Health inspection·February 3, 2025

F 0676 Level of Harm - Minimal harm or potential for actual harm Other Malignant Neoplasm Of Skin, Unspecified Mental Disorder Due To Psychological Condition, Abnormalities Of Gait And Mobility, Unspecified Lack Of Coordination, Unsteadiness On Feet, Need For Assistance With Personal Care. R9's MDS (Minimum Data Set) dated 12/16/24 BIMS (Brief Interview for Mental Status) score is 15 out of 15 indicating intact cognition and requires set up/cleaning assistance with personal hygiene. Residents Affected - Few Facility provided policy titled, Shower and Hygiene dated 08/19/24 which documents in part, it is the policy of this facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin and any resident who needs hygienic care will be provided care to promote hygiene (facial, body, perineal care, etc.). Facility provided policy titled, General Care dated 07/30/24 which documents in part, it is the facility's policy to provide care for every resident to meet their needs. Facility provided copy of contract between resident and the facility titled Attachment D: Statement of Resident Rights dated January 2022 which documents in part, the right to live in an environment that promote and supports each resident's dignity, individualism, independence, self-determination, privacy, and choice and to be treated with consideration and respect. Facility provided policy titled Staffing dated 08/19/24 which documents in part, it is the facility's policy to provide adequate staff to meet the needs of the residents which is the requirements under the federal regulations. Facility provided document titled, Facility Assessment Tool 2024 dated 08/26/24 which documents in part, evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs and total number needed or average or range for nurses' aides is 15-20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 2 of 11 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 02/03/2025 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)

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 follow their policy and procedures by not checking in on and/or provide incontinence care every two hours for 3 (R2, R7, R8) dependent residents out of a total of 6 residents reviewed for improper nursing care. Residents Affected - Few Findings Include: On 2/2/25 at 10:25 AM, Surveyor entered R2's room with V7 (Licensed Practical Nurse). R2 was lying in bed alert and able to verbalize needs. R2 stated that [R2's] incontinence brief was soiled and needed to be changed. R2 was unable to verbalize when was the last time R2's incontinence brief was changed. R2 stated, I can't tell you how long, but I've been uncomfortable for a while. Surveyor and V7 checked R2's incontinence brief and noted to be saturated with urine and feces. R2's incontinence under pad was also wet. On 2/2/25 at 10:36 AM, interviewed V8 (Certified Nursing Assistant/CNA) and stated [V8] is the CNA assign to R2. V8 stated [V8] provides incontinence care to residents a couple of times a shift. V8 stated [V8] has not checked on R2 and has not changed [R2's] incontinence brief yet. V8 stated that R2's incontinence brief was last changed by the night shift staff, and they leave at 7:00 AM. V8 stated [V8] started at 7:00 AM this morning. On 2/2/25 at 10:58 AM, interviewed V2 (Director of Nursing) and stated that incontinence care should be provided to residents at least every 2 hours and as needed. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact, always incontinent of bowel and bladder, and requires substantial/maximal staff assistance with toileting hygiene. R2's comprehensive care plan documents in part: R2 has potential for/an actual impairment to skin integrity and at risk for development of pressure injury related to self-care deficits, impaired mobility, incontinence, and present co-morbidities with one intervention that reads, keep skin clean and dry (date initiated 12/20/24). The facility's Toileting Interventions policy and procedures dated 8/19/24 document in part: Toileting interventions may be administered as follow depending on the resident's rehabilitation/restorative assessment: a. Incontinent care every 2 hours/after each involuntary episode to help keep patient clean and dry. On 02/02/2025 at 9:28 AM, R7 stated there are not enough nursing staff working here. R7 stated she wears an incontinence brief and needs the staff to assist her to change and bring her to the bathroom. R7 stated today someone on the night shift checked R7's incontinent brief at 5:00 AM. R7 stated no one has checked on R7 since then. R7 stated R7 gets in bed at 6:00 PM for the night and usually falls asleep by 8:00 PM. R7 stated no one checks on her during the night never. R7 stated when the staff checks on her at 5:00 AM she is very wet. On 02/02/25 at 9:10 AM, R8 stated no one has checked to see if R8 needed to be changed yet this shift. R8 stated the last time R8's incontinent brief was changed was at 5:00 AM this morning by the night shift staff. R8 stated, no one has checked on me since then. R8 stated R8 does not know if R8 is wet or not because R8 cannot tell. