Inspection·February 7, 2025

F 0550 Resident Rights policy dated 08/2022 reads: Level of Harm - Minimal harm or potential for actual harm The right to live in an environment that promotes and support each other's dignity with consideration and respect. Residents Affected - Few On 02/04/25, 10:43 AM, R18 was lying down in bed, wearing a hospital gown, wearing glasses, and in no apparent distress. Fall mats noted on the floor on both sides of R18's bed. R18's bed with lock on. A hot pink or fuchsia color sign at R18's head of the bed's wall documents in part R18's name, diet puree visible. On 02/04/25,12:47 PM, R69 in his room sitting on his wheelchair, dressed in his own clothes, and in no apparent distress. A yellow sign visible at R69's head of the bed's wall documents in part R69's name, dated 12/4/24, diet: regular solids, liquid: thin liquids. R69 states that he does receive occasional visitors. On 2/6/25, 12:39 PM, V14 (Director of Rehab) states that when speech therapy (ST) has recommendations for a resident, they will usually leave a swallow precaution sign with a list of instructions of what ST recommend. V14 states it is typically a hot pink sign and it is usually posted above the resident's bed or beside countertop. V14 continues to state that the swallow precaution sign will include information such as how the patient should be eating, and cues to remind patients if they are feeders. We give proper recommendations on how to properly feed the residents. V14 reports that the form will also notate if the resident requires 1:1 feeding assistance. V14 states that the rationale for posting the form is for speech department to make sure the staff are following precautions, so patients won't get aspiration pneumonia. V14 states that he does believe all the information on a swallow precaution form is a resident's medical record and it is their personal information because not everyone is on a special diet so not everyone should be aware of their medical records such as the type of diet they are on. V14 states if visitors are coming in to visit the resident or the resident's roommate, they can visibly see this information. R18's current face sheet documents R18 is a [AGE] year-old individual with diagnoses not limited to: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, other sequelae of other nontraumatic intracranial hemorrhage, dysphagia following cerebral infarction, aphasia. R18's MDS/Minimum Data Set Section C dated 12/13/2024, documents that R18 was unable to complete the interview for BIMS/Brief Interview for Mental Status. R18's current physician order set documents in part regular diet puree texture, nectar consistency. R69's current face sheet documents R69 is a [AGE] year-old individual with diagnoses not limited to: encephalopathy, unspecified, malignant neoplasm of overlapping sites of lip, oral cavity and pharynx, unspecified visual loss. R69's Minimum Data Set (MDS), dated [DATE], documents R69 has a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating R69 is cognitively intact. R69's current physician order set documents in part diet regular texture, thin liquids consistency. Facility document dated 8/22 titled Resident's Rights documents in part no resident shall be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 2 of 25 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 02/07/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm deprived of any rights, benefits, or privileges guaranteed by law, the constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of this Community, nor shall a resident forfeit any of the following rights: the right to confidentiality of the resident's medical, financial, or other records. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 3 of 25 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 02/07/2025 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to assess/monitor one of three residents (R30) for self-administration of medication out of a total sample of 21 residents reviewed. Residents Affected - Few Findings include: On 02/05/2025, at 9:07 AM, during a medication administration pass with V17 (Licensed Practical Nurse/LPN), surveyor observes V17 with a nasal medication labeled Fluticasone Propionate 50mcg. V17 gives the Fluticasone medication to R30. R30 asks V17 how many sprays, 2 right? V17 replies Yes. R30 then observed self-administering the Fluticasone medication to herself, administering 2 sprays into both of her nostrils. V17 states she gave R30s' Fluticasone medication to R30 to self-administer because R30 is able to self-administer her medication and does not trust the facility staff nurses to administer it to her correctly. Review of R30s' Physician order sheet/POS, medication administration record/MAR, and electronic health record/EHR documents that R30 does not have a physician order and has not been assessed to self-administer her own medications. Facility policy dated 07/02/2018, titled Medication Administration and Storage Policy documents in part, 13. Self-administration of medications by residents is permitted only when resident has been assessed and is capable of self-administration and a physician order has been written for self-administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 4 of 25 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 02/07/2025 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 0575 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of records the facility failed the following related to [NAME] Program: facility failed to display [NAME] information in a public and accessible location, a department provided poster informing residents of their right to explore or decline community transition, and their right to be free from retaliation, regardless of their decision on transition. Failure includes 12 out of 12 residents (R1, R6, R13, R25, R42, R47, R69, R98, R99, R103, R207, R307) included in the sample list for December 2024 and January 2025 of residents that can be a part of the [NAME] program. This failure has the potential to affect 12 residents (R1, R6, R13, R25, R42, R47, R69, R98, R99, R103, R207, R307) in their right to exercise community transition given proper information. Findings include: On 02/04/2025, at 2:35 PM, after checking all floors to verify the [NAME] program posting, there was none seen posted. V16 (Social Service Director) was asked about poster for the [NAME] program. V16 replied that she is not sure if there are any posting in the facility. V16 said that best area for resident to see any posting is the main dining room on the 1st floor. During that time, the bingo activity was going on. Upon checking all areas on the main dining room there was no poster found. V16 agreed to go to all floors to check for posting. Using the elevator, the 2nd floor was checked. The 3rd floor was checked as well. All floors were seen without posting for the [NAME] program. V16 stated that she will make sure poster will be posted for residents to have information and be able to see contact information when wanting to be a part of the [NAME] program. On 02/05/2025, at 10:28 AM, V16 stated educational materials and information to all residents was not given until yesterday after checking facility. There was no poster in the building. On 02/06/2025, at 12:15 PM, V16 stated that [NAME] program is important because it provides access to residents to see if they are ready to be in community setting. Community settings are less restrictive than skilled settings. There are residents that are self-sufficient that can live in the community. On 02/07/2025, at 8:21 AM, V16 provided list of possible candidates for [NAME] program for the month of December 2024 and January 2025. Included in the list are (R1, R6, R13, R25, R42, R47, R69, R98, R99, R103, R207, R307) that could be a part of the [NAME] program if proper information, assessments, and education were provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 5 of 25 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 02/07/2025 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records review, the facility failed provide privacy and confidentiality of personal information for one (R307) of four residents reviewed in a sample of 21. Residents Affected - Few Findings include: R307 is an [AGE] year-old individual admitted to the facility on [DATE], with medical diagnosis that include but not limited to: acute and chronic respiratory failure with hypercapnia, human immunodeficiency virus [hiv] disease, other abnormalities of gait and mobility. MDS (Minimum Data Set) section C- Section C Cognitive Patterns, Brief Interview for Mental Status (BIMS) Dated [DATE], documents R307's BIMS as 13/15, indicating R307 has intact cognitive function. On 02/4/2025, at 11:13 AM, R307 was observed in his room sitting on the bed and stated he came to the facility recently. R307 was observed wearing a white wristband which showed R307's full name, date of birth , and medical record number. R307 stated the wristband was from the hospital and the hospital staff were using it to identify him before he was transferred to the facility. R307 stated he does not want his information to be seen by other people. On 02/04/2025, at 11:31 AM, V4 (Registered Nurse-RN) went to R307's room with surveyor and observed R307 wearing a white wristband which showed R307's full name, date of birth , medical record number. V4 stated the wristband is from the hospital and should have been removed on 1/21/2025, when R307 was first admitted to the facility because it has his identifying private information which is visible to other residents and visitors. V4 stated that is a Health Insurance Portability and Accountability Act (HIPAA) violation and stated she would get scissors and cut R307's wristband off. On 02/04/2025, at 11:34 AM, V3 (Unit manager/Infection control nurse-LPN) stated there have been no issues with residents wearing their wristbands with identifying personal information from the hospital in the facility, but she was going to check with V10 (Assistant Director of Nursing-ADON) to confirm. On 02/04/2025, at 11:38 AM, V3 and surveyor spoke to V10 who stated residents should not be wearing wristbands from the hospital because these wristbands have private personal identifying information of the resident such as full name, and date of birth which is visible to other residents and visitors. V10 stated R307's wristband should have been taken off as soon as he got to the facility on 1/21/2025, to preventa HIPAA violation. Policy titled Resident's Rights dated 8/22 documents: -No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the constitution of the state of Illinois, or the constitution of the United States solely on account of his or her status as a resident of this Community, nor shall a resident forfeit any of the following rights: -The right to confidentiality of the resident's medical, financial, or other records. -The right to privacy in financial and personal affairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 6 of 25 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 02/07/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interviews the facility failed to ensure a Pre-admission Screening and Residential Review (PASSAR) were done for 5 out of 5 residents (R9, R15, R16, R37, R54) prior to admission. These failures have the potential to affect 5 residents (R9, R15, R16, R37, R54) in a total sample of 21. Residents Affected - Some Findings include: On 02/05/2025, at 10:25 AM, V16 (Social Service Director) submitted for R9, R16, and R37's print out document that reads PASRR Level 1 currently queued for review. V16 stated that she just submitted the request on 02/04/2025. V16 stated that PASRR is important to determine proper placement of resident. It should be done before the actual admission in the facility. R9 is [AGE] years old with diagnosis that includes psychosis, schizophrenia, schizoaffective disorder, and major depression. Per R9's PASSR report it documents the following: Notice Date: February 5, 2025: PASRR Level 1 review date February 5, 2025, determination of Level 1 is to refer to Level 11 onsite with suspected or confirmed PASRR condition of Mental Health Disability (MH). PASRR Outcome Explanation of Notice of PASSR Level 11 Onsite Evaluation Required. Your health care professional and Maximus completed a Preadmission Screening and Resident Review (PASSR) Level 1 screen for you. This screen shows that you need a face-to-face Level 11 evaluation. PASSR Level1 screens and Level 11 evaluations are required by Federal law. You need this evaluation because you may have serious mental illness or intellectual/developmental disability. The purpose of this evaluation is to decide whether a nursing facility is able to meet your needs. R9's diagnosis includes Schizophrenia, Schizoaffective disorder, Major Depression. R37 is [AGE] years old with severely cognitive impairment BIMS (Brief Interview for Mental Status) dated 01/02/2025, scored 99 because R37 unable to complete interview. R37 medical diagnosis includes dementia, anxiety disorder, major depression disorder, psychotic disorder. Per R37's PASSR report it documents the following: Notice Date: February 5, 2025: PASRR Level 1 review date February 5, 2025, determination of Level 1 is to refer to Level 11 onsite with suspected or confirmed PASRR condition of Mental Health Disability (MH). PASRR Outcome Explanation of Notice of PASSR Level 11 Onsite Evaluation Required. Your health care professional and Maximus completed a Preadmission Screening and Resident Review (PASSR) Level 1 screen for you. This screen shows that you need a face-to-face Level 11 evaluation. PASSR Level1 screens and Level 11 evaluations are required by Federal law. You need this evaluation because you may have serious mental illness or intellectual/developmental disability. The purpose of this evaluation is to decide whether a nursing facility is able to meet your needs. R37 Diagnosis includes Major Depression, Psychotic/Delusional disorder, anxiety disorder, other mental health diagnosis, insomnia. R16 is [AGE] years old with diagnosis that includes major depression and psychosis. Per R16's PASRR level 1 dated 02/05/2025, reads that level 11 is not required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 7 of 25 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 02/07/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Facility policy on Pre-admission Screening and Residential Review (PASRR) dated 11/2024, reads: To comply with State and appointed screening agency. Request full and complete Pre-admission Screening (PAS) documents to help assess and determine what type of problems, needs and issues need to be addressed to help resident function at his/her maximum level of well-being. R15s' Facesheet documents that R15 was admitted to the facility on [DATE], with diagnoses not limited to: Other psychotic disorder not due to a substance or known physiological condition. R15s' Level I PASARR/Preadmission Screening and Resident Review screening dated 11/13/2024, documents that R15 does not require a Level II PASARR because R15 does not have a SMI/severe mental illness, ID/intellectual disability, or RC/related concern. R33s' Facesheet documents that R33 was admitted to the facility on [DATE], with diagnoses not limited to: Bipolar disorder and unspecified psychosis not due to a substance or known physiological condition. R33s' Level I PASARR/Preadmission Screening and Resident Review screening dated 09/02/2023, documents that R33 does not require a Level II PASARR because R33 does not have a SMI/severe mental illness, ID/intellectual disability, or RC/related concern. On 02/06/2025, at 11:04 AM, V16 (Social Services Director) states she is responsible for