Health inspection·July 17, 2025

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 interview and record review the facility failed to supervise a confused wandering male resident from wandering in female rooms during smoke times causing resident mental abuse. This failure affected 2 (R2 and R6) residents in a sample of 57. The facility failed to prevent residents from smoking inside the facility (R7, R10) per policy. Findings include: 1. R2 has a diagnosis of but not limited to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, MULTIPLE SITES, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED, OTHER LACK OF COORDINATION, ABNORMAL POSTURE, ACQUIRED ABSENCE OF RIGHT LEG ABOVE KNEE, UNSPECIFIED ASTHMA, UNCOMPLICATED, OSTEOMYELITIS, UNSPECIFIED, SUICIDAL IDEATIONS, MAJOR DEPRESSIVE DISORDER, RECURRENT.R2 has a BIMS (Brief Interview Mental Status) of 15 which is an indication of an intact cognition. R4 has a diagnosis of but not limited to UNSPECIFIED DEMENTIA, OTHER FORMS OF SCOLIOSIS, LUMBAR REGION, UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN, EPILEPSY, UNSPECIFIED, OTHER PANCYTOPENIA, SYNCOPE AND COLLAPSE, UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORALDISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, COGNITIVE COMMUNICATION DEFICIT, NICOTINE DEPENDENCE, UNSPECIFIED, UNCOMPLICATED. R4 has a BIMS (Brief Interview Mental Status) of 10 which is an indication of moderately impaired function. R6 has a diagnosis of but not limited to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE, DYSPHAGIA, OROPHARYNGEAL PHASE, REPEATED FALLS, ACUTE EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VEINS OF UNSPECIFIED LOWER EXTREMITY, ESSENTIAL (PRIMARY) HYPERTENSION, and HYPO-OSMOLALITY AND HYPONATREMIA.R6 has a BIMS (Brief Interview Mental Status) of 8 which is an indication of moderately impaired function. Surveyor reviewed R2's, R4s, and R6's Face Sheet, Care Plan dated (Abuse Focus) 6/13/2025, IDPH Reportables dated 4/2025 to 6/2025, Concerns/Response 4/2025 to 6/2025, Resident Council Meetings 4/2025 to 6/2025, and Abuse Policy with no concerns noted.Surveyor reviewed Grievance document titled, Opportunity Resolution Form dated 6/25/2025 documents in part, (R4) (male resident) is roaming in R2's room in the afternoon during smoke times and the resolution was to in-service staff regarding escorting resident back and forth to the smoking patio.Surveyor reviewed facility's Sex Offenders list and R4 is not listed. On 7/14/2025 at 1:05 PM, R2 stated R4 has been wandering in her (R2's) room for over 4 months going to the washroom and then laying in an empty bed. R2 stated when she (R2) informs R4 that he is in the wrong room, he (R4) swears at her and makes threatening remarks towards her. R2 showed surveyor a picture on her (R2's) phone with a time stamp of 9:02 AM, that shows R4 being escorted out of a bed diagonally across from R2's bed and a second photo with a time stamp around 6 pm with R4 lying in the bed diagonally across from R2 on 6/25/2025. R2 stated on 7/2/2025, she (R2) noticed R4 was sitting in the Parlor around 11:30 AM, which made her feel unsafe since he has a habit of wandering. R2 stated she (R2) found out that R4's room is directly above her room and that is the reason he (R4) keeps wandering in my room. R2 stated R4 has not wandered in her room since 7/2/2025. R2 stated she hasn't experienced any verbal or physical abuse from staff; there are roaches in the facility; the facility never has enough linen and run out of diapers occasionally; checks and credit cards were missing from her room when she returned from the hospital a long time ago, but no belongings missing recently; and has not heard anything about any overdosing in the facility. 7/14/2025 at 1:35 PM, V5 (Certified Nurse Aide) stated she (V5) is aware of R4 wandering in R2's room. She (V5) stated an in-service on a resolution to R4 wandering in R2's room which was to implement escorting R4 to and from the smoking room to prevent him (R4) from wandering in R2's room. V5 stated R4 has not wandered in R2's room since the staff started following the new intervention and she is unaware of a rape occurring in the facility. On 7/15/2025 at 2:45 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 2 of 4 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 145625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Terrace 2829 South California Blvd Chicago, IL 60608 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 PM, V9 (Unit Manager/LPN) stated R2 informed her (V9) that R4 was wandering in and out of her room after smoke times on 6/24/2025. V9 stated R4 suffers from confusion and has wandered to R2's room, so a resolution has been implemented to have staff escort R4 to and from the smoking patio before and after smoking times. V9 stated R4 has not wandered in R2's room since that intervention has been put in place to her knowledge. On 7/16/2025 at 12:07 PM, V25 (Housekeeper) stated she (V25) remembers entering R2's room and noticed R4 (male resident) in a female's room. V25 stated, I told him (R4) to leave the room immediately because males should only be in male rooms. On 7/16/2025 at 2:05 PM, V27 (Assistant Director of Nursing) stated R4 wandering in R2's om was brought to V27 during a morning meeting with V1, ‘but I (V27) can't remember the exact date'. V27 stated this is the resident's home and the staff redirects the residents as much as possible considering their disease processes. R27 stated the facility is always having in-services and because R4 wanders, staff have been educated to escort R4 to the smoke patio during and after smoke