Health inspection·February 9, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to refer three (R5, R24, R30) residents with newly evident or possible serious mental disorder to the appropriate state-designated authority for review. Findings include: On 02/08/24 at 1:39 PM, V16 (Clinical Director of Admissions) stated that she is responsible for making sure Level 1 Pre-admission Screening and Resident Review (PASARR) are in the residents' records. V16 said that sometimes the residents are admitted to the facility from the hospital before a level 1 PASARR is completed. V16 said that she then makes the level 1 PASARR request, and the assigned state agency will come into the facility and complete the screening. V16 stated that if a resident requires a level 2 PASARR screening then the state agency sends her an email requesting for updated resident information. V16 stated that this is a situation she has not delt with before. V16 stated that she was informed by the state agency that social services need to notify V16 of the residents with mental health conditions that should have a level 2 PASARR. V16 stated that she will collaborate with social services to conduct a list and send the request to the state agency to get those residents to have a level 2 PASARR completed. R5's Face sheet documents that R5 is a [AGE] year-old male admitted to the facility on [DATE] who has diagnoses not limited to: schizophrenia, major depressive disorder. There is no documentation to show that R5 was screened for a Level 2 PASARR. R24's current face sheet document R24 is a [AGE] year-old individual admitted to the facility on [DATE] and current medical diagnosis are listed to include but not limited to: bipolar disorder, current episode depressed, severe, without psychotic features, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified. Review of R24's health records do not document a Level 2 PASARR was completed for R24. R30's Facesheet documents that R30 is a [AGE] year-old female who has diagnoses not limited to: delusional disorders, major depressive disorder, schizophrenia, and brief psychotic disorder. R30's Facesheet documents that R30 was admitted to the facility on [DATE]. R30 has a diagnosis of schizoaffective dated 05/02/2022 and a diagnosis of delusional disorders dated 11/02/2020. Record reviewed documents that R30 has an initial Level 1 Pre-admission Screening and Resident Review/PASARR dated 06/26/2020. There is no documentation to show that R30 was screened for a Level 2 PASARR. Facility policy date 02/01/2022 titled admission Criteria documents in part, 9. b. If the level I screen indicates that the individual may meet the criteria for a MD (mental disorder), ID (intellectual disability), or RD (related disorder), he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 2 of 13 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 02/09/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 that two low air loss mattresses were set according to manufacturer recommendation for residents (R29, R33) who are identified as high risk for pressure injury. Residents Affected - Few Findings include: On 02/06/2024 at 10:15am, Surveyor observed R29 lying on a low air loss mattress with the weight control/knob set at 350lbs. On 02/06/2024 at 12:45pm, Surveyor observed R33 lying on a low air loss mattress control with the weight control/knob set at 180lbs. On 02/06/2024 at 12:25pm, V11 (Licensed Practical Nurse) states, Air mattress settings should be the same as the resident weights. If the settings are not correlated with residents weight it can cause a pressure wound. On 02/08/2024 at 9:30am, V14 (wound care nurse) states, Low air mattress should be set at residents' current weight according to the manufacturer's recommendations. I have a wound tech that check settings daily. I also check settings daily when doing wound rounds to make sure bed is on proper settings. Air loss mattress could work against you, if it's not on the proper weight setting it can possibly cause a pressure wound or skin breakdown. R33 Physician order sheet (POS) 2/7/2024 orders document may use air loss mattress. please verify it's in good working condition every shift for wound care. According to facility weight and vital summary R33 most current weight documents on 2/1/24 R33 weighed 54.8lbs R33 recent BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK assessment dated [DATE] documents R33 scored 10.0 indicating R33 is at high risk for pressure injury. R29 Physician order sheet (POS) 2/7/2024 documents Low Air Loss Mattress every shift According to facility weight and vitals summary R29 most current weight documents on 2/8/24 R29 weighed 180lbs. R29 recent BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK assessment dated [DATE] documents R29 scored 10.0 indicating R29 is at high risk for pressure injury. Facility policy not dated, titled Low Air-loss mattress/Bed documents in part, A specialty bed will be obtained upon provider order. The low air-loss mattress/bed will be utilized according to manufacturer's recommendations. Operational [NAME] titled Proactive Medical Products documents in part, operating instructions step six states, determine the patients' weight and set the control knob to that weight setting on the control unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 3 of 13 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 02/09/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to a.) ensure controlled substances were counted, and documented, at the beginning and end of each shift for 4 out of 22 shifts and b.) keep an accurate count of all narcotic medications for two (R11, R22) residents reviewed for medications. These failures have the potential to affect 42 residents residing in the facility. Findings include: On 02/06/2024 at 10:03AM, V5 (LPN/Licensed Practical Nurse) states that she did not perform a narcotic drug count. V5 was responsible for the 3rd floor Team 2 medication cart for rooms 301 and rooms 309-320. On 02/06/2024 at 10:03AM, review of the Shift Change