Health inspection·January 10, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and toileting) r/t symptoms of depression. Intervention dated 11/19/24- Keep call lights within reach when in bedroom or bathroom. On 1/07/25 at 11:41AM, R416 in bed with call light hanging on floor next to bed. On 1/07/25 at 11:43 AM, V24 (Certified Nurse Aide) stated that her call light should be placed within reach in case she needs to ask for help or ask for water. Reviewed R416s medical records. R416 is admitted on [DATE] with diagnoses listed in part but not limited to history of falling, weakness, adult failure to thrive. Intervention dated 1/7/25- Keep call lights within reach when in bedroom or bathroom. On 1/09/25 at 12:36 PM, V2 (Director of Nursing) state her expectations for call lights are not to be on the floor, call light should be clipped on bed, or some residents preferred the call light to be tied to the bed rail. All call lights should be within resident's reach. Facility's policy on Call light revised 7/26/24. Policy statement It is the policy of this facility to ensure that there is prompt response to the residents call for assistance. The facility also ensures that the call system is in proper working order. Procedures 5. Be sure call lights are placed within reach of residents who are able to use it at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 2 of 20 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 01/10/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and record review the facility failed to refer a resident to the appropriate state-designated authority for a PASRR/Preadmission Screening and Resident Review level 2 screening for evaluation and determination of newly evident serious mental illness related condition, for one of one resident (R111) reviewed for a PASRR level 2 screening in a sample of 32. Findings include: On 1/9/2025 at 1:20pm V16 (Social Service Director-SSD) said that she is responsible for making sure resident's that have new mental illness diagnosis receive an updated PASRR level 2 screening but was not made aware that R111 had new diagnosis until now and that she had contacted the agency to have a PASRR level 2 screening completed so that R111 can receive the appropriate treatment and services. On 1/10/2025 at 10:30am V36 (Admissions Director) stated that R111 had an PASRR level 1 screening completed before admissions and did not need any further evaluation at that time if a resident has a new mental illness diagnosis, then social services will be responsible to obtain a PASSAR level 2 screening for appropriate services. On 1/10/2025 at 2:00pm V1 (Administrator) stated I'm aware that R111 had new diagnosis since admitting and I did inform the social service director of a new PASRR Level 2 screening needed for appropriate services and treatment to be put place. A record review of R111 medical diagnosis indicated that R111 had a new diagnosis of major depression dated on 11/21/2023, unspecified psychosis not due to substance abuse or know physiological condition on 6/19/2022 and unspecified dementia with agitation unspecified severity on 10/1/2022. Facility Policy: Revised on 8/16/2024 PASRR Screening of residents with mental disorder or intellectual disability Policy: It is the facility's policy to ensure that residents with mental disorder and those with intellectual disorder will receive PASRR screening within the timeframe allowed. Procedure: 1. The facility will not allow admission from the hospital without a preadmission screening which includes OBRA screen 1 and OBRA screen 2 (PASRR screening) for those with mental or intellectual disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 3 of 20 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 01/10/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure preventive measures are in place to prevent developing of new skin impairment and deteriorating of current pressure ulcer to resident who is at high risk. This deficiency affects one (R139) of three resident in the sample of 32 reviewed for Pressure Ulcer Prevention management. Residents Affected - Few This failure resulted in R139 developing a new moisture associated skin disorder (MASD) to bilateral buttocks and deteriorating pressure ulcer on sacrum area to unstageable. Findings include: On 1/7/25 at 11:30AM, R139 lying in bed with her V13 Family member/daughter and V14 Caregiver at bedside. V13 stated that she has concern regarding poor nursing services provided to her mother. V13 stated that they arrived today around 8:30AM and found R139 soaked with urine and feces. R139's bed was wet from her upper back/shoulder down to her both ankles. V13 stated that she called and showed observation to V11 ADON (Assistant Director of Nursing). V13 stated she presented concerns of not providing incontinence care to R139 from night shift until morning shift. V13 stated that R139 developed pressure ulcer in her sacral area in the facility and deteriorating. V13stated that R139 has a stage 3 pressure ulcer on sacral area. R139 is on low air loss mattress with flat sheet and cloth pad over the mattress. She (R139) wears disposable adult brief. On 1/9/25 at 12:30PM, R139 lying in bed with low air loss mattress. R139 is alert, oriented and can verbalize needs to staff. R139 stated that she developed bedsore in the facility and causing her pain on her buttocks area. R139 stated that the nurses are changing her dressing on her buttocks, but they are not changing her brief when she was soiled. R139 stated they do not answer her call light. R139 stated that her mattress had a problem, and they switched her bed with her roommate. R139's roommate was not in her room, but the roommates