Health inspection·August 2, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviews, the facility failed to follow fall care plan intervention for a resident with history of falls and failed to update care plan fall interventions after fall had occurred. These failures affected 1 (R204) of 4 residents reviewed for falls out of a sample of 19. Findings Include: R204 admitted to the facility on [DATE] with diagnosis not limited to Seizures, Epilepsy, Repeated Falls, Major Depressive Disorder, Unspecified Hearing Loss, Dementia, Bipolar Disorder with Psychotic Features, Schizophrenia, Psychotic Disturbance, Mood Disturbance, Drug Induced Subacute Dyskinesia, Legal Blindness, As Defined In USA, Parkinson's Disease, Restlessness and Agitation, Chronic Obstructive Pulmonary Disease. R204's MDS (Minimum Data Set) dated 06/14/24 documents BIMS (Brief Interview of Mental Status) score of 03/15 indicating severely impaired cognition. R204's Fall Risk Assessment completed on 02/12/24 identified R204 as being at high risk for falls. R204's care plan dated 02/12/24 documented in part, (R204) is high risk for falls related to unsteady gait, diagnosis of epilepsy and blindness and intentions included but not limited to ensure that (R204) is wearing appropriate footwear (non-skid socks) when ambulating. R204 sustained an unwitnessed fall on 05/31/24 resulting in a fractured right femur requiring post intramedullary nailing. R204's care plan dated 05/16/24 documented in part to provide appropriate footwear (non-skid socks) and encourage (R204) to wear when out of bed. On 08/01/24 at 10:15 AM, V22 (Certified Nursing Assistant/CNA) stated V22 is taking care of R204 today and V22 is the one who dressed R204 today. At 10:19 AM, observed R204 sitting in a chair in the unit dining room wearing regular white socks. The socks were not non-slip socks. R204 was not wearing shoes. On 08/01/24 at 10:20 AM, V21 (Restorative Certified Nursing Assistant) observed R204 sitting in a chair in the unit dining room and stated, he's wearing regular socks and he still tries to get up on his own that is why he's on 1:1 now. On 08/01/24 at 11:56 AM, V22, CNA, observed R204 sitting in a chair in the unit dining room and stated, he's wearing regular socks. I don't know if he needs to be wearing non-slip socks or not. I'll have to ask the nurse. On 08/01/24 at 11:59 AM, V15 (Licensed Practical Nurse) stated, R204 does not need to wear any type of special socks. On 08/01/24 at 12:01 PM, V27 (Director of Rehabilitation) stated with R204's muscle strength R204 can stand up on his own and that R204 is very impulsive so R204 remains at high risk for falling. V27 stated R204 has poor safety awareness and judgement and decreased vision/hearing all of which contribute to R204 being at continued risk for falls. V27 stated R204 should be wearing non-slip socks instead of regular socks to prevent him from sliding or slipping when R204 goes to stand up to walk or transfer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 2 of 23 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 08/02/2024 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)

F 0689 On 08/01/24 at 12:10 PM, observed R204 sitting in wheelchair in R204's room wearing gray non-slip socks. Level of Harm - Minimal harm or potential for actual harm On 08/01/24 at 12:12 PM - V8 (Certified Nursing Assistant) stated V8 is the one who changed R204's socks just now. V8 stated, I took off the regular socks he had on and put on the non-slip socks to prevent him from falling. He's still able to walk and transfer so he needs the non-slip socks. Residents Affected - Few On 08/01/24 at 9:05 AM, V2 (Director of Nursing) stated all fall episodes are reviewed by the clinical team and interventions are discussed at that time which are then updated on the resident's care plan. V2 stated after every fall there should be a change in the interventions to make sure the facility is meeting the needs of the resident. V2 stated the interventions in place depend on the resident, they are individualized. V2 stated after R204's fall on 05/31/24 based on the care plan that I'm looking at no changes were made to the care plan interventions. V2 stated the interventions were last updated 05/16/24 and stated to continue with non-skid socks when R204 is out of bed. V2 verbalized that was the same intervention in place before R204 had fallen. V2 stated we did put new interventions in place such as assigning R204 to be on one-to-one supervision with staff to anticipate R204's needs because R204 is still trying to ambulate and remains at high risk for falls due to impulsivity but that intervention has not been documented in R204's care plan yet. On 08/01/24 at 10:23 AM, V17 (MDS Coordinator) during interview conducted over the phone stated the purpose of the care plan is to address residents' specific needs with goals and appropriate interventions on how to manage the problem and concern area. V17 stated care plans should be specific to the resident and changed as needed. V17 stated care plans drive the residents care so the staff needs to know what the interventions are to provide the resident with the care they need. V17 stated V17 is the one that is responsible for updating the interventions and care plans. V17 stated when a resident has a fall V17 updates the care plan with the dates of the fall and changes to interventions. V17 stated V17 was looking through R204's care plan on V17's computer and stated the same interventions were continued after R204's fall on 05/31/24. V17 stated to my knowledge none of these interventions have been changed otherwise I would have updated them in the care plan. Facility provided policy titled Fall Program dated 03/2021 documents in part, upon completion of the fall evaluation a care plan is developed or updated, new fall interventions are reviewed. Review of interventions and care plan occurs. Facility provided policy titled Care Plan Development dated 03/2021 document in part, 1.) The facilities interdisciplinary team in consultation with the resident and his her representative develops and implements a person centered care plan for each resident that includes measurable objectives and time frames to meet the residents of medical, nursing, mental and psychological needs that are identified in the evaluation process. 2.) Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require data gathering, sequencing of events and clinical decision making. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 3 of 23 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 08/02/2024 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)

