Health inspection·May 18, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to assist one resident (R1) of three reviewed in a sample of three with communication and access to services inside and outside the facility. This failure resulted in R1 not getting his social security card. Findings include: R1's current face sheet documents R1's medical conditions to include but not limited to: type 2 diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease, stage 3 unspecified, acquired absence of right/left leg below knee, unspecified combined systolic (congestive) and diastolic (congestive) heart failure. MDS (Minimum Data Set) section C -Cognitive Function dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) as 15/15 indicating R1 has intact cognitive function. On 05/17/2025, at 10:06 AM, R1 was observed laying in bed awake. R1 was alert, oriented to person, place, time, and situation. R1 stated he applied for his Social Security (SS) card about four weeks ago, but he has not yet received it. R1 stated he wanted to go to social security administration offices and follow up on his SS card. R1 called the senior citizen bus company for transportation to take him to SS offices but the facility told him he cannot go alone and that the facility would assist him. R1 stated to date no one in the facility has assisted him in following up with his SS card. R1 stated he needs his SS card to apply for housing and financial assistance. On 05/17/2025, at 12:40 PM, V7 (Business Office Manager) stated if R1 has applied for his social security card, the facility has not received it yet. V7 stated V9 (Psychiatric Rehabilitation Services Coordinator (PRSC) come to the admissions office a few weeks ago in April (Cannot remember date) and was talking to V10 (Admissions Director). V10 mentioned that R1 wanted to go to social security office to get a social security card. V7 stated V10 told V9 that R1 did not have to go to the Social Security office to apply for his social security card because he can do it at the facility through the phone. V7 stated she did not follow up after that conversations and does not know if R1 was assisted with applying for or following up on his social security card. V7 stated a social security card is used for identification purposes for various things. If R1 was asking for assistance getting it, he should have been assisted by the facility. V7 stated when a resident comes to the facility all their identification including a social security card is uploaded in their electronic medical record. V7 stated R1 does not have a social security card uploaded in his electronic medical record and if R1 was assisted with getting his card, it could have been uploaded into his medical records. V7 state she, V9 and V10 could have assisted R1 in following up on his SS card. (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 05/18/2025 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)