Health inspection·December 31, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few had become unclear. V33 stated that R1's speech before the fall was clear. V33 stated that R1 was a huge fall risk because she kept trying to get out of bed and self-ambulate. V33 stated that he did not inform R1's doctor that R1 was restless and did not want to go to bed.On [DATE] at 9:50am V32 (CNA) stated that R1's bed alarm was on, but the bed alarm had a faint sound. V32 stated that R1's bed alarm needed a new battery and only maintenance could change the battery. V32 stated that the CNA before her had reported that she already informed everyone that R1's bed alarm was low and needed a battery. V32 stated that R1's bed alarm was on at the time of R1's fall, but it was too low for anyone to hear it.R1's care plan revision date [DATE] documents in part, R1 is a high risk for falls related to pain weakness and MUTL (multiple) MED (medical) condition. R1 will be free of minor or major injury RT (related to) an undetected incident of fall.Update upon return: Room closer to nurses' station, bed alarm, bed position in lowest position.R1's care plan revision date [DATE] documents in part, R1 is at risk for altered thought process related to chronic left SDH (subdural hematoma) . R1 will be free from any injury r/t (related to) accidents through the next review date. R1's needs will be anticipated. Call MD (medical doctor) for any changes in cognitive functioning and/or any changes in behavior.R1's Final Reportable Incident to state agency dated [DATE] documents in part, Final Investigation/Conclusion: Based on staff interview. On [DATE] approximately 10:30pm CNA noted resident wanting to get up verbalized that she does not want to miss her appointment and want to go home. CNA suggested to go to the washroom, resident responded no, diaper dry. CNA gotten resident up in wheelchair and situated by the nurses' station with bedside table in front of resident.Approximately 2:30am observed resident sleepy, instructed the CNA to take resident to her room and assist to bed. Resident was taken to her room, checked and diaper changed. 3:01am CNA observed resident sound asleep, bed in lowest position call light within reach: CNA stepped out of room to do her routine rounds. Approximately 3:10am both nurses at the nurse's station heard and responded to a thud sound: observed resident in a supine position on hallway floor in front of 212 just slightly across her room. Resident unable to relay what happened. [DATE] resident remains in the hospital at this time. R1's hospital records dated [DATE] documents in part, Chief complaint: Fall. Visit Diagnoses: Acute on chronic intracranial subdural hematoma, Intracranial hemorrhage, Brain herniation, Unresponsive, Fall. R1's hospital records dated [DATE] documents in part, Physical Exam: Constitutional: Patient is unresponsive with a Glasgow Coma Scale of 3. Respiratory Patient is intubated. General: She is in acute distress. R1's CT scan dated [DATE] documents in part, Findings and Impression: Large acute on chronic subdural hematoma along the right lateral convexity measures 1.8cm (centimeter) in thisness. Significant mass effect on the right cerebral hemisphere resulting in 9 mm (millimeter) of leftward midline shift and mild right uncal herniation. There is also considerable amount of acute hemorrhage throughout the cerebral cisterns. R1's hospital records dated [DATE] documents in part, Hospital Course: The patient is an [AGE] year old female with a history of hypertension with hypertensive heart disease with chronic HFpEF (Heart Failure with preserved ejection fraction), type II diet diabetes with nephropathy/CKD (chronic kidney disease) stage IV, history of TIA, asthma, dementia, and multiple recent presentations with falls with resultant subdural hematoma who again present after presumably mechanical fall when found unresponsive, and was note to have a large right acute on chronic subdural hematoma with cerebral edema and midline shift with uncal herniation. 1. Unwitnessed fall with acute on chronic right subdural hematoma with associated cerebral edema, midline shift, and right uncal herniation. The patient was initially admitted to the SICU (Surgical Intensive Care Unit) when CT head showed the above. Neurosurgery was consulted who advised nonoperative management due to overall poor prognosis of the injury. She was initially intubated for airway protection, and did require (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 2 of 4 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 12/31/2025 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete intermittent pressor support. Unfortunately, she did not improve, and palliative care was consulted. Family ultimately elected to proceed with palliative extubations and transition to comfort measures only. She is treated with a morphine drip for air hunger and/or pain. An order was placed to consult inpatient hospice, who reached out to the family, but inpatient hospice was not established prior to the patient expiring. The patient expired on [DATE] at 11:34pm. Facility's job description titled RN Floor Nurse dated [DATE] documents in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Registered Nurse plays a critical role in providing superior customer service and nursing care to all Guests and guests. The RN provides supervision of staff and will safeguard the health, safety and welfare of all Guests under their care by following applicable laws, regulation, and established nursing policies and procedures. Essential Functions: 9. Responsible for all nursing care of assigned Guest while on duty. Must notify appropriate persons if there is any significant change in a Guest's condition or any transfer to hospital. 