Inspection·May 5, 2025

F 0908 Keep all essential equipment working safely. 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 document review the facility failed to maintain all mechanical equipment in safe operating condition. This failure affected all residents in the facility by not providing hot water due to equipment failure. Residents Affected - Many Findings include: On 4/30/25 the facility was toured and hot water accessible to the resident was measured with V5 (Maintenance Director) with a facility provided dial stem thermometer. 3rd floor mens common toilet at hanksink 11:10AM 90F . 3rd floor womens common toilet room. 11:13AM . No water supply at both handswashing sinks. 3rd floor womens shower and bathroom across room [ROOM NUMBER]. At shower 89F 11:16AM 89F. At handsink 91F. 3rd floor mens shower room across room [ROOM NUMBER] 11:20AM at handsink 90F. At shower 80F. 2nd floor mens shower room [ROOM NUMBER]:29AM handsink 87F, at shower 86F. 2nd floor womens shower room [ROOM NUMBER]:35AM handsink 88F, at shower 88F. 1st floor womens restroom/shower room [ROOM NUMBER]A 11:45 AM at handsink 83F at shower 88F. 1st floor mens toilet room [ROOM NUMBER]C 11:50 AM handsink 70F. On 4/30/25 at 12PM the basement boiler room was observed in the following condition. The boiler room was entered with V5. The walkway was flooded and water was running along the floor towards the sump pit Water was observed flowing from the hot water mixing valve located next to the 2 hot water tanks. On 4/30/35 at 12:05 PM V5 was questioned as to what was wrong. V5 stated the mixing valve is no good and I have a new one. I have to replace the mixing valve when we are done here. V5 failed to mention this condition to the surveyor when the facility hot water temperatures were being taken during tour. On 5/1/25 at 12:20PM V6 (Corporate Project Manager) stated we have the wrong mixing valve and a new (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: 146062 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 146062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center Home Hispanic Elderly 1401 North California Chicago, IL 60622 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)