Health inspection·October 16, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said I have been here since [DATE]. At 11:58PM V13 said the facility needs authorization to withdraw any funds. At 12:16PM the surveyor reviewed the signatures with V13 from four documents provided by the facility with V19's signature. V13 said the signature on the consent for withdrawal does not look the same to me. V13 said the first letter looks like an F to me and V13 signs with the P initial on the other documents. V13 said I don't see the P on the withdrawal signature. V13 said if I was doing this in a large amount, I would get a witness in case of something of this sort happened. V13 said we have no policy for this. On [DATE] at 9:36AM V13 said when a resident is Medicaid pending the bill is still sent out with full bill amount. V13 said once Medicaid approves the resident, the patient responsibility amount can change. While reviewing the Transaction report for R3, V13 said R3 was paying an amount less than her portion, in the amount of $113.00, and the amount is still owed. V13 said the $113.00 shortage each month continued to accumulate. V13 said Medicaid determined R3's patient liability was $1097 for July, August and [DATE]. At 11:06AM V13 said R3's bills changed if she enrolled in other services, dental and vision plans. V13 said $113 was to pay for her dental and vision plan if she signed up for it. V13 said R3 wasn't paying her dental vision and she still owed it to the facility. V13 said that amount kept accumulating. On [DATE] at 1:25PM V13 said the amount on the LTC Inquiry Results (TPL) form for the date ranges show the amount we are allowed to take out for resident care cost. V13 said the amount on the form should be the same as the amount on the resident bank statement withdrawal. V13 said that is how much medicaid has allowed them for their care, it includes dental and vision. V13 said the withdrawal amounts on the statement for R3 are different because she has elected to have vision and dental benefits. On [DATE] at 11:41AM the surveyor asked V7, Administrator, why V13 was sent a check for her full amount if she still owed $398.42? V7 said V19 would not agree to that amount be taken out. V19 said they have to agree for us to take it. On [DATE] at 2:05PM V13 presented a Cash Receipts Report for R3. V13 said we are going to refund $2156.00 related to the vision and dental benefits to V13 for R3's account. Facility presented a letter regarding R3 dated [DATE] addressed to the financial department. Letter states V19 would like for R3's $5504.06 amount to applied to her back balance. Also, continue to deduct R3's $30.00 each month and apply towards the back balance until the balance is paid in full. There are 2 signatures on document, includes V19 and former BOM. Review of R3 bank statements $30.00 not taken out. The facility presented four documents with V19's signature, witness certificate dated [DATE], certification for surrogate dated [DATE], and the withdrawal letter and a letter written by V19 requesting she be removed from the bill dated [DATE]. The signature on the withdrawal document that the facility alleges is V19 is not similar to the other two documents. The withdrawal consent is dated [DATE]. On [DATE] V7 Administrator said we were sending V19 collection letters for the balance owed. R3's banking statement reviewed since [DATE]. Every month SSA Treas credit was made. Every month an amount, determined to be R3's care cost was withdrawn by the facility. After 2020 R3 had balance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 2 of 12 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Evergreen Park 10124 South Kedzie Evergreen Park, IL 60805 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 0602 Level of Harm - Minimal harm or potential for actual harm amounts between $4000.00 - $5000.00. The facility did not present collection letters requested during the survey on [DATE] or [DATE]. The facility was unable to present an itemized billing statements for the alleged BALANCE FORWARD $7894.72. On [DATE] R3's banking statement description is Resident Advance Debit $5504.06. Residents Affected - Few The facility presented R3 billing statement dated [DATE]. The statement list BALANCE FORWARD $7894.72 The facility paid out $840.94 to V19 and did not deduct the alleged $398.42 owed as stated on the facility's IDPH (Illinois Department of Public Health) report. Dental Insurance plan dated [DATE] notes a monthly premium of $199.36 for R3. Documents states, in part, I authorize the facility to disburse payment. Document was signed by R3. Vision Policy application dated [DATE] notes R3 monthly premium increased to $70.00. This amount totals $269.36, not $113.00. The Resident Rights booklet provided by the facility states if you ask the facility to manage your money it may only spend your money with your permission. It must give you a current, itemized written statement at least once every three months. If your facility manages your money and you get Medicaid your facility must tell you if your savings come within the amount Medicaid allows you to keep. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 3 of 12 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Evergreen Park 10124 South Kedzie Evergreen Park, IL 60805 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R1 diagnosis include but not limited to Alzheimer's Disease, History of Falling, Unsteadiness On Feet, Repeated Falls, Scoliosis, Age Related Osteoporosis, Dementia, Mood Disorder, Generalized Anxiety Disorder. Fall with Injury report dated 9/17/24 stated R1 observed laying on floor. Facility Final Incident Report stated 9/25/24 states R1 transported to hospital for evaluation. R1 return to the facility with 8 sutures to forehead and a closed nondisplaced fracture of second metacarpal bone of right hand. R1 fall without injury dated 7/16/2024 notes R1 on the floor. R1 stated she was trying to transfer herself from wheelchair to bed. Root cause analysis states R1 was trying to get back in bed. On 10/5/24 at 10:41AM R1 in regular wheelchair, no pommel cushion, R1 wearing black slacks. R1 crescent shape bruise, yellow/light blue under right eye, right arm dressed in what looks like a white ace wrap. On 10/8/24 at 11:05AM V3, Registered Nurse (RN), said on 9/17/24 R1 was in the wheelchair. V10, CNA, said she got R1 up for lunch and she was eating in her room. V3 said V10 said she left the room to care for another patient. V3 said V10 said she left R1 alone about 10 minutes. V3 said R1 said she did not know what she was trying to do when she fell. V3 said R1 probably fell forward. V3 said R1 was a resident at risk for falls. On 10/8/24 at 12:22PM V10, Certified Nursing Assistant (CNA), said on 9/17/24 I got R1 up for lunch and sat her at the side of the bed, with her tray table. V10 said after R1 ate I picked up her tray and went to the bathroom and then I stopped by another resident's room. V10 said in that time a co worker came and told me R1 was on the floor. V10 said the Nurse and coworker were in R1's room when I got there. V10 said when I left the room R1 had been sitting in the wheelchair. V10 said R1 had one cushion in her wheelchair at the time. V10 said I was in the room with R1 while she ate and after I got her tray I left her alone. V10 said I am not sure if R1 could sit in her room alone. V10 said I knew she was a fall risk. On 10/8/24 at 12:09PM V6, CNA, said R1 has confused memory. V6 said R1 is a two person assist for transfer and she can be resistant. V6 said R1 can stand. V6 said I would not recommend R1 be left in her room in her wheelchair alone because she tries to get up unassisted. After interview V6 showed the surveyor R1 sitting on royal blue pommel cushion during meal. Surveyor observed R1 also sitting on black wheel chair cushion. V6 with ace bandage on right wrist. (R1 had not been on this cushion during earlier observation.) At 12:55PM the surveyor observed R1 with only the one blue pommel cushion, the black one had been removed. On 10/8/24 at 1:03PM V9, Fall Coordinator, said R1's intervention since the July fall is to not leave her alone in the room when in her wheelchair. V9 said R1's 2nd fall (9/17/24) they left her in the room and when staff returned R1 was on the floor. V9 said they should have taken R1 to activity and not left her alone in her room. V9 said we place the interventions on the care plan. V9 said I don't put the dates on the careplan interventions. R1 fall report on 7/16/24 stated R1 mental status confused, alert and oriented times one, poor safety awareness. R1 attempting to stand/transfer without assistance. Root cause analysis of fall states (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 4 of 12 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Evergreen Park 10124 South Kedzie Evergreen Park, IL 60805 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 R1 stated she was trying to get back in bed when she fell. Level of Harm - Actual harm R1's safety fall care plan initiated on 9/12/22 includes risk factors of poor sitting balance, poor standing balance, poor safety awareness, unsteady gait, and needs assistance in transfer. Interventions dated 9/12/24 include therapy evaluation, floor mats, pommel cushion. Residents Affected - Few R1's hospital emergency department record dated 9/17/24 reads, noted to have large laceration to head. Laceration repair performed to 3cm laceration on forehead, 8 sutures. R1's hospital emergency department record dated 9/19/24 states R1 presenting for evaluation of right hand pain. Sent back for evaluation of right wrist pain that has been going since her fall 2 days ago. Right wrist and right hand x-rays an acute nondisplaced oblique fracture involving the proximal metadiaphysis of the right second metacarpal. 