year 2025. The (undated) Food Storage - Outside Sources documented, in part Foods or beverages brought in from the outside will be monitored by nursing staff for spoilage, contamination and safety. 3. Foods/beverages brought in may be stored in the resident's personal refrigerator. Nursing staff will be responsible for checking resident personal refrigerator daily for temperature recording. On 1/13/2025 at 12:00 pm, R3's personal refrigerator was observed without a thermometer, the temperature log sheet with missing signatures for January 10, 2025, January 11, 2025, and with a temperature of 40 degrees presigned for January 14, 2025, a temperature of 39 degrees presigned for January 15, 2025, and a temperature of 40 degrees presigned for January 16, 2025. On 1/13/2025 at 2:03 pm, this observation was brought to V22 (Licensed Practical Nurse, LPN) and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 36 of 40 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 01/16/2025 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some V22 stated, I (V22) don't see a thermometer in the refrigerator (referring to R3's refrigerator). I don't know how it was recorded through January 16, 205, today is just the 13th. When V22 was asked who is responsible for monitoring the residents personal refrigerators, V22 stated that it is the nursing and housekeeping departments responsibility to monitor the residents personal refrigerators. When V22 was asked regarding how often the residents personal refrigerators should be monitored and V22 stated that the residents personal refrigerators should be monitored daily, and the temperature should be recorded. When V22 was asked regarding the importance of the residents personal refrigerators having a thermometer and being monitored daily and V22 stated, It should have a thermometer and checked daily to make sure nothing spoils. On 01/15/24 at 9:29 am, V2 (Director of Nursing, DON) stated that monitoring the residents personal refrigerators is the responsibility of the housekeeping staff. V2 then stated the residents personal refrigerators should be monitored every day by the nursing staff. When V2 was asked regarding what can happen if a residents personal refrigerator is not monitored daily. V2 stated, It can fall out of range, food can spoil, get contaminated and residents can get sick. When V2 was asked regarding thermometers for the residents personal refrigerators. V2 stated, Every residents personal refrigerator should have a thermometer at all times to assess the settings. R3's face sheet shows that R3 has a diagnosis which includes but not limited chronic obstructive pulmonary disease (COPD), and asthma. R3's Brief Interview for Mental Status (BIMS) dated 12/22/25 shows that R3 has a BIMS score of 13 which indicates that R3 is cognitively intact. The facility's document dated Year: 2025 and titled Daily Refrigeration Temperature Monitoring shows R3's Daily Refrigeration Temperature Monitoring with missing temperature logs for January 10, 2025, January 11, 2025, and with a temperature of 40 degrees for January 14, 2025, a temperature of 39 degrees for January 15, 2025, and a temperature of 40 degrees for January 16, 2025, prefilled on R3's personal refrigerator log sheet. The facility's undated policy titled Food Storage-Outside Sources documents, in part: Procedure: Nursing staff will be responsible for checking resident personal refrigerators daily for proper labeling, temperature recording ad storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 37 of 40 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 01/16/2025 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the dumpster was not overflowing with trash and the dumpster's lid was closed in an effort to prevent pest and rodents migration to the facility. This failure has the potential to affect all the residents at the facility. Residents Affected - Many Findings include: The (01/13/2025) facility census was 114 residents. On 01/13/2025 at 9:51am with V4 (Dietary Supervisor) made an observation of the outside dumpster. The outside dumpster was overflowing with black and white trash bags and one of the 3 lids was open. V4 stated the big dumpster was overflowing with trash and one of the lids was open. V4 stated the black trash bags are from the Dietary. Maintenance is in charge of the dumpster. On 01/15/2025 at 10:06am, V32 (Maintenance Director) stated the dumpster lid should be closed always so nothing could go in the dumpster like rats and flies because if these live in the dumpster they could go anywhere inside the building. The (undated) Waste Management Policy documented, in part Purpose: to prevent the spread of infection. Standards: 4. Dumpster lid kept closed. 