Complete Care At Margate Park

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

1. 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired.Resident R1's

(07/29/2025) Progress note documented, in part: Resident came up with a skin tear behind his left leg at 3:10pm, wound care book filled up, pls follow up with the wound department for appropriate dressing.

Authored by: V11. Resident R1's (07/31/2025) Initial Wound Evaluation & Management Summary documented, in part Focused Wound Exam (Site 1) Burn Wound of The Left Leg Full Thickness. Wound Size (L x W x D): 18.5 x 7.4 x 0.1 cm. Surface Area: 136.90 cm^2. Pain assessment: Described as Severe. Signed by: V6 (Wound Care Doctor). No note that V3 was notified. Resident R1's (08/11/2025) Wound Evaluation & Management Summary documented, in part Site 1: Surgical Excisional Debridement Procedure. Indication For Procedure: Remove Necrotic Tissue and Establish the Margins of Viable Tissue. Consent For Procedure: Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 08/11/2025 to the patient and health care surrogate: (V3 - Resident R1's family member) who indicated agreement to proceed with the procedure(s). Of note, notification of V3 was done 13 days after

the injury was noted. Resident R1's (07/28/2025 - 08/05/2025) Progress notes were reviewed, with no notes of family notification. The (09/22/2025) email correspondence with V15 (Assistant Director of Nursing) documented,

in part Unable to locate SBAR for 7/29/25.The (9/1/2024) Notification of changes documented, in part Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: Accidents a. Resulting in injury.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Margate Park

4920 North Kenmore Chicago, IL 60640

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

reported and investigated. A burn is a serious injury. Resident R1's admission Record documented that Resident R1's diagnoses (include but not limited to) type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, chronic systolic (congestive) heart failure.Resident R1's (08/05/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns.

C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired.Resident R1's (07/29/2025) Progress note documented, in part Resident came up with a skin tear behind his left leg at 3:10pm, wound care book filled up, pls follow up with the wound department for appropriate dressing. Authored by: V11. Resident R1's (07/31/2025) Initial Wound Evaluation & Management Summary documented, in part Focused Wound Exam (Site 1) Burn Wound of The Left Leg Full Thickness. Wound Size (L x W x D): 18.5 x 7.4 x 0.1 cm. Surface Area: 136.90 cm^2. Pain assessment: Described as Severe. Signed by: V6 (Wound Care Doctor). The (09/18/2025) email correspondence with V1 (Administrator) documented, in part Do you have any reportables for injury of unknown origin? V1 responded Nothing in the past 90 days, and no injuries of unknown for close to a year maybe more.The (9/1/2024) Abuse, Neglect and Exploitation documented, in part Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. VII.

Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours

after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Margate Park

4920 North Kenmore Chicago, IL 60640

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

not investigated. Yes, it should be reported and investigated because facility didn't know how the resident got the injury, and per policy, it should be reported and investigated. Resident R1's admission Record documented that Resident R1's diagnoses (include but not limited to) type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, chronic systolic (congestive) heart failure. Resident R1's (08/05/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. Resident R1's (07/29/2025) Progress note documented, in part Resident came up with a skin tear behind his left leg at 3:10pm, wound care book filled up, pls follow up with the wound department for appropriate dressing. Authored by: V11. Resident R1's (07/31/2025) Initial Wound Evaluation & Management Summary documented, in part Focused Wound Exam (Site 1) Burn Wound Of The Left Leg Full Thickness. Wound Size (L x W x D): 18.5 x 7.4 x 0.1 cm. Surface Area: 136.90 cm^2. Pain assessment: Described as Severe. Signed by: V6 (Wound Care Doctor). The (09/18/2025) email correspondence with V1 (Administrator) documented, in part Do you have any reportables for injury of unknown origin? V1 responded Nothing in the past 90 days, and no injuries of unknown for close to a year maybe more. The (9/1/2024) Abuse, Neglect and Exploitation documented, in part Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: 1. Identifying staff responsible for the investigation, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 6. Providing complete and thorough documentation of the investigation.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Margate Park

4920 North Kenmore Chicago, IL 60640

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

him (Resident R1) around. (Resident R1) goes up and down the floor using the elevator and he (Resident R1) never uses the stairs. V15 said the nurses and the CNAs are supposed to supervise Resident R1 while he is on the floor. V15 stated she does not know how and still asking herself how the wound happened. V156 said she is not sure if he is supervised while in the elevator because he (Resident R1) knows where he is going and when to comeback on the floor. V15 stated she wishes she could explain how it happened. V15 stated with an injury like that, somebody should know and should report it. V15 said it is not expected of a resident to be injured at the facility, and no one knew about it and somebody should know. V15 stated if no one knew how the injury happened, he (Resident R1) was not supervised adequately. Resident R1's admission Record documented that Resident R1's diagnoses (include but not limited to) deaf, type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, chronic systolic (congestive) heart failure. Resident R1's (08/05/2025) Minimum Data Set documented, in part: Section C. Cognitive Patterns.

C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. Resident R1's (07/29/2025) Progress note documented, in part: Resident came up with a skin tear behind his left leg at 3:10pm, wound care book filled up, pls follow up with the wound department for appropriate dressing. Authored by: V11. Resident R1's (07/31/2025) Initial Wound Evaluation & Management Summary documented, in part Focused Wound Exam (Site 1) Burn Wound of The Left Leg Full Thickness. Wound Size (L x W x D): 18.5 x 7.4 x 0.1 cm. Surface Area: 136.90 cm^2. Pain assessment: Described as Severe. Signed by: V6 (Wound Care Doctor). The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. Your facility must provide services to keep your physical and mental health at their highest practicable levels. Your facility must be safe.The (undated) Accidents and Supervision documented, in part Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents.

Event ID:

Facility ID:

If continuation sheet