Inspection·July 18, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few separated. DON and social services made aware.R5's progress note dated 07/01/2025 at 11:16AM, written by V14 (Social Services) documents, R5 was given a behavior contract and educated on appropriate and acceptable bx with peers, the consequences as well as the risks of consuming alcoholic beverages. R5 was receptive of the education, and requested if he can apologize to the peer, he had a disagreement with. R5 was informed Social Services will remain available for R5's needs or concerns.On 07/15/2025 at 1:12PM, V3 (LPN/Nursing Supervisor) stated she was made aware by V4 (Receptionist) of a verbal altercation between R4 and R5 and R5 called R4 a snitch. V3 stated this altercation occurred approximately 2.5 weeks ago. V3 stated she went to talk to R4 but R4 did not want to provide any information regarding the altercation and refused an assessment. V3 stated, the next day, as she was punching out, she overheard R4 telling a social services staff member about the altercation. V3 stated she then assessed R4's leg and observed there was a superficial scrape on R4' leg with skin intact, no bruising, no bleeding. V3 stated she took a picture of R4's leg and showed it to V2 (Director of Nursing/DON) then V3 left the facility. V3 stated she was going on vacation once she left the facility and have since deleted the picture of R4's leg. V3 stated she is unaware of what happened to R4's leg because R4 did not tell her. V3 stated she informed V2 (DON) so V2 could follow up. V3 stated she later found out R4 tried to get pass R5 but R5 did not move and R4 got a superficial scrape on his leg.On 07/15/2025 at 2:33PM, V2 (DON) stated she was made aware via telephone by V3 (LPN/Nursing Supervisor) of a verbal altercation took place between R4 and R5. V2 stated she was informed R4 and R5 were in the elevator and R4 was trying to come off the elevator and R5 did not move and R4 pushed himself pass R5. V2 stated she asked V3 if she had informed V1 (Administrator) of the incident and V3 said yes. V2 stated she then asked V3 if R4 and R5 were separated and V3 said yes. V2 stated R4 and R5 were informed to stay away from one another. V2 stated the next day she was shown a picture of R4's leg by V3. V2 stated R4's leg appeared to be a superficial scratch with no swelling, no bruising, no bleeding, or redness. V2 stated the superficial scratch on R4's leg appeared to be an older wound and did not look fresh and was scabbed over. V2 stated a couple of hours after she saw the picture of R4's leg, she attempted to ask R4 what happened and R4 told her, Don't worry about it. V2 stated she has never heard of an altercation of R5 taking his rollator walker and ramming it into R4's leg and this would be considered abuse. V2 stated she has never had a conversation with R5 about the altercation took place between R4 and R5. V2 stated R5 has been avoiding her and doesn't come around her much. V2 stated V1 (Administrator) is the abuse coordinator and she reported to V1 a verbal altercation occurred between R4 and R5.R4's progress note dated 07/01/2025 at 1:24PM, written by V2 (Director of Nursing/DON) documents, Writer was notified by staff R4 was on the elevator with another resident and when trying to get passed the other resident, R4 scratched his leg. Assessment was done and scratch noted on right leg. Area was cleaned. R4 was educated he needs to be patient while leaving the elevator.On 07/15/2025 at 2:50PM, V1 (Administrator) stated he has been the abuse coordinator at the facility for one year. V1 stated as the abuse coordinator, he is responsible for ensuring the safety of residents and the prevention of residents being hurt through any form of abuse. V1 stated R4 came into his office screaming and yelling and told him his leg was scratched. V1 stated there was an altercation and R4 was squeezing past R5 and R4 scratched his leg in the process. V1 stated he asked R5 what happened during the altercation and R5 told V1 R4 brushed pass him and R4 scratched his leg on R5's walker. V1 stated he did not think the altercation between R4 and R5 was considered abuse. V1 stated he was never made aware by R4 or anyone else R4 made allegations of R5 ramming his walker against R4's leg. V1 stated this is the first time he is hearing of the allegations and will now report to the state agency. V1 stated he has received abuse training, and it is a requirement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 2 of 8 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 07/18/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete for the renewal of his license. V1 stated abuse training is also incorporated into the orientation process upon being hired at the facility. V1 stated he is responsible for reporting allegations of abuse to the state agency within the required time frames.On 07/16/2025 at 9:27AM V4 (Receptionist) stated R4 informed him he was in an altercation with R5. V4 stated R4 reported to him R5 won't leave R4 alone and is messing with R4. V4 stated R4 