Inspection·April 3, 2025

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** 2. On 3/31/2025 at 11:20am observed brown stains in the ceiling above R180's bed, also observed two blue pads on the floor next to R180's bed. R180 stated, Water leaks from the ceiling above my bed when it rains or snows. Paint chips fall from the ceiling onto my bed. I put the blue pads on the floor to catch the water and the paint chips. The light fixture in the ceiling fills up with water and the maintenance person comes in to drain the water out of the globe attached to the light. In the bathroom, there is a hole under the sink where the pipe meets the wall. Roaches come into the bathroom from the hole underneath the sink. I would like these problems to be fixed. R180's Brief Interview for Mental Status (BIMS) dated 1/31/2025 documents R180 has a BIMS score of 15, which indicates R180's cognition is intact. 3. On 3/31/2025 at 11:30am observed R85's closet door missing in room, R85 had several shirts and coats hanging in the closet. R85 stated, My closet door is missing, and I would like a closet door to prevent my things from being stolen. On 4/02/2025 at 11:14am V24 (Maintenance Director) stated the ceiling was plastered a month ago. V24 stated the area in the ceiling needs to be sanded and painted. V24 was questioned as to why the ceiling area still had brown stains; V24 stated the maintenance staff plastered the ceiling but it still has the brown stains, but the area has been plastered. V24 stated the water coming from the ceiling is from the roof which seeps through the concrete and comes out from the ceiling. V24 stated the closet door was taken down last week and the door has not been replaced. V24 stated, I see the hole in the wall underneath the bathroom sink, I can close the hole by placing plaster around the hole in the wall. R85's Brief Interview for Mental Status (BIMS) dated 1/16/2025 documents R85 has a BIMS score of 12, which indicates R85's cognition is moderately impaired. On 4/02/2025 reviewed the facility's Homelike Environment Policy revised February 2025 which documents in part; The facility's department director and all staff will provide residents with a safe, clean, comfortable environment which emphasizes the person-centered care, resident's comfort, independence and personal needs and preferences. Based on observation, interview, and record review, the facility failed to ensure 1 resident's (R62) bed, with exposed wires, was repaired; failed to ensure 1 resident's (R85) missing closet door was replaced; and failed to repair 1 resident's (R180) leaky ceiling. These failures affected 3 residents (R62, R85 and R180), reviewed for resident's rights to enjoy a homelike environment, in a total sample of 62 residents. Findings include: 1. On 3/31/25 at 11:20am, surveyor observed R62 sitting on the side of his bed. At the end of the bed, the location of the mechanical controls to raise and lower parts of the bed, was broken causing exposed wiring. R62 said, My bed's been broken for weeks. I (R62) told the CNAs (certified nursing assistants) many, many times about my bed because I (R62) don't want to get electrocuted by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 2 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 wires. They (CNAs) told me to be careful and not to touch the wires. Of course, I'm (R62) not going to touch the wires, but you never know. S*** happens. Hell! Those wires might cause a fire. R62's Face Sheet documents diagnoses that include but are not limited to type 2 diabetes mellitus, chronic obstructive pulmonary disease, mononeuropathy of bilateral lower limbs, acquired absence of other right toe(s), and acquired absence of other left toe(s). R62's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 13 which indicates that R62 is cognitively intact. On 4/01/25 at 1:19pm, while in R62's room, V24 (Maintenance Director) said, The cover is broken to his (R62) bed. Those wires are not shockable wires. I (V24) was not aware of this. Typically, maintenance should fix it. No one told me about it. Yeah, those wires are not supposed to be showing. I'll (V24) get that fixed. Facility policy titled, Equipment Maintenance and Repair, revised date 7/24, documents, in part, All equipment utilized in this facility shall be maintained, operated, and repaired as directed . Daily rounds are conducted (i.e. Guardian Angel), to ensure all equipment is clean and in working condition . If equipment shows signs of needing repair, staff shall immediately stop usage of the equipment and report it to maintenance . Facility presented document titled, RESIDENTS' RIGHTS for People in Long-Term Care Facilities, revised date 11/18, documents, in part, . our facility must be safe, clean, comfortable and homelike . Facility policy titled, STATEMENT OF RESIDENTS' RIGHTS, undated, documents, in part, The facility shall insure that all residents are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care for personal needs and communication with and access to persons and services inside and outside the facility. The facility shall protect and promote the rights of each resident, and shall encourage and assist each resident in the fullest possible exercise of these rights . Facility job description titled, Maintenance Supervisor, undated, documents, in part, The primary purpose of the Maintenance Supervisor is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current, federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner . Repair facility/resident property as necessary . Ensure that supplies, equipment, etc., are maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to the Administrator . Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 3 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete Minimum Data Set (MDS) assessments accurately in accordance with the Resident Assessment Instrument (RAI) guidelines. This failure affects 1 resident (R165) in a sample of 61. Residents Affected - Few Findings include: Record review of R165's admission record documents in part the following diagnosis: Record review of R165's MDS ([DATE]) documents in part that R165 has a Brief Interview of Mental Status (BIMS) Summary Score of 8, indicating that R165 has cognitive impairment and that R165 has had wandering occur within the lookback period 4 to 6 days but less than daily. A modification request was completed on [DATE] due to a data entry error. Record review of R165's electronic health record for the lookback period does not document any non-purposeful movement or wandering. On [DATE] at 11:22 AM, R165 denied any non-purposeful movement or wandering within the facility. R165 denied ever getting lost or turned around within the facility. R165 stated that R165 has been in the facility for a while now and knows the way around. On [DATE] at 12:08 PM, V34 (Registered Nurse (RN)/MDS Coordinator) affirmed V34 is the RN assessment coordinator for the facility. V34 explained that V34 reviewed R165's MDS ([DATE]) and it was incorrectly coded by the social worker. V34 completed a modification and transmitted the assessment on [DATE]. V34 affirmed R165 did not have any behavior that met the RAI definition of wandering in the lookback period. V34 stated wandering is defined as non-purposeful movement. Record review of CMS' RAI Version 3.0 Manual (10/2024) documents in part, .E0900: Wandering-Presence and Frequency . Steps for Assessment 1. Review the medical record and interview staff to determine whether wandering occurred during the 7-day look-back period. o Wandering is the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The wandering resident may be oblivious to their physical or safety needs. The resident may have a purpose such as searching to find something, but they persist without knowing the exact direction or location of the object, person or place. The behavior may or may not be driven by confused thoughts or delusional ideas (e.g., when a resident believes they must find their parent, who staff know is deceased ). 2. If wandering occurred, determine the frequency of the wandering during the 7-day look-back period. Coding Instructions for E0900 o Code 0, behavior not exhibited: if wandering was not exhibited during the 7-day look-back period. Skip to Change in Behavior or Other Symptoms item (E1100). o Code 1, behavior of this type occurred 1-3 days: if the resident wandered on 1-3 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days. Proceed to answer Wandering-Impact item (E1000). o Code 2, behavior of this type occurred 4-6 days, but less than daily: if the resident wandered on 4-6 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days. Proceed to answer Wandering-Impact item (E1000). o Code 3, behavior of this type occurred daily: if the resident wandered daily during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days. Proceed to answer Wandering-Impact item (E1000) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 4 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based upon interview and record review the facility failed to follow policy procedures, failed to ensure the vaccination consent form includes a refusal option, and failed to ensure staff provide informed consent prior to obtaining resident signature for one of five residents (R19) reviewed for immunization administration. Residents Affected - Few Findings include: The facility Vaccination Consent Form includes signature of patient or authorized representative to receive vaccine however refusal of vaccine is excluded. R19's (8/19/24) Pfizer - Covid 19 and Flu Vaccination Consent Form was endorsed (by R19) and states signature of patient to receive vaccine however evidence that R19 received these vaccines was not received (as requested). On 4/1/25 at approximately 12:43pm, surveyor inquired about R19's vaccinations V4 (Infection Preventionist) stated He (R19) had refused the Flu and Covid. Surveyor inquired about R19's (8/19/24) Covid 19 and Flu Vaccination Consent Form which affirms consent to receive the vaccines. V4 responded, The consent is signed it looks like whoever did the clinic put refused on the face sheet and then the signatures on the back of the consent form. Surveyor inquired why the (8/19/24) Vaccination Consent Form excludes refusal if R19 refused the Flu and Covid 19 vaccines. V4 replied, How I do it is that they sign, and I put refuse next to where they sign if they refuse. The (undated) Covid 19 vaccination policy states all residents, employees, and contracted staff will be educated and counseled on the importance of Covid 19 vaccination per CDC guidelines and recommendations. The influenza vaccine policy (revised 10/2024) states resident and/or representative has the right to refuse vaccination. If refused, appropriate entries will be documented in the residents' EHR (Electronic Health Record) indicating the refusal of the influenza vaccination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 5 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide ADL (Activity of Daily Living) care to one resident (R138) reviewed for ADL care in a sample of 62. Residents Affected - Few Findings include: R138's diagnoses include but not limited to osteoarthritis, chronic pain syndrome, Transient Ischemic Attack (TIA), artificial shoulder joint, and anxiety. R138's (3/25/25) Brief Interview of Mental Status (BIMS) score is 15. R138 in cognitively intact. R138's functional assessment affirms R138 requires substantial/maximal assistance with