Health inspection·October 4, 2023

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many According to the National Oceanic and Atmospheric Administration, National Weather Service at: https://www.weather.gov/lot/2023_08_2324_Heat#:~:text=Chicago%20officially%20observed%20a%20high,was%20116% Chicago officially observed a high temperature of 98°F on the 23rd at O'Hare Airport, setting a record daily high temperature for this date. The peak heat index observed at O'Hare Airport on the 23rd was 116°F**. According to Weather Underground at: https://www.wunderground.com/history/daily/us/il/chicago/KMDW/date/2023-8-23, in Chicago on 8/23/23 times and temperatures were as follows: 5:53 PM 96 °F 6:53 PM 86 °F 7:05 PM 92 °F 7:53 PM 89 °F - observed a truck located on the side of the facility building pumping air into the facility through 2 blue tubes placed in open windows. On 8/23/23 at 6:30 pm, - observed the facility to be very hot inside and uncomfortable. - observed multiple fans/cooling units operating in the hallways and dining room area on the 1st floor. On 8/23/23 at 6:46 pm, the (2nd floor) temperature was uncomfortably hot and there was a notable urine odor. V8 (Social Service Director) stated the facility air conditioner has been out since Monday 8/21/23 (2 days prior). On 8/23/23 at approximately 7:00 pm, a total of 39 residents (R4, R5, R7, R8, R11, R19, R20, R25, R29, R32, R33, R38, R42, R43, R45, R54, R56, R62, R63, R65, R66, R74, R75, R82, R84, R85, R86, R88, R92, R94, R96, R99, R106, R107, R116, R120, R121, R127, R133) were observed inside and/or outside the facility therefore not evacuated from the facility (roughly 9 hours after hazardous temperature was identified). On 8/23/23 at 7:15 pm, 1st floor staff were noted to be sweating and their clothes visibly wet. R21 is [AGE] years old with diagnoses which include but not limited to Alzheimer's disease, type II diabetes mellitus, and hypertensive heart disease. R21's (6/30/23) BIMS (Brief Interview Mental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 2 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Status) determined a score of 10 (moderately impaired). R21's (6/30/23) functional assessment affirms (1 person) physical assist is required for bed mobility, transfers, locomotion, and toilet use. On 8/23/23 at approximately 7:30pm, surveyor observed R21 throwing up (3 times) in the (1st floor) dining room. R21 stated I'm not feeling well, it's too hot. I need to lie down, I feel weak and appeared exhausted (unable to sit upright in the wheelchair). V11 (Licensed Practical Nurse) took R21's blood pressure which read 100/62 however no additional vital signs were obtained at this time. [Low blood pressure, fatigue and weakness are signs/symptoms of heat exhaustion. Vomiting and sweating due to excess heat cause heat exhaustion]. On 8/23/23 at 7:00pm, V16 (Maintenance Director) affirmed the portable air chillers came today around 3:00pm - after the evacuation was initiated. On 8/23/23 at 7:00pm, R19 stated the air is not working in my room. On 8/23/23 at 7:02pm, V5 (PRSA/Psychiatric Rehabilitation Service Aide) stated cooling buses got here this morning around 10am and left at 5:30pm when we began evacuating the residents, however residents remained at the facility with hazardous temperature till after midnight (6+ hours longer). On 8/23/23 at 7:07pm, R79 stated it has been hot for about a month now, they (staff) provided fans. R79's (6/6/23) BIMS (Brief Interview Mental Status) determined a score of 12 (moderate impairment). On 8/23/23 at 7:22pm, R92 reported feeling hot. R92 affirmed she was in her room and (approximately 1 hour ago) staff brought her to the 1st floor dining room. R92's (7/25/23) BIMS determined a score of 15 (cognitively intact). On 8/23/23 at 7:27pm, R75 stated I feel terrible, I feel hot, I have not had anything to drink. Staff offered me something to drink but I refused to keep from having to use the bathroom. R75's (8/17/23) BIMS determined a score of 10 (moderate impairment). On 8/23/23 at 7:30pm, R45 stated yesterday and today it got really hot. The AC (Air Conditioner) in my room didn't work this morning, staff tried to turn it on, but it didn't work. R45's (7/21/23) BIMS determined a score of 12. On 8/23/23 at 9:38pm, V9 (Regional Director of Operations) stated we (facility) were able to maintain comfortable temperature levels in the building until this morning. The City of Chicago Building Department called around 12:30pm, the temperature levels were not comfortable, but the portable chillers were in route. We (facility) were told to evacuate the residents. At this time one resident (referring to R21) has been sent to the hospital. On 8/31/23 at 10:39am, surveyor inquired about the facility AC. V16 (Maintenance Director) stated two compressors went down (not working) a week prior to 8/23/23. We've (facility) been using 17 temporary portable air conditioning units. V16 affirmed on 8/23/23 around 7:30 am it was beginning to get hot in the facility, and around 9:30 am the temperature became uncomfortable. V16 stated, residents started to complain about the facility temperature around 10:30am. During an emergency weather plan, we (facility) make sure residents are hydrated and cool. We put them in one area that we know is cooler. V16 stated, my (V16) role in the emergency weather plan is to make sure the dining room is cool until everything is fixed. I (V16) put all the fans in the dining area. [note: documenting hourly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 3 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many hazardous temperature was excluded]. V16 stated, the facility had temporary fixes in place, but the main air conditioning unit would not be able to be fixed without new compressors. The city (Building Department, Fire Department, Police) was at the facility (8/23/23) because someone called 311. By the time the portable AC unit got to the facility it was too late, the evacuation had started. V16 said temperatures are not taken daily. When temperatures get above 80 degrees outside, then we (facility) start taking temperatures every two to three hours in random rooms and in all hallways. V16 stated, the air conditioning company came out to check the air conditioning unit, V16 thinks on the 17th, and found the compressors were down. We (facility) called the air conditioning company because we (facility) thought the unit was low on freon because of the way it was blowing the air out. V16 affirmed the air was not as cold as it should have been. On 8/31/23 at 11:02am, surveyor inquired if the facility AC malfunctioned prior to 8/23/23. V17 (Corporate Administrator) replied, I want to believe that they had a problem with the air conditioner prior to that day, which they had temporary measures (portable coolers on all the floors that blow cold air, fans, taking temperature of the building to ascertain if there's any need to evacuate) in place but because of the weather that day (referring to 8/23/23) it made the measure in place not working. Surveyor inquired about staff identification of hazardous temperature in the facility. V17 responded, the maintenance person takes temperature, the policy talks about certain thresholds and when they need to notify the administrator. Surveyor inquired when facility temperatures should be documented V17 responded, daily before the threshold, it should be every hour after that (beyond the threshold). On 8/31/23 at 12:11pm, surveyor inquired about the (8/23/23) facility temperature. V6 (Licensed Practical Nurse) stated it was humid and warm in the morning and got hotter as the day went on. Around 3pm, V2 (Director of Nursing) said to make sure residents are hydrated. Surveyor inquired about the (8/23/23) facility evacuation. V6 responded, around 4pm, V2 announced that there was a heat emergency, and the facility is evacuating [6 hours after hazardous temperature was documented]. V6 stated, the evacuation process was controlled chaos, there were no plans made to evacuate before we (staff) did it. The only orders beforehand where to hydrate the residents. V6 affirmed at 11:20pm, there were nine residents still in the facility. On 9/1/23 at 4:10pm, R86 stated, We (residents) are in another building because they (facility) didn't fix the air conditioner. They (facility) wouldn't get the compressors fixed on the unit. They were acting like nothing happened. I bought me a fan before it got really hot. Even with the fan I was hot. It was sweltering in the building. I was sweating, it was uncomfortable. It was 96F in my room. My AC (air conditioner) was not working in my room. The staff was drenched in sweat. It was hot two days before. On 9/5/23 at 12:34pm, surveyor inquired who reported the (8/23/23) facility safety concerns (re: hazardous temperature). V20 (Chicago Building Department Deputy Commissioner) stated it probably came in with 311 (non-emergency 911 equivalent) which would be called if there's a violation. Surveyor inquired about the (8/23/23) facility temperature. V20 responded V20 did temperatures in all common areas and patient rooms, readings were 85-91F between 12:30pm and 1:30pm. At that point, we (Fire/Building Departments) had made the decision that the building needed to be closed due to patient safety. We waited outside the building until all the residents were gone which was about 1 am (15 hours after hazardous temperature was identified). V20 stated, there was no deferred maintenance being done at this facility, it did not appear to me. Over time you're supposed to reinvest in your facility and make sure that any work that needs to be done gets taken care of. About a month before we shut down this building (facility) we (Buildings Department) received a complaint about their (facility) air (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 4 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0584 Level of Harm - Immediate jeopardy to resident health or safety conditioning not working. We (Buildings Department) sent someone out to take temperatures and they (facility) wouldn't let him in. I (V20) got a call from one of my inspectors that said the contractor did not get a call until that day (8/23/23) to repair the air conditioner. They (staff) tried to say that they had temporary cooling at the facility but basically, they just had fans not air conditioning. There was no air conditioning functioning in this building. This is the type of building that every room needs cooled because of the population. Residents Affected - Many On 9/5/23 via email sent at 1:07pm, V17 (Corporate Administrator) wrote V16 (Maintenance Director) stated V16 did not take the temps during the evacuation due to the emergency. On 9/5/23 at 4:20pm, V2 (Director of Nursing) stated CHUG (Collaborative Healthcare Urgency Group) sent a CTA (Chicago Transit Authority) cooling bus and it was at the facility from approximately 11am until approximately 6pm. V16 (Maintenance Director) took temperatures in the building. The previous days before 8/23/23 it was warm but comfortable because we had the portable units. V16 stated, I was told the compressors went out on the air conditioning unit, but I don't know when. The (8/23/23) census includes 132 residents. The (8/23/23) facility Air Temperature Log affirms the temperature was 86.2F with humidity 76.1F in resident's room, 86.0F with humidity 77.2F in another resident's room and 86.1F with humidity 78.2F at the (2nd floor) Nurse's station documented 10:00am-10:20am. The last temperature documented (8/23/23) was at 10:40am - not hourly as warranted due to temperature above 80F. According to the National Oceanic and Atmospheric