F 0689 3.) Level of Harm - Minimal harm or potential for actual harm Evaluation of the residents are ongoing and care plans are reviewed and revised by the dissenter disciplinary team after each evaluation including both the comprehensive quarterly reviews and as information about the resident condition changes. Residents Affected - Few 4.) The care planning interdisciplinary team is responsible for the reviews and updating of the care plans when there has been a significant change in condition, and when the desired outcome is not met. Facility provided document titled Care Plan Use dated 03/2021 which documents in part the care plan is one of the tools used in developing the resident/patient's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 4 of 23 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 08/02/2024 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)

F 0692 Provide enough food/fluids to maintain a resident's health. 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 follow its policy by not performing a nutritional evaluation on readmission for 1 (R45) resident with significant weight loss. This failure affected 1 (R45) of 2 residents reviewed for nutrition in a sample of 19. Residents Affected - Few The findings include: R45's face sheet showed admission date on 2/26/2024 with diagnoses not limited to Chronic obstructive pulmonary disease, Hypertensive heart disease without heart failure, Type 2 diabetes mellitus, Major depressive disorder, Anxiety disorder, Cachexia, Calculus of kidney, Low back pain, Unspecified osteoarthritis, Hyperlipidemia, Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, Unilateral inguinal hernia, Alcohol dependence, Other psychoactive substance dependence, Anemia, Subsequent non-st elevation (nstemi) myocardial infarction, Acute embolism and thrombosis of unspecified deep veins of right lower extremity, Unspecified right bundle-branch block, Chronic kidney disease, stage 4 (severe), Supraventricular tachycardia. On 7/30/24 at 11:03 AM, Observed R45 sitting up on bed, alert and verbally responsive, appears skinny with collar bone protruding. R45 stated he prefers to stay in bed. He said went to the hospital several times but does not know why. R45 also stated he has been eating well. On 7/30/24 at 12:05pm Observed sitting up on bed, eating lunch, can feed self-post tray set up. Lunch tray with turkey burger in a bun, potato wedges, pineapple tidbits, juice. Observed R45 ate about 75% of the food served. On 7/31/24 at 12:46 PM V2 (Director of Nursing / DON) stated IDT (interdisciplinary team) is conducting a meeting every morning regarding health condition / issues including weight loss. She said it is important to refer to dietician and do an evaluation/ assessment for resident with weight loss to address the concern. Stated R45 had multiple hospitalization. MD (medical doctor) / NP (nurse practitioner) aware of poor appetite and weight loss and was transferred to the hospital because of this concern. On 7/31/24 at 3:18 PM V29 (Registered Dietician) was interviewed via phone and stated has been working remotely for over a year and does not come to the facility. She said nutritional assessment should be done upon admission and readmission to make sure that weights is within normal limits, if underweight - we will use nutritional supplement to maintain weight and reach a healthy weight. Nutritional assessment should be done within the month of admission or readmission. Surveyor reviewed electronic health record of R45 with V29 and stated he had multiple hospitalization in June and July. Stated that nutritional evaluation was done on 4/16/24 and today (7/31/24), she added ensure twice a day between meals to supplement poor intake. She said there should be a nutritional evaluation done in June's readmission, but it was not completed. Stated she was out and there was coverage during that month but still it was her responsibility. V29 stated R45 was hospitalized due to weight loss and poor appetite. Stated R45's BMI (Body Mass Index) = 16, is considered underweight. V29 said R45 had a significant weight loss of 8.5% for the last month. July weight was 93.2lbs (pounds) and June weight was 101.9 lbs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 5 of 23 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 08/02/2024 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS (Minimum Data Set) dated 7/16/24 showed R45 needed supervision or touching assistance with eating; Substantial / maximal assistance with oral, toileting and personal weight loss, not on physician-prescribed weight loss regimen. R45's health record showed the following weights: 7/10/2024 = 93.2 lbs (pounds); 6/19/2024 = 101.9 lbs; 6/7/2024 =101.9 lbs; 5/13/2024 = 99.8 lbs; 4/3/2024 =105.0 lbs; 3/14/2024 = 102.0 lbs. R45's progress notes showed multiple hospitalization on 6/11/24, 6/21/24 and 7/16/24 and was readmitted to the facility on [DATE]. R45's Nutrition/Dietary Note dated 7/31/2024 documented in part: Significant weight loss of 8.5% x 1 month possibly r/t (related to) recent hospitalization. Weight gain is desired for resident r/t malnutrition. Recommend adding a regular diet order and two cartons of Ensure daily between meals to support weight gains. R45's health record showed dietician evaluation on 4/16/24 and 7/31/24. Dietician / nutritional evaluation was not found for June's readmission. Facility's policy for nutritional evaluation dated 5/2020 documented in part: The dietary department will perform a nutritional evaluation on all new admissions, readmissions, quarterly, annually and with any significant change. The dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional evaluation for each resident. The nutritional evaluation will be documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 6 of 23 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 08/02/2024 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to date and store nebulizer mask inside a plastic bag when not in use for 1 (R103) resident in a sample of 19. Residents Affected - Few Findings Include: From 07/30/24 to 08/02/24, surveyor observed R103's nebulizer mask by the window, undated and not inside a plastic bag when not in use. On 07/30/24 at 11:10 AM, V6 (Registered Nurse/RN) stated the Nebulizer mask should be dated and kept in a plastic bag when not in use to prevent contamination which could potentially cause infection for R103. V6 stated the nebulizer was administered by previous shift, V6 then discarded the undated nebulizer mask and replaced with a new dated mask in a plastic bag. On 07/30/24 at 12:07 PM, V2 (Director of Nursing) V2 stated it is V2's expectation that nurses will date and keep nebulizer mask inside the plastic bag when not in use