5. R2 diagnosis include but are not limited to Alzheimer's Disease, Dementia, Hallucinations, and Encounter for Palliative Care. R2 incident report dated 9/19/24 at 3:00AM states writer heard a thump, upon investigation, R2 observed sitting on the floor. Post fall investigation notes R2 was attempting to get out of bed. R2 alert, poor safety awareness. Root Cause Analysis states a summary of the fall. R2 was unable to explain the nature of the incident. Interventions to address incident noted perimeter cover and room change close to the nurses station. Actual cause of the fall is not included. On 10/10/24 at 10:09AM V12, CNA, said on 9/19/24 the last time I saw R2 she was asleep in the bed. V12 said when I saw R2 on the floor she was sitting with her legs up, with squatting legs, looked like she was trying to get up. V12 said R2 was in the middle of the room, between the beds. R2 was barefoot, she was not on the floor mat. V12 said I had never had R2 try to get up before. V12 said R2 is usually a check and change at night. V12 said I didn't think R2 could walk. V12 said I had not worked with her again. V12 said to my knowledge R2 had not fallen before. On 10/4/24 at 2:00PM R2's bed observed in her room. Air mattress in use and white flat sheet. On 10/8/24 at 12:55PM R2 bed observed, no ridged/lipped mattress on the bed. Air mattress in place, pump at foot of the bed. On 10/8/24 at 11:20AM V4, CNA, said R2 requires total care to get into her reclining chair. V4 said once she is up she is to come out to a supervised area. V4 said R2 is a fall risk, she scoots to the edge of the bed. On 10/8/24 at 1:57PM The surveyor asked V15, Licensed Practical Nurse (LPN), to show R2's perimeter cover. V15 looked in the computer and paper and was unable to answer. V14, Medical Records, walked to R2's room with the surveyor. V14 removed the covers on R2's bed and presented only the air mattress. V14 said the perimeter covers need to be brought to the unit when needed. V16, Clinical Manager, approached and surveyor asked if R2 is supposed to have a perimeter cover. V16 went to get a list and said R2's name is on the list and yes she should have one. V16 showed the surveyor what a perimeter cover looks like. Perimeter cover has raised bolster like areas along the head of the bed and foot of the bed. On the surveyors observations 10/4/24 and 10/8/24 R2's bed did not have the device in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 5 of 12 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Evergreen Park 10124 South Kedzie Evergreen Park, IL 60805 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 - Actual harm Residents Affected - Few On 10/9/24 at 11:52AM V9, Fall Coordinator, said after R2's fall on 9/6/24 we had got a new bed that goes lower to the floor than her prior bed. On 9/19/24 R2 had a fall. V9 said they probably removed her socks. V9 said proper footwear can be shoes or non-skid socks. V9 said on 9/6/24 R2 has a 15 fall risk score, it means she is a high fall risk. V9 said the interventions for R2 were not effective to prevent an injury on 9/19. V9 said the perimeter cover was added after R2's fall on 9/19/24. R2's care plan date initiated 1/9/24 states if resident is ambulating staff to make sure that resident is wearing proper footwear. Interventions include low bed, fall mats, and perimeter cover. R2 was high fall risk with a score of 15 on 9/6/24. R2's cognition assessment on 9/5/24 score is 6, severely impaired. R2 Functional Abilities assessment dated [DATE] states she is dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and rolling when in bed. Walking and transferring was not attempted. R2 fell on 9/6/24 at 7:45AM. R2 observed sitting on the floor at the foot of the bed. Post fall investigation states R2 was attempting to get out of bed, was confused, poor safety awareness, R2's last fall was 8/21/24. Root cause analysis notes R2's diagnosis, BIMS score 6, alert times 1. R2 observed in a sitting position on the floor by her bed. R2 was unable to recall the nature of the incident. Intervention notes low bed (hospice). Actual cause of fall is not included. R2's hospice records reviewed. Medical equipment provided does not include the mattress perimeter cover. Employee statement dated 9/19/24 written by V17, LPN, reads R2 was bare foot when she fell. R2's hospital record states has a 3cm laceration above her right eye. Laceration repair performed on 9/19/2024 for 3cm length laceration to right eyebrow region, 6 sutures. 