Health inspection·June 24, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitted to the facility on Friday 06/20/25 and her experience so far has been bad (referring to care). R1 stated that my room was uncomfortable but on Saturday and Sunday (06/21/25 and 06/22/25) it was so hot, it was horrible. R1 stated her assigned (Certified Nurse's Aide) identified as (V10) help her into the hallway where she stayed for some hours R1 stated that the family and friend who visited complained to the facility staff on both days and her niece had to bring a portable fan that was on the bedside dresser. R1 stated this morning (06/23/25) the facility started rushing her to another room that she is currently staying after suffering through the weekend. On 06/23/25 at 1:12pm, both R3 and R4 are roommates and they both stated that their room is very hot, but the staff are aware of it, and they have done nothing about it. R3 stated this has been worse on the last weekend (referring to 06/21 and 06/22/25. V8 (Maintenance Director) who was present listening by the hallway to the room doorway then stated I (V8) guess I should provide a portable fan for the residents who are still complaining (about the hot temperature in their rooms). On 06/24/25 at 2:00pm, V10 CNA (Certified Nurse Assistant) stated in part that at the beginning of the shift 3pm to 11pm on 06/21/25 it was very hot and by the end of the shift it was cooling down. V10 stated in part that some of the residents have their windows open and the supervisor told the staff to close the windows and that makes sense to her. V10 could not remember the supervisor's name or the nurse that relayed the message to her (V10). R1' medical record admission Record showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to Acute respiratory distress, dependence on supplemental oxygen, severe persistent asthma uncomplicated, and Epilepsy. R2 medical record diagnosis information listed includes but not limited to Mild intermittent asthma with acute exacerbation, presence of automatic (implantable) cardiac defibrillator, anemia, dependence on supplemental oxygen, heart transplant status, and immunodeficiency. R1 medical record showed that MDS (Minimum Data Set) is in progress. R2's MDS (Minimum Data Set) dated 4/4/2025 showed that R2's BIMS (Brief Interview for Mental Status) as 09. R3's MDS dated [DATE] scored BIMS as12, indicating that R3 is moderately cognitively impaired. R4's medical record MDS dated [DATE] scored R4 BIMS as 15, indicating that is cognitively intact. R5's medical record MDS dated [DATE] scored R5 BIMS as 14, indicating that R5 is cognitively intact. R6's medical record admission Record showed that R6 was admitted [DATE] with MDS in progress. R7's MDS dated [DATE] scored R7's BIMS as 14, indicating that R7 is cognitively intact. On 06/23/25 at 3:02pm, V4 stated that on 06/21/25 he did take the temperature when he noted that the building was warm and the temperature are between 76-and 78-degrees Fahrenheit, but the vents are not cooling enough because the fan belt are broken and this affect mostly the 100-units because the individual AC are not in working condition. V4 stated that the AC must be properly functioning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2025 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility policy on Ambient Temperature presented documented that it is the facility's policy to ensure that facility ambient temperature at comfortable level. Listed procedure includes but not limited to keeping temperature level all throughout the facility between 71 - to 80-degrees Fahrenheit, and in extreme hot temperature procedure should be activated. Facility policy on Extreme High temperature and Hot Weather documented that Administrative Code: Zones of Physiological Perception Comfort Level is between 68- to 75 degrees and following hot weather and extreme high temperatures precautions have been established for personnel to follow during the hot weather of summer (outdoor temperatures climb into the 80's and above. Listed guidelines includes but not limited to identify high risk residents who are susceptible to heat exhaustion and adverse health effects of hot weather, check air conditioning system for proper functioning, refer to maintenance for needed repairs or services, making sure the residents are properly dressed. The facility Job Description for Director of Maintenance summary objective documented that in keeping with our organization's goal of improving the lives of the guest (referring to Residents) we serve, the Director of Maintenance plays a role in maintaining all physical plant assets on the property. The director of maintenance manages the day-to-day operations of the maintenance department. Listed essential functions includes but not limited to responsible for all service and repair task as assigned, operates the maintenance department in a safe manner by ensuring compliance with Federal, State, and local regulations and following established policies and procedures, and ensure that regular equipment and system maintenance schedules are monitored must be followed. Facility Job description for Nurse supervisor LPN (Licensed Practical Nurse) documented under summary /objectives that in keeping with our organization's goal of improving the lives of the guest (referring to Residents) we serve, the Nurse Supervisor (LPN) plays a critical role in providing superior customer service and nursing services to all guest on the assigned unit as well in the facility as a whole, and the nurse supervisor LPN assist the Assistant Director of Nursing and the Director of Nursing (DON) in planning, development and overall operation of the assigned unit, which ensures that the guest (residents) receive quality care. Facility Job description for Nurse supervisor RN (Registered Nurse) documented under summary /objectives that in keeping with our organization's goal of improving the lives of the guest (referring to Residents) we serve, the RN unit manager plays a critical role in providing superior customer service and nursing services to all guest on the assigned unit as well in the facility as a whole, and RN Unit Manager assist the Assistant Director of Nursing and the Director of Nursing (DON) in planning, development and overall operation of the assigned unit, which ensures that the guest (residents) receive quality care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 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 145734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2025 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assure that the resident environment remains comfortable and homelike with cooling system in proper working order to maintain acceptable temperature within 71- to 81-degree Fahrenheit. This failure affected 100-unit and 200-unit wings in the facility. Findings include: On 06/23/24 at 9:45am, V4 (Assistant Maintenance Director) stated in part that the whole 100 units in the building was hot the AC (Air-conditioner) was not working well with the temperature outside very hot it became hard to keep the inside cool. V4 stated that there were 20 unit of the fans in the roof and two fan belts were broken. The vents are not producing enough cool air for circulation since the belt is broken. On 06/23/25 at 10:25am, V1 (Administrator) stated that she was made aware of this problem with the temperature on Sunday 06/22/25. During the facility tour observation starting at 1:02pm with V8 (Maintenance Director) the following observation made: 100-unit back hallway by room [ROOM NUMBER] temperature measured 81.3-degree Fahrenheit, Unit 200 back hallway temperature measured 81.5 degrees Fahrenheit. V8 stated we are working on it. On 06/23/24 at 2:29pm when this observation was brought to V1 (Administrator)'s attention, V1 stated that the external AC repair company will be supplying and installing portable AC units for the hallways in the building that will be big enough to circulate the areas in each unit. On 06/23/25 at 3:02pm, V4 stated that he did take the temperature when he noted that the building was warm and the temperature are between 76-and 78-degrees Fahrenheit, but the vents are not cooling enough because the fan belt are broken and this affect mostly the 100-units because the individual AC are not working. V4 stated that the AC must be properly functioning. The facility policy on Ambient Temperature presented documented that it is the facility's policy to ensure that facility ambient temperature at comfortable level. Listed procedure includes but not limited to keeping temperature level all throughout the facility between 71 - to 80-degrees Fahrenheit, and in extreme hot temperature procedure should be activated. The facility Job Description for Director of Maintenance summary objective documented that in keeping with our organization's goal of improving the lives of the guest (referring to Residents) we serve, the Director of Maintenance plays a role in maintaining all physical plant assets on the property. The director of maintenance manages the day-to-day operations of the maintenance department. Listed essential functions includes but not limited to responsible for all service and repair task as assigned, operates the maintenance department in a safe manner by ensuring compliance with Federal, State, and local regulations and following established policies and procedures, and ensure that regular equipment and system maintenance schedules are monitored must be followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145734 If continuation sheet Page 4 of 4