to prevent infection. V2 stated when the nebulizer mask/tubing is not dated, nurses will not know when the tubing was changed and that can increase the risk of infection for R103. R103's Physician Order Sheet (POS) shows active order dated 7/26/24 of Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 4 hours for Shortness of Breath. Facility Policy titled, Nebulizer Mist Therapy dated 03/2021 documents in part: Labelled and dated plastic bag for nebulizer and mouthpiece or mask storage. Store dried nebulizer, t-piece, mouthpiece, or mask in separate, labeled plastic bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 7 of 23 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 08/02/2024 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R19's face sheet shows an admission date of [DATE] with diagnoses not limited to Schizophrenia, Chronic obstructive pulmonary disease, Drug induced subacute dyskinesia, Centrilobular emphysema, Vascular dementia, Major depressive disorder, Polyosteoarthritis, Gastro-esophageal reflux disease without esophagitis, Nicotine dependence, Acute kidney failure, Thrombocytopenia, Hyperlipidemia, Diverticulitis of intestine, Hypertensive heart disease without heart failure, Cachexia, Dyskinesia of esophagus, Unspecified protein-calorie malnutrition, Other specified diseases of blood and blood-forming organs, Chronic vascular disorders of intestine. On [DATE] at 11:17 AM Observed 3 pills inside a plastic cup at R19's bedside table. V2 (DON) requested to R19's room and shown the 3 pills inside the plasyic cup. Vv took the cup away and stated these should not be left at bedside. V2 showed 3 pills to V6 (Registered Nurse / RN), nurse on duty and stated she cannot recognize those medications, she said it was not given today. V6 stated scheduled morning medications were given to R19 while she was in the dining room. On [DATE] at 12:46 PM V2 (DON) stated nurses are not supposed to leave medications at bedside. They should get an order from the doctor for them to leave the medication at bedside. Potential problems could happen so nurses are educated not to leave medication at bedside. Facility's medication storage policy dated 3/2021 documented in part: The facility maintains proper store of a variety of medications in accordance to the pharmacy recommendations and regulatory guidelines. The facility acknowledges that medications can be stored in a variety of storage areas located within the nursing unit and under lock and key. Based on observation, interview and record review, the facility failed to follow standards of professional practice by leaving medications at the bedside of one resident (R19), failed to date insulin for one resident (R25) and failed to store insulin inside the refrigerator for one resident (R49) in a sample of 19. Findings Include: 1. On [DATE] at 11:25 AM, 1 of 2 medication carts and 1 of 1 medication storage room inspected for medication storage and labeling. Surveyor observed R25's multi-dose vial of Humulin R Injection solution (Insulin Regular Human) inside the medication cart, opened and undated. V9 (Licensed Practical Nurse/LPN) stated the multi-dose vial of Humulin R Insulin is opened and should have been dated per the facility's policy. V9 also stated the potential problem of the opened, undated Humulin R insulin is that it may not be effective because nurses may not know when it was opened, and V9 stated nurses may be administering an expired Humulin R Insulin to R25. 2. Surveyor also observed R49's unopened new multi-dose vial of Lantus Insulin injection 100/ML inside the top drawer of the medication cart. As per pharmacy written recommendation on the insulin label, unopened vial of Lantus Insulin should be kept refrigerated. V9 (LPN) stated the multi-dose vial of Lantus Insulin was not opened, and it was delivered a day ago. V9 stated the unopened multi-dose vial of Lantus Insulin should have been refrigerated as written and recommended by the pharmacy. V9 stated, not following the recommendation of the pharmacy to refrigerate the unopened multi-dose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 8 of 23 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 08/02/2024 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)

F 0761 vial of Lantus Insulin may cause the Lantus to lose its effectiveness when administered to R49. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 12:10 PM, V2 (Director of Nursing/DON) stated it is the expectation of V2 that nurses would keep unopened vial of Lantus insulin inside the refrigerator has written on the label and recommended by the pharmacy to maintain the potency. V2 also stated that opened insulin should be labeled and dated per facility's policy for effectiveness and to avoid administering expired insulin. V2 stated undated insulin should not be used. Residents Affected - Few Surveyor reviewed facility's policies: Medication Storage dated 03/2021 documents in part: The facility maintains proper store of a variety of medications in accordance with the pharmacy recommendations and regulatory guidelines. And Medication Administration dated 3/2024 documents in part: multi-dose solutions vials labeled with date opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 9 of 23 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 08/02/2024 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)

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation and record review, the facility failed to provide dental care services to one resident (R20) in a sample of 19 residents. Residents Affected - Few Findings include: On 07/30/24 at 10:41 AM R20 stated I would like to get dentures. Someone here, I don't know her name, said that we would make an appointment with the dentist, but I haven't had an appointment yet. On 07/31/24 at 9:37AM, V16 (Registered Nurse) reviewed R20's electronic health record and stated R20 does not have an order to see a dentist. It looks like his care plan has an intervention to coordinate arrangements for dental care as needed. It is dated 1/28/2024. It looks like R20 should have seen a dentist. He did not go to the dentist. On 07/31/24 at 10:54 AM V17 (Minimum Data Set/Care Plan Coordinator) stated that R20 has a care plan for dental that states: dental appointments as needed. V17 stated It has been an intervention since 1/28/2024. We have to coordinate appointments and transportation. I would have to refer to social services regarding coordinating the dental appointment. We met in April about R20. I don't recall any conversation about his oral health. On 07/31/24 at 11:30 AM - V2 (Director of Nursing). I am looking into R20. He doesn't have an appointment to see the dentist. We can get him an appointment. On 7/31/2024 at 4:51 PM, V1 (Administrator) sent email stating that R20 is scheduled to see the dentist on 8/15/24 at 9am. Review of the provider orders has no order for a dental visit for R20. 