Inspection·August 29, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated that the resident reports a fair appetite depending on the meal, will request subs for menu dislikes, also states orders food out at times. Resident declined extra portions or ONS (oral nutritional supplements) offered. Updated food preferences and will relay to kitchen. The DPN indicated nutritional interventions: 1.) Add super cereal at double eggs at breakfast, ice cream at lunch and dinner.Dietician recommendation on 03/06/25 per progress note 1.) Add super cereal at double eggs at breakfast, ice cream at lunch and dinner. (Cereal, double eggs at breakfast, ice cream at lunch and dinner was recommended but never ordered or provided to the resident). A review of the Dietary Progress Notes (DPN) completed by the dietician dated 04/30/25 reflected that the resident weight of 177.5 pounds on (04/09/25), 178 pounds on (03/11/25), 180.3 pounds on (02/18/25) and 201 pounds on (01/15/25) significant weight loss -11.7% x 3 months from admission weight. Presents with significant unplanned weight loss > 3 months.Physician order document in part as follows: No Salt Packet diet, Regular texture, thin liquids consistency Diet dated 01/22/25, Discontinued 07/15/25. 1:1 Feeder & give medication one at a time or if trouble swallowing can crush medications dated 05/22/25, Discontinued 07/03/25 swallow eval, noted cough with eating. ST (Speech Therapy) eval (evaluation) and treat 2-4x a week for 4 weeks for dysphagia follow up and safety dated 05/22/25. ST (Speech Therapy) eval (evaluation) and treat 2-3x a week for dysphagia management dated 07/15/25. No Salt Packet diet, Mechanical Soft texture, thin liquids consistency for diet dated 07/15/25 13:00, discontinued 07/23/2025. Exam and modified barium swallow study dx. (diagnosis) dysphagia 07/17/25. No Salt Packet diet, Mechanical Soft texture, Nectar Thick Liquids Consistency Diet dated 07/23/25 11:27. Super cereal one time a day with breakfast Supplement dated 07/25/25 09:00. Med Plus 2.0 two times a day 120 ml (med pass 2.0 or nectar-thick equivalent supplement) dated 07/24/25 17:00 Swallow evaluation to be scheduled at Hospital dated 08/01/25. Video swallow evaluation, DX CVA (Diagnosis Cerebral Vascular Accident) dated 08/04/25. DC ST (Discontinue Speech Therapy) services dated 8/11/25. GI (Gastrointestinal) consult 09/24/25 @ (at) 09:00am please schedule transportation and escort dated 08/27/25.Speech Therapy Evaluation and Plan of Treatment document in part: Staff will feed patient with 1:1 assist, small bites, slow rate, one sip at a time in 90% of [NAME] (opportunities) to decrease signs and symptoms aspiration (Target 06/04/25). Baseline (05/22/25) difficulty feeding self, coughing observed. Current referral: Reason for referral: Patient referred to speech therapy due to observed coughing/gagging during meals with concerns patient needs increased assist.Speech Therapy Treatment Encounter Note(s) Date of Service: 07/15/25 Precautions Details: Feeder, dysarthric, mechanical soft. Practiced strategies for small bites, alteration of bites/sips, slow rate, increased time between bites. Educated nursing on downgrade and plan of treatment.Speech Therapy Evaluation and Plan of Treatment document in part: Baseline 07/15/25 In order to safely consume highest level of oral intake, patient will use bolus size modifications, general swallow techniques/precautions, effortful swallow, rate modification and alteration of liquid/solids and upright posture during meals 90% of opportunities in order to decrease risk for weight loss, efficiently consume diet of choice, minimize aspiration and safely consume highest level of oral intake. Current referral: Reason for referral/Current illness: Patient referred to speech therapy due to noted difficulties swallowing, with observed coughing and need to remove from oral cavity from certified nurse assistant. Concerns/complaints: Certified Nurse Assistant and nursing with concerns with decline and choking risk. Malnutrition risk: Malnutrition Risk Factors Identified as part of Assessment = Need for altered diet, Poor PO (oral) intake. Swallow Strategies: 1:1 assist, small bites/sips, slow rate.Speech Therapy Treatment Encounter Note(s) Date of Service: 08/19/25 Precautions Details: Feeder, dysarthric, mechanical soft, nectar thick liquids.Modified Barium Swallow Study dated 07/23/25 document in part: Primary referral diagnosis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 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 145510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Dysphagia. Clinical reason for referral: increased difficulty swallowing. Summary: Patient presents with a mild oral dysphagia and mild-moderate pharyngeal dysphagia. Swallow function declined as the study progressed: most likely due to muscular fatigue. Patient demonstrated trace silent aspiration of thin toward end of study with a liquid wash of solids. Question