Inspection·September 7, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the edge of his bed eating lunch alone, wearing socks. R1's call light was tangled on the floor underneath the head of bed. Water pitcher, tissue box or urinal was not in reach. R1 stood up and walked around in the room the bed alarm did not sound off. V14 stated, I am an agency nurse and work here often. I am familiar with R1. He [R1] is a high fall risk and a frequent fall resident. Nursing staff provides R1 with frequent monitoring and supervision. R1 needs stay in his room because he has a cough. R1 is negative for Covid and influenza, but in nurse-to-nurse report, R1 needs to stay in his room. R1 is not on isolation. R1's call light in tangled up on the floor, its supposed to be in reach at all times. I think the bed alarm is not on, because it did not sound when R1 stood up off the bed. I did not turn the bed alarm off, but the alarm needs to be on. R1 does not have any bruises now, but he had some face and shoulder bruises about a month ago from a fall.On 9/6/25 at 12:22 PM, V16 [Activity Assistant] stated, I am familiar with R1. He has not participated in activities for a couple of days because he must stay in his room due to coughing. R1 enjoys sensory, touching, music, exercise, and coloring. Typically, when is resident is on isolation I would go and complete one-to-one activities in their room. R1 has not had one-to-one activity in his room, but I can start today.On 9/6/25 at 2:33 PM, V7 [Licensed Practical Nurse] stated, R1 is alert but very confused, and requires constant supervision and monitoring due to wandering and frequent falls. On 8/22/25, R1's family member [V4] requested R1 to be sent out to the hospital due to bruising on his forehead and shoulder from a previous fall. All test results were negative for fractures. On 8/27/25 R1 returned back to the facility around 1:00 PM. Later around 3PM, R1 was in the dining room, I guess he tried to sit on another resident's lap, but he missed the chair and fell on his buttocks. R1 was alert when he came back from the hospital, but when I fell, he was unconscious for approximately five minutes. R1 was sent to the emergency room, all tests were negative for injuries. Some fall interventions for R1 are low bed, call light in reach, bed alarm, and activities. I try to keep my eyes on him at all times, but I also have other resident to monitor.On 9/6/25 at 3:00 PM, V6 [Nurse Practitioner] stated, I am R1's Nurse Practitioner, and I assessed R1 on 8/22/25. R1 had old bruises colored yellowish on his forehead and shoulder, all skin was intact from a previous fall on 8/15/25. R1 is a wander with a diagnosis of dementia. R1 has experience several falls, but with no major injuries. R1 is not on isolation. R1 returned from the hospital with a cough, R1 was negative for Covid and Flu, but positive for common cold. R1 is able to leave his room, staff encourages R1 to wear a face mask when possible. R1 needs close supervision and monitoring and re-direction to prevent further falls.On 9/6/25 at 3:50 PM, V2 [Director of Nursing] stated, I took over the fall coordinator responsibilities, until I find a replacement for the position. R1 is alert but confused and has a diagnosis of dementia. R1 has fallen 11 times from 3/25 to 9/25 with no major injuries. Some of R1 falls required him to be evaluated at the hospital, but each time the results were negative for fractures or injuries.On 8/21/25 R1's family member [V4] requested R1 to be sent to the hospital emergency room due to R1 having an old bruise on his face and shoulder from a previous fall on 8/15/25. R1 was doing well. R1 did not voice nor have any signs or symptoms dizziness, headaches, or difficulty moving. R1 only went to the hospital per V4's request. There was discoloration on his forehead and shoulder, no open areas, no bleeding.If the resident falls one time, they are automatically a high fall risk. For every fall there should be an individualized intervention in place to their care plan, hopefully preventing another fall from occurring. The nursing staff need to ensure they follow each resident's individualize care plan. R1's care plan fall interventions are to keep all needed items like water pitcher, tissue box, urinal within reach, provide a safe environment, and a working and reachable call light, Engage R1 in activities that interest him during the day, R1 to assisted putting on appropriate footwear (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 2 of 3 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 09/07/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete when out of bed in the morning, and bed alarm. All R1's fall interventions should be in place and followed to help prevent further falls. R1 is not on isolation and does not have to stay in his room, and should be allowed to participate in activities, as it is part of R1's care plan as a fall intervention. However, if resident is on isolation and activity staff would go into their room to engage the resident with one-to-one activities. The bed alarm purpose to alert nursing staff that the resident has gotten off the pad, to prevent a fall. If the bed alarm is not turned on, the resident could get up and staff would not be alerted. Nurses should check the bed and chair alarms at the start of their shifts. All residents should have their call light and frequently used items in reach. R1 requires close monitoring and supervision. R1 needs one-to- one supervision, we are having a meeting with R1's family to discuss options.Policy documented in part:Fall Occurrence dated 6/30/25.It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are re-evaluated and revised as necessary. If a resident had fallen, the resident is automatically considered a high fall risk.The nurse may immediately start interventions to address falls in the unit, even prior to the fall's coordinator investigation. Ultimately, the fall coordinator may change the interventions provided by the nurse if the fall coordinator investigation identifies a more appropriate intervention for the individual fall. The fall coordinator will add the intervention to the resident's care plan.The fall interventions will be re-evaluated and] revised as necessary. Event ID: Facility ID: 145510 If continuation sheet Page 3 of 3