Health inspection·December 31, 2025

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 on observations, interviews and record reviews, the facility failed to prevent live roaches from being in residents' rooms and crawling in bed with residents. This failure affected four residents (R2, R6, R18, and R21) in a sample of 10. This failure has the potential to affect all 250 residents residing in the facility.Findings include:a.R2's Face Sheet documents that R2 was admitted to the facility on [DATE] and R2's diagnosis includes Schizophrenia, Schizoaffective, Bipolar Disorder, Conduct Disorders, and Auditory Hallucinations. R2's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact with little to no impairment.On 12/22/2025 at 2:32 PM, R2's family member (V6) stated R2's mattress was rotten and there were big cockroaches running throughout the mattress. V6 said that the mattress needed sterilizing. V6 added that roaches ran out of the clean sheets that were placed on R2's bed. V6 said the bug problems took place when R2 live on the second floor with R2's former roommates.b.R6's Face Sheet documents that R6 was admitted to the facility on [DATE] with a diagnosis of muscle wasting and atrophy, unsteadiness on feet, other lack of coordination, unspecified psychosis not due to a substance or known physiological condition, low vision right eye category one, low vision left eye category one, and neurocognitive disorder. R6's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 13 indicating cognitively intact with little to no impairment.On 12/22/2025 at 2:15 PM, V26 (Certified Nursing Assistant (CNA) stated that roaches on the second floor are usually seen during first shift sometimes on the second shift. V26 added that V26 sometimes work first shift, second shift and all four floors so V26 stated that the roaches are prevalent throughout the facility where residents reside. V26 said that the roaches appear on the floor when they order food for the residents from the kitchen. V26 stated that R6 attracts roaches because R6 likes to hide food especially sandwiches under the cushion of R6's wheelchair. V26 added that V26 saw roaches in V26's room last night as well as Thursday of last week. V26 provided other rooms where roaches usually crawl but the surveyor's data was lost.c.R18's Face Sheet documents that R18 was admitted to the facility on [DATE] with a diagnosis of muscle weakness, idiopathic peripheral autonomic neuropathy, simple chronic bronchitis, major depressive disorder, generalized anxiety disorder, and cognitive communication deficit.R18's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact with little to no impairment.On 12/24/2025 at 10:39 AM, R18 stated that just last night R18's roommate killed a roach on their dresser by the television. At 10:30 AM, R21 said that R1's room had many roaches, and they were alive. While in R1's room, R1 had multiple devices that was purchased to trap and kill the roaches. R21 stated that the roaches hide and live behind the decorative wall trimming/band that was about waist-length above the wall. R21 then pulled open the trimming and a large black insect about one and half inches in diameter ran down the wall. R21 believe the roaches are embedded and live in the wall behind R21's bed and within the Residents Affected - Many (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145625 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 12/31/2025 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)