patient's ability to maintain adequate nutrition, as patient reported not eating very much at meals as well as reported weight loss. Given fatigue/decline in swallow function with exertion, patient may benefit from smaller meals with high calorie snacks between meals. Diet Recommendation: Solid soft and bite sized (Mechanical Soft). Liquid Mildly thick (nectar thick). Recommended swallow/feeding precautions to improve safety with PO intake: Care giver assist with feeding, No Straws, Supervision with oral intake 1:1. Swallow strategies should include: secondary swallow, alternate consistencies, no straws, patient should be upright in chair for all meals.On 08/26/25 at 12:36 PM R1 was observed in bed on a low air loss mattress with the setting of 160. Surveyor asked does she (R1) feed herself and R1 shook her head indicating no.On 08/26/25 at 01:14 PM R1 indicated yes when asked did the staff feed her and no, when asked did she like the food. R1 indicated yes when asked did she drink the juice and eat the grilled cheese sandwich. R1 indicated that her appetite is not good, she lost a lot of weight, and she drinks the supplements.On 08/28/25 12:22 PM Per telephone interview V14 (R1's Family Member) stated They called me yesterday at 06:16pm to let me know R1 lost 4 pounds. R1 is having difficulty swallowing liquids. I told them R1 does not like the food there. I was sending R1 food at least twice a week. I stay on top of them to make sure R1 is being fed. R1 has noticeable weight loss.On 08/27/25 at 12:31 PM V13 (Certified Nurse Assistant) was observed feeding R1 a tuna fish sandwich and red thickened juice. [NAME] beans, a banana, orange juice and a cup of thin lemonade was observed on the meal tray. R1 consumed 75% of the tuna fish sandwich. A large cup of water with no thickener and a straw was observed on the overbed table in front of R1. Restorative weighed R1 this morning. R1 will eats her food but it depends on what it is. Whatever R1 is able to eat she will eat.On 08/27/25 at 12:51 PM V12 (Registered Dietician) stated I have worked for the facility about a year, and I come see the resident once a week. R1 is someone who has been on my radar. R1 came in with diagnosis of failure to thrive and she stays in bed a lot. R1 has been losing weight and has a worsening swallowing disorder. R1 is working with speech therapy, updating preferences, ordered fortified cereal and liquid ensure supplement. The goal is to slow the weight loss and maintain the R1's weight. R1 was working with the speech therapist to see what diet is best for her. This is unplanned weight loss for R1. There is a potential for the development of wounds. The supplements would help prevent that from happening. On 08/27/25 at 02:30 PM Per telephone interview V18 (Nurse Practitioner) stated I was notified of R1's weight loss by speech therapy, and they did a video swallow evaluation. R1 has silent aspiration, and we recommended a gastric tube. We told R1's family she needed a gastric tube, and they said that they wanted a second opinion. I found someone at a Hospital and R1 has a follow-up appointment on 09/24/25. We started R1 on thicken liquids but R1 refuse. R1 is declining. On 06/16/225 R1 weighed 167.0 pounds, and I picked her up. R1 does not have a really good cough. The 6 pounds R1 lost in 12 days is water weight. That is my biggest complaint about the food, residents say it is awful. I spoke to the family myself. I peaked in on Friday and R1 was sleeping. On 08/08/25 I wrote a note. R1's weight loss is unavoidable. R1 really needs a gastric tube.On 08/27/25 at 02:05 PM Per telephone interview V15 (R1's Attending Physician) stated I was notified of R1's weight loss and they are doing nutritional support. I think they need to do a workup, CT (Computed Tomography) of the chest, an entire workup and try sending R1 to the hospital. The tests are normally done outpatient. I will have to probably try to get R1 admitted to the hospital. It is hard to say what the cause is of R1's weight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 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 145510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few loss, it can be thousands of causes, and it is not one test that can identify the weight loss. Surveyor informed V15 that R1 has had a weight loss of 54.5 pounds since her admission on [DATE]. V15 responded, that is a huge weight loss. Earlier it was not bought to my attention but recently it was brought to my attention in the last 2 months. This is alarming and I will address it right away.On 08/27/25 at 04:25 PM V20 (Contracted Speech Therapist) stated I have an outside contract and have worked here since November. I originally say R1 in January and February. R1 came from the hospital and had a decline in speech, slurred, was on thick liquids and was upgraded to thin liquids. At the end of May R1 was consulted for difficulty swallowing and coughing. There was no coughing or