08/01/24 at 9:02 AM V9 (Licensed Practical Nurse) stated We would have to get an order for a resident to see a dentist. On 8/1/2024 at 1:25 PM V2 (Director of Nursing) was asked if V2 had a provider order for R20's dental visit. V2 stated I will get one. On 8/1/2024 at 1:30 PM V2 (Director of Nursing) entered an order from V34 (Physician) which stated: May be seen by outside clinic on 8/15/2024 at 9 AM. R20's Care Plan dated 1/28/2024 documents: Focus: R20 has oral/dental health problems related to being edentulous. Goal: R20 will be free of infection, pain or bleeding in the oral cavity by/through review date. Interventions/Tasks: Bullet 2: Coordinate arrangements for dental health, transportation as needed/as ordered. (Date initiated 1/28/2024). The facility's guideline titled Dental Services effective date 3/2021 stated in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 10 of 23 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 08/02/2024 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)

F 0790 Guideline: Dental services will be made available to residents requiring such service and as requested. Level of Harm - Minimal harm or potential for actual harm Procedure: 1. During the initial evaluation, an oral evaluation is completed. Residents Affected - Few 3. Appointments for the dentist are made by the resident/family if possible. If not the facility will assist in making arrangements for the dentist. The facility's guideline titled Care Plan effective date 3/2021 stated in part: Guideline: A person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs, that are identified in the evaluation process, is developed and implemented for each resident. Procedure: 2. Each resident's care plan will describe the following: Bullet one: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The facility's policy titled Care Plan Use effective date 3/2021 stated in part: Policy: The care plan is one of the tools used in developing the resident/patient's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Procedure: 3. Documentation should be consistent with the resident/patient's care plan. The facility's policy titled Resident Rights effective date 4/2020 stated in part: Process: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Bullet 6: Communication with and access to people and services both inside and outside the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 11 of 23 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 08/02/2024 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)

F 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observations, interviews, and record reviews, the facility failed to follow physician's orders for nectar-thick liquids for one resident (R353) out of a total sample of 19 residents. Residents Affected - Few Findings include: R353's admission Record documents in part: medical diagnosis of dysphagia, oropharyngeal phase. R353's 5/20/2024 Modified Barium Swallow Study documents in part: Moderate to severe oropharyngeal dysphagia [secondary to] decreased oral control/formation and propulsion, as well as decreased pharyngeal efficiency/motility resulting in moderate to severe diffuse hypopharyngeal residual after the swallow. It documents in part that R353 is at continued risk for aspiration. Recommendation is pureed diet with nectar thick liquids. R353's Order Summary Report (7/02/2024) and comprehensive care plan (4/09/2024) document in part nectar-thick liquid consistency. On 7/30/2024 at 12:08 PM, R353 sat in the dining room. V7 (Certified Nurse Aide-CNA) placed a seven-ounce cup of pink lemonade in front of R353. Lemonade was thin consistency and not nectar thick. At 12:11 PM, R353 took a drink of the pink lemonade and started coughing. V7 stated hold on [R353]. Hold on. V7 sat down next to R353. V7 stated R353's drinks need to be thickened. V7 stated the pink lemonade had thickener in it but V7 has not stirred it yet. V7 stirred it and pink lemonade began to thicken. Surveyor asked what consistency R353 needed. V7 stated you just have to thicken it until it won't be thin no more. It'll be thick. Surveyor asked how much thickener V7 added to the pink lemonade. V7 stated about two teaspoons or until the water is thick. On 7/31/24 at 10:22 AM, V4 (Dietary Director) showed surveyor the box of food thickener the facility uses to thicken R353's liquids. The label documents in part that the recommended usage for a four fluid ounce serving of water, clear juices, coffee, or tea is one tablespoon for nectar consistency. V4 stated staff should thicken the liquids to the ordered consistency prior to serving it to the residents. On 7/31/2024 at 10:34 AM, V11 (Activity Aide) prepared a mug of coffee for R353. There was a clear, seven-ounce cup half filled with thickener on the cart. V11 poured some of the thickener into the coffee mug without measuring it. V11 stirred the coffee and placed it in front of R353. The coffee was thin and not nectar thick. On 7/31/2024 at 10:35 AM, V11 stated you only need like a pinch of it (thickener). Usually, we have a scoop but they have it in the front at the nurses' station. Surveyor asked V11 what liquid consistency R353 needed. V11 stated For [R353] it just needs to be a little thick. Sorry I don't know the term for it. V11 did not know the physician's order for R353's liquid consistency. On 7/31/2024 at 12:40 PM, V2 (Director of Nursing) stated the kitchen staff will send the food thickener up in a clear cup. Nurses are thickening the liquids for the residents. V2 stated that the CNAs, restorative aides, and activity aides can do it if they were trained to thicken the food. V2 stated but I've seen them give it to the nurse to thicken the drinks. V2 stated facility trained V7 to thicken liquids. V2 stated staff should thicken the liquids to the ordered consistency prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 12 of 23 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 08/02/2024 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)

