Health inspection·September 8, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete her about the sexual assault allegation. On [DATE] at 2:02 PM, V1 (Administrator) stated that she is the abuse coordinator and the facility's abuse policy is to report any abuse allegation to IDPH (Illinois Department of Public Health) no later than 2 hours. V1 stated that V11 reported to her that R1 had texted V11 that he was sexually assaulted in the community. V1 stated that V11 called her over the weekend on a Saturday ([DATE]), but V1 does not remember the exact time. V1 stated she did not do the initial reporting to IDPH within two hours and did it the next day because there were conflicting stories. V1 stated that R1 refused to tell V23 (Registered Nurse/Nursing Supervisor) anything when R1 came back in the facility. V1 stated R1 did not disclose the sexual assault to the hospital. V1 stated the next day ([DATE]), V16 questioned R1 specifically. R1 did tell V16 that he was sexually assaulted and that's when V1 did the initial report to IDPH. The facility's Abuse Report Initial Form for R1's sexual allegation shows date and time the report was sent to IDPH: [DATE] at 4:00 PM. Date and time the alleged incident occurred: [DATE] at 7:30 PM. Allegation details documents in part: [R1] stated that when he went out on independent pass yesterday with his cousin [V3] he was drugged and sexually assaulted in the community on the south side of Chicago on the street at a bus stop by 2 individuals unknown to him [R1]. A nursing assessment was done with no new injury noted, no swelling, bruising noted. [R1] complains of pain on bilateral upper extremities and dorsal aspect of the toes of both feet. The police were called, an officer came to interview [R1] and a police report was filed with report number JJ396568. [R1] is being sent to the ER [Emergency Room] for evaluation. A final report will be sent to the state within 5 working days.The facility's Abuse and Neglect policy dated [DATE] documents in part: All allegations of abuse will be reported to IDPH immediately not exceeding 2 hours after the initial allegation is received. 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 09/08/2025 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** Based on interviews and record reviews, the facility failed to follow their policies and procedures to ensure (a) the police were contacted to assist with finding a resident who was on supervised community pass and did not return as indicated on the sign out sheet, (b) a resident was reviewed for risk for elopement concerns upon admission, and (c) a person-centered care plan was initiated timely to address community pass privilege. These failures affected one (R1) out of three residents reviewed for community pass privileges.Findings Include:R1's clinical records revealed an admission date of 7/24/25 with included diagnoses but not limited to major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder. R1's admission minimum data set (MDS) assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief interview for Mental Status) score of 15 and requires supervision with activities of daily living. R1's electronic health records (EHR) revealed no risk for elopement was completed upon admission. R1's physician order shows R1 may go out on pass with his family ordered on 8/26/25. R1's outside pass privilege care plan was initiated on 9/3/25.R1's RELEASE OF RESPONSIBILITY FOR LEAVE OF ABSENSE (OUT ON PASS) signed by V3 (R1's Cousin) on 8/29/25 at 4:30 PM reads in part: I, [V3], here to accept complete responsibility for [R1] while away from [The facility], and absolve the management of said nursing home, its personnel and the attending physician of responsibility for deterioration in condition, or accident that may happen while the patient is away. I understand that a bed will be reserved for the above named patient when he/she returns on or before 8:00 PM.R1's progress notes dated 8/30/25 at 7:40 PM revealed R1 came back in the facility on 8/30/25 at 7:35 PM.On 9/7/25 at 9:42 AM, R1 stated he went out on pass on 8/29/25 at around 4:30 PM with V3. R1 stated V3 signed him out. R1 stated they went out for a family dinner. R1 stated after dinner, he got separated from V3 and that his phone ran out of battery. R1 got back at the facility on his own on 8/30/25 at 7:30 PM.On 9/7/25 at 11:38 AM, V11 (Assistant Director of Nursing) stated that R1 can go out on pass with escort. Family member or facility staff. They just have to sign [R1] out. V11 stated residents can go out on pass from 10:00 AM to 8:00 PM. V11 stated that if a resident does not return the facility by 8:00 PM, the nursing supervisor on duty informs administration and they contact whoever was listed as emergency or whoever sign them out. V11 stated that administration will make determination when to call 911 if resident does not return in the facility by a certain period. V11 