Health inspection·August 14, 2025

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 08/12/2025 at 11:09am, V2 (Director of Nursing) stated there should be no medication at bedside. There are steps for self-administration of medication. The resident should be educated and be able to return demonstrate how to administer the medication. The facility has to have a doctor's order the resident may self-administer the medication. V2 stated it is expected of the staff not to leave medications at bedside to ensure the medication is administered to the right person and because facility needs to keep the residents' environment free of hazard. It is a hazard, first to the resident and then to other residents in the unit. R138's (Active Order as of: 08/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypertension, hemiplegia and hemiparesis, and candidiasis of skin and nail. Order Summary: Nystatin External Powder 100000 UNIT/GM Apply to scrotum, left arm fold, etc. topically as needed for wound. Nystatin External Powder 100000 UNIT/GM Apply to scrotum, left arm fold, etc topically one time a day for wound. Of note, no order to may self-administer Nystatin. R138's (06/28/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15 Indicating R138's mental status as cognitively intact. Section M – Skin Conditions. M1040. Other skin problems. G. Skin. M1200. Skin and Ulcer/Injury Treatments. H. Applications of ointment/medications. The (08/14/2025) email correspondence with V1 (Administrator) documented, in part (R138) does not have a care plan for self-administration of medication. The (undated) Self-Administration of Medication Procedure documented, in part Purpose: the residents have the right to self-administer their medications if they have the cognitive, physical, and visual ability and the interdisciplinary team has determined the practice is safe for the resident. Procedure: 2. The assessment results will be discussed with the attending physician and an order obtained to self-administer. 8. Drugs in the room should be written in the medication record as may keep at bedside. 12. A care plan indicates the resident's self-administering of medications. Facility's policy titled Administering Medication dated 01/01/2020 documents in part, Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations.Procedure: 4. Medications may be self-administered by residents who have been assessed and determined to be safe and upon physician order.14. Medications may only be administered to the individual in which the medication was prescribed. Facility's undated job description titled Charge Nurse documents in part, Job Summary: Organize and assign all jobs to be done on his/her shift so that the work load is evenly divided among his/her employees on the basis of staff size and qualifications, pass medications at the appropriate times, and care for the clinical nursing needs of residents on his/her wing.Main Duties: L. Administer all medications.P. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty.Z. Follow established safety precautions when performing tasks and when using equipment and supplies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 2 of 26 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 08/14/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to ensure that a code status physician's order was in a resident's electronic medical record (EMR). This failure affected two residents (R5 and R114) in a sample of 54 residents reviewed for advance directives.Findings include: 1. R5 face sheet shows R5 has diagnosis which include but not limited to bacterial infection, other bacterial infection unspecified site, venous insufficiency, and chronic obstructive pulmonary disease. R5'S Physician Order Sheet (POS) shows active order dated 08/11/25 with no orders for R5's code status. On 08/12/25 at 11:57 am, V11 (Director of Social Services) stated the social service department is responsible for ensuring all residents have a code status on the residents POS. V11 stated every resident should have a code status order for full code or DNR (Do not resuscitate) so everyone knows what to do if the residents codes at the facility. On 08/13/25 at 9:23 am, V2 (Director of Nursing, DON) stated the importance of the code status is to follow the residents wishes if something was to occur such as if the resident were to stop breathing or have an acute change in conditions the staff would know how to procedure. V2 explained on admission the code status is verified through the residents clinical record and then followed up with the resident. V2 said the nurse is responsible for putting the residents code status order on a physician order sheet. R5's POLST (Providers Order for Lift Sustaining Treatment) dated 04/03/20 shows full treatment order for R5. R5's Care plan dated documents, in part: R5 wishes to be a DNR (Do Not Resuscitate)/Full code. On 08/13/25 at 1:24 pm, Surveyor reviewed R5's care plan with V11 (Director of Social Services). V11 stated, Social service is responsible for care planning the residents advance directives. I just fixed it (referring to R5's code status care plan). It should only say full code. The last social worker had floor did. 2. R114's has a diagnosis of but not limited to Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Difficulty in Walking, Abnormal Posture and Hypertension. R114 has a Brief Interview of Mental Status score of 15 indicates resident's cognition is intact. On 8/11/2025 at about 10:00am R114's profile screen and orders screens in Point Click Care (PCC) software did not display a code status. On 8/13/2025 at 12:15pm V20 (Licensed Practical Nurse-LPN) stated a resident's code status should be included on the profile screen and in the orders. The facility undated policy titled Advanced Directives documents, in part: Purpose: To establish guidelines to assure each resident is provided information on advanced directives. Standards: . 9. A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 3 of 26 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 08/14/2025 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 0578 written physician's order is required in response to the resident's Advanced Directives (s). Physician's order shall be specific and address each Advanced Directive(s). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 4 of 26 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 08/14/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident with new diagnoses of schizoaffective disorder was referred to the appropriate state-designated agency for a new Preadmission Screening and Resident Review (PASRR). This failure affected 1 (R9) resident reviewed for PASRR in the total sample of 54 residents.Findings include:R9's admission Record documented that R9's Original admission Date was on 10/05/2020 and was readmitted to the facility on [DATE]. That R9 has a diagnoses of schizoaffective disorder with onset date of 05/08/2023. R9's State Department on Aging Care Coordination Unit - Choices for Care Screening Verification Form was dated 10/02/2020. R9's (06/10/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating R9's mental status as moderately impaired. Delirium. C1310. Signs and symptoms of Delirium. B - Inattention: 2 - Behavior present, fluctuates. C. Disorganized Thinking: 2 Behavior present, fluctuates. On 08/12/2025 at 12:51pm, V11 (Social Services Director) stated that PASRR is done to ascertain the proper placement of resident; to ensure the services needed by the resident is met. PASRR Level I should be completed upon admission and when there is a new diagnosis. At this time, this surveyor handed to V11 R9s ‘10/02/2020 State Department on Aging Care Coordination Unit - Choices for Care Screening Verification Form' which was provided to this surveyor upon the request of R9's PASRR level II screening. V11 stated he believes that's the only screening the facility has for him and a new screening should be completed for R9 on 05/08/2023, upon the onset of the new diagnosis of schizoaffective disorder. On 08/12/2025 at 1:18pm, V23 (Business Office Manager) stated she is familiar with PASRR and if (R9) has a new diagnosis, the level of care changes and a new PASRR should be completed on 05/08/2023. The (08/12/2025) email correspondence with V1 (Administrator) documented, in part As for PASSR- we follow the MAXIMUS guideline, no specific policy. The expectation is that we obtain the PASSR screen from MAXIMUS. However, if there is a new diagnosis that would trigger a Level II, we ask for a post screen, to obtain a PASSR that encompasses the new diagnosis. This should be requested in a timely manner, no more than 5 business (days) after a new diagnosis. The (08/2024) PASRR Preadmission Screening Resource documented, in part Resident Review. *Current NF (nursing Facility) resident experiencing a significant change. Is a level I PASRR screen required? Yes. When is it submitted? Upon discovery of significant change. Event ID: Facility ID: 145625 If continuation sheet Page 5 of 26 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 08/14/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care received grooming and shaving. This failure affected two residents (R64 and R186) out of 54 residents reviewed for ADL care. Findings include: Residents Affected - Few 1. Review of R64, Minimum Data Sheet, Section GG – Activities for Daily Living (ADL) dated 7/11/2025 documents Partial/moderate assistance – helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. This ADL function applies to both Upper Body Dressing and Lower Body Dressing. Review of R64 Care Plan dated 7/12/2025 indicates that Resident #64 has a self-care deficit (ADLs/Mobility) and requires one assist with dressing/hygiene tasks. On 08/11/2025 at 10:20 AM, R64 stated They do not wash my clothes. This started about 6 months ago. And the clothes that they do wash, they have not returned them. I have no clothes. R64 was wearing black pants, red cardigan-type sweater and dark orange shirt. On 08/12/2025 at 9:50 AM, Surveyor observed R64 sitting on bed wearing black pants, red cardigan-type sweater and dark orange shirt as yesterday. On 08/13/2025 at 8: 42 AM, R64 was lying in the bed wearing the same black pants, red cardigan-type sweater and dark orange shirt again. On 08/13/2025 at 8: 45 AM, V27 (Certified Nursing Assistant) stated that in the mornings R64 dresses herself. When asked why R64 was still in the bed sleeping, V27 responded that R64 was up and about earlier and had already eaten breakfast. On 08/13/2025 at 8: 45 AM, V32 (Certified Nursing Assistant) stated, I showered R64 Monday morning and dressed her with the clothes that you have seen her wear since Monday. Since then, R64 has refused changing clothes or ADL care because she thinks someone will steal the clothes once they are taken off. When asked V32 for proof of shower documentation, V32 referred me to the facility' s reception area where shower records are kept. Review of R64 Shower Notes dated 8/9/2025 indicates that R64 received her last shower on Saturday, 8/9/2025. On 08/13/2025 at 2:02 PM, the V2 (Director of Nursing) stated, It is my expectations that ADL's for each resident is performed daily and/or as needed. For resident refusals, it is my expectation that they are reported directly and immediately to the floor nurse. The DON said, I was not notified of R64 ADL refusal situation until this afternoon. The DON added that proper ADL care is important because it makes the resident feel better and it important for their dignity. 2. R186 has a diagnosis which includes but not limited to: Dementia, other lack of coordination, altered mental status, and abnormal posture. R186 Brief Interview for Mental Status (BIMS) dated 05/28/25 shows that R86 has a BIMS score of 9 which indicates that R186 has some cognitive impairments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 6 of 26 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 08/14/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm R186 Minimum Data Set, dated [DATE] shows that R186 requires supervision or touching assistance for personal hygiene. On 08/13/25 at 10:04 am, R186 was observed ambulating in the hallway ungroomed with facial hair and beard. R186 stated, I don't know the last time I've been shaved. The nurse has to do it. Residents Affected - Few On 08/14/25 at 9:30 am, V2 (Director of Nursing, DON) stated that residents who can shave themselves are giving razors to shave and the razor are returned to the nurse for discarding after shaving the resident is completed. V2 explained that residents who are unable to shave themselves the Certified Nursing Assistant (CNA) is responsible for shaving the resident during Activities of Daily Living (ADL) care. V2 explained that shaving is a part of ADL and grooming. V2 explained that residents should be offered shaving daily during ADL care and as needed. V2 then stated that residents who need supervision with shaving, the staff should be present, monitoring and overseeing the residents shaving. V2 stated, It is important for the residents to be shaved as a part of the residents everyday life and to make sure the resident presents well. It's a dignity issue. The facility policy dated 01/15 and titled Policy and Procedure Dignity documents, in part: Policy: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Purpose: To establish guidelines in protecting the resident's right to be treated with dignity and respect. 1. Residents should be treated with dignity and respect, even cognitively impaired residents. The facility undated policy titled Activities of Daily Living (ADLS) documents, in part: Purpose: To preserve ADL function, promote independence, and increase self-esteem and dignity . Grooming Maintaining personal hygiene, including planning the task and gathering supplies combing and /or styling hair, face, and hands, brushing teeth, shaving, or applying makeup, oral hygiene, self-manicure (safety awareness with nail care), and/or application of deodorant or powder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 7 of 26 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 08/14/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record review, the facility failed to ensure the low air loss mattress was set on the recommended setting. This failure affected 1 (R238) resident reviewed for the prevention of pressure injury in the total sample of 54 residents. Findings include:On 08/11/2025 at 11:59am, R238 is lying on a low air loss mattress. The low air loss mattress is set at firm. The ‘Static' button is also turned ‘On'. On 08/11/2025 at 12:00pm, these observations were pointed out to V17 (Licensed Practice Nurse). V17 stated the setting is at firm and the ‘Static' button is on. V17 also stated she is a new nurse. On 08/11/2025 at 12:15pm, V5 (Wound Care Nurse) stated the setting of the low air loss mattress is according to resident's weight so the air flows evenly preventing pressure ulcer. The setting should not be higher than the resident's weight because setting the low air loss mattress higher than the resident's weight defeats the purpose of the low air loss mattress. On 08/11/2025 at 12:17pm, V5 checked the setting of R238's low air loss mattress and stated the weight setting is at ‘Firm'. V5 moved the dial to 350lbs and stated she will check (R238) weight. On 08/11/2025 at 12:18pm, V5 stated his weight is 167lbs. The low air loss mattress setting should not be set at 350lbs because it makes the mattress firm defeating the purpose of the low air loss mattress. On 08/13/2025 at 1:34pm, V5 stated the ‘Static' button is turned on if staff is transferring the resident. The ‘Static' button should not be left on because if left ‘ON' the low air loss mattress provides a firm surface.R238 (Active Order as of: 08/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypertension, muscle weakness, and dementia. Order Summary: Pressure reduction mattress in place. Active. Order Date: 08/03/2025.R238's (Effective Date: 05/11/2025 08/11/2025) Weight and Vitals Summary documented that R238 weighed 167.2 lbs. on 08/07/2025.R238 (07/10/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. Section M - Skin Conditions. M0100. Determination of Pressure Ulcer/Injury Risk. A. Resident has a pressure ulcer/injury. M0150. Risk of pressure Ulcers/Injuries: 1- Yes. M1200. Skin Ulcer/Injury Treatments. B. Pressure reducing device for bed.The Pressure Low Air Loss Mattress Replacement System documented, in part INDICATIONS The Med Aire Melody Alternating Pressure and Low Air Loss Mattress Replacement System