Health inspection·June 25, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some No, it wasn't abusive, that he wouldn't stop talking. R7 said CNAs are not instructed to listen to the patient. It's their way or not done. R7' facility assessment dated [DATE] shows she has moderate cognitive impairment and does not have behaviors. 6. On 6/23/24 at 12:28PM, R9 (R7's roommate) said, Staff can be abrupt at times. Are they having a bad day, I don't know. Are they doing anything bad to me? No, but they can be harsh. R9 said she didn't want to say anything bad about anyone. R9 said, I don't want them to mad to me. I'm here for the long haul. R9 said she does not think it's abusive when they are abrupt but some of them could find out more about the patient they are caring for. R9 said, This would help the patient and them get along better. There are so many new girls. Like a sheet about the patient that says what they like would be helpful. R9 said it's hard, and it makes her feel like they don't care about her. R9's facility assessment dated [DATE] shows she is cognitively intact, has no behaviors, and is dependent on staff for toileting and personal hygiene. On 6/23/24 at 12:38PM, V27 (Nurse Supervisor) said asking residents their preferences, ensuring privacy, and addressing questions and concerns would be examples of treating residents with dignity. How staff speak and interact with residents is part of treating residents with dignity. On 6/23/24 at 1:14PM V1 (Administrator) said the expectation is to treat residents with dignity and respect. On 6/24/24 at 1:14PM, V2 (Director of Nursing) said everyone should be treated with dignity. Their choices should be respected, and privacy provided. Yes, how staff communicate with residents is part of dignity. We always train staff to let the residents know what they are doing and to communicate with them. The facility Privacy and Dignity Policy, revised on 6/6/24 shows: It is the facility's policy to ensure that resident's privacy and dignity is respected by staff at all times. 5. Residents will not be addressed in an undignified manner by staff at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145607 If continuation sheet Page 2 of 6 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 145607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Palos Heights 7850 West College Drive Palos Heights, IL 60463 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 7 residents (R2) reviewed for abuse in the sample of 9. The findings include: R2's facility assessment dated [DATE] shows she is cognitively intact, does not have behaviors, and is dependent on staff for toileting hygiene. This assessment shows R2 needs partial/moderate assistance from staff rolling side to side in bed (helper does less than half the effort) and is dependent on staff for transfers in and out of the bed. R2's admission record printed 6/23/24 shows diagnoses to include: major depressive disorder, malignant neoplasm of the colon, generalized anxiety disorder, morbid obesity, sciatica, history of TIA (cerebral infarct), disc degeneration, rheumatoid arthritis, and bilateral hearing loss. R2's Physician Order Set printed 6/23/24 shows an order for alprazolam 0.5mg every 8 hours as needed for anxiety. Hydrocodone-acetaminophen 7.5/325mg (narcotic pain medication), give one tablet by mouth at bedtime for pain, and Hydrocodone-acetaminophen 7.5/325mg 1 tablet every 6 hours as needed for moderate to severe pain. R2's care plan reviewed on 6/11/24 shows, resident requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). Interventions include: [R2] uses half siderails to assist with bed mobility. Staff is to assist with bed mobility as needed .encourage participation in ADL's . R2's Abuse Report Final Form dated 5/1/24 shows, Resident is alert and oriented x3, able to make her needs known, and BIMS (Brief Interview for Mental Status) score is 13/15 (cognitively intact). This form shows on 4/25/24 [R2] reported to [V9-Nursing Supervisor] that her CNA that evening was rough when providing ADL care .Agency CNA was immediately sent home and suspended from working the facility, pending the outcome of the investigation. Full body assessment completed. No injuries noted. Responsible party and MD made aware of the allegation .Wellness checks continued. No concerns or signs of distress noted. Upon being re-interviewed, [R2] stated, that was no big deal. I already forgot about it'. She said the CNA was moving too quickly when providing care. She didn't hurt her. She just wasn't very pleasant or patient. She stated that she feels safe and comfortable in the facility. She feels the CNA would benefit from further customer service education .the CNA was interviewed. She stated that she was not rough when providing care to [R2]. She also added that she did not turn the resident too quickly. She provided the care as requested. [R2] did not tell her that she was being rough .Based on the interviews and clinical record review, abuse cannot be substantiated. [R2] stated that is 'no