also reported he felt like R5 was intoxicated and targeting him. V4 stated sometime in June 2025 on a Sunday at approximately 7:30PM-8:00PM, V4 was located at the front lobby desk and R4 reported this to him. V4 stated he received a report on R5's behavior the day prior so he was inclined to believe R4. V4 stated he reported to V3 (LPN) what R4 reported to him. V4 stated the day prior, he received a report from another staff member R5 appeared to be intoxicated with alcohol in the facility. V4 stated R5 smelled like alcohol but he was unsure if R5 was drunk or not. V4 stated R5 previously had an independent community pass but it was restricted due to violations of facility rules related to intoxication. V4 stated R4 informed him R4 would be reporting to V3 about the altercation between him and R5. V4 stated V3 called the police and V3 instructed him to let V3 know when the police arrived. V4 stated approximately 40 minutes later, police arrived at the facility, and he directed the police officer to the floor where V3 was located. V4 stated he assumed a police report was filed but he is not aware of a police report number or the police officer's name/badge number. V4 stated he believed the police was called due to an argument and he was not made aware of any physical altercations between R4 and R5. V4 stated he was informed R4 and R5 should be separated and to keep other residents from being in contact with R5.Ombudsman Residents' Rights for People in Long-Term Care Facilities dated 11/2018 documents in part, You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually.Facility documents dated 10/24/2024, titled Abuse Prevention Policy documents in part, This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to facility staff, other residents.Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident .The term willful, in this definition of abuse means the individual must have acted deliberately, not the individual must have intended to inflict injury or harm. Event ID: Facility ID: 145881 If continuation sheet Page 3 of 8 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 07/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations of physical abuse for one (R4) resident out of three residents reviewed for physical abuse. Findings include: On 07/15/2025 at 11:36AM, R4 stated R5 rammed his walker against his left leg while they were waiting on their smoke break on the first floor of the facility. R4 stated this incident happened approximately 2 to 3 weeks ago. R4 stated R6 was present and witnessed the entire incident. R4 stated he has never seen R5 with alcohol in the facility but R5 gets drunk when out on community pass. R4 stated he informed V4 (Receptionist) and V3 (LPN/Nursing Supervisor) of the altercation between himself and R5. R4 stated V3 took a picture of his leg and told him she would report the incident. R4 stated V3 informed him she reported the altercation to V1 (Administrator). R4 stated he overheard the police were called to the facility, but he did not get a chance to speak with a police officer or file a police report. R4 points to his left leg and surveyor observes a scabbed abrasion on R4's left calf measuring approximately 2 inches in length. R4 stated R5 caused this abrasion when R5 rammed his wheelchair against R4's leg. R4 stated after two days, he did not hear anything from the facility regarding the altercation between himself and R5. R4 stated he then went to talk to V1 (Administrator) to inform V1 R5 rammed his leg with a walker and inquire about what was being done about the altercation. R4 stated V1 acted like he didn't care and was not listening to him. R4 stated that's when he started cursing and became very upset during his conversation with V1. R4 stated he told V1 that V1 needed to report the incident. R4 stated he was sent out to the hospital for psychiatric evaluation instead.R4's MDS/Minimum Data Set, dated [DATE], documents R4 has a BIMS/Brief Interview for Mental Status of 15/15, indicating R4 is cognitively intact. On 07/15/2025 at 12:13PM, R6 stated he is a witness to the altercation took place between R4 and R5. R6 stated this incident happened approximately 3 weeks ago. R6 stated he was located on the first floor awaiting his smoke break. R6 stated R5 was using his walker to block R4's path from getting past the elevators so R4 squeezed his way past R5. R6 stated R5 became upset about this and R5 used his rollator walker and rammed it into R4's leg. R6 stated this caused a scar on R4's leg. R6 stated he got in between R4 and R5 and broke them apart. R6 stated surveyor's interview is the first time anyone is inquiring to him about the incident between R4 and R5. R6's MDS/Minimum Data Set, dated [DATE], documents R6 has a BIMS/Brief Interview for Mental Status of 15/15, indicating R6 is cognitively intact.On 07/15/2025 at 1:12PM, V3 (LPN/Nursing Supervisor) stated she was made aware by V4 (Receptionist) of a verbal altercation between R4 and R5 and R5 called R4 a snitch. V3 stated this altercation occurred approximately 2.5 weeks ago. V3 stated she went