Inspection·October 21, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's undated policy and titled Infection Control For Food Service Covid 19 Prevention documents, in part: Policy: The facility stores, prepares, distributes and serves food in a sanitary manner to prevent foodborne illness, cross contamination and to assure infection control. The facility's job description document titled Food Service Director documents, in part: 2. Adheres to all sanitary and food safety regulations governing handling and serving of food . 14. maintains the department and regulatory compliance . 15. concerns his/herself with the safety of all center customers in order to minimize the potential for fire and accidents. Also ensures that the center adheres to legal, safety, health care health, fire, and sanitation codes by being familiar with his or her role. Event ID: Facility ID: 145834 If continuation sheet Page 2 of 6 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 145834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Oasis, The 901 South Austin Blvd Chicago, IL 60644 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 Based on observation, interview, and record review, the facility failed to ensure that the dumpster was closed and fee from overflowing trash. These failures have the potential to affect all 178 residents residing at the facility. Residents Affected - Many Findings include: On 10/15/24, V2 (Director of Nursing , DON) stated that the facility census was 178 residents at the facility. On 10/16/24 at 2:15 pm, Surveyor and V24 (Dietary Aide) toured the facility dumpster area and observed the dumpster area open with two broken lids and overflowing with trash. V24 stated, Someone broke this (referring to the broken dumpster lids). They (referring to garbage pickup) come and get the trash every other day. They (referring to garbage pickup) should be here today. When V24 was asked regarding who is responsible for the dumpster lids to be repaired V24 stated, V21 (Maintenance Director). When V24 was asked regarding the importance of the dumpster lids to remain close V24 stated, So that it (referring to the dumpster) does attract rodents to the facility. On 10/17/24 at 1:04 pm, V21 (Maintenance Director) stated that the dumpster is managed by V22 (Housekeeping). V21 stated that if the lids on the dumpster are missing or broken V21 is responsible for ensuring the dumpster lids are repaired or replaced. V21 stated that V21 don't dump garbage and garbage is left in front of the maintenance room so unless an issue is reported to V21 regarding the dumpster V21 don't see the dumpster area. On 10/17/24 1:27 pm, V22 (Housekeeping Director) stated that the dumpster area is maintained by the housekeeping staff. V22 stated that V22's department is responsible for ensuring the dumpster area is clean and free from trash/garbage around the dumpster. V22 stated that V22 was aware the dumpster lids have been missing from the dumpster area for about 2 weeks. When V22 was asked regarding what could happen if the dumpster lids are broken, missing, or remain open and V22 stated, If the dumpster is open it can increase rodents in the facility. V22 stated that V22 will call the number on the dumpster to repair the dumpster as soon as possible. The facility's policy dated 11/14 and titled Pest Control Policy documents, in part: Purpose: To prevent or control insects and rodents from spreading disease. Responsibility: Administrator, Environmental Service Director. Standards: . 16. Outside dumpster's shall be of sufficient size that the lid can be tightly closed. The container shall be stored on a smooth surface of nonabsorbent material. #17 the dumpster shall be kept clean and maintain in good repair. The facility's job description titled Environmental Services/Housekeeping Director documents, in part: Responsibilities/Accountabilities: 12. Concerns his/herself with the safety of all customers in order to minimize the potential for fire and accidents. Also, ensures that the center adheres to the legal, safety, health, fire, and sanitation codes by being familiar with his/her role in carrying out the centers fire, safety and disaster plans and by being familiar with current MSDS (Material Safety Data Sheet). The facility's job description titled Maintenance Director documents, in part: Job Summary: The maintenance director is responsible for the day-to-day activities of the maintenance department in accordance with current federal, state, and local standards, guidelines and regulations governing our (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145834 If continuation sheet Page 3 of 6 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 145834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Oasis, The 901 South Austin Blvd Chicago, IL 60644 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete facility and maintained in a clean, safe, and comfortable manner. As the maintenance director you are delegated the administrative authority responsibility and accountability necessary to carry out your assigned duties. Essential duties and responsibilities: 2. Maintains the building and good repair and free of hazards such as those caused by electrical plumbing heating and cooling systems life safety etc. (etcetera) . 12. Maintains the building and grounds and compliance with federal, state, local, and Joint Commission laws and standards. Event ID: Facility ID: 145834 If continuation sheet Page 4 of 6 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 145834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Oasis, The 901 South Austin Blvd Chicago, IL 60644 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 Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure that the facility's kitchen is free of insects. This failure has the potential to affect all 178 residents in the facility. Residents Affected - Many Findings include: On 10/15/24 at 12:40 pm, Surveyor and V3 (Dietary Manager) toured the facility's kitchen and observed poor cleaning all over the entire kitchen area (food on kitchen floor, trash on kitchen floor, soiled floors, dirty stagnant draining water, and soiled walls). Surveyor and V3 also observed an infestation of flies (fruit flies, gnats) throughout the kitchen in the food prep area where V18 (Dietary Aide) was preparing sandwiches for residents to eat and in the pots and pans area where V24 (Dietary Aide) placed