Health inspection·March 4, 2021

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to properly dispose of debris and loose medications in the medication cart, failed to ensure that medications are stored with proper label, and failed to remove expired medications from the medication cart. This failure has the potential to affect all 132 residents currently receiving medications from the facility. Findings include: On 03/02/21 at 10:45AM, review of the 1 medication cart and 1 medication room with V18 (RN) and noted 1 box of glycerin suppository with an expiration date of 10/2020,1 ophthalmic solution for R116 with an expiration date of 2/5/2021, 10 loose pills of different colors and sizes, 1 half pill and 1 lancet. V18 was unable to identify the pills and not sure if the lancet was used or not. On 3/2/2021 at 11:00AM, checked one medication cart in the Hope section of the facility with V19 (RN) and noted one open insulin bottle with an open date but no discard date, 1 bottle of fleet Enema with an expiration date of January 2021 and 3 loose pills of various shapes and colors. There was also a shortage in the narcotic count for one resident, which V19 stated, she had given to the resident but forgot to sign it out. The cart was also missing the verification sheet for narcotic count by nurses for the month of March. Surveyor presented V19 with this observation and asked her how she verified the narcotic count with the outgoing nurse if there is no signature sheet, V19 said, It was here this morning, maybe the night shift nurse pulled it out, I will try to find it. Document presented by V1 (Administrator) titled Medication Storage and Labeling with a revision date of 8/5/2020 states that it is the facility's policy to comply with federal regulations in storage and labeling medications. Under procedures, item #3 states that medications will be stored safely under appropriate environmental controls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145667 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 145667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Park Ridge 1601 North Western Avenue Park Ridge, IL 60068 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician order for resident to be on NPO (Nothing by Mouth) status by continuing to provide a resident with an oral food diet. This failure affected one resident (R117) reviewed for therapeutic diets. Findings include: R117 is a [AGE] year old female who was originally admitted to the facility on [DATE], with past medical history including, but not limited to cerebral infarction due to unspecified occlusion or stenosis of right middle artery, Hemiparesis and Hemiplegia following cerebral infarction affecting left dominant side, dysphagia, gastrostomy status, etc. R117 was sent to the hospital on 2/23/2021 and was readmitted to the facility on [DATE], a health status note dated 2/26/2021 at 19:52 reads; Hospital called to clarify previous diet order. Patient is to remain NPO until further evaluation by speech, continue tube feeding as ordered. Nurse's admission summary dated [DATE] @21:40 reads; resident is on NPO, peg tube in place, Osmolite 1.5 50cc/hr., and 225ml free water flush every 6 hours. Nutrition/Dietary note dated 2/28/2021 at 20:19 reads in part, resident returned from hospital with an NPO diet order. G-tube feeding is her sole source of nutrition ---------------, resident was previously on dual feedings, RD to adjust tube feeding as appropriate pending SPL follow up. Physician Order Summary (POS) dated 2/24/2021 has a dietary order of enteral feed, every shift osmolite 1.5 at 50ml/hour, there is no physician order for an oral diet in resident's medical record. The POS further reads, Speech therapy evaluate and treat, patient is NPO till evaluated by speech. Records received from the dietary department shows that resident has received 17 oral meals from 2/26/2021 to 3/3/2021. On 03/01/21 at 11:39AM, R117 was observed in her room, awake and alert but nonverbal, able to nods yes or no to questions. Resident on G-Tube feeding with Osmolite 1.5 at 50ml/hr. On 3/2/2021 at 11:55AM, resident was observed again receiving G-tube feeding, but there was a lunch tray by the bedside. Surveyor asked resident if she receive oral diet and she nodded yes. On 3/3/2021 at 12:02PM, resident was observed again with a lunch tray and V10 (C.N.A) was in the room feeding her with a pureed diet, resident also had a carton of milk on tray. Surveyor asked staff if resident is on thickened liquid, V10 said no, just regular liquid. At 12:15PM, V16 (LPN), the assigned nurse for R117 stated that resident receives oral diet. Surveyor presented the fact that resident's diet order in her medical record is nothing by mouth, V16 reviewed the order with surveyor and stated, I cannot find an order for an oral diet, and I don't know why she is receiving it. 03/03/21 at 12:37PM, V2 (DON) stated that prior to hospitalization, R117 was on G-Tube. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145667 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 145667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Park Ridge 1601 North Western Avenue Park Ridge, IL 60068 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interview, and record review, the facility failed to properly monitor the dishwashing machine to ensure correct functioning, failed to follow their policy to maintain the cleanliness and sanitation of the kitchen and food service equipment, and failed to follow their policy and procedures on dented cans. This failure applies to 132 residents currently in the facility. Findings include: On 03/01/21 11:27 AM Observed multiple 6 pound cans with dents at the lip area, ranging in size from a small finger width to multiple finger width, in the dry storage area stocked with non dented cans. V14 (Dietary Manager) stated cans are considered dented if the top of the can is raised and bacteria can be observed growing inside the can. V14 stated dented cans are kept in her office and returned to the vendor. Six pound can of tropical fruit with dented lip area, sitting on the sink in the kitchen , with 2 other 6 pound cans of tropical salad for preparation to be served for the dinner meal. V15 (Dietary Aide/Dishwasher) stated he does not use temperature testing strips to monitor the dishwashing machine temps and relies on the temperature gauges. V14 (Dietary Manager) stated temperature testing strips are not used to monitor the dish machine's temperatures unless necessary and relies on the temperature gauges. V14 stated the functioning of the temperature gauges and overall functioning is determined by observations from staff who are familiar with how the machine works, such as when staff may notice a change in the sound of the dish machine. V14 stated the functioning of the dish machines temperature gauges and overall functioning may also be determined based on if the dishes do not appear clean or feel warm after being washed. Observed 2 food collection carts that contained food and beverage items collected from the residents rooms during lunch were extremely soiled. V14 (Dietary Manager) and V22(Dietitian) acknowledged the food collection were heavily soiled and should be clean when in use. V14 stated the food collection carts needed to be replaced as well due to being worn which causes them to appear unclean. Observed ceiling in kitchen to have food spatter and cracked paint in various areas. Observed the tile grout on the floor throughout the kitchen to have significant buildup of food and debris. V14 stated ceiling in the dry storage area is also extremely soiled. V14 stated the ceilings in the kitchen and dry storage area needed to be cleaned and the floor regrouted to address the buildup to ensure the kitchen is clean and sanitary. V22(Dietitian) stated the CCHO meals are prepared for diabetic residents and intended to maintain consistent blood sugar levels. V22 stated CCHO meals are modified if necessary such as if a breaded meat is being served for a meal the CCHO meat will be replaced with a non breaded grilled meat. V22 stated if the residents physician requires a more restrictive diet the kitchen will follow the doctors orders for that resident and modify their meals accordingly. The facility's kitchen policy received 03/03/21 states: Cans with dents you can lay a finger to should be returned and not used. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145667 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 145667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Park Ridge 1601 North Western Avenue Park Ridge, IL 60068 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 0812 Dented cans will be returned to the food company and will not be used prior to expiration. Level of Harm - Minimal harm or potential for actual harm Food trays should be clean and in good condition. Kitchen should be kept clean in general. Residents Affected - Many The facility's dinner menu for Tuesday 03/02/2021 lists tropical fruit cup. The operational requirements for the dishwasher received 03/03/21 states: Minimum washing temperature is 150°, the pumped rinse tank minimum temperature is 160°, and the minimum final sanitizing rinse temperature is 180°. The facility did not have a dishwasher temperature log that included temperature testing strips and could not provide evidence of any other method for determining if the dishwashing machine is functioning properly during the time of the survey. The facility did not provide a cleaning schedule for the kitchen as requested 03/03/21 at 12:15PM. The facility's list of residents who receive nothing by mouth dated 03/03/21 lists 8 residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145667 If continuation sheet Page 5 of 5