Inspection·April 11, 2025

F 0558 and requires substantial/maximal assistance with toileting hygiene and total dependence for transfers. Level of Harm - Minimal harm or potential for actual harm R49's comprehensive care plan contains focuses for risk for falls and assistance with activities of daily living (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). Intervention for fall risk document in part, please make sure that (R49) call light is within her reach and encourage her to use it for assistance as needed. (R49) would like staff to address her needs with a prompt response to all requests for assistance. Intervention for ADL assistance includes to keep call lights within reach when in bedroom or bathroom. Residents Affected - Few R118 has diagnosis which includes but not limited to Pathological Fracture in Neoplastic Disease Hip, Subsequent Encounter for Fracture with Routine Healing, Muscle Wasting and Atrophy, Abnormalities of Gait and Mobility, Malignant Neoplasm of Lung, Secondary Neoplasm of Liver and Intrahepatic Bile Duct, Secondary Neoplasm of Bone, Secondary Neoplasm of Breast, Unspecified Fracture of Left Ilium. R118's MDS (Minimum Data Set) dated 03/13/25 documents in part, BIMS (Brief Interview for Mental Status) score is 14 out of 15 indicating intact cognition, functional limitations in range of motions to lower extremities, and requires substantial/maximal assistance with toileting hygiene and total dependence for transfers. R118's comprehensive care plan contains focuses for risk for falls and assistance with activities of daily living (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). Intervention for fall risk document in part, Remind (R118) to ask for assistance. Reorient (R118) on how to use the call light, if necessary. Intervention for ADL assistance includes in part, keep call lights within reach when in bedroom or bathroom. Facility provided policy titled, Call Light Policy last revised 07/26/2024, document in part: Be sure call lights are placed within reach of residents who are able to use it at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 2 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 (R68) resident was free from physical restraint. This failure could potentially affect 1 (R68) of 2 residents reviewed for physical restraint in a sample of 36. Residents Affected - Few The findings include : R68's admission record showed admission date on 10/8/22 with diagnoses not limited to Acute and chronic respiratory failure, Dependence on respirator [ventilator] status, Tracheostomy status, Acute on chronic diastolic (congestive) heart failure, Dysphagia oropharyngeal phase. On 4/9/25 at 9:58 AM Surveyor observed R68 lying in bed on moderate high back rest, with G-tube feeding infusing Glucerna 1.2 At 70ml/hr via pump machine. R68 with tracheostomy tube, indwelling urinary catheter. Observed R68 wearing bilateral mittens. On 4/9/25 At 11:49 AM V18 (Licensed Practical Nurse / LPN, Restorative Director) stated he has been working in the facility since 2018. He said restraint use should be assessed on admission, readmission, quarterly or significant change in condition. V18 stated there should be a consent prior to use of restraint and physician order should be obtained. He said the purpose of restraint is to prevent harm to self or others. V18 said other restrictive interventions should be done first prior to restraint application. He said care plan is done for restraint use. V18 said restraint should be applied or used if there is an order from the doctor, once assessment was done and consent was obtained. He said mittens are considered a restraint. Surveyor reviewed R68's EHR (Electronic Health Record) with V18 and said no doctor's order for restraint / mitten use found. He said no assessment for restraint use found when R68 was readmitted to facility on 3/20/25. Surveyor informed that R68 was using mittens. V18 said care plan dated 12/24/2024 R68 has physical restraints right hand mittens related to behavior of pulling out g-tube and tracheostomy. On 4/10/25 at 9:44 AM Surveyor observed R68 lying in bed wearing bilateral mittens on right and left hand. Surveyor requested V39 (Certified Nursing Assistant / CNA), V39 stated she is assigned to R68. V39 Stated R68 is wearing mittens on right and left hand to prevent pulling out tubes. On 4/10/25 at 10:09 AM Surveyor requested V8 (LPN) to R68's room and stated R68 is wearing bilateral mittens. Surveyor instructed V8 to check physician order for mittens. On 4/10/25 at 10:14 AM V2 (DON / Director of Nursing) stated he has been working in the facility since 2017. Surveyor reviewed R68's EHR with V2 and stated R68 has an active restraint physician order dated 4/9/25 to apply Right arm mitten to prevent pulling out tube. Remove right arm mitten every 2 hours. He said there is no order of mitten on left hand. V2 said R68 has Care plan for Right hand mitten. V2 said Mittens are considered a restraint, needs a physician order, assessment and consent before application or use. He said staff is not supposed to apply mitten / restraint with no doctor's order, assessment or consent. MDS (Minimum Data Set) dated 3/26/25 showed R68's cognition was severely impaired. She needed total assistance or dependent to staff with oral, toileting and personal hygiene, shower / bathe self, upper and lower body dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 3 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0604 Level of Harm - Minimal harm or potential for actual harm Care plan with review date on 4/3/25 showed in part: R68 has physical restraints right hand mittens related to behavior of pulling out g-tube and tracheostomy tube. R68's Physical restraint informed consent dated 12/4/24 showed in part: Right hand mitten. Resident pulling trach tubing and G-tube. Residents Affected - Few R68's order summary report dated 4/9/25 showed active order not limited to apply right hand mitten to prevent pulling at tubes. Order was put in on 4/9/25 after surveyor informed V18 that R68 was wearing mittens. No physician order found for left hand mitten. No restraint assessment found in R68's EHR for readmission on [DATE]. Facility's restraints policy dated 8/19/24 showed in part: It is the facility's responsibility to ensure that each resident is