Administration, National Weather Service at https://www.weather.gov/wrh/climate?wfo=lot, the maximum temperature was 98F on 8/23/23 in the Chicago area. According to Weather Underground at https://www.wunderground.com/history/daily/us/il/chicago/KMDW/date/2023-8-23, in Chicago on 8/23/23 times and temperatures were as follows: 7:53 AM 80 °F 8:53 AM 84 °F 9:53 AM 88 °F 10:53 AM 91 °F 11:53 AM 94 °F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 5 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0584 12:53 PM Level of Harm - Immediate jeopardy to resident health or safety 95 °F Residents Affected - Many 97 °F 1:53 PM 2:53 PM 97 °F 3:53 PM 97 °F 4:53 PM 97 °F 5:53 PM 96 °F 6:53 PM 86 °F 7:05 PM 92 °F 7:53 PM 89 °F 8:53 PM 90 °F 9:53 PM 89 °F 10:53 PM 89 °F 11:53 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 6 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0584 87 °F Level of Harm - Immediate jeopardy to resident health or safety City of Chicago, Department of Buildings, effective date 8/23/2023, documents in part: Re: Commissioner Closure Order, Community Care Center, located at 4314 S. Wabash Avenue. Emergency Closure Order. Community Care Center, located at 4314 S. Wabash Avenue, Chicago, Illinois is a public nuisance that is dangerous, hazardous and endangers the public health due to the violations as stated in the attached Property Condition Report. It has therefore been determined that the building constitutes an imminent and actual danger to the tenants and occupants, and to the public at large. I hereby order that Community Care Center, located at 4314 S. Wabash Avenue, Chicago, Illinois, be immediately closed, and remain vacant, and that entry be denied except by licensed and bonded contractors engaged to examine, repair, and otherwise correct the aforementioned conditions, or otherwise by authorized City of Chicago personnel until further order. Residents Affected - Many City of Chicago, Department of Buildings, Department of Buildings Property Condition Report, Building Code Violations That Constitute an Actual and Imminent Danger, Inspection Date 8/23/2023, Commissioner Closure: Community Care Center, documents in part: Cooling system at this facility is inoperable, entire premises. Facility policy Hot Weather/Heat Emergencies Policy and Procedures, 11/1/2022, documents in part: Administrator will be aware of the weather forecast of extreme temperatures and comfort levels inside the facility. Maintenance Director will monitor the facility's air conditioning to ensure that all are in good working order. The Maintenance Director will monitor temperatures to ensure that air temperatures in the facility maintain comfortable temperature range of 71-80 degrees Fahrenheit. If temperatures increase, readings will be taken every hour. Maintenance will check all AC units to assure they are operating properly. On 9/5/23 via email sent at 12:54pm, V17 (Corporate Administrator) wrote we (facility) do not have a policy for homelike environment. The surveyor confirmed on 10/02/2023 through interview, record review, that the facility took the following actions to remove the Immediate Jeopardy: The facility implemented all measures on the removal plan. 1) The facility has taken the following action concerning the IJ component: a.) R21 was transferred to the hospital on 8/23/23. Per hospital, R21 has since been discharged on 8/28/23 to (alternate) facility to be closer to family. *On 9/6/2023, surveyor contacted alternate facility and affirmed R21 resides there. b.) All residents in the facility were safely relocated to other facilities in an orderly manner. *Resident evacuation from the facility was completed on 8/24/23 at approximately 1:00am per V20 (Chicago Building Department Deputy Commissioner). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 7 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0584 c.) The facility reached safe and comfortable temperatures in the building on 8/23/23. Level of Harm - Immediate jeopardy to resident health or safety *The (8/30/23) letter provided by contractor states company was engaged to supply necessary equipment to provide temporary air conditioning to the building due to broken compressor to the facility air conditioning equipment. The temporary equipment was brought in and set up by 6:00pm CST on 8/23/23. After the equipment was running for about 30-40 minutes it brought the temperature down considerably. By the time we (contractors) left the site it was already comfortable inside the building. Residents Affected - Many 2) Statement regarding residents that have the potential of being affected. a.) All residents in the facility that have been identified to have potential to be affected were relocated on 8/23/23. *Resident evacuation from the facility was completed on 8/24/23 at approximately 1:00am per V20 (Chicago Building Department Deputy Commissioner). 3) Measures the facility will take or systems to ensure the problems will be corrected and will not recur. a.) The facility contracted a vendor to provide temporary cooling of the entire building. Temporary cooling was installed on 8/23/23. *The (8/23/23) service agreement affirms temporary air conditioning at the facility was provided by (2) 30-ton air conditioners. b.) The facility purchased replacement compressors to be installed in the facility. The compressors were delivered on 8/30/23. The installation is in process. *The (8/23/23) service agreement includes scope of work: non-functioning AC. Approximate start date 8/24/23. *The (8/29/23) consignee delivery receipt includes three (3) compressors sent to facility address. *On 9/25/23 at 2:25pm, V17 (Corporate Administrator) stated the AC is completely fixed. c.) The facility initiated in-servicing for all staff on the facility policy provision and maintenance of comfortable temperature in the facility. Staff in-servicing was completed on 9/1/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 8 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0584 *On 9/25/23 at 2:25pm V17 stated we completed the in-services by 9/1/23 except for the staff that were on vacation and affirmed the facility remains vacant. Level of Harm - Immediate jeopardy to resident health or safety *The (Undated) facility staff roster (including phone numbers) affirms there are 150 employees. Residents Affected - Many * The facility provided PowerPoints titled Maintaining Facility Temperatures which excludes a date and/or topic discussed. * On 10/3/2023, the facility provided the attachment to the staff/roster signature page including in-service date and topic of discussion. d.) All employees on vacation and any contract staff will be in-serviced before their first day of work. *In-service titled Maintaining Facility Temperatures was documented on 10/02/2023 and includes 16 staff * A list of staff no longer working at the facility and/or unable to be reached via telephone for the in-service was also provided by the facility on 10/03/2023 4) The Director of Nursing will monitor continued compliance via the following Quality Improvement Programs once re-entry to the building is permitted by the City of Chicago. a.) A QA tool will be developed to monitor ensure safe and comfortable temperatures are maintained throughout the building by auditing the temperature logs in the building. daily. The monitoring will continue for 4 weeks and twice weekly for 8 weeks. *The F584 QA tool states the maintenance director/designee will check daily temperature on all floors and audit the temperature log to determine if the temperature is at a comfortable level however actual temperature is excluded. *On 9/27/23 at 10:52am, surveyor requested F584 QA tools for the abatement plan V17 affirmed they were not implemented. *On 9/27/23 at 3:39pm, V17 provided F584 QA tool (dated 9/27/23) which excludes temperatures. The (9/27/23) F584 QA tool was subsequently updated (as requested) to include temperatures. * On 10/03/2023 at 1:38 PM, V17 provided QA Tools with daily temperature starting logs in the building affirming that facility temperatures are taken daily starting 9/27/2023 and did not go beyond 76.3 F. b.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 9 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0584 The results of the monitoring will be submitted to the QA/QI Committee quarterly for review and follow-up. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 10 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0624 Prepare residents for a safe transfer or discharge from the nursing home. 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 a safe and orderly transfer for all 132 residents residing in the facility who were subjected to hazardous temperatures above 80F (Fahrenheit) on 8/23/23 requiring evacuation and transfer to different facilities. This failure affected all 132 residents residing in the facility. This failure also resulted in an unnecessary hospital transfer for R50 due to the receiving facility not being able to accommodate R50's physical needs. Residents Affected - Many Findings include: R50 is [AGE] years old with diagnoses that include but are not limited to type 2 diabetes mellitus, schizoaffective disorder, heart failure, morbid obesity, myasthenia gravis, chronic kidney disease, chronic obstructive pulmonary disease, hypotension, schizophrenia, non-pressure chronic ulcer of buttock. R50 was observed being prepared for transport to the hospital by EMS (Emergency Medical Services) after returning from the receiving facility. R50 is listed on the list of Vulnerable Residents provided by the facility. Review of R50 MDS, 8/10/23, indicates R50 requires one to two persons physical assist for total dependence with bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, bathing and R50 has impairment on both sides of lower extremities. On 8/23/23 at 8:25pm, V2 (Director of Nursing) stated staff verbally told residents they were leaving for a couple of days and where they were going. V2 stated, I got orders to transfer everyone out/emergency evacuate from the doctor. Social Service called everybody's family. We are sending staff to sister facilities. Medications, face sheets, transfer forms are going with them. We encouraged residents to take two to three days of belongings. Nurses and CNAs (Certified Nursing Assistants) are with vulnerable residents and assessing them. They are taking vitals, checking for dehydration, signs, and symptoms of distress. I told the morning shift to document. Everyone will document eventually. Staff drove the van to sister facilities. CTA (Chicago Transit Authority) came with a cooling station from approximately 11am - 6pm. On 8/23/23 at 8:30pm, V8 (Social Service Director) stated V8 sent an automated/Robo message to POAs (Power of Attorneys), State Guardians, emergency contacts, friends, and family that the air conditioner is down. V8 stated, I explained we are taking care of the residents, checking hydration, they are in cool areas. I started around 12pm. I talked to the majority of calls. On 8/23/23 at 8:45pm, V2 (Director of Nursing) stated R50 was sent to a receiving facility. The receiving facility did not have a mechanical lift that R50 requires so R50 was sent back here (facility). The city inspector said R50 could not come back into the building. R50 is going to the hospital. On 8/31/23 at 12:11pm, V6 (Licensed Practical Nurse) stated on 8/23/23, V6 was in the facility from 7:15am until 11pm. V6 said it was humid and warm in the building in the morning and it got hotter as the day went on. V6 said it was uncomfortable but tolerable and the residents were uncomfortable but not really complaining that much. V6 