5. Maintenance and Housekeeping personnel shall assure the dumpster area is kept clean and all trash bags are inside the dumpster, and the dumpster lids are closed. The (undated) Safe Food Handling - Dumpster Policy and Procedure documented, in part Policy: All food will be handled safely and disposed of in a safe manner. Procedure: Dietary trash will be disposed of in sealed plastic trash bags. The sealed bags will be disposed of in the outside dumpster. The dumpster will be securely covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 38 of 40 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 01/16/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based upon observation, interview, and record review the facility failed to ensure that isolation signs are posted properly, failed to ensure that assigned staff/visitors were made aware that (R11) requires contact isolation, failed to ensure that visitors don required PPE (Personal Protective Equipment) prior to entering an isolation room, and failed to ensure that staff perform hand hygiene during dining services. These failures have the potential to affect all 114 residents residing in the facility. Residents Affected - Many Findings include: The (1/13/25) census includes 114 residents. R11's (8/7/24) care plan states, resident is on isolation related to ESBL (Extended Spectrum Beta Lactamase). Interventions: set up isolation per facility protocol. Educate resident/family on isolation. On 1/13/25 at 11:17am, V11 (Registered Nurse) was assigned to R11. Surveyor inquired which type of isolation R11 requires. V11 stated He (R11) had ESBL, he's not on it no more, the sign needs to come down. However, R11's name was noted to be on the facility isolation log (received 1/13/25). On 1/13/25 at 11:30am, two pieces of paper were observed taped to R11's door. However they were noted to be falling off (the top corners were not secured which caused the signs to dangle upside-down, showing only the blank side). V17 (Chaplain) was in R11's room without PPE (Personal Protective Equipment) on at this time. On 1/13/25 at 11:52am, surveyor inquired if R11 is currently on isolation. V8 (Infection Preventionist Nurse) replied He (R11) is on contact isolation for ESBL of the urine. V8 subsequently approached R11's room and stated, Unfortunately the tape that we have don't work because its hot in the building and attempted to place the (contact isolation) signs correctly on R11's door. Surveyor advised that V17 was observed in R11's room without PPE on. V8 responded That's a big problem cause he's (R11) on isolation. The infection control policy states it is the policy of this facility to maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to prevent or eliminate when possible, the development and transmission of disease and infection. Transmission Based Precautions: additional precautions are applied when the transmission characteristic of, or impact of, infection with a specific microorganism are not fully prevented by routine practices. Additional precautions include contact precautions. Personal protective equipment is an essential element in preventing the transmission of disease-causing microorganisms. The (01/13/2025) facility census documented that there were 41 residents on the second floor. On 01/13/25 at 12:11 PM, there were 8 residents seated in the dining/activity room; one table with 4 residents and another table with 3 residents including R61; R50 was seated on a geriatric chair. A bedside table was in front of R50. V16 (Restorative Aide/CNA) handed a tray to V12 (Certified Nursing Assistant), V12 set up the tray in front of R61. After setting up R61's tray, V12 propelled R61's wheelchair closer to the table. V16 handed another tray to V12 and V12 took the tray without performing hand hygiene and set up the tray in front of R50. After setting up R50's tray, this surveyor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 39 of 40 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 01/16/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many informed V12 of this observation and inquired for staff expectation after touching R61's wheelchair and prior to setting up R50's tray. V12 stated I should have sanitized my hands to make sure my hands are clean. No, I did not sanitize my hands. On 01/13/2025 at 12:39pm, V8 (Infection Preventionist) stated staff are expected to perform hand hygiene after touching a resident's wheelchair and prior to setting up another resident's meal tray to prevent the spread of germs. We don't have a sink in the dining room; staff are expected to use the hand sanitizer located in the dining room. R50's (Active Order as Of 01/13/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) heart failure, cardiac arrhythmia and anxiety disorder. R50's (12/16/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 07. Indicating R50's mental status as severely impaired. R61's (Active Order as Of: 01/13/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) anorexia, heart failure and Type 2 Diabetes Mellitus. R61's (10/22/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 2. Indicating R61's mental status as severely impaired. The (9/14) Hand washing Policy documented, in part Purpose: to remove dirt, organic material, and transient microorganism which are found on the hands to reduce the potential or resident morbidity and morality from nosocomial infection. Policy: All facility staff will practice hand washing activities with an anti-microbial agent or waterless antiseptic agent in accordance with this policy. Standards: 1. Handwashing will be practiced as follows: c. after contact with source of microorganism (inanimate objects that are likely to be contaminated). i. Before handing food or food trays. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146062 If continuation sheet Page 40 of 40