is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. Pressure-adjust Knob. Determine the patient's weight and set the control knob to that weight setting on the control unit. Static/Alternating control. Press ON to set the air mattress to static mode of OFF to set to alternating pressure mode. Operating Instructions: Step 6 Determine the patient's weight and set the control knob to that weight setting on the control unit. Step7 Press the Static button to shift between Alternating mode and Static Mode. When in Static mode, and the Static indicator will come on. The static mode will be started within approximately 6 minutes. In Alternating Pressure mode, the air cells will alternate in 1O min cycles. NOTE! In static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 8 of 26 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 08/14/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to ensure a resident's environment was free from hazard. This failure affected 1 (R138) resident reviewed for accident hazard and has the potential to affect all the 25 residents in Unit 3A. Findings include: The (08/11/2025) census documented there are 25 residents in Unit 3A.R138's admission Record documents that R138 resides in Unit 3A.On 08/11/2025 at 10:39am, during the initial tour of the facility, V13 (Registered Nurse) stated Unit 3 has more psyche residents than dementia residents. On 08/11/2025 at 10:52am, there is a razor at R138's nightstand.On 08/11/2025 at 10:56am, this observation is pointed out to V13 (Registered Nurse). V13 stated there is a razor blade at his (R138) bedside. V13 picked up the razor and stated razors should never be at bedside because anybody who walks inside the room may grab it and harm themselves or the resident.On 08/12/2025 at 11:13am, V2 (Director of Nursing) stated the razor should be disposed of appropriately by putting the razor in the sharps container. Other resident in the unit may pick the razor and harm him (R138) or other residents. R138's (Active Order as of: 08/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypertension, hemiplegia and hemiparesis, and candidiasis of skin and nail. R138's (06/28/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15 Indicating R138's mental status as cognitively intact. The (undated) Shaving Male & Female Residents documented, in part Purpose: To provide cleanliness, comfort, and improved morale. Procedure: 10. Remove and clean equipment and leave resident in comfortable position. Rationale/Amplification. Place disposable safety razor in bio-hazardous sharps container. Event ID: Facility ID: 145625 If continuation sheet Page 9 of 26 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 08/14/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to contain oxygen equipment (nebulizer masks and nasal cannula tubing) per facility's policy. This failure affected three residents (R30, R165 and R205) reviewed for oxygen equipment, in a total sample size of 54 residents.Findings include: Residents Affected - Few 1. R30's face sheet shows R30 has diagnosis which includes but not limited to unspecified asthma. R30 Physician Order Sheet (POS) shows active order dated 08/11/25 documents, in part: Albuterol Sulfate Nebulization Solution (2.5mg (Milligram)/3ml (Milliliter) 0.083% 3 ml inhale orally via nebulizer every 6 hours as needed for Shortness of Breath related to Other Chronic Obstructive Pulmonary Disease. On 08/11/25 at 10:20 am, R30 was observed in bed with a nebulizer mask not contained hanging from R30's nightstand drawer. R30 stated, I use my mask every day. On 08/11/25 at 10:24 am, this observation was brought to V6 (Licensed Practical Nurse, LPN) and V6 stated that nebulizer mask should be contained when not in use to avoid dusk, bacteria, and germs from entering the nebulizer mask. On 08/13/25 at 9:20 am, V2 (Director of Nursing DON) stated that once the resident's nebulizer treatment is completed the nurse is responsible for ensuring the nebulizer mask and/or tubing is covered with a bag and stored appropriately in order to make sure that the nebulizer mask/tubing does not come into contact with any environmental contaminates. The facility policy dated 08/14/25 and titled Oxygen Equipment documents in part: Objective: To administer oxygen in conditions in which infection control is maintained . 5. Oxygen tubing/nebulizer masks will be covered when not in use. 2. R165's diagnoses include but is not limited to presence of cardiac pacemaker, heart failure, essential hypertension, dilated cardiomyopathy, presence of prosthetic heart valve. R165's physician order dated 08/05/25 documents in part, Administer O2 (oxygen) therapy with titrated low rates to reach SPO2 (oxygen saturation in peripheral vein) greater than or equal to 93% as ordered. R165's care plan dated 08/06/25 documents in part, R165 received oxygen therapy r/t (related to) CHF (Congestive Heart Failure), ineffective gas exchange. On 08/11/25 at 11:17am R165's nasal cannula tubing observed laying on portable oxygen machine no contained. On 08/11/25 at 11:27am V22 (Licensed Practical Nurse/LPN) stated that R165's nasal cannula should be in a bag when not in use. V22 stated that the nasal cannula should be in a bag for sanitation and contamination reasons. 3. On 08/11/2025 at 11:08am, R205 nebulizer mask is lying on top of R205's nightstand, not contained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 10 of 26 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 08/14/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/11/2025 at 11:12am, observation was pointed out to V13 (Registered Nurse). V13 stated once the treatment is completed, the nurse is supposed to put it in a plastic bag for safety because it is out in the open and anything can go inside the mask, like pathogens. V13 stated she does not know what is flying around in the air and this can go inside the mask. On 08/12/2025 at 11:17am, V2 (Director of Nursing) stated the nebulizer mask should be bagged or contained after use to make sure no organism gets in contact with the mask and so it will not be contaminated from environmental factors. R205's (Active Order as of: 08/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) COPD (Chronic Obstructive Pulmonary Disease) with acute exacerbation, hypertension, and chronic respiratory failure. Order Summary: Pulmicort suspension 0.25mg/2ml inhale orally every 12 hours for wheezing related Chronic Obstructive Pulmonary Disease. R205's (06/13/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Indicating R205's mental status as moderately impaired. R205's (Target Date: 09/21/2025) care plan documented, in part has the potential for Oxygen Therapy r/t Ineffective gas exchange secondary to her diagnosis COPD. Give medications as ordered by physician. R205's (Target Date: 09/21/2025) care plan documented, in part has COPD (Chronic Obstructive Pulmonary Disease). Will display optimal breathing. Give aerosol as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 11 of 26 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 08/14/2025 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 0760 Ensure that residents are free from significant medication errors. 