big deal' and she feels safe and comfortable in the facility .Additional customer service education will be provided should the CNA return to the facility . R2's Post Alteration/Alleged Abuse assessment dated [DATE] day 1/5 shows, did the resident sustain any physical injury after the incident- no. Psychosocial harm- did the resident exhibit any of the following? Check all that apply - n. None of the above. This assessment was completed day 2/5, 3/5,4/5, and 5/5. None of the above was checked all 5 days under Psychosocial Harm. R2's nurse progress note dated 4/25/24 at 9:53PM, authored by V9 shows, body audit completed. No new bruises, skin tears, or areas of redness noted. Resident with existing R buttock wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145607 If continuation sheet Page 3 of 6 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 145607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Palos Heights 7850 West College Drive Palos Heights, IL 60463 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's 4/26/24 at 2:30PM Social Service Note shows well-being check. Met with resident. She verbalized her thoughts and feeling about altercation. Reassured her that the CNA wouldn't be providing her care any longer. Resident expressed relief . R2's 5/1/24 at 2:34PM Social Service shows, well-being check with Admin. Resident reports that she has moved on from allegation I forgot all about it. Reports no new concerns. Feels safe. Resident thanked this writer and Admin . V9's undated, unsigned facility statement identified as being obtained by phone, shows the nurse [V30] made her aware of a concern R2 had with her CNA being rough. [R2] told me the CNA rolled her on her side to change her but was moving very quickly. She seemed like she was in a hurry and wasn't very pleasant. I did a head-to-to assessment and did not find any injuries, bruising, or skin alterations. CNA was sent home immediately pending the outcome of the investigation. V30's undated unsigned statement provided by the facility shows a phone interview was conducted. V30's statement shows [R2] informed her the CNA was rough when providing ADL care. Body assessment completed. No injuries noted. Denied pain. V25's (R2's CNA) unsigned, undated statement provided by the facility shows she was interviewed by phone. The statement states I went to change [R2], per her request. Her leg kept moving and I had to keep readjusting it. I wasn't rough at any point. She didn't tell me that I hurt her. R2's undated statement, initialed by the resident shows I already forgot all about it. It wasn't a big deal. She didn't hurt me. She was moving too fast and seemed like she didn't want to be here. I don't think she did anything intentionally wrong. My leg kept slipping and she needed to readjust it. I've never had her before. She just didn't seem very pleasant. I feel safe and comfortable here. On 6/23/24 at 10:05AM, R2 was resting in bed with a gown on. R2 had a black, soft brace to her right wrist. R2 had the bottom of her bed elevated, and her feet were raised off the bed. R2 had pillows positioned under each arm, and behind her head. R2 said weeks ago she had a problem with a staff member. She had never seen her before. When I asked her to be careful, she said real rough, do you want to be changed or not?. She was shoving me side to side like a piece of meat. I was kind of blue on my arm. She was like no other. I said you don't like your job and she said, no I don't. R2 said, no she did not think it was abusive, she just did not know her own strength. R2 said she didn't know if she meant to hurt her. It was like she was mad, shoving me around. It was really hurting me, she wouldn't stop. R2 said she is not easy to help, and she can't help them. She was rolling me in bed back and forth, and she kept bouncing me up and down. R2 said she had a couple bruises and pointed to the top of her right arm. R2 said she was knocked around onto the rail and pointed to the right-side rail. R2 had bilateral quarter side rails up. I asked her to stop, and she kept saying, do you want to be changed or not?. Like if I wasn't happy, she would just leave. On 6/23/24 at 2:32PM, R2 said, Staff here are both good and bad. It depends on who you get. Some are just here for a paycheck and will tell you they don't like their job. Do you feel safe here? Oh yeah I feel safe. On 6/23/24 at 10:21AM, V29 (Registered Nurse) said if a resident asks an aide to stop during care, they should stop and let the nurse know the patient does not want care from them. V29 said she would inform the Director of Nursing right away if a resident reported a staff member was rough during care. On 6/23/24 at 11:05AM, V30 (CNA) said R2 is alert and oriented and lets you know what she wants and doesn't want. R2 is a 2 person assist and is able to help a little bit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145607 If continuation sheet Page 4 of 6 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 145607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Palos