Accountability Record Sheet for Control Substances for the month of February 2024 for cart identified as Team 2 medication cart located on the 3rd floor of the facility indicated for 2 shifts in February 2024, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 02/05/24, 1st shift oncoming and off-going (7am-7pm) On 02/06/24, 1st shift oncoming (7am-7pm) On 02/06/2024 at 10:03AM, surveyor and V5 (LPN) located on the third floor of the facility performing a controlled substance count and record review. Surveyor observed the following: A medication bingo card labeled R11's name, Lacosamide 100mg, surveyor observed there were 6 pills inside of the medication bingo card. R11's controlled drug receipt record documents a count of 8 pills. A medication bingo card labeled R11's name, Clobazam 10mg, surveyor observed there were 13 pills inside of the medication bingo card. R11's controlled drug receipt record documents a count of 14 pills. A medication bingo card labeled R22's name, Hydroco/Apap 5-325mg, surveyor observed there were 27 pills inside of the medication bingo card. R22's controlled drug receipt record documents a count of 28 pills. On 02/06/2024 at approximately 10:16AM, V6 (RN/Registered Nurse) located on the third floor of the facility with V2 (Director of Nursing). V2 and V6 observed standing at the medication cart identified as Team 1 medication cart with a red controlled substance book open. Surveyor observes V6 writing inside of the red controlled substance book as surveyor approaches the Team 1 medication cart. On 02/06/2024 at approximately 10:18AM, surveyor asks V6 what did she just write inside of the red controlled substance book? V6 pointed to the February 6th 7am-7pm shift on the Shift Change Accountability Record Sheet for Control Substances and states, I just signed here. V6 (RN/Registered Nurse) states she forgot to sign her signature for the narcotic count when she started her shift this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 4 of 13 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 02/09/2024 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 0755 morning. V6 was responsible for the 3rd floor Team 1 medication cart for rooms 302-308. Level of Harm - Minimal harm or potential for actual harm On 02/06/2024 at 10:18AM, review of the Shift Change Accountability Record Sheet for Control Substances for the month of February 2024 for cart identified as Team 1 medication cart located on the 3rd floor of the facility indicated for 2 shifts in February 2024, nurses had not counted and documented the controlled substances. Residents Affected - Some The following dates were missing signatures: On 02/03/24, 2nd shift (7pm-7am) On 02/06/24, 1st shift (7am-7pm) (Shift surveyor observed V6 signing) Facility census dated 02/06/2024 documents a total of 42 residents on the third floor of the facility reside in rooms 301-320. Facility policy dated 03/01/2022 titled Controlled Substances, documents in part, 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. 10. Upon Administration: a. The nurse administering the medication is responsible for recording: (5) quantity of the medication remaining; 12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determines the count together. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 5 of 13 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 02/09/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to obtain consent for psychotropic medication administration for two (R24, R34) residents reviewed for psychotropic medications in a sample of 18 residents. Findings include: R24's current face sheet documents R24 is a [AGE] year-old individual admitted to the facility on [DATE], with current medical diagnosis that include but not limited to: bipolar disorder, current episode depressed, severe, without psychotic features, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified. R24's Minimum Data Set (MDS) section C dated 1/24/2024 documents R24 has a Brief Interview for Mental Status (BIMS) score of 11/15 indicating R24 has moderately impaired cognation. On 02/08/2024 at 2:20pm, V2(Director of Nursing) stated psychotropic consents needs to be signed by the resident or their representatives before the resident starts to take the medications so that the resident can be aware of what he/she is taking the medications for. V2 stated she does not start psychotropic medications before a resident signs the consent form. On 2/08/2024 at approximately 2:35pm, surveyor asked V12 (Infection Preventionist) for the psychotropic consent form for R24. V12 brought the consent form for R24 with a signed date of 2/8/2024 by V12. V12 said residents should sign the consent form before they start receiving the medication. Review of R24's Psychotropic Medication Consent form documents V12 signed the consent form on 02/08/2024. R24's current Physician Order Sheet (POS) documents: Active 8/6/2022 -Sertraline HCl Tablet. Give 50 mg by mouth one time a day related to anxiety disorder, unspecified, major depressive disorder, single episode. Active 8/7/2023 -SEROquel Tablet 50 MG (QUEtiapine Fumarate). Give 0.5 tablet by mouth at bedtime related to unspecified psychosis not due to a substance or known physiological condition. R34 R34's Facesheet documents that R34 is a [AGE] year-old female who has diagnoses not limited to: Cerebral infarction, type 2 diabetes mellitus, schizoaffective disorder, unspecified dementia, and major depressive disorder. R34's Facesheet documents that R34 was admitted to the facility on [DATE]. R34 has a diagnosis of schizoaffective disorder dated 02/25/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 6 of 13 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 02/09/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R34's physician order sheet/POS documents an order for Seroquel 25mg- Give 1 tablet by mouth two times a day. With a start date of 12/28/2023. R34's psychotropic medication consent form was requested from the facility on 02/08/2024. Record reviewed documents that R34's