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 3 of 11 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 02/03/2025 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/02/25 at 8:47 AM, V15 (Certified Nursing Assistant) stated there are only two CNAs working on the 4th floor today. V15 stated there should be at least three CNAs but ideally there should be four CNAs. V15 stated the typical number of CNAs on this unit are usually two or three and we are shorted staff a lot. On 02/02/25 at 9:20 AM, V16 (Certified Nursing Assistant) stated when V16 comes on shift V16 rounds on all of V16's residents to see if they are wet/soiled, or bedding is wet and/or clothing is wet and change them if they are wet/soiled. V16 stated V16 has to manually check if a resident is wet/soiled, not just ask them verbally because some of them may not be able to know if they are wet or not. V16 stated V16 has not been in to check on R7 or R8 yet today because there are only two CNA working the floor and V16 is still trying to get up the residents on V16's get up list because they are the priority. V16 stated R8 is incontinent and dependent on staff for ADL/activities of daily living toileting care. V16 does not know if R8 is wet or soiled right now. V16 stated R7's wears incontinent briefs and can change and transfer herself to the bathroom. V16 stated R7 is continent and therefore V16 does not have to do a manual check on R7. On 02/02/25 at 12:37 PM, V11 (Restorative Nurse/Licensed Practical Nurse) stated R7 needs partial/moderate assistance with toileting and all transfers. V11 stated R7 requires weight-bearing assistance from the staff and needs help from staff transferring herself from the wheelchair to the bathroom. V11 stated the staff should make rounds every 2 hours and should manually check to see if R7 is wet. V11 stated R8 needs maximum to total assistance with toileting and requires total assistance for transfers with the mechanical lift. V11 stated R8 is incontinent, and the staff should be checking on R8 every 2 hours and doing a manual check to see if R8 is wet. On 02/02/25 at 2:55 PM, V19 (Restorative Aide/Certified Nursing Assistant) stated the residents on this floor require a lot of supervision and care and therefore they should have four CNAs to provide care and monitoring. V19 stated without the four CNAs the quality of resident care goes down which impact if ADL care is given including showers/baths, incontinence care/diaper changes, and repositioning. V19 stated there is not enough staff and they often have to run short-staffed. On 02/02/25 at 4:10 PM, V2 (Director of Nursing) stated residents should be rounded on every two hours and the CNAs should be checking the residents at the start of their shift for incontinence care which includes manually checking the resident and changing them if there are wet or soiled. V12 (Staffing Scheduler) stated on 02/02/25 the facility has 14 CNAs working the (7-3 shift) and should have 17-19 CNAs working the (7-3 shift). R7 has diagnoses which include but not limited to Type 2 Diabetes Mellitus Without Complication, Fluency Disorder Following Cerebral Infarction, Personal History of Transient Ischemic Attack (Tia), And Cerebral Infarction Without Residual Deficits, Depression, Myopia, Bilateral, Diplopia, Lattice Degeneration of Retina, Right Eye, Generalized Anxiety Disorder. R7's MDS (Minimum Data Set) dated 12/24/24 BIMS (Brief Interview for Mental Status) score is 14 out of 15 indicating intact cognition and requires partial/moderate assistance with toileting hygiene and transfers include chair/bed to chair and toilet transfer. R7 has a care plan in place for ADL self-performance and impaired mobility which documents in part, I (R7) would like staff to assist me to (transfer onto toilet, transfer off toilet) to use toilet and high risk for falls and injury related to decreased visual acuity. R8 has