inputting residents' PASARR information into the screening agency website. V16 states a PASARR/Preadmission Screening and Resident Review is a screening that needs to be done prior to a resident being admitted to the facility. V16 states the facility checks to see if a resident has a PASARR screening upon admission. V16 states usually, the hospital completes a residents' PASARR prior to the facility admitting the resident to the facility. V16 states the facility is responsible for ensuring that residents' PASARR information is accurate prior to admitting the resident to the facility. V16 states she is aware that the PASARR screenings are indicative of determining if a resident is appropriate for the nursing home setting or not. V16 states a PASARR Level II is needed for a resident if it is determined that the resident has a severe mental illness/SMI. V16 states the determination for a Level II PASARR screening is based off of the results of the Level I PASARR screening. V16 states R15 and R33s' current Level I PASARR screening are inaccurate, and they both require a new Level I PASARR screening to be completed. V16 states a new Level I PASARR screening has to be completed and submitted before R15 and R33 can receive a Level II PASARR screening. V16 states now that she is aware of this information, she will follow up to ensure that R15 and R33 have new PASARR screenings completed. Facility policy dated 11/2024 titled Preadmission Screening and Residential Review (PASRR) documents in part, Policy: 1. To comply with Illinois and the appointed screening agency. Procedure: 2. The screening material must be reviewed as a component of the assessment process and treatment, suggestions and recommendations should be identified and appropriately addressed. 6. All residents with possible serious mental disorders, intellectual disability or newly diagnosis with a mental disorder will be referred for Level II screening. R54 is a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE]. medical diagnosis includes but not limited to: schizoaffective disorder, bipolar type dated-6/19/2023, major depressive disorder, recurrent, mild dated -9/20/2023. R54's MDS (minimum Data Set) dated 12/07/2024, documents R54's Brief Interview for Mental Status (BIMS) as 14/15. Indicating R54 has intact cognitive abilities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 8 of 25 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 02/07/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 02/05/2025, at 1:45 PM, V17 (Social Services Director) provided R54's Preadmission Screening and Resident Review (PASRR) 1 & 11 referral form dated 02/05/2025. On 02/05/2025, at 3:00 PM, V17 stated residents need to have their PASRR 1 completed before the resident comes to the facility, and the admissions office usually looks at the resident's referral packet from the hospital to see if there is a PASRR 1. V17 stated if the PASRR 1 is not in the packet, the admissions office should call the hospital to ask for it to be completed before the resident is discharged to the facility. V17 stated a PASRR 1 is completed to determine if a resident is a candidate for a nursing facility. V17 stated if the resident is coming from the community, or supportive living program, the facility must complete a PASRR 1 within 48 hours of the resident arriving to the facility. V17 stated R54 was first admitted to the facility on [DATE], from a community hospital and should have had a PASRR 1 completed from the hospital and should have been part of R54's medical records received from the hospital. V17 stated if R54 did not have a PASRR 1 upon admission, the admission director should have gone to PASRR screening agency's website and searched R54 under his social security number and put him on the queue so that the screening agency can come to the facility and complete R54's PASRR 1 screening assessment. V17 further said the facility should have referred R54 for a PASRR 11 screening because R54 has serious mental health diagnosis of schizophrenia, mood disorder, and major depressive disorder since 2023. V17 stated a PASRR 11 evacuation lets facility know what specialized treatment R54 needs to stay the facility for treatment and monitoring. V17 stated a PASRR 11 determines if a resident is approved for short term stay or long term stay for specialized services at the facility, and because R54 has not been assessed for PASRR level 11, he is not receiving the specialized treatment he requires. R54's PASRR 1 & 11 referral is dated 02/05/2025. PASRR Outcome Explanation -Notice of PASRR 11 Onsite Evaluation Required documents: -Your health care professional and outside screening vendor completed a Preadmission Screen Review (PASRR) Level 1 Screen for you. PASRR 1 screens and Level 11 evaluations are required by Federal law. -You need this evaluation because you have serious mental illness or an intellectual/developmental disability. -The purpose of this evaluation is to decide whether a nursing home facility is able to meet your needs. Policy titled Pre-admission Screening and Residential Review (PASRR) documents: -The admissions director and/or social service director will request the complete screening from the referral source. -All residents with possible serious mental health disorders, intellectual disability or newly diagnosed with a mental disorder will be referred for level 11 screening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 9 of 25 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 02/07/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to help a resident maintain their highest practical level by failing to provide consistent restorative therapy for one of three residents (R61) in a total sample of 21. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. 02/04/25, 11:33 AM, R61 lying down on his bed, with his personal belongings within reach. R61 alert, responsive, and in no apparent distress. R61 states that this is the first time someone applied his splint in a very long time. R61 states that he understands now probably because the state agency is in the building. R61 reports that staff are supposed to come and exercise his legs, but staff do not do this. R61 states that staff do not come in to talk about restorative therapy or exercises. 2/6/25, 11:17 AM, V12 (Restorative Aide / Certified Nursing Assistant) states that her and another restorative aide split the 4th floor. V12 states that the restorative aides document in the resident's electronic medical record in POC (plan of care) tasks, under restorative rehab programs. V12 states that on the weekend the assigned CNAs (certified nursing assistants) should be providing the restorative therapy to the residents since restorative aides work Monday through Friday. V12 states that she does not get pulled to work the floor assignment as much. V12 states that restorative aides get pulled approximately 1-3 times a month. V12 states that the importance for a resident to wear a splint is to not lose the mobility they have and to make sure you don't lose the independent you have and helps avoid develop contracture. 