Health inspection·June 1, 2025

F 0600 R1's Progress notes indicated in part: 4/25/2025 8:07 pm Level of Harm - Actual harm Daily Skilled Note, Note Text: R1 returned from eye clinic, no new orders noted. Residents Affected - Few R2's clinical record indicates the following in part: R2 is a seventy-four-year-old male with medical diagnosis include but not limited to violent behavior, psychotic disturbance, mood disturbance, schizoaffective disorder, and hypertensive heart disease. Minimum data set [MDS] section C indicates R2 is cognitively intact, able to make his needs known. R2 MDS section [GG] indicates R2 is independent with ADL care, transfers, and able to ambulate independently. R2's Progress Notes in part; 4/25/2025 07:52 am Behavior Note Note Text: Staff reported to writer that R2 exhibited physical aggression toward a co-peer. Staff responded immediately, intervening to de-escalate the situation and ensure the safety of all residents. Individual was receptive to redirection. Staff provided counseling and educated R2 on the potential consequences of such behavior. No injuries were reported at this time. MD has been notified, and a petition has been initiated for the R2 to be transferred for further evaluation. R2 remains on 1:1 until the arrival of ambulance. R2's Progress Notes in part; 4/25/2025 9:29 am, General Note Text: R2 was transferred to Hospital. Petition, face sheet and med list sent with. R2's Progress Notes in part; 4/25/2025 8:51 am: Daily Skilled Note Note Text: Follow up call placed to hospital, spoke to Nurse, resident admitted with a diagnosis of aggressive behavior. Interviews: On 5/31/25 at 12:10 PM, R1 stated, R2 hit me four times and he hurt my eye. On 5/31/25 at 11:30 AM R2 stated, R1 and I was in the day room and R1 got mad at me. R1 told me he was going to kill me, so I started hitting him. R1 then started hitting me, I threw him onto the floor and started stomping on him like this: [ Surveyor observed R2 hold up his leg bending his knee and came down with his leg hitting his foot against the floor making a loud noise several times.] Then the staff stopped me from hitting R1, but R1 shouldn't have told me he was going to kill me. On 5/31/25 at 11:45 AM, R3 stated, I have not been abused at the facility nor have I witness abuse. I feel safe residing here at the facility. On 5/31/25 at 1:30 PM, V3 [Licensed Practical Nurse] stated, I was working on 4/25/25. I was passing medications in the day room. I heard yelling and looked up and seen R2 bent over with his arms swinging fast in the air back and forth. I yelled out for help and security assisted me with separating the two residents. R2 jumped on R1 and was punching him in the facial areas. R1's right eye and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 2 of 6 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 06/01/2025 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 over his face was bruised black and blue in color. I called the V2 [Director of Nursing] she was in the facility, and she came up to the day room. V2 called V1 [Administrator], and he was made aware of the incident, I heard him on the phone with V2. R1 was sent out to an eye specialist the same day for emergency eye appointment. Residents Affected - Few On 5/31/25, at 1:50 PM, V4 [Licensed Practical Nurse] stated, I heard a commotion coming from the day room, I saw R1's eye was swollen and black in color. I phoned the hospital eye clinic and got him the same day appointment. R1 went out the eye appointment and returned with no new orders. On 5/31/25 at 2:10 PM, V5 [Certified Nurse Assistant] stated, I did not witness the incident between R1, and R2 I was not on the floor. On 5/31/25 at 2:23 PM, V6 [Certified Nurse Assistant] stated, I was in another residents' room providing ADL and when the incident occurred between R1 and R2. On 5/31/25 at 4:00 pm V7 [Social Service] stated, , R2 has a history of physical aggression. Upon R2's admission R2 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 R2 was hitting R1 in the face. R2 was petitioned out for psych evaluation. R2 had two other incidents of physical aggression toward other residents. R2 was sent out for another psych eval from a physical altercation with another resident and returned to the facility on 5/5/2. R2 is monitored one to one by social service staff. I am trying to find a nursing facility that can meet R2's needs. We will be monitoring R2 closely. On 5/31/25 at 3:00 PM, V2 [Director of Nursing] stated, I had just walked into the facility, and I was phoned, and I went up immediately to the day room. R1 had a discolored right eye, R2 was sitting with one-to-one staff monitoring. I immediately phoned V1 [Administrator] and made him aware of the physical altercation. R2 has a history of physical aggression and was petition out for psych evaluation. On 5/31/25 at 3:15 PM, V1 [Administrator] stated, The incident between R1 and R2 occurred on 4/25/25, not 4/24/25 that date was a typo mistake. [Surveyor asked V1; What was the conclusion of his investigation] V1 sated, I do not remember what happened or if I was told about the allegation, read the report, all the information you need is on there. The allegation of physical abuse was substantiated, R2 hit R1 in the facial area and note discoloration on R1's face. All new hires receive abuse training, and all staff receive abuse training annual and as needed. Policy document 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 3 of 6 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 06/01/2025 