Inspection·January 24, 2025

F 0677 color. The certified nurse assistant striped the bed because they gave R1 a bath. Level of Harm - Minimal harm or potential for actual harm On 01/21/25 at 12:26 PM R1 was observed in bed on a low air loss mattress dressed in a gown in a semi-Fowler_position with enteral feeding infusing via a gastric tube. R1's tracheostomy tube was intact with oxygen in use per a humidity collar and connected to an oxygen concentrator. R1's hair was observed uncombed, tangled with matted hair in the back of the head. Residents Affected - Few R6 has a readmission date to the facility on [DATE] with diagnosis not limited to Tracheostomy Status, Gastrostomy Status, Myoclonus, Asthma, Essential (Primary) Hypertension, Malignant Neoplasm of Unspecified Site of Unspecified Female Breast, Atrial Fibrillation, Non-St Elevation (Nstemi) Myocardial Infarction, Type 2 Diabetes Mellitus, Hyperlipidemia, Hypothyroidism, Anemia, Dysphagia, Chronic Obstructive Pulmonary Disease, Anoxic Brain Damage, Atherosclerotic Heart Disease of Native Coronary Artery, Abnormal Levels of other Serum Enzymes, Chronic Respiratory Failure, Cardiac Arrest, Acute Embolism and Thrombosis of Deep Veins of Right Upper Extremity, Vitamin D Deficiency, Heart Failure, Epilepsy, Dependence on Respirator [Ventilator] Status and Presence of Urogenital Implants. R6's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicate R6 is rarely/never understood. R6's Care Plan documents in part: Focus: Communication: R6 is noted to have no speech and is rarely able to be understood when communicating information to others and rarely able to understand information presented as per section B of the MDS. Focus: R6 requires assistance with ADL's bed mobility, transfers, dressing, personal hygiene, eating and toileting. Interventions: Assist resident with shower/bathing per schedule. Focus: R6 has an ADL Self Care Performance Deficit and Impaired Mobility r/t (related/to) Activity intolerance, Limited mobility. Interventions: Personal Hygiene/Oral Care: R6 requires 1-2 staff participation with personal hygiene and oral care. Bathing: R6 is totally dependent on staff to provide a bath per facility shower schedule as necessary. R6's MDS Section B - Hearing, Speech, and Vision document in part: Speech Clarity: 1. Unclear speech. Make self-understood: 3. Rarely/never understood. Ability to understand others: 3. Rarely/never understands. Cognitive Patterns Section C document in part: Cognitive Skills for Daily Decision Making: 3. Severely Impaired - never/rarely made decisions. Section GG Functional Abilities: 01. Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. On 01/21/25 at 12:44 PM R6 was observed in bed in a semi-Fowler_position with a tracheostomy tube connected to a ventilator dressed in a gown with enteral feeding infusing via a gastric tube. R6's hair appeared uncombed, tangled, and matted with brown particles scattered throughout R6's hair. R6's scalp appeared dry with flakes of brown particles on the scalp. On 01/21/25 at 12:48 PM V7 (Certified Nurse Assistant) entered (R1, R6) room. Surveyor asked V7 was he assigned to provide care to R1 and R6. V7 responded yes. Surveyor asked what care he provides for R1 and R6. V7 responded I give bed baths, wash their face, clean their mouth with the mouth sponge and liquid mouth wash. I did nothing with R6's hair. I did not comb R1 or R6's hair. R1's hair is a little knotted up. R6's hair is wild and that looks like grease (referring to the brown particles). On 01/21/25 at 01:02 PM Surveyor asked V8 (Licensed Practical Nurse) what type of care that she provides R1. V8 responded I give medicine, nursing care, make sure R1 has her gastric feedings, make sure ADL's (Activities of Daily Living) are done, turn every 2 hours and let the doctor know if changes occur. If R1's hair is not combed, I instruct the certified nurse assistant to comb the hair. I will let V7 (Certified Nurse Assistant) know about R1's hair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145632 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr South Loop 1725 South Wabash Chicago, IL 60616 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 Residents Affected - Few On 01/21/25 at 01:06 PM Surveyor asked V9 (Certified Nurse Assistant) to enter R1's and R6's room. V9 stated I did not take care of R1 on 12/24/24. When we care for a resident we wash them, do hair, nails, and oral care. I make sure that I wash the hair with a towel and comb through R1's hair. Surveyor asked V9 how she would describe R6's hair. V9 put on a pair of gloves and began touching R6's hair then responded, scabs are coming up; it is dry and some of the hair is like matted. V9 removed the gloves, went in the bathroom, washed her hands, and