to talk to R4 but R4 did not want to provide any information regarding the altercation and refused an assessment. V3 stated, the next day, as she was punching out, she overheard R4 telling a social services staff member about the altercation. V3 stated she then assessed R4's leg and observed there was a superficial scrape on R4' leg with skin intact, no bruising, no bleeding. V3 stated she took a picture of R4's leg and showed it to V2 (Director of Nursing/DON) then V3 left the facility. V3 stated she was going on vacation once she left the facility and have since deleted the picture of R4's leg. V3 stated she is unaware of what happened to R4's leg because R4 did not tell her. V3 stated she informed V2 (DON) so V2 could follow up. V3 stated she later found out R4 tried to get past R5 but R5 did not move and R4 got a superficial scrape on his leg.On 07/15/2025 at 2:33PM, V2 (DON) stated she was made aware via telephone by V3 (LPN/Nursing Supervisor) of a verbal altercation took place between R4 and R5. V2 stated she was informed R4 and R5 were in the elevator and R4 was trying to come off the elevator and R5 did not move and R4 pushed himself past R5. V2 stated she asked V3 if she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 4 of 8 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 07/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few informed V1 (Administrator) of the incident and V3 said yes. V2 stated she then asked V3 if R4 and R5 were separated and V3 also said yes. V2 stated R4 and R5 were informed to stay away from one another. V2 stated the next day she was shown a picture of R4's leg by V3. V2 stated R4's leg appeared to be a superficial scratch with no swelling, no bruising, no bleeding, or redness. V2 stated the superficial scratch on R4's leg appeared to be an older wound and did not look fresh and was scabbed over. V2 stated a couple of hours after she saw the picture of R4's leg, she attempted to ask R4 what happened and R4 told her, Don't worry about it. V2 stated she has never heard of an altercation of R5 taking his rollator walker and ramming it into R4's leg and this would be considered abuse. V2 stated she has never had a conversation with R5 about the altercation took place between R4 and R5. V2 stated R5 has been avoiding her and doesn't come around her much. V2 stated V1 (Administrator) is the abuse coordinator and she reported to V1 a verbal altercation occurred between R4 and R5.On 07/15/2025 at 1:34PM, V1 (Administrator) provides surveyor with Facility Reported Incidents/FRIs dated 04/14/2025 to 06/28/2025. V1 stated the provided FRIs are all the facility reported incidents during time frame. V1 stated he currently does not have any pending FRIs to be reported to the state agency. V1 stated there are no facility reported incidents for the month of July 2025.Facility Reported Incidents dated 04/14/2025 to 06/28/2025 does not document any reports of alleged assault/abuse involving R4 and R5. On 07/15/2025 at 2:50PM, V1 (Administrator) stated he has been the abuse coordinator at the facility for one year. V1 stated as the abuse coordinator, he is responsible for ensuring the safety of residents and the prevention of residents being hurt through any form of abuse. V1 stated R4 came into his office screaming and yelling and told him his leg was scratched. V1 stated there was an altercation and R4 was squeezing past R5 and R4 scratched his leg in the process. V1 stated he asked R5 what happened during the altercation and R5 told V1 R4 brushed past him and R4 scratched his leg on R5's walker. V1 stated he did not think the altercation between R4 and R5 was considered abuse. V1 stated he was never made aware by R4 or anyone else R4 made allegations of R5 ramming his walker against R4's leg. V1 stated this is the first time he is hearing of the allegations and will now report to the state agency. V1 stated he has received abuse training, and it is a requirement for the renewal of his license. V1 stated abuse training is also incorporated into the orientation process upon being hired at the facility. V1 stated he is responsible for reporting allegations of abuse to the state agency within the required time frames.On 07/16/2025 at 9:27AM V4 (Receptionist) stated R4 informed him he was in an altercation with R5. V4 stated R4 reported to him R5 won't leave R4 alone and is messing with R4. V4 stated R4 also reported he felt like R5 was intoxicated and targeting him. V4 stated sometime in June 2025 on a Sunday at approximately 7:30PM-8:00PM, he was located at the front lobby desk and R4 reported this to him. V4 stated he received a report on R5's behavior the day prior so he was inclined to believe R4. V4 stated he reported to V3 (LPN) what R4 reported to him. V4 stated the day prior, he received a report from another staff member R5 appeared to be intoxicated with alcohol in the facility. V4 stated R5 smelled like alcohol but he was unsure if R5 was drunk or not. V4 stated R5 previously had an independent community pass but it was restricted due to violations of facility