6. R8 diagnosis include but are not limited to End Stage Renal Disease, Malignant Neoplasm of Bronchus, Anemia in Chronic Kidney Disease, Depression, Anxiety, Chronic Right Heart Failure, Cirrhosis of Liver, Arthritis, Adult Failure to Thrive, Dependence on Renal Dialysis, and Difficulty in Walking. The facility Incident Report initial date 9/25/24; final dated 10/1/24 states R8 received sutures to his right eyebrow. On 9/25/24 at 00:30AM R8 observed on the floor on front of his walker near his bed. Noted with an open area to his right eyebrow. R8's cognition score is 11/15. R8 said I got up from my bed with a walker in the dark to walk to the bathroom. I tripped over a wheelchair and fell hitting my head and face on the floor. According to assigned CNA, around 10:20PM R8 was toileted and made comfortable in bed. On 10/15/24 at 11:13AM V24, CNA, said R8 was in bed asleep, I rounded on him about 10:45PM him and all his room mates. V24 said I sat down at the nurses station, the call light came on, when I went in the room I saw R8 on the floor with the walker by his side. V24 said R8 said he was walking to the washroom, I called the nurse, and she came in. V24 said the room mate had called with the call light. V24 said R8 was by bed one and bed two at the foot of the roommates' bed. V24 said R8 had not made it to the bathroom. V24 said we put him in the bed 911 was called and they came and got him. V24 said R8 was not wet when we found him. V24 said R8 had a bowel movement after he was in the bed. V24 said I was not assigned to R8. V24 said before that day, there are times, I had seen him in the bathroom calling for assistance with the call light. V24 said I had not taken R8 to the bathroom on my (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 6 of 12 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Evergreen Park 10124 South Kedzie Evergreen Park, IL 60805 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 shift, he was in bed asleep when I last saw him. V24 said my shift started at 2:30PM, I did a double. Level of Harm - Actual harm On 10/15/24 at 2:42PM V25, LPN, said R8 had his walker in front of him. V25 said the CNA, V24, notified me of the fall I was getting ready to go have lunch. V25 said the walker on the floor was the walker that was in his room. V24 said R8 had been using that walker before by himself. V25 said R8 had walked with that walker to the nurses' station to get snacks on other days. V25 said R8 was on the floor, right in front of the bathroom door. V25 said there were a couple of wheelchairs in the room. V25 said I didn't see a wheelchair that he said he tripped on. V25 said R8 said when he was turning he went down. V25 said I assume the room mates called for help, but I didn't ask them anything. Residents Affected - Few On 10/15/24 at 1:41PM V16, Unit Manager, said I helped R8 in a wheelchair. V16 said I never seen R8 walking with nursing. V16 said R8 was in a dialysis chair and I am not aware of R8 having a walker. On 10/15/24 at 12:39PM V26, Director of Rehab said R8 had diminished strength and endurance. V26 said R8 was non ambulatory with physical therapy because he had a lot of pain with range of motion and bed mobility. V16 said R8 used a manual wheelchair with supervision. V26 said therapy did not give R8 a walker because R8 could not even stand. V26 said therapy never gave R8 a walker and we (therapy) would have been the ones to give it to him. V26 said if restorative gave R8 a walker we would have been asked to assess him for the need. V26 said we never leave assistive devices in the room, unless it is someone who has been here long term. V26 said if we leave a walker in the room then we would say it is safe for the resident to use. At 2:28PM V26 provided the evaluation and plan of treatment for R8. V26 said R8 was unable to ambulate and he was disoriented when I attempted to screen after admission (period of 9/6/24-9/25/24). I attempted to screen R8 multiple times. V26 said R8 told us he was able to walk and take care of himself. During treatment we saw R8 was unsafe for a lot of physical therapy things and he had poor endurance even to sit up. V26 said when we had the care plan and we spoke with the family they said he was mainly here for therapy. V26 said the family said R8 was needing assistance with care. V26 said on R8's evaluation the goal was for R8 to ambulate 50 feet with a walker, but due to his safety and medical condition he couldn't even stand. V26 said when the evaluation states not attempted due to medical conditions or safety concerns it means R8 could not stand that was for transfers and gait. V26 said my goal for R8 was to spread out his therapy to prevent. V26 said R8's posture was poor, he couldn't even tolerate sitting. The surveyor asked if the staff should have been allowing R8 to walk without assistance? V26 said R8 should not have been walking. On 10/15/24 at 12:29PM V9, Fall Coordinator, said R8 got up in the dark to go to the bathroom attempting to take himself. V9 said V24 was the aid and she had taken him to the bathroom earlier. V9 said when R8 was taking himself he tripped over a wheelchair. V9 said I don't know who's wheelchair he tripped on. V9 said R8 needed assistance of 1 to ambulate. V9 said R8 had not received a urinal before so we gave him one and a nightlight. V9 said I am not sure if R8 was needing to have a bowel movement or urinate at that