not restrained for the purposes of discipline or convenience. The facility will utilize non-restraining interventions first before trying restrain-type devices which will be considered as last resort. Physical restraint is defined as any manual method, physical or medical device, equipment or material that meets ALL of the following criteria: (A) Attached or adjacent to the resident's body. (B) that the individual cannot intentionally remove easily, and (C) restricts freedom of movement or normal access to one's body. In the event that resident's condition warrants the use of restraint, a restraint device assessment will be done to determine if the device is appropriate for the resident. Once the assessment determines that the device or intervention is a restraint, a physician order will be obtained indicating the type of device to be used. A care plan will be put in place to address the use of restraint. A non restraining intervention or device should be reflected in the care plan or in the progress notes. Facility provided residents' rights in long term care facilities dated 11/18 showed in part: Rights to safety. Right to be free from physical restraints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 4 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders and plan of care for restorative services and failed to complete quarterly restorative assessments that detail the progress or lack of progress in the restorative services for 4 (R6, R71, R87, R159) residents out of 5 reviewed for limited range of motion and/or restorative services in the sample of 36. Findings Include: On 4/8/25 at 11:09 AM, R87 was lying in bed alert and able to verbalize needs. R87 was noted with left arm paralysis and contracture. When asked if R87 has been receiving some type of range of motion exercises for his left arm and hand in the last 30 days, R87 answered No. R87 stated that staff does not perform any exercises on his left arm/hand. Surveyor observed left hand splint was not applied on R87's left hand and was sitting on top of his bed side table. R87's clinical records show R87 was initially admitted in the facility on 3/25/19 with included diagnosis but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R87's Quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 1/27/25 shows R87 is moderately impaired with cognition. R87's comprehensive care plan shows R87 has contracture on the left hand, with left resting hand splint with interventions that read: Apply left resting hand splint to prevent further contracture. May wear up to 8 hours per day or as tolerated x 6-7 days, as per facility protocol. Gentle PROM [Passive Range of Motion] upon application and removal. Check skin daily. PROM to left hand before and after use 6 to 7 times per week. R87's Restorative minutes in the last 30 days from 4/9/25 shows R87 did not receive his restorative programs 6-7 days per week. R87's comprehensive care plan and last 30 days progress notes from 4/10/25 do not document R87 is refusing restorative programs and no documentation if physician was notified. R87's restorative assessment dated [DATE] does not detail R87's progress or lack of progress in the restorative services. On 4/8/25 at 11:20 AM, R6 was lying in bed alert and [NAME] to verbalize needs and noted with range of motion limitations on both arms. When asked if R6 has been receiving some type of range of motion exercises for his arms in the last 30 days, R6 stated maybe 4-5 times a week. R6's clinical records show R6 was initially admitted in the facility on 11/6/07 with included diagnosis but not limited to other specified disorders of bone density and structure, unspecified site. R6's Quarterly MDS assessment with ARD of 1/21/25 shows R6 has moderately impaired cognition and with functional limitation in range of motion to both upper and lower extremities. R6's order summary report printed on 4/8/25 shows orders for: NURSING REHAB (ordered 7/24/24) for active range of motion to both upper extremities and both lower extremities times10 reps times 15 minutes 6-7 days per week and as tolerated. NURSING REHAB (ordered 12/23/21) for dressing/grooming, [R6] will wash hands and face with soap and water times 6-7 days per week or as tolerated. R6's Restorative minutes in the last 30 days from 4/9/25 shows R6 did not receive his restorative programs 6-7 days per week as ordered. R6's comprehensive care plan and last 30 days progress notes from 4/10/25 do not document R6 is refusing restorative programs and no documentation if physician was notified. R6's restorative assessment dated [DATE] does not detail R6's progress or lack of progress in the restorative services. On 4/8/25 at 11:23 AM, R71's lying in bed alert and able to verbalize needs. R71's noted with left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 5 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some arm weakness and contracture. R71 stated, Every now and then it will get stiff that I can't move them. Same thing with my left leg. No one's doing any stretching or exercises. They are supposed to do at least some exercises, but they don't. When asked if R71 has been receiving some type of range of motion exercises for his left arm and leg in the last 30 days, R71 answered No. R71's clinical records show R71 was initially admitted in the facility on 5/22/20 with included diagnosis but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side. R71's Quarterly MDS assessment with ARD of 3/3/25 shows R71 is cognitively intact and with functional limitation in range of motion to one upper extremity and two lower extremities. R71's order summary report printed on 4/8/25 shows orders for: NURSING REHAB (ordered 5/24/21) to apply left foot brace to prevent further foot drop, may wear up to 8 hours a day or as tolerated times 6-7 days/week, as per facility protocol. Gentle PROM upon application and removal. Check skin daily. NURSING REHAB (ordered 6/2/20) of dressing/grooming, [R71] will wash hands and face with soap and water time 6-7 days per week or as tolerated. Provide verbal instructions and encouragement as needed. NURSING REHAB (ordered 6/2/20) of active range of motion to both upper extremities and both lower extremities time 10 reps times 15 minutes 6-7 days per week and as tolerated, provide verbal instructions