stated that on 8/30/25, around 4:00 PM, [R1] called [V11] that his phone was about to die and that [R1] was on his way back to the facility.On 9/7/25 at 11:58 AM, V18 (Social Service Designee) stated that the risk for elopement assessment was not completed for R1 on admission. It was completed on 9/1/25.On 9/7/25 at 12:48 PM, a phone interview was conducted with V19 (Registered Nurse). V19 stated that on 8/29/25, R1 went out on pass and did not return. V19 stated he contacted R1 but did not pick up. V19 stated he called V15 (R1's Brother) but does not know R1's whereabouts. V19 stated he did not call the police, but he informed V20 (Evening Registered Nurse Supervisor).On 9/7/25 at 12:54 PM, a phone interview was conducted with V20 and stated that on 8/29/25, V20 called R1 after 11:00 PM but was not picking up the phone. V20 stated he left around midnight and R1 was still not back in the facility. V20 stated he is not sure what is the facility's policy when to call the police if resident does not come back within the curfew. V20 stated that he posted to the facility's communication platform to notify management that R1 was out on pass with family and has not returned in the facility.On 9/7/25 at 1:38 PM, a phone interview was conducted with V23 (Registered Nurse/Nursing Supervisor) and stated that she was the nursing supervisor on 8/30/25 from 7:00 AM until 11:00 PM. V23 stated, I was notified that [R1] did not return the facility. At (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 09/08/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 8:00 AM, I started calling his [R1] cell phone multiple times. [R1] did not answer. I also tried calling [V3] he was the one signed him [R1] out but it was not connecting. I called [V3] multiple times. I informed [V2 (Director of Nursing)] and [V11] that [R1] has not returned. I also contacted his [R1] other responsible party they said that [R1] did not contact them. V23 stated that R1 returned in the facility on 8/30/25 at around 7:30 PM.On 9/7/25 at 3:04 PM, a phone interview was conducted with V25 (Receptionist) and stated that she worked on 8/29/25 PM shift. V25 stated, [R1] told me that he was going to head out. [R1] was waiting in the lobby area. [R1's] cousin [V3] came with another friend. They left the building around 4:30 PM. [V3] signed [R1] out. [V3] put his information on the sign out sheet. All three of them left the facility together at around 4:30 PM. When [R1] did not return at 8:00 PM, I called [R1] three times, and I called [V3] three times. [V3's] number went straight to voicemail. [R1] did not answer.On 9/7/25 at 2:45 PM, V1 (Administrator) stated that the facility calls the police if a resident does not return the facility from out on pass for more than 24 hours. V1 stated that R1 went out on pass with a family member on 8/29/25, did not return by 8:00 PM, but called at around 4:00 PM the next day informing the facility that he will be returning. V1 stated that all residents are allowed to go out on pass with escort or with family members. V1 stated that R1 is not allowed to go on independent pass because of R1's history of substance abuse and suicidal ideation.On 9/7/25 at 2:26 PM, V24 (Clinical Care Coordinator) stated that the out on pass privileges care plan is initiated after the order is obtained and the resident and the family have been informed that there's an order. V24 stated that the purpose of the comprehensive care plan is for the interdisciplinary team to be able to identify the active and potential problems and able to specify interventions to minimize or prevent or address the problems. V24 stated that if R1's out on pass privilege was ordered on 8/26/25 the comprehensive care plan should have been initiated between 8/26/25 to 8/29/25. V24 stated if it was initiated on 9/3/25, the care plan is late. The facility's Elopement policy dated 7/26/24 documents in part: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual plan of care. All residents shall be reviewed for safety awareness impairment and elopement/wandering concerns upon admission, readmission, quarterly, significant change in condition and as needed. If the case is that of a resident who went OOP [Out On Pass] and did not come back on the day and time indicated the resident is supposed to come back, the facility will wait for 2 more hours to allow time for resident to return (as in many situations, the delay in the resident's return is a result of traffic, [NAME] pick up, etc). One the 2 hour grace period has elapsed, the facility will contact the police to assist with finding the resident. The facility will also call possible places like hospital ERs, shelters, family and friend's houses, etc where the resident be at.The facility's Care Plan policy dated 6/30/25 documents in part: After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days. Event ID: Facility ID: 145679 If continuation sheet Page 4 of 4