Inspection·January 18, 2026

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete R.N. provides supervision of staff and will safeguard thehealth, safety and welfare of all Guests under their care by following applicable laws,regulations, and established nursing policies and procedures. Essential Functions 5. Administer medications within the scope of practice of the R.N. Licensure. 7. Place pharmacy orders, for and administer all newly prescribed medications and document. 12. Administer or supervise all treatments prescribed by physicians including but not limited to pressure ulcer care, Foley catheter care, hot and cold compounds and intravenous therapy. 13. Supervise serving of prescribed diets and fluids intake and immediately report any issues to the physician and DON/ADON. 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 01/18/2026 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** Based on observation, interview and record review, the facility failed to follow its policy, failed to ensure g-tube site was clean, dressing applied and failed to administer g-tube feeding at the ordered rate. This failure affected one of four (R1) residents reviewed for quality of care. Findings include:R1 is a [AGE] year-old male, admitted to facility on 08/13/2025 with diagnoses not limited to Malignant Neoplasm of Oropharynx, Muscle Wasting and Atrophy, Lack of Coordination, Disorders of Muscle, COPD/Chronic Obstructive Pulmonary Disease, Chronic Frontal Sinusitis, Unsteadiness on Feet, Abnormalities of Gait And Mobility, Chronic Kidney Disease, Atherosclerosis of other Arteries, Malignant Neoplasm of Prostate, Polyneuropathy, Peripheral Vascular Disease, History of Falling, Spinal Stenosis, Gastrostomy Status, Major Depressive Disorder, Insomnia, Bipolar Disorder, Atrial Fibrillation, Alcohol use.R1's 11/10/2025 BIMS Summary Score 11 indicating moderate impairmentR1's Care Plan dated 11/6/25 Focus: R1 is receiving gastric tube feeding due to atresia of esophagus with tracheoesophageal fistula. He is a risk for infections, fluid overload, dehydration, aspiration pneumonia. Has chronic esophageal fistula and esophagostomy bag. Goal: R1 will tolerate g-tube feeding without complication through next review Date Initiated: 11/06/2023 Target Date: 02/08/2026 Interventions: Check g-tube site for signs/symptoms of infection, such as redness, drainage, etc. and notify physician. Date Initiated: 11/06/2023 R1's Order Audit Report: Order date: 1/05/2026 13:30 (1:30pm) documents Order Summary: Cleanse enteral tube feeding site with normal saline and apply dry dressing Order status: Active R1's Treatment Administration Record January 2026 documents in part: Unscheduled: Other Orders Cleanse enteral tube feeding site with normal saline and apply dry dressing. Order not transcribed onto schedule area within Treatment Administration Record. No documentation that g-tube site care was performed for 1/5/2026 through 1/16/2025 at 1:30pm when surveyor spoke with V3, Assistant Director of Nursing (ADON) regarding R1's g-tube site Review of Nursing Progress notes: no documentation regarding R1's g-tube care for 1/5/2025. On 1/16/2026 at 1:18pm observed R1 push call light pushed, and staff responded. R1 dressed, groomed and lying in bed with scooter close by. R1 stated, he can do a lot of his care and is able to let staff know if he needs something. R1 stated, he knows how to change his colostomy bag and staff is getting him some more bags. R1 further stated, my g-tube is supposed to have a dressing on it, and to be cleaned by staff but they do not clean it all the time. R1 stated, sometimes they will clean it and some days they do not. R1 stated, the nurse removed the gauze yesterday (1/15/26) and never put it back and did not clean it. Surveyor observed R1's g-tube site with large amount of brownish blackish crust encircling g-tube stoma and without any dressing. On 1/16/2026 at 1:36pm V3, Assistant Director of Nursing (ADON) entered room and R1 showed V3 his g-tube stoma site. V3 stated, the g-tube site should be covered, and it looks like it should be cleaned and has crust build-up. When V3 assessed the g-tube site, R1 winced in pain and stated, it is sore. V3 stated, she needs to check R1's order. After V3 exited room, R1 stated because they do not clean my g-tube site, I will clean it myself with alcohol. When they took the gauze off yesterday, it hurt. On 1/16/2026 at 1:40pm V11, Agency Licensed Practical Nurse (LPN) entered room and stated, she did not change R1's dressing because it is changed on night shift at 6am. R1 showed V11 his g-tube site and V11 stated, g-tube is supposed to be cleansed with normal saline and gauze applied. R1's g-tube site has crust around g-tube site, and I will clean it, but I did not get in report that R1's g-tube site was not cleaned, but I will clean it up. On 1/17/26 at 10:36 am V2, Director of Nursing (DON), stated, nurses should be changing the g-tube dressing daily, they need to make sure the area is cleaned, and it is done daily. V2 stated, the nurses (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 01/18/2026 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 FORM CMS-2567 (02/99) Previous Versions Obsolete should place a date on the dressing when they change it. If the order is in the TAR (Treatment Administration Record) they should mark it off there or sometimes they will mark it on the MAR (Medication Administration Record).Facility Policy: Enteral Tube Feeding Care Revised: 6/30/25 documents in part: Policy Statement Enteral Tube- is an avenue of feeding and hydration nutritional support via gastrostomy route. Procedure 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 G tube bumper, otherwise, a slim layer of light breathable gauze can be inserted under the disc. Job Description: Floor Nurse Updated: 12/1/2019 documents in part: LPN Floor Nurse Summary/Objective L.P.N. provides supervision of staff and will safeguard the health, safety and welfare of all Guests/guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions 5. Administer medications within the scope of practice of the L.P.N. Licensure. 7. Place pharmacy orders, for and administer all newly prescribed medications and document.12. Administer or supervise all treatments prescribed by physicians including but not limited to pressure ulcer care, Foley catheter care, and hot and cold compounds. 13. Supervise serving of prescribed diets and fluids intake and immediately report any issues to the physician and DON/ADON. Job Description: Floor Nurse Updated: 12/1/2019 documents in part: RN Floor Nurse Summary/Objective R.N. provides supervision of staff and will safeguard the health, safety and welfare of all Guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions 5. Administer medications within the scope of practice of the R.N. Licensure. 7. Place pharmacy orders, for and administer all newly prescribed medications and document. 12. Administer or supervise all treatments prescribed by physicians including but not limited to pressure ulcer care, Foley catheter care, hot and cold compounds and intravenous therapy. 13. Supervise serving of prescribed diets and fluids intake and immediately report any issues to the physician and DON/ADON. Event ID: Facility ID: 145700 If continuation sheet Page 4 of 4