said staff tried to hydrate the residents as much as they could by handing out water and there was lemon water kept at the nursing station. Residents could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 11 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many access it themselves. V6 said residents were served breakfast and lunch and had sandwiches for dinner. V6 said the facility had big fans that had to have water in the bottom of them and they blew out cool air. V6 said V6 worked the 1st floor and had residents in wheelchairs but no dependent residents and none confined to bed. V6 said there was one CNA (Certified Nursing Assistant) on the 1st floor for the morning shift that helped with showers and meals, but residents were able to go to the bathroom on their own. V6 said, about 3pm the Director of Nursing said to make sure residents are hydrated and about 4pm, before dinner, the Director of Nursing announced to staff that there was a heat emergency, and the facility is evacuating. V6 said V6's role during the evacuation was to pack residents' medications in individual bags with the face sheets. Someone else printed the face sheets. V6 told residents that they have to leave now but they will be coming back soon. V6 said some residents were reluctant to pack up their stuff and leave. V6 said three to four residents on V6's floor said, I'm not going, I want to stay here. V6 said CNA's helped residents pack clothes. V6 said V6 did not tell residents where they were going or how long they would be there because V6 did not know where they were going or how long they would be there. V6 said Social Service contacted POA's (Power of Attorneys), and family. V6 said the facility evacuated the 2nd and 3rd floors to the 1st floor because it was cooler on the 1st floor. V6 said when V6 left the building at 11:20pm there were nine residents left in the building. V6 said V6 made sure their medications were ready and available. V6 said staff had a list of the residents getting on a certain bus. Staff would come and ask for those residents. V6 said the evacuation process was controlled chaos. V6 said there were no plans made to evacuate before we (facility) did it. The only orders beforehand where to hydrate the residents. V6 said the normal procedure for a transfer is to get orders from the doctor, give report to the receiving hospital, call the ambulance, and call the family. The nurse sends the face sheet and medication sheet with the resident when they go out. If a petition is needed, Social Service does the petition, and the nurse sends it with the face sheet and medication sheet with the resident. On 9/1/23 at 4:10pm, R86 stated we (residents) are in another building because they (facility) didn't fix the air conditioner. They wouldn't get the compressors fixed on the unit. They were acting like nothing happened. I bought me a fan before it got really hot. Even with the fan I was hot. It was sweltering in the building. I was sweating, it was uncomfortable. It was 96 degrees in my room. My AC (air conditioner) was not working in my room. The staff was drenched in sweat. It was hot two days before. They told us why we were being moved. I didn't get here (receiving facility) until 2am (8/24/23). Everything was so disorganized. I think they had to find a van that my electric chair could get in. Nobody was saying nothing/what was wrong. They finally told me where I was going around 1 am. They told us to pack clothes for three days. I been here near two weeks. They sent my medicine. I don't know when I'll be going back. Review of R86's medical records did not document if any nursing report was provided to the receiving facility. On 9/5/23 at 4:20pm, V2 (Director of Nursing) stated around 11am on 8/23/2023 they said the building inspector was in the building to check the air conditioner and room temperatures. The building inspector said we had to evacuate due to high temperatures. The building inspector, fire dept, police, ombudsman, and IDPH (Illinois Department of Public Health) were at the facility. It was chaos trying to take direction from all the different entities. I told staff to take vitals, hydrate the residents and to document. CHUG (Collaborative Healthcare Urgency Group) sent a cooling bus that was at the facility until approximately 6 PM. V16 (Maintenance Director) took temperatures in the building. The previous days before 8/23/23 it was warm but comfortable because we had the portable units. I was told the compressors went out on the air conditioning unit, but I don't know when. Staff was logging where the residents were going. I can't quote the evacuation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 12 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many policy. This was my first evacuation. At the point of evacuation, the temperatures were not safe for the residents. Nobody told me any residents were complaining of being too hot. For a typical transfer, we get doctors order, notify family, notify resident why they're being transferred, when they will be transferred, where they are going, how they are getting there, by ambulance, etc. and call and give report to the receiving facility. We may not have been able to call to notify everyone. There was no way that could have been done in an emergent situation. Corporate was working behind the scenes because there was no way we could keep up. They were assisting with getting doctors' orders, they gave access to the records to receiving facilities. R50 went to one of the facilities (V2 did not remember which one) and they didn't have a mechanical lift and R50 was brought back to the facility. The building inspector said R50 couldn't come back in the building, so we (facility) called 911 for R50 to go to the hospital to get R50 out of the heat. I don't know if the receiving facility got verbal report but corporate gave receiving facilities access to records. Direction came from corporate on where to send residents. Corporate was in the building giving assignments to staff and I was giving assignments to staff. Information to give for report includes cognition level, diet, vital signs, weight, etc. On 9/8/23 at 2:55pm, V24 (Administrator at receiving facility) stated R50 needed skilled nursing. We are an ICF (Intermediate Care Facility). We don't have a mechanical lift. The facility sent a van with approximately five residents, including (R50), in it and at least two staff. (R50) was sitting on a mechanical lift sling so I asked the staff if (R50) required skilled services. They said yes so, we (receiving facility) could not take (R50). I don't know if report was given to us. On 9/8/23 at 3:26pm, V25 (Director of Nursing at receiving facility) stated we (receiving facility) were unable to take R50 because R50 was a two person assist and required a mechanical lift. We don't take residents that require a mechanical lift in an ICF (Intermediate Care Facility) setting. We (V24 and V25) recognized R50 needed a mechanical lift, R50 was sitting on the sling, and R50 was sent back to the facility. It was approximately five residents on the van. We were able to keep the other residents. The facility telephoned and gave us (V24 and V25) a list of names of the residents they would be sending, and they gave us access to view records in the electronic record. We didn't have much time to look at all the records before the residents arrived at our facility. There was no verbal report given to any staff here (receiving facility), just a list of names and access to the electronic record. On 9/12/23 at 5:44pm, V91 (Primary Physician) stated there should be a hand off even between shifts, especially between facilities. The new/receiving nurse does not know the patient they are receiving. When transferring a resident, it is best standard of care to report to the receiving nurse/facility. If reporting is not done there may be gaps in care. Reporting is done to provide the best quality of care to the residents. Review of R50 physician order summary reveals an order May transfer out to receiving facility, ordered 8/23/2023, ordered by physician, created by V2 (DON) Review of R50 progress notes reveals no documentation for R50's transfer to another facility, including no documentation that report was given to another facility and no documentation of R50's transfer to a hospital. R50's hospital record reads registration date 8/23/2023; documents in part: is brought to the ED (Emergency Department) by EMS (Emergency Medical Services) from SNF (Skilled Nursing Facility) c/o buttock pain. EMS states the patient was initially being transferred today to another SNF as his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 13 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many original SNF lost air conditioning. The new, temporary SNF also lost air conditioning and the original SNF declined to bring the patient back as they still did not have air conditioning. The patient was then transferred to the ED for evaluation of buttock pain that began while waiting. The onset was today. The course/duration of symptoms is constant. Location: buttock. The character of symptoms is pain. The degree at onset was minimal. The degree at present is minimal. (Per EHR practitioner note). admit date [DATE] 21:19 CDT, discharge date [DATE]. Review of random residents' charts affirm that there was no documentation regarding any nursing report provided to the receiving facility. Facility Resident Rights policy, 4/2020, documents in part: The residents will be assured of the following rights: safe and good care. Facility Emergency Transfer/Discharge policy, 4/2020, documents in part: Emergency transfers should include the following: A. Obtain an order for emergency transfer or discharge. B. Contact an ambulance service and provide brief synopsis of emergency situation, a) a staff member should remain with the resident until the emergency transport team arrives, b) contact receiving emergency department and give verbal report. C. Complete and send with the resident the transfer form. D. Copies of the face sheet, physician orders, bed hold policy and advance directives should be sent with the transfer form. E. A copy of the bed hold policy should be given to the resident. F. Document information regarding the transfer and related assessments in the medical records. Facility Resident Rights policy, 4/2020, documents in part: The residents will be assured of the following rights: safe and good care. Facility Emergency Transfer/Discharge policy, 4/2020, documents in part: Emergency transfers should include the following: A. Obtain an order for emergency transfer or discharge. B. Contact an ambulance service and provide brief synopsis of emergency situation, a) a staff member should remain with the resident until the emergency transport team arrives, b) contact receiving emergency department and give verbal report. C. Complete and send with the resident the transfer form. D. Copies of the face sheet, physician orders, bed hold policy and advance directives should be sent with the transfer form. E. A copy of the bed hold policy should be given to the resident. F. Document information regarding the transfer and related assessments in the medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 14 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain safe and comfortable temperatures in the facility, failed to monitor residents for heat exhaustion, failed to provide adequate hydration during hazardous temperature, and failed to assess and supervise one resident (R21) with a change in condition related to heat exhaustion. These failures affected R21 who was sent to the hospital exhibiting heat related signs and symptoms and has the potential to affect all 132 residents. Residents Affected - Few This was identified as an Immediate Jeopardy which began on 8/23/23 at 9:35 am per (8/23/23) facility temperature log which documents a temperature of 81.2F (Fahrenheit) in resident room. On 8/30/23 at 2:22 pm, V9 (RDO/Regional Director of Operations), V17 (Corporate Administrator), V18 (Chief Financial Officer) and V19 (Attorney) were notified of the immediate jeopardy. The facility presented a final removal plan on 8/30/23 at 6:39 pm which was not approved. The facility presented a revised final removal plan on 9/1/23 at 12:46 pm which was not approved. The facility presented another revised final removal plan on 9/1/23 at 4:36 pm which was accepted/approved on 9/6/23 at 8:45 am. The surveyor conducted additional interviews and record reviews on 9/25/23 to 9/27/23 verify the plan was implemented. The immediate jeopardy was removed on (10/2/23) based on actions from the removal plan. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: The 8/23/23 census includes 132 residents. The (August 2023) Daily Air Temperature Logs affirm temperatures were documented 8/4, 8/7, 8/8 and 8/23 - not Daily as directed. On 8/23/23, the Chicago temperature was 98F (Fahrenheit) with heat index 116F per National Weather Service. On 8/23/23 at 6:24 pm, observed residents sitting outside of the facility in wheelchairs on the sidewalk with staff. No observation of water being offer or given to the residents outside. R21's admission Record documents, in part, that R21's diagnoses include Diabetes, depression, neuropathy, dementia, Alzheimer's, glaucoma, and hypertensive heart disease. R21's admission date to the facility is documented as 3/26/23. R21's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 10 which indicates that R21 is moderately impaired. R21's (6/30/23) functional assessment affirms (1 person) physical assist is required for bed mobility, transfers, locomotion, personal hygiene, and toilet use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 15 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 8/23/23 at 7:30 pm, surveyor observed R21 sitting in a wheelchair leaning over throwing up (3 times) in the (1st floor) dining room. R21 stated I need to lay down. V11 (LPN/Licensed Practical Nurse) pushed R21 via wheelchair into V2's (Director of Nursing) office where there was a window unit air conditioner. R21 stated, I'm not feeling well, it's too hot. I need to lie down, I feel weak. V11 took R21's blood pressure which read 100/62. V11 attempted to obtain R21's pulse oximeter reading a total of three times, however, was unsuccessful. No other vital signs were taken for R21 before leaving the building with the CFD (Chicago Fire Department). On 8/23/23 at 7:40 pm, R21 was transferred from the wheelchair to bed. V12 (CNA/Certified Nursing Assistant) attempted to obtain R21's pulse oximetry and was unsuccessful. On 8/23/23 at 7:43 pm, V11 (LPN) affirmed the physician was contacted and orders were received to send R21 to the hospital. V11 instructed V13 (CNA) to stay in the room with R21. On 8/23/23 at 7:50 pm, R21 stated, I felt like I was going to pass out, I've been hot all day. V10 (LPN) obtained R21's temperature which was 96.2 (axillary) at this time then left the room. V13 (CNA) also left the room leaving R21 unattended. Surveyor observed R21 from 7:50 pm to 8:31 pm (41 minutes) however, staff did not reassess and/or check on the resident. R21 was left in room unattended to. On 8/23/23 from 7:30 to 8:31 surveyor observed R21 not offered or given any kind of hydration from staff. On 8/23/23 at 8:31 pm, the Fire Department arrived to transport R21 to the hospital who was appearing weak and slow to respond to questions. The (8/23/23) facility Air Temperature Log affirms the temperature was 86.2F with humidity 76.1F in resident's room, 86.0F with humidity 77.2F in another resident's room and 86.1F with humidity 78.2F at the (2nd floor) Nurse's station documented 10:00am-10:20am. The last temperature documented (8/23/23) was at 10:40am - not hourly as warranted due to temperature above 80F. On 8/23/23 at 7:07 pm, R79 stated it has been hot for about a month now, they (staff) provided fans. R79's (6/6/23) BIMS determined a score of 12 (moderate impairment). On 8/23/23 at 7:15 pm, staff on the first floor were noted to be sweating and their clothes visibly wet. On 8/23/23 at 7:22 pm, R92 reported feeling hot. R92 affirmed she was in her room and (approximately 1 hour ago) staff brought her to the 1st floor dining room. R92's (7/25/23) BIMS determined a score of 15 (cognitively intact). On 8/23/23 at 7:27pm, R75 stated, I feel terrible, I feel hot, I have not had anything to drink. Staff offered me something to drink but I refused to keep from having to use the bathroom. R75's (8/17/23) BIMS determined a score of 10 (moderate impairment). On 8/23/23 at 7:30 pm, R45 stated yesterday and today it got really hot. The AC in my room didn't work this morning, staff tried to turn it on, but it didn't work. R45's (7/21/23) BIMS determined a score of 12. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 16 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 8/23/23 at 7:45 pm surveyor observed R12 sitting in the hallway not given any food or water. V10 (LPN) stated R12 has a g-tube and receives bolus feedings. R12's lips were dry and cracked. R12's MAR (Medication Administration Record) reviewed excluding R12's 5:00 pm feedings signed out on 8/23/23. No observation of incontinence care given to R12. On 8/30/23 at 11:00 am V2 DON (Director of Nursing) stated that the building was warm, and I instructed my staff to keep checking on the residents and hydrating them. We (facility) did have a cooling bus for the residents till around 6:00 pm. The building inspector said the facility had to evacuate due to high temperatures in the building. The facility started to evacuate the building around 12:00 pm. V2 DON stated that a resident with change in condition should have vital signs taken every 15 to 30 minutes until they get out of the building. V2 stated a resident with a blood pressure of 100/62 should have their vital signs taken every 15-30 minutes. Surveyor inquired about the frequency of R21's vital signs and V2 stated the nurse should have taken more vital signs. V2 stated that every nurse and CNA in the building is equipped to take vital signs. V2 stated that staff should not leave a resident unattended if the resident is unstable. Surveyorasked the DON, if a resident says they're hot, feeling weak and feel like they're going to pass out are they considered unstable? V2 stated yes, they are unstable and should have staff at bedside. On 8/31/23 at 11:43 am V11 LPN (License Practical Nurse) stated on 8/23/23 V11's shift started at 7:00 am and that morning the temperature in the building was warm and became warmer throughout the day. V11 stated after lunch at approximately 11:30 am-12:00 pm, staff was told that the building was being evacuated and all residents need to be transferred to another facility. The first thing we (Staff) did was put residents on a CTA cooling bus. V11 stated, I don't know if all the residents got on the bus. I saw two cooling buses. The buses stayed from 2:00 pm-5:00 pm. Surveyor asked V11 about R21's change in condition and V11 stated one of the staff members yelled that R21 was throwing up. V11 stated, I (V11) went into the dining room where R21 was and asked the staff to get some ice to help cool R21 down because of the hot temperature in the building. V11 stated R21 said, I (R21) do not feel good and feel weak. V11 stated R21 had been sitting up for a while and it was hot in the facility. The only cool place on the 1st floor was the Director of Nursing's (DON's) office. I took R21 to the DON's office where I took his VS (Vital Sign). Surveyor asked V11 what vital signs were obtained at that time? V11 stated, I took the blood pressure, pulse oximetry, pulse, respirations, and Accucheck. I didn't document the vitals because I did not have access to a computer. I did call the doctor because the blood pressure was low. The blood pressure was 100 over something. Surveyor asked V11 what the other VS were. V11 stated I don't remember. Surveyor asked V11 if the pulse oximetry was working and V11 stated, Oh, I forgot that the pulse oximetry was not working so I did not get the pulse oximetry or a pulse. I think the respirations were 22. V11 stated, R21 said again that he (R21) did not feel well, felt weak and wanted to lie down. I asked staff to assist me to move R21 to a room where R21 could lie down. Surveyor asked V11 if another set of VS was taken and V11 stated V11 did not take another set of VS. V11 stated, with it being very hot in the facility and R21 vomiting, V11 wanted to call the Doctor. V11 stated there was a male CNA (V12) and a female CNA (V13) in the room, and I told the female CNA (V13) to watch and monitor R21 while I went to call the doctor. V11 stated the doctor said to send R21 to the nearest ER (Emergency Room). V11 stated, I did not return back to R21's room until the ambulance came to pick up R21 at 8:31 pm. V11 stated a complete set of Vital Signs were not taken on R21 due to not having the assessable tools to assess the resident correctly. V11 stated that a complete set of vital signs is the temperature, blood pressure, respirations, pulse oximetry and if a diabetic we take an Accucheck as well. V11 stated if a resident has a change in condition, then VS should be taken every 30 minutes to an hour and the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 17 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few should be reassessed. Surveyor asked V11 if R21 should have had repeated VS and V11 stated, Yes, R21 should have had VS repeated. V11 stated, I'm upset because the residents had to leave their homes and the facility could have done better with the air conditioner situation. V11 stated V11 has not had any training on the heat exhaustion or the emergency evacuation plan. R21's (8/23/23) hospital records documents in part, history & physical states - presents with general malaise. The Nursing Home lost the air conditioning tonight and in the process of moving the patient to another facility, the patient vomited few episodes. Differential Diagnosis: dehydration, electrolyte imbalance, weakness, influenza, urosepsis, viral syndrome, dizziness. R21's (8/24/23) Critical care notes, documents in part, critical interventions of IV Fluids. R21's (8/27/23) progress note states nursing home patient presented to the emergency room complaining of nausea and weakness due to no air conditioning during the heat wave. Nausea and vomiting/weakness secondary to heat exhaustion. On 8/31/23 at 12:28 pm, V13 CNA (Certified Nursing Assistant) stated the scheduler called V13 into work. V13 stated, I (V13) got to work around 5:30/6:00 pm on 8/23/23. I was instructed to take the residents out to smoke to keep them calm. I came into the room with R21 to check on R21and to put some ice on R21's head because the facility was hot. Surveyor asked V13 if V13 was instructed to stay with R21 when V11 (LPN) left out of the room and V13 stated she do not remember V11 telling her to stay with R21. V13 stated I went back into the room with R21 to check on him. V13 stated if a resident has a change in condition, then someone is supposed to stay with them. V13 stated that a resident who has a change in condition VS should be taken every 15-30 minutes. V13 stated, I did not get any report to say what I should be doing with R21. I went into R21's room on my own because I heard R21 was throwing