diagnoses which includes but not limited to Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Non-Dominant Side, Hypertensive Urgency, Hypertension, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 4 of 11 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 02/03/2025 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nervousness, Transient Cerebral Ischemic Attack, Disorganized Schizophrenia, Cerebrovascular Disease, Homelessness, Hypothyroidism, Anxiety Disorder, Schizoaffective Disorder, Bipolar Type. R8's MDS (Minimum Data Set) dated 01/01/25 BIMS (Brief Interview for Mental Status) score is 12 out of 15 indicating moderately impaired cognition and is dependent on staff for toileting hygiene and requires substantial/maximal assistance with chair/bed to chair transfer. R8 has a care plan in place for self-care deficit and fall risk. R7's Concern/Response Form dated 11/18/24 documents in part, resident (R7) reported CNA did not attend to her in a timely manner. Facility provided policy titled, Toileting Interventions dated 08/19/24 which documents in part, incontinent care every two hours after each involuntary episode to help keep patient clean and dry. Facility provided policy titled, General Care dated 07/30/24 which documents in part, it is the facility's policy to provide care for every resident to meet their needs. Facility provided copy of contract between resident and the facility titled Attachment D: Statement of Resident Rights dated January 2022 which documents in part, the right to live in an environment that promote and supports each resident's dignity, individualism, independence, self-determination, privacy, and choice and to be treated with consideration and respect. Facility provided policy titled Staffing dated 08/19/24 which documents in part, it is the facility's policy to provide adequate staff to meet the needs of the residents which is the requirements under the federal regulations. Facility provided document titled, Facility Assessment Tool 2024 dated 08/26/24 which documents in part, evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs and total number needed or average or range for nurses' aides is 15-20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 5 of 11 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 02/03/2025 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure wound care dressing was in place and intact for 1 (R2) out of 3 residents reviewed for wound care. Residents Affected - Few Findings Include: On 2/2/25 at 10:25 AM, Surveyor entered R2's room with V7 (Licensed Practical Nurse). R2 was lying in bed alert and able to verbalize needs. R2 stated that R2's incontinence brief was soiled and needed to be changed. R2 was unable to verbalize when the last time R2's incontinence brief was changed. R2 stated, I can't tell you how long, but I've been uncomfortable for a while. Surveyor and V7 checked R2's incontinence brief and noted to be saturated with urine and feces. R2's incontinence under pad was also wet. R2's sacral open wound had no dressing in place. V7 stated that the wound is open to air. V7 stated that if a dressing falls off, the nurse should provide wound treatment and apply wound dressing as ordered. On 2/2/25 at 10:36 AM, interviewed V8 (Certified Nursing Assistant/CNA) and stated [V8] is the CNA assign to R2. V8 stated [V8] has not checked on R2 and has not changed [R2's] incontinence brief yet. V8 stated that R2's incontinence brief was last changed by the night shift staff, and they leave at 7:00 AM. V8 stated [V8] started at 7:00 AM this morning. On 2/2/25 at 11:00 AM, interviewed V4 (Wound Care Coordinator Registered Nurse) and stated that R2 was assessed on 1/15/25 with sacral pressure ulcer unstageable, and the treatment order is to cleanse it with normal saline, apply medical grade honey, and secure with border foam dressing three times a week and as needed. V4 stated that if the wound dressing falls off, the CNAs (Certified Nursing Assistants) would report to the nurse and the nurse will re-apply the dressing. V4 stated that R2's dressing should be in place at all times. R2 is on low air loss mattress, turning and reposition every 2 hours and as needed. V4 stated R2 is supposed to be clean and dry at all times. R2 is able to tell the staff if she needs to be changed. V4 stated R2 needs to be always clean and dry to promote wound healing, to prevent the wound to get worse and prevent [R2] from getting more wounds. R2's clinical records show an admission date of 1/14/25 with included diagnoses but not limited to Epilepsy and Peripheral Vascular Disease. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact, always incontinent of bowel and bladder, and requires substantial/maximal staff assistance with toileting hygiene. R2's skin/wound notes dated 1/16/25 and 1/27/25 show R2 assessed with sacral pressure ulcer measuring 6 cm (centimeters) x 7 cm x 0.1 cm. R2's February Treatment Administration Record (TAR), physician order sheet (POS), and skin care plan show R2 has a treatment order for sacral wound to cleanse with normal saline, apply medical grade honey then cover with bordered foam one time a day every Monday, Wednesday, Friday and as needed for soilage/dislodgement. The facility's Skin Care Regimen and Treatment Formulary policy dated 1/28/25 documented in part: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 6 of 11 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 02/03/2025 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview and record review, the facility failed to provide sufficient staffing to ensure staff is monitoring residents (R2, R7, R8) every two hours and to ensure ADL (Activities of Daily Living) needs are met in a timely manner. The facility's short staffing has the potential to affect all 212 residents residing in the facility as of census 02/02/25. Findings include: On 2/2/25 at 10:25 AM, a fellow surveyor entered R2's room with V7 (Licensed Practical Nurse). R2 was lying in bed alert and able to verbalize needs. R2 stated that (R2's) incontinence brief was soiled and needed to be changed. R2 was unable to verbalize when the last time R2's incontinence brief was changed. R2 stated, I can't tell you how long, but I've been uncomfortable for a while. Surveyor team member and V7 checked R2's incontinence brief and noted to be saturated with urine and feces. R2's incontinence under pad was also wet. On 2/2/25 at 10:36 AM, a fellow surveyor interviewed V8 (Certified Nursing Assistant/CNA) and stated (V8) is the CNA assign to R2. V8 stated (V8) provides incontinence care to residents a couple of times a shift. V8 stated (V8) has not checked on R2 and has not changed ([R2's) incontinence brief yet. V8 stated that R2's incontinence brief was last changed by the night shift staff, and they leave at 7:00 AM. V8 stated (V8) started at 7:00 AM this morning. On 02/02/2025 at 9:28 AM, R7 stated there is not enough nursing staff working here. R7 stated for example R7 wears an incontinence brief and needs the staff to change her and bring R7 to the bathroom. R7 stated today someone on the night shift checked R7's incontinent brief at 5:00 AM. R7 stated no one has checked on R7 since then. R7 stated R7 gets in bed at 6:00 PM for the night and usually falls asleep by 8:00 PM. R7 stated no one checks on me during the night never. R7 stated when the staff checks on R7 at 5:00 AM R7 is very wet. On 02/02/25 at 9:10 AM, R8 stated no one has checked to see if R8 needed to be changed yet this shift. R8 stated the last time R8's incontinent brief was changed was at 5:00 AM this morning by the night shift staff. R8 stated, no one has checked on me since then. R8 stated R8 does not know if R8 is wet or not because R8 cannot tell. On 02/02/25 at 8:47 AM, V15 (Certified Nursing Assistant) stated there are only two CNAs working on the 4th floor today. V15 stated there should be at least three CNAs but ideally there should be four CNAs. V15 stated the typical number of CNAs on this unit are usually two or three and we are shorted staff a lot. On 02/02/25 at 9:20 AM, V16 stated V16 has not been in to check on R7 or R8 yet today because there are only two CNA working the floor and V16 is still trying to get up the residents on V16's get up list because they are the priority. On 02/02/25 at 11:08 AM, V17 (Licensed Practical Nurse) stated V17 is one of the nurses working on the 3rd floor today. V17 stated there are three CNAs working on the unit today. V17 stated the unit runs better when there are four CNAs because more staff is needed for monitoring the residents. V17 stated the 3rd floor is one of the dementia floors so there are a lot of residents who wander, have behavior issues and are at fall risk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 7 of 11 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 02/03/2025 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 02/02/25 at 2:40 PM, V18 (Agency Licensed Practical Nurse) stated V18 has been working at the facility for approximately one year and covers