Health inspection·April 13, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain hot water at comfortable level in one resident's hand sink for one of four residents (R1) in a total sample of 5. Findings include: On 4/12/2025, at 10:44 AM, V3 (Maintenance Director) stated, I received a complaint from a resident on the 3rd floor. I don't know his name; I will know him when I see him. He is in room (3rd floor room) I was in a room, maybe three weeks ago, one of the nursing staff told me the water in resident's sink was coming out cold. I spoke with the resident; he told me staff don't let water in the hand sink run before filling his wash basin. (R1) said he receives cold bed baths. I did test the water temperature of the water in the hand sink, I turned it on, it felt really cold. I left it running, put my cart away and went downstairs to the basement to get my thermometer. I tested it when I retuned; it only got up to 105 or 106 (degrees Fahrenheit). Surveyor requested facility's temperature log and asked how often temperatures were checked. V3 said, You know what, that's a good question. Honestly, I dropped the ball on that. I don't keep a log on them. Shoot, I'm not going to lie, I probably checked them three weeks ago. I check the temperatures when I do water management on Mondays, Wednesdays, and Fridays (for legionnaires), but I don't record the temperatures. I didn't check the temperatures yesterday (Friday). No water temperature logs were provided to the surveyor. On 4/12/2025, at 11:42 AM, surveyor followed V3 (Maintenance Director) to R1's room. V3 identified R1 as the resident who earlier had a cold water complaint. V3 turned on the water in R1's hand sink, put his hand in the water and said, that's cold. On 4/12/2025, at 11:43 AM, R1 said I usually get my bed bath at 5:00 AM. The water is cold. It's going to be cold now when you check it. I reported this three to four weeks ago, it isn't any better. I don't know what the issue is. The maintenance man (V3-Maintenance Director) told me the water is cold because it takes time for the water to get up to the 3rd floor. V8 and V9 (CNAs-Certified Nursing Assistants) do not give cold baths. They get my bath water from across the hall, not my sink. On 4/12/2025, at 11:59 AM, V3's facility thermometer was verified as accurate to 32 degrees Fahrenheit (F) via ice bath prior to arrival to the floor. The water temperature was 97.3 degrees Fahrenheit. V3 said to surveyor, you let all my hot water run out. On 4/12/2025, at 12:25 PM, shower room water at northwest side of hallway is at 97 degrees. V3 (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 04/13/2025 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)