personal hygiene (shaving). On 3/31/25 at 11:30 am, R138 was observed in room watching television ungroomed with facial hair on the chin. Surveyor inquired if the facility assists R138 with shaving. R138 stated, Staff never offer to shave me. The hair on my chin makes me feel like a man and I do not like that. On 4/2/25 at 10:57 am, V2 DON (Director of Nursing) stated shaving should be done if the resident request to be shaved or if staff see hair. The staff should ask if the resident wants to be shaved and if the resident does want to be shaved then the staff should do it. A female resident should not have hair on her face if she does not want it. R138's care plan documents in part, R138 has an ADL (Activity of Daily Living) self-care performance deficit related to diagnosis/history . Facilities policy undated and titled ADL Policy documents in part, A. hygiene: a. Resident self-image is maintained. Resident has a right to a beard/facial hair but encouraged to be clean shaven. Staff to assist with grooming of facial hair as needed. Facility's job description titled Certified Nursing Assistant documents in part, Essential Duties and Responsibilities: Provide assistance in personal hygiene by giving . shaves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 6 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 Based on observation, interview, and record review the facility failed to ensure the low air loss mattress was not layered with multiple linens. This failure affected 1 resident (R16) reviewed for pressure ulcer/injury prevention and treatment in a sample of 62 residents. Residents Affected - Few Findings include: R16's diagnoses include but not limited to COPD (Chronic Obstructive Pulmonary Disease), hypertension, chronic kidney disease, left tibia fracture, tendinitis of left and right leg. R16's Brief Interview of Mental Status (BIMS) score is 15. R16 is cognitively intact. On 3/31/25 at 10:45 am, R16 was lying on a low air loss mattress with multiple layers between R16 and the low air loss mattress. The layers observed under R16 consisted of a flat sheet, a folded bath sheet folded multiple times, and an incontinent brief. On 4/2/25 at 10:23 am, V30 Wound Care Director stated the low air loss mattress should be layered with a single flat sheet. Surveyor asked V30 if a resident on a low air loss mattress should have a folded bath sheet, flat sheet, and incontinent brief under them. V30 stated, That is way too many layers. That many layers can increase the temperature that will increase perspiration and could cause skin breakdown. That many layers are more than recommended and it will defeat the purpose for the mattress, The purpose for the mattress is to provide repositioning and assist with off-loading pressure. On 4/2/25 at 10:57 am, Surveyor asked V2 (Director of Nursing/DON) if a resident on a low air loss mattress should have a folded bath sheet, flat sheet, and incontinent brief under them. V2 stated, All those layers should not be on an air loss mattress, because the purpose of the mattress is for wounds or potential wounds so the layering could cause a bigger wound or potential for an actual wound if they are at risk. A low air loss mattress layering should just be a flat sheet. R16's (4/2/25) Active Orders Summary Report documented in part, Low Air Loss Mattress in use every shift for prevention .Use flat sheet only . R16's Risk Assessment Profile dated 2/4/25 documents in part, R16's Braden Scale Score is a 15, indicating R16 is at risk for skin breakdown. R16's (3/14/25) care plan documents in part, Focus: R16 has potential for alteration in skin integrity r/t (related to) advance age, fragile skin, and incontinence. The (undated) Operation Manual for the air mattress documented in part, Intended use: to reduce the incidents of pressure ulcer while optimizing patent comfort. Installation: step 2 Cover with a cotton sheet to avoid direct skin contact and reduce friction. Facility policy undated and titled, Pressure Ulcer Prevention and guidelines documented in part, It is the policy of this facility to ensure based on assessment that residents at risk for skin break down are assessed and that preventative measures are implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 7 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 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 ensure that the 4th floor medication cart was locked while unattended. This failure has the potential to affect 51 residents on the 4th floor. Residents Affected - Some Findings include: The (3/31/25) census includes 51 (4th floor) residents. On 4/1/2025 at 11:11 am, with V29 (Licensed Practical Nurse-(LPN), during observation of the medication car on the 4th floor, V29 and surveyor walked away from the nursing medication cart to observe the medication refrigerator behind the nursing station. V29 did not lock and secure the nursing medication cart after leaving the nursing medication cart unattended. Surveyor inquired why the medication cart was left unlocked and unattended and V29 replied, I was rushing and forgot to lock the cart. The cart should be locked when unattended. On 4/2/2025 at 2:11pm, V2, (Director of Nursing-(DON), stated the medication cart should be always locked after medication. V2 stated residents can get into unlocked medication carts. Facility policy titled Storage of Medications dated 5/1/2018, document, in part, Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. Facility policy titled Storage of Medications dated 5/1/2018, documents, in part, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 8 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to follow policy procedures, failed to follow physician orders, failed to implement care plan