Inspection·March 31, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on record reviews and interviews, the facility failed to follow their policy and procedure to develop a baseline care plan that included individualized information to provide effective, person-centered care for 3 (R2, R15, R18) of 12 residents in a sample of 12 reviewed for baseline care plans. The Findings Include: R2's clinical records show an admission date of 3/1/23 with listed diagnoses not limited to fracture of lower end of left femur, hypoxemia, hypertension, and major depressive disorder. R2's physician order sheet (POS) shows R2 is receiving psychotropic medications, oxygen therapy, skin treatment, and on mechanically altered diet. R2's baseline care plan was not completed. R15's clinical records show an admission date of 2/17/23 with listed diagnoses not limited to acute respiratory failure with hypoxia, dependence on renal dialysis, heart failure, and diabetes mellitus type 2, and end-staged renal disease. R15's POS shows R18 is receiving outpatient dialysis, on diuretic, and on therapeutic diet. R15's baseline care plan was not completed. R18's clinical records show an admission date of 2/26/23 with listed diagnoses not limited to left humerus displaced fracture, left shoulder girdle fracture, chronic obstructive pulmonary disease, history falling, and major depressive disorder. R18's POS shows R18 is receiving as needed psychotropic and narcotic medications, and on skilled therapy services. R18's baseline care plan was completed and signed on 3/29/23. On 3/30/23 at 9:15 AM, V16 (MDS/Care Plan Coordinator) stated that baseline care plan should be completed and signed within 48 hours of the resident's admission. V16 stated that each area in the baseline care plan template is completed and signed by V16. At 11:59 AM, V2 (Director of Nursing) provided paper copies of R2, R15, and R18's Baseline Care Plan MC showing the timed stamps when they were signed as completed. V2 stated R2 and R15's baseline care plans were not completed and still in progress. V2 stated that R18 baseline care plan was completed and signed late on 3/29/23. The facility's policy titled; Baseline Care Plan dated 11/1/19 reads in part: 1. A baseline/admission care plan will be developed within 48 hours of the resident's admission. 2. The baseline/admission care plan will include information for the provision of effective person-centered care and will include the minimum healthcare information necessary to properly care for each resident immediately upon admission. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 2 of 13 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 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 0655 Level of Harm - Minimal harm or potential for actual harm The baseline/admission care plan will address the initial goals of the resident based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, if applicable. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 3 of 13 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 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 - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow policy and procedures for Fall Prevention and fall occurrence by not completing a fall risk assessment to determine fall risk factors and target interventions to reduce risks on a quarterly basis and after a new occurrence of a fall for one resident (R11) out of a total sample of 12 residents. This has the potential to an increased risk of repeated fall occurrence because of lack of appropriate interventions to prevent such occurrence. As a result of this failure , R11 fell on the floor unwitnessed on 3/27/23. The findings include: On 3/28/23 at 12:51 PM R11 stated I fell yesterday on the floor between my bed and recliner chair. R11 stated she (R11) fell around after lunch time and before supper time. R11 stated she (R11) called for help by activating her (R11) call light. R11 stated she (R11) was assisted by 4 staff. R11 stated she (R11) did not have any injury. R11 stated she (R11) was not hurt. R11 stated I don't know why I fell. R11 Electronic Health Record (EHR) admission date was on 6/25/22 with diagnosis not limited to Unspecified Sequelae of Cerebral Infarction, Parkinson's disease, Rheumatoid Arthritis, Chronic Kidney Disease, Essential Hypertension. R11 Minimum Data Set (MDS) dated [DATE] indicated that R11 was cognitively intact. R11 required limited assistance with bed mobility, transfer, and toilet use. R11 was always incontinent of bowel and bladder. R11 progress notes dated 3/27/23 documented in part: Resident called out from room for help after falling to floor trying to transfer from wheelchair to her recliner. Does not know exactly how she fell but said it happened while transferring top recliner. Claims wheels were locked and she was not too far away from chair. Reported striking cheek on rolling bedside table. Reports mild discomfort to right cheek and hip, denies need for pain