Inspection·August 29, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is away from her assigned room, R47's medical chart (physical records) which is accessible at the nursing station should be checked for availability of signed POLST form and copy of the active physician order to determine the resident's code status. Upon review of R47's medical chart, V4 stated that the resident had a signed POLST form showing that no CPR should be performed and that R47 had a DNR status. V4 reviewed the active physician order for R47 and stated that the resident was a full code which meant that CPR should be performed. According to V4, R47 had inconsistent and conflicting code status based on the physician order for full code and the signed POLST form for DNR. V4 stated that there is confusion as to what code status to follow for R47 in case of a medical emergency. V4 added that based on the conflicting code status for R47, she will follow the physician's order to perform CPR in case of R47's medical emergency. On [DATE], at 12:09 PM, V3 (Assistant Director of Nursing) confirmed during the interview that if a medical emergency happened inside a resident's room, the nursing staff were instructed to check the color of the name tag on the resident's wall by the door. V3 stated that a green name tag meant that the resident has a full code status, therefore CPR should be performed, and the white name tag meant that the resident has a DNR status, therefore no CPR should be performed. According to V3, the color of the name tag on each resident's wall by the door are constantly updated based on the physician's order and the available signed POLST form, and that the two documents should always be consistent. V3 further stated that if a medical emergency happened away from the resident's room, the nurses should check the resident's medical chart located at the nursing station to confirm the availability of the signed POLST form and the active physician's order for code status. With V3, the color of the name tag on R47's wall by the door was observed and the signed POLST form and active physician's order were reviewed from R47's medical chart. V3 acknowledged that R47's code status was inconsistent, conflicting and confusing because the physician's order does not reflect the wishes on the available signed POLST form. The facility's policy and procedure regarding Advance Directives and Code Status dated [DATE] showed in-part under procedure statement, Advance directives will be respected in accordance with state law and community policy. The policy under interpretation and implementation showed in-part, 2. Initiating a new Advance Directive or Changing an Advance Directive. A. Social Service . 2. Advanced Directive signed, a. Notify nursing to obtain corresponding physician's order, as needed, b. Scan into electronic chart, or place into paper chart, c. Update Resident Code Status Identifiers, d. Care plan per resident wishes as identified on the Advanced Directive. B. Nursing 1. Check that the Resident Code Status Identifiers are correct, 2. For DNR or other choices identified on an Advanced Directive a. Obtain and enter a physician order after confirmation that the community required form is signed, b. Care plan per resident wishes as Identified on the Advanced Directive, 3. Choice reviewed routinely, at the quarterly care conference, when there is a significant change and per resident/resident representative request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 2 of 16 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 08/29/2024 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit discharge Minimum Data Sheet (MDS) records within 14 days as required by state and federal regulations. Residents Affected - Some This applies to 5 of 5 residents (R76, R129, R66, R40, and R127) reviewed for Minimum Data Set (MDS) transmission in the sample of 21. The findings include: On August 27, 2024, at 10:21 AM, V16 (MDS Coordinator/Registered Nurse) stated that completed discharged records for R76, R129, R66, R40, and R127 were not transmitted as required within 14 days. On August 27, 2024, at 11:00 AM, V16 stated that R127 was discharged on June 7, 2024, and his completed discharge MDS record has not been transmitted yet. The following information was supplied by the facility on a spreadsheet document and was also confirmed by V16: R76 was discharged [DATE], and her discharge MDS was transmitted on August 26, 2024. R129 was discharged on May 21, 2024, and her discharge MDS was transmitted on August 26, 2024. R66 was discharged on May 23, 2024, and his discharged MDS was transmitted on August 26, 2024. R40 was discharged [DATE], per MDS Coordinator and the MDS was not transmitted August 26, 2024. The facility's Electronic Transmission of the MDS policy dated January 2024 showed the following: All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our community's MDS information system and transmitted to CMS' [Centers for Medicare and Medicaid] QIES [Quality Improvement & Evaluation System] Assessment Submission and Processing (ASAP) system in accordance with current state and federal regulations governing the transmission of MDS data. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 3 of 16 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 08/29/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. Residents Affected - Some This applies to 6 of 6 residents (R13, R44, R49, R91, R106 and R125) reviewed for ADLs (activities of daily living) in the sample of 21. The findings include: 1. R13 face sheet shows multiple diagnoses including vascular dementia, generalized muscle weakness and hemiplegia following cerebral infarction affecting left nondominant side, based on the diagnosis/history report. R13's quarterly MDS (minimum data set) dated July 4, 2024, showed that the resident was moderately impaired with cognitive skills for daily decision making. The same MDS showed that R13 required maximum assistance from the staff with personal hygiene. On August 26, 2024, at 10:48 AM, R13 was in bed, alert and verbally responsive with confusion. R13's fingernails were long and jagged with brown substances underneath the nails. R13 stated that she wants the staff to trim and clean her fingernails. On August 27, 2024, at 11:51 AM, R13 was in bed, alert and verbally responsive. R13's fingernails were long and jagged with black substances underneath the nail beds. V3 (Assistant Director of Nursing) was present during the observation and confirmed that R13's fingernails needed trimming and cleaning. R13's active care plan initiated on January 11, 2024, showed that the resident requires staff assistance with all her ADLs. 2. R91 had multiple diagnoses including cerebral infarction due to thrombus of left anterior cerebral artery, hemiplegia following cerebral infarction affecting right dominant side and weakness, based on the diagnosis/history report. R91's quarterly MDS dated [DATE], showed that the resident was severely impaired with cognition. The same MDS showed that R91 required maximum assistance from the staff with personal hygiene. On August 26, 2024, at 11:36 AM, R91 was in bed, alert and verbally responsive. R91 had accumulation of long facial hair and his fingernails were long and jagged with black substances underneath the nails. V5 (CNA/ Certified Nursing Assistant) was present during the observation. R91 stated that he needed help from the staff with trimming and cleaning of his fingernails and he needed staff assistance with shaving. On August 27, 2024, at 12:01 PM, R91 was in bed, alert and verbally responsive. R91 had accumulation of long facial hair and his fingernails were long and jagged with black substances underneath the nail beds. V3 (ADON, Assistant Director of Nursing) was present during the observation and confirmed that R91's fingernails needed trimming and cleaning, and that the resident needs staff assistance with shaving. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 4 of 16 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 08/29/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm R91's active care plan initiated on June 25, 2021, showed that the resident requires staff assistance with all his ADLs. 3. R106 had multiple diagnoses including Parkinsonism, dementia, and generalized muscle weakness, based on the diagnosis/history report. Residents Affected - Some R106's quarterly MDS dated [DATE], showed that the resident was severely impaired with cognitive skills for daily decision making. The same MDS showed that R106 required total assistance from the staff with personal hygiene. On August 26, 2024, at 11:09 AM, R106 was in bed, alert but non-verbal. R106's fingernails were long and jagged. V5 was present during the observation. On August 27, 2024, at 11:56 AM, R106 was in bed, alert but non-verbal. R106's fingernails were long and jagged. V3 was present during the observation and confirmed that R106's fingernails needed trimming and filing to prevent the resident from scratching and/or injuring herself. R106's active care plan initiated on March 13, 2024, showed that the resident had self-care deficit requiring total assistance with ADL care. The same care plan showed multiple approaches including, provision of care as needed and provision of assistance with personal care. 4. R125 had multiple diagnoses including dementia, need for assistance with personal care and generalized muscle weakness, based on the diagnosis/history report. R125's quarterly MDS dated [DATE], showed that the resident was moderately impaired with cognitive skills for daily decision making. The same MDS showed that R125 required maximum assistance from the staff with personal hygiene. On August 26, 2024, at 11:26 AM, R125 was sitting in bed, alert and verbally responsive. R125 had accumulation of long and curling facial hair on her chin, on both sides of her face and above her lips. R125's fingernails were long and jagged with black substances underneath the nails. According to R125 she needed help from the staff to trim and clean her fingernails and to shave her facial hair. On August 27, 2024, at 12:06 PM, R125 was sitting in her wheelchair inside the unit television area (in front of the nursing station). R125 was alert and verbally responsive. R125 had accumulation of long and curling facial hair on her chin, on both sides of her face and above her lips. R125's fingernails were long and jagged with black substances underneath the nail beds. V3 was present during the observation and confirmed that R125's facial hair needs to be removed/shaved by the staff and the resident's fingernails needs trimming and cleaning. R125's active care plan initiated on December 4, 2023, showed that the resident requires staff assistance with all her ADLs. The same care plan showed multiple approaches including provision of assistance to