up. It was hot in the building. I felt like I was going to pass out because of the temperature in the building, I just kept drinking water because of the heat. V13 stated I have never had any training on emergency evacuation or training on identifying heat exhaustion. On 8/31/23 at 12:45 pm, V12 (CNA) stated that he (V12) works 11pm-7am. I (V12) came in early to help put residents into the van to transfer out with the evacuation and when the residents wanted to smoke, we (staff) would take them out and try to make them (residents) comfortable. V12 stated that day it was extremely hot. V12 stated he saw they needed helped getting R21 in bed, so I went into the room to help. I tried to get a pulse oximetry on R21, but it was not working. The nurse did not tell me to stay with R21. There was another (CNA)V13 in the room when I (V12) left out of the room. V12 stated vital signs should be taken every hour with a change in condition resident. V12 stated that the last resident left the building around 1:00 am on 8/24/23. V12 stated V12 left the facility at 1:30 am after the last resident left. V12 stated, I have never had any training in emergency evacuation at the facility. On 8/31/23 at 2:00 pm V6 (LPN) stated I (V6) was working alone that day on the 1st floor. There were 33 residents on the first floor. V6 stated I work 7 am-3 pm and on 8/23/23 was asked to work a double. V6 stated that when I knew the facility had to evacuate the second shift had already come in, and the second shift starts at 3:00 pm. V6 stated it was warm in the building because it was warm outside. V6 stated on the second and third floor it was warmer, so the staff started bringing the residents from the second and third floor to the first floor around 4:00 pm, and that is when the evacuation began. The cooling buses came after lunch and the residents ate lunch around 11:30 am. I remember serving lunch and the buses came after that time. The surveyor inquired if V6 remembered R21. V6 stated R21 started vomiting in the dining room, R21 was leaning over, and I sat his (R21) head up then R21 started vomiting again. V11 (LPN) came to assist with R21. I went to get the blood pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 18 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few machine then R21 vomited a third time, so V11 pushed him (R21) in the DON's office where it was cool. V6 stated that she thinks R21 went to the hospital, but not sure. I do not remember V6 stated, V11 telling me to keep an eye on R21, as far as I know she was watching R21. R21 was moved from the DON's office into a room to lie down. I don't even know what room he went into. I was busy packing medications. I do not recall V11 telling me (V6) to watch R21. The Surveyor inquired about a change in condition, how often should vital sign and reassessment be done and what does a complete set of vital signs consist of? V6 stated, A change in condition the vital signs should be done every 2 hours. If a resident say that they feel weak, hot, and feel like they're going to pass out then you take vital signs every 1 hour. If a resident is going to the hospital check vital sign every 30 minutes to an hour. If a pulse oximetry device is not working, then you must find a pulse oximetry that works or put the resident on oxygen. V6 stated a complete set of vital signs consist of blood pressure, pulse, respirations, temperature, pulse ox, and Accucheck if a diabetic. V6 stated, the air conditioner in the building has been broken all year. Once it started to get warm that's when they (facility) started to get chillers to help cool the building down. The chillers came into the facility in July. V6 stated that she has not had been educated or in-serviced on extreme weather hot/cold or the emergency evacuation plan. On 8/31/23 at 3:30 pm V21(Primary doctor) stated he (V21) is very familiar with R21. V21 stated the nurse (V11) called and said that R21 was vomiting. V21 stated, I (V21) thought R21 could be septic because he has a wound, so I told the nurse to send R21 to the hospital. V21 stated the nurse (V11) did not tell him that the building was without AC (Air Conditioner). I was not aware of the extreme temperature in the building, that day (8/23/23) was very hot outside, so I can imagine how hot it was inside of the building where the residents were. V21 stated, If I had known the building did not have AC, I would have given an order to call 911 asap (as soon as possible) because in hazardous temperatures the residents can die. Some years ago, in Chicago there was an extreme heat advisory and there were 300 people who died in the city of Chicago because of extreme heat. I pronounced 20 of them, so I do not take lightly extreme heat situations. If I knew there was no AC, I would have told V11 to get him out of there now. Surveyor inquired if the signs and symptom R21 was exhibiting could have been due to the extreme temperature in the building. V21 stated, I could say yes, his condition was due to the extreme heat that could cause heat exhaustion. The signs that could have been related to the extreme heat is hypotension, mental status change then death. The facility cannot have an AC not working in a heat advisory situation. Residents who have comorbidities and even staff who is working there with normal conditions are at risk with extreme heat advisories. R21's condition was due to the physical environment that caused him to be like he was with the weakness and vomiting. I did not have the information about the AC. If I had that information, I would have given an order to call 911 and get him (R21) out of there (facility). This situation with R21 was preventable. I feel bad for the residents. This is the facility's responsibility to make sure the residents are taken care of 100%. The residents should have been kept safe and this was not a safe environment for the residents. On 9/6/23 at 12:10 pm V10 (LPN) stated that he came into work at 7:00 am on 8/23/23 and around 11:00 am the city came into the building because it was warm in the building. V10 stated, around 1:00 pm staff started moving mobile residents to the first floor. The non-mobile residents when down to the first floor after the mobile residents. Surveyor inquired about R21 and V10 stated the staff said R21 was sick so that's why I (V10) went into the room. I took a blood pressure and a temperature; I did not document my vital signs. I did give the vital signs to V6 (LPN). A resident with a change in condition VS should be taken every 15 minutes. I left out of the room and did not go back into the room where R21 was. A resident with a change in condition should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 19 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0684 not be left alone. 911 should have been called for R21. I've been hot since April. Level of Harm - Immediate jeopardy to resident health or safety R21's progress notes reviewed for 8/23/23, excludes documentation regarding the change in condition and transfer to hospital on 8/23/23. Residents Affected - Few R21's vital signs reviewed for 8/23/23, excludes documentation for blood pressure, temperature, pulse, and pulse oximetry regarding the change in condition. R21's name was on the list of vulnerable residents in the facility. Facility document titled List of Vulnerable Residents included R3, R12, and R13 on the list. Records reviewed for R3, R12 and R13 excluded documentation for vital signs on 8/23/23. Surveyor observations from 9:00 pm-10:00 pm residents in the first-floor dining room and by 1st floor nursing station. Eleven residents in the dining room and eight residents in the hallway by the nurse's station waiting to be transferred. Residents were frustrated and tired of waiting to be transferred. One resident stated, I'm sleepy and tired, I go to bed at 8:00 o'clock, why am I still waiting? No staff responded to resident. No observations of vital signs, fluids being offer to the residents or incontinent care to the residents who were still waiting to be transferred out. Facility Policy dated 4/2020 and titled Change in Condition, documents, in part, Guideline: To keep the physician or extender, who is in charge of medical care, responsible party, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. Standard: A need to alter treatment. Facility Policy dated (11/1/22) titled Hot Weather/Heat Emergencies, documents, in part, the Administrator will be aware of the weather forecast of extreme temperatures and comfort levels inside the facility. The Maintenance Director will monitor the facility's air conditioning to ensure that all are in good working order. The maintenance director will monitor temperatures to ensure that air temperatures in the facility maintain comfortable temperature range of 71-80 degrees F. If temperatures increase, readings will be taken every hour. Emergency Operations Plan: Remove residents from areas that are exposed to direct sunlight. Recommending residents to stay indoors during extreme heat conditions. Report any changes in the resident's condition. Be sure to have an up-to- date and accurate list of all residents who are high risk to be adversely affected by extreme temperatures. Facility job description undated and titled Registered Nurse, documents, in part, General Job Description: The primary purpose of the job is to provide licensed nursing care to residents on assigned unit in accordance with current federal, state, and local standards, guidelines and regulations. Duties and Responsibilities: Monitor the care delegated to the Certified Nursing Assistant. Document resident status, clinical care, and interactions in the medical record. Provide updates regarding resident's status to the health care providers. Facility job description undated and titled Licensed Practical Nurse, documents, in part, General Job Description: The primary purpose of the job is to provide licensed nursing care to residents on assigned unit in accordance with current federal, state, and local standards, guidelines and regulations. Duties and Responsibilities: Monitor the care delegated to the Certified Nursing Assistant. Document resident status, clinical care, and interactions in the medical record. Provide updates regarding resident's status to the health care providers. Facility job description undated and titled Certified Nursing Assistant/Guest Experience (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 20 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Coordinator, documents, in part, General Job Description: The purpose of the job is to provide ADL (Activity of Daily Living), Restorative and other care to residents of the facility within the scope of practice .Duties and Responsibilities: Report all changes in the resident's condition to the nurse as soon as practical. Report all accidents and incidents you observe on the shift that they occur. Perform Vital Signs, weights and other task as assigned. The surveyor confirmed on 10/2/23 through interview, record review, that the facility took the following actions to remove the Immediate Jeopardy: The facility implemented all measures on the removal plan. 1) The facility has taken the following action concerning the IJ component: a.) R21 was transferred to the hospital on 8/23/23. Per hospital, R21 has since been discharged on 8/28/23 to (alternate) facility to be closer to family. *On 9/6/2023, surveyor contacted alternate facility and affirmed R21 resides there. b.) All residents in the facility were safely relocated to other facilities in an orderly manner. *Resident evacuation from the facility was completed on 8/24/23 at approximately 1:00am per V20 (Chicago Building Department Deputy Commissioner). c.) The facility reached safe and comfortable temperatures in the building on 8/23/23. *The (8/30/23) letter provided by contractor states company was engaged to supply necessary equipment to provide temporary air conditioning to the building due to broken compressor to the facility air conditioning equipment. The temporary equipment was brought in and set up by 6:00pm CST on 8/23/23. After the equipment was running for about 30-40 minutes it brought the temperature down considerably. By the time we (contractors) left the site it was already comfortable inside the building. 