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 review, the facility failed to prepare insulin syringe dosage according to the prescribed sliding scale order. This failure affected one resident (R220) reviewed for medication administration and has the potential to affect all 10 residents receiving insulin products, that are residing on the second-floor unit of the facility. Findings include:Review of the facility's provided census (dated 8/12/2025), 231 residents live within the facility (10 residents receiving insulin on the second-floor unit). On 8/12/2025 at 10:30 AM, at R220's room's door entrance, V19 (Licensed Practical Nurse/LPN), measured R220's blood sugar and stated the blood sugar was 258. V19 stated, according to the active order for insulin sliding scale, R220 should receive 7 units of insulin subcutaneously.On 8/12/2025 at 10:40 AM, observed V19 (LPN) at the rim of R220's room to perform hand hygiene, and prepared R220's insulin injection. Observed 6 units of insulin inside of the prepared syringe. V19 affirmed, the amount of insulin V19 withdrawn into the syringe was 6 units. At this time, V19 was ready to enter resident's room for administration of R220's insulin, when the surveyor stopped V19 from walking into R220's room and administer the incorrect dosage of insulin and the surveyor asked V19 to recheck the order. V19 logged into the electronic records system and checked the orders for insulin. At this time, V19 stated the correct dosage should be 7 units of insulin instead of the 6 units V19 incorrectly prepared. V19 affirmed that V19 made a significant medication error and prepared wrong dosage of the insulin. V19 then discarded the 6 units of insulin and redrew a new syringe with the correct dosage of 7 units of insulin. V19 stated V19 should always double check the sliding scale orders and compare to what is prepared, and check all 5 rights of medication administration, before giving any medications to a resident. V19 stated the wrong dose could have interfered with the blood sugar levels of the resident. V19 also stated, if the incorrect dose of insulin would have been administered, R220's blood sugar levels would not sufficiently decrease to the desired therapeutic range. V19 was then observed preparing another insulin syringe.Face sheet documents R220's diagnosis included but not limited to Type 2 Diabetes Mellitus, Hyperlipidemia, Deficiency of other vitamins, and Glaucoma. Minimum Data Sheet (MDS) dated [DATE], in Section C- Cognitive Patterns documents Brief Interview for Mental Status (BIMS) Summary Score of 2 which indicates severely impaired cognitive function. On 8/12/2025 at 10:55 AM, V2 (Director of Nursing/DON), stated the expectation for insulin administration is for the nurse to clean hands and perform hand hygiene, clean the vial and the nurse should double check the insulin order to withdraw the correct dosage needed. V2 said the nurse should check the five rights for administration of medication, which include but not limited to the right resident, right medication, and right dosage to be given. V2 also stated, according to facility's policy, the nurse should triple check the medication and dosage against the physician's order prior to administering, to prevent a significant medication error from occurring. On 8/12/2025 at 11:30 AM, V20 (LPN), stated it is important to follow physician's orders and double check the orders to administer the correct dosage of the medication. On 8/13/2025, at 1:30 PM, V10 (Assistant to Director of Nursing/ADON), stated it is very important to triple check orders in the computer and it is crucial the correct dosage would be administered, especially insulin. V10 affirmed if a wrong dosage of insulin is withdrawn, it would be considered a significant medication error. V10 also stated if the wrong dosage would be administered, the resident could have experienced blood glucose levels in less than therapeutic value desired. R220's Order Summary Report, (8/12/2025) showed in part, an active order from 5/31/2023 for Humalog injection Solution 100 unit/ml, to inject as per sliding scale: BLOOD SUGAR 0-70 CALL MD; 71-150= 0 UNITS; 151-200 = 3 UNITS; 201-250 = 5 UNITS; 251-300 = 7 UNITS; 301-350 = 10 UNITS; 351+ = 12 Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 12 of 26 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 08/14/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete UNITS AND CALL MD SUBCUTANEOUSLY BEFORE MEALS.R220's Care plan report (7/14/2025), lists in part, R220 has Diabetes Mellitus and should receive monitoring and medication to help ensure R220's glucose levels remain within acceptable parameters and to administer diabetes medication as ordered by doctor. Care plan documents in part, to monitor and document resident for side effects and effectiveness of medication. R220's medication administration record documents in part, Accu-Chek monitoring should be performed three times a day and showed blood sugar level for R220 on 8/12/2025 at 11 AM was 258.Facility's policy titled, Injectable Medication administration, (10/25/2014), documents, in part, .Purpose to administer medications via subcutaneous, intradermal and intramuscular roues in a safe, accurate, and effective manner.Check 5 rights as medication selected is checked against order. Procedure Check 5 rights again as dose is prepared. Check 5 rights again after dose is prepared and before med is put away and injection administered.Facility's policy titled, Administering Medication, (1/1/2020), documents in part, . Medications shall be administered in physician's written /verbal orders upon verification of the right mediation, dose, route, time, and positive verification of the resident' identity.Facility's document titled, Job Description Assistant director of nursing, (Updated 10/2013), documents, in part, . Job Summary: Responsible for assisting the Director of Nursing in planning, .directing, coordinating. Management of facility, people, supplies and equipment in such a way meaningful nursing service is established to render the optimum level of resident care. Event ID: Facility ID: 145625 If continuation sheet Page 13 of 26 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 08/14/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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 dispose of loose pills in the bottom of the medication cart (Team 2) on the 2nd floor. This failure has the potential to affect all 33 residents receiving medications from cart 2 on the 2nd floor.Findings include:Findings include:On 8/11/2025 at 11:43am surveyor observed 18 loose pills of different sizes, shapes and color at the bottom of medication cart for Team 2 on the second floor.On 8/11/2025 at 12:11pm V18 (Registered Nurse) stated the 11:00pm-7:00am shift (3rd shift) are supposed to clean the medication cart.On 8/13/2025 at 9:37am V2 (Director of Nursing-DON) stated the nurses that are working the carts are supposed to clean the cart, and the cart is expected to be free of loose pills, spills and should be checked on a regularly basis. V2 stated the 3rd shift is responsible for making sure medication carts are kept clean. Storage of Medication Policy with an effective date of 10/25/2024 documents, in part, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier and contaminated medications without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal.Undated Job Description: Charge Nurse documents, in part, assure that established infection control and universal precaution practices are maintained when performing nursing procedures. Event ID: Facility ID: 145625 If continuation sheet Page 14 of 26 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 08/14/2025 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 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 observation, interview and record review, the facility failed to ensure that foods were stored and/or prepared under sanitary conditions. These failures have the potential to affect all 229 residents residing at the facility. Findings include:1. On 08/11/2025 at 10:12 AM, during the initial tour with V31 (Dietary Manager), the Surveyor observed boxes of cheese (5lbs), pork loins (50lbs), and deli turkey (20lbs) boxes placed in the middle of the floor of the walk-in refrigerator. There were several boxes of other products placed above the ones on cement floor. Also, the entire floor of the walk-in refrigerator was covered with water due to a leak in the ceiling.There were also cartons of milk in thin (so thin that the milk cartons were exposed to the concrete floor) plastic crates were set on top of puddle of water. This includes four crates directly on the floor. According to V31, each crate contained 50 cartons of milk. There were 15 subsequent crates on top of the 4 bottom crates of milk. According to V31, the puddle of water in the walk-in refrigerator was probably due to the ceiling leak.The Surveyor and V31 observed the following items on the floor of the walk-in- freezer: one box of zucchini (24 lbs.), one box of tater tots (frozen potato snacks) (24 lbs.) and one box of roast beef (40 lbs.). One large 3-level shelve in the storage room was completely empty.There were several boxes of food observed on the dirty (dark brown substances throughout the floor) sticky floor in the storage room. These items include cans of sweet potatoes, canned sliced apples, Ready Care Shakes, and boxes of chocolate chips cookies, corn flakes and rice crispies.V31 stated that the boxes of frozen meat, dairy products and dry storage goods should be six inches above the ground to prevent cross contamination. V31 added that following this food safety practice prevents residents from get sick from foodborne illnesses.On 08/13/2025 at 12:32 PM, V1 (Administrator) stated, It is my expectation that delivered boxes and food should be at least put on a pallet to raise it off the ground. I asked that the dietary consultant speak with the foodservice company to let them know to never again place boxes on the ground.The facility's Storage of Refrigerated/Frozen Foods, Section: Food Safety & Sanitation policy dated 4/22 documents Food should be stored at a minimum of 6 inches from the floor. The facility's Storage of Dry Foods/Supplies, Section: Food Safety & Sanitation policy dated 4/22 documents Foods and goods shall be stored at minimum of 6 inches off the floor. 