swallowing during being fed slow with the certified nurse assistant. In mid-July R1 was repeatedly coughing and there was a dramatic decline with R1's speech. R1's speech was more slurred, and it was difficult to understand. We did a down grade to a mech soft diet and downgrade to thick liquids on 07/23/25. R1's muscles got weaker, she had a trace aspiration and was unable to expel food from her airway. R1 would not be effectively getting it (food) out and had weak oral muscle skills. The plan was oral motor and pharyngeal exercises. I explained what we saw on video and our recommendation but R1does not like the soft food. R1refused the food in general and the option was soft food because of the risk of aspiration. The third option was a gastric tube so R1 could get the calories she needs if not eating. R1 does not want the gastric tube and wanted a second opinion. The interventions are small bites, small sips and if aspirating stop feeding. I educated the nurses, certified nurse assistants, explained to staff and family that R1 has a weak cough response. I called and told the family where we were at and saw R1 for 3 more sessions and education. I was not doing trials of thin liquids but would walk in R1's room and there would be thin liquids at the bedside. I would remove them and let the nurse know. R1 is not eating, and this is not sustainable for her. R1 would refuse the meals, and I got in touch with V18 (Nurse Practitioner) and asked was the gastric tube going to be inserted. It is up to the family to decide what the plan is going to be. That discussion was this month (August). R1 is refusing her food. The silent aspiration is just with the thin liquids which is why we recommended the nectar thick liquids. With solid foods R1 does gage and R1 is not to have any straws. I make recommendations and they are not followed through, this is frustrating. If R1 wants thin liquids for the quality-of-life R1 had to be a DNR (Do not Resuscitate) because she could end up with pneumonia and end up in the hospital. We recommended R1 be up in the chair when eating.On 08/27/25 at 03:48 PM V19 (Care Plan Coordinator) stated The care plan should be updated every 3 months, for newly admitted residents, within 24 hours and if there is a new problem that arises it should be updated within 24 hours. If there is a change in dietary the dietary should update the care plan. Sometimes I will oversee it, and it should be multidisciplinary. For weight loss also I started tracking when a care plan is updated and revised. Silent aspiration should have been updated in the care plan. The care plans are supposed to be person centered. There is nothing in R1's care plan. I will probably talk to R1's family about the silent aspiration and the refusal of the gastric tube placement.On 08/27/25 at 04:21 PM V1 (Administrator) presented the surveyor with a physician order and stated, this is R1's recommended calorie count, and I am giving extra education.On 08/28/25 V1 (Administrator) emailed the revised care plan. Focus: Nutrition/Aspiration. R1 is at risk for alteration in nutritional status related to an active therapeutic diet and mechanically altered texture. R1 was observed that she is potential for aspiration related to diagnosis Cerebral vascular Accident, Hemiplegia and Hemiparesis. Diagnosis Dysphagia Oropharyngeal Phase, Silent Aspiration. Wallow evaluation to be scheduled. 08/27/25 - 3day calorie count. Revision on 08/28/25. Goal: Resident will be free from signs and symptoms of dehydration or malnutrition. Resident will maintain stable weight to next review. Will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 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 145510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete be able to have no undetected incident of aspiration x 3 months. Date initiated 08/27/25. Interventions: Aspiration Precautions. Monitor for signs and symptoms of weight loss. Date initiated 08/27/24. 08/27/25 3 days calorie count. Date initiated 08/28/25. Monitor during mealtime, Keep head of bed elevated assist with ff (Free Fluid) swallowing strategies. Swallowing strategies should include secondary swallow, alternate consistencies, No Straws, R1 should be in upright position in chair for all meals, Registered Dietician Medical Doctor order. Monitor resident with difficulty swallowing, assess for signs of choking and/or aspiration. Provide thickened Nectar Thick liquids consistency. Date initiated 08/27/25. Other recommendations, R1/family education provided regarding study results and recommendations. Assess diet tolerance. Provide diet and supplements as ordered. Date initiated 08/27/25.Policy: Titled Care Plan revised 06/30/25 document in part: It is the policy of this facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. 5. These will be periodically reviewed and revised by a team of qualified person after each assessment. Event ID: Facility ID: 145510 If continuation sheet Page 5 of 5