and encouragement as needed. R71's Restorative minutes in the last 30 days from 4/9/25 shows R71 did not receive his restorative programs 6-7 days per week as ordered. R71's comprehensive care plan and last 30 days progress notes from 4/10/25 do not document R71 is refusing restorative programs and no documentation if physician was notified. R71's restorative assessment dated [DATE] does not detail R71's progress or lack of progress in the restorative services. On 4/8/25 at 11:36 AM, R159's lying in bed alert and able to verbalize needs. R159 was noted with both hands' contractures. R159 stated he can't walk anymore. When asked if R159 has been receiving some type of range of motion exercises for his contractures in the last 30 days, R159 answered No. They are not doing any of that. R159's clinical records show R159 was initially admitted in the facility on 9/11/24 with included diagnosis but not limited to polyosteoarthritis. R159's Quarterly MDS assessment with ARD of 2/26/25 shows R159 is cognitively intact and with functional limitation in range of motion to both lower extremities. R159's order summary report printed on 4/8/25 shows orders for: NURSING REHAB (ordered 12/3/24) for active range of motion to both upper extremities and both lower extremities times10 reps times 15 minutes 6-7 days per week and as tolerated. NURSING REHAB (ordered 12/3/24) for dressing/grooming, [R159] will wash hands and face with soap and water times 6-7 days per week or as tolerated. R159's Restorative minutes in the last 30 days from 4/9/25 shows R159 did not receive his restorative programs 6-7 days per week as ordered. R159's comprehensive care plan and last 30 days progress notes from 4/10/25 do not document R159 is refusing restorative programs and no documentation if physician was notified. R159's restorative assessment dated [DATE] does not detail R6's progress or lack of progress in the restorative services. On 4/9/25 at 10:53 AM, interviewed V18 (Restorative Director/Licensed Practical Nurse) and stated restorative assessments are done and re-evaluated quarterly, annually, and with significant changes to determine the appropriate programs for the residents. V18 stated that the assessment should also indicate if resident is refusing restorative programs. V18 stated restorative assessments are documented in the residents'' electronic chart. If they are refusing it is documented and should be in the care plan. The restorative aide documents the refusal in the resident's electronic charting. The restorative nurse will also document for refusals. V18 stated that sometimes restorative indicates the progress or lack of progress of the resident with restorative programs. The restorative programs should be in the physician orders, triggered in the residents' task for the restorative aide to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 6 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some document electronically if it's provided or not. V18 stated that the restorative staff provides restorative programs to the residents depending on the order usually 6-7 days a week for at least 15 minutes or more a day. Restorative staff would document electronically in the resident's chart if the programs were provided. V18 stated that if it's not documented, it is not done. V18 stated restorative programs are care planned. V18 stated R87's most recent restorative assessment was completed on 2/25/25. It does not say R87's progress with the programs, but the assumption is maintained. R87 is on bed mobility 6-7 days a week, resting hand splint for 8 hours per day 6-7 days, PROM (Passive Range of Motion) on left upper extremity and left lower extremity for 6-7 days a week. V18 stated R87 should have been getting 6-7 days a week of restorative programs since re-admission on [DATE]. V18 stated that based on the documentation, R87 received 16 days of restorative programs in the last 30 days. V18 stated R87 did not receive 6-7 days a week of restorative programs. V18 stated R71's most recent restorative assessment was completed on 2/25/25 and it does not state his progress with the restorative programs. V18 stated R71 is on dressing and grooming 6-7 days a week and PROM on both upper extremities and both lower extremities for 6-7 days a week. V18 stated R71 received 11 days of PROM, and dressing/grooming he received 8 days in the last 30 days. V18 stated R71 did not receive 6-7 days a week of restorative programs. V18 stated R6's recent restorative assessment was completed on 1/15/25 and his progress shows maintained. V18 stated R6 is on AROM (Active Range of Motion) and dressing/grooming 6-7 days a week. V18 stated R6 received 19 times of AROM in the last 30 days and 18 times of dressing/grooming. V18 stated R6 did not receive 6-7 days a week of restorative programs. V18 stated R159's recent restorative assessment was completed on 2/25/25 and it does not state if there is progress or lack of progress with restorative programs. V18 stated R159 is on dressing/grooming 6-7 days a week and AROM to both upper and lower extremities for 6-7 days a week. V18 stated R159 only received 3 days of AROM and dressing/grooming in the last 30 days. V18 stated R159 did not receive 6-7 days a week of restorative programs. The facility's Restorative Nursing Program policy dated 8/19/24 reads in part: Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. Nursing and restorative services shall be reflected in the resident's individualized care plan consistent to the completion of the resident comprehensive assessment. Restorative Programs shall be reflected and indicated in the resident's electronic restorative log in order to document the provision of services and the frequency by the nurses, cnas [Certified Nursing Assistants] and/or restorative aides. The Restorative Programs shall be evaluated on a quarterly basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 7 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 4/9/25 at 10:27 AM, Surveyor entered R6's room and observed R6's bed in a high position. R6 observed lying in bed with head of bed up at 30 degrees. R6's bed observed in a high position that reaches surveyor's waist measuring approximately 3 feet in height. R6 stated he is not sure why his bed is positioned so high. R6 stated he doesn't