time. At 1:03PM during a follow up interview, V9 said R8 tripped over the roommates wheelchair and hit his head. V8 said the Therapy Department gives the ambulation status and assistive devices. V9 said I gave R8 a urinal after the fall, when he came back from the hospital (10/1/24). V9 said I don't know if R8 had a urinal in the room the night of the fall. The surveyor asked if the resident tripped on a chair, how was his path free of clutter. V9 did not answer. Physical Therapy Evaluation and Plan of Treatment record dated 9/12/24-10/11/24 states R8 Transfer and Gait goals were not attempted due to medical conditions or safety concerns. Precautions listed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 7 of 12 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Evergreen Park 10124 South Kedzie Evergreen Park, IL 60805 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 - Actual harm Residents Affected - Few fall/safety risk intense low back and right thoracic area with movements. Dialysis. Bed mobility sit to lying and lying to sitting on side of bed not attempted due to medical conditions or safety concerns (unable to perform due to intense back and right thoracic pain with movement. R8's Medication Administration Record for September 2024 includes Amiodarone (cardiac anti-arrhythmic drug) start dated 9/10/24 and Sertraline (Antidepressant) start date 9/7/23. R8's Restorative assessment (UDA) dated 9/6/24 states requires assist with ambulation and transfer. Adaptive Equipment notes [NAME] (therapy said they did not give R8 a walker). R8 is one person assist for transfer. Fall risk score is not documented on this form. Medications listed on Fall Risk Evaluation list no for antidepressants. Mobility the resident is able to walk with assistant and/or assistive devices: yes. The residents gait is steady R8's care plan initiated on 9/6/24 Safety/ Fall R8 is at risk for fall due to multiple medical, functional, mental and physiological condition resulting to be at risk for fall. Ambulation: needs assist in walking, poor sitting balance, poor standing balance, unsteady gait, needs assistance in transfer, pain and discomfort. Forgetful needs reminders. Poor safety awareness regarding preventions to use call light. Period of restlessness and agitation. Interventions dated 9/6/24 include: Use assisted device during ambulation to prevent falls (therapy said R8 can not walk). Keep needed items, like urinal within reach (9/6/24) and staff to provide a safe environment free of clutter (9/6/24). Employee Statement dated 9/25/24 for V24, CNA, notes Yes I am the assigned CNA for the resident. (V24 said I was not assigned to R8.) R8's incident report dated 9/25/24 at 12:30AM stated observed on floor face down in room next to walker. Active bleeding to right eyebrow. R8 stated I fell trying to go to the washroom. I tripped. Laceration right eyebrow. R8 incident factors note ambulating without assist, using walker, toileting needs. R8 Post Fall Investigation for the fall on 9/25/24 notes R8 ambulating independently, has poor safety awareness, poor lighting, R8 not at risk for falls. R8 was toileted at 10:20PM, last seen in bed at 11:40PM by his CNA. R8 said I had to go to the bathroom. I got out of bed using a walker in the dark and tripped over a wheelchair. I fell and hit my face and head on the floor. I was feeling weak. Interventions to address incident: Night light and urinal. Date completed 9/25/24 (same day as the fall). The facility Incident Report initial date 9/25/24; final dated 10/1/24 states R8 the wheelchair the R8 tripped on was identified as the roommate's wheelchair, which was properly adjacent to the roommate's bed, not posing a hazard. R8 received sutures (No procedure report was included in the hospital record and no count of sutures was documented in R8's electronic record.) to his right eyebrow. Based on observation, interview, and record review the facility failed to ensure fall prevention intervention to include supervision/monitoring were implemented to reduce the risk of falling, failed to ensure residents were assessed and able to use assistive device safely to prevent falls and injuries. This affected six of six residents (R1, R2, R4, R5, R6, R8) reviewed for falls and safety. This resulted in R1, R2, R6, and R8 having fall resulting lacerations to the scalp, R4 being in a fall incident attempting to use an assistive device and sustained a left fibula fracture, and R5 bumping into open door using a motorized wheelchair and sustain a right and left tibia fracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 8 of 12 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Evergreen Park 10124 South Kedzie Evergreen Park, IL 60805 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 Findings include: Level of Harm - Actual harm 1. R4 face sheet shows diagnosis of hemiplegia, hemiparesis following cerebral infraction affecting right dominate