Health inspection·January 5, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the necessary follow up is done and that the pacemakers are in good working condition. This deficiency affects one (R97) of one resident in the sample of 28 reviewed for Professional Standards of Practice. Residents Affected - Few Findings include: On 1/2/24 at 12:20PM, observed R97 sitting on bed in her room. She is alert and oriented, speaks limited English language. She showed and pointed her pacemaker on the left side of her chest. R97 was admitted on [DATE] with diagnoses listed in part but not limited to Presence of Cardiac Pacemaker, Chronic Atrial Fibrillation, Acute on Chronic Diastolic (Congestive) Heart Failure. Active Physician Order Sheet (POS) does not indicate order for pacemaker monitoring. On 1/3/24 at 11:14AM, V19 Agency Nurse said that she is not aware that R97 has pacemaker. She said, it was not endorsed to her, and it was not written in the 24 hours report/endorsement. Surveyor and V19 went to R97 and observed pacemaker chest on the left side of her chest. R97 speaks limited English Language. Review R97's medical record with V19. Found no orders written in POS for pacemaker check /monitoring. V19 stated that pacemaker monitoring order should be written in POS upon admission. On 1/3/24 at 12:01PM, Informed V2 DON (Director of Nursing) of above observation and concern. V2 stated that resident on pacemaker should have a physician order written for Pacemaker monitoring/follow up in her chart. Requested for policy on Pacemaker management. Facility's policy on Pacemakers Revised 7/28/23 indicates: Policy Statement: It is the policy of the facility to ensure that the care for residents with pacemakers is provided in each facility according to current standards of practice. The facility shall also ensure that the necessary follow up is done to ensure that the pacemakers are in good working condition. Pacemakers check and interrogation can be done at the cardiologist's office, or it can be done remotely at the facility. Procedures: 1. Residents who have pacemakers must have the following documented in their medical record: a. The date of insertion, physician who inserted it and the place where it was inserted. b. Make, model and serial number of the pacemaker. c. Orders in the POS for how often the pacemaker is to be checked and by whom (physician office, cardiology clinic by telephone etc.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 2 of 11 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a means of communication for resident who has language barrier. This deficiency affects one (R97) of two residents in the sample of 28 reviewed for Communication. Residents Affected - Few Findings include: On 1/2/24 at 12:20PM, observed R97 sitting on bed in her room. She is alert and oriented but speaks and understand limited English language. She will make hand/body gestures to communicate but still difficult to understand. No communication board found in the room. On 1/3/24 at 11:14AM, V19 Agency Nurse stated that she is the assigned nurse to R97. V19 stated that R97 speaks mainly Polish Language with limited English Language. V19 stated that she did not know that R97 has a communication barrier. V19 stated she did not assess her. V19 stated she just gave R97 her morning medications. V19 state there is no communication board in R97's room. V19 stated she does not know how to use the translation service line posted at R97's bedroom wall. V19 stated that she is not aware that she has to use the translation service line or the communication board when communicating with R97. On 1/3/24 at 12:01PM, V2 Director of Nursing informed of above observation. V2 stated that they used the language interpreter communication line to communicate with R97 that was posted in her room. On 1/3/24 at 2:50PM, V1 Administrator stated that they used the communication board for resident with language barrier. On 1/5/24 at 8:56AM, V27 Registered Nurse stated that she is the nurse who worked with R97 on 1/1/23 11-7 shift. V27 stated that R97 had an unwitnessed fall on 1/2/24 around 4:00AM, she was found sitting on the floor. V27 stated that she did not use the translator service line that was posted by the R97's bedroom wall when she assessed R97. V27 stated she is not aware that she has language barrier. V27 stated she did not see communication board in R97's room. R97 is admitted on [DATE] with diagnosis listed in part but not limited to Acute/Chronic Congestive heart failure. R97s care plan indicates: Communication-foreign language. She speaks Polish and can speak and understand limited English. Goal: She will communicate through assistance from a translator. Intervention: Involve a translator to aid in communication. Utilize appropriate augmentative devices, i.e., communication board. Facility's policy on Communication Board Revised 7/27/23 indicates: Policy Statement: It is the policy of this facility to utilize a communication board/device to help augment method and strategy for communication between the facility personnel and resident either due to language barrier and or communication impairments e.g., aphasia. Procedure: 1. The communication board/device shall be provided to the resident