medication at this time. Full body assessment performed, no noted trauma to cheek, hip or other part of body, vitals: 151/69 79 94%. Notified PCP with no new orders. Resident notified POA (Power of Attorney). Will monitor frequently for change in status or need for pain intervention. R11 care plan date initiated on 6/23/22 and revision date of 6/23/23 documented in part: R11 is at risk for falls r/t (related to) history of falls, and fall prior to admission. She has a dx (diagnosis) of Syncope, and is receiving antidepressant medication. On 3/30/23 at 10:34 PM V2 (Director of Nursing - DON) was interviewed and stated that she (V2) has been working in the facility for 4 years. V2 stated that whenever there is a fall incident Inter Disciplinary Team (IDT) would do a fall meeting and discuss the fall incident. V2 stated Root Cause Analysis (RCA) and interventions will be discussed as well and will be communicated with staff and therapy if appropriate. V2 stated that Resident Fall assessment should be done upon admission, quarterly, Significant Change in condition and after a fall. V2 stated that care plan will be reviewed and interventions would be updated after a fall. At 10:40 AM V10 (Registered Nurse - Unit manager) was interviewed and stated that one of her (V10) responsibilities is Fall program. V10 stated that whenever there is a fall incident, manager will be informed by staff. V10 stated fall incident will then be discussed in the morning huddle. V10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 4 of 13 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 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 - Few stated that RCA, interventions will also be discussed by IDT. V10 stated that R11 had a fall incident on 3/27/23. V10 stated that R11 was trying to transfer from bed to recliner chair in the evening. V10 stated there were no injuries. V10 stated that the purpose of fall risk assessment is to identify the predisposing factors that might be a potential problem of falling. R11 EHR reviewed with V2 and V10 and both (V2, V10) stated that the last fall risk assessment done for R11 was on 12/10/22. V2 and V10 stated there should be a fall risk assessment completed on 3/10/23 for quarterly review to determine fall risk factors and target interventions to reduce risks. V2 and V10 also stated that there was no fall risk assessment completed after a fall on 3/27/23 in R11 EHR. Reviewed R11 fall scale assessment dated [DATE] documented in part: Category: High risk for falling. Reviewed facility's policy for fall prevention and fall occurrence dated May, 2018 documented in part: Purpose - To establish a procedure for the prevention and reduction of falls by the assessment analysis of the individual risk factors and fall history. Process / Procedure - 1. A Fall Risk Assessment will be completed at the following intervals: a) Upon admission b) Quarterly c) With a new occurrence of a fall d) Significant change in condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 5 of 13 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident received the correct oxygen flow rate as ordered by the physician and to ensure a person-centered comprehensive care plan was implemented to address oxygen use for 1 (R2) of 2 residents receiving supplemental oxygen in a sample of 12 reviewed for respiratory care. Residents Affected - Few The Findings Include: R2's clinical records show R2 has a diagnosis of Hypoxemia. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact, is receiving oxygen, and requires extensive two staff assist with bed mobility and transfer. R2's physician order sheet (POS) shows Oxygen per via Nasal Cannula at 1 Liters per Min Continuous Humidified ordered on 3/1/23. R2's comprehensive care plan does not address the use of oxygen. On 3/28/23 at 1:26 PM, R2's resting in bed alert and able to verbalize needs. R2 was receiving oxygen (O2) that was set to 2 liters per minute (LPM) via nasal cannula. R2 stated R2 is receiving the oxygen to help R2 breath easily. On 3/29/2023 at 9:43 AM, R2's resting in bed and was receiving oxygen that was set to 1.5LPM. At 9:54 AM, surveyor asked V9 (Licensed Practical Nurse) to check R2's oxygen order in R2's electronic health record (EHR). V9 confirmed that R2's oxygen flow rate order was 1LPM continuously via nasal cannula. V9 stated that R2 should be getting 1LPM of oxygen continuously and nursing should be monitoring the correct flow rate. V9 stated that R2's oxygen is for R2's diagnosis of Hypoxemia. V9 stated that the nurses have to follow and adjust the flow rate based on the doctor's orders. On 3/30/23 at 9:15 AM, V16 (MDS/Care Plan Coordinator) stated that a resident's comprehensive care plan should address the resident's diagnoses. V16 stated that the purpose of the care plan is to address the needs of the resident for safety and to take care of any problems that the resident is having. V26 stated that if the need of the resident is not addressed in the