2/6/25, 3:32 PM, V24 (Restorative Director/Registered Nurse) states that R61 is on a splint program every day in the morning. V24 states that the importance of restorative therapy program is like the name applies, it is to return or maintain the resident to their optimal function abilities. It can also be a continuing of physical therapy. We understand that some can decline after they stop physical therapy. V24 states that he is not sure why staff did not document. R61's current face sheet documents R68 is a [AGE] year-old individual with diagnoses not limited to: Rhabdomyolysis, paraplegia, unspecified, polyneuropathy, unspecified, other muscle spasm. R61's Minimum Data Set (MDS) section C, dated 11/22/2024, documents R61 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R61 is cognitively intact. R61's MDS section GG dated 11/22/2024, documents in part R61 has impairment on one side of his upper extremities and impairment on one side of his lower extremities. R61's current care plan documents in part R61 requires AROM (active range of motion) as evidence by the risk factors and potential contributing diagnosis of weakness, paraplegic, stroke. The goal is to prevent any contracture and maintain ROM (range of motion) through next review. Interventions document in part restorative program: active range of motion. Teach the resident to do the following: 10 repetitions times 3 sets. R61's current care plan documents in part R61 has impaired mobility and requires the use of a splint on; left functional hand splints as evidenced by the following limitations and potential contributing diagnosis; stroke. The goal is R61 will have maintained or improved functional movement with use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 10 of 25 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 02/07/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the splint. Interventions document in part ROM (range of motion) AM (before noon) and PM (after noon) shifts. Provide PROM (passive range of motion) to the joints affected by splint use. R61's past 90 days task nursing rehab: assistance with splint or brace: left functional splint. Apply after morning care for 6 hours as tolerated daily document in part several days (11/8/24, 11/9/24, 11/10/24, 11/14/24, 11/23/24, 11/24/24, 11/26/24, 11/29/24, 11/30/24, 12/01/24-12/4/24, 12/6/24-12/12/24, 1/11/25-1/13/25, 1/15/25, 1/17/25-1/24/25, 2/1/25, 2/2/25 no documentation that assistance with splint or brace provided. Facility document not dated documents in part the nursing rehabilitation restorative program will provide interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. Regulations require that a facility provide, and each resident receive the necessary care and services to attain or maintain the highest level of physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care. Criteria for nursing rehab program classification, must occur at least 7 days per week for at least 15 minutes per day. Daily documentation that programs were provided .the purpose of the nursing rehabilitation restorative splint or brace assistance program is to provide residents the opportunity to apply, manipulate or care for a brace or splint with an optimal level of independence or to maintain the best position of the affected body part to preserve function, prevent contractures and maintain skin integrity. Splint or brace application for progressive periods of time will allow for appropriate positioning of the affected body part. Splint or brace application will prevent loss of function (joint range of motion). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 11 of 25 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 02/07/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview, and record review the facility failed to ensure there are enough nursing staff to respond to call lights in a timely manner. In a resident council minute meeting residents' complain that sometimes the facility only has one or two CNAs (certified nursing assistant) for the 2nd and 3rd shift. Review of staffing data submitted via the PBJ system revealed the facility was triggered for excessively low weekend staffing. This failure places all 104 residents in the facility at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. 02/05/25, 10:15 AM, residents agreed that the resident council meets regular, monthly. Residents' complain that sometimes they only have one CNA (certified nursing assistant) on the 2nd or 3rd shift and the call lights don't get answered for a long time. 2/5/2025, 3:43 PM, V26 (Staffing Coordinator) states that the facility wants her to staff nine CNAs (certified nursing assistants) for the morning shift, nine CNAs for the evening shift, and 8 CNAs for the night shift. V26 states that she schedules five nurses for the morning shift, five nurses for the evening shift, and three nurses for the night shift. V26 states that she has been the staffing coordinator since September 2024. V26 states that prior to being the staffing coordinator she was the wound care tech. V26 states that when the census goes up, then she would have to have more staff. V26 states that the facility uses an application where the staff can view open shifts and they can pick up and as well as be able to view their schedules. V26 states that if no staff are able to pick up a shift then she reserves to agency. V26 continues to state that if the agency do not pick up an open shift then V26 states that she will come in to work. Facility document dated 2/4/25, documents in part there are 104 residents (census) in the facility. Facility document dated 03/1/2024, titled facility assessment documents in part nursing services staffing should have 12 CNAs for day shift, 9 for evening shift, and 8 for night shift. Facility document dated 07/24/2024, titled resident council minutes documents in part CNAs on their cell phones during work hours and not answering the call light in a timely manner. Facility provided document 7/20/24-7/21/24 titled simplified time detail documents in part work short bonus, 8 CNAs worked morning shift on 7/20/24, 6 CNAs worked night shift on 7/21/24. Facility provided document 7/27/24-7/28/24 titled simplified time detail documents in part work short bonus, 7 CNAs worked morning shift on 7/27/24, 5 CNAs worked morning shift on 7/28/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 12 of 25 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 02/07/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to a.) administer residents' prescribed medications in a timely manner according to the physician orders and b.) keep an accurate count of all narcotic medications for four (R3, R24, R30, R31) residents reviewed for medications in a total sample of 21 residents. Findings include: On 02/04/2025, at 9:24 AM, surveyor and V4 (Registered Nurse/RN) located on the second floor of the facility performing a controlled substance count and record review. Surveyor observes the following: A medication bingo card labeled R31s' name, Tramadol 50mg, surveyor observes there were 22 pills inside of the medication bingo card. R31s' controlled drug receipt record documents a count of 23 pills. A medication bingo card labeled R31s' name, Pregabalin 25mg, surveyor observes there were 13 pills inside of the medication bingo card. R31s' controlled drug receipt record documents a count of 14 pills. A medication bingo card labeled R31s' name, Diazepam 5mg, surveyor observes there were 19 pills inside of the medication bingo card. R31s' controlled drug receipt record documents a count of 20 pills. 