side, other lack of coordination, and history of falling. R4 MDS assessment dated [DATE] denotes in-part section C for cognition shows a score of 3 (cognitive impairment). Residents Affected - Few R4 incident report dated 9/11/24 denotes in-part writer summons to room by CNA, upon entering I (writer) observed resident sitting on floor in front of her closet. Prior to sitting in wheelchair near closet. Predisposing physiological factors- confused, gait imbalance. Predisposing situational factors- trying to stand without assist. R4 fall risk evaluation dated 9/11/24 denotes in-part a score of 13 (high risk), R4 fall risk evaluation dated 9/29/24 denotes in-part a core of 18 (high risk). R4 incident report dated 9/29/24 completed by V1 denotes in-part fall without injury, incident location, resident room. right at her residence bed alarm sounding upon entering residence room writer observed resident sitting on the edge of the bed holding her walker writer asked resident what she was trying to do, and resident stated she needed to use the restroom. While writer was assisting residents to the restroom, resident appeared to lose her balance, while assisting resident to the floor both the writer and resident fell resulting in resident falling on writer. Resident noted with non-skid socks on, room free of clutter. Call light in reach but not activated. Head to toe assessment completed no bleeding bruising or deformities noted at this time. Vitals assessed BP 110 / 60, heart rate 57, temp 97.6, blood sugar 100, respirations 18, O2sat 97% room air. Resident transfer back to bed via Hoyer lift, two staff assist, resident complaints of pain 0 of 10. Fall coordinator notified. Physician notified and orders received to send resident to (hospital name) hospital for further evaluation. Sister notified. Predisposing environmental factors none of the above. Predisposing physiological factor; use of blood thinners, diabetes, balance poor/balance disorders. Predisposing situation factors: ambulating with assist, recent room change, using walker. Agencies/people notified; DON/designee and family. R4 post fall investigation/ RCA (root cause analysis) dated 9/30/24 denotes in-part observed fall with injury, location- resident room, did incident result in injury-yes, type of injury- left closed fibula fracture. Activity at time- ambulating with staff, mental status- alert and orient 2-3, poor safety awareness, is resident at risk for falls- yes, does resident have history of falls- yes. Root cause analysis- R4 is a [AGE] year old female with diagnosis of bipolar disorder major depressive disorder hemiplegia and hemiparesis following cerebral infarction affecting right dominant side alert and oriented times 2 to 3 BIM score of three and a stand and pivot in transferring. R4 was changed in bed by CNA at 4:00 PM. The nurse responded to R4's bed it alarm sounding when the nurse entered the room R4 was observed sitting on the edge of the bed. When the nurse asked R4 what she was trying to do R4 stated she had to use the bathroom. The nurse was assisting a resident to the bathroom using a gate belt when R4 lost her balance the nurse eased the resident to the floor both resident and a nurse fell resulting in falling on top of the nurse resident was transferred out for evaluation per MD orders facility anticoagulation protocol. Therapy to evaluate and treat. On 10/4/24 R4 said the nurse was helping her to bathroom and she fell. R4 said she broke her ankle. On 10/8/24 at 11:48am V2 (CNA) said he has worked with R4, V2 said he has ambulated R4 using her walker. V2 said when he uses the walker, he put the wheelchair behind R4 just in case she gets weak (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 9 of 12 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Evergreen Park 10124 South Kedzie Evergreen Park, IL 60805 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 - Actual harm and fall. V2 was asked how is R4 safe to use a walker if she might get weak and fall. V2 said that's why I use the wheelchair too, it just depends on what she needs. V2 said he was R4's aide when R4 had a fall on 9/11/24. V2 said he observed R4 on the floor in her room sitting on her buttocks, R4 told him her legs got weak and she fell, when she was at the closet. Residents Affected - Few On 10/8/24 at 10:21am V1 (Nurse) said she heard R4 bed alarm sound, she went in the room and observed R4 sitting at the bedside with a walker. V1 said R4 stated she wanted to go to the restroom, V1 said she offered to help R4. V1 said she put a gait belt around R4 waist, she stood R4 up, R4 had the walker in front of her, as R4 was ambulating R4 lost her balance a fell backwards toward her, which caused her to fall with R4. V1 said R4 landed on top of her. V1 said R4 used a walker for ambulating. On 10/8/24 at 1:14pm V9 (Fall coordinator) said she conducted the fall investigation for R4 fall, date of fall was 9/29/24. V9 said