care plan it could cause harm to the resident. V16 stated that if a resident is receiving supplemental oxygen, it should be part of the intervention in the care plan related to their diagnosis. At 10:21 AM, V2 (Director of Nursing) stated that there is a doctor's order for residents receiving supplemental oxygen therapy. V2 stated that nurses have to follow doctors order for oxygen administration. V2 stated that the nurses should monitor the resident if the oxygen is therapeutic for them and if needs to be increased or decreased, then notify the doctor. V2 stated that the nurses should be monitoring the resident oxygen at least every shift that's in the right setting. The facility's policy titled; Oxygen Administration dated 11/1/19 reads in part: Purpose: To provide guidelines for safe oxygen administration. General Guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 6 of 13 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 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 1. Level of Harm - Minimal harm or potential for actual harm Verify that there is a physician's order in place for this procedure or community protocol. The facility's policy titled; Care Planning Resident/Elder Directed dated 5/2008 reads in part: Residents Affected - Few Purpose: To provide care centered on the needs and desires of the resident/elder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 7 of 13 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility: Residents Affected - Many 1. failed to properly store and label open items; 2. failed to discard open items by labeled use by dates; and 3. failed to ensure food is prepared and served [NAME] sanitary manner by failing to don personal protective equipment (PPE) properly; These failures have the potential to affect 23 residents who receive meals from the facility kitchen. 1. On 3/28/2023 at 11:13 am, during the initial tour of the kitchen, inside the ICE CREAM FREEZER, there were 5 tubs of opened ice cream with different flavors that are not labelled with date it was opened and use by date. V3, Kitchen Manager, stated, This kitchen serves the Assisted Living, Supportive Living and Skilled Unit of the facility. The icer cream buckets are not dated, I will throw them all away. Facility provided a document titled Mercy Circle Always Available Menu which affirms that Assorted Ice Creams are being offered and served to residents in the skilled unit. 2. Inside the UNDER COUNTER REFRIGERATOR, there were 2 cartons of liquid eggs with USE BY DATE of 3/27/2023. V3 stated that it is the cooks who check the refrigerators for expired foods. V3 then took the expired cartons of liquid eggs and threw them in the garbage container. 3. On 3/28/2023 at 11:14 AM V7, Cook, while preparing Monte [NAME], was wearing surgical mask but not covering the nose. On 3/28/2023 at 11:21 AM, during the 3rd floor dining room observation, V5, Server, while preparing the food on the steam table, was wearing her surgical mask under her chin, not covering the mouth and nose. V4, Director of Dining Services, motioned for V5 to place her (V5) surgical mask properly. V5 then proceeded to put her mask on properly with the nose and mouth covered. 3/29/2023 11:16 AM, V4, Director of Dining Services stated, Any opened food should have an open date and use by date. Both myself, V4 and V3, Kitchen Manager, check for expired foods in the storage freezers and refrigerators. Facility presented policy with subject Food and Supply Storage under Procedures document in part: Cover, label and date unused portions and open packages. Use the [NAME] orange label, Medvantage label or Ecolab Prep N Print label; complete all sections on the label. Products are good through the close of business on the date noted on the label Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 8 of 13 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow Water Safety Plan to send water sample annually to rule out Legionella (a bacteria that can cause a serious type of pneumonia (lung infection) called Legionnaires' disease) and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter) could grow and spread. These deficient practices has the potential to affect all 23 residents in the facility. Residents Affected - Many Findings include: On 03/29/2023 at 10:12 AM. V2 (Director of Nursing / Infection Preventionist) stated that facility is aware that water should be monitored to prevent Legionella infection or Legionnaires' disease. And the staff that is assigned to monitor water being used by residents is V17 (Director of Plant Operations). On 03/29/2023 at 10:20 AM. V17 (Director of Plant Operation) said, Yes, facility submits water sample to an outside vendor lab yearly. But I am new to this position, I started 15 months ago, and I think the last time facility submitted water sample to test for Legionella was 2019. I know it is important to make sure that water is free from Legionella. V17 submitted water report dated 03/08/2019. Per