want the bed that high. On 4/9/25 at 10:28 AM, V19 (Registered Nurse) stated that R6 is high risk for falling and one fall precaution is to make sure that R6's bed is in low position. Surveyor notified V19 of R6's bed being in a high position. On 4/9/25 at 10:29 AM, V19 and surveyor entered R6's room and observed R6's bed position. V19 stated R6's bed should not be this high. V19 asked R6, Hey why are you so high up? R6 did not answer. Surveyor observed V19 lowered R6's bed to the lowest position. On 4/9/25 at 1:18 PM, interviewed V29 (Fall Coordinator) and stated that R6 is high risk for fall because of poor cognition and he needs assistance from staff. V29 stated R6's fall interventions to prevent him from falling include incontinence care, two half side rails, call light within reach, and bed in the low position not high. V29 stated that if R6's bed is left in high position, he could potentially move himself and fall off the bed that could cause greater injury. The facility's Fall Prevention Program Guidelines dated 12/5/24 documents in part: Fall prevention guidelines shall be implemented to promote safety of all residents in the facility. The bed shall be in the locked position at all times and maintained in a position appropriate for resident transfer. Based on observation, interviews, and record review the facility failed to a.) ensure fall preventative measure was followed for a resident (R6) at high risk for falling, and b.) prevent a second fall post-hospitalization for an initial fall which occurred at the facility for one (R32) out of eight residents reviewed for falls in a total sample of 36. Findings include: R32 is a [AGE] year-old male, admitted to the facility 02/13/25 with diagnosis not limited to Idiopathic Peripheral Autonomic Neuropathy, Abnormalities of Gait and Mobility, History of Falling, Adult Failure to Thrive, Unspecified Severe Protein-Calorie Malnutrition, Chronic Pain, Rheumatoid Arthritis, Osteoarthritis of Knee, Systemic Involvement of Connective Tissue, Spinal Stenosis. R32's MDS (Minimum Data Set) dated 03/04/25 document R32's BIMS (Brief Interview of Mental Status) score of 14/15 indicating intact cognition. R32's Activities of Daily Living (ADLs) Assistance documents that R32 requires partial/moderate assistance with toileting and transfers. Per R32's Electronic Health Record (EHR) on 02/21/25, R32 had a mechanical fall while walking in his room. R32 was transferred to the hospital and admitted for left femoral fracture. R32 did not have surgery. R32 readmitted to the facility on [DATE] at or around 14:06 wearing a knee brace and sustained another fall at or around 16:40 on 02/27/25 in R32's room. R32's medical provider was notified and ordered x-rays to the left hip and left knee which showed no evidence of acute fracture, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 8 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0689 dislocation. Level of Harm - Minimal harm or potential for actual harm R32's Fall Risk Evaluation dated 02/13/25 documents R32's is at high fall risk based on score of 13.0. R32's initial fall risk care plan dated 02/20/25 documents (R32) is at risk for falls related to current medication use, medical diagnosis, and comorbidities. Focused intervention created on 02/20/25 documented, Remind me to ask for assistance. Reorientate me on how to use the call light, if necessary and Please teach me to change positions slowly, especially from lying to sitting to standing. Residents Affected - Few R32's Fall Risk Evaluation dated 02/27/25 documents high fall risk based on score of 13.0. R32's fall risk care plan interventions entered on 02/27/25 documents in part, Remind (R32) to ask for assistance. Reorient (R32) on how to use the call light, if necessary and Please teach (R32) to change positions slowly, especially from lying to sitting to standing. It was noted by surveyor that the intervention PT to evaluate for my strength and use my walker properly and safely and more frequent monitoring intervention was created on 02/28/25, after second fall had already occurred. On 04/09/25 at 1:20 PM, V29 (Fall Coordinator/Psychotropic Nurse) stated the initial fall risk assessment is completed by the admitting nurse and the restorative staff are responsible for doing the initial fall risk care plan. V29 stated she would not know if a resident was assessed as being at high fall risk because she is not the one who fills out the initial fall risk assessment. V29 stated residents who are identified as being at high fall risk are not referred to her. V29 stated she assumes restorative knows what interventions should be put in place for a resident who is identified as being at high risk for falls. V29 stated once a fall has occurred that is when she is notified and then she is the one who is responsible for investigating the fall and updating the fall care plan with new interventions to prevent another fall. V29 stated the goal is for the resident not to have any falls and/or injuries. V29 stated she completed the investigation of R32's fall on 02/21/25 in which R32 sustained a left femoral fracture and upon readmission post-hospitalization for that fall R32 had another fall on the same day of readmission. V29 stated R32 was trying to transfer himself from the bed to sit on a chair at the bedside and he lost his balanced and fell on his but. V29 stated R32 did not call for assistance before trying to transfer himself. V29 stated fall care plan interventions were put in place for R32 to be reminded to use the call light for assistance. V29 stated there should be new interventions after a fall to prevent another fall. On 04/10/25 at 8:55 AM. V2 (Director of Nursing) stated since R32 fell within one to two hours of being readmitted from the hospital on [DATE]. V2 stated verbal education was provided to R32 on using the call light, and R32's fall care plan was updated to include to remind him to ask for assistance and reoriented him on how to use the call light. V2 stated these interventions were entered into his care plan as soon as he entered the building, and they were new interventions. Surveyor reviewed with V2 that interventions dated 02/20/25 and 02/27/25 upon readmission post-fall were the same. V2 stated he did not realize R32 had those same interventions as part