R4 had a fall while ambulating to the restroom. V9 said the root cause of R4 fall was that R4 was ambulating and fell. V9 said R4 was not assessed to use a walker, V9 said R4 ambulation status was not assess or evaluated. V9 said she had never observed R4 ambulating. V9 said R4 had a room change and she believes that walker was left in the room. V9 said she called R4's family and the said they did not give R4 that walker. V9 said R4 should not have a walker, that's why she removed the walker when she found out staff was using that walker for R4. V9 said she was not aware that staff was ambulating R4, she was not aware that staff was ambulating R4 with a walker. V9 said R4 family did not want R4 to have any functional decline. V9 said she did not refer R4 to therapy for functional decline until R4 had the fall on 9/29/24. On 10/8/24 at 2:01pm V11 (Restorative Director) said staff should not ambulate a resident without having an assessment completed. V11 said staff should not be ambulating R4 with a walker if R4 was not assessed to use a walker by therapy. During a follow up interview V11 said R4 did not receive an evaluation or an assessment from restorative after the fall for 9/11/24. R4 was referred to physical therapy after the 9/29/24 fall with injury. On 10/11/24 at 1:59pm V22 (care plan coordinator) said she initiated R4 plan of care and the assistive device for ambulating should be a gait belt, V22 said she don't know why she did not document what assistive device that R4 uses. V1 (Nurse) witness statement denotes in-part, resident was being assisted by staff to restroom when resident lost her balance and was shaky and fell down with staff member. R4 current plan of care presented by V8 (Director of Nursing) denotes safety: fall admitted in unit was observed she is high risk for falls related to current medications use, poor safety awareness, unsteady gait, disease process: sarcoidosis, CHF, alcohol use with withdrawals cognitive impairment, gait problems, such as unsteady gait, even with mobility aid or personal assistance, slow gait, takes small steps, takes rapid steps or lurching gait, hemiplegia/hemiparesis, history of falls. Contributing factors: physical/function status, ambulation; needs physical and verbal assist, poor standing balance, unsteady gait, needs assist in transfers, on and off pain/ discomfort, incontinence, needs reminders: safety awareness, prev (prevention) of fall reminders to use call light. R4 will participate during safe transfer technique with 1-2 staff assistance from bed to chair w/o (without) resistance, w/o undetected, unrepeated incident of fall. R4 need to wear nonskid socks/shoes, proper footwear, bed locks/WC (wheelchair), locks engage for transfer, use assistive devices during ambulation to prevent falls, skilled rehab therapy eval and treatment as indicates, ensure call light, phone and supplies within reach, keep mostly needed items within reach, ensure room is clutter free and dry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 10 of 12 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Evergreen Park 10124 South Kedzie Evergreen Park, IL 60805 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 SPOST (status post) fall initial intervention5/3/24 sent to hospital for eval, signage (precaution) floor mat (1), bed alarm, restorative to evaluate/referral, therapy eval. Level of Harm - Actual harm R4 hospital records dated 9/30/24 denotes in part clinical impression closed fibula fracture. Residents Affected - Few Facility falls occurrence policy with last revised date of 7/26/24 denotes in-part 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. The fall assessment form will be completed by the nurse or the falls coordinator upon admission, quarterly, significant change and annually. Those identified as high risk for falls will be provided fall interventions. An incident report will be completed by the nurse by the nurse each time a resident fall. The falls coordinator will review the incident report and may conduit his/her own fall investigation to determine the reasonable cause of fall. The nurse may immediately start interventions to address falls in the unit even prior to the Fall Coordinator investigation. Ultimately, the falls coordinator may change the interventions provided by the nurse if the falls investigation identifies a more appropriate intervention for the individual. Facility care plan policy with last revised date of 7/26/24 it is the policy of the facility to ensure that all care plans including baseline care plans are in conjunction with the federal regulations. Comprehensive care plan must be developed after the comprehensive assessment of the resident. 