R125 with ADLs. On August 27, 2024, at 12:15 PM, V3 (Assistant Director of Nursing) stated that it is part of the facility's nursing care and service to assist any resident requiring assistance with ADLs, including shaving/ removing facial hair and to assist the resident with trimming and cleaning of fingernails to ensure that the president's personal hygiene and grooming are maintained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 5 of 16 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 08/29/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm 5. R49's face sheet showed diagnoses of hemiplegia following cerebral infarct affecting left non dominate side, unspecified osteoarthritis, unspecified dementia, unspecified severity. R49's MDS (Minimum Data Set) dated July 19, 2024, showed that R49 was moderately impaired in cognition and dependent on staff for personal hygiene. Residents Affected - Some On August 26, 2024, at 11:39 AM, R49 lying in bed in her room with a striped shirt on and R49's hair looked disheveled. R49 stated I only have this stripped shirt on. I only have a diaper underneath. They don't even comb my hair. R49's nails appeared long with blackish substance underneath. R49's left hand appeared contracted. R49 stated that she would like her nails trimmed and cleaned. On August 27, 2024, at 10:53 AM, R49 was lying in her bed and fingernails remained long and uncut on both hands with blackish substance underneath most of the nail beds that were visible from contracted hand. The nails in her contracted hand also appeared to be pressing into her palm. R49 remarked They need to be trimmed. This information was relayed to V14 (Registered Nurse) who stated that the Hospice nurse usually comes in and takes care of this task. On August 27, 2024, at 11:02 AM, R49 was seated in a high back chair in front of the wash basin in the bathroom brushing her teeth with her right hand and stated that she needs assistance to wash off toothbrush and her hands. R49's fingernails remained long with blackish substance underneath the nails. The visible nails in her contracted hand also appeared long with blackish substance underneath and were pressing into her palm. This was relayed to V9 (Certified Nursing Assistant) who stated that since R49's left hand is contracted, that she is unable to open R49's fingers. On August 27, 2024, at 1:19 PM, V11 (Rehab Director) stated that R49 refuses therapy to her contracted hands however staff should ensure that R49's fingernails are trimmed so that it will not dig into her palms. R49's care plan revised April 22, 2024, included that R49 has impaired mobility, requires assistance from staff for her ADLs (activities of daily living). Goal for the same included that staff will provide ADL assistance as needed with target date October 19, 2024. 6. R44's face sheet included diagnoses of unspecified Dementia, unspecified severity, Alzheimer's disease, unspecified psychosis. R44's quarterly MDS dated [DATE], showed that R44 was moderately impaired in cognition and is dependent on staff for personal hygiene. On August 26, 2024, at 10:59 AM, R44 was seated in a high back chair in front of nurses station. R44's left arm appeared contracted, and her fingers were curled into a fist and the visible fingernails were noted to be long and pressing into palms. R44's right hand also had long fingernails with blackish substance underneath the nail beds. R44 did not respond to queries and V12 (Activity Aide) stated that R44 is primarily Spanish speaking. On August 27, 2024, at 12:10 PM, R44 was seated in a high back chair and her fingernails remained long and with some of them jagged and with blackish substance underneath the nail beds. This information was relayed to V14 (Registered Nurse) who stated that R44's family comes in and usually takes care of it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 6 of 16 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 08/29/2024 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 0677 R44's care plan revised July 28, 2024, showed that R44 requires staff assistance for all ADLs with goal for this problem for staff will provide the needed assistance for ADLs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 7 of 16 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 08/29/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review the facility failed to have two staff assist during a full body mechanical lift transfer. Residents Affected - Few This applies to 1 of 3 residents (R49) reviewed for accidents and supervision in the sample of 21. The findings include: R49's face sheet showed diagnoses of hemiplegia following cerebral infarct affecting left non dominate side, unspecified osteoarthritis, unspecified dementia, unspecified severity. R49's MDS (Minimum Data Set) dated July 19, 2024, showed that R49 was moderately impaired in cognition and dependent on staff with the assistance of two or more helpers for bed to chair transfers. On August 26, 2024, at 11:39 AM, R49 was lying in bed in her room with a striped shirt on and R49's hair looked disheveled. There was a high back chair at foot of R49's bed. When asked if she prefers to stay in bed. R49 stated I want to get up. They don't get me up. They only get me once in a while. I don't know when they last got me up. They don't want to use the lift to get me up. V9 (Certified Nursing Assistant) was notified that R49 stated that