Inspection·January 26, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to (a) properly date opened multi-dose eyedrops for 1 (R9) resident and (b) ensure that medication was stored properly in the correct medication packaging and for the right resident for 2 (R2 and R9) residents. These failures could potentially affect 2 (R2 and R9) residents from one of one medication carts inspected for medication storage and labeling. The findings include: R2's health record documented admission date 12/8/23 with diagnoses not limited to Acute and chronic respiratory failure with hypoxia, Chronic right heart failure, Chronic lymphocytic leukemia of b-cell type not having achieved remission, Unspecified atrial fibrillation, Essential (primary) hypertension, Malignant neoplasm of unspecified kidney, Chronic kidney disease, Other pulmonary embolism with acute cor pulmonale, Dyspnea, Other allergic rhinitis. R9's health record documented admission date 11/15/23 with diagnoses not limited to Periprosthetic fracture around internal prosthetic right hip joint, Mild persistent asthma, Dementia in other diseases classified elsewhere, Shortness of breath, Cardiac murmur, Gastro-esophageal reflux disease without esophagitis, Dry eye syndrome of bilateral lacrimal glands, Other seasonal allergic rhinitis, Cough, Hypothyroidism. On 01/23/24 at 10:38 am, Medication cart inspected with V10 (Licensed Practical Nurse) and found the following: R9's Olopatadine HCl Ophthalmic Solution 0.2 % multi-dose eye drops without the date opened written. R2's clear plastic bag with pharmacy labeled Fluticasone nasal spray and inside the clear plastic bag was R9's Olopatidine multi-dose eye drops. V10 confirmed that R9's Olopatadine HCl Ophthalmic Solution 0.2 % multi-dose eye drops with no open date written and was kept in R2's plastic bag with pharmacy labelled Fluticasone spray. V10 stated that R9's eye drops should not be in R2's plastic bag because it is a different medication and different resident. V10 stated that eyedrops should have a date written when it was opened. On 1/24/24 at 10:54 am, V4 (RN/Registered Nurse manager) stated that all medications should have an open date written once opened to know when it was opened and when it is supposed to be discarded or disposed. V4 stated that medication should be kept in proper pharmacy packaging with correct medication and right resident to avoid confusion and potential medication error. At 11:14 am, V2 (DON/Director of Nursing) stated that all medications should have an open date written after opening to know the date when it was opened to guide when to dispose the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 2 of 5 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 01/26/2024 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 0761 Stated that medication should be kept in proper packaging with correct resident and medication to avoid confusion and potential administering medication to wrong resident. Level of Harm - Minimal harm or potential for actual harm R2 order summary report dated 1/23/24 with active order not limited to: Residents Affected - Few Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 2 sprays in both nostrils every 24 hours as needed for nasal. R9 order summary report dated 1/23/24 with active order not limited to: Olopatadine HCL ophthalmic solution 0.2% Instill 1 drop in both eyes in the morning related to Other Seasonal Allergic Rhinits. Facility's medication storage policy dated 8/2022 documented in part: Proper med storage is a standard of practice. The pharmacy fills medications using specially packaged administration systems designed to assist facilities in reducing medication error. Medication dating: Eye Drops - eye medication bottles / tubes with accelerated expiration dates must be dated / initialed upon opening. Medications should be stored separately according to route of administration. Further separate routes in medication carts (e.g. oral, injectables, liquids, eyes, ears, nose, inhalers). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 3 of 5 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 01/26/2024 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 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 kitchen staff wearing hair restraint while in the kitchen and failed to ensure frozen meats were stored six inches above the floor in the freezer. These failures have the potential to affect 22 residents in the facility who are receiving oral diet. Findings Include: On 1/23/24 at around 9:36 AM, during the initial tour in the kitchen, V15 (Utility Worker) was observed handling the dishes in the dishwashing machine area. V15 had short length hair on V15's head and was not wearing any hair restraint. At 9:49 AM, the main freezer was inspected with V14 (Director of Dining) and observed a frozen packed beef brisket and a frozen packed beef eye round on the floor under the shelving unit. V14 stated that foods should not be stored on the floor. V14 placed both packages of meat back at the bottom of the shelf in the freezer. At 9:56 AM, V14 stated that anyone who enters the kitchen especially kitchen staff should wear hair net or hair restraint to keep any loose hair falling off on to the food. On 1/24/24 at 10:11 AM, V13 (Chef Manager) stated that foods in the dry storage, in the cooler, and in the freezer should be stored six inches off the ground. V13 stated that if the food is left on the floor, it needs to be thrown out. V13 stated that there are no residents in the facility that are NPO (Nothing by Mouth). The facility's roster documents 22 residents in the facility. The facility's policy titled; UNIFORM DRESS CODE dated 1/17 reads in part: PROCEDURES: Wear the approved hair restraints when on duty. The facility's policy titled; FOOD AND SUPPLY STORAGE dated 1/18 reads in part: FROZEN STORAGE Store food items _ above the floor, consistent with local food protection codes* *6 above floor is the federal guideline. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 4 of 5 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 01/26/2024 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 observation, interview and record review, the facility failed to follow their policies and procedures to ensure proper infection control guideline practices are followed related to Personal Protective Equipment (PPE) was not worn prior to entering a contact/droplet isolation room for 1 (R20) out 4 residents reviewed for transmission-based precautions in sample of 12. This failure has the potential to affect all 22 residents residing in the facility. Residents Affected - Many Findings Include: On 01/23/24 at 10:42 AM, surveyor noticed R20's door was closed with droplet/contact isolation sign for staff and visitor was posted on the front of R20's door. Surveyor observed V9 R20's son entered R20's droplet/contact isolation (Covid-19) room with surgical mask but without the proper Personal Protective Equipment (PPE) gown, gloves, N95 mask, and face shield. Surveyor called V8 (Certified Nursing Assistant) and asked V8 if it is proper for V9 to enter R20's room without PPE. V8 stated it is not proper for V9 to enter R20's room (Covid-19) without the PPE, V9 can be infected and pass it to others. V8 then told V9 to come out of R20's room for V9 to wear the PPE. V9 came out of R20's room to put on the gown, gloves, N95 mask, and a face shield by the door of R20's room. V9 stated I know it is wrong not to wear the PPE, but I come here to visit R20 every day, and I don't put on the stuff (PPE) by the door. I know I should have put on the PPE. On 01/24/24 at 9:40 AM, V2 (Director of Nursing/Infection Preventionist) stated that staff and visitors should not enter isolation room without donning the appropriate PPE (gown, gloves, N95 mask and a face shield). Because V9 entered R20's room without donning the proper PPE, V9 is vulnerable to infecting others. V2 did Covid-19 test for the residents on 1/23/24, surveyor noticed additional 3 residents positive for Covid-19. Surveyor also noticed no staff redirected V9 from entering R20's room until the surveyor called V8. V2 stated V1 and V2 have written a letter to be sent to family members on the importance of adhering to infection prevention control policy. V2 has stopped the communal dining and other communal activities. The facility policy on Infection and Control Manual Coronavirus (COVID-19) Transmission Based Precaution (TBP) and Visitation dated 5/15/23 reads in part: Before visiting residents, who are on TBP, visitors should be made aware of the potential risk of visiting and precautions necessary to visit the resident. Resident should adhere to the core principles of infection prevention. Recommended PPE: N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face. The facility Daily Census dated 1/23/24 has active 22 residents of which 7 are positive for Covid-19 and additional 3 residents at the end of 1/23/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146174 If continuation sheet Page 5 of 5