low air loss mattress is unplugged. Verified information given by R139 to V26 WCC (Wound care coordinator). V26 stated confirmed that they switched R139's bed with her roommate just 45 minutes ago. On 1/9/25 at 12:40PM, V27 Wound care tech repositioned R139 on left side lying position. V26 WCC removed foam dressing on sacrum area. Observed R139 has moderate serous sanguineous with greenish wound drainage. V26 said that R139 has unstageable pressure ulcer on sacrum and MASD on bilateral buttocks. Observed multiple open wounds covered with white colored ointment. V26 said that R139 has 70% greenish slough formation attached to wound base, 10% eschar and 20% granulating tissues. V26 said that R139 is being seen by V30 Wound care Nurse Practitioner. V26 provided wound care to bilateral buttocks and sacrum. V26 said that checking resident every 2 hours for incontinence care, skin care after each incontinence episode, low air loss mattress and provided treatment as ordered are some of the wound care preventive measures the provided. R139 is initially admitted on [DATE] and was re-admitted on [DATE] with diagnoses listed in part but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Pressure ulcer of sacral region stage 3 during stay, Type 2 Diabetes Mellitus (DM) with diabetic neuropathy, Obesity. admission and current Braden/skin assessment indicated that she is at high risk for developing pressure ulcers/skin impairments. Active physician order sheet indicated: Bilateral buttocks cleanse with Hibiclens, apply triad wound paste, leave open to air everyday shift, and as needed for MASD. Air Mattress. Santyl ointment 250 unit/gm (Collagenase) apply to sacrum topically (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 4 of 20 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 01/10/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few everyday shift for wound cleanse with normal saline cover with foam dressing. Right heel cleanse with normal saline apply betadine /gauze /abdominal pad wrap kerlix every day shift M-W-F for DTI (Deep tissue injury). Barrier cream to be applied after each incontinence episode may be applied by CNA and kept at bedside. Comprehensive care plan indicates that she has pressure ulcer on sacrum, right heel, venous ulcer to the right lower leg and is high risk for further pressure ulcers related to impaired mobility, decreased ROM, incontinence, history of right humerus fracture, right side hemiplegia related to CVA (Cerebrovascular accident), DM, Obesity and CHF (Congestive heart failure). Intervention: Follow facility policies/protocols for the prevention/treatment of skin breakdown. She has an ADL (Activity of daily living) self-care performance deficit and impaired immobility. Intervention: totally dependent on staff for toilet use. She is on low air loss mattress due to presence of skin breakdown and to prevent further skin breakdown. Intervention: Check for proper functioning and setting of low air loss mattress every shift. On 1/9/25 at 1:16PM, Reviewed R139 medical records with V28 MDS/Resident assessment Coordinator. V28 stated that R139's MDS (minimum date set) admission assessment on 3/8/24 indicated that she was admitted with stage 2 pressure ulcer on sacral area. MDS assessment dated [DATE] indicated that her skin is intact. MDS assessment dated [DATE] indicated that she was re-admitted with stage 2 pressure ulcer on sacral area from the hospital. MDS assessment dated [DATE] indicated that she has stage 2 pressure ulcer on sacral area. MDS assessment dated [DATE] indicated a significant change of condition due to deterioration of sacral pressure ulcer from stage 2 to stage 3. On 1/10/25 at 12:01PM, V11 ADON stated that she was called to R139's room on 1/7/25 by V13 Family member and showed her observation made that R139 was soiled with urine. V11 stated the bed was wet and soaked from upper back/shoulder down to lower extremities/ankles. V13 presented above concerns to her (V11). Informed V11 that the concern form that she completed dated 1/7/25 did not indicate concerns presented by V13 that incontinence was not done due to R139's bed was soiled from upper back/shoulder to lower extremities/ankles when they visited R139 on 1/7/25. V13 also concern that R139 has pressure ulcers that getting worse. V11 documented on R139's concern form dated 1/7/25 indicated: Daughter expressed concern of her mother being soiled, states her mother is a heavy wetter and needs changing often. Daughter ensured rounds would be made on her mother every two hours and that a indwelling urinary catheter would be placed to ensure less moisture to her bottom. V11 said R139 should be check for incontinence every 2 hours. She said that resident who was left soiled for long period of time could developed pressure ulcer and deteriorate current pressure ulcer. Informed V11 that she did not investigate the night shift (11pm -7am) who worked on 1/6/25 and day shift 1/7/25 staff (nurse and CNA) who worked with R139 why she was soiled from upper back/shoulder down to lower extremities/ankles at 8:30am when V13 Family member and V14 Caregiver. On 1/10/25 at 12:13PM, V26 WCC said that R139 developed new MASD on bilateral buttocks and was seen by V30 Wound care Nurse Practitioner. She said R139 should be check for incontinence care every 2 hours. She said that resident who had prolong exposed to soiled brief and bed could develop pressure ulcer and could deteriorate current pressure ulcer. On 1/10/25 at 12:21PM, V30 Wound Care Nurse Practitioner stated that she has taking care of R139 since July 2024, presented with stage 2 pressure ulcer on sacrum area which now progressed to unstageable pressure ulcer. She recently