Health inspection·August 6, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete floor outside of the elevator with a small laceration on his head. Residents were immediately separated and placed on 1:1 supervision. Doctors were contacted and orders were given to send both residents to the hospital for further observation. Laceration was cleaned and covered and head to toe assessment done with no further concerns noted.R1's progress note of 7.21.2025 at 9:04 PM, documents in part, writer was informed by NOD (Nurse on Duty) that the resident was involved in a dispute with another resident on the elevator. When questioned, convicted that he was punched and pushed off the elevator by another resident. Resident refused to give any other information concerning the incident. Resident was reassessed per this nurse. Open area noted to the right side of the head, small amount of bleeding with slight swollen noted.R2's progress note of 7.21.2025 at 11:03 PM, documents in part, writer was informed by NOD (Nurse on Duty) that the resident was involved in a dispute with another resident on the elevator. When questioned, resident denies that he punched and pushed another resident off the elevator. Resident refused to give any other information concerning the incident. NP (Nurse Practitioner) gave orders to petition resident out to hospital for further evaluation.Abuse Prevention Policy (October 24, 2024) documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of 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.Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Event ID: Facility ID: 145881 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2025 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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and immediately start CPR (Cardiopulmonary Resuscitation) for resident found unresponsive on the floor for one of one resident (R3) reviewed for CPR in the sample of sample of nine. This failure resulted in R3 being without vital signs and not receiving immediate CPR.Findings include:R3's face sheet documents R3 was a [AGE] year-old admitted to the facility on 9.12.2011, with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Asthma, Hypertension, and Hyperlipidemia. R3's Order Summary Report (active orders as of 5.28.2025) documents R3 was a full code.R3's progress note of 5.29.2025 at 7:55 AM, documents in part, at about 6:15 AM, while the writer was passing medication, one of the CNAs notified the writer that resident was on the floor in the bathroom. The writer immediately called out the resident's name but he was not responding well. A code blue was indicated through the receptionist and CPR was started. 911 was called during the CPR the vitals are B/P 113/94, pulse 126, R-22, and the blood sugar is 356mg/dl at the time resident transfer to hospital.R3's death certificate documents cause of death as asthma. The immediate cause of death is complete heart block.On 8.4.2025 at 1:10 PM, via telephone, V14 (Former LPN-Licensed Practical Nurse) said, That day I believe I gave R3 her 6:00 am med. I left the room. After a while, a CNA came to tell me R3 was on the floor. I stopped what I was doing and went to R3. She fell in the shower room. Prior to the fall, she was able to walk, she was up and about on the unit. I went there to assess her. We pulled her out of the shower room because she is a tall lady. We started CPR. We called 911. They (911) took her out. I can't remember what time the CNA came to get me; it was during my morning med pass. The first thing I did was to call her name. She did turn her head but did not talk. She looked pale. I called for help but the CNAs that are working with me were with patients. I called a code blue at the nurses' station then went back to her. I checked her. She was not responding well. I called code blue. Me and my coworker did CPR. I don't remember taking vital signs. I don't remember if my coworker did. Somebody started CPR, not me. (Local fire department) came, they took over, and they took her out. I don't remember what time the CNA got me.On 8.4.25 at 2:29 PM, V2 (DON-Director of Nursing) said, V14 (Former LPN-Licensed Practical Nurse) was terminated for not running a code properly. V14 did not bring crash cart or participate in Code Blue for her assigned resident (R3). The Code Blue was initiated, when the other nurses (V6 LPN-Licensed Practical Nurse/Nurse Supervisor and V10 LPN-Licensed Practical Nurse) came. There was no crash in the room. One of them got it. They also said V14 had not initiated CPR. V14 should have initiated CPR when she determined R3 had coded.8.5.2025 at 11:53 AM, via telephone, V2 said per V12 (HR-Human Resources) there is no CPR card in (Nurse) personnel folder.8.4.2025 at 5:54 PM, via telephone, V6 (LPN-Licensed Practical Nurse/Nurse Supervisor) said, At approximately 6:30 AM, I immediately responded to a code blue. I took the stairs; it took me a couple of minutes to get to the unit. V10 (LPN-Licensed Practical Nurse) was with me. R3 was on the ground. There were some CNAs (Certified Nursing Assistants). I didn't see the crash cart in the room. No one was doing compressions, I just wanted them to start compressions. I told them to start CPR. I never saw V14 do CPR. When someone is found unresponsive, you should assess for airway, breathing, circulation. Compressions should be started immediately to get the heart pumping, to get blood and air circulating.8.5.2025 at 2:27 PM, via telephone, V9 (R3's Physician) said, If the resident is a full code, call 911 and start CPR until 911 arrives. The purpose of starting CPR immediately is to get blood to the brain, to push blood to the brain. Compressions won't restart the heart. CPR is continued until 911 arrives and takes over, they can attempt to re-start the heart by administering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145881 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2025 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 0726 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete medications such as epinephrine and shocking the patient. If CPR isn't started immediately severe anoxic encephalopathy (severe brain damage caused by a complete lack of oxygen) could occur.V10's Witness Statement (5.29.2025) documents, writer heard code blue 5th floor via overhead page. Writer along with housekeeping manager went to 5th floor. Writer along with other nurses assessed resident, no pulse noted, CPR initiated. 911 called by nursing staff. (Local Fire Department) on scene and noted vitals and pulse. Resident transferred to ER (Emergency Room) by (Local Fire Department). V10 (LPN-Licensed Practical Nurse) was not available for interview.V14's employee folder (Employee Action/Discipline of 5.29.2025) documents employee called a code blue on a resident but did not bring over needed materials for code and did not participate in code blue for her own assigned resident.Cardiopulmonary Resuscitation (CPR) policy (undated) documents in part, Procedure: 1. In the event a resident is identified unresponsive and upon a thorough A-B-C (Airway, Breathing, Circulation) assessment determines that there is no pulse or respiratory activity and the resident has declared a full code status, a licensed staff member will: a. Simultaneously with the initiation of chest compressions announce a full code per facility policy and direct a staff member to immediately retrieve the crash cart located on the nursing unit. Event ID: Facility ID: 145881 If continuation sheet Page 4 of 4