Health inspection·January 4, 2026

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a working call light for one (R4) of five residents reviewed for call lights. This failure resulted in a delay of staff helping R4.Findings include: R4 is a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses not limited to End Stage Renal Disease, Heart Transplant Status, Depression, Unspecified, Type 2 Diabetes Mellitus Without Complications, Essential (Primary) HypertensionR4's care plan documents in part: Focus: dated initiated:12/31/2025 Goal: I (R4) will be free of falls through Date initiated: 12/31/25 Interventions: I would like staff to provide me a safe environment: even floors, free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls Date Initiated: 12/31/2025On 1/2/2026 at 12:41pm R4 was sitting in chair in his room alert, able to make needs known, dressed and groomed. As surveyor was touring facility, R4 was calling out for help and repeating that he needed help. Surveyor knocked on door and R4 stated, surveyor could come in. R4 stated was not able to state how long he was calling for help, but he needed help getting back in bed and no one was coming. R4 further stated, he had been pushing call light, and it was not working, and the light did not come on. R4 was able to reach call light and was told if he needed something to use his call light so he could get help. Surveyor observed R4 pressing call light and the light did not come on above door, the light on the call light panel was not on, and there was no audible sound. On 1/2/2026 at approximately 12:45pm Surveyor approached V11 (Restorative Aide) and informed her that R4 needed help. V11 stated, staff was passing out lunch trays, but V11 and surveyor entered R4's room and V11 asked R4 what was needed. R4 showed V11 that he was pressing call light button. V11 stated, the light is supposed to light up outside the door and residents use the call light to let staff know they need help. R4 further stated, he wanted to go back to bed. On 1/2/2026 at 12:48pm V7, Agency Licensed Practical Nurse (LPN) was asked how residents get help if their call light does not work. V7 stated, that is a good question, without the call light we would not know the resident needs help. With R4's permission, Surveyor and V7 entered R4's room and V7 attempted to re-plug in call light. V7 stated, the light is not working for bed one or bed two, maintenance will have to be called. On 1/2/2026 at 12:52pm V12 (Maintenance Assistant) came to R4's room to check call light. V12 stated, when the resident presses the call button, the light is supposed to come on over the door. V12 stated, call lights are checked once a month, but if I go into a room, I will check everything. I just fixed this call light. Sometimes when the cord is wrapped around the bed it can get pulled out the wall. Both call lights for bed one and two go into one unit. If one does not work, the other will not work. If I cannot fix the call light, the resident will get a bell or moved to another room.On 1/2/2026 at 1:00pm V12 and surveyor entered R4's room with R4's permission. V12 stated, the call light is not working, it is not connected. Somehow it came off the wall the other day and I fixed it; it must have come lose. V12 detached the panel and Residents Affected - Few (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 01/04/2026 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)