psychotropic medication consent form was signed by V2 (Director of Nursing/DON) on 02/08/2024. Facility policy titled Antipsychotic Medication Use, no date, documents: -All psychotropics will have either a verbal or written consent from the patient or patient guardian within the time guidelines set for by the state requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 7 of 13 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 02/09/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for two (R23, R57) out of four residents reviewed for medication administration resulting in an 11.11% error rate. Residents Affected - Few Findings Include: R57's medication administration record (MAR) dated 02/01/2024- 02/07/2024 documents: Nebivolol HCL 5mg- Give 1 tablet by mouth one time a day scheduled at 9:00AM. On 02/07/2024 at 8:24AM, surveyor observed that this medication was not given during the 9:00AM medication administration pass with V11 (Licensed Practical Nurse/LPN). R23's medication administration record (eMAR) dated 02/01/2024 - 02/07/2024 documents: Protonix 40mg- Give 1 tablet by mouth one time a day scheduled at 9:00AM. Valsartan 80mg- Give 2 tablets by mouth two times a day scheduled at 9:00AM. On 02/07/2024 at 8:42AM during medication administration pass, V11 (Licensed Practical Nurse/LPN) observed administering three tablets of Valsartan 80mg to R23. On 02/07/2024 at 8:42AM, V11 (LPN) states that R23's scheduled Protonix medication is not available for administration. V11 states he will reorder the medication and deploys R23's electronic medication administration record (eMAR). Surveyor observes on R23's eMAR that R23's Protonix medication was reordered from the pharmacy on 01/28/2024. V11 states he is unable to locate R23's Protonix medication in the medication cart. V11 (LPN) states he would normally borrow Protonix medication from another resident to give to R23 but today he will notify his supervisor V2 (Director of Nursing/DON) of R23's missing medication. V11 continues his medication administration pass for other residents in the facility. V11 states he did not notify R23's physician of R23's missing Protonix dose. On 02/08/2024 at 1:48PM, V2 (DON) states the physician does not need to be notified of a resident's missing medication dose as long as the pharmacy delivers the medication in time. On 02/08/2024 at 1:57PM, V17 (LPN) states she is the nurse assigned to care for R23 today and R23's Protonix is still unavailable for administration, and she did not notify R23's physician. Facility policy, titled Administering Medications documents in part, 4. Medications are administered in accordance with prescriber orders, including any required time frames. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 8 of 13 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 02/09/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure medications were locked and secured while unattended. This failure has the potential to affect 35 residents residing in the facility. Findings Include: On 02/07/2024 at 8:09AM, surveyor located on the second floor of the facility. During medication administration pass with V11 (LPN), V11 observed preparing liquid antibiotic medication for R57. V11 observed leaving liquid antibiotic medication on top of his medication cart (identified as Team 2 medication cart) and walks away leaving the liquid medication unattended and out of V11's view. On 02/07/2024 at 8:09AM, V11 returns to the medication cart and states to surveyor, I knew you were standing here so that's why I left the medication on top of the cart. Surveyor states to V11 that surveyor is not responsible for monitoring V11's medication cart. V11 states a resident could have gotten the medication and self-administered it and possibly caused harm to the resident since the liquid medication was left unattended. On 02/07/2024 at 8:56AM during medication administration pass with V11 (LPN), V11 observed entering R52's room and leaves his medication cart unlocked and unattended. Medication cart observed with the outward side facing the hallway and accessible to the residents or anyone passing by. V11 states that residents can potentially get access to the medications if the cart is left unlocked and unattended. Facility census dated 02/06/2024 documents that a total of 35 residents reside on the 2nd floor of the facility. Facility policy, dated 01/22/2022 titled Storage of Medications documents in part, 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended and always in site or in view of the nurse. 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to the residents or others passing by. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 9 of 13 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 02/09/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and records review, the facility failed to follow their policy on Sanitation & Safety Operations by (a) failing to maintain proper food temperatures, (b) failing to date opened food items with open and use by date, (c) failing to unload clean dishes from the dishwasher in a sanitary manner. (d) dishwasher temperatures not consistently documented. These deficiencies have the potential to affect 76 residents who are on an oral diet and receiving meals from the kitchen. Findings include: On 02/06/2024 at 9:30am, during tour of the kitchen with V3(Dietary Manager), in the dry food pantry was observed three types of cereals: frosted flakes, rice krispies, and honey nut cheerios in open bags in a box with no open by date or expiration dates. V3 said all foods including the opened ones should have a open by date and expiration date so that kitchen staff know when the food needs to be thrown out and staff need to follow the first in first out rule. V3 said residents should be given fresh food that is not expired and stale, to prevent residents getting sick from expired foods. V3 said residents' appetite can be affected by stale foods. On 02/06/2024 at 9:43am, while observing kitchen staff washing dishes with V3, V4(Dietary