2. 08/12/2025 10:10 AM, While observing the purees, V34 (Dietary Aide), had plated 2.5 trays of brownies on dessert cups with his lower face partially covered with a beard mask. V34's beard was covered but not V34's mustache.When asked should V31's mustache be covered as well, V31 responded V34 should have both his beard and mustache covered. V31 then asked V34 to cover his mustache.On 08/12/2025 at 11:25 AM, V34 was observed a second time placing food on the residents' trays without facial hair (mustache) covered. At 11: 28 AM, V34 re-entered the kitchen without beard and mustache covered. V31 immediately left the tray line and gave V34 a beard covering. V31 stated the beard covers are distributed to dietary aides with beards as they enter the kitchen because the beard covers are not available at the kitchen door entrance.At 11: 41 AM, V34 stated that he has worked at the facility for 21 years and was not aware that both beard and mustache needed to be covered until today.On 08/13/2025 at 12:32 PM, V1 stated, It is my expectations that facial hair be covered to prevent hair in food, cross contamination and food borne illnesses. The facility's Employee Health & Personal Hygiene, Section: Food Safety & Sanitation policy dated 4/22 documents Hair restraints will be worn at all times. Beards should well-trimmed and covered with an appropriate hair restraint. 3. On 08/12/2025 at 10:35 AM, various size serving and mixing spoons were openly displayed on a dusty rack filled with grime on the wires. Earlier during the puree demonstration, V33 grabbed a large mixing spoon from the same display to portion out the chicken broth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 15 of 26 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 08/14/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete There were approximately 20 serving spoons some had dust, some had grease build-up and others black specks. Two 1/4 serving spoons that contained black speckles were washed by V31 and the discoloration/speckles disappeared, and the spoons were clean, again.V33 stated that his expectations are that all serving spoons should clean in order to prevent cross-contamination, bacteria build-up, and food-borne illness among the residents.On 08/13/2025 at 12:32 PM, V1 stated, Expectations are that serving spoons and mixing spoons be clean, sanitized and good repair after each meal. This is important due to cross-contamination concerns. 4. On 08/11/2025 at 10:30 AM, during the initial tour with V31 (Dietary Manager), the Surveyor noticed that crates of sliced whole bread were not labeled. V31 stated that the bread upon entering the storage room should be dated and dated again upon opening. V31 said, It is important to label the bread because it helps to show that the bread is usable and not molded. This important because it helps to prevent residents from becoming sick.On 08/12/2025 at 10:40 AM, crates of sliced whole bread were still un-labeled. V31 said Yes, they are not still labeled.On 08/13/2025 at 12:32 PM, V1 stated, Food should be labeled upon entering the building. Event ID: Facility ID: 145625 If continuation sheet Page 16 of 26 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 08/14/2025 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to monitor personal refrigerator temperature logs; and failed to ensure that a residents personal refrigerator had a thermometer. These failures affected two residents (R2 and R109), and out of 54 residents in the total sample. Findings include: Residents Affected - Few 1. R109 has a diagnosis which includes but not limited to unspecified protein-calorie malnutrition and muscle wasting and atrophy, not elsewhere classified, multiple sites. On 08/12/25 at 1:00 pm, V25 (Housekeeping Supervisor) stated the residents personal refrigerators are not monitored by the housekeeping department. V25 explained that V25 does not know what department is responsible for monitoring the residents personal refrigerator. On 08/13/25 at 9:24 am, V2 (DON) stated it is the responsibility of housekeeping department to monitor the residents personal refrigerators. V2 explained that the Nursing department only monitors the medication and specimen refrigerators on each unit. On 08/13/25 at 1:15 pm, V1 (Administrator) stated the residents personal refrigerators are monitored with a collaboration of the housekeeping department and nursing department. V1 explained that personal refrigerator should be monitored every day. V1 explained the housekeeping department is responsible for cleaning the residents personal refrigerators and the nursing department is responsible for recording the residents personal refrigerator temperatures. V1 further explained that every residents personal refrigerator should have a thermometer for safety and to prevent any food borne illness. V1 explained that the nursing department should alert V1 if there are no thermometers in the residents personal refrigerators. The facility's policy dated 11/28/16 and titled Food Brought into the Facility by Friends/Family/Others (Outside Sources) for Residents Policy documents, in part: Procedure: 4. Facility staff will monitor residents rooms, resident personal refrigerators, unit pantries as well as facility refrigerators and freezers for food and beverage disposal needs for safety . 6. All refrigerators in use in the facility have an internal thermometer to monitor temperature. All refrigerators have their internal temps (temperatures) recorded daily. 2. R2's history includes but not limited to cirrhosis of the liver, hypertension, atrial fibrillation, heart failure, gastro esophageal reflux disease, and chronic hepatitis C. R2's Brief Interview for Mental Status (BIMS) dated 8/5/25 documents that R2 has a BIMS score of 15. R2 is cognitively intact. On 8/11/25 at 10:25 am, Observed R2's personal refrigerator without a refrigerator temperature thermometer. The refrigerator temperature thermometer was noted on R2's nightstand. R2 stated that the refrigerator thermometer gauge had been on the nightstand for about 3 days. R2 stated that the thermometer gauge was broken, and the staff was supposed to replace it and has not replaced it yet. On 8/11/25 at 12:02 pm V20 LPN (License Practical Nurse) stated there should be a thermometer in all resident's refrigerators. Purpose for the thermometer is for food safety to make sure the residents are not receiving soiled food. V20 stated that the night shift is supposed to check the refrigerator temperatures, but V20 will get a thermometer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 17 of 26 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 08/14/2025 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the dumpster grounds were free from food related trash and that the dumpster lid was closed. These failures have the potential to affect all 231 residents residing at the facility.Facility Ray, Carlyn (36383) - KitchenFindings include:On 8/11/2025, V1 (Administrator) stated that the resident census was 231 residents at the facility.On 8/13/2024 at 11:00 am, Surveyor and V31 (Dietary Manager) inspected the facility outside dumpster area and observed dietary trash covering the grounds and one dumpster lid open. Trash items surrounding the dumpster grounds included open individual-sized milk cartons, used paper