Inspection·February 24, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some all over the wall, the base wall trims were all peeled off revealing the inner wall and some area have holes in them, floor looked very dirty with brownish stains, shower curtain rod was dirty and brownish in color, shower curtain was thorn. Surveyor presented these observations to V5 and asked him if he would take a shower in this room and he said no, the place needs to clean and repaired. The 300 unit shower room have the base wall trimmings ripped off from the wall, there were wheelchairs stored in the shower room, and V5 was wondering if the staff are using the room for showers, 200 unit shower room looks very dirty with brownish stains on the ceiling, V5 said that it is not mold and they do not have any leakage, it is probably from some staff smoking in there during the night though they are not supposed to do that. V5 added that the whole bathroom needs to be changed, there are lots of repairs that need to be done in the facility and he does not make the decision when the repairs are to be done, just follows instructions. 2/20/2025 at 11:30AM, surveyor asked V5 to recheck the temperature in the rooms that the facility uses space heater, and the reading was between 68 and 70 degrees. 2/20/2025 at 12:20PM, observed lunch in the first-floor dining room and noted the room to be very cold. surveyor asked V5 to check the temperature in the dining room with a temperature gun and the first reading was 69 degrees, some parts of the dining room was reading 50 and 56 degrees. 2/20/2022 at 3:00PM, V1 (Administrator) said that that the facility has a problem with water entering the boiler that control the heat in the 500 unit, they have someone on ground trying to evacuate the water and it will probably help with warming the temperature in that wing and the first-floor dining room. Surveyor asked V1 how often the facility evacuate the water and he said that it is usually done when they notice that hot air is not coming out of the boiler. 2/20/2025 at 4:02PM, V1 was presented with the observation of the shower rooms on the first floor, and he said that they have not gotten to them yet because they have other priorities, the shower rooms on the second floor were remodeled 5 years ago, the facility is in the process of getting a new generator that will probably cost a million dollars. 2/24/2025 at 9:00AM, R1 was observed again in his room wearing a winter coat and a hat, stated he still does not have any heat, the staff have not returned his space heater, he asked about it and they told him that it is coming. R1 has about 5 blankets on his bed, he said he uses them to keep warm, but his room is still cold. Care plan initiated 1/19/2024 stated that R1 has diabetes mellitus, goal resident will have no complications related to diabetes through the review date. Interventions include avoid exposure to extreme or cold. 2/24/2025 at 10:57AM V1 (Administrator) said that R1 will not be getting the space eater back, he was supposed to move to another room, but he prefers to stay in his current room because he likes the room. Electric appliance policy (undated) states in part, only authorized appliances will be permitted in the resident living areas. Residents may not maintain any electrical appliances (i.e. heating irons, cooking utensils, etc.) within their living area unless approved in writing by the administrator or his/her designee. Cold weather policy (undated) states its purpose as to ensure the well-being and comfort of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 2 of 3 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 145220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Crest Health Care 3300 West 175th Street Hazel Crest, IL 60429 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete residents throughout the cold weather months particularly during the periods of severe weather and below normal temperatures. Under procedures, the policy states in #9. If a heating unit fails in an area of the facility and/or temperature becomes uncomfortable, upon the direction of the administrative personnel, residents affected may be moved to another area in the facility where the temperature is adequate. Maintenance service policy undated provided by V1 (Administrator) stated in its policy statement that maintenance service shall be provided to all areas of the building, grounds, and equipment. Under policy interpretation and implementation, the document states that the maintenance department is responsible for always maintaining the building grounds and equipment in a safe and operable manner. The following functions are performed by maintenance: b. maintaining the building in good repair and free of hazards. D. maintaining the heat/cooling system, plumbing fixtures, wiring, etc. in good condition. Event ID: Facility ID: 145220 If continuation sheet Page 3 of 3