Health inspection·May 7, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few was sitting in the chair. This writer started yelling stop, stop! Called for security intervention, removed the lesser resident [R2] who was being hit to a safe location. When asked the aggressor [R1] what happened, he stated she [R2] got to stop cussing me. Then R1 then took a seat in the dining room and calmed down. Call was placed to R1's physician who gave an order to send the resident to emergency department with a petition. Administrator [V1] made aware, call placed to R1's family member, left voice mail message. R1's care plan documents in part: R1 exhibited physical aggression behavior towards another resident [4/5/25]. R1 exhibited physical aggression towards another co-peer [3/27/25]. R1 has a behavior problem [5/5/25]. R1 exhibits sexually inappropriate behavioral symptoms related to physical touching, grabbing, of staff when being assisted with ADL's. R2's clinical record indicates in part: R2 is a seventy-five-year-old female that needs an assistive device of a walker for mobility. R2 was admitted with the following medical diagnosis of schizoaffective disorder, bipolar type, chronic obstructive pulmonary disease, hypertensive heart disease, overactive bladder, unhappiness, and personal history of mental disorders. MDS section [C] indicates R2 is cognitively intact. R2's care plan document in part: R2 is at risk for abuse due to diagnosis of mental illness [11/21/24]. Interventions, assure R2 is in a safe and secure environment with caring professionals. Monitor R2's behavior to prevent predisposition to abuse [11/21/24]. R2 was involved in a physical altercation with another resident [R1] [ 3/27/25]. R2 uses psychotropic medication related to behavior management. R2 has diagnosis of schizoaffective disorder, bipolar and depressive types. R2 has a history of inappropriate attention seeking behavior but has demonstrated stability during the admission screening process; Intervene when any inappropriate behavior is observed. Communicate assertively that R2 must exercise control over impulses and behavior. R2 has history of poor verbal skills of expressing herself with the use profanity. Interviews: On 5/6 25 at 12:33 PM R1 stated, I been doing okay. I just came back from the hospital because I punched this [NAME] in the eye. I got into another fight with a lady here because she wouldn't not stop yelling. I went over and I started hitting her to make her shut up. I think I was hitting her in the head, face and chest, I am not sure I just kept swinging on her to make her shut her mouth. The nurse ran over and pulled me off R2. The lady kept screaming and crying. All that yelling makes me nervous and mad. I want to go back to my old facility where my brother lives. I do not like it here; the people here keep making me mad. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 2 of 4 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 05/07/2025 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)

F 0600 Level of Harm - Actual harm Residents Affected - Few On 5/6/25 at 1:10 PM R2 stated, I was attacked one morning while I was eating breakfast. This man out of nowhere started hitting me all in my head, face, and chest areas. I fell out of my chair on to the floor. I was yelling for help. The nurse stopped R1 from hitting me and helped me off the floor. I was in shock and scared. I did not know what was happening or why I was attacked. My head, face, and chest were hurting me, and I felt so humiliated, embarrassed, depressed, and scared that R1 might get mad at me because he was sent out to the hospital. I felt bad about myself, I did not know why me? Why was I attacked by this man in front of every one [residents] to see me get beat up for no reason. I cried for days every time I thought about what happened to me. They moved him to another floor. I feel safe here, but I will be nervous that I might see him again, I do not want to get beat up anymore. On 5/7/25 at 10:00 AM V3 [Licensed Practical Nurse] stated, On 3/27/25, I was in the dining room administering medications. I notice R1 moving fast, anxious, and pacing back and forth in the dining room. My intuition told me something was not right with R1. I should have removed R1 from the dining area or called extra staff for assistance, I was the only staff member in the dining area. I continue to administer medications; I could not focus all my attention on R1. Then I heard R2 say something, I am not sure what she said, but it was loud. When I looked up, I saw R1 with his hand raised up in the air standing over R2 as she was sitting in a chair, R1 started hitting R2. R1 was hitting her in the head, shoulder, and chest areas. I started to scream 'stop it, stop it' as I ran over to R2. R1 did stop striking R2 and I got R2 out of the chair to remove her from the area. During the time R1 was hitting R2, she was screaming to the top of her lungs and crying. R2 was just crying uncontrollably, she [R2] was mortified and devastated. All I could do was hug R2 trying to console her. R2 did not complain of any pain, she was just yelling out crying for quite some time, she really was not talking or answering my questions, she could not stop crying. I phoned R1 and R2's physicians, I received an order to petition R1 out for psych evaluation. I also notified the abuse coordination [V1] administrator of the incident. Moving forward I will act on my intuition and changes in resident behavior to remove the resident away from other residents to prevent an altercation. On 5/7/234 11:10 AM, V11 [Certified Nurse Assistant] stated, The day of the incident between R1 and R2, I was providing ADL care to another resident in their room. I heard screaming, and the nurse started calling my name. I ran into the dining room and saw R1 walking away from R2. She [R2] was yelling and crying. I stayed with R2, and the nurse called R1's physician. On 5/7/25 at 9:40 AM, V4 [Social Service Director] stated, R1 has a history of physical aggression. Upon R1's admission R1 appeared to be calm, but also exhibited inappropriate behaviors of physical touching, grabbing, of staff when being assisted with ADL's. I was not present during the altercation between R1 and R2, I heard R1 was hitting R2. R1 was petition out for psych evaluation. R1 had two other incidents of physical aggression toward other residents. R1 was sent out for another psych eval from a physical altercation with another resident and returned to the facility on 5/5/2. R1 is monitored one to one by social service staff. I am trying to find a nursing facility that can meet R1's needs. We will be monitoring R1 closely. On 5/7/25 at 3:40 PM, V1 [Administrator] stated, R1 and R2 had a physical altercation, V3 told me that R1 walked over and punched R2 in the chest area, while R2 was sitting in a chair. While R2 was being punched she did no retaliate or hit R1 back she did not do anything. R1 said that R2 was cursing, and he wanted her stop. R1 was petition out for psych evaluation. R1 has a history of physical aggression with other residents in the facility. Until we find placement, R1 is on one-to-one supervision to ensure the safety of other residents. All new hire receives abuse training during orientation. All staff received abuse training annually and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 3 of 4 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 05/07/2025 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)

F 0600 On 5/6/25 V10 [Registered Nurse], V7, V8, V9 and V11 [Certified Nurse Assistants] all said they received abuse training about two months ago and the abuse coordinator was the administrator. Level of Harm - Actual harm On 5/6/25, R3 stated, I have not experienced any abuse in the facility, I feel safe here. Residents Affected - Few Policy documented in part: Abuse dated 12/2024. -This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse neglect, misappropriation of resident property, involuntary seclusion, and exploitation. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Mental abuse includes but not limited to humiliation, harassment, threats of punishment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 4 of 4