examined R139 on 1/8/25 with new MASD (Moisture associated skin disorder) to bilateral buttocks. V30 said that she was not aware that R139 was left soiled in bed on 1/7/25 as witnessed by V13 Family member and V11 ADON. V11 stated that prolong exposure to soiled brief and bed from urine and feces are factors in developing new skin impairment and deteriorating current pressure ulcer. The facility should follow its wound/pressure ulcer prevention and management (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 5 of 20 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 01/10/2025 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 0686 policies. Level of Harm - Actual harm R139's Skin/Wound notes documented by V30 Wound care Nurse Practitioner on 1/8/25 indicated: 1. Sacrum- Unstageable pressure ulcer, measures 10.5cm x 7cm x 0.1cm, 90% slough, 10% granulation. 2. New Moisture Associated Skin Disorder (MASD) on bilateral buttocks, partial thickness, 100% epithelial, Dermatitis, exposed epithelium tissues. 3. Right heel pressure, DTI (Deep tissue Injury), measures 2.5cm x 3cm x 0cm, 100% epithelial. V30 documented: 12/23/24 Upon assessment, patient was noted to be on a deflated air mattress. Sacral worsening. 12/30/24 Patient on regular mattress today, RN to notify facility coordinator to get her another air mattress. Sacral wound worsening. Preventive measures: The resident is incontinent of bowel and bladder, thorough skin care with each incontinent episode. Continues alternating air/low mattress for pressure reduction. Residents Affected - Few On 1/10/25 at 12:53PM, Informed V1 Administrator and V2 Director of Nursing (DON) of above concerns and requested for Wound /Pressure Ulcer Management policy. Facility's policy on Skin Care Regimen and Treatment Formulary Reviewed 1/24/24 indicated: Policy statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Procedures: 6. Residents who are not able to turn and reposition themselves will be turned and repositioned at least every 2 hours unless otherwise specified by the physician. 9. Residents with stage 3 or 4 pressure injuries will be placed in specialized air mattress like low are loss mattress Facility's policy on Incontinent and Perineal Care Revised 7/31/24 indicated: Policy statement: It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation and to observe the resident's skin condition. Procedures: 1. Do rounds at least every 2 hours to check for incontinence during shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 6 of 20 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 01/10/2025 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 Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure safety interventions were in place for a resident who is at high risk and has history of falls. This deficiency affects two (R27 and R216) of three residents in the sample of 32 reviewed for fall prevention program. This failure resulted in R216 falling and sustaining a laceration to his right eyebrow that required a visit to the hospital for suturing. Findings include: On 1/7/25 at 10:30AM, V2 Director of Nursing (DON) stated that R216 was discharged home from the facility on 10/27/24. V2 stated that V29 Agency nurse who worked with R216 on the day of his unwitnessed fall was no longer working in the facility, she was terminated. Per R216's medical record R216 was admitted on [DATE] with diagnoses listed in part but not limited to Displaced fracture of shaft of humerus right arm, history of falling, Dementia with Anxiety, Cataract, Glaucoma, Abnormalities of gait and mobility, lack of coordination, Weakness, Malaise, Malignant neoplasm of prostate. Fall admission assessment done on 10/11/24 indicated at high risk for falls. R216s Admission/Baseline care plan dated 10/11/24 identified fall risk but no intervention indicated. R216's admission functional mobility assessment dated [DATE] indicated that he needs partial/moderate assistance with roll left to right, sit to lying, lying to siting on side of the bed, bed to chair transfer, toileting transfer. R216's unwitnessed fall incident documented by V29 Agency Nurse on 10/11/24 at 7:30PM indicated: V23 CNA notified writer that resident was noted sitting by edge of the bed and bleeding from his right eyebrow. Upon head-to-toe assessment resident was noted with laceration to right eyebrow. Resident denied Shortness of breathing or dizziness. Vitals: Blood pressure 134/72, Heart rate 90, Respiratory rate 18, Temperature 97.9F, 95% oxygen saturation on room air. Resident complained of pain at laceration site, right eyebrow. Per resident, he was trying to reach out to pick up his phone and he ended up on the floor. 911 was called and resident was transferred to the hospital for further evaluation. R216's unwitnessed fall incident initial report was sent to the State Agency on 10/13/24 at 10:00PM. Final report was submitted to the State Agency on 10/19/24 at 10:00PM indicated: At approximately 7:30PM on 10/11/24, R216 was observed by V23 CNA sitting on the floor at the right side of the bed with blood coming from his right eyebrow. R216 stated that he was trying to answer the phone on the nightstand next to his bed when he fell over hitting his head on the nightstand. R216 was sent to the hospital for evaluation. R216 returned to the facility with sutures to the right eyebrow. R216's hospital emergency department records dated 10/11/24 to 10/12/24 (7 hours) discharged summary indicated: Injury of head, Multiple falls, laceration of scalp, rapidly progressive Dementia. Procedure: Laceration repair of 4cm oblique V shaped partially avulsed laceration through right eyebrow. 4cm length and 4cm depth. 