interventions, failed to measure/record urine output, and failed to timely report hematuria to the physician for one of 62 residents (R19) in the sample reviewed for incontinence/catheter. Findings include: R19's diagnoses include neuromuscular dysfunction of bladder and retention of urine. R19's Physician Order Sheets include (12/17/24) Xarelto (anticoagulant) 10 milligrams daily to prevent blood clots. (12/28/24) Indwelling catheter measure and record urinary output, color, clarity, and device status every shift. R19's care plan includes (7/6/22) indwelling catheter related to retention of urine and neurogenic bladder, interventions: monitor/record/report to Medical Doctor signs/symptoms UTI (Urinary Tract Infection): pain, burning, blood-tinged urine. (10/2/24) Resident is on anticoagulant therapy, interventions: Monitor/document/report adverse reactions: blood tinged or red blood in urine. R19's (March 2025) Medication Administration Record includes indwelling catheter - measure and record urinary output, color, clarity, and device status every shift however on 3/31/25, nothing was documented on evening and night shift (both entries are blank). R19's (3/7/25) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). R19's (3/7/25) functional assessment affirms resident requires substantial/maximal assistance with toileting hygiene. On 3/31/25 at 11:20am, hematuria was noted throughout R19's indwelling urinary catheter tubing and bag. Surveyor inquired about R19's catheter R19 stated, They (staff) switched out the bag Friday, they change it every Friday and affirmed he (R19) was unaware that there was blood in his urine. On 3/31/25 at approximately 11:23am, surveyor inquired about the appearance of R19's urine. V10 (Licensed Practical Nurse) stated, The urine is red-like, it's a red-like urine which I have to let the doctor know asap. Surveyor inquired if the staff made V10 aware of R19's hematuria. V10 responded No. R19's 3/31/25 (11:40am) progress note (entered after surveyor inquiry) states during rounds resident (brand name) catheter bag was noted with a cranberry like urine, doctor on file was notified. Resident is on Xarelto 10mg tab, doctor ordered to hold Xarelto and send resident to Hospital for hematuria. The catheter care policy (revised 10/2024) states ensure catheter care is performed to prevent infection and reduce irritation. Documentation must include color, amount, consistency, and odor of urine. Notify the physician of any condition change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 9 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that enteral feed orders include daily total volume, failed to follow physician orders, and failed to provide enteral feedings as ordered for one of 62 residents (R122) in the sample reviewed for hydration/nutrition. Findings include: R122's diagnoses include encephalopathy, dysphagia, and gastrostomy. R122's (3/3/25) BIMS (Brief Interview Mental Status) affirms cognitive skills for daily decision making is severely impaired, inattention and disorganized thinking are present. R122's (3/3/25) functional assessment affirms resident is dependent on staff for eating, resident does none of the effort to complete the activity. R122's (3/4/25) Care Plan states resident is NPO (nothing by mouth) and receives nutrition via G (gastrostomy) tube, intervention: provide tube feeding as ordered. R122's (3/19/25) Physician Order Sheets include Nepro 1.8 (enteral feed) administer continuous via Pump 70ml (milliliters) per hour over 21 hours (daily total volume is excluded). Downtime: 6am back on at 9am. On 3/31/25 at 10:28am, R122's Nepro 1.8 was infusing at 70ml per hour (via g-tube) however the start time was 3:40am per label, the bottle appeared full (over 900ml) and only 27ml was delivered (per pump). Surveyor inquired about R122's enteral feeding V10 (Licensed Practical Nurse) stated, She's (R122) supposed to be getting it at 70 per hour and normally when I come in the morning, I start it at 10am. Surveyor asked why R122's tube feeding was hung at 3:40am, if it's started at 10am. V10 responded, It was hung on the night shift. I have to verify the time that they stop it, but I start it at 10 in the morning [1 hour after the prescribed start time]. The tube feeding policy (revised 12/2024) states provide nutrients, fluids, and medications as per physician orders. Prescribed amount of formula volume is given over a specific period of time - 24 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 10 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to post required staffing information in a high visibility area and failed to ensure the staffing posting included all required information. This failure has the potential to affect all 192 residents residing within the facility. Residents Affected - Many Findings include: Review of facility-provided census documents in part that 192 residents reside within the facility. On 3/31/2025 at 10:30 AM, facility tour was conducted. Posted staffing information was not noted in any high visibility areas on the resident units, dining rooms, activity rooms, or entry areas. On 3/31/2025 at 12:37 AM, surveyor inquired where the required staffing posting was kept. V36 (Receptionist) stated, We don't have a document that says anything like hours on it, just the staffing schedule. V36 pulled a binder off the side counter of the reception desk area and provided a copy of the facility's nursing schedule from the binder. On 3/31/2025 at 12:39 AM, observed the location of the binder sitting on top of the side counter of the receptionist desk area. No residents were seen within this area throughout the course of the survey. Prior to entering the area where the binder is located, a door identifying a staff