of his care plan prior to hospitalization. V2 stated different interventions should be put into place to prevent possible new falls. Facility provided policy titled, Fall Occurrence revised 07/26/24, documents in part, it is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 9 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided to residents by not applying dressing to G-tube site and not following enteral feeding formula as ordered by physician. These failures have the potential to affect 2 (R141 and R149) of 3 residents reviewed for Tube Feeding in a sample of 36. The findings include: R141's admission record showed admit date on 10/12/23 with diagnoses not limited to Severe hypoxic ischemic encephalopathy, Chronic respiratory failure with hypoxia, Dependence on respirator [ventilator] status, Unspecified diastolic (congestive) heart failure, Chronic embolism and thrombosis of deep veins of unspecified upper extremity, Peripheral vascular disease, Dysphagia oropharyngeal phase, Pressure ulcer of sacral region stage 4, Type 2 diabetes mellitus with other skin ulcer, End stage renal disease, Anoxic brain damage, Unspecified protein-calorie malnutrition, Gastrostomy status, Tracheostomy status. R149's admission record showed admit date on 11/06/2024 with diagnoses not limited to Acute respiratory failure, Chronic kidney disease, Encounter for attention to tracheostomy], Paroxysmal atrial fibrillation, Chronic diastolic (congestive) heart failure, Gastrostomy status. On 4/09/25 at 9:51 AM Observed R149 lying in bed, with tracheostomy, alert and verbally responsive using mouth words. R149 showed G-tube (Gastrostomy) site to surveyor and observed no dressing in place. She stated it was never covered and she did not refuse for G-tube dressing. Surveyor requested V8 (LPN / Licensed Practical Nurse) to R149's room and stated G-tube dressing should be done daily and as needed to make sure site is clean and G-tube is in place. V8 checked R149's G-tube site and stated there is no dressing in place. MDS (Minimum Data Set) dated 2/4/25 showed R149's cognition was intact. R149 physician order summary report dated 4/9/25 showed active order not limited: Cleanse enteral tube feeding site with normal saline and apply dry dressing. On 4/10/25 at 9:57 AM Surveyor observed R141 lying in bed, on moderate high back rest with G-tube feeding infusing Two Cal HN 2.0 at 55ml/hour via pump machine. Tube feeding formula bottle was labelled with start date on 4/10/25 and start time at 1:00am. On 4/10/25 at 10:07 AM Surveyor asked V8 about R141 tube feeding doctor's order and stated Vital 1.5 at 55ml/hr. Surveyor requested V8 (LPN) to R141's room. V8 checked tube feeding formula infusing to R141 and stated Two Cal HN 2.0 at 55ml/hr. R141 MDS dated [DATE] showed R141's cognition was severely impaired, no BIMS (Brief Interview for Mental Status) score. R141 order summary dated 4/9/25 showed active order not limited to: Enteral feeding- Tube type: Gtube, Vital 1.5, Rate: 55 ml/hr, continuously. start at 7am, off at 5am. Turn off during ADLs and PRN (as needed). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 10 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/10/25 at 10:14am V2 (DON / Director of Nursing) stated he has been working in the facility since 2017. He said G-tube dressing should be done daily and as needed or as ordered by physician. V2 said the purpose of G-tube dressing is to prevent skin breakdown and to make sure G-tube is patent and site is clean to prevent complications. Surveyor reviewed R141's physician order for G-tube feeding with V2 and V2 said Vital 1.5 at 55 cc/hr start 7am and off at 5am. He said nurses are expected to follow doctor's order for tube feeding, if not followed resident could potentially not get the prescribed calories or nutrition as ordered by physician. V2 said R141 could have reactions or complications from enteral feeding, if doctor's order was not followed. Facility's enteral tube feeding care policy dated 7/26/24 showed in part: Nurse to check in the POS (physician order sheet) / MAR (medication administration record) the order for enteral feeding interventions: Feeding formula. Enteral tube stoma care: Site must be cleansed and covered with a dry gauze daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 11 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 4/8/25 at 11:33 AM, R159 was lying in bed alert and able to verbalize needs. R159 was noted on Oxygen via nasal cannula with the oxygen concentrator flow rate set to 5 liters per minute (LPM). R159 stated he has emphysema. Residents Affected - Some On 4/8/25 at approximately 11:37 AM, Surveyor asked V19 (Registered Nurse) to check R159's oxygen. V19 confirmed that the oxygen flow rate was set to 5LPM. V19 stated that R159 should be getting 4LPM of oxygen. R159's clinical records show included diagnoses but not limited to congestive heart failure, pulmonary hypertension, and chronic obstructive pulmonary disease. R159's Minimum Data Set, dated [DATE] shows R159 is cognitively intact and requires substantial/maximal staff assistance with transferring from bed. R159's order summary report printed on 4/8/25 reads in part: Oxygen continuous (4) L/min via nasal cannula every shift (order date 9/11/24). R159's care plan shows R159 is on oxygen therapy related to respiratory illness with one intervention that reads: Give oxygen as ordered by the physician. Based on observations, interviews and record reviews, the facility: 1. Failed to change and maintain proper storage of nebulizer mask when not in use for 1(R30) resident. 2. Failed to change oxygen nasal cannula tubing and humidifier bottle for 1(R50) resident. 3. Failed to maintain proper storage of nebulizer mask when not in use for 1(R145) resident. 4. Failed to follow oxygen liter flowrate as ordered for 2 (R50, and R159) residents. These failures could potentially affect 4 (R30, 50, R145, and 159) of 4 residents reviewed for respiratory care in a sample of 36. Findings Include: R30's Minimum Data Set (MDS) dated [DATE], Brief interview score (15) indicates R30 is cognitively intact. R30's Physician Order Sheet (POS) dated 4/8/25 shows an active diagnosis of Chronic Obstructive Pulmonary Disease (COPD), and Dyspnea unspecified with active order for Ipratropium-Albuterol 3ml inhale orally every 6 hours as needed for shortness of breath (SOB)/Congestion. R50's MDS dated [DATE], Brief Interview Score (15) indicates R50 is cognitively intact. R50's POS dated 4/8/25 shows an active diagnosis of Acute and chronic respiratory failure with hypoxia and Cardiac arrhythmia with an active order for Oxygen at 2 Liters/Minute/nasal cannula as needed for SOB. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 12 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R145's MDS dated [DATE], Brief Interview score (15) indicates R145 is cognitively intact. R145's POS dated 4/8/25 shows an active diagnosis of unspecified Asthma with acute exacerbation with an active order for Ipratropium-Albuterol 3ml inhale orally every 6 hours as needed for shortness of breath (SOB)/wheezing. On 4/8/25 at 12:16 PM, Surveyor observed nebulizer mask dated 3/17/25, R30 stated she takes the nebulizer treatment three times a day and that she has taken the treatment today. At 12:18 PM, V9 (License Practical Nurse/LPN) entered R30's room, V9 and surveyor observed R30's Nebulizer mask dated 3/17/25 and was not in a bag when not in use. V9 stated, the nebulizer mask is dated over two weeks ago, the mask should be changed weekly, and should have been in a bag when not in use. Failure to change the mask weekly and keep inside a plastic bag when not in use could cause R30 to breathe in germs or bacteria. On 4/8/25 at 12:24 PM, R145 stated that he uses the nebulizer treatment every day and he has taken the treatment today. V9 and surveyor observed R145's nebulizer mask was not inside a plastic bag when not in use. V9 stated that the mask should be inside a plastic bag when not in use to prevent infection. On 4/8/25 at 12:34 PM, R50 received oxygen at 3 liters per nasal cannula/NC dated 3/31/25 with humidifier bottle. V9 stated that R50 is on oxygen at 3/L per NC, the NC tubing and the humidifier bottle dated 3/31/25 should have been changed. V9 and surveyor reviewed R50's POS with an active order for oxygen at 2L/NC. V9 stated nurses should follow the physician order for the flow rate to prevent dry up of nasal passages and nosebleeds. V9 changed R50's oxygen flow rate to 2L/NC per physician's order. On 4/10/25 at 10:56 AM, V2 (Director of Nursing/DON) stated, it is V2's expectation that nurses will keep Nebulizer mask in a clean Ziplock plastic bag when not in use to maintain good hygiene and prevent bacterial infection. The Nebulizer mask, oxygen tubing, and humidifier bottle should be changed and dated weekly, during 11-7 shift, and as needed to prevent infection. V2 also stated that nurses should follow the physician order including oxygen flowrate to prevent dryness/irritation of nasal passages. Facility Policy titled, Oxygen Therapy and Administration dated 8/16/24 documents in part: Oxygen therapy shall be administered to patients as indicated and upon a physician's order. Facility Policy Titled, Respiratory Therapy Equipment Use dated 8/19/24 documents in part: All oxygen equipment including nasal cannula, humidifier, and nebulizer mask will not be reused. Once opened, this equipment will be dated and discarded after 7 days of use, whether used continuously or on a prn (as needed) basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 13 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the appropriate side rails were used for one resident (R87) out of a total sample of 36 residents reviewed for accidents/hazards. Findings Include: On 4/8/25 at 11:09 AM, R87 was lying in bed alert and able to verbalize needs. R87 was noted with left arm paralysis and contracture. R87's bed had three half side rails up: 2 half upper rails and 1 half lower rail. On 4/9/25 at 10:26 AM, R87 was sleeping in bed and noted with three half side rails up. On 4/9/25 at 10:53 AM, interviewed V18 (Restorative Director/Licensed Practical Nurse) and stated, We have to get consent and see what the use of the side rail is for. The side rail assessment should be under restorative assessment and should be re-evaluated quarterly, annually, and as needed. The side rail consent should be signed prior to using them. The purpose of the side rail assessment is to determine the appropriate use of the side rail and prevent resident's entrapment. The purpose of the consent is if the patient understood the use of the side rail. It would say in the assessment how many side rails the resident should be using. Nursing does provide in-services for the use of side rail. The nurse should be educating the CNA [Certified Nursing Assistant] on how many side rails the resident should be using. [R87's] recent side rail assessment was done 2/25/25 and the appropriate side rails for him is 2 half-length rails for enabler to help him positioning in bed. The resident would be at risk for entrapment if they are not using the appropriate side rails based on the resident's assessment. R87's minimum data set assessment dated [DATE] shows R87 has moderately impaired cognition and is dependent on staff's assistance with positioning in bed. R87's side rail assessment dated [DATE] revealed R87 was assessed to only use 2 half-length rails. R87's side rail consent dated 3/26/19 also shows 2 upper-half side rails to be used for R87. R87's care plan revealed R87 to use bilateral half siderails to enhance functional independence and promote skin integrity. The facility's Side Rail policy dated 8/19/24 documents in part: Prior to the use of side rails, alternative devices like pillows, wedges, foams, and other repositioning devices will be utilized first for residents in need of repositioning. If the alternative devices failed to assist the resident in repositioning, the resident will be assessed for the use of side rails, to determine risk for entrapment and other potential danger to the resident. If side rails are appropriate for the resident, a verbal or written consent will be obtained by the facility prior to the use of side rails. The use of side rails will be evaluated at least on a quarterly basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 14 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on interview and record review facility failed to follow their policy for residents that meet the Subpart S guidelines for one resident (R138) out of three residents reviewed for