2. R6 face sheet shows diagnose of history of falling, unspecified dementia. R6 MDS dated [DATE] denotes in part, BIMS score of 7 (cognitive deficits). Section GG for functional abilities and goals denotes toileting hygiene: 03 (partial to moderate assist). R6's final incident report to the department dated 9/17/24 denotes in-part, diagnosis COVID, hypertension, anemia, hyperlipidemia, atherosclerotic heart disease, atherosclerotic coronary artery bypass graft, GERD, prostate hyperplasia, non-infective gastroenteritis colitis, type 2 diabetes mellitus, COPD, dementia. R6 was observed lying on the floor near his bedside. Body assessment was completed, resident noted with small cut to the left side of his head. Area was cleansed with normal saline and dry dressing applied. Pain medication administration per physician order. Range was limited as patient did not want to move. BP (blood pressure) 148/76, P (pulse) 77, R(respiration) 19, T(temp) 97.6, 02 sat 95%. Physician was notified. Resident transported to hospital for further evaluation. R6 readmitted back to the facility with three staples to the left side of his head. No additional injuries noted. The plan of care has been reviewed and updated to address the resident's needs. Injury: yes, 3 staples to left side of head. When interviewed R6 stated I got up to go to the bathroom by myself I didn't push the call light for help because I thought I could make it by myself. I took a couple steps and lost my balance landing on floor. Based upon further investigation, staff interviews, and medical records review. Prior to the incident at 11:30 PM the assigned CNA did rounds and noted the residence in the dry and resting comfortably. At 1:50 AM upon rounds the nurse heard R6 calling out for assistance, when she entered the room, she noted R6 laying on the floor his incontinence brief was open and urine on the floor. Body assessment was completed. Resident sustained a small cut to left side of his head. Area was cleaned with normal saline and dry dressing applied. Pain medication administered. V9 was asked if R6 had the mental capacity to remember to pull call light before going to the bathroom. V9 said R6 knew how to use the call light. V9 was asked does R6 have the mental capacity to understand safety concerns and that he could injury himself if he did not press the call light and wait for staff to coma and take him to the bathroom. V9 did not respond. Facility incident report dated 9/11/24 denotes in-part upon doing rounds resident noted on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 11 of 12 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Evergreen Park 10124 South Kedzie Evergreen Park, IL 60805 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 - Actual harm floor near his bedside with his brief off and urine on the floor. Prior to the incident resident was noted resting in bed comfortably with no distress noted. Injury type: top of scalp. Pain:8. Oriented to person. Wet floor, incontinent, weakness/fainted, altered mental status, dementia related behaviors, fragile skin. Physician, ombudsmen, and family notified. Residents Affected - Few Facility post fall investigation/ RCA (root cause analysis) R6 is an [AGE] year-old male with diagnosis of unspecified dementia, history of falls, COPD, type 2 diabetes, alert, and oriented x2-3 with periods of confusion. R6 was observed by CNA in the bed at 11:30pm, resting comfortably and dry. R6 stated he had to go to the bathroom and did not pull his call light for assistance, he got out the bed independently, took a couple of steps and that's when he fell onto the floor. R6 couldn't remember if he had any socks or shoes on and 45 minutes prior to the incident, R6 was seen in bed asleep by the nurse. R6 admission/ readmission assessment shows call light evaluation- is the resident cognitively able to use the call light, no is checked. R6 fall risk assessment dated [DATE] shows a score of 17 (high risk). On 10/10/24 at 10:02am V9 (Fall coordinator) said R6 was admitted on [DATE], R6 fell on 9/11/24. V9 said R6 was admitted for rehab and due to a respiratory infection. V9 said R6 was alert times 2 (person, place) with episodes of confusion. V9 said R6 root cause of his fall was due to R6 had a fall because he got up to go to the bathroom. V9 said the incident happened around 1:50am. V9 said R6 had a sitter that was provided by the family during the day. V9 said the unit Nurse's informed her that R6's family request that R6 have a chair alarm and that R6 had previous falls at home. V9 said she provided R6 with the chair alarm. V9 said she did not follow up with the family to inquire about R6 fall history at home and why the family was requesting a chair alarm. V9 said the nurse did not give her any information regarding R6 fall history. V9 said she don't know if the nurse asked the family about R6 fall history. V9 did not respond when asked if she asked R6 about his fall history at home. V9 said she don't know if R6 was getting up at night at home when his falls occurred. V9 said she should have inquired further about R6 fall hi[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 12 of 12