entrance is noted. Record review of the staffing posting provided by V36 (dated 3/31/2025) does not document the total number and actual number of hours worked in the shifts. On 4/2/2025 at 11:53 AM, V1 (Administrator) affirmed the staffing notice was not posted on 3/31/2025 and the form was currently posted at the front desk. V1 affirmed that the staffing notice should list the hours worked and should be posted in a high visibility area. V1 stated the facility does not have a policy for staffing posting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 11 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to discard expired medication. This failure has the potential to affect three residents (R64, R144, R189) in a sample size of 62. Findings Include: 1. On [DATE] at 10:05 am, the second-floor's medication cart had R189's Insulin Lispro Injection Solution 100 UNIT/ML labeled with an expiration date of [DATE]. R189's admission diagnosis includes but not limited to Type II Diabetes Mellitus, Hypertension, and Obesity. R189's Physician Order Sheet documents in part an active order for Insulin Lispro (Injection Solution 100 Unit/ML) with an order date of [DATE] and start date of [DATE]. R189's Medication Administration Record (MAR) documents in part Insulin Lispro Injection Solution had a check mark indicating administration dates of [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 10:51 am, the fourth-floor's medication cart had R64's Insulin Glargine (Injection 100 Units/ML) labeled with an opening date of [DATE] and expiration date of [DATE]. On [DATE] at 10:13 am, V10 (Licensed Practical Nurse-(LPN) stated that V10 (LPN) cleans the cart every 2 days. V10 stated the Insulin Lispro vials expired between 26 and 28 days. V10 verified the expiration date of R189's Insulin Lispro is [DATE]. V10 stated V10 did not administer R189 Insulin Lispro this morning. 2. R64's admission diagnosis includes but is not limited to Type II Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure Morbid Obesity and Long-Term Use Of Insulin. R64's Physician Order Sheet documents in part an active order for Insulin Glargine (Injection Solution 100 Unit/ML) with an order date of [DATE] and a start date of [DATE]. R64's Medication Administration Record (MAR) documents in part Insulin Glargine Solution 100 UNIT/ML with a check mark indicating administration dates of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 11:02 am, V29 (Licensed Practical Nurse-(LPN) stated R64's Insulin Glargine has an opening date of [DATE]. V29 (LPN) stated R64's Insulin Glargine Solution is expired and should not be on the medication cart. 3. On [DATE] at 10:59 am, the fourth floor's medication cart had R144's Insulin Glargine Solution Injection 100 Units/ML labeled with an expiration date of [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 12 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 - Few R144's admission diagnosis includes but is not limited to Type II Diabetes Mellitus with Diabetic Retinopathy, Type II Diabetes with Chronic Kidney Disease, and Type II Diabetes Mellitus with Diabetic Nephropathy. R144's Physician Order Sheet has an active order for Insulin Glargine Solution 100 UNIT/ML with an order date of [DATE] and start date of [DATE]. R144's Medication Administration Record (MAR) documents in part Insulin Glargine Solution 100 UNIT/ML with a check mark indicating medication administration dates of [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 11:04 am, V29 (Licensed Practical Nurse-(LPN) stated R144's Insulin Glargine Injection Solution has an expiration date of [DATE] and should be discarded. V29 stated Insulin should be discarded from the medication cart 28 days after opening. On [DATE] V2 (Director of Nursing-(DON) at 2:11 PM stated that Insulin should have an opening date and an expiration date. V2 stated Insulin should expire 28 days of opening and insulin should be discarded 28 days after opening. Facility Policy titled Storage of Medications dated [DATE] documents, in part, the following: 1. Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel. Pharmacy personnel, or staff members lawfully authorized to administer medications. 2. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter that the manufacturer's expiration date to insure medication purity and potency. 3. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of if according to procedures for medication disposal if a current order exists. 4. The nurse will check the expiration date for each medication before administering. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 13 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 observation, interview, and record review the facility failed to ensure foods in the walk-in freezer were labeled with a date indicating when the items were placed in the freezer and labeled with a use by date to prevent expired foods from being served. This failure has the potential to affect all 188 residents in the facility who are receiving an oral diet. The findings include: On 3/31/2025 at 9:30am observed the Walk-In Freezer #3 accompanied by V17 (Dietary Manager). Observed a 10-pound box of flame broiled rib shaped pork patties (53 count per box) and a 10-pound (25-pound packages) box of diced ham which were not dated with a date the item was stored in the freezer, nor dated with a use by date. On 4/2/2025 at 12:09pm V17 (Dietary Manager) stated all kitchen staff are responsible for labeling food items placed in the freezer with a date indicating when it was placed into the freezer. V17 stated it is my expectation that all kitchen staff are labeling all food items with a date when the food item was received and placed into the freezer. V17 stated the food items are labeled