4 sutures. Patient states he was in bed reaching for a phone over his head and rolled out of bed. Patient had fell at home sustaining fracture humerus status post humeral fixation on 10/5/24. Patient was discharged to nursing home facility on 10/11/24 for rehabilitation where he fell. Patient has baseline confusion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 7 of 20 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 01/10/2025 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 Residents Affected - Few On 1/9/25 at 9:52AM, Review of R216's medical records with V2 DON. V2 stated she (V2) is aware that R216 was at high risk for falls prior to admission due to clinical intake that she (V2) received from the hospital. V2 stated that R216 had an unwitnessed fall at home and sustained a right arm fracture. V2 stated that R216 was admitted to the nursing home facility for rehabilitation on 10/11/24 at 2:43PM. V2 stated R216 had an unwitnessed fall on the same day of admission at 7:30PM and sustained a laceration on his right eyebrow. V2 stated R216 was reaching out for his cell phone and fell from bed and hit his head on the nightstand. V2 stated R216 was sent to the hospital for evaluation. V2 stated that she (V2) was notified of R216's fall incident with laceration around 8:00PM. V2 stated she (V2) called the facility around 7:00AM on 10/12/24 regarding the status of R216. V2 stated she was told that R216 returned on 10/12/24 at 3:59AM with sutures to his right eyebrow. V2 stated she submitted the initial report on 10/13/24 at 10:00PM. V2 stated that she (V2) is still in compliance of submission because it is within the 24-hour period from the time the resident came back to the facility. Surveyor informed V2 that R216 fall admission assessment dated [DATE] indicated at high risk. R216 admission baseline care plan identified him as fall risk, but no care plan intervention indicated. V2 stated that the admission nurse should indicate baseline fall interventions. On 1/9/25 at 11:59AM, V23 CNA stated that she was the CNA assigned to R216 on 10/14/24 3-11 shift on the day R216 had the unwitnessed fall. V23 stated that she was aware that R216 is at high risk for falls as endorsed to her. V23 stated R216 has fracture of right arm and had bandage/dressing. V23 stated R216 is confused. V23 stated around 7:30pm after dinner, she (V23) observed R216 sitting on the edge of the bed with blood coming from is eyebrow. V23 stated she told R216 that he should not get up. V23 stated R216 stated that he was trying to answer his phone and fell when trying to reach the nightstand/bedside dresser. V23 stated that personal belongings such as cellphone should be placed within resident's reach. Facility's fall prevention program guidelines revised 12/5/21 indicates: 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. Procedures: 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. On 1/10/2025 at 1:00pm V2 (Director of Nursing-DON) stated that R27 is alert to name only is able to assist with turning and repositioning and needs one assist with bed activity of daily living-ADL'S. R27 did have a fall from the bed on 1/6/2025. V35 (certified nursing assistant-CNA) stated that R27 was too close to the edge of the bed when R27 was turned and R27's legs went out the bed and V35 slid R27 to the floor. V2 stated I asked V35 why she didn't reposition R27 before turning R27 and V35 stated I did not realize she was that close to the edge. On 1/13/2025 at 12:30pm V35 (Certified Nursing Assistant-CNA) stated that R27 is alert but confused, can assist very minimal with turning and repositioning and that she (V35) considers R27 a total (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 8 of 20 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 01/10/2025 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete assist. V35 stated that she turned R27 to her stomach to clean her and R27 legs went out the bed and she lowered her to the floor. V35 stated I (V35) did not think R27 was that close to the edge to the bed that she needed to be repositioned. V35 stated she did not hurt herself she was sent out to the hospital to make sure she had no injury. A care plan dated 12/13/2024 indicated that R27 has an history of Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the left non-dominant side and a history of falls. A post fall investigation with an root cause analysis dated 1/9/2025 indicated that R27 was too close to the edge of the bed and that staff must ensure that R27 is in the center of the bed prior to starting activity of daily living -ADL care. Event ID: Facility ID: 145700 If continuation sheet Page 9 of 20 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 01/10/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to supervise residents while taking medications during medication administration for two of four residents (R53, R100) observed for medication administration. The facility also failed to account for the usage, disposition, and reconciliation of controlled medications for one of five medication carts (2nd floor [NAME] medication cart) observed for medication storage affecting all seven residents (R3, R11, R29, R73, R76, R86, R149) on controlled medications on 2nd floor [NAME] medication cart. Findings include: 1. On 01/07/2025 at 10:47AM during unit rounds, medication cup with 3 big white pills was on the food tray of R53. On 01/07/2025 at 10:50AM, R53 was with V4 (Licensed Practical Nurse) taking the medications in the medication cup on the food tray. On 01/07/2025 at 10:47AM during interview with R53, R53 stated that the nurse usually leaves it with her because the nurse trusts that R53 will take it and R53 stated that she will take it. On 