Inspection·April 18, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's Change in a Resident's Condition or Status policy last approved 01/2024 Policy Statement stated: Our community shall promptly notify the resident, his or her health care provider, and representative of changes in the resident's medical/mental condition and/or status. Policy interpretation and Implementation: D. Unless otherwise instructed by the resident, a nurse will notify the resident's representative, consistent with his or her authority when: a need to alter treatment significantly (stop a form of treatment because of adverse consequences or commence a new form of treatment to deal with a problem). Event ID: Facility ID: 145029 If continuation sheet Page 2 of 5 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 145029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Joliet 210 North Springfield Avenue Joliet, IL 60435 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was retaining urine had his bladder scanned and was catheterized. These failures resulted in the resident being hospitalized with urosepsis for eight days. This applies to 1 of 3 residents (R1) reviewed for urinary catheters. The findings include: On 04/17/24 at 1:45 PM R1 was in his room sitting in a high back wheelchair. R1 was alert and oriented x 3. R1 had an indwelling urinary catheter draining yellow urine and a right arm PICC (Peripherally Inserted Central Catheter for intravenous [IV] medication). R1 said on 04/05/24, he had a fever and chills, and prior to the fever and chills, he was having bladder spasms that he reported to the nurses. R1 said he saw the physician and received orders for a bladder scan and to be intermittently catheterized every four hours because he has a history of urinary retention. R1 said the nurses did not do the bladder scans to see if I needed to be catheterized. I would need to be catheterized if I had more than 400 ml of urine in my bladder. R1 said that did not happen every four hours. R1 said when he was admitted to the hospital on [DATE], he was diagnosed with urosepsis, and now must be on IV antibiotics daily at 4:00 AM for a month and was not happy about it. R1 Physician Order Sheet (POS) showed a March 10, 2024, order as May straight cath. (If more than 400 cc foley needed.) R1's March 10, 2024, progress note from 10:22 AM showed Writer paged [MD regarding] results received from renal ultrasound done yesterday .was informed NP [Nurse Practitioner name] was covering. Writer spoke with NP asked if urine was collected for UA & C/S [urinalysis and culture/sensitivity], writer informed her that an order was in place for urine to be collected but has not at this time, writer stated to NP that she will attempt to collect urine this shift. NP gave orders to straight cath as needed, if retaining more than 400 cc of urine, foley catheter will be needed. R1's progress notes from March 12, 2024, showed a temperature of 99 degrees Fahrenheit and complaints of nausea. R1's March 17, 2024, note from 10:28 PM showed Bladder scanned at [8:30 PM] 786 ml residual, straight cathed .200 ml from straight cath. Paged MD for clarification on bladder scan orders no return call. [Power of Attorney] called with concerns about [patient] not emptying his bladder . No progress note was included that showed an indwelling urinary catheter was placed per order. R1's March 18, 2024, progress note from 4:50 PM showed Message left for urologist [name] office regarding resident's order for [post-void residual (PVR)] every 4 hours. According to staff resident has been urinating ok and having multiple wet briefs. Bladder scans performed with small PVR amounts A 5:14 PM addendum showed Resident bladder scanned at 5pm 554 was amount. Wants to be straight cathed after he eats. Will notify [MD name] office with residual amount and get clarification on how long he should have PVR/bladder scans done. R1's 5:59 PM progress note showed straight cath resident able to get over 700 cc urine. Upon changing resident, he had a full brief of urine as well. R1's 9:52 PM note showed Bladder scan performed stating 550. Straight cath resident able to retrieve 500cc (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 3 of 5 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 145029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Joliet 210 North Springfield Avenue Joliet, IL 60435 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 0690 urine. No progress notes showed an indwelling urinary catheter was placed per order. Level of Harm - Actual harm A handwritten nursing note from March 19, 2024, in R1's EMR (Electronic Medical Record) showed R1 was catheterized, and 575 ml of urine was drained. No other progress notes were included again until March 31, 2024 (twelve days), when a 9:26 PM note showed Writer went to do bladder scan on patient, noted covers to be soiled with urine, bladder scan showed no retaining of urine. Writer voiced to resident that bladder scan showed nothing and resident stated to writer that