Health inspection·March 30, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on interview and record review, the facility failed to document in residents electronic health record and notify family regarding a resident's fall. This failure affected one resident (R4) out of eight residents reviewed for quality of care. Findings include: R4 was [AGE] years old with diagnosis but not limited to: Senile Degeneration Of Brain, Shortness Of Breath, Dysphagia, Difficulty In Walking, Muscle Wasting And Atrophy, Muscle Wasting And Atrophy, Gerd, Hypertension , Conversion Disorder With Seizures Or Convulsions, History Of Falling, Dependence On Renal Dialysis, Raynaud's Syndrome Without Gangrene. On 3/29/25 at 9:32 am V12 (Fall Nurse) said R4 on 3/19/25 had fall. V12 said, R4 was transferred to bed 30 minutes prior to the fall and the bed was in low position. V12 said, during rounds R4 was observed lying next to her bed on the floor, she was a hospice resident, she was not sent out to the hospital as there was no need for hospital admission. V12 said, the protocol for falls is V12 herself need to be notified, doctor and hospice also. V12 said, nurse on the floor (V13) did not know the protocol when a resident has a fall. V12 said, the hospice nurse came in and made V13 aware R4 had a fall so V12 opened up the investigation regarding this. V12 said, she spoke to the nurse (V13) and the aide from the night shift, and they told her the resident did have a fall. V12 said, the nurse called the doctor and not family and should have called herself (V12). V12 said, V13 should have filled out the risk management forms, however V13 did not know how to do that and V13 ended up filling the forms out and she educated V13 on the fall protocol. V12 said, V13 should have called the family but did not and should have documented the incident. V12 said, V13 initiated the risk management documentation, but did not fill it out. On 3/29/25 at 10:02 am V13 (Licensed Practical Nurse) said she was the nurse on duty for R4 on 3/19/25. V13 said regarding the fall, V13 was on a break and she was informed by another nurse R4 was on the floor, after she was informed she went in and assessed R4 and she opened up the risk management (forms to fill out when a resident has a fall) but did not fill it out. V13 said, she notified the doctor and no one else, that was it. V13 said, she did not know who to call, she was agency at that time and she just got hired to be a wound nurse at the facility. V13 said, she has now received an education by V12 on documentation when a resident has a fall. Surveyor asked V13 if she documented a progress note regarding this incident, V13 said she did. V13 and surveyor reviewed R4's progress notes for 3/19/25 and V13 stated I guess I did not document the incident in the residents medical record (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145734 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 03/30/2025 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)