with a date so the staff will know which food items are to be used first; first in/ first out. V17 stated if a food item is placed in the freezer and not dated, then this food item may expire. V17 stated if a food item expires and a resident is served this expired food item, then the resident can get sick. Reviewed the facility's policy titled Food & Nutrition Services Sanitation & Food Safety- Labeling and Dating Foods, which lacks the facility's letterhead and documents in part, Underneath Policy: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded. Reviewed the facility's undated Dietary Manager's Job Description which documents in part, The primary purpose of the Dietary Manager is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Dietary Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Dietary Department is maintained in a clean, safe and sanitary manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 14 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop a QAPI (Quality Assurance Performance Improvement) plan that meets regulatory standards. This failure has the potential to affect all 192 residents that reside within the facility. Residents Affected - Many Findings include: Review of facility-provided census documents in part that 192 residents reside within the facility. On 4/2/2025 at 10:00 AM, surveyor received QAPI meeting minutes and sign-in sheets for all QAPI activities from 2024 through present. A copy of the facility's QAPI plan was not received and was not received prior to the exit of the survey. On 4/2/2025 at 10:40 AM, V1 (Administrator) provided a copy of the facility's QAPI policy. V1 stated the purpose of QAPI is to have ongoing monitoring of data to ensure quality outcomes. On 4/2/2025 at 1:38 PM, surveyor requested to review the facility's QAPI plan. On 4/2/2025 at 3:02 PM, V1 (Administrator) stated the facility does not have a separate QAPI plan and the QAPI policy is the facility's QAPI plan. Record review of facility policy titled QAPI program (8/2024) documents, Title: QAPI Program Policy: QAPI is the coordinated application of two mutually - reinforcing aspects of quality management systems. Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and date driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home care givers in practical and creative problem solving. QA is the specification of standards for quality of service and outcomes and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is ongoing, both anticipatory and retrospective in its efforts to identify how the organization is performing including where and why the facility performance is at risk or has failed to meet standards. PI (also called quality improvement and performance improvement) is the continuous study and improvement of processes with the intent to better services or outcomes and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systematic problems or barriers to improvement. PI in nursing homes aims to improve to improve processes involved in health care delivery and resident quality of life. PI can make food quality even better. Procedure: 1. The administrator will advise and oversee the duties and responsibilities of the QAPI steering committee. 2. The administrator will appoint staff members to the QAPI steering committee. 3. The administrator and QAPI steering committee are responsible for planning, designing, implementing and coordinating care and services and selecting the QA activities to meet the needs of the resident. 4. The QAPI committee will meet at a minimum quarterly and/or more frequently as deemed by the committee. 5. Minutes of meetings will reflect membership and all attendance of those who participate in the meeting. 6. The QAPI committee will ensure the plans and goals are carried out and are clearly communicated to all staff. 7. Annual training will be conducted to all staff utilizing the annual QAPI report to summarize goals, progress and revisions to performance improvement plans. Revised August, 2024. This policy is not a plan and does not include pertinent information for a QAPI plan, including but not limited to, description of how the facility will ensure care and services delivered meet accepted standards of quality, description of how the facility will identify problems and opportunities for improvement, and ensure progress toward correction or improvement is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 15 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete achieved and sustained; the process for identifying and correcting quality deficiencies (including key components such as tracking and measuring performance, Establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies, identifying and prioritizing quality deficiencies; Systematically analyzing underlying causes of systemic quality deficiencies; Developing and implementing corrective action or performance improvement activities; Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed); describe all systems of care and management practices; include clinical care and resident choice; describes how the facility will utilize the best available evidence to define measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents; and describes the complexities, unique care and services that the facility provides. Event ID: Facility ID: 145881 If continuation sheet Page 16 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to develop policies and procedures on how the facility obtains and uses feedback from residents, resident representatives, and staff to identify high-risk, high-volume, or problem prone issues as well as opportunities for improvement; Develop and implement policies and procedures which include how it ensures data is collected, used and monitored