presenting language barrier and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 3 of 11 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 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 0676 or impairments in communication by activity/social service department on date of admission. Level of Harm - Minimal harm or potential for actual harm 3. The indicators for the use of communication board must be relayed to the resident's direct care providers and appropriate disciplines by the facility. Residents Affected - Few 5. The communication board must be always readily accessible to the resident. In addition, device must be available for use by the resident in the resident's room, during therapy and medical appointments. Facility's Quick reference guide for Language line solutions indicates: How to access an interpreter: When receiving a call: 1. Use your phone's conference feature to place the Limited English Proficient (LEP) speaker on conference/hold 2. Dial [PHONE NUMBER] 3. Provide your client 1D# 228198 4. Select the language you need a. Press 1 for Spanish b Press 2 for all other languages and state the name of the language you need ** Press) for agent assistance of you do not know the language You will be connected to an interpreter who will provide his/her name and ID number 5. Brief the interpreter. Summarize what you wish to accomplish and provide any special instructions. 6. Add the LEP onto the call 7. Say End of call to the interpreter when your call is completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 4 of 11 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review the facility failed to ensure effective interventions were in place to reduce the risk of falls for one of three residents' (R91) reviewed for falls in a sample of 28. Residents Affected - Few Findings Include: On 1/3/2024 at 12:10pm R91 was observed up in wheelchair in the dining room with chair alarm not turned on. On 1/3/2024 at 12:15pm V23(Licensed Practical Nurse-LPN) stated R91 is a fall risk and the chair alarm should be on whenever the resident is up in the chair. On 1/3/2024 at 12:17pm V24(Certified Nursing Assistant-CNA) state the alarm should be turned on and then proceeded to turn on the chair alarm. On 1/3/2024 at 12:30pm V2(Director of Nursing-DON) said R91 is a fall risk, and the chair alarm should be turned on if she is in the chair. An Order summary report dated 1/3/2024 indicated that R91 has a history of falling, an order that was placed on the order sheet on 1/3/2024 to check bed/chair alarm is working properly every shift. R91s care-plan dated 10/17/2023 indicates a bed/chair alarm. Facility Policy: Fall Occurrence Revised 7/17/2023. Policy Statement 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 reevaluated and revised as necessary. Procedure: 2. Those identified as high risk for falls will be provided fall interventions. An interim fall care plan may be started but a falls care plan is necessary and required after the state required MDS was done. 3. If a resident had fallen, the resident is automatically considered as high risk for falls. Therefore, the nurse does not have to fill out the fall risk assessment to determine if the resident is high risk for falls or not, after the resident had fallen. 6. The nurse may immediately start interventions to address falls in the unit, even prior to the falls coordinator's investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 5 of 11 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow physician order of checking bladder scan every shift for resident who has urinary retention. This deficiency affects one (R72) of one resident in the sample of 28 reviewed Bladder Management program. Findings include: On 1/2/24 at 11:50AM, observed R72 sitting in wheelchair in her room. She is alert and oriented, able to verbalize her needs to staff. R72 stated that she has a problem urinating, she has problem letting the urine out. R72 stated that it has been going on for a while. R72 was admitted on [DATE] with diagnoses listed in part but not limited to Neuromuscular dysfunction of bladder, Chronic Kidney Disease Stage 3. R72s Active physician order indicates: Bladder scan every shift dated 12/7/23. On 1/3/24 at 11:48AM, observed R72 sitting in wheelchair in her room with V16 RN (Registered Nurse). R72 stated that she has a hard time urinating. R72 added, like yesterday, I did not urinate for the whole day not until the evening. On 1/3/24 at 11:57AM, V16 RN stated that he worked with R72 yesterday 7-3 shift, but R72 did not complain to him and there was no endorsement that she has problem with urinating. Reviewed R72's medical records with V16 RN. Informed V16 that R72 has bladder scan every shift ordered since 12/7/23. V16 stated that they are not doing the bladder scan to R72. It was not written in the TAR (Treatment Administration Record) nor in monitoring record. V16 stated that V17 Agency Nurse who worked on the day did not carry out properly the physician order. R72's chart indicated that bladder scan every shift was not implemented since it was ordered on 12/7/23. V16 stated that the Bladder scan is to check for urinary retention. R72 has the diagnosis of neurogenic bladder and history of urinary retention. On 1/3/24 at 12:01PM, informed V2 Director of Nursing (DON) of above observations and concern. V2 DON stated that they are expected to follow and implement physician orders. Requested policies for Bladder scan and Bladder program. On 1/3/24 at 1:35PM, V18 Nurse Consultant stated that they don't have policies on Bladder scan and Bladder program. Facility's policy on Physician Orders Revised 7/26/23 indicates: Policy statement: It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's order. The facility shall ensure to follow physician orders as it is written in the POS (Physician Order Sheet). Procedures: 3. Physician orders must be documented in the POS section of the patient's clinical records. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 6 of 11 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 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 0690 Level of Harm - Minimal harm or potential for actual harm 4. The physician may also call-in telephone orders, write physician orders in the POS, or put the orders in electronically personally. 6. Physician orders will be carried out at a reasonable time. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 7 of 11 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/3/24 at 10:23 AM the Glucerna 1.2 was at the bedside and turned off for R12. The feeding was not connected to the gastric tube. On 1/3/24 at 12:15 PM the Glucerna 1.2 was at the bedside and turned off for R12. The feeding was not connected to the gastric tube. On 1/3/24 V21 (LPN-Licensed Practical Nurse) stated I turned it off to do care. It is supposed to run from 7:00 AM to 5:00 AM and turn it on at 7:00 AM. The night nurse turned it off. I didn't get it back on. There was a discrepancy this morning. They didn't know if I was supposed to be here or where I would be. I had to get access to the computer. I am not an employee here, I am agency. On 1/4/24 12:35 PM V2 (Director of Nursing) stated it should be up one hour before or one hour after it is scheduled. The Physician's Order for R12 indicates Glucerna 1.2 rate 70 ml/hr (milliliters per hour) x 22 hrs (1540 ml). Flush of 90 ml H2O (water)/hr (hour) to fun with TF (tube feeding) 0600-0400 (6:00 AM-4:00 AM). The Medication Administration Record indicates Enteral Feeding-Tube type; G-tube (gastric tube) Glucerna 1.2 rate 70 ml/hr x 22 hrs (1540 ml). Flush of 90 ml/H2O/hr x 22 hrs to run with TF. Run 0600-0400. Start Date 12/11/2023. Based on observation, interview and record review the facility failed to follow physician order in providing enteral feeding and enteral stoma care. This deficiency affects two (R12 and R246) of three residents in the sample of 28 reviewed for Enteral Tube Feeding Management. Findings include: On 1/2/24 at 11:26AM, observed R246 lying in bed. Gastric tube (GT) feeding pump off with feeding bag of Jevity 1.2 empty and disconnected. On 1/2/24 at 1:30PM, observed R246 lying in bed. GT feeding pump off with feeding bag of Jevity 1.2 empty and disconnected. On 1/3/24 at 11:39AM, observed R246 lying in bed connected to GT feeding of Jevity 1.2 running at 90ml/hour and flushing of water at 30ml/hr. V19 Agency Nurse said that R246 receives 22 hours of tube feeding from 6AM to 4AM. V19 assessed GT site, observed no dry dressing in placed. V19 said that GT dressing is done by night shift. R246 was admitted on [DATE] with diagnoses listed in part but not limited to Gastrostomy, Disorder of Glossopharyngeal nerve. Active R246 Physician Order Sheet (POS) indicates: NPO (Nothing by mouth). Enteral feeding order: Jevity 1.2 rate: 90ml/hour with flush of 30ml water /hour, both 22 hours. Cleanse enteral tube feeding site with normal saline and apply dry dressing every night. Care plan indicates: Enteral feeding: He requires feeding as the primary source of nutrition due to following conditions and risk factors: Dysphagia diagnosis. Intervention: Enteral nutrition prescription as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 8 of 11 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 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 0693 follows: Jevity 1.2 at 90ml/hour with flush of 30ml/hour x 22 hours, on 12N and off at 10AM. Level of Harm - Minimal harm or potential for actual harm On 1/4/24 at 12:30PM, observed R246 lying in bed connected to GT feeding of Jevity 1.2 running at 90ml/hour and flushing of water at 30ml/hr. Residents Affected - Few On 1/4/24 at 12: 40PM, V20 LPN (Licensed Practical Nurse) stated that he took care of R246 on 1/2/24 7-3 shift. He said that R246 should have his enteral feeding resumed at 12noon. He said he did not start the feeding not until after 2PM on that day. R246 feeding is from 12N to 10AM total of 22 hours. On 1/4/24 at 12:51PM, V16 RN (Registered Nurse) stated that he is the nurse assigned to R246. He stated that he started his enteral feeding at 12N. R246 enteral feeding is from 12N to 10AM total of 22 hours daily. On 1/4/24 at 1:30PM, informed V2 DON (Director of Nursing) of above observation and concerns. She stated that they are expected to follow physician orders in enteral feeding and stoma/GT care. Facility's policy on Enteral Tube Feeding Care Revised 7/28/23 indicates: Policy statement: Enteral tube is an avenue of feeding and hydration nutritional support via gastrostomy route. Procedure: 1. Nurse to check in the POS /MAR (Medication Administration Record) the order for enteral feeding interventions. a. Feeding formula b. Type: Bolus, continuous c. Rate d. Duration 8. Enteral tube stoma care: Site must be cleansed and covered with a dry gauze daily. Dry gauze should be placed on top of the Gastric tube bumper, otherwise, a slim layer of light breathable gauze can be inserted under the disc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 9 of 11 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/3/24 at 9:17 AM V19 (Registered Nurse) retrieved a gown from the PPE (Personal Protective Equipment) cart. V19 dropped a gown on the floor and picked it up and returned it to the cart on top of the clean gown and closed the drawer. Surveyor asked if that was acceptable, she said I don't know what I was thinking. She removed the dropped gown and the clean gown from the cart. Residents Affected - Some V19 then measured the vital signs for R134. V19 cleaned the blood pressure cuff and the pulse oximeter with a bleach wipe and removed her gloves. She did not perform hand hygiene and proceeded to pour and administer medications to R134. Surveyor asked V19 why hand hygiene wasn't performed after removing her gloves. V19 stated I should have done that. On 1/3/24 at 1:20 PM V2 (Director of Nursing) stated it (gown) should be discarded. It is no longer clean. V2 stated hand hygiene should be done after cleaning equipment and removing gloves. R134 has a physician order that indicates isolation-enhanced barrier precautions. Reason for isolation: wound. Based on observation, interview and record review the facility failed to perform hand hygiene after direct resident contact and after cleaning equipment. The facility also failed to implement infection control protocol by wearing used gloves when walking down the hallway, failed to discard gown that fell on the floor and failed to ensure that the indwelling catheter bag is not touching the floor. This deficiency affects four (R77, R94, R134 and R246) of four residents in the sample of 28 reviewed Infection control Program. Findings include: On 1/3/24 at 11:39AM, observed V19 Agency Nurse donned gloves and assessed R246 Gastric tube. She removed the gloves and left the room without performing hand hygiene. Surveyor called attention of V19 and informed of observation made. V19 stated that she forgot to wash her hands. V19 stated that she should wash her hands after removing her gloves. R246 is admitted on [DATE] with diagnosis listed in part but not limited to Gastrostomy, Chronic disease of Glossopharyngeal nerve. Active physician order sheet indicates that he is on enteral feeding. Facility's policy on Hand hygiene revised 7/28/23 indicates: Policy statement: Hand hygiene is important in controlling infections. Hand hygiene consists of either hand washing or the use of alcohol gel. The facility will comply with the CDC (Communicable Disease Center) Guidelines regarding hand hygiene. Procedures: 1. Hand hygiene using alcohol- based hand rub is recommended during the following situations: a. Before and after direct resident contact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 10 of 11 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 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 Level of Harm - Minimal harm or potential for actual harm On 1/2/2024 at 12:15pm V26(Certified Nursing Assistant-CNA) was observed leaving out of R77s room with enhanced barrier precautions. V26 had used gloves on walking down the hallway. On 1/2/2024 at 12:17pm V26 was asked should she be in the hallway with used gloves on and V26 stated oh I should not have them on. Residents Affected - Some On 1/2/2024 at 1:05pm V2(Director of Nursing-DON) stated I expect all staff to remove their gloves and wash their hands before leaving the room and follow the infection control protocol. An order summary report dated 1/3/2024 indicates that R77 has a history of Gastrostomy status, pressure ulcer of sacral region stage 4 and a Neuromuscular dysfunction of the bladder, an order dated 12/16/2023 for enhanced barrier precautions for the presence of indwelling catheter, feeding tube and wounds. On 1/2/2024 at 12:40pm R94 was observed in bed with the urine collection bag facing the outside door with no dignity pouch covering and the bag was touching the floor. On 1/2/2024 at 12:45pm V25(Nurse-Agency) stated R94s urine collection bag should be covered with a dignity pouch and off the floor. On 1/2/2024 at 1:00pm V2(Director of Nursing-DON) stated the urine collection bag should be off the floor and should have a dignity pouch over the urine bag. An order summary report dated on 1/2/2024 indicates that R94 has a history of Neuromuscular dysfunction of bladder. An order on 9/6/2023 indicates R94 has an indwelling catheter 16 French with 10ml balloon for a (Neurogenic bladder). Facility Policy: Urinary Catheter Care Revised 7/28/23. Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. General Guidelines: Infection Control b. Be sure the catheter tubing and drainage bag are kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 11 of 11