plates, foam drinking cups, dietary napkins, and other dietary related trash. V31 stated that all garbage and refuge should be disposed of properly by kitchen staff and referred me to the facility's maintenance director for further guidance.On 8/13/2024 at 11:10 am, Surveyor and V26 (Maintenance Director) inspected the facility outside dumpster area and observed dietary trash covering the grounds and one dumpster lid open. When V26 was asked about the outside dumpster lid open and surrounding trash and debris, V26 stated, Trash is supposed to be placed securely into the dumpsters and not unto the ground. This is ridiculous especially since both dumpsters are not even full. V26 added that not placing trash in the dumpsters properly can attract various animals unto the property.On 8/13/2024 at 12:32 PM, V1 stated the dumpster lid should be closed and the grounds around the area should be clean. V1 said that area surrounding the facility has a [NAME] issue, so trash be disposed of properly. V1 added that having trash disposed of properly prevents pests and animals from entering the facility's premise and surroundings. The facility's undated document titled Safe Food Handling Dumpster, documents Dietary trash will be disposed of in a sealed plastic trash bag. The dumpster will be securely covered. The ground surrounding the dumpster will be free of trash and debris. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 18 of 26 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 08/14/2025 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 0880 Provide and implement an infection prevention and control program. 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 review, the facility failed to perform appropriate hand hygiene after contact with residents during tray pass, prior to entering and after exiting resident room on Enhanced Barrier Precautions (EBP), and between residents medication pass; failed to ensure staff does not touch a resident's oral medications; failed to ensure staff sanitize shared medical equipment between each resident's use; failed to ensure EBP sign was posted and Personal protective equipment (PPE) bin available for residents on EBP; and failed to ensure staff do not store soiled linen on clean linen cart in an effort to prevent the spread of infectious microorganism. These failures affected six (R10, R129, R141, R157, R228, and R237) residents reviewed for infection control and have the potential to affect all 180 residents on 2nd, 3rd and 4th floors.Findings include: Residents Affected - Some Review of the facility's provided census (dated 8/11/2025), 231 residents live within the facility (69 residents live on the second-floor unit, 55 residents live on the third-floor unit and 56 residents live on the fourth-floor unit). 1. On 8/11/2025 at 10:50 AM, on the second-floor unit, observed V28 (Certified Nursing Assistant/CNA) walk in R157's room (Enhanced Barrier Precautions (EBP) room), without performing hand hygiene. V28 was in the room approximately five minutes and then was observed exiting the same EBP room without performing hand hygiene. No use of gloves, gown or handwashing were observed when V28 exited the EBP room. On 8/11/2025 at 10:52 AM, on the second-floor unit, observed V7(Licensed practical nurse/LPN) entering R157's room (Enhanced Barrier Precautions (EBP) room), without using hand sanitizing gel or performing hand washing. Approximately two minutes later, V7 exited R157's room without performing handwashing or using a hand sanitizing gel. On 8/11/2025 at 11:53 AM, on the second-floor unit, observed minimum of five lunch trays passed to the residents in the dining room and to the residents in the rooms by V29 (CNA) and V30 (CNA), with no hand hygiene performed between each resident's tray deliveries. Observed V29 readjust V29's scrub pants around the waist, then take a liquid vitamin supplement bottle to a resident's room without performing hand hygiene or using a hand sanitizing gel. On 8/11/2025 at 12:05 PM, on the second-floor unit, V29 (CNA) stated that V29 is not sure what the round orange stickers means by the resident's name. V29 asked another CNA who had a list of different stickers and the explanation attached to a badge and stated that the orange round sticker is used for residents that have enhanced barrier precautions in place. On 8/11/2025 at 12:07 PM, on the second-floor unit, observed V7 (LPN), for a second time enter and exit R157's room, (EBP room) without using any PPE, handwashing, or hand sanitizing gel before or after resident care. On 8/12/2025 at 8:55 AM, during medication pass on the second-floor unit, observed V18 (Registered Nurse/RN) administering medications to R10, R129, and R228 without using hand sanitizing gel or performing handwashing between each resident. R10, R129 and R228 reside in the same room that has enhanced barrier precautions sign displayed and there was an orange round sticker placed next to R10's name. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 19 of 26 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 08/14/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 8/12/2025 at 08:57 AM, observed V18 (RN) performing blood pressure checks on R129 and R228 in the Enhanced Barrier Precaution (EBP) room, without performing a hand washing or using a hand sanitizer. Observed V18 using a wrist blood pressure machine on R129 first, then administered R129's medication. V18 did not wiped and sanitized the wrist blood pressure machine with anti-infective agent (wipes) after used on R129. V18 then placed the contaminated wrist blood pressure monitor on R228 and performed blood pressure reading, then administered R228's medication. V18 was not observed performing handwashing or using a hand sanitizing gel before or after each resident's medication administration, or a resident care. On 8/12/2025 at 09:05 AM, observed V18 (RN), to touch with V18's right pointing finger R228's tablets inside of medication administration cup while counting how many tablets inside of the cup without gloves, or performing hand hygiene. On 8/12/2025 at 9:10 AM, observed V28 (CNA), enter R10, R129 and R228's room (EBP room) and picked up R228's breakfast tray and exit the room. V28 then entered the same room again and picked up R129's breakfast tray and exited the room. During the process, V28 never performed hand hygiene, used gloves, or used hand sanitizing gel between touching the resident's trays and then performing resident's care. On 8/12/2025 at 09:30 AM, V18 (RN), stated hand hygiene should be performed between each resident's care or each resident's medication pass. V18 stated V18 should have perform hand hygiene and wipe the wrist blood pressure monitor with anti-infective agent (wipes) after each resident's use to prevent infection spread. On 8/12/2025 at 09:50 AM, V19 (Licensed practical nurse/LPN) stated the orange sticker next to resident's name on the door means the resident is on Enhanced Barrier Precautions (EBP) and that hand hygiene should be performed each time prior to entrance and exit out of the resident's rooms and that medical equipment used on resident's should be thoroughly wiped with an anti-infective agent (wipes) after each use. On 8/12/2025 at 09:50 AM, V2 (Director of Nursing/DON), stated medication cart should be cleaned with anti-infective agent (wipes) and kept clean. V2 stated the expectations for providing care and medication administration for residents in EBP room, are for all staff to perform proper hand hygiene either by washing hands in the sink or by using had sanitizer and to use isolation gown and gloves for direct patient care if there is a risk to exposure to bodily fluids. V2 stated the medical equipment used on residents (Accu-Chek machines, blood pressure machines), should be wiped with anti-infective agent (wipes) after each resident's use and completely dried before using on a different resident. V2 stated that the reason for proper hand hygiene practices is to prevent infection spreading to residents or to the staff. On 8/12/2025 at 11:30 AM, V20 (Licensed Practical Nurse/LPN) stated the staff should be performing hand hygiene and washing hands after each resident's care and to help the correct length of hand washing, V20 singed the alphabet song. V20 also stated that hand hygiene