I am not concerned with the retention, I am concerned with possible infection, writer then asked resident was he having any burning when urinating and he stated yes, writer asked resident how long he has been having this symptom and he stated for about two days now. Writer spoke with [MD] . orders given to collect urine for UA & C/S . No note showed an indwelling urinary catheter was placed per order. Residents Affected - Few R1's POS/physician order contained the March 31, 2024 order to Collect urine for [urinalysis] and [culture and sensitivity]. The next progress note in R1's EMR on April 4, 2024 (four days after the order) that showed Clean catch done to collect UA C/S. Collected dark amber colored urine . R1's April 5, 2024, nursing note from 6:55 PM showed an ambulance company was at the facility to transport R1 to the hospital. R1's note at 10:36 PM showed R1 was diagnosed with urosepsis. On 04/18/24 at 11:50 AM V6 (Nurse Practitioner) said he was notified of R1 having dysuria prior to his last admission to the hospital. V6 said R1 was hospitalized on [DATE] with urosepsis. V6 said the Nurse Practitioner that was on call on 03/10/24 gave orders for the bladder scans every four hours and to straight catheterize R1. V6 said he was not aware of the nursing staff not performing the bladder scans and straight catheterizing R1 as ordered. V6 said it is his expectation that the nurses follow all orders. V6 said the nurses should have done the bladder scans and straight catheterized R1 as ordered because urinary retention and not emptying the urine from the bladder could have caused an infection and R1 becoming septic. Under R1's Assessment and Plan in the April 12, 2024, hospital Infectious Disease Physician Report, it showed Sent in due to altered mentation, confusion, refusing meds, and had fever of 102.4. 1. Sepsis present on admission with bacteremia lactic acidosis R1 was admitted back to the facility on [DATE] at 9:12 PM with diagnoses of UTI/sepsis. On 04/17/24 at 1:00 PM V5 (Licensed Practical Nurse) said on 04/05/24 she was the nurse taking care of R1 and she straight catheterized R1 that morning and got 200 ml of urine. V5 said R1 told her he was not feeling good that morning and he had a urinalysis pending. V5 said in the evening, R1 had chills and was shaking and R1 had a low-grade temperature and wanted to go to the hospital. V5 said R1 was transferred to the hospital and admitted with urosepsis. V5 said she was aware of R1 orders for bladder scans every 4 hours and straight catheterization every shift. V5 said on 04/05/24, she had only straight catheterized R1 but in the past, she would do bladder scans. V5 said she was aware of R1 having urinary retention. V5 said if a resident with urinary retention does not receive bladder scans or straight catheterization, they could develop a UTI/urinary tract infection. V5 said all nurses should follow the bladder scan and straight catheterization orders as written. V5 said the bladder scan should have been done every four hours as ordered. On 04/17/24 at 11:19 AM V2 (Director of Nursing) said on 04/05/24 the nurse on the floor texted the on-call phone and said R1 was having chills and had a temp of 99.3. V2 said she had no knowledge of R1 having a history of urinary retention. V2 said she was made aware after R1 was admitted to the hospital of R1's order for bladder scans and to be straight catheterized when needed. V2 said since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 4 of 5 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 145029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Joliet 210 North Springfield Avenue Joliet, IL 60435 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 0690 Level of Harm - Actual harm Residents Affected - Few R1 had orders for bladder scans every four hours, the bladder scans and straight catheterization should have been done as ordered. V2 said if orders are not followed for bladder scans and straight catheterization, the outcome could be urinary retention, a rupture, and an infection. V2 said her expectation is for the nurses to follow physician orders. V2 said she knows that the bladder scans and straight catheterizations were not done as ordered and the resident had to be hospitalized . R1's Face Sheet included diagnoses of urinary tract infection, abnormalities of gait and mobility, Parkinson's, dysarthria and anarthria, adult failure to thrive, and low back pain. The facility's January 2024 Catheterization, Residual Use policy showed Documentation: the following information should be recorded in the resident's medical record; the date and time the procedure was performed, all assessment data obtained during the procedure, how the resident tolerated the procedure, the amount of residual urine obtained, the character of the residual urine obtained Reporting: notify the physician of the amount of the residual urine, if any, and if there are any abnormalities in the character of the urine FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 5 of 5