Inspection·May 25, 2024

F 0689 touching assistance with walking from 10-150 feet. Level of Harm - Actual harm R2's Fall Risk Evaluation dated 04/24/2024 documents she is continent of bowel and bladder, has an unsteady gait, just had a fall, and had a score of 17 indicating she is at high risk for falls. Residents Affected - Few R2's hospital report dated 04/24/2024 documents R2 reported she was walking to the bathroom and slipped, falling, and striking her head on the left side of the floor; she presented to the emergency department after a fall. Radiology Results Report dated 04/29/2024 documents an x-ray was performed for R2 with results showing an acute fracture of the left foot, no Osteoporosis or Osteopenia. Fall Incident Report dated 04/24/2024 documents on 04/24/2024 V20 (Agency Nurse) heard R2 call out for help from her room bathroom, V20 ran down there to see her sliding off her wheelchair in the bathroom. R2 reported she was trying to use the bathroom by herself. Final Facility Incident Investigation Report dated 05/08/2024 documents R2 was observed on the floor in the bathroom, complained of pain to the left foot, the physician ordered an x-ray of the left foot which resulted in an acute fracture to the left 5th toe. R2 was sent to hospital for evaluation. R2 reported she hit her left foot on a pipe under the sink in the bathroom during a fall on 04/24/2024 while attempting to self-transfer from the toilet to the wheelchair. R2 was seen by ortho with recommendation for a postop shoe and follow up on x-ray in three weeks. On 05/24/2024 at 2:41 PM V14 (Registered Nurse) stated R2 requires assistance with transfers on and off the toilet and usually uses her call light if she needs assistance. On 05/24/2024 at 2:52 PM V15 (Certified Nursing Assistant) stated someone always assists R2 with going to the bathroom and she always asks for assistance for toileting. On 05/24/2024 at 3:03 PM when asked by V3 (Assistant Director of Nursing) how staff were alerted that she fell and needed help on 04/24/2024, R2 stated she yelled out for help and a nurse came to get her. On 05/24/2024 at 3:08 PM V16 (Certified Nursing Assistant) stated on 04/24/2024 R2 had put her call light on because she needed to be toileted, but she was busy providing care to other male residents. V16 stated she observed R2's call light was on when she went into the hall to get towels. V16 stated she responded to R2's call light, cut it off and let her know that she would return after she finished providing care to other residents and R2 agreed to wait. On 05/24/2024 at 3:20 PM V17 (Certified Nursing Assistant) stated on 04/24/2024 while watching residents in the dining area a nurse came and asked her for help because R2 had fallen. V17 stated when she asked R2 what happened R2 stated she had gotten herself out of bed and went to the bathroom on her own. V17 stated she believed this was not true because R2 cannot physically transfer herself out of bed, into her chair, or onto the toilet. V17 stated R2 has become increasingly confused lately. V17 stated there were a total of four certified nursing assistants working during the evening shift when R2 fell. V17 stated R2 usually won't get up without assistance. V17 stated she heard R2's call light right before the nurse came and asked her for help with a resident who fell. On 05/24/2024 at 3:25 PM R2 stated sometimes it takes staff a long time to respond to the call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2024 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 light. R2 stated if staff take too long to respond to the call light when she has to urinate, she won't be able to hold it. Level of Harm - Actual harm Residents Affected - Few Fall Incident Witness statement completed by V16 (Certified Nursing Assistant) dated 04/24/2024 documents V16 reported she was R2's assigned CNA during that shift, she last saw R2 a few minutes before her fall, she was giving care to another resident during R2's fall incident, she had answered R2's call light and she stated she needed to use the bathroom, she told R2 she was in the middle of giving care to another resident and asked if she could give her a few minutes to finish with them and she will be right back to assist her to the bathroom. Fall Incident Witness statement completed by V22 (Certified Nursing Assistant) dated 04/24/2024 documents the last time she saw R2 was at dinner, she was providing patient care during the incident, and she was not present at the time of the incident. Fall Incident Witness statement completed by V15 (Certified Nursing Assistant) dated 04/24/2024 documents she was giving care to a resident in her assigned area and was not aware of R2 falling until after she was back in bed. On 05/24/2024 at 3:40 PM V2 (Director of Nursing) stated fall risk assessments are completed on admission, when a fall occurs, after a change in condition, quarterly, and annually for minimum data set assessments. V2 stated R2 requires one person assistance with transfers and usually calls for assistance. V2 stated R2 uses her call light, verbalizes the need for assistance when in the dining area, and will ambulate in her wheelchair to the nurse's station to ask for assistance with toileting. V2 stated R2 walks with restorative as part of a program. V2 stated toileting assistance for R2 includes ambulating her in her wheelchair to the handrail so she can stand, then she'll turn and pivot to sit down on the toilet, then the staff will need to assist her with pulling down and up her pants and brief during the process. V2 stated after R2 is done with toileting staff will clean her, pull her brief, and pants up or change her brief if necessary. V2 stated R2 will then turn and pivot back to the wheelchair. V2 stated staff can then place R2 in front of the sink where she can wash and dry her hands independently. V2 stated typically staff will close the door to provide R2 privacy while toileting and she will pull the call light to inform staff she has finished toileting. V2 stated staff can either stand outside the bathroom or room door while R2 is toileting. V2 stated staff should definitely be in either area while R2 is toileting. On 05/24/2024 at 4:58 PM V2 (Director of Nursing) stated she recalls now that R2 transferred herself from the bed to the wheelchair and then to the bathroom on the day she fell 04/24/2024. V2 stated R2 shouldn't transfer herself but is capable of doing so. On 05/24/2024 at 5:31 PM V2 (Director of Nursing) stated if a resident who can be toileted needs to go to the bathroom and their certified nursing assistant can't immediately assist them the expectation is the aide would ask another aide or nurse to assist the resident, or for the aide to finish up their task and then assist the resident. V2 stated older residents may only be able to wait for assistance with toileting for 2-3 minutes because they can't hold their bladder very long. V2 stated the aide should ask for assistance with getting the resident toileted in a timely manner. V2 stated it would not have been safe for R2 to transfer herself from her bed to her wheelchair, from her wheelchair to her bathroom toilet, and then back to her wheelchair after toileting on 04/24/2024 when she fell. V2 stated V16 (Certified Nursing Assistant) could have gotten someone else to assist R2 with using the bathroom during that time if she was not available to assist her. V2 stated the appropriate thing for V16 to do if she couldn't immediately assist R2 with going to the bathroom would have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 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 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2024 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 been to get someone to assist R2 to the bathroom right away. V2 stated it is possible that having to wait to go to the bathroom could have placed R2 in a position to attempt to transfer herself to the bathroom. Level of Harm - Actual harm Residents Affected - Few R2's medical records only included an admission fall risk assessment dated [DATE] and post fall risk assessment dated [DATE]. The facility's Fall Occurrence Policy received/reviewed 05/24/2024 states: It is the policy of the facility to ensure that residents are assessed for risk for falls. A Fall Risk Assessment form will be completed by the nurse or the Falls Coordinator upon admission, quarterly, and annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 4 of 4