Inspection·May 2, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few to sitting to standing. Per R2's MAR and blood pressure log there are days when R2's systolic blood pressure drops less than 95 mm/Hg and Midodrine was not documented as administered per physician's order. Per blood pressure log, the day before R2 fell (03/08/2025), R2's blood pressure was recorded once with result of 124/70 mm/Hg. R2 has an order for vital signs check every eight (8) hours equivalent to three (3) checks a day. R2 fell on [DATE], when V12 took R2's vital signs, R2's systolic blood pressure result was 85/63 which is lower compared to R2's baseline. Fall happened around 08:00 AM when R2 got up went to the bathroom and attempted to pick up something on the floor that resulted to R2's injury. On 04/30/2025 at 12:12 PM, V9 (Restorative Nurse/Licensed Practical Nurse) and V10 (Restorative Nurse/Licensed Practical Nurse) stated that all fall care plans, fall assessments and prevention of fall is done by V11 (Fall Coordinator/Registered Nurse). On 04/30/2025 at 12:19 PM, V11 (Falls Coordinator/Registered Nurse) stated that R2 fell on [DATE] when he was trying to pick up something on the floor. V11 stated that R2 was independent in standing up and walking. V11 stated that prior to the fall, R2 has two (2) interventions in the care plan on position teaching and asking for assistance. After the fall, 1 intervention was added monitoring was done one and a half (1.5) hour intervals instead of two (2) hours. V11 stated that she does not do quarterly assessments for falls and only does assessments when a resident falls. V11 stated that restorative does fall assessment and cannot locate any fall assessment in R2's electronic health records. V11 stated that she does not remember if restorative coordinated to her their quarterly fall assessments. V11 stated that care plan is also done by restorative including interventions. And she (V11) only does fall interventions when a resident falls. V11 was asked if she based her plan of care interventions to prevent fall on any assessment. V11 answered that she based her fall plan of care interventions on the resident's mental status, mobility, diagnosis, what medication the resident is taking. V11 was asked if R2's care plan interventions were based on R2's medication and medical diagnosis? V11 said, I don't remember if I checked his (R2) current medication. V11 was made aware that during the fall R2's blood pressure was low with a result of 85/63 mm/Hg as shown in the incident report. V11 stated that was low, that R2 maintains systolic blood pressures over 100. V11 said, I never see it that low. It could be orthostatic hypotension that he fell. R2 likes to lie down much. When he gets up it can be a problem. V11 asked the writer if a resident has hypotension that led to a fall, should the hypotension be addressed in the falls care plan? On 04/30/2025 at 01:29 PM, V12 (Licensed Practical Nurse) stated that she found R2 on the floor. R2 stated he slipped when he was coming from the bathroom with his walker. R2 was found next to his bed on the floor. R2's forehead was gashing with blood to his face. V12 stated that she thought she needed to do code blue because R2 stopped breathing and looked discolored. V12 stated that she was not able to check R2's vital signs prior to the fall. V12 stated that R2's blood pressure result was hypotensive because R2 usually has a normal blood pressure and that R2 has medication for hypotension. V12 stated that hypotension causes confusion, lightheadedness that can contribute to fall. V12 stated that R2's vital signs needed to be taken twice on her shift and that she (V12) usually takes vital signs during medication pass or when she gives medication to residents around 08:00 AM. V12 stated that she was doing medication pass when R2 fell. V12 clinical notes dated 03/09/2025 at 08:09 AM when R2 fell, documents that R2 was noted to have decreased level of consciousness, confused and disoriented. On 05/01/2025 at 11:01 AM, V2 (Director of Nursing) stated that Restorative Nurse and Falls Nurse work overlaps but as to fall concerns it will be the Falls Coordinator that will do the assessment. Restorative Nurses focus on activities of daily living and range of motion. V2 stated that V11 (Fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 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 - Actual harm Residents Affected - Few Coordinator/Registered Nurse) is having a hard time with the computer. V2 stated that R2 went to the washroom bent down and fell. V2 stated that he does not know R2's blood pressure baseline he cannot say if blood pressure is a concern for R2. V2 stated that signs and symptoms of hypotension includes syncope (fainting or passing out), body shaking and disorientation. V2 stated that R2 has medication Midodrine that increases the blood pressure and it needs to be given when blood pressure is low as prescribed. V2 was asked if it would help to check R2's blood pressure prior to the fall? V2 replied, It does not matter what time to check. One nurse taking care of many residents. What if other residents have hypotension too? Then V2 stated that it would be a good intervention to monitor R2's vital signs. V2 was asked if hypotension or blood pressure record of R2 were reviewed to prevent recurrent falls? V2 said, I don't have to have hypotension to feel dizzy. I have to check if hypotension is one of R2's diagnosis. V2 stated that R2 went to the hospital for suture of laceration on the forehead and have left lower arm laceration due to the fall. Per hospital records R2's laceration needs repair via suture. R2's fall care plan interventions dated 09/09/2024 prior to fall are as follows: First, teaching how to position. And