specialized rehabilitation service. This failure resulted in the facility not following R138's individualized treatment plan to receive psychotherapy and did not document that R138 was not attending or had refused attend psychotherapy since October 27, 2024. Findings Include: Facility's list of residents receiving Psychotherapy services does not refelct R138s' name on it. R138's care plan reads: Feeling down, depressed, or hopeless, Little interest or pleasure in doing things, Poor appetite or overeating, Trouble concentrating on things, such as reading the newspaper or watching television, Trouble falling or staying asleep, or sleeping too much Meet with me to discuss ideas to moderate and reduce mood distress symptoms, such as: becoming more active and engaged in the life of the facility, reconciling conflicts/making amends with family or old friends and sharing thoughts and feelings that have contributed to depression. Initiated 6/26/2023. R138's Medical Professional Progress Note from 10/27/2024 17:13 Details: Patient Presentation Does the patient have the capacity to participate meaningfully and benefit from psychotherapy ? Yes LTCPsychotherapy, 16-37 minutes with patient. Summary of Today's Session: Therapist met with client for ongoing psychotherapy. Client ranked it at a two stating that he has felt fine over the past two weeks and has not heard voices or experienced hallucinations. Client reports that he has stayed out of his room and has engaged with other residents. Therapy will continue with a plan to practice reminiscent therapy during future sessions. Client will practice reminiscent therapy during each session. Progress will be made by clinician observation. Goal Start Date: 10/24/2024 Target Completion Date: 01/24/2025. R138's 12/12/2024 19:16 Psychiatry Progress Note reads: HPI: 53, male, CC: follow-up psychiatric assessment. Available documentation reviewed and discussed with interdisciplinary team. Upon assessment: Depression: mild Anxiety: mild Mania: - Psychosis: mild Diagnosis: Schizoaffective Disorder Bipolar Type / Anxiety NOS Treatment Plan: 1. Risk Assessment: Patient is a current danger to self or others ( no ) 2. Medications: Continue present management 3. Side effects / risks / benefits of medications explained to patient 4. Patient notified that if condition worsens, he should notify nursing staff 5. Patient understood and agreed with above plan 6. Group and /or individual psychotherapy recommendation as needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 15 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During interview on on 4/9/25 at 12:45 pm V34 (Psyche Nurse Practitioner) stated residents with SMI (serious mental illness) are seen by him 3-4 months. V34 stated he oversees the medication management of those residents and the psyche therapist oversees the psychotherapy portion. V34 stated residents with SMI benefit from antipsychotic medication and psychotherapy to improve or to keep their symptoms from getting worse. V34 stated R138 does have depression but he has not recently displayed any signs of extreme depression, like not eating, being suicidal or mood swings. V34 stated for the past year R138 has been at his baseline which is that he likes to stay in his room but may come out briefly. V34 stated a lot of residents that live in the nursing home like to stay in their rooms the majority of the time. V34 stated at this time there is no evidence that R138'S depression has worsened. V34 stated hedid recommend when he saw R138 in December that he receive psychotherapy. On 4/9/25 at 11:30 amV14 (Social Worker Director) stated she has been a social worker for five years and that he just became the social worker director at this facility two months ago. V14 stated there is a psychotherapy program ran by two psyche therapist (V32,V33). V14 stated they come to the facility every week to meet with residents that are in the psychotherapy program. V1 stated residents that meet the Sub part S guidelines are supposed to be receiving psychotherapy. V14 stated was not aware that R138 was not getting psychotherapy until today when V33 verbalized during phone interview with surveyor that R138 was refusing psychotherapy. V14 stated if she had known R138 had been refusing would have been visiting R138 on a weekly basis or would have delegated it to another social worker to meet with him to discuss his feelings/mood. V14 stated will have to start documenting on R138 when they see him and his progress. On 4/9/25 at 12:15 pm V33 (Psyche Therapist) stated the last time he saw R138 for psychotherapy was last year in October. V33 stated whenever he went to R138's room to talk to him R138 would refuse to meet with him or participate in his treatment plan. V33 stated he did not document in R138 medical records that he refused psychotherapy. V33 stated he thought it was enough when he told the social service department that R138 was refusing psychotherapy. On 4/9/25 at 11:50 am V32 (Psyche Therapist) she stated they get a list of residents from the facility that require psychotherapy. V32 stated her and V33 come to the facility to see those residents on the list. V32 stated she is aware of R138 but believes V33 was seeing him. V32 stated if a resident has a diagnosis of Schizoaffective Disorder and Bipolar is someone that should be in the psychotherapy program. V32 stated if a resident refuses to participate there should be documentation that they refused to participate. On 4/9/25 at 1:15 pm V36 (Registered Nurse) stated he has been taking care of R138 for about a year. V36 stated normally R138 stays in his room and the only time he comes out is to take his medicine or shower. V36 stated R138 has never reported to him that he was suicidal or homicidal. On on 4/9/25 at 2:05 pm V35 (Licensed Practical Nurse) stated he has been taking of R138 since September of last year. V35 stated R138 keeps to himself and stays in his room most of the time. V5 stated R138 can walk and go to the bathroom on his own V5 stated he asks R138 how he is feeling, R138 tells them he is okay and never reported to him that he was feeling down or that he was suicidal. V5 stated R138 has been compliant with his meds. Facility's' Sub-part S denotes and Individual treatment plan (ITP) shall be developed and shall specify