Health inspection·August 25, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that R1 and R2 needed their clothes washed and dried due to bed bugs. V5 states a CNA/certified nursing assistant brought their clothes down to the laundry room. V5 states V1 (Administrator) also came down to the laundry room and told her to wash R1 and R2's clothes right away and return them right away. V5 states she washed R1 and R2's clothing the same day and it took about 2.5 hours to complete. V5 states once R1 and R2's clothes were cleaned and dried, she wrote their names on a piece of paper and placed it inside of their laundry bags for identification purposes. V5 states she then placed their bags of clothes on a table located outside the laundry room so they can be picked up. V5 states she also called V1 to inform her that R1 and R2's clothing was ready to be picked up from laundry. V5 states V1 informed her that someone would come down to pick up R1 and R2's clothes. V5 states she then left for the day and has not seen R1 and R2's clothing items since then. V5 states she did not see who picked R1 and R2's clothes up, but the next day, their clothes were no longer there. V5 states R1 and R2's clothes should not be missing because she followed instructions and washed and returned the clothes like V1 asked her to do. V5 states resident's clothes should not be kept for long periods of time and should be returned to them either the same day or by the next day. On 08/24/2025 at 3:01PM, V1 (Administrator) states she currently does not know the location of R1 and R2's clothes and have to continue to follow up with this matter. V1 states she spoke with V2 (Assistant Administrator) and V2 informed her that he brought R1 and R2's clothes to the directly. V1 states if the facility is unable to located R1 and R2's belongings, the facility will reimburse R1 and R2 within one week because she wants R1 and R2 to have clothes to wear.Ombudsman Residents' Rights for People in Long-Term Care Facilities dated 11/2018 documents in part, You have the right to keep and wear your own clothing. You may keep and use your own property. Event ID: Facility ID: 145679 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for two (R1, R2) residents out of three residents reviewed for pest control. This failure has the potential to affect all 169 residents residing in the facility. Findings include:On 08/24/2025 at 10:08AM, R1 states about three weeks ago, the facility found bed bugs in his room and he and his roommate (R2) had to be moved to another room on the second floor. On 08/24/2025 at 10:18AM, R2 states he does not know why he was moved to another room, but the facility took his clothes and moved him to another room temporarily. R2 states he has not seen any bed bugs in his room. Surveyor observes multiple, small, dried blood spots on R2's bed sheets and one red bed bug crawling on his bed. R2 then grabs the bed bug and smashed it with his fingers and throws it into the garbage bin. R2 states that was not a bed bug that he just smashed with his fingers.On 08/24/2025 at 10:57AM, V3 (Maintenance) states about a month ago, bed bug sightings were reported in R1 and R2's room. V3 states V4 (Maintenance Director) went to R1 and R2's room to look for himself and V4 did confirm that there were bed bugs in their room. V3 states the facility called the pest control company and they came out to the facility to treat R1 and R2's room for bed bugs. V3 states he is not sure, but he believes the pest control company uses chemicals and not heat to treat the bed bugs. V3 states R1 and R2 were moved to another floor while their belongings were bagged and washed. V3 states the CNA/certified nursing assistant staff takes the bags down to the laundry to be cleaned. V3 states everything was removed from R1 and R2's room so that the pest control company could treat the room. V3 states once the pest control company sprayed and finished servicing R1 and R2's room, he visited their room to confirm that the room was free of bed bugs. V3 states he then informed the housekeeping staff that it was okay to clean R1 and R2's room. V3 states the housekeeping staff then thoroughly cleaned the room from top to bottom and included cleaning the drawers, mattresses, and curtain drapes.On 08/24/2025 at 11:12AM, V3 and surveyor located inside of R1 and R2's room and V3 is observed checking R2's bed for bed bugs. After inspecting R2's bed, V3 states Yes, these are bed bugs. Surveyor then sees multiple bed bugs crawling on R2's bed once V3 lifted R2's mattress.On 08/24/2025 at 11:15AM, V3 makes V2 (Assistant Administrator) aware that bed bugs were found in R2's room. On 08/24/2025 at 11:30AM, V1 (Administrator) states she was made ware about bed bugs found in R1 and R2's room about 3 weeks ago. V1 states the facility called the pest control company and they thoroughly treated R1 and R2's room for bed bugs. V1 states the mattresses were thrown away, the drawers were cleaned, and the curtains were cleaned with high heat. V1 states the facility has been using the services of their current pest control company for eight years now without any concerns. V1 states the facility has had a bed bug situation before and the pest control company always chemically treat the facility for bed bugs. V1 states she was not aware of R2 currently having bed bugs in his bed because R2 did not report them to her. V1 states she found out today that R2 has bed bugs during surveyor's investigations.Facility census dated 08/24/2025 documents a total of 169 residents resides in the facility. Record review documents that R1 and R2 were moved to the second floor of the facility on 08/06/2025 and returned to the fourth floor on 08/08/2025. There is no documentation to show that R1 and R2's new rooms were inspected for bed bugs upon being relocated.Facility's Pest Control Service Inspection Report dated 08/07/2025 documents that bed bugs were found in R1 and R2's room. Service inspection reports reviewed from 05/30/2025 to 08/23/2025. There is no documentation to show that a follow up inspection was conducted in R1 and R2's room. Facility's Policy dated 07/03/2025 titled Pest Control documents in part, It is the facility's policy to ensure that there is an effective pest control process in the building.Facility's Policy dated 06/26/2025 titled Bed Bug Handling documents in part, 2. B. Residents Affected - Many (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm iv. A pest management professional should inspect the suspect room, adjacent rooms, and the patient's new room, all furniture and equipment, and lounge and public areas the family may have been using. vi. Emphasize non-chemical control measures. viii. Incorporate non-chemical methods such as steam treatment, heat, aggressive cleaning and laundering, and targeted vacuuming whenever practical. ix. Medical equipment and furniture is best disinfected with heat or fumigation off-site. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145679 If continuation sheet Page 4 of 4