8 liquid medication bottles labeled R24s' name, Methadone 10mg/ml R24s' controlled drug receipt record documents a count of 9 liquid medication bottles. V4 (RN) states she administered the medications to R24 and R31 this morning and forgot to document that she administered them. On 02/05/2025, at 8:37 AM, surveyor observes that the following medication was not given to R3 during the 9:00 AM medication administration pass with V17 (Licensed Practical Nurse/LPN): Gemtesa 75mg. V17 states R3s' Gemtesa medication is not available in the facility, and she has to reorder it from the pharmacy. V17 observed deploying R3s' electronic medication administration record (eMAR) and reordering R3s' Gemtesa medication from the pharmacy via computer. R3 has diagnoses not limited to: Type 2 Diabetes without complications, Hemiplegia and Hemiparesis Following Cerebrovascular disease, and overactive bladder. R3s' electronic medication administration record (eMAR) dated 02/01/2025 - 02/28/2025 documents: Gemtesa 75mg- Give 75mg by mouth one time a day scheduled at 9:00 AM. R3s' eMAR documents that R3s' Gemtesa medication was not administered on 02/05/2025 and 02/06/2025 at 9:00 AM. Facility document dated 02/06/2025, titled Inventory Replenishment Report documents that R3s' Gemtesa medication is not available stored inside of the automated medication dispenser/AMD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 13 of 25 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 02/07/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 02/06/2025, at 10:20 AM, surveyor located at the medication cart with V17 (LPN) and observes that R3s' Gemtesa is not located inside of the medication cart. V17 states she did not notify R3s' physician that R3s' Gemtesa medication was not administered on 02/05/2025 and 02/06/2025. On 02/05/2025, at 9:07 AM, surveyor observes that the following medication was not given to R30 during the 9:00 AM medication administration pass with V17 (Licensed Practical Nurse/LPN): Mupirocin External Ointment 2%. V17 states R30s' Mupirocin medication is not available in the facility, and she has to reorder it from the pharmacy. V17 observed deploying R30s' electronic medication administration record (eMAR) and reordering R30s' Mupirocin medication from the pharmacy via computer. R30s' electronic medication administration record (eMAR) dated 02/01/2025 - 02/28/2025 documents: Mupirocin External Ointment 2%- Apply to bilateral thighs topically one time a day scheduled at 9:00 AM. R30s' eMAR documents that R30s' Mupirocin medication was not administered on 02/05/2025, at 9:00AM. R30s' eMAR documents that R30s' Mupirocin medication was administered on 02/06/2025 at 9:00 AM. On 02/06/2025, at 10:20 AM, surveyor located at the medication cart with V17 (LPN) and observes that R30s' Mupirocin medication is not located inside of the medication cart and V17 is unable to locate R30s' Mupirocin medication. V17 states she did not administer R30s' Mupirocin medication today on 02/06/2025. V17 states she documented that she administered R30s' medication in error because she wasn't paying attention when she was clicking the computer mouse to sign for medications. V17 states she did not notify R30s' physician that R30s' Mupirocin medication was not administered on 02/05/2025 and 02/06/2025. Facility document dated 02/06/2025 titled Inventory Replenishment Report documents that R30s' Mupirocin medication is not available stored inside of the automated medication dispenser/AMD. Facility policy dated 07/02/2018, titled Medication Administration and Storage Policy documents in part, 2. Medications shall be given within one (1) hour of the specified time, by the same nurse that prepared the dose. 11. Narcotics and all class II drugs must be recorded when given on the individual sheet 19. Narcotics must be signed out in the HER/electronic health record and the narcotic sheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 14 of 25 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 02/07/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for two (R3, R30) residents reviewed for medication administration in a total sample of 21 residents reviewed, resulting in a 7.69% error rate. Residents Affected - Few Findings Include: R3 has diagnoses not limited to: Type 2 Diabetes without complications, Hemiplegia and Hemiparesis Following Cerebrovascular disease, and overactive bladder. R3s' electronic medication administration record (eMAR) dated 02/01/2025 - 02/28/2025 documents: Metformin HCL 500mg- 1 tablet by mouth two times a day scheduled at 9:00 AM. On 02/05/2025, at 8:37 AM, surveyor observed that this medication was not given to R3 during the 9:00 AM medication administration pass with V17 (Licensed Practical Nurse/LPN). R30 has diagnoses not limited to: Multiple Sclerosis, Essential (primary) hypertension, trigeminal neuralgia, and history of falling. R30s' electronic medication administration record (eMAR) dated 02/01/2025 - 02/28/2025 documents: Lidocaine External Patch 5%- Apply to left shoulder topically one time a day scheduled at 9:00 AM. On 02/05/2025, at 9:07 AM, surveyor observed that this medication was not given to R30 during the 9:00 AM medication administration pass with V17 (LPN). On 02/06/2025, at 10:20 AM, V17 (LPN) states she did not administer R3s' Metformin medication on 02/05/2025, because R3s' Metformin medication was not available in the facility, and she had to reorder it. V17 states the facility has an automated medication dispenser/AMD located on the fourth floor of the facility. V17 states the AMD has emergency medications inside available to administer to residents if their own personal supply of medications run out. V17 states she has access to the AMD via password but did not think to check the AMD for R3s' Metformin medication on 02/05/2025. V17 states R30s' Lidocaine patch medication is considered house stock supply and is available inside the facility located in the basement central supply stock room. V17 states she did not check in the central supply stock room for R30s' Lidocaine patch medication on 02/05/2025, because she was nervous and wasn't thinking. V17 states she did not notify R3s' or R30s' physician of medications not administered on 02/05/2025. On 02/06/2025, at 10:49 AM, surveyor located in the basement of the facility with V23 (Central Supply). Surveyor observes several boxes of Lidocaine 5% patches on a utility storage shelf. V23 states the Lidocaine patches are house stock supply and readily available for resident use. V23 states V17 (LPN) just left the central supply room approximately 4-5 minutes ago. V23 states V17 retrieved a box of Lidocaine patches from the utility shelf. On 02/06/2025, at 9:59 AM, V2 (Director of Nursing/DON) provides surveyor a list of medications available inside of the emergency automated medication dispenser/AMD. Facility document dated 02/06/2025, titled Inventory Replenishment Report documents that R3s' Metformin medication is readily available stored inside of the AMD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 15 of 25 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 02/07/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Facility policy dated 07/02/2018, titled Medication Administration and Storage Policy documents in part, Policy: To ensure medications are administered and stored in accordance with Standard of Practice. 20. Physician must be notified when medications are not administered as per physician orders. 21. Physician orders must be obtained for medications that are held. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 16 of 25 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 02/07/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to a.) remove and discard expired medications that had been open in three of six medication carts, b.) remove and discard expired enteral feedings located in one of three medication storage rooms, and c.) properly label medications that had been open for resident use. These failures have the potential to affect 68 residents residing in the facility reviewed for medication labeling and storage. Findings Include: On 02/04/2025, at 9:24 AM, surveyor and V4 (Registered Nurse/RN) located on the second floor of the facility at the medication cart performing a controlled substance count and record review. Surveyor observes the following: 1 open liquid medication bottle labeled R32s' name, Morphine Sulfate 20mg/ml inside of the medication cart. R32s' liquid Morphine medication observed with an expiration date labeled 05/17/2024. V4 states that R32s' liquid Morphine medication should not be stored in the medication cart and should have been discarded once it expired on 05/17/2024. V4 states R32 could experience adverse reactions if she is given expired medications. On 02/04/2025, at 10:01 AM, surveyor and V6 (Licensed Practical Nurse/LPN) located on the third floor of the facility at the medication cart. Surveyor observes the following: 1 open house stock bottle medication labeled Bisacodyl Enteric Coated 5mg with an expiration date labeled 12/2024. 