she would like to get up. On August 27, 2024, at 10:44 AM, R49 was lying in bed fully clothed with shirt and jeans. V9 (Certified Nursing Assistant) came in with a full mechanical lift and stated that she is about to get her up. On August 27, 2024, at 11:02 AM, R49 was seated in a high back chair in front of wash basin in bathroom brushing her teeth with right hand. R49 stated that only V9 assisted her during the transfer that morning and that usually she is assisted by one staff by the lift when she gets up. V9 came in shortly afterwards into the bathroom. When asked, V9 stated that she got R49 up by herself with the mechanical lift. On August 27, 2024, at 11:32 AM, V10 (Registered Nurse) stated Usually, it should be two persons assistance by mechanical lift. On August 28, 2024, at 2:41 PM, V2 (Director of Nursing) stated that there should be two staff during mechanical lift transfer for safety of the resident as one staff is involved with the operation of the equipment and the other staff ensures that the resident is secure. Facility policy and procedure titled Lifting Machine, Using a Portable (revised 12/2017) included as follows: Purpose: The purpose of this procedure is to help lift residents using a manual lifting device. General guidelines: Two (2) nursing associates are required to perform this procedure. Procedure for total lift transfer: A) Explain procedure to resident, to ensure their comfort and understanding of situation. Always have 2 persons provide transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 8 of 16 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 08/29/2024 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 - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to provide incontinence care in a manner that would prevent urinary tract infection (UTI). Residents Affected - Some This applies to 4 of 5 residents (R26, R117, R126, and R9) reviewed for bowel and bladder care in the sample of 21. The findings include: 1. On August 27, 2024, at 1:16 PM, V18 (Certified Nursing Assistant/CNA) rendered incontinence care to R26 who was wet with urine and had a bowel movement. V18 wiped R26's frontal perineum up and down with wet washcloth, the washcloth got soiled with fecal matter as it went down to the mid perineum. V18 only wiped the outer area of the labial fold and the surface of the groins without wiping deeper into the groins, then V18 proceeded to clean the back perineum. R26's face sheet shows that R26 has a history of UTI. 2. On August 28, 2024, at 10:24 AM, V17 and V18 (Both CNAs) rendered incontinence care to R9 who was wet with urine. V17 cleaned R9's perineum from front to back. However, V17 did not separate the labia to clean the inner folds. 3. On August 28, 2024, at 10:48 AM, V17 and V18 stated they rendered incontinence care to R126 who was wet with urine and had a bowel movement. V17 cleaned R126 from the front to back, V17 cleaned the surface of the groin but did not go deeper into the folds, and she did not clean R126's scrotal area. R126's face sheet shows that R126 has diagnoses of obstructive and reflux uropathy, hydronephrosis with ureteral stricture, calculus of ureter, and benign prostatic hyperplasia with lower urinary tract symptoms. 4. On August 28, 2024, at 10:57 AM, V17 and V18 they rendered incontinence care to R117 who was wet with urine. V17 cleaned R117 from front to back of the perineum. However, V17 did not separate labia to clean the inner folds and cleaned only the surface of the groins without going in deeper into the folds. On August 28, 2024, at 4:11 PM, V2 (Director of Nursing/DON) stated that when staff provides incontinence care the staff must completely clean the resident from front to back. The staff must clean the abdominal folds, the vaginal area, separate the labial folds to clean the inner area, and the whole groins. The staff must wipe in one direction and not up and down. This is to prevent infection. The Facility's Policy and Procedure for Peri-Care dated January 2024 shows: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident. to prevent infections, and skin irritation, and to observe the resident's skin condition. Steps in the Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 9 of 16 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 08/29/2024 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 I. For Female Resident: Wash the perineal area, wiping from front to back. Level of Harm - Minimal harm or potential for actual harm a. Separate labia and wash area downward from front to back. Residents Affected - Some b. Continue to wash the perineum including thighs, alternating from side to side, and using downward strokes. J. For Male Resident: Wash the perineal area starting from the urethra and working outward. c. Continue to wipe the perineal area including the penis, scrotum, and inner thighs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 10 of 16 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 08/29/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and provide gastrostomy tube (g-tube) care as ordered by the physician. This applies to 1 of 3 residents (R15) reviewed for Tube Feeding in the sample of 21. The findings include: The electronic medical records (EMR) shows that R15 has multiple medical diagnoses which include epileptic seizure, unspecified encephalopathy, gastrostomy status, muscle weakness and dementia. Minimum Data Sheet (MDS) dated [DATE], shows that R15 moderately impaired with his cognition. On August 28, 2024, at 1:49 PM, R15 was in his bedroom. Upon assessment of his g-tube, with V18 (Certified Nursing Assistant/CNA), it was noted that his g-tube dressing was dated August 24, 2024. The dressing was soiled with dry brown discharge which filled the lower half of the 4 x 4 gauze dressing and had odor emanating from it. Surveyor called the attention of V20 (Nursing Supervisor). V20 came in and assessed R15's g-tube site. V20 removed the soiled dressing which revealed redness and small open area to the surrounding skin of the g-tube insertion site. The skin was wet, it appeared raw, and had an odor coming from the site. V20 described it as maceration. V20 stated that the g-tube dressing is supposed to be changed daily and as needed, and skin should be assessed every shift. R15's Wound Assessment Report dated May 20, 2024, shows, admission skin assessment noted with g-tube stoma to the left lower quadrant, resident g-tube is water flush only at this time. Stoma site free from any signs and symptoms of infection at this time, bumper noted in place. Resident noted no other skin alterations at this time. Resident is incontinent of bowel and bladder. Education regarding pressure relief to bony areas such as heels, shoulder blades, buttocks, and elbows provided to nurse on duty. Education also provided to nurse on duty regarding monitoring of g-stoma site for any signs/symptoms of infection. Staff to continue to monitor and assess as needed. R15's Wound assessment dated [DATE], shows, G-tube stoma site assessed and noted with redness and maceration, slight odor and a small open area to left side of the stoma. Resident denies pain/discomfort at stoma site, area cleansed with warm soap and water, pat dried thoroughly, triad and drain sponge applied, treatment orders initiated. Education provided to nurse on duty regarding monitoring of the stoma site for signs and symptoms of infection at site, resident's complaints of pain/discomfort at site. No other skin alterations noted at this time. Staff to continue to monitor and assess. The same wound assessment shows that it has scant drainage surrounding skin is macerated, and measured as Length (L) 0.2 centimeter (cm) x Width (W) 0.2 cm. Physician Order Summary (POS) shows: G-tube stoma monitor for signs and symptoms of redness, warmth, edema, and drainage (or dehiscence), dressing placement, keep clean and dry every shift. Notify physician and wound care with any changes. Gastrostomy Status Care Plan with revised date of July 3, 2024, shows R15 has risk for impaired skin integrity related to impaired mobility and nutrition through feeding tube. The same care plan shows multiple interventions that includes daily skin inspection, report any changes in skin or signs of possible skin breakdown or redness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 11 of 16 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 08/29/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm On August 29, 2024, at 12:47 PM, V21 (Nurse Practitioner/NP) stated that she was not aware of R15 having a skin breakdown in the surrounding area of the g-tube site. However, V21 was notified today about the maceration in R15's g-tube area. V21 expected the nurses to follow the physician order regarding g-tube care. V21 added that not following the physician's order can cause potential skin breakdown. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 12 of 16 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 08/29/2024 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 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 administer medications according to physician's order. There were 26 medication opportunities with 2 medication errors resulting to 7.69 % error rate. Residents Affected - Few This applies to 1 of 6 residents (R12) reviewed for medication administration in the sample of 21. The findings include: On August 27, 2024, at 8:44 AM, V4 (Nurse) administered medications to R12 which include Loratadine, Sitagliptin, Vitamin B12, Docusate Sodium, Escitalopram, Carvedilol, Amiodarone, Metformin, Magnesium, and Artificial Tears. After the medication administration, V4 stated that these were all the medications scheduled for this morning. R12's Medication Administration Record (MAR) dated August 2024 showed the above medications, however, there were other medications that were supposed to be given at that time which includes Polyethylene Glycol 17 grams, Medi-Pads 50% topical for hemorrhoids. On August 28, 2024, at 4:14 PM, V2 (Director of Nursing/DON) stated nurses should give the medications as ordered by the physician and to follow the 5 rights of medication administration such as the right patient, dose, medication, time, and route. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 13 of 16 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 08/29/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to serve ground chicken for residents on mechanical soft diets. This applies to 4 of 4 residents (R67, R105, R109, R296) reviewed for dining in the sample of 21. The findings include: Facility menu spreadsheet for Monday lunch (week 1) showed to serve ground same as base for mechanical soft diet. The base was documented as garlic herb-based chicken breast for mechanical soft diet. On August 26, 2024 at 12:02 PM during meal service in the secure unit dining room on the 1st floor, V8 (Dietary Aide) was plating the food from the steam table. The mechanical soft chicken breast, which was pre-plated in bowls, appeared chopped into varying lengths. V8 stated that it was pre-plated in the facility kitchen. V6 (Dietary Manager), who had come into the vicinity, was showed the same and V6 stated that she will have to ask V7 (Cook) how he prepared it. R67, R105, R109 and R296 were observed to receive the chopped chicken and their diet ticket showed give ground meat. R65 and R109 received meals in the secure unit dining room and R105 and R296 received room trays on the 2nd floor. R105 had poor dentition and R296 was edentulous and did not eat all the chicken. On August 26 at 12:19 PM, V7 (Cook) stated that he chopped up the chicken on a cutting board as the blender was in use by another dietary staff member. On August 28 at 12:35 PM, V15 (Registered Dietitian) stated that for ground consistency a [NAME] should be used as the texture of the product will not be even when chopped. Facility policy and procedure titled Modified Texture Foods (revised January 2024) included as follows: Policy: Provide a standardized process for modified texture foods to meet community-approved diet guidelines and to assure palatability, flavor, texture, and nutritious value. Procedure: -The regular diet menu item will be used to prepare all modified-textured menu items unless otherwise indicated by menu spreads. -Foods requiring modification to other levels (e.g., ground meat, minced and moist, soft and bite sized) will be provided per guidelines established by the community and approved in the diet manual. Facility diet order listing of residents printed on August 26, 2024, showed that R67, R105, R109 and R296 were on mechanical soft diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 14 of 16 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 08/29/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow infection control process related to hand hygiene and gloving during provisions of incontinence care. Residents Affected - Some This applies to 5 of 21 residents (R9, R26, R116, R117, R126) reviewed for infection prevention in the sample of 21. The findings include: 1. On August 27, 2024, 1:01 PM, V19 (Certified Nursing Assistant/CNA), rendered peri-care to R116 after he had a bowel movement in the bed pan. V19 cleaned R116 from front to back, she then touched clean bed linen, applied clean incontinence brief, and applied barrier cream, V19 also placed a pillow underneath R116's left lower extremity, placed linen sheet and blanket over R116, adjusted bed height by using bed control and opened the privacy curtain, while wearing the soiled gloves all throughout these procedures. 2. On August 27, 2024, at 1:16 PM, V18 (CNA) rendered incontinence care to R26 who was wet with urine and had a bowel movement. V18 cleaned R26 from front to back perineum, applied barrier cream, applied a clean disposable brief, repositioned R26, and placed linen, and blanket over R26, while wearing the same soiled gloves all throughout the care. 3. On August 28, 2024, at 10:24 AM, V17 and V18 (Both CNAs) rendered incontinence care to R9 who was wet with urine. V17 cleaned R9's perineum from front to back, applied clean disposable brief, repositioned R9, assisted R9 to put the pants on, opened R9's closet to get a sweatshirt, and transferred R9 via mechanical lift while wearing the same gloves all throughout the care procedure. 4. On August 28, 2024, at 10:48 AM, V17 and V18 rendered incontinence care to R126 who was wet with urine and had a bowel movement. V17 cleaned R126's perineum from front to back, applied new disposable brief, and repositioned R126 while wearing the same set of gloves all throughout the care. 5. On August 28, 2024, at 10:57 AM, V17 and V18 rendered incontinence care to R117 who was wet with urine, V17 cleaned R117's perineum from front to back, applied incontinence brief and repositioned R117, and adjusted bed height using the bed remote control while wearing the same gloves. On August 28, 2024, at 3:57 PM, V2 (Director of Nursing/DON) stated that staff should follow protocol for when providing incontinence care. The staff must perform hand hygiene before and after care, they should change gloves and perform hand hygiene in between glove changes and in between tasks to prevent the spread of infection. Facility's Policy and Procedure for Hand Hygiene dated August 2024 shows: This community considers hand hygiene the single most important practice to prevent infections and promote resident safety. Evidence based hand hygiene guidance is practiced to reduce the risk of transmission pathogenic microorganisms to residents, associates, and visitors. Policy Interpretation and Implementations: F. Hand Hygiene is practiced: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 15 of 16 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 08/29/2024 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 0880 3. Before moving from work on a soiled body site to a clean body site on the same resident. Level of Harm - Minimal harm or potential for actual harm 4. After touching a resident or the resident's immediate environment. 5. After contact with blood, body fluids, or contaminated surfaces. Residents Affected - Some H. The use of gloves does not replace hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145029 If continuation sheet Page 16 of 16