10. Ensure that Guest care plans are being followed and assess each Guest's status in accord with their care plan. Facility's undated job description titled Certified Nursing Assistant documents in part, Job Summary: The primary purpose of your job position is to provide residents of this facility in you nursing unit with nursing and personal care under the supervision of a Charge Nurse, and to safeguard the health, safety , and welfare of all resident of the facility, in accordance with the facility's established policies and procedures and applicable laws and regulation, and the directions your supervisors, who include the Administrator, Director of Nursing, Assistant Director of Nursing, House Supervisor, Charge Nurse, Rehabilitation Director, and other members of the facility's management to whom such persons report, in order to assure that the highest degree of quality care is maintained at all times. Main Duties: P. Detect and report situations that have a high probability of causing accidents or injuries to residents and/or staff. U. Report all equipment malfunctions and breakdowns to the charge nurse as soon as possible and keep his/her informed of supply needs and equipment needing replacement. Facility's policy titled Fall Prevention Program Guidelines revised date [DATE] documents in part, Policy Statement: Fall prevention program guidelines shall be implemented to promote safety of all residents in the facility. This program shall include measures to determine the individual needs of each resident by assessing the risks for fall and the implementation of evidence-based prevention interventions. Procedure. 2. Safety interventions shall be initiated and implemented for each resident identified at risk for fall. 3. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. 7. An individualized evidence-based plan of care shall be created to reflect fall prevention interventions which could be but not limited to h. Residents shall be observed to ensure the resident is safely positioned in bed or chair. Provide care as assigned in accordance with the plan of care. k. May utilize personal alarms when appropriate such as bed alarms, chair alarms and motion sensor alarm and floor mat alarms.p. Ensure equipment is properly functioning and maintained. If malfunctioning, equipment must be removed immediately and reported to maintenance department for repair or replacement. Event ID: Facility ID: 145510 If continuation sheet Page 3 of 4 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 12/31/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to administer covid 19 vaccine to one resident (R5) that consented for the covid 19 vaccine. The facility also failed to document the administration or declination of covid 19 vaccine for the same resident. This failure affected one resident (R5) in a sample of four residents reviewed for covid 19 vaccine administration. R5 admitted to facility on 11/17/2025 with diagnosis that documents in part; Cerebral infarction, hyperlipidemia, essential hypertension, chronic atrial fibrillation, insomnia, protein calorie malnutrition, covid 19 (12/1/25).On 12/29/25 at 3:15pm, V2 (Director of Nursing) stated that she expects the infection control nurse to obtain consents for resident vaccinations and schedule a vaccine clinic to ensure that vaccinations are administered and recorded in the immunization tab in chart.On 12/30/25 at 1:05 pm, V19 (family member of R5) stated that he did give consent for R5 to receive the covid 19 vaccine on 11/18/2025 and that he wanted R5 to have the covid vaccine administered.On 12/30/25 at 09:45 am, V30 (Infection Control Nurse/LPN) stated the covid outbreak started 11/23/25 which was a Sunday and we started testing based on contact tracing with guidance from Chicago Department of Public Health (CDPH), it was one case on 2nd floor and one case on the 5th floor. By 11/26/25 we had so many cases around 18 that CDPH stated to begin unit base testing. One of our staff aides tested positive who worked directly with R5 on 11/28/25, this was discovered thru contact tracing. V30 stated the purpose of consents and declination forms is to ensure that residents and staff are educated on benefits and risk of vaccines. I feel it is important for residents and staff to sign the consent and declination forms and also receive their vaccine if they consent to be vaccinated. Currently we have two residents that are on isolation for covid 19 in the facility.Review of facility contact tracing log for residents displays that R5 tested positive for Covid 19 on 12/1/25 and is no longer a resident in the facility.Review of facility policy titled Infection prevention control with revision date of 6/30/25 documents in part: Policy statement; the facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for the identified infection.;29.) The facility shall comply with infection control recommendations provided by the IDPH or certified local health department, including, but not limited to, testing plans, infection control assessments, training or other measures designed to reduce infection rates and disease outbreaks. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145510 If continuation sheet Page 4 of 4