01/07/2025 at 10:50AM during interview, V4 stated that R53 was eating her breakfast when she was passing medications, so she V4 left the medicine with R53. V4 stated that R53 is alert so she it is okay to leave the medications with R53. V4 also stated that R53's medications should have not been left with R53. V4 stated that residents should be supervised when taking medications. On 01/09/2025 at 11:28AM during interview with V2 (Director of Nursing), V2 stated that they do not have any residents that can self-administer medications. V2 stated that nurses are expected to wait and supervise the residents when taking all their medications, and if the residents refused to take the medications, nurses should take it with them back to the cart and discard. Review of R53's Medication Administration Record for January 2025 indicated Amoxicillin-Potassium Clavulanate 1 tablet and Potassium Chloride 2 tablets were given at 9AM and 8AM respectively by V4 on 01/07/2025. Review of R53's Order Summary Report dated 01/09/2025 indicated admission date of 07/25/2024, diagnoses of not limited to Essential Hypertension and Unspecified Atrial Fibrillation. 2. On 01/09/2025 at 8:43AM during medication administration with V17 (Registered Nurse), V17 gave R100 the medication cup with 7 pills in it and a cup of water mixed with Polyethylene Glycol, then left the room to get Lactulose for R100. V17 went back to R100 to give R100's lactulose then left the room without watching R100 take her medications. On 01/09/2025 at 9:25AM during interview, V17 stated that R100 is alert and oriented to time, place, person, and situation so V17 is sure that R100 will take her medications. On 01/09/2025 at 11:28AM during interview with V2 (Director of Nursing), V2 stated that they do not have any residents that can self-administer medications. V2 stated that nurses are expected to wait and supervise the residents when taking all their medications, and if the residents refused to take the medications, nurses should take it with them back to the cart and discard. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 10 of 20 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 01/10/2025 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 0755 Review of R100's January 2025 Medication Administration Record indicated that R100 was admitted in the facility on 04/23/2021 and the following were given to R100 on the morning of 01/09/2025 by V17: Level of Harm - Minimal harm or potential for actual harm 1. Amlodipine 10mg tablet (BP=111/50) Residents Affected - Few 2. Aspirin EC 81mg tab 3. Cholecalciferol 1000 units 2 tablets 4. Ferrous Sulfate 325mg tablet 5. Gabapentin 100mg capsule 6. Polyethylene glycol 17gm powder 7. Colace 100mg capsule 8. Lactulose 10gm/15ml 30ml 3. On 01/09/2025 at 9:45AM during controlled medication review with V18 (Licensed Practical Nurse), 2nd floor [NAME] cart Controlled Substance Count Log for January 2025 had no initials on January 1st 7AM-3PM outgoing shift, January 8th 7AM-3PM incoming and outgoing shift, and 3PM-11PM outgoing shift. At the same time, R29's Tramadol 50mg blister pack has only one tablet left and R29's Controlled Drug Administration Record indicated three tablets left. On 01/09/2025 at 9:48AM during interview with V18, V18 stated that both outgoing and incoming shifts should count the controlled medications together and sign the log after. V18 also stated that R29's Controlled Drug Administration Record should have been signed as soon as the medications were removed from the blister pack. Review of R29's Order Summary Report dated 01/09/2025 indicated admission date 12/29/2023, diagnoses of not limited to unspecified osteoarthritis, and order for Tramadol 50mg (milligrams) 2 tablets to be given at bedtime with order date of 12/29/2023. Review of facility's policy entitled Controlled Medications count revised 07/26/2024 indicated the following: Procedure 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 11 of 20 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 01/10/2025 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 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 label insulin and inhalers with open date and follow pharmacy/manufacturer's recommendation on discarding for two of five medication carts (2nd floor East-West and 2nd floor [NAME] medication carts), and one of two medication room storage (3rd floor medication room) observed for medication storage and labeling. Findings include: On 01/09/2025 at 9:15AM V17 (Registered Nurse), 2nd floor East-West Medication cart had the following: 1. R47's opened Insulin glargine pen without open date. Manufacturer's storage recommendation includes throwing away opened insulin glargine pen after 28 days. 2. R39's opened Insulin lispro pen without open date 3. R125's opened insulin glargine pen without open date 4. R79's opened fluticasone furoate and vilanterol inhalation powder 100 micrograms(mcg)/25mcg without open date and label indicated to discard 6 weeks after opening. 5. R47's opened budesonide and formoterol fumarate dihydrate 160mcg/4.5mcg inhaler without open date and manufacturer's recommendation to discard 3 months after taking out from foil pouch On 01/09/2025 at 9:45AM during observation with V18 (Licensed Practical Nurse/LPN), 2nd floor [NAME] Medication cart had the following: 1. R17's opened fluticasone propionate and salmeterol inhalation powder 250mcg/50mcg with open date of 10/29/2024 and label indicated to discard 1 month after opening foil 2. R73's insulin aspart 100 units/milliliters (ml) pen with open date of 12/09/2024 and expiration date of 01/07/2025. Label indicated to store at room temperature up to 28 days once opened. 