Heights 7850 West College Drive Palos Heights, IL 60463 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/23/24 at 1:14PM V1 (Administrator) said she is the abuse prevention coordinator. V1 said she talked with R2 today. V1 said, She told me the same thing she did before, that it was no big deal, and the CNA was probably having a bad day. She wouldn't say it was abuse, could she have done it differently, yes. V1 said, I don't think I need to do a new investigation; her responses were consistent (with the first interview). V1 said the nursing supervisor did the initial interview and she (V1) followed up the next day with the resident. V1 said they gave the CNA a DNR- do not return notice. V1 said rough care would fall under physical abuse. The expectation is to treat residents with dignity and respect. On 6/23/24 at 1:45PM, V9 (Nursing Supervisor) said she was working the night R2 made an allegation against a CNA. V9 said R2 said the CNA was rude to her and she might have said the CNA was rough with her. V9 said she does not remember all the details. R2 was not crying or anything. V9 said, She is always like this. She gets upset easily with everyone. V9 said she sent the CNA home immediately. V9 said R2 did not report any injury. V9 said she completed the body assessment and didn't see anything on her. V9 said she does not remember if R2 gave her any specific details. V9 said, I don't think it was really anything significant because I would remember that. V9 said she thinks R2 told the nurse, and the nurse notified her of the allegation. On 6/23/23 at 2:15PM, V30 (LPN) said R2 told her, to the best of her recollection, the CNA was rough when she turned R2. V30 said, I asked her if she pushed her and she said she didn't know, she was just rough. It was an agency CNA. V30 did not recall working with her before, and she remembers she was tall. V30 reported the allegation immediately to her supervisor and the CNA was sent home. V30 said, I did go back and tell R2 the CNA was no longer at the facility. I checked her, and I didn't see any redness, skin alterations, no bruising, or scratches. I told her she looked ok. I think I asked her if she was in pain, I may have given her a pain med, I think she takes Norco. Oh, ya she [R2] was upset which is why I called the supervisor. R2 was flustered, like her face was scrunched up and she verbalized she was upset. R2 said she pushed me rough; she was rough when she turned me over. I asked if she turned her with her hand or used the draw sheet and she said I don't know, she was just rough. The CNA completely denied it. She said I didn't push her rough or rough house her. She said she pulled the draw sheet towards her to turn her over and clean her. No other residents had complaints that night about care. To my knowledge, yes, the CNA was caring for her by herself. Not sure if she is a 1 or 2 person assist. On 6/23/24 at 2:28PM, V26 (Social Service Director) said she follows up with patients after an allegation is made and would make a recommendation if needed. V26 said she met with R2 after the allegation was made. V26 said R2 thought the staff was rough. V26 said she didn't recall her exact words, but she [V26] thinks they were moving her [R2]. V26 said she recently met with R2 and discussed hearing aids. V26 said, no R2 does not have any ongoing concerns with the CNA and what happened. V26 said, She seems ok now and has not brought it up again and I have met with her since then. V26 said if a resident reported to her an allegation of rough care, she would report it immediately to the administrator. On 6/24/24 at 1:14PM, V2 (Director of Nursing) said if a patient has concerns regarding care, if a CNA or nurse was rough, they would investigate to see if it was intentional, and if the resident was in danger. V2 said they would interview the patient and if it was determined the rough handling was intentional, yes, it would be abuse. If a resident asks a CNA to stop providing care, then the CNA needs to stop. The facility Policy Abuse and Neglect effective 6/6/24 shows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145607 If continuation sheet Page 5 of 6 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 145607 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Palos Heights 7850 West College Drive Palos Heights, IL 60463 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 0600 Level of Harm - Minimal harm or potential for actual harm It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. Abuse is the willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Residents Affected - Few Types of abuse: 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples .roughly handling. 2. Verbal Abuse includes but is not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc. 3. Mental abuse includes but is not limited to humiliation, harassment, threat of bodily harm, punishment, isolation, or deprivation to provoke fear or shame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145607 If continuation sheet Page 6 of 6