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 Mental abuse includes but not limited to humiliation, harassment, threats of punishment. Level of Harm - Actual harm The facility should identity occurrence and patterns of potential mistreatment. Residents Affected - Few Physical abuse is he infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Final Investigation Report: The investigator will report the conclusion of the investigation within five working days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 4 of 6 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 06/01/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility [A] failed to follow their Abuse Prevention Program Policy and report an allegation of abuse within 2 hours of the incident to IDPH (Illinois Department of Public Health) and [B] failed to submit the final report to IDPH within five business days for two 2 (R1 and R2) of three [R3] residents reviewed for abuse. Findings include, R1's clinical record indicates the following in part: R1 is a seventy-four-year-old male with medical diagnosis of Parkinson's Disease, chronic obstructive pulmonary disease, dysphagia, seizures disorder, contracture of left knee, contracture of right knee, major depression disorder and schizophrenia. [NAME] Date Set [MDS] section [C] indicates R1 is cognitively impaired. R1's MDS section [GG] indicates he needs maximal assistance with ADL Care, and transfers. R1 is unable to ambulate. R2's clinical record indicates the following in part: R2 is a seventy-four-year-old male with medical diagnosis include but not limited to violent behavior, psychotic disturbance, mood disturbance, schizoaffective disorder, and hypertensive heart disease. Minimum data set [MDS] section C indicates R2 is cognitively intact, able to make his needs known. R2 MDS section [GG] indicates R2 is independent with ADL care, transfers, and able to ambulate independently. Interviews: On 5/31/25 at 12:10 PM, R1 stated, R2 hit me four times and he hurt my eye. On 5/31/25 at 11:30 AM R2 stated, R1 and I was in the day room and R1 got mad at me. R1 told me he was going to kill me, so I started hitting him. R1 then started hitting me, I threw him onto the floor and started stomping on him like this: [ Surveyor observed R2 hold up his leg bending his knee and came down with his leg hitting his foot against the floor making a loud noise several times.] Then the staff stopped me from hitting R1, but R1 shouldn't have told me he was going to kill me. On 5/31/25 at 1:30 PM, V3 [Licensed Practical Nurse] stated, I was working on 4/25/25. I was passing medications in the day room. I heard yelling and looked up and seen R2 bent over with his arms swinging fast in the air back and forth. I yelled out for help and security assisted me with separating the two residents. R2 jumped on R1 and was punching him in the facial areas. R1's right eye and over his face was bruised black and blue in color. I called the V2 [Director of Nursing] she was in the facility, and she came up to the day room. V2 called V1 [Administrator], and he was made aware of the incident, I heard him on the phone with V2. R1 was sent out to an eye specialist the same day for emergency eye appointment. On 5/31/25 at 3:00 PM, V2 [Director of Nursing] stated, I had just walked into the facility, and I was phoned, and I went up immediately to the day room. R1 had a discolored right eye, R2 was sitting with one-to-one staff monitoring. I immediately phoned V1 [Administrator] and made him aware of the physical altercation. R2 has a history of physical aggression and was petition out for psych evaluation. On 5/31/25 at 3:15 PM, V1 [Administrator] stated, The incident between R1 and R2 occurred on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 5 of 6 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 06/01/2025 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 0609 4/25/25, not 4/24/25 that date was a typo mistake. Level of Harm - Minimal harm or potential for actual harm [Surveyor asked V1; What was the conclusion of his investigation] V1 sated, I do not remember what happened or if I was told about the allegation, read the report, all the information you need is on there. The allegation of physical abuse was substantiated, R2 hit R1 in the facial area and note discoloration on R1's face. All new hires receive abuse training, and all staff receive abuse training annual and as needed. Residents Affected - Few The incident occurred on 4/25/25 I uploaded documents and typed in the incident director on the IDPH portal on 5/6/25. I completed the IDPH follow up by typing in direct information on 5/12/25, that time I did not upload any documents or the final report. The IDPH portal did not give me any confirmation. Abuse allegation is to be reported immediately and the final report to IDPH is to be sent within five business days. Reviewed Facility's IDPH Report Incident of 4/25/25. Initial was loaded on the IDPH Portal on 5/6/25. [The physical abuse allegation was reported ten days later] The final report on the IDPH Portal was submitted on 5/31/2025 at 12:28 PM by V1. Policy document 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. The facility should identity occurrence and patterns of potential mistreatment. Physical abuse is he infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Final Investigation Report: The investigator will report the conclusion of the investigation within five working days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146164 If continuation sheet Page 6 of 6