Health inspection·July 15, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to provide and acquire medications as ordered by the doctor to meet the needs of each resident. These failures could potentially affect 2 (R1 and R5) of 5 residents reviewed for improper nursing care. The findings include: R1's face sheet documented admission date on 4/5/2024 with diagnoses not limited to Chronic obstructive pulmonary disease, Transient cerebral ischemic attack, Suicidal ideations, Antiphospholipid syndrome, Coagulation defect, Hypertensive heart disease without heart failure, Hematuria, Hyperlipidemia, Calculus of kidney, Systemic lupus erythematosus, Unspecified urinary incontinence, Personal history of transient ischemic attack, and cerebral infarction without residual deficits, Major depressive disorder. R5's face sheet documented admission date on 2/1/2024 with diagnoses not limited to Type 2 diabetes mellitus with foot ulcer, Chronic obstructive pulmonary disease, Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed, Major depressive disorder, Hypertensive heart disease with heart failure, Non-pressure chronic ulcer of other part of right foot with fat layer exposed, Hypoglycemia, Chronic kidney disease, Anemia, Altered mental status, Hypo-osmolality and hyponatremia, Overactive bladder, Hyperlipidemia, Gastro-esophageal reflux disease without esophagitis, Schizophrenia, Schizoaffective disorder. On 7/14/24 at 11:05am Observed R1 up and about, alert, and oriented x 4, verbally responsive. R1 said she has been residing in the facility for 3 months and did not get her COPD (Chronic obstructive pulmonary disease) inhaler (Symbicort and Albuterol) since she came to the facility. R1 stated inhaler was not available. R1 said the physician / nurse practitioner and nurses are aware and was told that they will order the inhaler. R1 said she is having constant mucus in her lung, having problem with breathing at times. R1 said today she is okay. R1 said she has been taking her inhaler (Symbicort) twice a day for 12 years and she has another as needed inhaler (albuterol) if she needs it for hard time breathing. R1 stated she kept asking the nurses since admission, but she was told that inhaler was not available, and it was not given to her. R1 observed breathing easy, no shortness of breath. At 11:28am V4 (Licensed Practical Nurse / LPN) said has been working in the facility since 2018. V4 stated she is taking care R1, did not see R1 having hard time or difficulty breathing and R1 did not ask her for inhaler. V4 checked R1's physician order for inhaler and stated R1 has an order for (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146164 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 07/15/2024 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)