Water Safety Plan dated 2019 water sampling for Legionella frequency should be done annually with a minimum of ten (10) samples. On 03/30/2023 at 11:11 AM. V17 stated, I will check on the lab that handle checking water sample for legionnaire because I think there are specific days that they accept samples. I will also work on the details like checking water temperature. I know this is a concern, and it is important to check that water being used by residents. To reduce cases of Legionnaires' disease in health care facilities, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare certified healthcare facilities must develop and maintain water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. The directive has an immediate effective date. (https://www.ashrae.org/about/news/2017/cms-issues-directive-requiring-medicare-certified-healthcare-facilities-to-impleme Legionella, the bacterium that causes Legionnaires' disease, .Legionella can pose a health risk when it gets into building water systems. Legionella first must grow (increase in numbers). Then it has to spread through small water droplets (aerosolization) that people can breathe in. (https://www.cdc.gov/legionella/wmp/overview/growth-and-spread.html) Seven key elements of a Legionella water management program are to: Establish a water management program team, describe the building water systems using text and flow diagrams; identify areas where Legionella could grow and spread; decide where control measures should be applied and how to monitor them; establish ways to intervene when control limits are not met; make sure the program is running as designed (verification) and is effective (validation) and document and communicate all the activities. (https://www.cdc.gov/legionella/wmp/overview.html) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 9 of 13 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and review of records, the failed to follow policy on testing residents immediately after a single new case (V11) of COVID-19. These failure has the potential to affect all 23 residents in preventing the risk of Covid-19 infection Residents Affected - Many Findings include: On 03/28/2023 at 09:37 AM. During entrance conference, V2 (Director of Nursing (DON) / Infection Control Preventionist) stated that facility does not have resident positive of Covid-19. At 11:15 AM, at the floor V2 approached writer and said, I know I said in the conference room that we (facility) do not have Covid-19 positive resident. But today after testing 1 resident was positive (R1). One of the staff who worked 2 weeks ago tested positive. Then we decided to test the whole floor because we only have small number of residents. R1 was seen with V18 (R1's Power Of Attorney/POA) at the bedside. V18 said, I am here every day and takes care of R1. I am R1's power of attorney. Few days ago, R1 had a cold-like symptoms and a mild sore throat. V18 was seen with face shield, gown, and mask but her gloves was on the floor. V18 was asked if she was informed to wear gloves since she is performing direct care to R1. V18 took the gloves on the floor and wear the same gloves on both of her hands. At 02:44 PM, V2, DON, identified V11 (Licensed Practical Nurse) as the staff that tested positive for Covid-19. V2 said, Last time V11 worked on the floor was Wednesday (03/22/2023). And yes, V11 did have direct care with all residents every time she (V11) worked on the floor being a nurse. V2 came back and presented facility nursing staff schedule that reads, V11 worked on 03/18/2023 (Saturday), 03/19/2023 (Sunday), 03/20/2023 (Monday) and 03/21/2023 (Tuesday) evening shift between 2:00 PM to 10:00 PM. V2 said, I was mistaken, V11 last worked in the facility on Tuesday, March 21, 2023. V11 notified us that she (V11) was positive with Covid-19 infection on Friday (03/24/2023). We tested staff during weekend, Saturday and Sunday and residents were tested today (03/28/2023), which is 4 days after learning that V11 tested positive. V2 was asked why residents were tested 4 days after and not sooner because R1 turned out positive and may have exposed other persons on the floor. V2 kept silent for few minutes, and when asked again. V2 said, I am thinking. And did not answer the question. When asked why since V18 (R1's POA) who comes in the facility every day has seen R1 with cold-like symptoms, why was there no testing done with R1 until today (03/28/2023)? V2 said, Nursing staff on the floor did not observe R1 with cold-like symptoms. V2 confirmed that when facility tested all residents after 4 days of knowing that V11 had COVID-19 infection, R1 tested positive for COVID-19. V2 said, Yes R1 was positive, and it is considered an outbreak if a single staff is positive of Covid-19. V2 submitted list of staff positive of Covid-19 that includes 6 staff including V11: V20 (Therapist/Agency) on 02/26/2023 V21 (Reception Staff) on 03/01/2023 V22 (Nurse) on 03/06/2023 V23 (Human Resource Staff) on 03/13/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 10 of 13 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 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 0886 V15 (Reception Staff) 03/14/2023. Level of Harm - Minimal harm or potential for actual harm V11 (Licensed Practical Nurse) 3/24/2023 Residents Affected - Many V2 also submitted list of 6 residents including R1 that are Covid-19 positive date range from 01/03/2023 to 03/28/2023. Per facility policy for Infection Prevention and Control Coronavirus (Covid-19) provided by V2 dated as reviewed on 03/08/2023, in part reads: Under Outbreak Management, a single case of SARS-CoV-2 infection in any HCP (Healthcare Personnel) or resident should be treated as potential outbreak. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could be exposed. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier that 24-hours after exposure, and if negative, again after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3 and day 5. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 11 of 13 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and review of records, the facility failed to track and secure documentation of vaccination status of a contracted direct care staff (V17) who has been granted exemption from the COVID-19 vaccination (V17). This failure has the potential to affect all 23 residents residing in the facility in preventing the spread of COVID-19 infections. Residents Affected - Many Findings include: On 03/28/2023 at 09:37 AM. During entrance conference, V2 (Director of Nursing / Infection Control Preventionist) stated that facility does not have resident positive of Covid-19. At 11:15 AM, at the floor V2 approached writer and said, I know I said in the conference room that we (facility) does not have Covid-19 positive resident. But today after testing 1 resident was positive (R1). One of the staff who worked 2 weeks ago tested positive. Then we decided to test the whole floor because we only have small number of residents. On 03/28/2023 at 09:355 AM. V17 (Hospice Nurse / Agency) was seen with R1. V2 later confirmed V17 was providing direct care with R1 since R1 was admitted to hospice. R1's order for hospice was dated 12/12/2022. At 02:44 PM, V2 submitted facility staff matrix or log that documents vaccination status of all staff including contracted or agency staff working in the facility. V2 also submitted names of contractual companies that includes, companies providing services for rehab/therapy and dining. Hospice company and staff performing direct care was not included. And upon review of facility matrix or log hospice staff was also not include. On 03/29/2023 at 10:01 AM. V2 presented hospice company and staff that the facility utilizes to perform direct care to residents. Under the document ,V17 (Hospice Nurse), who performed direct care to R1 was exempted and did not receive vaccination for Covid-19. On 03/30/2023 at 02:00 PM. After request for testing of exempted employees including contractual staff or agency, V2 with V12 (Human Resource Director) said, Yes, V17 is included on agency staff that is not vaccinated due to exemption. V17 performs direct care and was not tested for Covid-19. V2 submitted list of staff positive of Covid-19 that includes 6 staff including V11: V20 (Therapist/Agency) on 02/26/2023 V21 (Reception Staff) on 03/01/2023 V22 (Nurse) on 03/06/2023 V23 (Human Resource Staff) on 03/13/2023 V15 (Reception Staff) 03/14/2023 V11 (Licensed Practical Nurse) 3/24/2023 V2 also submitted list of 6 residents including R1 that are Covid-19 positive, date range from 01/03/2023 to 03/28/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 12 of 13 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 146174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mercy Circle 3659 West 99th Street Chicago, IL 60655 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 0888 Level of Harm - Minimal harm or potential for actual harm Covid-19 Staff Vaccination Matrix Instructions for Providers as provided by V2 does not contain information regarding vaccinationn status of V17. Instructions under Section 1 reads: Total number of staff: All staff that work in the facility. Staff includes facility employees (regardless of clinical responsibilities or resident contact), licensed practitioners, adult students, trainees, and care, treatment, or other services for the facility and/or its residents, under contract or arrangement. Residents Affected - Many Covid-19 Prevention Policy dated 7/8/2021, in part reads: Non-employees include but are not limited to non-employed clinical staff, contractors, consultants, temporary staff, students, volunteers, and service partners. Each Health Ministry will identify a member of the leadership team for each non-employee group who will be accountable to ensuring that non-employees who are conducting business in the facility are fully vaccinated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 13 of 13