Aide) was observed rinsing dirty dishes and putting them in the dishwasher, and when the dishwasher was done washing, V4 was observed taking out the clean dishes and putting then on the clean dishes cart without changing her gloves. V3 said V4 should be changing gloves before touching the clean dishes to prevent cross contamination which can cause residents to get sick. V4 said she should have changed her dirty gloves before touching the clean dishes to prevent them from getting dirty/contaminated, which can make residents sick. V3 said the dish washer is tested every day and test strips of the temperature outcome are placed on the Dish washer temperature log to keep track of the temperatures to make sure the temperatures are above 150 degrees during washing cycle. Review of Dish Washer Temperature Log with V3 showed no temperature log was recorded for 2/2/24, 2/3/24, 2/5 and there was no temperature label for those days. V3 said the dishwasher temperature log should be completed every day to make sure the dish washer is washing at the right temperature to prevent food borne illness to the residents. On 2/6/2024 at 11:57am during kitchen tour and food temperature checks with V3, Oven fried chicken was observed in the warmer and V8 (Cook) was observed serving the chicken into residents' plates to be bused to units. V3 checked temperatures of foods in the tray being served onto resident plates and the last of the Oven fried Chicken's temperature was 121 degrees F. V3 said foods should reach the correct internal temperature and chicken should reach at least 165F to prevent residents from risk of getting food borne illnesses. On 2/7/2024 at 11:37am during kitchen tour and food temperature checks with V3, Spaghetti was observed in the warmer and V8 (Cook) was observed serving food into residents' plates to be bused to units. V3 took temperature of the Spaghetti and it was observed to be 101F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 10 of 13 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 02/09/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many V3 said foods such as Spaghetti should reach the correct internal temperature of at least 145F when cooked to prevent residents from risk of getting food borne illnesses form uncooked foods. Facility policy titled Labeling and Dating Foods, no date documents: -Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality product for the residents and minimize waste. - Bagged or boxed food once removed from the original package will be placed in an ingredient bin that is labeled with the common name of the food and the date the item is placed in the bin. Examples of these items include oatmeal, cereals flour, sugar, and thickeners. Facility Policy titled Dietary Department-Sanitation & Safety Operations, no date, documents: -Wash hands between handling soiled and clean ware. -Hot foods will be held at a minimum temperature of 135 degrees F for a minimum of 4 hours Facility Dish washer log documented the last temperature test completed was 2/1/2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 11 of 13 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 02/09/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, facility failed to follow their policy to provide influenza and pneumococcal vaccination with its education for 3 residents (R15, R229 and R49) out of 5 in a sample of 18. Residents Affected - Few Findings include: On 02/07/2024 at 11:40 AM, surveyor sat down with V12 (Infection Preventionist/Clinical Consultant) to go over immunization status for residents. V12 stated all the immunization records, consent and education provided are documented in the resident's electronic health record. V12 stated that R15 refused their influenza immunization. Surveyor asked V12 if R15 had received education for the influenza vaccine. V12 stated yes but the education provided check box was not checked. Surveyor observed V12 click the check box at that moment. V12 also stated that R229 refused pneumococcal immunization. Surveyor asked V12 if R229 had received education for the pneumococcal vaccine. V12 replied yes but the education provided check box was not checked. Surveyor observed V12 click the check box for education provided for R229 at that moment as well. On 02/07/2024 at 11:50 AM, when reviewed R49's immunization record, no date was noted for when R49 refused consent for the influenza immunization, no check marked in the check box that education was provided. Surveyor observed V12 check off in front of surveyor that education was provided to resident regarding the influenza immunization. V12 said that he is the one that provided the verbal education and just had forgotten to mark it off. On 02/08/2024 at 12:30 PM, V2 (Director of Nursing) stated after you do any care or treatment or teaching, you have to document. V2 quoted, I don't care if you tell me it's done. if something is not documented, of course it's not done. I always tell my nurses how important documentation is. R15's immunization record documents in part: No influenza vaccine administered. No documentation of education provided. R229's immunization record documents in part: No pneumococcal vaccine administered. No documentation of education provided. R49's immunization record documents in part: No influenza vaccine administered. No documentation of education or consent. Facility's influenza policy (1/1/2022) documents in part: All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually during flu season to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to all residents. Prior to the vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's/employee's medical record. Facility's Pneumococcal policy (1/1/2022) documents in part: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 12 of 13 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 02/09/2024 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 0883 be documented in the resident's medical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145776 If continuation sheet Page 13 of 13