second, instruction for assistance. No revision was made until after R2's fall dated 03/09/2025. R2 fall care plan intervention after fall dated 03/10/2025 added one (1) intervention monitoring of R2 every one and a half (1.5) hours. All interventions do not identify that R2 has medical diagnosis of hypotension upon initial admission dated 08/29/2025 that R2 has medication for low systolic blood pressure/orthostatic hypotension. The blood pressure of R2 at the time of the fall was hypotensive 85/63 mm/Hg. R2's blood pressure record documents drop of systolic blood pressure lower than 95 mm/Hg on certain days which requires medication to increase systolic blood pressure as prescribed by physician. Fall Occurrence Policy dated 07/26/2026: It is 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. A fall risk assessment form will be completed by the nurse or the Falls Coordinator upon admission, readmission, quarterly, significant change, and annually. Ultimately, the Falls Coordinator may change the intervention provided by the nurse if the Falls Coordinator's investigation identifies a more appropriate intervention for the individual fall. The Falls Coordinator will add the intervention in the resident's care plan. The interventions will be reevaluated and revised as necessary. Federal Drug Agency (FDA) information on Midodrine reads: INDICATIONS AND USAGE ProAmatine® (Midodrine) is indicated for the treatment of symptomatic orthostatic hypotension (OH). Centers for Disease Control and Prevention National Center for Injury Prevention and Control program STEADI (Stop Elderly Accidents, Death and Injuries) dated 2017 reads: Postural hypotension-or orthostatic hypotension- is when your blood pressure drops when you go from lying down to sitting up, or from sitting to standing. When your blood pressure drops, less blood can go to your organs and muscles. This can make you more likely to fall. These symptoms can differ from person to person and may include: dizziness or lightheadedness, feeling about to faint, passing out, or falling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 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 Headaches, blurry or tunnel vision Level of Harm - Actual harm Feeling vague or muddled Residents Affected - Few Feeling pressure across the back of your shoulders or neck Feeling nauseous, or hot and clammy Weakness or fatigue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interviews, the facility failed to administer physician-prescribed medications to treat hypotension or low blood pressure. The failure applied to 1 (R2) of 3 residents evaluated for pharmacy services. This failure resulted in R2 experiencing low blood pressure and a fall sustaining injuries of laceration on the forehead and left arm. Findings include: R2 is [AGE] years old, initially admitted on [DATE]. R2's diagnosis includes, hypotension, abnormalities of gait and mobility, lack of coordination, muscle wasting and atrophy. R2's cognition is intact with BIMS score of 15 dated 02/13/2025. R2's bed mobility and transfer is supervision and touch assist. R2 is ambulatory based on MDS assessment dated [DATE]. On 03/09/2025 at 08:00 AM, R2 fell sustaining injuries of laceration on the forehead and left arm. During the fall, R2 has hypotension with blood pressure result of 85/63 mm/Hg. Normal blood pressure accepted by current professional standard is 120/80 mm/Hg. R2 was prescribed by physician to receive Midodrine 10 MG (milligram) when systolic (upper number) blood pressure is lower than 95 mm/Hg. Review of R2's blood pressure log documents that R2 has record of systolic blood pressure lower than 95 mm/Hg. MAR (medication administration record) of R2 does not document that Midodrine 10 MG was administered on days that R2 had hypotension or systolic blood pressure lower than 95 mm/Hg. On 05/01/2025 at 11:01 AM, V2 (Director of Nursing) stated that R2 has medication Midodrine that increases the blood pressure and it needs to be given when blood pressure is low as prescribed. V2 stated that when medication was not documented on the MAR (Medication Administration Record) as administered meaning it was not given. V2 stated that the expectation is to follow physician's order to give as needed medication. Medication Pass policy dated 08/16/2024: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. After medication is administered to each resident, sign MAR (medication administration record) that it was given. Federal Drug Agency (FDA) information on Midodrine reads: INDICATIONS AND USAGE ProAmatine® (Midodrine) is indicated for the treatment of symptomatic orthostatic hypotension (OH). Centers for Disease Control and Prevention National Center for Injury Prevention and Control program STEADI (Stop Elderly Accidents, Death and Injuries) dated 2017 reads: Postural hypotension-or orthostatic hypotension- is when your blood pressure drops when you go from lying down to sitting up, or from sitting to standing. When your blood pressure drops, less blood can go to your organs and muscles. This can make you more likely to fall. These symptoms can differ from person to person and may include: dizziness or lightheadedness, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 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 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 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 0755 feeling about to faint, passing out, or falling Level of Harm - Minimal harm or potential for actual harm Headaches, blurry or tunnel vision Feeling vague or muddled Residents Affected - Few Feeling pressure across the back of your shoulders or neck Feeling nauseous, or hot and clammy Weakness or fatigue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 6 of 6