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 Page 1 of 2 146164 146164 04/13/2025 Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tried to remove the shower head from the hose. It will be warmer without the shower head. 97 or 98 degrees Fahrenheit is okay. If it gets down to the 80's that's cold. On 4/12/2025, at 5:00 PM, V1 (Administrator) said during peak hours (early morning) residents are getting up, taking showers; bed baths are given. That's when we anticipate that water will be a little colder. The few times he (R1) complained that it (bath water) was cold, maintenance went to check. He (V3) didn't put the exact temperature on the concern form. The rooms below R1's room would be cold as well; hot water rises. It (water temperature R1's hand sink) was till 97 or 98 degrees when we (V1 and V3) checked it; it's hot but not up to what he (R1) wants. It's not cold in such a way that it's not acceptable. If it's too cold the CNAs (Certified Nursing Assistants) know to notify maintenance; maintenance will adjust the water from the boiler as needed. R1 is the only resident who complained of cold water in March. I followed up on the concern by reviewing the form, the issues were resolved. V1 said water temperatures are checked daily as part of the facility's water management program. V3 randomly hits (checks) showers and residents' rooms. We don't keep a log of every single temperature in residents' rooms. We don't have a specific policy for water temperatures. The facility did not provide water temperature policy. On 4/13/2025, at 8:31 AM, via telephone, V7 (PRSC-Psychiatric Rehabilitation Services Coordinator) initially said she did not recall speaking with R1's Emergency Contact # 1 (V12). She recalled the conversation after the surveyor read the concern of 3/26/2024 to V7. V7 said, What I was doing during that call was to let that person know who I am and what support I can provide. I was instructed by my supervisor (V5 (PRSD-Psychiatric Rehabilitation Services Director) to reach out to the POAs (Power of Attorney)/emergency contacts. I overheard some of things that were going on, it was just kind of a suggestion. I guess it was just a suggestion with being new and how I could handle the caseload. Of, course the family members need to know who I am. V12 wanted information about R1's care plan, shower and diet. You would have to ask V12 they had any concerns. Now if they (V12) wanted to have specific details about showers, that not my duty, I would refer them to nursing. V12 wanted to know if R1 is taking showers, is there a showering schedule. On 4/13/2025, at 9:11 AM, via telephone, V12 (V1's Emergency Contact # 1) said, R1 told me about the cold water. They wash him up with a wipe. V7 (PRSC-Psychiatric Rehabilitation Services Coordinator) called me to introduce herself. She asked me if there was anything she could do to help me. I told her about the cold water, the baths. She was sending me all over the place. She couldn't help me with anything. I don't feel that my concerns were resolved. Maintenance App Form Task# 34342764 submitted by V8 (CNA-Certified Nursing Assistant) on 3/3/2025, at 1:07 PM, documents hot water not working in room [ROOM NUMBER]. Task was assigned to V3 on 3/5/2025, at 5:43 AM. Under Notes: hot water is getting hotter. Concern and/or Compliment Action Form completed by V7 (PRSC-Psychiatric Rehabilitation Services Coordinator) on 3/26/2027 (2025), referral date 3/27/2025 documents: Patient's emergency contact #1 verbalized concerns regarding being brought abreast on patient's care plan, expressed concerns about showering patient and/or patient's showering schedule and explained that patient does not eat pork and has concerns about pork regularly being served to the patient. Action taken or resolution: PRSD (Psychiatric Rehabilitation Services Director) spoke with the CNA and dietary supervisor regarding the concerns expressed. The issue would be resolved. No time or date resolved noted on form. 146164 Page 2 of 2