the facility two to three times per week on the 7AM-7PM shift. V18 stated today on the 4th floor there were two CNAs covering the unit initially. V18 stated on a good day there are three CNAs covering the unit, rarely four CNAs. V18 stated due to the ratio and acuity of the residents two CNAs covering the whole floor is not enough staff. V18 stated the residents on this floor are long-term residents many of which have dementia and so they wander around and are at high risk for falls. V18 stated if there are not enough staff on the unit then there is an increased risk for residents to fall because not enough people are available to do rounds and monitor the residents. V18 stated the other problem with only having two CNAs is there is delay in rounding and should be checking on residents every two hours but if there is not enough staff this could be delayed. V18 stated we have to ask the mangers for help and demand for them to get us more coverage. V18 stated V18 hears the CNAs saying, we cannot work like this! V18 stated the scheduler (V12) will help at times with an assignment but no one else from management does. V18 stated V19 (Restorative Aide/Certified Nursing Assistant) was eventually pulled from the 3rd floor today and given an assignment on this floor because we were so short staffed. V18 stated V18 thinks V19 came up later in the morning sometime. On 02/02/25 at 2:55 PM, V19 stated (Restorative Aide/Certified Nursing Assistant) is responsible for applying resident's splints, doing ROM (Range of Motion) exercises, and ambulating the residents. V19 stated today V19 was supposed to be working on the 3rd floor but V19 was pulled to work on the 4th floor because there were only two CNAs covering this unit. V19 stated fully staff is having four CNAs on the 4th floor but usually there are only three CNAs, and three CNAs are not enough. V19 stated the residents on this floor require a lot of supervision and care and therefore they should have four CNAs to provide care and monitoring. V19 stated without the four CNAs the quality of resident care goes down which impact if ADL care is given including showers/baths, incontinence care/diaper changes, and repositioning. V19 stated there is not enough staff and they often have to run short staff which also means that since V19 was assigned to a different unit as a CNA none of V19's Restorative work was done on V19's regular unit today. V19 stated staff shortages on one or two floors affect the rest of the floors because often the Restorative staff gets pulled to work a shift which leaves the residents without being provided Restorative Services. On 02/02/25 at 11:55 AM, V12 (Staffing Scheduler) stated the facility does not use agency for the CNAs, only for Registered Nurses and Licensed Practical Nurses. V12 stated the desired breakdown for the CNA staffing schedule based on the census is as follows: 2nd floor 7-3 and 3-11 shift there should be three CNAs each shift and for 11-7 shift should be three CNAs. 3rd floor 7-3 and 3-11 shift should have four CNAs and for 11-7 shift should have three CNAs. 4th floor 7-3 and 3-11 shift should have four CNAs and 11-7 shift should have three CNAs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 8 of 11 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 02/03/2025 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)

F 0725 5th floor 7-3 and 3-11 shift should have three-four CNAs and 11-7 shift should have three CNAs. Level of Harm - Minimal harm or potential for actual harm 6th floor 7-3 and 3-11 shift should have three-four CNAs and 11-7 shift should have three CNAs. Residents Affected - Many Total CNAs per 7-3 and 3-11 shifts is 17-19 CNAs and for 11-7 shifts is 15 CNAs. Total CNAs needed per day is 49-53 CNAs. Reviewed Daily Schedule with V19 which showed the following: On 02/02/25 (Sunday) Day CNAs 7AM-3PM a total of 14 CNAs working. V12 stated the 2nd floor is running short staffed today because there were call outs and V12 could not get anyone else to cover the shift. V12 stated the 3rd and 4th floor is the memory care units with higher acuity so those residents are at a higher risk for falls and need more supervision and monitoring which is why V12 schedules an extra CNA on those units. V12 stated today a Restorative Aide had to be pulled to work an assignment on the 4th floor because there were only two CNAs working on the 4th floor in the morning. V12 stated there are now three CNAs working on the 3rd and 4th floor (7-3 shift) but there should be four