F 0805 serving it to the residents. Level of Harm - Minimal harm or potential for actual harm On 7/31/2024 at 1:05 PM, V25 (Activity Director) stated activity aides are supposed to go to the nurse and inform them that the resident's liquids need to be thickened. V25 stated that since the activity aides including V11 are not CNAs, the nurse must be the one to thicken the residents' liquids. The nurse will scoop out the thickener and thicken the liquids to the ordered consistency. Residents Affected - Few Facility's 5/2020 Therapeutic Diets policy documents in part: GUIDELINE: Therapeutic diets are prescribed by the Attending Physician or extender to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. A 'therapeutic diet is considered a diet ordered by a physician, or extender as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example but not limited to: Altered consistency. Facility's 5/2020 Food and Nutrition Services policy documents in part: Meals and/or nutritional supplements will be provided as indicated by the diet order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 13 of 23 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 08/02/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to ensure that there was no ice build-up in their walk-in freezer, separate the prep area from the sanitization area, and air-dry their blender container and pans prior to use. This has the potential to affect all 59 residents receiving nutritional needs from the kitchen. Findings include: Facility's list of residents on specialized diets document in part one resident that does not receive oral nutrition (nothing by mouth). On 7/30/2024 at 9:31 AM, V4 (Dietary Director) stated there were 60 residents in the building with one resident not receiving nutrition prepared in the kitchen. Surveyor conducted a brief kitchen tour with V4. Inside the walk-in freezer, there was ice build-up on the condenser and the surrounding areas. There was ice build-up on the food boxes, metal shelf, and floor under the condenser. There was ice build-up on the ceiling and on the metal shelves and food boxes underneath it. V4 stated V5 (Cook) left the door open earlier because [V5] was rearranging stuff in the walk-in freezer. On 7/30/2024 at 9:38 AM, V5 (Cook) was at the food prep station slicing potatoes. To V5's right side, at the end of the food prep table, there were two buckets filled with soapy solutions and a rag. V4 stated it was the sanitation area. On 7/31/2024 at 10:08 AM, V5 stated [V5] just finished pureeing the bread and was rinsing the blender container and blade in the sink. V5 then put it through the high temperature dishwasher. V4 stated the dishwasher also uses chemical solution to clean the dishes. At 10:13 AM, V4 used a brown paper towel to clean the inside of the blender container. Liquid remained after wipe-down. V5 placed two servings of scallop potatoes in the blender and proceeded to puree it. At 10:16 AM, V4 brought a small metal pan that had some liquid on it. Pan was not dry. V5 sprayed the pan with oil spray and then placed the pureed potatoes in the pan. During pureed observations, surveyor noted that the scalloped potatoes were in a metal pan next to the two buckets used for sanitization. Facility's plastic wrap and foil were next to the two buckets. V5 stated that's where [V5] has been wrapping the food after cooking-next to cleaning buckets. Facility's 5/2020 Food Receiving and Storage policy documents in part: Foods shall be received and stored in a manner that complies with safe food handling practices. Facility's 5/2020 Refrigerator and Freezers policy documents in part: The facility will monitor for safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The Dietary Manager will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Facility's 5/2020 Food Preparation policy documents in part: Food shall be prepared and served in a manner that complies with safe food handling practice. Areas for cleaning dishes and utensils are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 14 of 23 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 08/02/2024 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)

F 0812 located in a separate area from the food service line to assure that a sanitary environment is maintained. Level of Harm - Minimal harm or potential for actual harm Facility's 5/2020 Dishwashing Machine Use policy documents in part: After running items through entire cycle, allow to air-dry. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 15 of 23 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 (X3) DATE SURVEY COMPLETED A. Building 08/02/2024 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. R6's admission Record documents in part medical diagnoses of overactive bladder, neuromuscular dysfunction of bladder, benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, disorder of male genital organs, retention of urine, and presence of urogenital implants. Residents Affected - Some R6's Order Summary Report documents in part orders for an indwelling urinary catheter. It does not include orders for Enhanced Barrier Precautions. R6's comprehensive care plan documents in part that R6 has an indwelling urinary catheter related to diagnosis of obstructive uropathy and benign prostatic hyperplasia (initiated 3/11/2024). R6's care plan does not document in part Enhanced Barrier Precautions. On 7/30/2024 at 10:41 AM, surveyor observed an isolation bin outside R6's bedroom. There was no isolation sign inside the bin or on R6's bedroom door. V26 was cleaning the room. V26 stated R6 was not on strict isolation but was on enhanced barrier precautions for urinary catheter. V26 did not know where the sign was located. On 7/30/24 at 10:56 AM, R6 stated having a urinary catheter for many years. Facility's 12/2019 Enhanced Barrier Precautions policy documents in part: Enhanced Barrier precautions are a new approach for preventing the spread of infections in facilities. Enhanced Barrier Precautions will be in place for residents with wounds, indwelling medical devices (central lines, catheter, feeding tube, trach) regardless of MDRO [Multi-Drug Resistant Organism] status to address the issue of unknown colonization status and silent spread of MDRO's. A sign will be placed on the door for Enhanced Barrier Precautions which indicates high contact resident care activities. Facility's 3/2021 Care Plan Development documents in part: GUIDELINE: A person-centered care plan that includes measureable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs, that are identified in the evaluation process, is developed and implemented for each resident. Each resident's care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require data gathering, sequencing of events and clinical decision making. The resident comprehensive care plan is developed within 72 hours of admission and reviewed after the completion of the comprehensive MDS assessment. Based on observation, interview, and record review the facility failed to have Enhanced Barrier Precautions signage posted on the resident's hallway door and failed to have accessible personal protective equipment (PPE) available for 5 [R6, R18, R49, R104, R153] of 9 residents reviewed for infection control in the sample of 19. The facility also failed to have an order in place for Enhanced Barrier Precautions (EBP) for R6 and failed to include EBP in R6's comprehensive care plan. Findings include: 1. On 7/30/24, at 10:30 AM, during initial tour, surveyor entered R18 room and observed an enhanced barrier precaution sign over R18's bed. R18 was alert, oriented and dressed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 16 of 23 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 08/02/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R18 stated, I do not know why that sign is above only my bed and not my roommates. V8 [Certified Nurse Assistant] helped me get ready today. V8 nor any other certified nurse assistants ever wear any gown or gloves when they assist me. On 7/30/24 at 10:35 AM, V8 stated, I am R18's certified nurse assistant today. I do not have to use a gown or gloves with R18. The sign [Enhanced Barrier Precautions signage] over his bed is there because sometimes R18 goes to radiation treatment. The personal protective equipment [PPE] cart in way down the hallway near the nursing station, if I need to use a gown, I must go to the end of this hall to get a gown. On 7/30/24 at 10:45AM, surveyor entered R49's room and observed an enhanced barrier precaution sign over R49's bed. R49 was alert and oriented. R49 stated, I have no idea why I have that sign over my bed. I need the nurse to come a place a dressing on my leg wound, it is open, because the dressing got wet during my shower and the certified nurse assistant removed the bandage. The nurse nor certified nurse assistants wear a gown, only gloves when they change my wound dressing. If the certified nurse assistant come to assist me, transfer, wash my back, or like today in the shower the certified nurse assistant did not wear any gown. On 7/30/24 at 10:55 AM, V9 [Licensed Practical Nurse] stated, I am R49's nurse today. I am not sure why R49 has an Enhanced Barrier Precautions signage over his bed. That is an old sign from the previous resident. R49 stated, I need you to put a new dressing on my wound. V9 stated, I did not know R49 had a wound, I will replace the dressing. I guess R49 have a sign due to his wound. On 7/30/24 at 11:05 AM, surveyor entered R104's room and observed an enhanced barrier precaution sign over R104's bed. R104 was alert and oriented to self. V6 [Registered Nurse] stated, I am R104's nurses. R104 have an Enhanced Barrier Precautions signage over her bed because she has a gastric feeding tube. The Enhanced Barrier Precautions signage should be posted on the door, I am not sure why the sign is over her bed and not the door. On 8/1/24 at 9:00 AM, V3 [Infection Preventionist/ LPN] On 8/1/24 at 8:47 AM, V3 [Infection Preventionist (IP)/Licensed Practical Nurse] stated, I been working here since 6/23, and return to the facility in 1/24. I started being the IP nurse 4/24. The Enhance Barrier signage is use for residents with central lines, Intravenous catheters, urinary catheters, gastric feeding tubes, traches, wounds, port-a-caths, any skin openings with a device inserted. V2 told me to place the signage above the resident bed, not the door. There are two PPE carts on each side of the nursing station, one cart on each hall for nursing staff to use. The nursing staff should place on gloves and a gown when providing care to the residents with the enhance barrier precaution signs. If nursing staff do not place on gloves and a gown while providing care, dressing, bathing, transferring, changing linen, providing ADL care, incontinence care, dental care, or device care, it could potentially spread infection to other residents. On 8/1/24 at 11:02 AM, V2 [Director of Nursing] stated, I started working at the facility in March 2024. I was told that the enhanced barrier precaution signs should be placed over the resident's head of bed, not the door. The PPE carts should be placed outside the resident rooms on enhanced barrier precaution or isolation of any kind. If the sign is not posted on the door, the staff would not know to place on PPE prior to entering the room to provide care. The purpose for enhanced barrier precaution, is to prevent the spread of infection, if PPE is not being worn as needed, infection can (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 17 of 23 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 08/02/2024 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)

F 0880 spread over the nursing unit. Level of Harm - Minimal harm or potential for actual harm Policy: Documents in part: Enhanced Barrier Precaution [EBP] dated 12/2019 Residents Affected - Some - enhanced barrier precaution is a approach to prevent to spread of infections in facilities. - enhanced barrier precaution will be in place for residents with wounds, indwelling medical devices -Gloves and gowns should be used when providing the following high contact activities: dressing, bathing, showering, transferring, providing hygiene, changing linens, changing under briefs, assisting to toilet, device care, use of the device, and wound care. -A sign will be placed on the door for enhanced barrier precaution -PPE including gloves and gowns are available out the resident room -Each room should have access to alcohol-base hand rub both inside and out the room 3. R153's face sheet showed admission date on 7/11/2024 with diagnoses not limited to Type 2 diabetes mellitus, Osteomyelitis of vertebra, Muscle weakness (generalized), Unsteadiness on feet, Abnormal posture, Hypertensive heart disease without heart failure, Hereditary and idiopathic neuropathy, Hyperlipidemia, Myositis, Cutaneous abscess, Other specified diseases of liver, Disorder of thyroid, Low back pain. On 7/30/24 at 10:53 AM Observed with PPE supplies by the door entrance. No signage by the room. V6 (Registered Nurse / RN) stated R153 is on reverse isolation because of the IV access. Observed R153 lying in bed, alert and oriented x 3, verbally responsive. Observed IV (Intravenous) pump machine at bedside with empty IV antibiotic (Piperacillin, Vancomycin) solution bag hanging on the pole. Observed with dressing on R153's right upper arm. R153 said IV access site was removed because it was bleeding, and she is scheduled for IV reinsertion today. R153 said has been residing in the facility for 3 weeks. Stated she is on IV antibiotic for infection in the bone due to back problem. On 7/31/24 at 11:09 AM R153 observed lying in bed, alert, oriented x 3 and verbally responsive. Observed with single lumen midline on left upper arm with dressing dated 7/30/24. R153 said it was inserted yesterday and nurses were not using disposable gown when administering IV antibiotic medication. Surveyor did not observe signage by the door entrance and no PPE (Personal Protective Equipment) supplies nearby. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 18 of 23 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 08/02/2024 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)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their Antibiotic Stewardship Program, [A] failed to develop a report for the number of residents on antibiotics that did not meet criteria for active infection, and [B] failed to keep an accurate report for surveillance tracking for 4 [R1, R6, R10, R17,] out of 5 residents reviewed for antibiotic stewardship in a sample of 19. Residents Affected - Few Findings Include: On 7/31/24, surveyor and V3 [Infection Preventionist (IP)/Licensed Practical Nurse] reviewed the following facility antibiotic stewardship record-Infection Control Log dated 1/1/24 thru 7/23/24: R1 was admitted on [DATE], and his urine was collected for testing, no signs or symptoms documented on the log. On 1/26/24, R1's urine resulted in bacterial growth, the organism was not documented on the log. On 1/27/24, R1 was ordered Cipro 500mg twice daily for ten days. R1's antibiotic use was not observed on the facility's surveillance tracking log. R6 was admitted on [DATE], and his urine was collected for testing, no signs or symptoms documented on the log. On 2/3/24, R6's urine resulted in bacterial growth, the organism was not documented on the log. On 2/7/24, R6 was ordered Bactrim DS 800/160mg twice daily for ten days. R6's antibiotic use was not observed on the facility's surveillance tracking log. R10 was admitted on [DATE], and his urine was collected for testing, no signs or symptoms documented on the log. On 3/30/24, R10's urine resulted in bacterial growth, the organism was not documented on the log. On 3/30/24, R10 was ordered Cipro 250mg twice daily for five days. R10's antibiotic use was not observed on the facility's surveillance tracking log. R17 was admitted on [DATE], and his urine was collected for testing, no signs or symptoms documented on the log. On 3/30/24, R17's urine resulted in bacterial growth, the organism was not documented on the log. On 3/30/24, R17 was ordered Bactrim DS 800/160mg twice daily for ten days. R17's antibiotic use was not observed on the facility's surveillance tracking log. On 8/1/24 at 8:47 AM, V3 [Infection Preventionist (IP)/Licensed Practical Nurse] stated, I been working here since 6/23, and returned to the facility on 1/24. I started being the IP nurse 4/24. For the antibiotic stewardship program, I use the Mc Greer's criteria guidelines for urinary tract infections. The nurses and I need at least one symptom of the following: fever, rigors, new onset of hypotension, elevated white blood count, suprapubic pain, or abdominal tenderness, before a urinary test and culture is ordered. After the urinary culture is reviewed with 100,000 or greater colonies noted, the physician then will order an antibiotic. I understand the facility's antibiotic program. However, I was told by nursing administration that all admissions is to have a urine analysis and culture, complete blood count, and any other test needed according to their diagnosis. Most of the residents tested came back with bacterial growth and was started on antibiotics. I do not have a report for the number of residents on antibiotics that did not meet the criteria for an active infection, I was not aware I needed a report. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 19 of 23 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 08/02/2024 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)

F 0881 Level of Harm - Minimal harm or potential for actual harm I do not know why R1, R6, R10, and R17, or any of the residents tested upon admission that came back with positive for urinary bacterial growth was not included on the surveillance tracking log. I did not include signs or symptoms on the infection control log, because R1, R6, R10, and R17 was ordered urinary test upon admission, not due to any signs or symptoms of a urinary tract infection. The nursing staff and I was only doing what nursing administration told us to do. Residents Affected - Few On 8/1/24 at 11:02 AM, V2 [Director of Nursing] stated, I been working here since March 2024. Upon admission the residents are all ordered completed blood counts and any blood work that needed for other diagnosis. I was not made aware that a urinary test and culture was order on all admission automatic. The infection control process, the nursing staff uses a criteria to determine signs and symptoms of an active infection. Such as fever, rigors, new onset of hypotension, elevated white blood count, suprapubic pain, or abdominal tenderness, prior to a urinary test and culture is ordered. I have not told staff to completed urinary test on all admissions, maybe the prior nursing administration told the staff. I will in service the staff right away. Everyone has bacteria growth, but if there is no signs or symptoms of an active infection, antibiotics should not be prescribed, it could potentially cause antibiotic resistant for future antibiotics needed to help fight infection. The infection control log, and surveillance logs should be accurate and up to date, with the organism, signs and symptoms documented. Policy documents in part: Antibiotic Stewardship Program -Antibiotic stewardship program which will promote appropriate use of antibiotics while optimizing the treatment of infections. -This policy has the potential to limit antibiotic resistance, while improving treatment efficacy and resident safety. -Include a separate report for the number of residents on antibiotics that did not meet criteria for active infection. Tracking -The type of antibiotic ordered, route of administration, and weather appropriate test such as cultures were obtained before ordering antibiotic. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 20 of 23 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 08/02/2024 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)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to follow their Influenza and Pneumococcal Immunization policy and administer immunizations for 3 [R5, R11, R46] of 5 residents reviewed for immunizations in the sample of 19. Residents Affected - Few Findings Include: On 7/31/24, surveyor and V3 [Infection Preventionist (IP)/Licensed Practical Nurse] reviewed the following facility immunization records dated 1/1/24 thru 7/28/24: R5 consented on 1/17/24 for pneumococcal and influenza vaccine on 1/17/24. V3 stated, R5 originally consented on 1/17/24 according to his electric clinical record under misc. documents both consents were effective dated on 1/17/24 and scanned into R5's chart on 1/17/24. I was not aware R5 consented on 1/17/24. I received his consents again on 5/15/24 for pneumococcal and influenza vaccines. R5 did not received the influenza vaccine, R5 did not receive the pneumococcal vaccine, it was documented he was not eligible. However, I know now that R5 has a diagnosis of type II diabetes, heart disease and chronic obstructive pulmonary disease. R5 is eligible for the pneumococcal vaccine and should have received the vaccine. R5's clinical record does not document he received the Influenza and Pneumococcal vaccinations on the immunization section, physician orders, or medication administration records. There is no documentation in the medical record, with a contraindication that R5 should not receive the vaccination provided by the attending physician. R11 consented for the Influenza and Pneumococcal vaccines on 2/16/24. V3 stated, R11's clinical record does not document he received the Influenza and Pneumococcal vaccinations on the immunization section, physician orders, or medication administration records. R46 consented for the Pneumococcal vaccine on2/3/24. V3 stated, R46 did not receive the pneumococcal vaccine, it was documented he was not eligible. However, I know now that R46 has a diagnosis of type II diabetes, and hypertensive heart disease. R46 is eligible for the pneumococcal vaccine and should have received the vaccine. R46's clinical record does not document he received the Pneumococcal vaccinations on the immunization section, physician orders, or medication administration records. There is no documentation in the medical record, with a contraindication that R46 should not receive the vaccination provided by the attending physician. Surveyor reviewed R5, R11, and R46's clinical record and did not observe any record documented in their immunization section, physician orders, or medication administration records that the vaccinations were given. On 8/1/24 at 8:47 AM, V3 [Infection Preventionist (IP)/Licensed Practical Nurse] stated, I been working here since 6/23, and returned to the facility on 1/24. I started being the IP nurse 4/24. I track all the resident's vaccinations in the resident electronic chart in the immunization section, and consents are noted under the forms section. Once I receive consent for a vaccine, the vaccine should be given within one to two days. All vaccines are offered upon admission, the influenza vaccine is offered from October 1st thru April 1st. The facility has there I am not sure how R5, R11, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 21 of 23 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 08/02/2024 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)

F 0883 R46's vaccination was missed. Level of Harm - Minimal harm or potential for actual harm On 8/1/24 at 11:02 AM V2 [Director of Nursing] stated, The Influenza and Pneumococcal Immunization are offered and administered upon admission. Once the resident consents, the vaccine should be administered that day or the next. The facility pharmacy supplied the vaccines so they would be readily available. If a resident consented to vaccine and did not receive the vaccine, it could potentially cause an adverse outcome on the resident. Residents Affected - Few Policy documents in part Flu and Pneumovax Vaccine policy dated 10/2020 -An initial pneumococcal vaccine will be offered to all residents who have never received the vaccine -For anyone less than [AGE] years old who smoke, has chronic heart disease, chronic obstructive pulmonary disease, asthma, or diabetes mellitus one dose of pneumococcal polysaccharide-23 vaccine [PPSV23]. -Documentation of the medical contraindication should be provided by the attending physician FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 22 of 23 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 08/02/2024 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)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure that resident' call light is functioning for one (R22) out of a total sample of 59 residents reviewed for resident call system. Residents Affected - Few Findings Include: On 07/30/24 at 11:15 AM, surveyor observed R22 lying in bed. Surveyor observed R22's call light not functioning. R22 stated R22's call light is not working since last storm 2 Mondays ago (7/15/24). R22 stated the staff are aware of the broken call light. R22 stated R22 cannot get out of bed independently, and R22 stated R22 must wait until staff come in to help R22 when staff feel like. R22 stated R22 is wet and sad that the call light is not working. R22 stated the staff come to check on R22 sometimes. On 07/30/24 at 11:25 AM, V13 (Registered Nurse/RN) and surveyor observed R22's call light not working. V13 stated the call light is broken, and V13 did not know that the call light is broken. V13 stated R22 will not be able to communicate with the staff for toileting care and any care as needed. V13 stated the potential problem is that R22 could develop skin breakdown. On 07/30/24 at 11:45 AM, V7 (Certified Nursing Assistant/CNA) stated the importance of the call light is to keep resident safe, and for staff to be able to respond to their needs. V7 stated the potential problem could be fall, emotional fear, increased risk of skin breakdown. V2 stated the maintenance is aware that the call light is broken since weekend. On 07/30/24 at 12:03 PM, V2 (Director of Nursing/DON) stated, it is the expectation of V2 that staff will ensure safety of the resident by making sure the call light is working. V2 stated broken call light should be fixed immediately, V2 stated a broken call light cause the resident to miss necessary care and attention needed. V2 denied awareness of the broken call light. On 07/30/24 at 12:53 PM, V20 (Maintenance Manager) stated call light is a life and death issue. Normally the CNA will notify V20, but nobody told V20 about any broken call light. On 07/31/24 at 12:33 PM, R22's call light remains broken, and R22 is not happy about it. R22's MDS Section C (07/16/2024) documents in part: R22's BIMS score is 12, which means R22 awareness is cognitively intact. Call light policy (03/2021) documents in part: Report all defective call lights to the nurse supervisor and/or maintenance director; remove the guest from the room if the call light cannot be repaired. Maintenance Job Description, undated, documents in part: Inspects and identifies equipment or machines in need of repair and completes repairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 23 of 23