for all departments; Develop policies and procedures for how it will identify, report, and track, adverse events, and high risk, high volume, and/or problem-prone concerns; Establish priorities for its improvement activities, focus on high-risk, high- volume or problem-prone areas, as well as resident safety, choice, autonomy, and quality of care; Conduct at least one PIP annually focuses on high-risk or problem prone areas, identified by the facility, through data collection and analysis; and measure the success of actions implemented and track performance to ensure improvements are realized and sustained. This failure has the potential to affect all 192 residents reside within the facility. Findings include: Review of facility-provided census documents in part 192 residents reside within the facility. On 4/2/2025 at 10:00 AM, surveyor received QAPI (Quality Assurance Performance Improvement) meeting minutes and sign-in sheets for all QAPI activities from 2024 through present. A copy of the facility's QAPI plan was not received and was not received prior to the exit of the survey. No records of the completion of a Performance Improvement Plan (PIP) were received prior to the exit of the survey. On 4/2/2025 at 10:10 AM, V35 (Medical Records Director) affirmed V35 is in charge of the QAA/QAPI programming within the facility. V35 stated the facility completes QAPI meetings quarterly and each department brings items to discuss at the meeting. V35 was unsure if there was any specific document identifies what each department is to bring to the meeting. V35 stated the facility completes PIPs after every concern is identified. Surveyor inquired what the process of a completing PIP is and V35 replied, The department manager does corrective action. V35 denied a charter is completed, committee formed, or root cause analysis is completed. V35 denied knowledge of root cause analysis. V35 could not identify what items a formal PIP was completed on within the last year. Surveyor requested records of a PIP completed within the last year from V35 and this was not received by the exit of the survey. V35 reviewed the QAPI meeting minutes and data from the 1/21/2025 meeting (signed and prepared by V35) and the identified concerns/corrective action. No proof of corrective action was documented within the provided QAPI documents (i.e., in-service documents). V35 was unsure if the corrective action was completed as identified in the meeting minutes and notes. Surveyor inquired how V35 and the QAA committee would know the corrective action was completed without documentation, and V35 responded, Yeah, I see what you mean. Surveyor requested documentation of the identified corrective action for all items identified in the 1/25/25 meeting from V35 and the documentation was not received prior to the exit of the survey. On 4/2/2025 at 10:40 AM, V1 (Administrator) affirmed V35 is in charge of the QAPI programming but V1 supervises V35. V1 affirmed V1 participates in the QAPI committee as the governing body. V1 stated the facility had completed a PIP within the last year on falls. V1 could not recall the specifics of the PIP, including but not limited to, data collection, how often data was reviewed, all staff members involved with the PIP. Surveyor requested the documentation from the falls PIP. V1 responded, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 17 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0867 we do not have documentation of the PIP. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled QAPI program (8/2024) documents, Title: QAPI Program Policy: QAPI is the coordinated application of two mutually - reinforcing aspects of quality management systems. Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and date driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home care givers in practical and creative problem solving. QA is the specification of standards for quality of service and outcomes and a process throughout the organization for assuring care is maintained at acceptable levels in relation to those standards. QA is ongoing, both anticipatory and retrospective in its efforts to identify how the organization is performing including where and why the facility performance is at risk or has failed to meet standards. PI (also called quality improvement and performance improvement) is the continuous study and improvement of processes with the intent to better services or outcomes and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systematic problems or barriers to improvement. PI in nursing homes aims to improve to improve processes involved in health care delivery and resident quality of life. PI can make food quality even better. Procedure: 1. The administrator will advise and oversee the duties and responsibilities of the QAPI steering committee. 2. The administrator will appoint staff members to the QAPI steering committee. 3. The administrator and QAPI steering committee are responsible for planning, designing, implementing and coordinating care and services and selecting the QA activities to meet the needs of the resident. 4. The QAPI committee will meet at a minimum quarterly and/or more frequently as deemed by the committee. 5. Minutes of meetings will reflect membership and all attendance of those who participate in the meeting. 6. The QAPI committee will ensure the plans and goals are carried out and are clearly communicated to all staff. 