is important to prevent spreading of germs between residents or between the staff members. V20 also stated, that the hand sanitizing gel is attached to each medication cart so the nurses would have easier access to was hands during medication passing. On 8/13/2025 at 1:15 PM, V10 (Assistant of Director of Nursing/ADON, Infection Preventionist/IP) stated it is very important to practice hand hygiene and wash hands between the resident's care to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 20 of 26 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 08/14/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some prevent infections from spreading. V10 stated for the rooms with Enhanced Barrier Precaution (EBP) rooms, the staff should use isolation gowns and gloves when providing direct patient care where the exposure to bodily fluids is likely to happen, but not necessary when just checking in and talking with a resident. V10 stated the staff should perform hand washing in the sink prior to passing resident's meals after at least every third resident but should perform a hand hygiene with minimum at least hand sanitizer between each resident's tray served. V10 stated during medication administration the nurse should not touch the pills with bare hands, instead the nurse should use gloves or a tongue depressor. V10 also stated that the hand hygiene by using the hand sanitizing gel at minimum, should be performed between each resident's medication pass. V10 also stated, that medical equipment should be wiped with anti-infective agent between each residents use and should be completely dry before applied to another resident. 2. On 08/11/2025 at 10:39am, during the initial tour of the facility, V13 (Registered Nurse) stated he (R141) has an indwelling catheter. On 08/11/2025 at 11:22am, there was no EBP (enhanced barrier precautions) sign posted and no PPE bin available outside of R141's room. These were pointed out to V13. V13 stated he (R141) has an indwelling catheter, and he should be on EBP. There should be an EBP sign posted and PPE bin available so the staff who are going in and out of his room know what PPE (personal protective equipment) to put on when they provide ADL care. On 08/11/2025 at 11:30am by R141's door, V10 (ADON/IP/RN) stated (R141) has a suprapubic catheter and there should be an EBP sign posted and PPE bin available by the door to protect staff and the resident when they perform ADL (Activities of daily living) care. PPE bin should be available so they can wear gown and gloves when performing ADL care. On 08/12/2025 at 11:15am, V2 (Director of Nursing) stated the expectation is to make sure the sign is posted by the door and PPE bin available outside the door of the resident. The sign indicates specific precautions we need to use when providing services to the resident. The sign lets the staff know ahead of time what the staff need to wear prior to entering the room. The PPE bin should be by the door, so the PPEs are readily available for use. R141's (Active Order as of: 08/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) Type 1 Diabetes Mellitus, abscess of prostate, and acute prostatism. Order Summary: Monitor patient supra pubic French 20 Foley catheter urine output q (every) shift and document. Active. Order Date: 08/02/2025. R141's (07/16/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R141's mental status as cognitively intact. Section H. Bladder and Bowel. H0100. Appliances. A. indwelling catheter. Yes. R141's (08/11/2025) care plan documented, in part is at higher risk for infection secondary to presence of catheter. Will receive Enhanced Barrier Precautions during care. PPE (personal protective equipment) to be worn during high contact care. R141's (08/11/2025) care plan documented, in part has indwelling catheter. Will be free remain from catheter-related trauma. The (08/12/2025) email correspondence with V1 (Administrator) documented, in part, I don't see a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 21 of 26 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 08/14/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some policy specifically for signage for EBP. The expectation is as follows: Signs are posted for EBP. PPE is readily available for use by staff as needed when coming in close contact with those on enhanced precautions. The (11/28/2022) Enhanced Barrier Precautions Policy and Procedure documented, in part Purpose: reduce the transmission of novel or targeted multi-drug-resistant organism. Procedure: 1. Enhanced Barrier Precautions require the use of gown and gloves during high contact resident care activities. High contact resident care activities include use of an indwelling medical device such as urinary catheter. 3. Enhanced Barrier Precautions apply to residents with indwelling medical device (urinary catheter). 3. On 08/11/25 at 11:13am V27 (Certified Nursing Assistant/CNA) was observed placing soiled linen on clean linen cart. On 08/11/25 at 11:13am V27 (CNA) stated all the linen on the bottom shelf is dirty linen. V27 stated that she placed he dirty linen on the clean linen cart because she did not have a bag to place the dirty linen in. V27 stated that dirty linen should not be on the clean linen cart because it is not clean. On 08/13/25 at 9:49am V2 (Director of Nursing/DON) stated that dirty linen should not be placed on the cart with clean linen. V2 stated that placing dirty linen on the clean linen cart is an infection control issues and causes cross contamination. Facility's undated job description titled Certified Nursing Assistant documents in part, Job Summary: The purpose of this position is to assist the nurses in the providing of resident care primarily in the area of the daily living routine.Main Duties:R. Assure that established infection control and universal precaution practices are maintained when performing nursing procedures. Facility's policy titled, Infection Control (01/2024), documents, in part. 14. All facility personnel are required to routinely wash hands and use appropriate barrier precautions to prevent transmission of infection .17. Handwashing is essential. Alcohol-based rubs/gels int eh Gold Standard of Prevention Facility's policy titled, Hand Hygiene, (Revised 11/8/2022), documents, in part, .3. The use of gloves does not replace hand hygiene. 4. Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE). Washing Hands with Soap and Water 1. Staff will perform hand hygiene by washing hands for at least twenty (20) seconds with antimicrobial or non-antimicrobial soap and water should be performed under the following conditions: . b. Before entering and leaving an isolation room c. Before applying gloves and after removing [NAME] or other PPE . e. After handling items potentially contaminated with blood, body fluids, or secretions. g. After providing direct resident care .j. If exposure to an infectious disease is suspected or proven. Using Alcohol-Based Hand Gel 1. If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations. b. Before preparing or handling medications .f. after providing direct resident care. i. If exposure to an infectious disease is suspected or proven. l. After contact with inanimate objects (e.g., medical equipment) in the immediate vicinity of the resident. Facility's policy titled, Enhanced barrier Precautions, (Revised 4/28/25), documents, in part, .Enhanced Barrier Precautions (EBP) require the use of gown and glove during high contact resident care activities.Note: Gowns and gloves are the minimum level of PPE.7. Adhere to other infection control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 22 of 26 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 08/14/2025 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 0880 practices such as * Hand hygiene * Cleaning and disinfection of environmental surfaces * Equipment care. Level of Harm - Minimal harm or potential for actual harm Facility's policy titled, Administering Medication, (1/1/20), documents, in part, . 