3. R20's insulin lispro 100 units/ml vial with open date of 12/06/2024 and expiration date of 01/04/2025. Label indicated that once opened, refrigerated or not, discard after 28 days. On 01/09/2025 at 10:44AM V4 (LPN), 3rd floor medication refrigerator had open vial of Tuberculin Purified Protein Derivative without open date and label indicated to discard used vials after 30 days. On 01/09/2025 at 9:15AM during interview with V17, V17 stated that insulin and inhalers should be dated when opened and discarded per manufacturer's recommendation. On 01/09/2025 at 9:45AM during interview with V18, V18 stated that insulin and inhalers should have open dates. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 12 of 20 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 01/10/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 01/09/2025 at 10:44AM during interview with V4, V4 stated that the vial of Tuberculin Purified Protein Derivative should have been dated when opened. Review of R47's Order Summary Report dated 01/09/2025 indicated admission date of 12/06/2021 and diagnoses of not limited to Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus without complications. It also indicated order for Insulin glargine with order date of 01/31/2022 and budesonide and formoterol fumarate dihydrate with order date of 12/24/2021. Review of R39's Order Summary Report dated 01/09/2025 indicated admission date of 04/27/2021 and diagnoses of not limited to Type 2 Diabetes Mellitus with other skin complications. It also indicated order for Insulin lispro with order date of 05/23/2024. Review of R125's Order Summary Report dated 01/09/2025 indicated admission date of 05/13/2023 and diagnoses of not limited to Type 2 Diabetes Mellitus with diabetic polyneuropathy. It also indicated order for Insulin glargine with order date of 05/13/2024. Review of R79's Order Summary Report dated 01/09/2025 indicated admission date of 08/27/2018 and diagnoses of not limited to Chronic Obstructive Pulmonary Disease, unspecified Asthma and Chronic Respiratory Failure with hypoxia. It also indicated order for fluticasone furoate and vilanterol inhalation powder with order date of 05/09/2021. Review of R17's Order Summary Report dated 01/09/2025 indicated admission date 04/28/2022 and diagnoses of not limited to moderate persistent asthma. It also indicated order for fluticasone propionate and salmeterol inhalation powder with order date of 07/08/2024. Review of R17's Order Summary Report dated 01/09/2025 indicated admission date 04/28/2022 and diagnoses of not limited to moderate persistent asthma. It also indicated order for fluticasone propionate and salmeterol inhalation powder with order date of 07/08/2024. Review of R73's Order Summary Report dated 01/09/2025 indicated admission date of 05/03/2024 and diagnoses of not limited to Type 2 Diabetes Mellitus without complications. It also indicated order for Insulin aspart with order date of 12/06/2024. Review of R20's Order Summary Report dated 01/09/2025 indicated admission date of 07/27/2009 and diagnoses of not limited Type 2 Diabetes Mellitus with diabetic neuropathy. It also indicated order for Insulin lispro with order date of 07/19/2023. Review of facility's policy entitled Medication Pass revised on 08/16/2024 indicated the following: Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. Medication Labeling: 1. All opened medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening except for Levemir insulin which can be discarded 42 days after opening and Xalatan eye drops which can be discarded 6 weeks after opening. 2. Follow pharmacy recommendation as to when the medication should be discarded after opening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 13 of 20 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 01/10/2025 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 0761 3. Insulin vials are to be discarded within 28 days after opening, except for Levemir insulin which are to be discarded 42 days after opening. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 14 of 20 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 01/10/2025 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 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 observation, interview, and record review the facility failed to fill the sanitation kitchen rags bucket with appropriate amount of sanitizer per manufacturer's recommendation to prevent foodborne illness. This deficiency has a potential to affect 158 residents who received oral food from the kitchen. Findings include: On 1/7/25 at 9:56AM, Surveyor asked the V6 Dietary Manager (DM) to test the sanitation bucket with kitchen rag. V6 stated that they are using Quaternary test strip. The sanitation bucket is tested using the test strips to ensure the sanitizer concentration is correct. V6 stated using the color comparison the expected color should fall between 300 to 400 parts per million (ppm), pale green to dark green. V6 dipped the strip to the water with sanitizer inside the red bucket for more than 10 seconds but only obtained 0-100ppm, orange color to pale orange. V6 attempted 3 times and even stirred the water with sanitizer solution but still obtained the same results. V7 Dietary aide stated that she changed the sanitation bucket around 9:00AM and used the sanitizer automatic dispenser. Surveyor requested for policy and procedure guidelines for Sanitation bucket. On 1/9/25 at 11:08AM, V6 DM stated that they change the sanitation bucket three times a day. They also tested the sanitation bucket daily and documented. V6 stated that the acceptable color should fall on 200ppm to 300ppm (olive green to pale green color) of the testing