CNAs. V12 stated for today there are a total of 14 CNAs working the (7-3 shift) instead of 17-19 CNAs. V12 stated if V12 cannot find anyone to come in the units have to run short and the department heads are asked to fill in with answering call lights, passing meal trays, filling ice water but the department heads cannot help to provide direct care to the residents such as doing ADL care, feeding, or bathing/showering. V12 stated the potential risk with running the units with less staff is although the staff will respond in a timely manner to call lights there could potentially be a delay in delivering care. V12 stated another potential risk of not having the right amount of staffing is a resident could have more falls because they wander and need more redirection and monitoring so if that is not provided due to decreased staffing, there is the potential residents could have more falls. On 02/02/25 at 4:10 PM, V2 (Director of Nursing) stated if the facility does not have the targeted number of CNAs working on a unit this could potentially impact resident care. Resident/Food Council Meeting Minutes dated 12/03/24 documents in part, more CNA's staff is needed. Facility provided policy titled Staffing dated 08/19/24 which documents in part, it is the facility's policy to provide adequate staff to meet the needs of the residents which is the requirements under the federal regulations. Facility provided document titled, Facility Assessment Tool 2024 dated 08/26/24 which documents in part, evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs and total number needed or average or range for nurses' aides is 15-20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 9 of 11 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 02/03/2025 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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide food at an appetizing temperature for three (R7, R8, R9) of three residents reviewed food temperatures. Residents Affected - Few Findings include: On 02/02/25 at 9:25 AM, R8 lying in bed eating breakfast. R8 stated the hot food is always cold. Observed R8 had consumed 100% hot cereal, 0% eggs, 0% sausage links, 0% toast. R8 stated the eggs are nasty and I couldn't eat them because they are so cold. R8 stated that cold food is not appealing, and that is why R8 won't eat it. On 02/02/25 at 9:27 AM, R7 stated, the food here is always cold. R7 stated the eggs were cold this morning but R7 ate them anyway because R7 was hungry. R7 stated hot food being cold is not just a problem with today's meal, it is a problem with a lot of the meals. R7 stated, I'm hungry so I just eat the food even if it is cold. On 02/02/25 at 9:55 AM, R9 stated the food here is always cold. R9 stated today R9 received eggs and sausage for breakfast. R9 stated the eggs were cold and the sausages were warmish. R9 stated R9 has been here for approximately 6 weeks and R9 has never received any hot food except for the coffee. R9 stated R9 eats the food because R9 is hungry but that R9 would enjoy the food more if the hot food was hot. R9 stated, it would be more appetizing to me. On 02/02/25 at 8:43 AM, surveyor observed breakfast trays arrive on the 4th floor. The breakfast meals did not have a heated palate underneath the ceramic plates and the ceramic plates were not heated. On 02/02/25 at 8:49 AM, V16 (Certified Nursing Assistant) stated sometimes the kitchen uses heated palates but they do not always use them, like now. On 02/02/25 at 9:15 AM, a test tray was conducted using a digital thermometer provided by the kitchen after the last tray was passed out. The temperatures were read aloud by V16 who observed the test tray process. The temperatures were as follows: apple juice 62 degrees Fahrenheit (F), scrambled eggs 85 degrees F, and sausage links 88.5 degrees F. Surveyor tasted the scrambled eggs which tasted cold and rubbery. The sausage links were cold to the touch and the juice felt to be at room temperature. On 02/02/25 at 9:17 AM, V16 (Certified Nursing Assistant) stated V16 did not want to taste any of the food on the test tray. V16 stated V16 hears a lot of the residents complaining about the hot food being served cold at the meals. V16 stated, I believe the residents. V16 stated there is a microwave on the unit but it would not be possible for V16 to microwave everyone's food. V16 stated the hot food should be delivered hot/warm to the residents and that the residents would eat better if the kitchen served the food at the right temperature. On 2/02/25 at 10:11 AM. V14 (Diet Aide) stated the kitchen usually uses the hot palates under the ceramic plates but because the kitchen is short-staffed today there is not enough staff to work in the dish room and using the hot palates creates extra pieces of equipment which need to get washed. V14 stated the kitchen used to heat up the ceramic plates before serving but something happened to the warmer, the plug does not work so the kitchen does not heat up the plates anymore. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 10 of 11 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 02/03/2025 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)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/02/25 at 10:28 AM, via telephone V25 (Director of Dietary) stated the kitchen should be heating the ceramic plates and using the heat palate system at every meal to keep the hot food staying hot when it goes up the floors. V25 stated it is expected there will be some drop in food temperature during the delivery process because of the time it takes to pass out the trays and the heated plates and heat palate system will help the food stay warmer to prevent the temperature of the food from dropping quickly. V25 stated when the resident receives their food the hot food temperature should at least 110-115 degrees F and cold food should be 41 degrees F or below. V25 stated we do not want the food in the temperature danger zone. Surveyor shared test tray temperature results with V25 and V25 stated, those temperatures are unacceptable. V25 stated the goal is for the hot food to be hot and the cold food to be cold and if the resident is getting cold hot food or hot cold food, they will not enjoy the food and maybe this could have an effect on the amount of food they eat. R7 has diagnoses which include but not limited to Type 2 Diabetes Mellitus Without Complication, Fluency Disorder Following Cerebral Infarction, Personal History of Transient Ischemic Attack (Tia), And Cerebral Infarction Without Residual Deficits, Depression, Myopia, Bilateral, Diplopia, Lattice Degeneration of Retina, Right Eye, Generalized Anxiety Disorder. R7's MDS (Minimum Data Set) dated 12/24/24 BIMS (Brief Interview for Mental Status) score is 14 out of 15 indicating intact cognition. R7's diet order is regular consistency, No Concentrated Sweets, thin liquids. R8 has diagnoses which includes but not limited to Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Non-Dominant Side, Hypertensive Urgency, Hypertension, Nervousness, Transient Cerebral Ischemic Attack, Disorganized Schizophrenia, Cerebrovascular Disease, Homelessness, Hypothyroidism, Anxiety Disorder, Schizoaffective Disorder, Bipolar Type. R8's MDS (Minimum Data Set) dated 01/01/25 BIMS (Brief Interview for Mental Status) score is 12 out of 15 indicating moderately impaired cognition. R8's diet order is regular consistency, No Salt Packet, thin liquids. R9 has diagnoses which includes but not limited to Chronic Systolic Congestive Heart Failure, Hyperlipidemia, Hypertension, Arteriosclerotic Heart Disease, , Infection And Inflammation Reaction Due To Indwelling Urethral Catheter, Obesity, Sepsis, Personal History Of Transient Ischemic Attack And Cerebral Infarction Without Residual Deficits, Chronic Kidney Disease Stage 3, Personal History Of Other Malignant Neoplasm Of Skin, Unspecified Mental Disorder Due To Psychological Condition, Abnormalities Of Gait And Mobility, Unspecified Lack Of Coordination, Unsteadiness On Feet, Need For Assistance With Personal Care. R9's MDS (Minimum Data Set) dated 12/16/24 BIMS (Brief Interview for Mental Status) score is 15 out of 15 indicating intact cognition. R9's diet order is regular consistency, thin liquids. Concern Response Form dated 01/06/25 which documents in part, resident received food items, temperature cold. Facility provided policy titled, Food Temperature Maintenance dated 07/26/24 which documents in part, food shall be prepared in methods that maintain nutritional integrity and palatability and hot food items should leave the kitchen or steam table and served to the residents at temperature above 135 degrees Fahrenheit. Cold foods should be stored and served to the residents at a temperature at or below 41 degrees F. Facility provided policy titled, Kitchen dated 08/16/24 which documents in part, hot food temperature should be 135 degrees F or above and cold food temperatures should be 41 degrees and below. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 11 of 11