rules related to intoxication. V4 stated R4 informed him R4 would be reporting to V3 about the altercation between him and R5. V4 stated V3 called the police and V3 instructed him to let V3 know when the police arrived. V4 stated approximately 40 minutes later, police arrived at the facility, and he directed the police officer to the floor where V3 was located. V4 stated he assumed a police report was filed but he is not aware of a police report number or the police officer's name/badge number. V4 stated he believed the police was called due to an argument and he was not made aware of any physical altercations between R4 and R5. V4 stated he was informed R4 and R5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 5 of 8 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 07/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete should be separated and to keep other residents from being in contact with R5.During record review, there is no documentation to show a police report was filed for the assault allegations involving R4 and R5.Facility document dated 10/24/2024, titled Abuse Prevention Policy documents in part, Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations of suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Event ID: Facility ID: 145881 If continuation sheet Page 6 of 8 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 07/18/2025 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 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident had routine preventative screening for 1 resident (R3) out of 3 residents reviewed for routine screenings. This failure resulted in R3 not receiving recommended annual breast mammograms while residing in the facility, which resulted in R3 being diagnosed with stage 4 breast cancer which metastasized to other parts of her body. Findings Include:R3's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Neutropenia, malignant neoplasm of unspecified site of right female breast, secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes, secondary malignant neoplasm of mediastinum, secondary malignant neoplasm of other specified sites. Minimum Data Set Section (MDS) section C (dated 09/26/2024) documents R3 has an Interview for Mental Status (BIMS) score of 11, indicating that R3 had moderate cognitive impairment. Care plan (dated 09/05/2023) documents that R3 has potential for pain related to Dx of left breast cellulitis, bilateral breast mass and right breast cancer with metastasis to right axilla, retro pectoral, mediastinum, spleen, left axilla and liver. Mammogram Policy (revised February 2025) documents in part: Female residents 55 and younger will have mammogram screenings conducted annually unless otherwise indicated by physician. On 07/16/2025 at 11:03AM, V2 (director of nursing) stated R3 was admitted to the facility 07/15/2004. R3 complained of breast pain on 05/30/2023. R3 was assessed due to complaining of tenderness and pain in the right breast. R3 was seen by the nurse practitioner due to pain in the right breast, on 05/30/2023, the same day she complained. Upon assessment, the nurse on the floor noted the right breast to be bigger than the left breast and hardening of the right breast. On 05/30/2023, the nurse practitioner ordered a breast ultrasound for R3 to be done in the hospital, and a consultation with the oncologist. On 06/27/2023, resident was taken to the hospital for the ultrasound appointment. That same day, the radiologist recommended a CT scan of the chest for further evaluation, which was done the same time as the ultrasound. The CT of the chest showed cancer which metastasized to the spleen, liver and axillary area. When R3's breast cancer was found, it was already spread to other parts of the body. R3 was admitted to the hospital from the appointment due to right breast cellulitis. R3 was seen by the oncologist at the hospital while she was admitted . R3 was receiving weekly chemotherapy treatments. When R3's cancer was found, it was treated right away. The breast exams are performed when a resident complains of pain or tenderness at the breast site. The facility's protocol is to perform breast exams when there is a concern voiced by the resident. According to the facility's policy, residents who are [AGE] years old and younger should have a breast mammogram every year. V2 stated, (R3) had a breast mammogram in 2017, and I don't see any mammograms for R3 after the one she had in 2017. (R3) had mental health co-morbidities and she often refused to be touched, refused examinations a lot of the time, and refused tests. (R3) was verbal and a lot of the times she would state that she was fine and refused assessments and examinations. Residents [AGE] years of age and under should have a routine mammogram every year. The only mammogram for (R3) that there is on record is from 06/07/2017, and (R3) was [AGE] years old at the time. (R3) should have had another mammogram after 2017, however, I cannot find a mammogram for (R3) from 2018. (R3) did not pass away in this facility. (R3) was sent out to the hospital on [DATE] for a mental health evaluation, and she did not return to this facility. I don't know where (R3) discharged to. She was receiving weekly chemotherapy treatments and going to see the oncologist on a regular basis while she resided here. On 07/17/2025 at 10:10AM, V12 (nurse practitioner) stated, The last time I seen R3 was on September 24, 2024. On 05/30/2023 R3 complained of breast pain, tenderness and swelling. I placed an order for antibiotic because the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 7 of 8 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 07/18/2025 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 0776 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete breast was swollen and tender and it was suspicious for mastitis. I also ordered an ultrasound of the breast and I ordered R3 an appointment with an oncologist, because I was suspecting breast cancer based on the presentation of the breast. R3's breast appeared to be tender, red, and swollen and I immediately suspected breast cancer. From then on, the oncologist picked right up, and he planned the treatments for R3, and we followed the oncologist's direction. When I see a change of status, take action right away, so I placed interventions for R3 immediately when her right breast was swollen. I do not believe that R3 had a mammogram prior to her breast being tender. The first mammogram for R3 that I know of was 06/20/2023. R3 should have had an annual breast mammogram prior to 06/20/2023. R3 was supposed to have a routine yearly mammogram. There was a breast mammogram done for R3 back in 2017, and it was negative, and it was recommended for R3 to have a repeat mammogram in 2018. From the records that I am looking at, I do not see a mammogram performed for R3 in 2018. The dangers of not performing routine annual breast mammograms are breast cancer and missed diagnosis. If R3 would have had the routine breast mammograms yearly, we would have caught the breast cancer earlier. R3's Mammography Report (dated 06/07/2017) documents in part: No suspicious masses, calcifications or other abnormalities are seen. Routine follow-up mammogram in 1 year is recommended. R3's Progress Note (dated 05/30/2023) documents, Resident reported having pain in the right breast, upon assessment the right breast was noted to be bigger than the left breast and hard to touch. NP notified and came to assess resident with orders for right breast ultrasound and follow up with Dr. C. at community hospital for further evaluation. R3's Progress Note (dated 05/30/2023) documents, A [AGE] year-old AA female with past medical history listed below was seen and examined today 5/30/2023 due to RN reporting that patient is complaining of tenderness and pain of right breast and to follow up on chronic medical conditions management. Patient is observed to be in the hallway and starts yelling and screaming upon trying to assess the right breast lump. RN and social worker assisted during assessment. Patient is known to be non-compliant with medical regimen despite education. Patient denies fever, chills, cough, sore throat, congestion, hoarseness, shortness of breath, HA, chest pain, abdominal pain, NVDC, burning and tingling during urination, change in bowel habits. All available health notes reviewed. BREAST: Swelling, tenderness, hardness noted on right breast. No redness, bleeding, drainage, and dimpling noted. No swollen and hardened axillary lymph nodes palpated. Limited palpation study due to patient complaining of pain. R3's Hospital Records (dated 06/27/2023) documents in part: R-Mastitis, Non-lactational/R-Breast Malignant Mass with Metastasis. CT-chest/A/P showed metastasis to the LNs (axillary, retro-pectoral, mediastinal) spleen and liver. R3's Progress Note (dated 06/27/2023) documents, Resident went to oncology appointment and was admitted to community hospital with dx of Cellulitis to R Breast/Abscess to R Breast. Resident belongings in room. Medication in cart. Sister made aware. So noted. R3's Progress Note (dated 06/30/2023) documents, Resident is a 58 y/o female alert and oriented x 2. Resident has an admitting dx of right breast cellulitis and right breast malignant mass with metastasis to liver, spleen and axillary. Dx/HX of COPD, DM, Anxiety and OP. Resident is a limited assistance of one staff member for ADLs. Resident is continent of bowel and has occasional incontinence of bladder. Resident is able to ambulate without any assistive device. Resident requires cueing for task. Resident has dressing to right side of breast post biopsy. Resident is noted with appointment to follow up with oncology Wednesday. Resident is currently on Clindamycin 300mg every 8 hours for 7 days and Levaquin 750mg PO daily x 7 days. Resident sister informed of transfer in. Medications verified by MD. Resident is acclimated to room. Belongings brought down to new room. So noted.R3's Death Certificate (dated 02/18/2025) indicates that R3's cause of death as breast cancer with metastasis to brain. Event ID: Facility ID: 145881 If continuation sheet Page 8 of 8