times. V27 stated he (V27) R4 has not wandered in R2's room since the intervention was implemented. Facility's policy titled Supervision and Safety dated 3/15 documents in part, our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility-wide priorities. Our facility-orientate approach to safety addresses risks for groups of residents such as wanders, behaviors, aggressiveness, confusion, etc. Resident supervision is a core component to resident safety. Facility's policy titled Behavior Management dated 1/2025 documents in part, It is the policy of the Nursing Department to determine the cause of behaviors when possible and initiate interventions to reduce, control, or prevent identified behaviors. F-Tag Initiation: Supervision for Resident Smoking in Their Rooms2. R7 has a BIMS (Brief Interview Mental Status) of 11 which indicates a moderately impaired cognition. R7's care plan dated 6/4/2025 documents in part, a focus initiated 3/6/2025 for socially inappropriate behavior for smoking in resident rooms, stairwells, hallways, bathrooms, and elevators along with begging, borrowing, stealing, burning clothes and lips. R7 does not have privileges to keep his (R7's) cigarettes in his possession. R7's smoking assessment dated [DATE] documents in part, a history of hazardous behavior of smoking cigarettes in unauthorized areas of the facility. On 7/14/2025 at 1:53 PM, R7 was sitting in the room watching television. Surveyor observed the smell of smoke and smoke in the air in R7's room. R7 verified he (R7) smelled smoke. R8 (R7's roommate) was standing in front of his bed fanning the air. R7 and R8 denied smoking in the room. Surveyor observed a cigarette butt on the floor by the foot of the R7's bed, another cigarette butt on the floor by the R7's dresser and a whole cigarette on the resident's bed. Surveyor stepped out of the room and called V12 (Licensed Practical Nurse) to the room. V12 stated she (V12) smelled cigarette smoke and verified there were 2 cigarette butts on the floor at the foot of R7's bed and by R7's bed. R7 had removed the whole cigarette from his bed and stated he (R7) didn't have a whole cigarette. R7 admitted to smoking in his room this morning to V12. R8 stated he (R8) tells R7 to put the cigarettes out when he (R7) is smoking in the room. V12 stated the residents are not supposed to have cigarettes and lighters in their rooms. V12 informed the nurse manager that R7 was smoking in the room and requested a room search to remove the cigarette and lighter from R7. 3. R10 has a BIMS (Brief Interview Mental Status) of 10 which is an indication of moderately impaired cognition. R10's care plan dated 5/23/2025 documents in part, a focus of a history of smoking in unauthorized areas that was initiated 1/14/2025. R10's smoking assessment dated [DATE] documents in part, a minimal history of smoking (#7) in unauthorized areas and in the comments section (#10) Resident was caught smoking in her room. Counseling and redirection to appropriate behavior provided. Resident requires supervision when smoking. On 7/15/2025 at 1:34 PM, V17 (Certified Nurse Assistant) verified with surveyor there was a smoke smell in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 3 of 4 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 145625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Terrace 2829 South California Blvd Chicago, IL 60608 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 FORM CMS-2567 (02/99) Previous Versions Obsolete hallway. V17 verified a smog of smoke in the air of the hallway and smelled smoke. V17 and surveyor verified the smoke was coming from R10's room because there was a smog of smoke around her (R10's) bed and a pack of cigarettes on R10's bedside table. R10 stated she was not smoking, and staff need to talk to the residents that are smoking weed and cocaine in the facility. R10 stated, My daughter brought me (R10) the cigarettes a week ago and staff has not complained about it so now all of a sudden y'all got a problem with it. V17 called V3 to the unit. On 7/15/2025 at 1:37 PM, V3 (Director of Nursing) arrived on the 3rd floor. As V3 walked towards R10's room, V3 verified with surveyor there was a smog of smoke outside of R10's room and stated, I (V3) know it was her (R10) smoking. V3 asked R10 was she smoking in the room and R10 stated no. V3 and surveyor left the room and V3 called social service to the third floor. On 7/15/2025 at 1:40 PM, V20 (Assistant Social Services Director) arrived on the 3rd floor and walked to R10's room with surveyor. V20 verified a smog of cigarette smoke, and the smell of smoke was in the hallway by R10's room and in R10's room. V20 removed the cigarettes on R10's bedside table and informed her (R10) she does not have privileges to keep cigarettes on her person. R10 became very angry and began to make swearing remarks at V20. V20 stated any resident caught smoking in their room will revoke their safe smoking privilege right to keep their cigarettes otherwise cigarettes are kept locked up until smoking times. V20 stated staff will take residents to the smoking patio once the residents receive their cigarettes from the nurse. Facility policy titled Facility Smoking Safety Policy undated documents in part, R7's care plan dated 6/4/2025 documents in part, a focus initiated 3/6/2025 for socially inappropriate behavior for smoking in resident rooms, stairwells, hallways, bathrooms, and elevators along with begging, borrowing, stealing, burning clothes and lips. R7 does not have privileges to keep his (R7's) cigarettes in his possession. Event ID: Facility ID: 145625 If continuation sheet Page 4 of 4