Inspection·July 12, 2024

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to properly assess, monitor, and evaluate one (R2) resident after a fall incident on 3/13/24 and 5/18/24. These failures could potentially affect one (R2) of three residents reviewed for improper nursing care. Residents Affected - Few The findings include: R2's health record documented admission Date on 2/1/2024 with diagnoses not limited to Unspecified fracture of left ilium, History of falling, Dysphagia oral phase, Thyrotoxicosis, Dementia in other diseases classified elsewhere, Major depressive disorder, Restlessness and agitation, Xerosis cutis, Atrophic disorder of skin, Depression, Insomnia, Iron deficiency anemia, Constipation, Alzheimer's disease, Unspecified protein-calorie malnutrition, Difficulty in walking, Other symptoms and signs involving the musculoskeletal system. On 7/10/24 At 10:10am R2 observed sitting up in wheelchair, wheeled by staff, alert and verbally responsive with bouts of confusion. At 12:01pm V17 (Fall and psychotropic Registered Nurse) requested if he could have V2 (Director of Nursing / DON) during the interview. V17 Stated he has been working full time in the facility for 3 years as a floor nurse then transitioned to Fall and Psychotropic nurse in January 2024. V17 stated the nurse should monitor / assess / document every 8 hours for 72 hours post fall incident. R2's EHR (electronic health record) reviewed with V2 and V17 states R2 is a fall risk. Had a fall incident on 3/13/24. It was an Unwitnessed fall. She was ambulatory with no device at that time. There was no injury post fall. Surveyor and V17 reviewed 72hour documentation post fall incident, V17 stated with missing documentation. There was only one documentation on day 1 and day 3 that should have been three documentations as R2 should be monitored, assessed, or evaluated for any injury every 8 hours. There was no documentation found on day 2 post fall incident. V2 stated that documentation should be done by nurses every 8 hours x 72 hours post fall to ensure there are no changes or injury within 72 hours. V2 stated documentation is a tool that staff is monitoring or assessing the resident. V2 stated R2 was still ambulatory after the fall incident on 3/13/24, no changes physically with the resident. Standard nursing practice if no documentation, it was not done. V17 stated there was another Fall incident for R2 on 5/12/24 while she was out on pass. V2 stated R2's daughter informed the nurse on duty that R2 fell while she was running after her grandkids on the stairs at home. R2's daughter took R2 to the hospital with diagnosis of left iliac fracture. V2 stated prior to fall incident on 5/12/24, R2 was ambulating on and off, uses wheelchair for long distance. V2 stated after that fall incident with fracture, resident was Non ambulatory, there was a significant change in condition. V2 and V17 unable to (continued on next page) 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 Page 1 of 3 Event ID: 145510 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 145510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Lincoln Park 1366 West Fullerton Avenue Chicago, IL 60614 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)