pots and pans dishes that were cleaned. V3 stated that V3 sees flies infest the kitchen daily and that V3 has seen roaches in the kitchen near the pots and pans area. V3 stated that pest control last visited the kitchen about 2 weeks ago however the flies and roaches are still an issue in the kitchen. Surveyor also observed broken tiles under sink/dishwasher area, holes in the wall behind and underneath the food prep area and food cart storage area in the kitchen. V3 stated that V21 (Maintenance Director) was aware of the holes in the wall in the kitchen in need of repair. When V3 was asked regarding who is responsible for cleaning the facility's kitchen area V3 stated that all kitchen staff are responsible for cleaning the kitchen. When V3 was asked regarding what could happen if the kitchen is not kept clean and sanitation is not kept in the kitchen, V3 stated that the kitchen can become infested with rodents and insects. On 10/15/24 at 12:45 pm, Surveyor toured the kitchen and spoke with V13 (Dietary Aide), V14 (Dietary Aide), V15 (Cook), V16 (Dishwasher), V17 (Dietary Aide), V18 (Cook), and V19 (Dietary Aide) who all stated seeing roaches, fruit flies and gnats and the facility kitchen daily. On 10/16//24 11:38 am, V21(Maintenance Director) stated that V21 coordinates the pest control company visiting the facility with V1 (Administrator). V21 stated that pest control company should be checking and treating the kitchen for pest and rodents every time pest control visits the facility. V21 explained that staff from the kitchen should be reporting pest control concerns in the kitchen in the front desk pest control log. V21 also stated that V21 rounds with pest control sometimes if V21 is not tied up with another project in the facility. V21 stated that V21 has recently seen gnats and fruit flies in the kitchen and is unsure if pest control treated the issue and if the issue of flies in the kitchen is resolved in the kitchen. When V21 was asked regarding the holes in the wall in the kitchen in need of repair and V21 stated that V21 is aware and will repair the issue. When V21 asked regarding what could happen if a kitchen has holes in the walls and V21 stated that it can create and entry way for pest, insects, and rodents to entire the kitchen. On 10/16/24 at 2:10 pm, Surveyor and V3 toured the facility kitchen and observed a large dead insect on the floor in the dry storage room. V3 also stated that pest control treated the kitchen on 10/15/24 but did not treat all areas of the kitchen including the dry storage area during the pest control visit. V3 stated, I (V3) don't think they come in here when they (referring to pest control) visits the kitchen. On 10/17/24 1:27 pm, V22 (Housekeeping Director) stated that the housekeeping department does not clean in the facility kitchen. V22 stated that it is the responsibility of the kitchen staff to clean in the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145834 If continuation sheet Page 5 of 6 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 145834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Oasis, The 901 South Austin Blvd Chicago, IL 60644 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility's document dated 09/24/24 and titled Service Inspection Report documents, in part: Area Comments: Healthcare Combined: Kitchen dish room: Poor cleaning all over dish room area especially under dishwasher machine, behind washing racks and all corners, stagnant water, broke titles and leaks need to be cleaned and fix to eliminate breeding areas for German roaches. The facility's document dated 10/16/24 and titled Service Inspection Report documents, in part: Area Comments: Healthcare Combined: Kitchen Main Kitchen Area: poor cleaning all over kitchen and dish room area especially under dishwasher machine, behind washing racks, all corners under/behind equipment, stagnant water, broken tiles under sink/dishwasher, missing grout between towers, floor drains, dust pan and dirty mops and needs to be cleaned and fixed to eliminate breeding areas for fruit flies. The facility's undated policy and titled Infection Control For Food Service Covid 19 Prevention documents, in part: Policy: The facility stores, prepares, distributes and serves food in a sanitary manner to prevent foodborne illness, cross contamination and to assure infection control. The facility's job description document titled Food Service Director documents, in part: 2. Adheres to all sanitary and food safety regulations governing handling and serving of food . 14. maintains the department and regulatory compliance . 15. concerns his/herself with the safety of all center customers in order to minimize the potential for fire and accidents. Also ensures that the center adheres to legal, safety, health care health, fire, and sanitation codes by being familiar with his or her role. The facility's job description document titled Dietary Aide documents, in part: Position Summary: the dietary aid performs a variety of food service functions and maintaining clean and sanitary conditions of food service areas, facilities, and equipment. Responsibilities accountabilities . 12. Maintains cleanliness and sanitation through entire work areas . 13. performs daily or scheduled cleaning duties, in accordance with established policies and procedures, scrubs and mops doors, cleans and sanitizes equipment . 14. empties trash contains regularly. The facility's policy dated 11/14 and titled Pest Control Policy documents, in part: Purpose: To prevent or control insects and rodents from spreading disease. Responsibility: Administrator, Environmental Service Director. Standards: 1. The Environmental Services Director will be responsible for coordinating the facility pest control program. 3. The pest control program will be conducted on a regular and as needed basis. 5. Employees are instructed to promptly report all observations of pest to their department heads. 9. All building openings shall be tight -fitting and free of breaks. 10. The facility shall be kept in such conditions and cleaning procedures used to prevent the harborage or feeding of insects and rodents. 11. Floors, and wall finishes in the food preparation, storage and utensil washing areas, walk-in refrigerator units, dressing rooms, lockers, toilet which may be washed and cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145834 If continuation sheet Page 6 of 6