Inspection·October 25, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm V4 stated R5 was approved for level II PASARR for 60 days on [DATE]th, 2023, was renewed on Dec, 1st 2023, for 30 days and expired [DATE], therefore, R5 needed another level II PASARR, and someone (No name provided) should have requested another PASARR completion. Instead a referral for a Specialized Mental Health Rehabilitation Facility (SMHRF) was completed. But R4 was denied SMHRF, therefore, R5's PASARR II should been renewed by the facility before [DATE]st, 2023, because R5 remained in the facility. Residents Affected - Some R5's current face sheet documents R5's admission date as [DATE], readmission was [DATE], and his diagnosis, dated [DATE], include but not limited to schizoaffective disorder, unspecified, bipolar disorder, current episode mixed unspecified, depression, unspecified, schizophrenia, unspecified, attention -deficit hyperactive disorder, unspecified type. V4 stated R6 was admitted to the facility on [DATE]. R6 was discharged to the community on [DATE] and readmitted to the facility from the hospital on [DATE]. R6's PASARR level II was done in the hospital on [DATE]. It was approved for 180 days, and the approval ended on [DATE], therefore R6's PASARR II should have been renewed. V4 stated a service letter, which stated R6's PASARR level II should be renewed was sent to the facility on [DATE], but the facility did not follow up on the assessments needed. R6's current face sheet documents R6 initial admission date as [DATE], readmitted on [DATE] and documents R6's diagnosis dated [DATE], as major depressive disorder, recurrent, unspecified, anxiety disorder unspecified, [DATE]-violent behavior, suicidal ideations. V4 stated she sent the renewal assessments for R2, R3, R4, R5, R6 yesterday ([DATE]) after interview with surveyor on [DATE]. She was not aware before then that these residents needed a PASARR II screening because she was new at the facility, and further stated she has now created an assessment tool for R2, R3, R4, R5, R6 to be reviewed by the appointed screening agency. V4 stated it was important for PASARRs to be completed on time to assure the residents are receiving their specialized programs and treatment goals and to make sure the residents are in the right environment related to their diagnosis. V4 further stated if the PASARRs are not completed, the resident will not get the services they need and are in a stand still position because the facility will not know what the resident's rehabilitation needs are. Therefore, these needs will not be met, and the resident might not be stabilized. On [DATE], at 10:37AM, V4 (Social Services Director) stated newly admitted residents should come with a Preadmission Screening and Resident Review (PASARR) level 1 from the hospital. PASARR level 11 is completed for residents who have Serious Mental Illness (SMI), Intellectual Disability (ID), or Developmental Disability (DD) or significant change in mental condition. V4 further said the facility's social services department is responsible of entering a resident's information into the assessment tool of the appointed screening agency so that the screening agency can access and review the date and schedule a time to come to the facility to assess the resident for PASARR 11 within 48-72 hours. On [DATE], at 1:16 PM V5 (Business office manager) stated when a resident is admitted to the facility, the business office adds the resident's information into the online assessment tool so that the newly admitted residents needing PASARR II, can be screened by appointed screening agency within 15 days of admission to the facility. V5 stated that some PASARR II's were not completed because there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 2 of 3 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 145885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Complete Care at the Boulevard 5905 West Washington Chicago, IL 60644 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was a transition period in social services and the facility did not have a Social Services Director to enter resident PASARR information into the assessment tool which alerts the appointed screening agency that a resident need to be assessed for PASARR 1 or 11. V5 stated new social services director (V4) started on [DATE], and is training on entering the assessments into the assessment tool on-line. V5 stated it is the facility's responsibility to update the screenings and to notify the appointed screening agency when a staff member who collaborates the residents need for PASARR assessments is no longer working in the facility and give appointed agency the new contact information to reach the right worker at the facility for residents' assessments needs. V5 stated the appointed screening agency was sending service matters request for reviews for the residents, but there was no response from the facility since the social services director was no longer working at the facility. V4 stated when a resident comes to the facility from the hospital with a new diagnosis of a severe mental health issue, social services is supposed to use the online assessment tool within 12-48 hours so that the appointed screening agency can come to the facility to screen the resident for level II PASARR. V5 stated the appointed screening agency comes within 24-48 hours to assess the complete the resident assessment. V4 stated if the resident is not reviewed and assessed on time, they are not getting the services they need such as programs/interventions for their psychiatric diagnosis. Document titled: Path Tracker Census documents dates with exclamation mark residents needing PASARR review attention. Policy titled: Preadmission Screening and Resident Review, no date, documents: -PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needed considered along with personal goals and preferences in planning long-term care. - In brief, the PASRR process requires that all applicants to Medicaid-certified nursing facilities be given preliminary assessment to determine whether they might have SMI or ID. This is called Level 1 screen. Those individuals who test positive at level 1 are then evaluated in depth, called Level 11 PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for the services to inform the individual's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 3 of 3