1 vial of Lispro insulin inside a clear plastic zip lock bag without a pharmacy label. V6 states the Lispro insulin belongs to R71. V6 states the Bisacodyl medication should not be stored in the medication cart and should have been discarded once it expired on 12/2024. V6 states R71s' Lispro insulin should have a proper pharmacy label identifying R71s' name, medication, and dosage on the insulin package. On 02/04/2025, at 10:05 AM, surveyor located inside of the third-floor medication storage room with V6 (LPN). Surveyor observes the following: 2 house stock enteral feeding containers labeled Nepro 1.8 CAL 33.8 ounces with an expiration date labeled 11/2024. Surveyor also observes milk curdles at the bottom of both enteral feeding containers. V6 states the enteral feeding containers should not be stored in the medication storage room for resident use and should have been discarded once it expired on 11/2024. V6 states residents could potentially get sick if expired enteral feedings are administered to them. On 02/04/2025, at 10:22 AM, surveyor and V22 (Licensed Practical Nurse/LPN) located on the fourth floor of the facility at the medication cart. Surveyor observes the following: 1 open house stock bottle medication labeled Bisacodyl Enteric Coated 5mg with an expiration date labeled 09/2023. 1 open house stock bottle medication labeled Vitamin C 500mg with an expiration date labeled 11/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 17 of 25 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 02/07/2025 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 0761 1 open house stock bottle medication labeled Vitamin D 250mcg with an expiration date labeled 10/2024. Level of Harm - Minimal harm or potential for actual harm V22 states the Bisacodyl, Vitamin C, and Vitamin D medications should not be stored in the medication cart for resident use and should have been discarded once they expired. Residents Affected - Some On 02/05/2025, at 9:07 AM, during a medication administration pass with V17 (Licensed Practical Nurse/LPN), surveyor observes V17 with a nasal medication labeled Fluticasone Propionate 50mcg. Fluticasone medication does not have a pharmacy label with R30s' name, medication, and dosage on the packaging. V17 states R30s' Fluticasone medication should have a proper pharmacy label identifying R30s' name, medication, and dosage on the package. V17 states she cannot be sure if the Fluticasone medication is prescribed to R30 since it does not have a proper pharmacy label. Facility census dated 02/04/2025, documents a total of 43 residents resides on the third floor of the facility and 21 residents reside on the fourth floor of the facility. Facility document titled G-tube Residents lists a total of 6 residents residing in the facility who have gastrostomy tubes for enteral feedings. Facility policy dated 07/02/2018, titled Medication Administration and Storage Policy documents in part, 7. A nurse may not write the name and/or strength of the medication on the label. Should the pharmacy fail to label it properly, the drug must be returned to the pharmacy for proper labeling. 8. House stocked medications should not be administered after expiration date located on the manufacture's bottle. 16. Never use medicine from an unmarked container. Return containers bearing illegal, unclear or stained labels to pharmacy for re-labeling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 18 of 25 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 02/07/2025 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy and ensure night-time snacks were offered and served consistently in accordance with the facility's policy for one (R87) resident in a sample of 21. 02/05/25, 10:15 AM, during resident council meeting, R87 states that he does not receive or is offered the nighttime snacks consistently and he would like to receive them consistently. 2/6/25, 1:01 PM, V8 (Dietary Manager) states that if a resident is not diabetic, they get the graham crackers or peanut butter crackers and juice at night-time snack. V8 states that everyone is supposed to be offered a night-time snack. V8 continues to state we close at 7:30 PM at night. Before my aids leave, they take the snacks to the floors, and give them, on a tray or in a bag. They are given to the floor CNAs (certified nursing assistants). V8 continues to state at that point, whoever is on the floor at that time, will distribute the evening snacks to the residents.V8 states once we drop them off it is out of dietary's hand, and it is nursing responsibility to pass out the snacks to the residents. Normally they are in the dining room, and when we drop them off it is out of my hands. V8 states that from time to time they will say they haven't received it. V8 states that R71 said that he didn't receive his snack last Saturday. V8 states that if the resident does not receive their night snack, V8 states she is assuming they will be hungry, if they are diabetic, V8 states she is assuming their sugar may drop. V8 states that's what I hear, I am diabetic I need my snack. 2/6/2025, 2:43 PM, V2 (Director of Nursing) states that she was made aware of the concern last week and she placed a note on the board by the nurse's station. V2 states that she did not conduct in-services or training to the staff. R87's current face sheet documents R87 is a [AGE] year-old individual with diagnoses not limited to: difficulty in walking, not elsewhere classified, non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin, other low back pain. R87's Minimum Data Set (MDS) section C, dated 1/3/2025, documents R87 has a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating R87 is cognitively intact. R87's nutrition snack offered task 30-day look-back documents in part, R87 was not offered snack on the following dates: 1/8/25, 1/11/25, 1/17/25, 1/20/25, 1/22/25, 1/23/25, 1/25/25, 1/27/25, 1/29/25, 1/30/25. Facility document not dated titled night-time snacks documents in part nourishments will be provided to the residents at approximately bedtime. Nursing will distribute the bedtime nourishments. Residents will receive appropriate bedtime snack according to their diet order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 19 of 25 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 02/07/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and records review, the facility failed to follow their policy on sanitation and food safety by failing to (a) dish washer temperatures not reaching recommended temperatures, (b) properly sanitizing dishes in the three-compartment sink, (c) properly wearing hair net in the kitchen, (d) date open food item with open date and use by date. This failure has the potential to affect 101 residents who are on an oral diet. Findings include: On 02/04/2025, at 9:30 AM, V7 (Cook) was observed washing dishes in the three-compartment sink. The third compartment sink (Sanitizing) was observed with water that had whitish particles and the water was whitish cloudy. V8 (Dietary Manager) and surveyor observed V7 test the chlorine concentration on the third compartment sink with chlorine testing strips marked 10 P.P.M, (Parts per million) 50 P.P.M, 100 P.P.M, 200 P.P.M. The testing strips had color change marks from very light purple to black. V8 stated the black marking indicated the highest chlorine concentration. The testing strips did not turn color and remained white. V7 and V8 stated the chorine testing strips should turn blackish and at lease reach 100 PPMs to make sure the dishes are properly sanitized to prevent cross contamination which can make residents sick. The chlorine test strips were observed with an expiration date of 12/26/21. V8 stated she was not aware test strips have an expiration date, and stated there are 101 