applied a pair of gloves and walked over to R1's bed. Surveyor asked V6 to describe how she (V9) observed R1's hair. V9 responded, R1's hair is matted, dry and probably can get unmatted if you wet and soften it up. On 01/21/25 at 01:13 PM Surveyor asked V10 (Agency Licensed Practical Nurse) to enter R1 and R6 room. Surveyor asked how she (V10) observed and would describe R6's hair. V10 stated R6 skin is dry and looks like cradle cap, looks a little matted and needs to be washed. V10 walked over to R1's bed and was asked to describe how she (V10) observed R1's hair. V10 responded, in the back R1's hair is matted and looks like it needs to be washed. On 01/21/25 at 01:22 PM V11 (Licensed Practical Nurse) stated when doing resident care the certified nurse assistants comb hair, wash the face and do oral care. On 01/21/25 at 03:33 PM V13 (Agency Certified Nurse Assistant) stated I provide R1's ADL's. R1's hair is clustered together when I have seen her and taken that set. R1's hair is hard to comb and R1 makes faces when trying to change her or comb her hair. On 01/22/25 at 11:28 AM V15 (Agency Certified Nurse Assistant) stated I worked with R1 with another certified nurse assistant. When I first saw R1 I could tell the night shift did not do anything. R1 was wet from the night shift before. On 12/24/24 I went and washed R1, put grease on her hair because it was pushed up and I brushed it down. Before I combed R1's hair it was matted to her head, and I sprayed her hair with soap and water. R1's hair was so mated' it smelt. R1's hair is normally matted to her head. I don't know the words to describe it, but it was not a good smell. V4 (R1's Family Member) arrived right before lunch. R1 is alert to shake her head. I think that was R1's shower day and the mattress was not properly wiped down. R1 is bed bound and can't do anything. I stripped the bed, it smelt like R1 had not even been changed and the mattress smelt of urine and poop. On 01/22/25 at 09:23 AM R6 was observed in bed in a semi-Fowler_position with a tracheostomy tube connected to a ventilator dressed in a gown with enteral feeding infusing via a gastric tube. R6 hair was combed and brushed back with no particles observed in R6's hair. On 01/22/25 at 09:24 AM R1 was observed in bed on a low air loss mattress dressed in a gown in a semi-Fowler_position with enteral feeding infusing via a gastric tube. Tracheostomy tube was intact with oxygen in use per a humidity collar and connected to an oxygen concentrator. R1 hair was combed and brushed back. On 01/22/25 at 12:07 PM V16 (Nurse Consultant) stated when I went to R1's/R6's room they were about to wash R6's hair. They had tried to comb R6's hair and it was getting ready to be shampooed. We were on it. R1's hair in the back of the head it was more like it was stuck to her head a little that is what I remember. We do not have a policy for shampooing and combing hair. On 01/22/25 at 12:57 PM V2 (Director of Nursing) stated when I went to see R6 they had started washing her hair and it was not as dry. R1's hair was tangled in the back; it was stuck together, and they had to pick it out. During a.m. care bathing is done, washing of the face, brushing teeth, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145632 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr South Loop 1725 South Wabash Chicago, IL 60616 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 Residents Affected - Few combing hair, and oiling them down with a moisturizer for their skin each time they do a.m. care. The residents receive showers twice a week and bathes daily or when needed. If a resident's hair is not combed on a regular basis, it will become dirty and unkept. It should be combed every day to prevent the hair from being unkept, stuck to the head and not being cleaned. Policy: Titled Shower and Hygiene revised 08/19/24 document in part: It is the policy of this facility to ensure that resident shower/hygiene care is provided by the nursing staff to promote cleanliness, provide comfort to the resident, and observe the condition of the resident's skin. 1. Any resident who needs hygienic care will be provided care to promote hygiene (facial, body, perineal care, etc.). Policy: Titled Restorative Nursing Program revised 08/10/24 document in part: It is the policy of this facility to assess for comprehensive nursing and restorative needs upon admission. Procedure: 2. Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. 3. Nursing and Restorative Services may include the following: d. Bathing, e. Dressing, k. Other nursing care needs . 9. Resident assistance with ADL's (Activities of Daily Living) will be based on the functional assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145632 If continuation sheet Page 4 of 4