Health inspection·November 9, 2023

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Facility policy Resident Rights, no date, documents in part: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: be informed of, and participate in, his or her care planning and treatment. Facility policy Care Plans, Comprehensive Person-Centered, 2/1/22, documents in part: The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: participate in the planning process; request meetings; see the care plan and sign it after significant changes are made. The interdisciplinary team must review and update the care plan: at least quarterly, in conjunction with the required quarterly MDS assessment. Event ID: Facility ID: 145776 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 145776 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three residents (R12, R26, R30) have a safe, clean, comfortable, and homelike environment. Findings include: On 11/2/23 while touring facility with V16 (Building Manager), surveyor observed: Call light fixture/plate not fully attached to the wall in room [ROOM NUMBER]. Call light functioning. Cracks, chipping/peeling paint, rust color along the baseboards in R30's bathroom; on the ceiling in the dining room on the 3rd floor; on the third-floor shower room floor. R12's television not working and does not have a remote control. On 11/3/23 while touring facility with V16, surveyor observed: Cracks, chipping/peeling paint, rust color on the second-floor shower room floor. On 11/3/22, Surveyor observed cracks, chipping/peeling paint, rust color on the ceiling over R26 bed. On 11/2/23 at 10:15 AM, R17 stated there are televisions that are not working or not working properly. There is a problem with the system according to maintenance. On 11/02/23 at 12:11 PM, R26 states R26 told a staff member about the condition of the ceiling above the bed, but nothing is being done about it. On 11/02/23 at 12:29 PM, another survey team member located in the shower room located on the second floor of the facility adjacent to room [ROOM NUMBER] with V6 (Certified Nursing Assistant/CNA). V6 stated there are two showers on the second floor but this is the shower room that is used by the residents to take their showers. Surveyor observed dried feces on the seat of a shower chair, black, mold-like substance in the cracks and floor seams of the shower and shower floors, and peeling paint on the shower floors. V6 stated the black mold-like substance in the shower appears to be mold and the residents do not like going near that part of the shower because they feel it is nasty. V6 states she is not sure when the shower chair was last cleaned. On 11/02/23 at 12:53 PM, R22 states R22 washes R22's body everyday but does not go into the shower room because a staff member said that it's feces in there and it's disgusting. On 11/2/23 at 12:54 PM, R12 implied with a head nod that R12's television works but R12 can't turn it on. On 11/7/23 at 1:13 PM, V1 (Administrator) stated some of the walls are stained because it's an older room. There is no mold that I'm aware of. Cracks, rust color in ceiling on walls is probably a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 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 145776 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few leak in the ceilling. The expectation is for the building to be clean, and residents are comfortable. Some televisions are old some are new. We are constantly replacing the remotes. Sometimes the signals are bad. On 11/7/23 at 3:36 PM, V16 (Building Manager) stated I don't know what the peeling/chipping paint, rust coloring is from. I wouldn't want my family member sleeping under that. The television system is an older system. We are looking at different alternatives to fix it. Sometimes, in the past if we replace the wiring that helps. I'm not sure what the problem is. It's a very old system, still analog, I think. We had someone from the cable company come and they could not fix it. We have a few remotes downstairs. The residents are constantly losing them. On 11/7/23 at 4:10 PM, V16 stated maintenance confirmed the cracks, chipping/peeling paint, rust color on the ceiling in the third-floor dining room is due to the old roof leaking and needs to be painted. The ceiling above R26's bed is from a leaky pipe that will be fixed. Sleeping under that would not make me feel good. I do rounds throughout the building. Facility policy Homelike Environment, 6/13/22, documents in part: Staff provides person-centered care that emphasizes the residents comfort, independence and personal needs and preferences. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary and orderly environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 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 145776 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640 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. Based on observation, interview, and record review, the facility failed to a.) provide supervision and monitoring for residents during the designated smoking time to ensure residents practice safe smoking in the designated area and b.) failed to complete a quarterly smoking safety evaluation as required. These failures affected three (R30, R31, R32) residents reviewed for smoking safety. Findings include: On 11/03/2023 at 2:15PM, surveyor observed R30, R31, and R32 outside on the 1st floor patio smoking and not being supervised by staff members. V12 (Activity Aide) observed inside of the facility with the door closed and her back facing the door of the smoking patio. On 11/03/2023 at 2:19PM, V11 (Dietary Manager) observed outside smoking with R30, R31, and R32. On 11/03/2023 at 2:20PM, V11 now located back inside of the facility and states that she is not responsible for monitoring the residents who are smoking and went out on the patio to smoke herself. V11 stated R30 informed her that he did not have any more cigarettes, V11 stated she gave R30 one of her own personal cigarettes. V11 stated that employees are sometimes allowed to smoke in the designated smoking areas with the residents. V11 stated that V12 is the person responsible for monitoring the residents while they are smoking. V11 stated that there should be someone outside with the residents at all times to monitor them while they are smoking. On 11/03/2023 at 2:27PM, V12 stated herself or another staff member should have been outside with the residents who were smoking. V12 stated that R30, R31, and R32 could have fallen, choked, or gotten burned while not being supervised. V12 stated she was busy helping the other residents with activities inside the facility and could not properly monitor the residents outside on the smoking patio. R30's smoking safety evaluation dated 10/09/2023 documents that R30 has insufficient fine motor skills needed to securely hold a cigarette. Review of R31's electronic medical record documents that R31 does not have a current smoking safety evaluation. R31's smoking safety screen dated 02/16/2023 documents that R31 smokes 2-5 cigarettes per day and requires supervision and assistance with smoking. Review of R32's electronic medical record documents that R32 does not have a current smoking safety evaluation. R32's smoking safety screen dated 05/26/2019 documents that R32 smokes 2-5 cigarettes per day and does not require supervision with smoking. Facility policy, undated, titled Smoking Policy-Residents documents in part, This facility shall establish and maintain safe resident smoking practices. 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 8. A resident's ability to smoke safely will be re-evaluated quarterly, 11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 15. Staff members and volunteer workers are not permitted to purchase and/or provide any smoking articles for residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 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 145776 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640 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 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to employ a full time Social Service Director. This has the potential to affect all 78 residents residing in the facility whom require medical social services. Residents Affected - Many Findings include: On 11/02/2023 at 3:29PM, V1 (Administrator) states the facility is licensed for 143 beds and does not have a full-time social worker working at the facility. V1 states that the facility should have a full-time social worker at the facility and is looking to hire a full-time social worker as soon as possible. The facility assessment, dated 02/27/2023, documents in part, Indicate the number of residents you are licensed to care for: (enter number of beds) 143. The facility assessment documents that the facility provides services to residents that include skilled care, therapy services, wound care, restorative care, respiratory care, mental health and behavioral care, as well as a variety of other medical needs. The assessment also lists Social Services as a type of staff needed to care for residents in the facility. Facility assessment documents in part, staffing plan 3.2- General approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time: Staff- Other, Plan- 2 Social services. The facility's Social Service Director Job Description, dated 03/24/2016, documents, Social Services Director Summary: The primary purpose of the Social Services Director is to assist in planning, organizing, implementing, evaluating, and directing the overall operation of our Social Service Department in accordance with federal, state and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. Facility time clock documentation reviewed and documents that a social worker is not employed at the facility on a full-time basis. Facility Census dated 11/02/2023 documents that a total of 78 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 6 of 6