residents on oral diet receiving food from the kitchen. On 02/04/2025, at 9:36 AM, V10 (Dietary Aide) was observed assisting with loading the dish washing machine in the kitchen wearing a hair net that only covered the top of her hair bun, and the rest of her hair was observed without a hair net. V10 stated her hair is too big to fit in one hair net. V8 and V10 stated all staff in the kitchen should cover their hair completely to prevent hair from getting into resident food to prevent contamination. V10 stated she will wear two hair nets to cover the rest of her hair that was not covered. On 02/04/2025, at 9:40 AM, dishes were being washed in the dish washer. After each wash, the next load was put in and the machine was run immediately. V8 put a test strip (yellow with a white strip) in the dish washer to test if the machine was washing and sanitizing dishes properly. V8 stated the center of the testing strips which is white is supposed to turn black indicating the machine is working properly. The test strip did not turn black. V8 run the machine again and the hot water gauge for hot water was observed to be approximately 100-110 degrees F. V8 stated the washing cycle should reach at least 150 degrees F, and sanitation cycle should reach at least 180 degrees. V8 stated the water cools down if the machine is run continuously, and asked staff to wait a little bit before running each cycle to let the water heat up. V8 tested the machine three times and each time the testing strips remained white. V8 stated the dishwasher was recently serviced and the yellow testing strips are new, and she did not know why they did not turn black. V8 stated if the strips don't turn black, it means the right temperatures were not reached during the wash/sanitize cycle, and the dishes are not being washed and sanitized properly. V8 stated this can cause cross contamination which can lead to residents getting food borne illnesses. V8 stated the dishwasher is a high temperature machine and the wash cycle water temperature should be above 150 degrees F, and the rinse cycle above 180 degrees F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 20 of 25 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 02/07/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 02/04/2025, at 2:32 PM V15(Dishwasher Repair Services/Vendor) stated the company has been having a lot of problems with the yellow dish washer testing strips he gave to the facility to test the dishwasher two weeks ago. The facility called him today (02/04/2025) to let him know the dishwasher temperatures are not reaching the recommended temperature. V15 stated he has just checked the dishwasher sprays and they had food particles clogging the sprays and that could have contributed to the water not getting hot, therefore, V16 has cleaned the spays and turned up the dishwasher temperatures and now its washing at over 200 degrees F. On 02/04/2025, during tour of the kitchen, with V8, observed in the freezer, an open big plastic bag of peas and carrots without a date indicating when opened or expiration date. V8 stated all opened food should be labeled with date it was opened and use by date so that it can be used before the food expires to prevent expired foods being cooked for the resident which can make residents sick. Policy titled Mechanical Cleaning and Sanitizing dated 2010 documents: Dish machines using hot water for sanitizing may be used if temperature of washing water is no less than that specified by the manufacturer, which may vary from 150 degrees F to 165 degrees F, depending on the type of machine, and if the final rinse temperature is no less than 180 degrees F. Policy titled Manual Sanitizing dated 2010 documents: -Chlorine-50 -100 PPM minimum 10 second contact time. -A test kit or other device that accurately measures the parts per million concentrations of solution will be available and used. Precision Chlorine Test Paper documented: Use dry finders to remove strip of paper from vial, dip strip into solution to be tested, without agitation and compare immediately with color chart on label. This color indicates approximate strength of the solution in parts per million (p.p.m) available chlorine. Policy titled hair restrains/Jewelry dated 2010 documents: -To reduce the spread of microorganism, employees shall use effective hair restraints. -Hair nets will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated if necessary. -If taken out of original container, food will be tightly wrapped and labelled with the name of the item and date of delivery. Dish washer Operational Manual titled Getting started- introduction to CMA-180 documents: -Operation of the CMA-180 is automatic. The water tank heater will maintain the water temperature at 155 degrees F. The booster heater will produce a minimum of 180 degrees F final rinse water each cycle providing the in coming water supply is 120 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 21 of 25 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 02/07/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interview the facility failed to accurately classify resident record on psychotropic medication consent form to 1 out of 1 resident (R37) for a total of 5 residents reviewed for psychotropic medication. This failure has the potential to affect 1 resident (R37) on psychotropic medication side effects. Consent was given with error in classifying psychotropic medication having different side effects for which the consent was given. Findings include: R37 is [AGE] years old with severely cognitive impairment BIMS (Brief Interview for Mental Status) dated 01/02/2025, scored 99 because R37 unable to complete interview. R37 medical diagnosis includes dementia, anxiety disorder, major depression disorder, psychotic disorder. On 02/06/2025, at 11:11 AM, V10 (Psychotropic Nurse / Assistant Director of Nursing) presented R37's Psychotropic Medication Form dated 02/04/2025, for Remeron or Mirtazapine medication. V10 stated that currently he is updating consent for all residents in the facility because psychotropic consent needs to be updated every 15 months per policy. That is why R37's consent form is date is 02/04/2025. V10 was asked to present Psychotropic Consent Form prior to 02/04/2025. V10 reviewed R37's electronic record and Psychotropic Medication Form for the same medication (Remeron or Mirtazapine) dated 03/03/2021, was noted. Per comparison between two (2) forms, Psychotropic Medication Form dated 03/03/2021, classify Remeron as antipsychotic but Psychotropic Medication Form dated 02/04/2025, classify Remeron as antidepressant. V10 stated that form dated 03/03/2021 is wrong. Remeron should be classified as antidepressant. V10 stated that R37 was taking Remeron (antidepressant) for a long time since 03/03/2021, as seen on the form. Prolonged use of psychotropic medication has potential side effects. Antidepressants have different side effects than antipsychotics. The consent that was given when wrongly classified can be a problem. The person consenting does not give consent to the side effect of antidepressant but to antipsychotic. Per Food and Drug Administration (FDA) Drug information dated 03/2020, reads: Under indication and use, REMERON is indicated for the treatment of major depressive disorder (MDD) in adults. Per facility's Psychotropic Consent Form, antidepressant have dizziness, nausea, and syncope as a side effect that is not included with antipsychotic medication. Facility policy on Psychotropic Medication Consent dated 12/2024, reads: Psychotropic medication will have appropriate indication for use and will be monitored for continued side effects and will be reduced or discontinued as clinically indicated. Psychotropic consent to be updated upon readmission and/or every 15-months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 22 of 25 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 02/07/2025 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review the facility failed to ensure the designated Infection Prevention nurse completed specialized training in infection prevention and control in nursing homes. This failure has the potential to affect 104 residents residing in the facility. Findings include: During the survey period, the facility was not able to provide valid documentation/certification for V3 (Infection Preventionist / Licensed Practical Nurse) of the completion of the required training program to implement programs and activities to prevent and control infections in nursing homes. 