specific approach to meet objectives, skills training, behavior therapy including frequency, quantity, duration. ITP need to be reviewed quarterly. Attendance in programs needs to be recorded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 16 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 4/8/25 at 12:03 PM, R167 was lying in bed and noted with right leg dressing wrapped with ace wrap. R167 stated she has an open vascular wound with daily dressing changes. When asked if staff wears isolation gown and gloves during dressing changes, R167 stated staff only wears gloves not gown. Surveyor noted no EBP signage posted outside R167's room/door. R167's name was also not posted on her door. Residents Affected - Some On 4/9/25 at 10:25 AM, a follow up observation conducted for R167 and still noted with no EBP signage posted outside R167's room/door. On 4/9/25 at 12:04 PM, interviewed V4 (Infection Preventionist Nurse) and stated residents with chronic wounds like vascular wounds are also placed on EBP to minimize the spread of infection. V4 stated that there should be an EBP signage posted on the door to alert staff what proper PPE to use. The orange dot for a resident on EBP should be by the resident's name on the door. V4 stated R167 should be on EBP because of her chronic wound on the right leg. V4 stated the EBP signage should be posted on the door. R167's Minimum Data Set, dated [DATE] shows R167 is cognitively intact. R167's skin/wound evaluation dated 2/27/25 shows R167 has open venous ulcer wound on the right leg. R167's comprehensive care plan shows R167 is on enhanced barrier precaution. Based on observation, interview and record review the facility failed to follow their policy and procedures to ensure (a) signage outside of the resident's room indicating Enhanced Barrier Precaution (EBP) was posted for 1 resident (R167); and (b) proper Personal Protective Equipment (PPE) were worn by staff when providing high contact resident care activities to 2 (R24 and R68) residents. These failures have the potential for cross contamination or transmission of infection to 11 residents assigned to V22 (Licensed Practical Nurse/LPN). The findings include: R24's admission record showed admission date on 12/15/20 with diagnoses not limited to Acute and chronic respiratory failure, Dependence on respirator [ventilator] status, Tracheostomy status. R68's admission record showed admission date on 10/8/22 with diagnoses not limited to Acute and chronic respiratory failure, Dependence on respirator [ventilator] status, Tracheostomy status, Acute on chronic diastolic (congestive) heart failure, Dysphagia oropharyngeal phase, Neuromuscular dysfunction of bladder, Chronic obstructive pulmonary disease with (acute) lower respiratory infection, Obstructive sleep apnea (adult), Other seizures, Anxiety disorder, Paroxysmal atrial fibrillation. On 4/9/25 at 9:58 AM Surveyor observed door signage to R68's room indicating EBP (Enhanced Barrier Precautions). EBP signage showed in part: staff must wear gloves and a gown for the following high-contact resident care activities. Device care use: Feeding tube. Observed R68 lying in bed on moderate high back rest, with G-tube feeding infusing Glucerna 1.2 At 70ml/hr via pump machine. Observed V22 (LPN / Licensed Practical Nurse) handling / caring for R68's G-tube (Gastrostomy) site wearing only gloves and mask. V30 was not wearing gown. On 4/9/25 at 10:01 AM Surveyor observed R24's room with signage indicating EBP. Observed R24 lying in bed on moderate high back rest with G-tube feeding infusing Jevity 1.5 At 65ml/hr. Observed V22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 17 of 18 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 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 0880 handled / cared for G-tube site without wearing proper PPE. He donned gloves, no gown worn. Level of Harm - Minimal harm or potential for actual harm On 4/9/25 At 12:08PM V4 (INFECTION PREVENTIONIST / IP NURSE) said for residents on EBP, staff is expected to wear proper PPE (gown and gloves) during high contact resident care activities such assisting with wound care, changing the linens, handling medical devices (G-tube, indwelling urinary catheter, trach tube). V4 said gown and gloves should be worn by staff when handling or caring for G-tube site to prevent cross contamination or infection. V4 said if staff is not wearing proper PPE they could potentially cross contaminate other residents that he is taking care of. Residents Affected - Some On 4/10/25 at 10:14am V2 (DON / Director of Nursing) stated he has been working in the facility since 2017. V2 said if resident is on EBP, staff is expected to wear proper PPE (gown and gloves) when handling G-tube to prevent transmission of infection. V2 said assigned staff not wearing proper PPE caring for resident on EBP could potentially cross contaminate other residents he is working with or assigned to. On 4/10/25 At 11:18am V2 (DON) said V22 was assigned to 11 residents and provided census report dated 4/10/25 showing 11 highlighted rooms with 11 residents. Care plan with review date on 3/3/25 showed in part: R24 is on Enhanced Barrier Precaution for: Colonized MDRO (Multidrug-resistant organisms). Care plan with review date on 4/3/25 showed in part: R68 is on Enhanced Barrier Precaution for: Colonized ESBL (Extended - Spectrum Beta - Lactamase) urine. Change gown and gloves before caring for the next resident. Ensure that gown and gloves are used during high-contact resident care activities (like device care or use for those with feeding tube) that provide opportunities for transfer of MDROs to staff hands and clothing. Facility's Infection Prevention and Control policy dated 2/10/25 showed in part: A sign will be provided outside the room for residents on transmission-based precaution indicating the type of the precaution (Contact, Droplet, or EBP). Precautions to prevent transmission of infectious agents: EBP - an infection control intervention designed to reduce transmission of MDRO which includes ESBL. The goal is to prevent transmission of MDROs to others. Involves the use of gloves and gowns during high contact resident care activities for residents with indwelling medical devices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 18 of 18