2) Statement regarding residents that have the potential of being affected. a.) All residents in the facility that have been identified to have potential to be affected were relocated on 8/23/23. *Resident evacuation from the facility was completed on 8/24/23 at approximately 1:00am per V20 (Chicago Building Department Deputy Commissioner). 3) Measures the facility will take or systems to ensure the problems will be corrected and will not recur. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 21 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0684 a.) Level of Harm - Immediate jeopardy to resident health or safety The facility contracted a vendor to provide temporary cooling of the entire building. Temporary cooling was installed on 8/23/23. Residents Affected - Few *The (8/23/23) service agreement affirms temporary air conditioning at the facility was provided by (2) 30-ton air conditioners. b.) The facility purchased replacement compressors to be installed in the facility. The compressors were delivered on 8/30/23. The installation is in process. *The (8/23/23) service agreement includes scope of work: non-functioning AC. Approximate start date 8/24/23. *The (8/29/23) consignee delivery receipt includes three (3) compressors sent to facility address. *On 9/25/23 at 2:25pm, V17 (Corporate Administrator) stated the AC is completely fixed. c.) The facility initiated in-servicing for all staff on the facility policy provision and maintenance of comfortable temperature in the facility. Staff in-servicing was completed on 9/1/23. *On 9/25/23 at 2:25pm V17 stated we completed the in-services by 9/1/23 except for the staff that were on vacation and affirmed the facility remains vacant. *The (Undated) facility staff roster (including phone numbers) affirms there are 150 employees. * The facility provided PowerPoints titled Maintaining Facility Temperatures which excludes a date and/or topic discussed. * On 10/3/2023, the facility provided the attachment to the staff/roster signature page including in-service date and topic of discussion. d)The facility will initiate in servicing for all staff. On the facility policy for monitoring and supervision of residents during inclement weather condition. In-services was initiated on 8/31/23 and completed by 9/1/23. The facility nurses were in-service on identification of residents showing signs and symptoms of heat exhaustion and providing hydration during hazardous temperatures. The (undated) facility staff roster (including phone numbers) affirms there are 150 employees. The facility provided Power Points entitled Maintaining Facility Temperatures & Evacuation Plan: What is my role and staff roster (endorsed by 91 staff) which excludes a date, citation number and /or topic of discussion. On 10/2/23 facility provided more in-services for facility nurses. Topic: Facility Policy on Change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 22 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0684 Level of Harm - Immediate jeopardy to resident health or safety in Condition. Nursing signatures noted on in-service sheet were 5RN (Register Nurses) and 17 LPN (License Practical Nurses). e) All employees on vacation and any contract staff will be in serviced before their first day of work. New signatures received on 10/2/23 after the initial signature page. Residents Affected - Few f) Post education will include the facility staff will demonstrating their knowledge of the facility policy related to identifying signs and symptoms of heat exhaustion. On 9/26/23 Staff interviewed about the in-services received and could not recall the content of the in-services. 4)The Director of Nursing will monitor continued compliance via the following Quality Improvement Programs once re-entry to the building is permitted by the City of Chicago: a) A QA tool will be developed to ensure safe and comfortable temperatures are maintained throughout the building by auditing the temperature logs in the building daily. The monitoring will continue for 4 weeks and twice weekly for 8 weeks. On 9/27/23 at 10:52 am, V17 affirmed the F684 QA tool was not implemented yet due to building closure ongoing. The temperature QA tool content includes Direction: The maintenance director/designee will daily check temperature on all floors and audit the temperature log to determine if the temperature is at a comfortable level. Date, Floor, was temp log audited? If yes, is temp at comfortable level? If no, what corrective action taken? Comment. b) A QA tool will be developed and completed daily to monitor residents showing a change of condition and determine the cause. On 9/27/23 at 10:52 am, V17 affirmed the F684 QA tool was not implemented yet due to building closure ongoing.

F684 QA tool content includes Direction: Daily, The DON/Designee will conduct rounds on the floor to monitor if there is any resident showing signs and symptoms of change in condition (heat Exhaustion) and determine root cause. Date, Floor, was all residents monitored? If yes is there any resident showing signs of change in condition? If yes, was action taken including finding root cause? c)The results of the monitoring will be submitted to the QA/QI Committee Quarterly for review and follow-up. On 9/27/23 at 10:52 am, V17 affirmed the F684 QA tool was not implemented yet due to building closure ongoing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 23 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 - Actual harm Based upon observation, interview, and record review the facility failed to administer medications as ordered and failed to ensure that three of three residents (R21, R51, R52) reviewed for medication administration remained free from significant medication errors. These failures resulted in R21 sustaining a high blood glucose level of 249 on 8/23/23. Residents Affected - Few Findings include: 1) On 8/23/23, the facility was being evacuated due to hazardous temperature in the building. R21'S diagnoses include type II diabetes mellitus. R21's (1/13/23) POS (Physician Order Sheets) include Lispro (Insulin) per sliding scale if blood glucose 200 (and above) three times daily. R21's (8/23/23) MAR (Medication Administration Record) affirms (11:00am) blood glucose level was 400 therefore 8 units of Lispro (per sliding scale) was administered. R21's (4:00pm) blood glucose level and/or Lispro insulin however were not documented (as scheduled). On 8/23/23 at 8:31pm (4.5 hours after scheduled Lispro), R21 was observed leaving the facility via ambulance. R21's (8/23/23) history & physical affirms bedside glucose level was 249 at 9:15pm. On 9/18/23 at 12:16pm, surveyor inquired about potential harm if R21 did not receive (8/23/23) blood glucose check and/or Lispro insulin as ordered V21 (Medical Director) stated, it's not good, maybe because of the chaos (referring to evacuation) they (staff) didn't do their job. He (R21) can go into a DKA (Diabetic Ketoacidosis) or something like that, it's a dangerous thing. Surveyor inquired why DKA is dangerous. V21 responded, it's not life threatening but it (DKA) can kill you. It's (DKA) preventable, I think they (facility) need to reteach the Nurses. 2) R51's diagnoses include hypertensive heart disease. R51's (4/27/23) POS includes Lisinopril (Antihypertensive) 10mg (milligrams) daily. R51's (8/23/23) MAR affirms Lisinopril was not documented at 9:00am (as scheduled). R51's (8/23/23) 9:10pm progress note states resident left facility, going to receiving facility (12 hours after scheduled Lisinopril). 3) R52's diagnoses include paranoid schizophrenia, bipolar disorder, delusional disorders, and unspecified psychosis. R52's (11/26/22) POS includes Aripiprazole (Antipsychotic) 0.5mg twice daily for behavioral disorder. R52's (8/23/23) MAR affirms Aripiprazole was not documented at 5:00pm (as scheduled). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 24 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 R52's (8/23/23) progress notes exclude discharge information. Level of Harm - Actual harm On 9/18/23 at 11:17am, surveyor inquired about the regulatory requirement for medication administration. V2 (Director of Nursing) stated, they (staff) need to pass them (medications) as prescribed. If they (residents) took them (medications) they (staff) supposed to sign it (Medication Administration Record). They (staff) are supposed to document they (residents) did not take it (medications). Surveyor inquired what a blank entry indicates on the MAR. V2 responded it shouldn't be a blank, it should be code for if they (staff) did or didn't give it (medications). V2 stated, The blank entry according to the law says you didn't give it. The day we had to evacuate (8/23/23) they (Building Inspectors) were trying to get the residents out the building, so I can't say what happened with medication administration that day. The instructions went out the wind when you got other entities (Building Department) giving other directions. Residents Affected - Few The (undated) Licensed Practical Nurse job description states provide licensed nursing care to residents on assigned unit in accordance with current federal, state, and local standards, guidelines, and regulations. Dispense medications. Document the care and services delivered to the residents. The (4/2020) medication administration policy states medications are administered according to state and federal law. Document medication administration after delivering. At completion of med pass, review all EMAR's (Electronic Medication Administration Records) to assure all medications have been administered and documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 25 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based upon observation, interview, and record review the facility failed to ensure the menu was followed, failed to post alternate menu, failed to provide meal options, and failed to provide meals timely. This failure has the potential to affect 130 residents receiving meals from facility. Findings include: The 8/23/23 menu includes the following: Lunch; spaghetti noodles, Italian blend vegetables, strawberry blondie, garlic Texas toast, coffee/tea. Supper: chicken nuggets, crispy French fries seasoned corn, watermelon, milk, coffee/hot tea. On 8/23/23, residents were being evacuated from the facility due to hazardous temperatures in the building. On 8/23/23 at approximately 7:00pm, surveyor observed sandwiches, fruit and juice being served to residents however an alternate menu was not posted and/or offered at this time. On 8/23/23 at 7:05pm, V6 (Licensed Practical Nurse) affirmed dinner had not been served but they (staff) are bringing something for the residents now. On 8/23/23 at 7:15pm, R86 stated there was no dinner served, residents just got a sandwich. R86's (6/20/23) BIMS (Brief Interview Mental Status) determined a score of 14 (Cognitively Intact). On 8/23/23 at 8:25pm, V2 (Director of Nursing) stated we changed to a cold menu for lunch and dinner today. For lunch residents had turkey and cheese with beets