strip instead of 300 to 400 ppm as she mentioned interviewed dated 1/7/25. On 1/9/25 at 12:09PM informed V7 Dietary [NAME] of the concern identified on 1/7/25 when sanitation bucket was tested using quaternary testing strip to ensure sanitizer concentration is correct, but it did not meet the manufacturers recommendation. V7 said that she just estimated the water and sanitizer solution into the bucket. V7 said that they only monitor and log the pots and pans sanitations daily not the sanitation bucket. Facility's policy on Kitchen revised 8/16/24 indicates: Policy statement: The facility will comply with state and federal regulations in operating facility's kitchen. Procedures: 9. Other kitchen areas: c. Sanitation bucket will be filled with sanitizer per manufacturer's recommendation (Quaternary 150-400ppm, Chlorine 50-100ppm) d. Before using kitchen rags on food prep surfaces, the sanitizer bucket level will be checked to ensure proper level of sanitizer is still present. e. The kitchen staff will not use the rags from the sanitizer bucket unless the sanitizer level is at the right level (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 15 of 20 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 01/10/2025 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 0812 Facility's QT-10 Instructions: Level of Harm - Minimal harm or potential for actual harm For testing n-alkyl dimethyl benzyl and or n-alkyl dimethyl benzyl ammonium chloride. Immerse for 10 seconds compare when wet. 0 PPM (part per millions)- orange, 100ppm-pale orange, 200ppm- olive green, 300ppm -pale green and 400ppm- dark green. Residents Affected - Many QT instructions: *Dip paper in quat solution. Not foam surface for 10 seconds. Don't shake. Compare colors at once. *Testing solutions should be between 65-75F *Testing solution should have a neutral pH *Follow manufacturer's dilution instruction carefully. Facility unable to provide Manufacturer's dilution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 16 of 20 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 01/10/2025 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 On 1/7/25 at 10:50AM, V9 RN (Registered Nurse) taking Blood Pressure (BP) and Oxygen saturation of R113 using BP apparatus and pulse oximeter. After taking the vital signs, V9 proceeds to R217 without disinfecting the medical equipment used. After taking vital signs of R217 V9 used hand sanitizer but did not disinfect the medical equipment used. V9 stated that R113's BP is 107/57 and oxygen saturation is 92% and R217 's BP is 132/60 and oxygen saturation is 97%. Residents Affected - Some On 1/7/25 at 11:00AM, V9 RN proceeds to R416 and took R416's BP and oxygen saturation. V9 used hand sanitizer but did not disinfect the medical equipment used. V9 stated that R416's BP is 114/59 and oxygen saturation is 92%. Informed V9 of above observations that she took BP and oxygen saturation of 3 residents placing the BP cuff on their upper arm and pulse oximeter on their index finger without disinfecting the medical equipment in between residents' usage. V9 stated she should disinfect the medical equipment used after each resident with disinfectant wipes. On 1/7/25 at 11:10AM, V10 CNA (Certified Nurse Assistant) stated that R134 has Gastrostomy (GT) tube. V10 went to R134's room without knocking. Enhanced Barrier Precaution (EBP) noted on R134's door. V10 lifted R134's gown and to see R134's GT site and showed surveyor. V10 then left the room without performing hand hygiene. On 1/9/25 at 10:18AM, informed V2 Director of Nursing (DON) of above observations. V2 stated that staff should disinfect the medical equipment used such as BP apparatus and pulse oximeter after each resident used. V2 stated staff should wear PPE (Personal Protective Equipment) such as gown and gloves when touching or direct contact of resident on EBP and should perform hand hygiene before leaving the room. On 1/9/25 at 11:00AM, Informed V3 Infection Preventionist of above observations. V3 stated staff should disinfect medical equipment such as BP apparatus and pulse oximeter after each resident usage. V3 stated that staff should wear PPE- gown and gloves when touching or direct contact of resident on EBP and should perform hand hygiene before leaving the room. Facility's policy on Enhanced Barrier Precaution revised 7/26/24 indicates: Policy: The facility will use Enhanced Barrier Precaution (EBP) to reduce transmission of multi-drug resistant organism in the nursing homes. EBP involves the use of gown and gloves to reduce transmission or resistant organisms during high contact resident care activities for residents known to be colonized or infected with MDROs as well as residents with wounds and or indwelling medical devices. Facility's policy on Medical equipment, instruments and health IT devices infection control plan revised 8/16/24 indicates: Policy statement: It is the policy of this facility to prevent infection and create/maintain a safe environment for the residents, their visitors and staff thru proper handling, cleaning and sanitizing of medical care equipment, instruments and or other related health IT devices. Procedures: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 17 of 20 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 01/10/2025 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 Residents Affected - Some 7. Nursing personnel shall wipe down/clean reusable equipment between residents using a facility approved cleaner/disinfectant. On 01/09/2025 at 12:32PM during medication administration observation with V18 (Licensed Practical Nurse), R133's room has Enhanced Barrier Precaution sign on the door. V18 was giving medication