2/4/25, the facility was asked to provide completion of Infection Prevention program certification, including total hours for accumulated for V3 (Infection Preventionist / Licensed Practical Nurse). 2/6/25, V3 provided a CDC (Centers for Disease Control and Prevention) Certificate of Training, Completion for Nursing Home Infection Preventionist Training Course, dated 2/5/2025. 2/06/25, at 9:13 AM, V3 (Infection Preventionist / Licensed Practical Nurse) stated V3 has been the IP nurse since January 2024. V3 does the antibiotic surveillance, immunizations, outbreaks of Covid, flu, C. diff (Clostridium difficile), etc., all infections, immunizations for residents and staff. V3 makes sure infection protocols are maintained throughout the building. V3 stated the infection prevention program requires completing the training modules and then taking and passing a cumulative/completion test. The test shows completion of the required hours and competency for the IP role. 2/6/25, at 4:05 PM, V2 (Director of Nursing) stated it is important to have a certified IP (Infection Preventionist) because it keeps us up to date with CDC (Centers for Disease Control and Prevention) recommendations. That person is updated with the latest bacteria and germs, isolation requirements and protecting the staff and residents. Facility policy Infection Prevention Program, no date, documents in part: The Infection Preventionist serves as a resource for all staff and all departments relating to prevention of infections. The Infection Preventionist has knowledge, competence, and interest in infection prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 23 of 25 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 02/07/2025 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to minimize the risk of acquiring, transmitting, or experiencing complications from influenza and Covid-19 for six residents (R27, R62, R73, R207, R257, R307). Residents Affected - Some Findings include: According to R27 progress note, 8/29/2024, R27 was offered and refused the influenza (flu) vaccination in 8/2024. The facility is not able to provide documentation that R27 was offered the influenza vaccination subsequently or provide a refusal of the influenza vaccination by R27 for the current flu season. According to electronic record, immunizations sections for R62, R73 and R307, they were not provided immunization education prior to vaccine administration or refusal. Review of R207 Authorization and Release for Influenza Vaccine, 2/4/25, does not indicate if R207 consented or refused the influenza vaccine. Also, according to V3 (Infection Preventionist / Licensed Practical Nurse), V3 signed the form for R207 and there is no witness signature. Review of R257 Authorization and Release for Influenza Vaccine, no date, indicates R257 consented to receive the influenza vaccination. R257 has not received the influenza vaccine to date. Review of R257 Authorization and Release for Vaccinations, 1/28/25, indicates R257 consented to the administration of the Covid-19 vaccine. R257 has not received the Covid-19 vaccine to date. 2/6/25, at 9:13 AM, V3 (Infection Preventionist / Licensed Practical Nurse) stated V3 has been IP nurse since January 2024. V3 does the antibiotic surveillance, immunizations, outbreaks of Covid, flu, C. diff (Clostridium difficile), etc., all infections, immunizations for residents and staff. V3 makes sure infection protocols are maintained throughout the building. Influenza season starts in September and ends in March. During the season I offer to residents and staff the influenza immunization. If they refuse, I continue to offer throughout the season and encourage and educate of the benefits and risks of receiving the vaccine for added protection. If they want it, then I place an order for the vaccine or schedule a clinic. I started offering it on 9/2024 for flu season 2024/2025. If it is a new admission resident, within 72 hours I offer any and all immunizations/vaccines. I take historical information. I document and offer education. If they refuse, I document and offer education and tell them I'll come back to reoffer. I continue to document that I offer. I educate and encourage each time. I document under immunizations or progress notes in the electronic record. I offered R27 the influenza vaccine in January, but I did not document it. R27 has not received the flu vaccine. R27 received RSV (Respiratory Syncytial Virus). There was an issue with R27's insurance not paying. R27 was hospitalized for pneumonia. I don't have a refusal for this flu season for R27. Education is provided so the residents know the risks and benefits of the vaccine. If education is not given the resident is not informed. R62, R73 and R307 education is not documented. R207 did not want to sign the consent. R207 wanted me to sign. The ADON (Assistant Director of Nursing) was a witness but did not sign the consent as a witness. Consent was given 1/27/25 for R257 to receive the influenza and pneumo (Pneumococcal pneumonia) vaccines but the influenza has not been given at this time. I had given R257 the pneumo vaccine. R257 did not get the influenza because I was spacing it from the pneumo vaccine. I wanted to space the vaccines out. I talked to the NP (Nurse Practitioner) who consulted with the doctor. It is not documented that I received an order to space out the vaccines. I received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 24 of 25 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 02/07/2025 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some consent for R257 for Covid-19 on 1/28/25. R257 has not been given Covid-19 vaccine. It was refused by pharmacy due to no insurance. I have not checked with our pharmacy. I have not ordered the Covid-19 vaccine yet for R257. 2/6/25, at 4:05 PM, V2 (Director of Nursing) stated immunizations are important because of a lot of different populations in the facility, immunosuppressed residents. We have to safeguard the population by making sure of no outbreaks, keeping residents healthy, and keeping them vaccinated from viruses and diseases. Facility policy Immunizations, no date, documents in part: In order to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and pneumococcal pneumonia, it is the policy of this facility to offer influenza and pneumococcal vaccination to all residents. Each resident or the resident's representative will receive education regarding the benefits and potential side effects of influenza immunization. Each resident will be offered the influenza vaccination between October 1 and November 30 or as soon as possible if vaccine is not available by November 1, unless the immunization is medically contraindicated or the resident has already been immunized during this time period. Residents admitted after November 30 and until March 31 shall as medically appropriate receive an influenza vaccination prior to or upon admission or as soon as possible if vaccine is limited. The residents medical record will indicate: a. That the resident or residents legal representative was provided education regarding the benefits and the potential side effects of influenza immunization; and b. That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 25 of 25