12. Adherence to established facility infection control procedures shall be followed during the administration of medications. * Hand hygiene shall be required between residents * Medications shall not be handled, .in a clean manner using the lids of multi- dose bottles or medication cups. Residents Affected - Some Facility's document titled, Job Description Certified Nursing Assistant, (Undated), documents, in part, .R. Assure that established infection control and universal precaution practices are maintained when performing nursing procedures. Follow established safety precautions when performing tasks and when using equipment and supplies. T. Assure that equipment is cleaned and prepared for the next shift. Z. Follow established.infection control. Facility's document titled, Job Description Charge Nurse, (Undated), documents, in part, .D. Supervise all aides in performing their duties by checking their work closely.Y Assure that established infection control and universal precaution practices are maintained when performing nursing procedures.AE. Follow established . infection control . policies and procedures. Facility's document titled, Job Description Assistant director of nursing, (Updated 10/2013), documents, in part, . Job Summary: Responsible for assisting the Director of Nursing in planning, . directing, coordinating. Management of facility, people, supplies and equipment in such a way that meaningful nursing service is established to render the optimum level of resident care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 23 of 26 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 08/14/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement a facility wide system to monitor the use of antibiotics. This failure has the potential to affect all 231 residents that reside in the facility. Findings include:On 08/11/25 at 3:07pm V10 (Infection Preventionist/IP) handed surveyor a list with three residents in the facility are currently receiving antibiotics.On 08/11/25 at 3:07pm V10 (IP) stated the list with the three residents was just typed to give to surveyor. V10 stated he delegated the antibiotic stewardship monitoring to V2 (Director of Nursing/DON). V10 (IP) stated V2 (DON) has not been keeping up with monitoring residents on antibiotics because V2 (DON) has a lot of personal things going on. V10 (IP) stated he is unable to provide previous months monitoring of residents who received antibiotics.On 08/13/25 at 9:49am V2 (DON) stated she assists the IP nurse with some of the IP duties. V2 (DON) stated she is not up to date with the antibiotic stewardship monitoring log. V2 (DON) stated it is important to keep up with the log to track the residents and keep up with the antibiotics so they can keep up with what's going on in the facility.Facility's policy titled Policy and Procedure Antimicrobial Stewardship Policy dated 01/2022 documents in part, Policy Statement: An Antimicrobial Stewardship program (ASP) is established under the leadership of the Infection Preventionist (IP). The responsibility of the program is to develop and maintain a system to monitor antibiotic use. Additionally, the ASP will promote safe and effective antibiotic use to improve resident care and strive to reduce antimicrobial resistance.Procedures: the core elements for antimicrobial stewardship in the facility include.Appropriate facility staff accountable for promoting and overseeing antibiotic stewardship.Trach measures of antibiotic use in the facility.The Antibiotic Stewardship Committee will.3. Review a subset of antibiotic prescriptions for appropriateness of dose, duration, and indication. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 24 of 26 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 08/14/2025 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 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure that a resident had a privacy curtain which extended around the bed. This failure affected one resident (R15), out of 54 residents in the total sample. Findings include: R15's face sheet documents R15 has diagnoses include but not limited to depression, hypertension, syncope, and collapse.R15's Brief Interview for Mental Status (BIMS) dated 6/13/25 documents R15 has a BIMS score of 12. R15 has moderate cognitive impairment.On 8/11/25 at 11:00 am, observed R15's room without privacy curtains. R15 stated, I been here for 2 months and have not had any privacy curtains. I know I should have the curtains whether I use them or not.On 8/13/25 at 9:32 am, V2 DON (Director of Nursing) Privacy curtain should be with every resident because if provides privacy while rendering service. It's a dignity issue.On 8/13/25 at 1:20 pm V1 Administrator stated every resident should have privacy curtains in their rooms, to ensure privacy during care and as needed. On 8/13/25 at 1:24 pm, V25 Housekeeping Supervisor stated every resident should have a privacy curtain if they are in a room with another resident, if we have them (curtains). We have to have the right size we are in the process of measuring the tract and ordering them. The residents should have a privacy curtain for HIPAA (Health Insurance Portability and Accountability Act) purposes. A facility provided document titled, Residents Rights for People in Long-Term care Facilities documents in part, You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care. Facility policy dated 10/2024 and titled Safe, Clean, Comfortable and Homelike Environment documents in part, Procedure: 2. Promote a homelike environment, F. Having a privacy curtain is clean and good condition. The facility's undated job description document titled Housekeeping Assistant documents, in part: Job Summary: The primary purpose of this job is to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines, and regulations governing the facility, and as may be directed by the Administrator and/or the Director of Housekeeping, to ensure the facility is maintained in a clean, safe, and comfortable manner. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 25 of 26 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 08/14/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and record review, the facility failed to maintain an effective pest control program to ensure that the facility free of insects. This failure has the potential to affect all 231 residents at the facility. Findings include:R114's has a diagnosis of but not limited to Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Difficulty in Walking, Abnormal Posture and Hypertension.R114 has a Brief Interview of Mental Status score of 15 that indicates resident's cognition is intact.On 8/11/2025 at 11:06am surveyor observed a brown bug (roach) crawl from behind the activities calendar taped to R114's wall.On 8/11/2025 at 11:06am R114 said between the roaches and the gnats it's quite scary for her to go to sleep and she doesn't know how many gnats she has swallowed because she sleeps with her mouth open. R114 stated the exterminator did recently come but he did not spray any areas and he just applied bait in the dresser draws and put down some traps.On 8/12/2025 at about 8:35am surveyors saw a live black bug (Roly Poly) in front of the elevator.On 08/13/2025 at 1:35pm R114 stated she has seen about 5 more roaches since 08/11/2025 and they were crawling down the window screen, and she doesn't know if they are coming from other rooms or upstairs.On 8/13/2025 at 9:37am V2 (Director of Nursing) stated when insects or mice are seen staff makes V1 (Administrator) aware and she will contact pest control company to come out.On 8/13/2025 at 11:09am V26 (Maintenance Director) stated staff are to notify him (V26) if there are sightings of bugs or mice and he will notify V1, and the pest control company comes about every two weeks and more often if necessary.On 8/13/2025 at about 12:20pm V1 stated the maintenance director oversees Pest Control program, but staff will notify her so she can contact the pest control company to come out and treat the facility and this is done as often as needed.Service Inspection Report dated 7/16/2025 documents, in part, Service-General-room [ROOM NUMBER]: dead roaches were seen at time of service.Service Inspection Report dated 7/16/2025 documents, in part, Healthcare Combined-Preventative Maintenance: dead roaches were seen at time of service.Pest Control Policy with a date of 11/14 documents, in part, to prevent or control insects and rodents from spreading disease and the facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145625 If continuation sheet Page 26 of 26