Inspection·January 25, 2026

F 0921 Level of Harm - Potential for minimal harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observations the facility failed to provide a safe, functional, sanitary and comfortable environment for the residents of the facility. This failure involved the common area shower rooms on both the first and second floors and affects all residents in the facility. The shower facilities available to the residents are in need of repairs and deep cleaning to give the residents a space to feel comfortable using on a daily basis. R1 will be known as R5 and is not available to be interviewed while writer was at the facility. R5 is a 67 year of female whose diagnosis includes: DISORDER OF THYROID, UNSPECIFIED(E07.9),ESSENTIAL (PRIMARY) HYPERTENSION(I10), PARANOID SCHIZOPHRENIA(F20.0), UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION(F29), THYROTOXICOSIS, UNSPECIFIED WITHOUT THYROTOXIC CRISIS OR STORM(E05.90), DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, MILD, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY(F02.A0), MENTAL DISORDER, NOT OTHERWISE SPECIFIED(F99), VITAMIN D DEFICIENCY, UNSPECIFIED(E55.9), OTHER CONSTIPATION(K59.09), SPASMODIC TORTICOLLIS(G24.3)R5 was unavailable at the time of survey to be interviewed. The complainant for this survey was V11 (her Maximus Case Manager) to whom R5 made the complaint. V11 in turn did not make the facility aware of the complaint, per his Agency's policy he just called the hotline to make the complaint. V11 stated that this was to protect the identity of the resident. V11 was reached by telephone on 01/23/26 at 10:31AM. V11 was able to state that he met with his client at the facility during a visit last year, in the Fall in the conference room on the first floor. V11 then stated that the shower room in question was located right next to the conference room. This description of the location matched the conference room that this writer was working from on the first floor of the facility. V11 described the condition of the bathroom as horrible with broken tiles on the floor, no curtains for privacy and mold throughout the bathroom. 01/23/26 -11:00AM Conference room: V4 (Maintenance Director) and V5 (Housekeeping Manager) and I began to tour the common area shower rooms; we started with the 400 hall shower room which was locked (allegedly due to residents smoking in there on the overnight shift). V4 had been called to assist with unlocking the bathroom door, as the nurse and V5 did not have a key to unlock the door. Once inside the shower room, it was apparent that this shower room had not been cleaned for a while as evidenced by the dark brown stains in the toilet bowl. The toilet was functional and did flush, when activated, it spewed dark brown water. The tiles on the floors and walls have tiles that are chipped, there are a couple of shower areas in the shower room that are not separated by a curtain, and assistive devices are stored in the room. There is also varying degrees of a dark substance on the grout of parts of the walls and floors throughout the shower room. 01/23/26 11:15AM 200 hallway shower room was next to be reviewed by V4, V5 and this writer. This door was unlocked and was unoccupied at the time. There were bath blankets on the floor and there was urine in the toilet that was not flushed. There were chipped 1x1 tiles on the floor and other chipped and/or broken tile on the walls. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145220 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 01/25/2026 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)