7. Annual training will be conducted to all staff utilizing the annual QAPI report to summarize goals, progress and revisions to performance improvement plans. Revised August, 2024.This policy does not include descriptions of how the facility obtains and uses feedback from residents, resident representatives, and staff to identify high-risk, high-volume, or problem prone issues as well as opportunities for improvement; include how it ensures data is collected, used and monitored for all departments; describe how the facility will identify, report, and track, adverse events, and high risk, high volume, and/or problem-prone concerns; Establish priorities for its improvement activities, focus on high-risk, high- volume or problem-prone areas, as well as resident safety, choice, autonomy, and quality of care. No other related QAPI policy documents were received prior to the exit of the survey. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 18 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff report maintenance concerns, failed document maintenance requests/repairs, and failed to repair malfunctioning equipment for one of 62 residents (R63) in the sample. Residents Affected - Few Findings include: R63's (3/10/25) functional assessment includes mobility devices: wheelchair. R63's (3/10/25) BIMS (Brief Interview Mental Status) determined a score of 8 (moderate impairment). On 3/31/25 at 12:40pm, surveyor inquired about concerns R63 stated, My leg rest for my chair (referring to the wheelchair) it's broke. V3 (Assistant Director of Nursing) subsequently placed the left leg rest on R63's wheelchair however was unable to lower the foot pedal. Surveyor inquired if R63's foot pedal was broke V3 responded, It won't move, this part (referring to the foot pedal) doesn't slip down. I can't get this one down. Surveyor inquired if V3 was unable to lower R63's foot pedal V3 replied, It's like it's caught up on here and doesn't go through so I'm gonna have maintenance come take a look at it. On 3/31/25 and 4/1/25, surveyor requested the facility maintenance log however the log was not received. On 4/2/25 at 10:49am, surveyor inquired about facility maintenance requests/repairs V24 (Maintenance Director) stated, Typically they (staff) call us (maintenance), or they text us then we (maintenance staff) fix it, or when we do our rounds, and we see something we fix it. Surveyor inquired about the facility maintenance log which was not received V24 responded, Typically, we don't keep a log, we didn't keep a log of it (maintenance request/repairs). Surveyor inquired if V24 received a call and/or text to repair a broken wheelchair on Monday (3/31/25) V24 replied, No I didn't and advised that V27 (Maintenance) may have received the request. On 4/2/25 at 11:00am, surveyor inquired about facility maintenance requests/repairs V27 (Maintenance) stated, Normally they (staff) call or page us (maintenance) to come to the floor or they text us to come fix stuff. Surveyor inquired where maintenance requests are documented V27 responded, When they call, I just go straight there and fix what they call us to do, I just go straight there. If it happens during the night they always call the department head and let us know in the group message. Surveyor inquired if staff reported R63's broken wheelchair on Monday (3/31/25) V27 replied, No they didn't. The equipment maintenance and repair policy (revised 7/24) states, all equipment utilized in this facility shall be maintained, operated, and repaired as directed. Daily rounds are conducted to ensure all equipment is clean and in working condition. Staff shall use the maintenance requisition form for any concerns or repairs that need to be completed. Each unit shall be provided maintenance requisition forms and/or maintenance log to communicate repairs to maintenance staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 19 of 20 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 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at Margate Park 4920 North Kenmore 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 0944 Level of Harm - Minimal harm or potential for actual harm Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interview and record review, the facility failed to ensure all staff were trained annually on the facility's QAPI program. This failure has the potential to affect all 192 residents residing within the facility. Residents Affected - Many Findings include: Review of facility-provided census documents in part that 192 residents reside within the facility. On 4/2/2025 at 10:16 AM, V35 (Medical Records Director) affirmed V35 manages the QAA and QAPI programming for the facility. V35 stated QAPI stands for Quality assurance performance and . uhh . I don't know. V35 did not know what the term root cause analysis meant. V35 reviewed nearby documents and could not state what QAPI stands for. V35 stated the facility does not train all staff on QAPI as the department heads are the identified staff that participate in QAPI. V35 could not remember the last time V35 had QAPI training, stating it was probably many, many years ago. On 4/2/2025 at 10:40 AM, V1 (Administrator) affirmed V35 is in charge of the QAPI programming but V1 supervises V35. V1 affirmed V1 participates in the QAPI committee as the governing body. V1 stated V1 was unsure the last time the facility completed all staff QAPI training. Surveyor requested the staff in-servicing records regarding required QAPI training, and these records were not received by the end of the survey. On 4/2/2025 at 11:22 AM, V2 (Director of Nursing) stated V2 is a part of the QAA/QAPI committee. V2 could not recall the last time V2 received QAPI training. V2 was unsure if all staff were trained on QAPI annually. Record review of facility policy titled QAPI Program (8/2024) documents in part . 7. Annual training will be conducted to all staff utilizing the annual QAPI report to summarize goals, progress, and revisions to performance improvement plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 20 of 20