through gastrostomy tube to R133 then proceeded to apply topical pain gel to both knees of R133 without changing gloves and performing hand hygiene, On 01/09/2025 at 12:42PM during interview with V18, V18 stated that she was supposed to change gloves and perform hand hygiene in between giving medications through gastrostomy tube and applying topical pain gel to R133, but she thought she was inside already and has no access to another pair of gloves. On 01/09/2025 at 12:55PM during interview with V3 (Infection Preventionist), hand hygiene and gloves should have been changed in between two different procedures. Review of R133's January 2025 Medication Administration Record indicated admission date of 02/01/2024 and Diclofenac Sodium External Gel and Guaifenesin was given on 01/09/2025 by V18. Review of facility's policy on hand hygiene revised on 07/30/2024 indicated the following: 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 guidelines in regards to hand hygiene. Procedures: 1. Hand hygiene using alcohol-based hand rub is recommended during the following situations: h. After contact with blood, body fluids or surfaces contaminated with blood and body fluids. i. After removing gloves including during wound dressing change. On 01/07/2025 at 11:45AM during observation, R26's and R120's room had a sign at the door that reads Droplet & Contact Precautions indicating that providers and staff must put on gloves before room entry. Transmission-based precaution set up outside of R26's and R120's room did not have gloves. On 01/07/2025 at 11:47AM during observation with V5 (Agency Licensed Practical Nurse), R26's and R120's bathroom did not have any hand soap. On 01/07/2025 at 12:00PM during observation with V3 (Infection Preventionist), R26's and R120's transmission-based precaution set up did not have gloves and mask. On 01/07/2025 at 11:47AM during interview with V5, V5 stated that all bathrooms should have hand soap. V5 also stated that the transmission-based precaution set up for R26's and R120's room should have gloves. On 01/07/2025 at 12:00PM during interview with V3 (Infection Preventionist), V3 stated that transmission-based precaution set up for droplet and contact precaution should have gowns, gloves, face (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 18 of 20 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 01/10/2025 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 Residents Affected - Some shields, mask, and disposable stethoscope. V3 also stated that all rooms should have hand soap regardless of if the residents in the room are on transmission-based precaution or not. Review of R26's laboratory test result reported on 01/02/2025 indicated positive for RSV (Respiratory Syncytial Virus). Review of R26's Order Summary Report dated 01/09/2025 indicated admission date of 03/20/2023 and order to maintain strict contact/droplet isolation precautions due to an active RSV infection with order date 01/03/2025. Review of R120's Order Summary Report dated 01/09/2025 indicated admission date of 02/08/2023 and order to maintain strict contact/droplet isolation precautions due to an active RSV infection with order date 01/03/2025. Review of facility's policy entitled Infection Prevention and Control revised 11/21/2024 indicated the following: Procedures: 7. A transmission-based precaution set up will be provided outside the resident's room to provide Personal Protective Equipment (PPE) like gown and gloves to staff and visitors entering the resident's room. Precautions to Prevent Transmission of Infectious Agents and Transmission Based Precaution: 2. Contact Precaution b. Use of Gown and gloves is necessary prior to room entry. 3. Droplet Precaution b. Eye protection and mask should be worn for close contact with the resident. Based on observation, interview, and record review the facility failed to ensure appropriate infection control practices in proper handling of respiratory equipment and disinfecting medical equipment in between resident use. The facility also failed to use appropriate infection control practices for residents on transmission-based precautions. This deficiency affects 8 (R26, R98, R113, R120, R217, R133, R134, R416) of 8 residents in the sample of 32 reviewed for Infection control. Findings include: On 1/07/25 at 10:51 AM, R98 in bed alert and verbal. R98 said that he receives nebulizer treatments about every other day and said that the nurses are the ones who administer it. R98 nebulizer mask observed hanging of floor from nightstand, mask uncovered and not labeled. On 1/07/25 at 10:53AM, V17 (Licensed Practical Nurse) stated that she is unsure who left nebulizer mask hanging on floor. V17 stated the nebulizer mask should be covered in a plastic bag and labeled when not in use to keep mask clean. On 1/09/25 at 12:36 PM, V2 (Director of Nursing) stated the nebulizer mask should be labeled with date and placed in a bag after use and put away in the drawer to prevent any infections and to make (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 19 of 20 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 01/10/2025 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 sure it is clean when it is used again. Level of Harm - Minimal harm or potential for actual harm Facility's Policy on Oral Inhalation Administration Purpose Residents Affected - Some To allow for safe, accurate and effective administration of medication using an oral inhaler or nebulizer. Nebulizer 23. When equipment is completely dry, store in a plastic bag with the resident's name and date on it. 24. Change equipment and tubing every according to facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 20 of 20