and onions, Kool-Aid and milk. For dinner residents had tuna sandwiches, fruit, and apple juice. On 8/29/23, surveyor requested the (8/23/23) alternate menu however received the always available menu dated 8/23/23 which includes but not limited to chicken nuggets, cottage cheese, deli sandwich, cheeseburger, peanut butter & jelly sandwich, grilled cheese sandwich, grilled chicken patty with cheese sandwich, and chef's salad. The (8/23/23) census includes 132 residents. On 9/11/23 at 4:09pm, surveyor inquired how many residents receive meals from the facility V22 (Dietary Manager) stated All except 2, we had 2 NPO (nothing by mouth). [therefore 130 residents]. Surveyor inquired what was served on 8/23/23 V22 responded If I'm not mistaken it was a tuna salad sandwich, a tossed salad, cookies, and juice for supper because we evacuated after lunch. We had deli sandwiches for lunch. Surveyor inquired what time supper is scheduled V22 replied at 5:00 (pm). Surveyor inquired what time supper was served on 8/23/23 V22 stated It was between 5 and 7 (pm). Surveyor inquired if chicken nuggets, cottage cheese, cheeseburgers, grilled cheese sandwich, grilled chicken patty with cheese sandwich, and/or chef's salad were served on 8/23/23 V22 responded Um, grilled cheese, I don't think so. Maybe chef salad or cottage cheese I would say yes because it wasn't no hot food served that day. We were serving tuna salad sandwiches and I wanna say beet salad and chips for regular diets. [chips, cottage cheese, cookies and/or salads were not observed 8/23/23 on resident plates]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 26 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 9/11/23 at 4:21pm, surveyor inquired if an alternate menu was posted throughout the facility on 8/23/23 V23 (Cook) stated It should have been, I'm not for sure. Surveyor inquired what was served 8/23/23 V23 responded We didn't serve supper, we served breakfast and lunch. Supper was supposed to be tuna though. For lunch, we did deli sandwiches with beets and onions. For supper they were evacuating so we had to prepare tuna sandwiches for residents that were still there. Surveyor inquired what time supper was served on 8/23/23 V23 replied When IDPH (Illinois Department of Public Health) got there [IDPH surveyors entered the facility at approximately 6:30pm] I know someone called down and said supper needed served to residents that were left. Surveyor inquired if chicken nuggets, cottage cheese, cheeseburgers, peanut butter & jelly sandwich, grilled cheese sandwich, grilled chicken patty with cheese sandwich, and/or chef's salad were served on 8/23/23 V23 stated No, I think it was just fruit plates we had watermelon, cantaloupe, grapes, oranges or pineapples we put 3 different fruits on a plate. Some have cottage cheese or yogurt. [Yogurt was also not observed 8/23/23 on resident plates]. The (5/2020) menus policy states menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. Deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. If a food group is missing from a resident's daily diet (e.g., dairy products) resident is provided an alternate means of meeting his or her nutritional needs (e.g., calcium supplementation or fortified non-dairy alternatives). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 27 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide resources in a safe, effective, and efficient manner, and failed to provide adequate supervision, direction and instruction during the evacuation and discharge of facility residents. These failures have the potential to affect all 132 residents residing in the facility. Residents Affected - Many Findings include: The (8/23/23) census included 132 residents. On 8/23/23, the Chicago temperature was 98 degrees Fahrenheit with heat index 116 degrees Fahrenheit per National Weather Service. The Emergency closure order documents, in part, effective date 8/23/23. Community Care Center, located at 4314 S. Wabash Avenue, Chicago, IL is a public nuisance that is dangerous, hazardous and endangers the public health due to the violations as stated in the attached Property Condition Report: Department of Building Property Condition Report, Building Code Violations that Constitute an Actual and Imminent Danger, and Lift Safety: Cooling system at the facility is inoperable, Location Entire Premises. On 8/23/23 at 6:24 pm, surveyor observed residents sitting outside of the facility in wheelchairs on the sidewalk with staff. No observation of water being offer or given to the residents while outside. On 8/23/23 at approximately 7:00 pm, a total of 39 (R4, R5, R7, R8, R11, R19, R20, R25, R29, R32, R33, R38, R42, R43, R45, R54, R56, R62, R63, R65, R66, R74, R75, R82, R84, R85, R86, R88, R92, R94, R96, R99, R106, R107, R116, R120, R121, R127, R133) residents observed by surveyor inside and/or outside the facility. On 8/30/23 at 11:00 am V2 DON (Director of Nursing) stated, the building was warm, and I (V2) instructed my staff to keep checking on the residents and hydrating them. We (facility) did have a cooling bus for the residents till around 6:00 pm. The building inspector said the facility had to evacuate due to high temperatures. V2 stated, I did not know the temperature in the building. The facility started to evacuate the building around 12:00 pm. On 8/31/23 at 11:02 am, surveyor inquired to V17 (Corporate Administrator) if facility staff were aware of the (8/23/23) impending heat advisory. V17 responded, I (V17) think the Administrator and the Maintenance were aware. Surveyor inquired if the facility AC (Air Conditioner) was working prior to 8/23/23. V17 replied, I want to believe that they had a problem with the air condition prior to that day which they had temporary measures (portable coolers on all the floors that blow cold air, fans, hydrating residents, taking temperature of the building to ascertain if there was any need to evacuate) in place but because of the weather that day (referring to 8/23/23) it made the measures in place not work. On 8/31/23 at 10:39 am, V16 (Maintenance Director) stated, two compressors went down (not working) a week prior to 8/23/23. We (facility) have been using 17 temporary portable air conditioning units. V16 affirmed on 8/23/23 around 7:30am it was beginning to get hot in the facility, and around (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 28 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0835 Level of Harm - Minimal harm or potential for actual harm 9:30am the temperature became uncomfortable. Residents started to complain about the facility temperature around 10:30am. The facility had temporary fixes in place, but the main air conditioning unit would not be able to be fixed without new compressors. The city (Building Department, Fire Department, Police) was at the facility (8/23/23) because someone called 311. By the time the portable AC unit got to the facility it was too late, the evacuation had started. Residents Affected - Many August 2023 Daily Air Temperature Logs affirm temperatures were documented 8/1 -8/3/23, 8/5-8/6/23, and 8/23/23 no hourly temperatures recorded. On 9/5/23 at 12:34 pm, V20 (Chicago Building Department Deputy Commissioner) stated, I (V20) did temperatures in all common areas and patient rooms readings were 81-91 degrees between 12:30 pm and 1:30 pm. At that point, we (Fire/Building Departments) had made the decision that the building needed to be closed due to patient safety. We waited outside the building until all the residents were gone which was about 1am. Surveyor inquired who initiated the facility evacuation. V20 replied, this was a joint closure from the Department of Buildings and Chicago Fire Department. The fire alarm was not functioning properly, and the stairwells have electronic locks where you have to type in a security code, but the problem was it took a very long time to find a staff that could access those codes and a door was inoperable. V20 stated, it was chaotic in the facility. When the facility was told the building needed to be closed, it seemed like there was no organized plan to evacuate the residents and nobody knew what to do. On 9/5/23 at 4:20 pm V2 (DON) stated with a typical transfer, the facility got doctors order, notify family, notify resident why they're being transferred, when they (resident) will be transferred, where they (resident) are going, how they are getting there, and call and give report to the receiving facility. We (facility) may not have been able to call to notify everyone. There was no way that could have been done in an emergent situation. Corporate was working behind the scenes because there was no way we could keep up. On 9/11/23 at 2:12 pm, V1 (Administrator) stated, she was aware of the (8/23/23) impending heat advisory from the local news report, and I was aware that the AC was not working in the facility. The implementation that was put in place to address the facilities AC malfunction prior to 8/23/23 was the regional director put in portable? cooler units, they were supposed to be used throughout the facility. That was temporary. A contractor came out to look at the AC for repairing. Surveyor asked how staff have been trained regarding hazardous temperatures. V1 stated, the Maintenance director and department managers communicated with their staff the temperatures in the building and what to do to make the residents comfortable. V1 stated, requirements for an evacuation could be if the temperatures are above the normal temperature of 81 degrees. Surveyor asked on 8/23/2023 what time were hazardous temperatures identified in the facility. V1 stated, I believe it was 10:30 am. I cannot recall the exact time. Surveyor inquired, when did the building department and/or fire department arrived at the facility on 8/23/2023. V1 stated the building department arrived around 11:30 am or 12:00 pm. A resident family member called them. Surveyor asked, on 8/23/2023 what time did residents began evacuating from the facility. V1 stated, I don't know what time the resident started to evacuate we started putting then on a cooling bus. That was shortly after the building people came maybe around 1:00 pm. V1 stated, the social service director was notifying family members. All family members were notified within 24 hours. V1 stated, the time the residents left the facility was not on the log sheet only where the residents were transferred to. V1 stated, the regional team was responsible for the emergency plan for evacuation. V1 stated, the last resident that left the building was after midnight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 29 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility evacuation did not start as soon as hazardous temperatures were observed. Management was not aware what time the evacuation started. The facility did not start evacuating until the City of Chicago Building Dept. told them to do so around 1:00 pm when the engineers arrived in the building. Temperatures were not taken every hour. Management did not provide supervision to staff to ensure policies were being implemented. Some residents were left outside the building around 6:30 pm, management did not provide direction to ensure residents are not exposed to hazardous temperature. Evacuation was disorderly, management did not provide direction to staff to ensure safe transfer and evacuation. Facility Policy dated (5/1/23) titled Evacuation, Transportation and Relocation Plan, states each facility shall establish and implement policies and procedures in a written plan to provide for the health, safety, welfare and comfort of all residents when the heat index/apparent temperature (see Section 300. Table D) as established by the National Oceanic and Atmospheric Administration, inside the facility exceeds 80 degrees F. (Facility) shall have policies and procedures which address the needs of evacuees. (Facility) shall ensure that policies and procedures shall also address staff responsibilities during evacuations. (Facility) shall consider the patient population needs as well as their care and treatment. Facility Policy dated (11/1/22) titled Hot Weather/Heat Emergencies, documents, in part, the Administrator will be aware of the weather forecast of extreme temperatures and comfort levels inside the facility. The Maintenance Director will monitor the facility's air conditioning to ensure that all are in good working order. The maintenance director will monitor temperatures to ensure that air temperatures in the facility maintain comfortable temperature range of 71-80 degrees F. If temperatures increase, readings will be taken every hour. Emergency Operations Plan: Remove residents from areas that are exposed to direct sunlight. Recommending residents to stay indoors during extreme heat conditions. Report any changes in the resident's condition. Be sure to have an up-to- date and accurate list of all residents who are high risk to be adversely affected by extreme temperatures. Facility job description undated and titled Maintenance Associate- Environment Services Associate, documents, in part, General Job Description: The primary purpose of the job position is to perform general maintenance and repairs for assigned equipment and facilities including plumbing, electrical, basic carpentry, heating and cooling, and other building systems and respond to safety concerns. Duties and Responsibilities: Inspect and identifies equipment or machines in need of repair and complete repairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 30 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 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 upon observation, interview and record review the facility failed to document AC (Air Conditioner) concerns on a maintenance log/worksheet, failed to repair malfunctioning AC, failed to ensure that the AC remained operable, and failed to maintain facility air temperature below 80F (Fahrenheit). These failures affected 132 residents residing in the facility. Residents Affected - Many Findings include: The (8/23/23) census includes 132 residents. The (8/23/23) daily air temperature log includes but not limited to the following hazardous temperatures: 81.2F in room [ROOM NUMBER], 86.0F in room [ROOM NUMBER], 86.1F at the (2nd floor) Nurse's station and 86.2F in room [ROOM NUMBER]. On 8/23/23 at 6:46pm, the (2nd floor) temperature was uncomfortably hot. V8 (Social Service Director) stated the facility air conditioner has been out since Monday 8/21/23 (2 days prior). On 8/23/23 at 7:07pm, R79 stated it has been hot for about a month now, they (staff) provided fans. R79's (6/6/23) BIMS (Brief Interview Mental Status) determined a score of 12 (moderate impairment). The daily air temperatures were not documented (8/9/23-8/22/23) therefore unable to ascertain actual temperatures during that timeframe. On 8/23/23 at 7:15pm, 1st floor staff were noted to be sweating and their clothes visibly wet. On 8/23/23 at 7:22pm, R92 reported feeling hot. R92's (7/25/23) BIMS determined a score of 15 (cognitively intact). On 8/23/23 at 7:27pm, R75 stated I feel terrible, I feel hot. R75's (8/17/23) BIMS determined a score of 10 (moderate impairment). On 8/23/23 at 7:30pm, R45 stated yesterday and today it got really hot. The AC in my room didn't work this morning staff tried to turn it on, but it didn't work. R45's (7/21/23) BIMS determined a score of 12. On 8/23/23 at 9:38pm, V9 (RDO/Regional Director of Operations) stated we were able to maintain comfortable temperature levels in the building until this morning. The City of Chicago Building Department called around 12:30pm, the temperature levels were not comfortable. We (facility) were told to evacuate the residents. The (8/23/23) emergency closure order states I, Commissioner of the City of Chicago Department of Buildings, pursuant to Chicago Municipal Code Chapter 14A-3-307, hereby find that the property known as (Facility Name) is a public nuisance that is dangerous, hazardous and endangers the public health due to the violations as stated in the attached property condition report. The attached (8/23/23) property condition report states cooling system at this facility is inoperable. Location: entire premises. On 8/29/23, 8/30/23 and 9/5/23 surveyor requested the (July/August 2023) facility maintenance logs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 31 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0908 from V2 (Director of Nursing) and V17 (Corporate Administrator) however none were received. Level of Harm - Minimal harm or potential for actual harm On 8/31/23 at 10:39am, surveyor inquired about the facility AC V16 (Maintenance Director) stated two compressors went down (not working) a week prior to 8/23/23. We've (facility) been using 17 temporary portable air conditioning units. On 8/23/23 around 7:30am it was beginning to get hot in the facility, and around 9:30am the temperature became uncomfortable. Residents started to complain about the facility temperature around 10:30am. The facility had temporary fixes in place, but the main air conditioning unit would not be able to be fixed without new compressors. Residents Affected - Many On 8/31/23 at 11:02am, inquired if the facility AC malfunctioned prior to 8/23/23 V17 (Corporate Administrator) replied I want to believe that they had a problem with the air conditioning prior to that day which they had temporary measures (portable coolers on all the floors that blow cold air, fans, taking temperature of the building to ascertain if there's any need to evacuate) in place but because of the weather that day (referring to 8/23/23) it made the measure in place not working. The Chicago temperature was 98F (Fahrenheit) with heat index 116F per National Weather Service on 8/23/23. On 9/5/23 at 12:34pm, inquired about the (8/23/23) facility temperature V20 (Chicago Building Department Deputy Commissioner) responded I did temperatures in all the common areas and patient rooms, readings were 85-91F between 12:30pm and 1:30pm. At that point, we (Building/Fire Departments) had made the decision that the building needed to be closed due to patient safety. There was no deferred maintenance being done at this facility, it did not appear to me. Over time you're supposed to reinvest in your facility and make sure that any work that needs to be done gets taken care of. About a month before we shut down this building (facility) we (Buildings Department) received a complaint about their (facility) air conditioning not working. We (Buildings Department) sent someone out to take temperatures and they (facility staff) wouldn't let him (Buildings Inspector) in. I (V20) got a call from one of my inspectors that said the contractor did not get a call until that day (8/23/23) to repair the air conditioner. They (staff) tried to say that they had temporary cooling at the facility but basically, they just had fans not air conditioning. There was no air conditioning functioning in this building. This is the type of building that every room needs cooled because of the population. On 9/6/23 a service agreement to repair facility AC (prior to 8/23/23) was requested from V17 (Corporate Administrator). On 9/7/23 at 10:17am, an email was received (from V17) which states the facility does not have an AC service agreement. The facility employs facility maintenance personnel, including regional personnel experienced in HVAC (Heating Ventilation Air Conditioning) repair. Prior to 8/23/23, the facility and regional maintenance team continued to attempt to repair the system while looking for a replacement chiller. The following repairs were made to the system: relief valve replaced, cooling system recharged, refrigerant levels inspected. On 9/7/23 at 1:22pm, surveyor inquired how maintenance concerns are reported. V16 (Maintenance Director) stated every floor in the building has a log with maintenance care on it, staff/residents will fill it out and the log gets checked daily. Surveyor inquired if V16 has HVAC experience, V16 responded 'no ma'am and I don't mess with anything I don't know about, I call Corporate'. Surveyor inquired when the facility AC broke V16 replied, the AC went down on us on a Wednesday and affirmed it was sometime prior to Wednesday 8/23/23 evacuation. Surveyor inquired how V16 determined the AC was broken. V16 replied it wasn't getting as cool as it was and when I checked it (AC), it was off. I told Corporate that day it wasn't blowing cold air and we needed someone to come look at it. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 32 of 33 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 146164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (Corporate staff) came the very next day and brought freon. One of the AC compressors (the first one) was cracked and seized the other two compressors. You can't put freon in the first compressor, that's the one that leads to the other two compressors, so if you put freon in the first one (compressor) its (freon) just running out. Surveyor inquired what the facility implemented when the AC was broke. V16 stated we had the (Brand Name) portable cooling system. They were located throughout the building in the dining areas and hallways on each floor. We (facility) went and bought about 8 or 9 window AC units and threw them in the windows, we didn't have it (AC) in every room. By the time we (Facility) got preparation the heat took over. An invoice was provided by the facility with itemized descriptions and receipts dated 7/20/23-8/13/23 however compressors (required to repair the AC - per V16) are excluded. Eight (8) portable coolers (dated 8/4) were documented on the invoice. The (8/4/23) attached receipt includes 8 brand name (reconditioned) portable evaporative coolers (for 950 square feet). The facility is 62,529 square feet (per document received by facility 9/7/23) therefore likely not sufficient to cool the entire building. On 9/11/23, surveyor requested receipts for window AC's ordered by the facility. The (8/23/23) receipt (received 9/11/23) affirms two (2) 5,000 BTU (British Thermal Unit) window AC's were purchased. According to the EPA's (Environmental Protection Agency) rule of thumb role, 5,000 BTU room size should be 250 square feet (or less) for effective cooling. On 9/12/23, the facility provided (8/4/23) receipt including two (2) 5,000 BTU window AC's and (8/23/23) receipt including two (2) 5050 window AC's and two (2) booster fans [also likely not sufficient to cool the entire building]. The (2013) maintenance repair worksheet policy & procedure states it is the policy of this facility to communicate needed repairs to the maintenance department via the maintenance worksheet. Purpose: to assure that all maintenance needs are addressed in a regular and timely fashion. To provide staff and residents an effective reporting method for needed maintenance services. To track response time of maintenance services. The maintenance supervisor is to review this worksheet each morning and delegate assigned items between him/herself and the maintenance assistant. The maintenance worksheet must be completed for each reported item. Filed and completed maintenance worksheets are to be maintained in a separate binder labeled maintenance worksheet records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 33 of 33