Complete Care At Margate Park

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, interviews, and record review, the facility failed to assess a resident's ability to safely self-administer medication, failed to obtain a doctor's order to self-administer medication, and failed to care plan self-administration of medication prior to initiating self-administration of medication. This failure affects 1 (Resident R16) resident reviewed for self-administration of medication in the total sample of 21 residents. Findings include:On 11/18/2025 at 9:56am during medication administration observation with V37 (Licensed Practice Nurse) for Resident R16's, observed a tube of Hydrocortisone cream on Resident R16's bedside table. Resident R16 requested V37 to give him additional tube of hydrocortisone cream as his tube was almost empty. Resident R16 stated the night shift nurse gave him the tube of hydrocortisone cream a long time ago and the CNA applied the cream on his back because he could not reach his back. On 11/18/2025 at 10:05am, V37 stated he should not have the hydrocortisone cream at bedside because anyone might come in his room and take the medication. On 11/19/2025 at 10:31am, V14 (Unit Manager/Assistant DON/RN) stated for resident on self-administration of medication, there should be an assessment first to make sure he can safely administer the medication. It also needs a doctor's order and to care plan the self-administration of medication. V14 stated she assessed him on 11/18/2025, got a doctor's order to self-administer and was care planned after the fact. Resident R16's admission Record documented Resident R16's diagnoses (include but not limited to) COPD (Chronic Obstructive Pulmonary Disease), Type 2 Diabetes Mellitus, and candidiasis.Resident R16's (Active Order as of: 11/18/2025) Order Summary Report documented, in part Hydrocortisone External Cream 0.5 % (Hydrocortisone (Topical)) Apply to back lower/thigh back topically two times a day for itching. Active 04/23/2025. Of note, no order to self-administer Hydrocortisone cream. Resident R16's (11/11/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15.

Indicating Resident R16's mental status as cognitively intact.Resident R16's (11/18/2025 at 4:52pm) Medication Self-Administration safety screen was authored by V14. Of note, completed on the date Resident R16 was observed with Hydrocortisone cream at bedside.Resident R16's (11/18/2025) care plan documented, in part Focus: has a physician order for self-administration of medication. Of note, Resident R16 was care planned on the date the medication was observed in Resident R16's room. The (09/01/2024) Resident Self-Administration of Medication documented, in part It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facilities interdisciplinary team has determined which medications may be self-administered safely. The explanation and compliance guidelines: 1. Each resident is offered the opportunity to self-administer medications during their routine assessment by the facilities I think their disciplinary team. 4. The results of the interdisciplinary team assessment are recorded in self-administration of medication assessment. 14. The care plan must reflect that self-administration and storage arrangement for such medications.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

11/20/2025

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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

(09/01/2024) Resident Rights documented, in part, The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Respect and dignity. The resident has a right to be treated with respect and dignity. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. 5. Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: d. The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner, that does not impose on the rights of another resident.7. Privacy and confidentiality. The resident has a right to personal privacy. The (09/01/2024) Promoting/ Maintaining Resident Dignity documented, in part It is the practice of this facility to protect and promote resident rights and treat each other with respect and dignity as well as care for each resident in a manner and in an environment, it maintains or enhances quality of life by recognizing each resident's individuality. Compliance guidelines: 9. Maintain resident privacy. 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.

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

11/20/2025

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility failed to follow a physician order after administering inhaler sprays to a resident potentially placing a resident at risk for oral thrush. This failure affected 1 (Resident R16) resident out of 5 residents reviewed for medication administration. Findings include: On 11/18/2025 at 9:56am during the medication administration observation with V37 (Licensed Practice Nurse) of Resident R16's medications, V37 placed the mouthpiece of the Budesonide/Formoterol inhaler on Resident R16's mouth, pressed down the canister of the inhaler and instructed Resident R16 to inhale the medication orally. After Resident R16 orally inhaled the medication, V37 instructed Resident R16 to drink water. On 11/18/2025 at 10:00am, inquiring about expectation after Resident R16 orally inhaled 2 puffs of budesonide/formoterol, V37 stated she should have instructed him to swish and spit water to prevent him from having fungal infection. On 11/18/2025 at 10:04am, Resident R16 stated nurses usually asked him to swish and spit after he took his liquid protein (Pro-Heal), and he did not know the purpose of swish and spit.On 11/19/2025 at 10:37am, V14 (Unit Manager/Assistant DON/RN) stated nurses are expected to instruct the resident to swish and spit water

after taking the inhaler because it can cause oral thrush. Resident R16's admission Record documented that Resident R16's diagnoses (include but not limited to) COPD (Chronic Obstructive Pulmonary Disease), Type 2 Diabetes Mellitus, and candidiasis.Resident R16's (Active Order as of: 11/18/2025) Order Summary Report documented, in part Symbicort Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puffs inhale orally every 12 hours related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE; PULMONARY FIBROSIS. Rinse mouth with water and spit back into cup after use. Active: 10/09/2025.Resident R16's (11/11/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating Resident R16's mental status as cognitively intact.The (11/18/2025) Administering of Corticosteroid Inhaler, documented, in part When administering an inhaler: 7. Rinse your mouth with water and spit. Why do we have residents rinse their mouth and speak after using a corticosteroid inhaler? To prevent the patient from contracting thrush, a fungal infection of the tongue.The (09/01/2024) Administration of Metered-Dose Inhaler documented, in part It is the policy of this facility to ensure medications are administered as prescribed in accordance with professional standards of practice and only by persons legally authorized to do so. Policy explanation and compliance guidelines: 16. If using

a corticosteroid, allow resident to rinse and gargle with water to remove medication from mouth and back of throat.

Residents Affected - Few

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

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

11/20/2025

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 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

schedule for garbage pick-up should be revised, as needed, based on the volume of refuse.Facility's Job description titled Environmental Service Director dated 11/2019 documents in part; Primary duty: manages and supervises housekeeping and provides support to ensure quality standards are met; touring building several times per day to assess work quality using audits for documentation purposes. Essential job functions: Daily audits and follow through on all assignments to ensure task completion.Reviewed Resident Council Meeting minutes dated 10/21/2025 documents in part that 46 residents attended the meeting ;4) resident has the right to live in a clean and comfortable environment. Announcements from activity director: if they see pests to please inform the staff so that the area is treated, and traps can be set. No further concerns.

Event ID:

Facility ID:

If continuation sheet