Health inspection·February 21, 2024

F 0755 On 2/21/24 at 10:46 AM, V4 Nurse Manager stated medications are considered late if administered later than one hour after the medication is scheduled. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145816 If continuation sheet Page 2 of 5 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 145816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a significant medication error did not occur for a newly admitted resident. This failure applies to 1 of 4 residents (R1) reviewed for medication administration in the sample of 11. Residents Affected - Few The findings include: R1's admission Record showed R1 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. R1's February 2024 Medication Administration Record (MAR) showed a physician order (dated 2/8/24) for R1 to receive Humalog Mix 75/25 Insulin, 15 uts (units) subcutaneously, twice a day at 9:00 AM and 9:00 PM. The MAR showed R1 did not receive her prescribed doses of insulin at 9:00 PM on 2/8/24, 9:00 AM on 2/9/24, or 9:00 PM on 2/9/24. On 2/21/24 at 10:32 AM, V6 Registered Nurse (RN) stated she admitted R1 to the facility on 2/8/24. V6 stated R1 did not get her 9:00 PM dose of Humalog 75/25 (insulin) because it had not been delivered from the pharmacy. On 2/21/24 at 10:35 AM, V5 Licensed Practical Nurse (LPN) stated he cared for R1 on 2/9/24. V5 stated he did not administer R1's 9:00 PM dose of insulin because the facility didn't have it. On 2/21/24 at 10:46 AM, V4 Nurse Manager stated R1 missed three doses of her Humalog 75/25 insulin because the facility's pharmacy was not able to provide it. It's not an insulin we commonly use anymore. V4 stated a new resident's medications are reviewed, once the resident's admission has been accepted and prior to the resident arriving to the facility, by a corporate liaison. V4 stated, We should have a resident's medications in-house by the time they are admitted or shortly there after. We should have had (R1's) insulin delivered by the morning of 2/9/24, at the latest. A medication Delivery Manifest order form for R1 showed R1's Humalog Mix 75/25 insulin was not delivered to the facility, from an outside pharmacy, until 11:18 PM on 2/9/24. On 2/21/24, a facility policy on insulin administration was requested. The facility was unable to provide a policy on this subject. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145816 If continuation sheet Page 3 of 5 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 145816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure opened, multi-dose vials of medication were labeled with expiration dates for 4 of 7 residents (R2, R5, R10, R6) reviewed for medication storage in the sample of 11. The findings include: 1. R2's physician order dated 2/16/24 showed an order for R2 to receive 15 units (uts) of Insulin Aspart, subcutaneously (SQ), three times a day, prior to meals. On 2/21/24 at 8:15 AM, V7 Licensed Practical Nurse (LPN) withdrew 15 uts of insulin out of an opened vial of Insulin Aspart labeled with R2's name. At 8:32 AM, V7 administered the insulin to R2. At 8:35 AM, R2's insulin vial was reviewed by this surveyor and V7. No opened date or expiration date was noted on the vial. V7 stated all opened medication vials need to be dated when opened and with the date the medication expires to ensure residents aren't receiving expired medications. V7 stated she was not aware that R2's insulin vial had not been dated prior to administering the insulin to R2. V7 stated she should have checked for the expiration date on the vial of R2's insulin prior to giving it. At 8:39 AM, V7's first floor medication (med) cart was reviewed by this surveyor and V7. A small medication cup, containing 13 green, unlabeled pills, was noted in the top drawer of the med cart. V7 stated, I think those are iron pills. I am not sure why these are in a cup. Over-the-counter (OTC) pills should be labeled and kept in it's original bottle. V7 threw the cup of pills into the garbage on her med cart. 2. On 2/21/24 at 9:00 AM, a second floor med cart was reviewed with V9 Registered Nurse (RN). The following medications were found opened, with no opened dates or expiration dates, in the cart: One opened bottle of Brimonidine Tartrate eye drops for R5. No expiration date had been documented on the bottle. A physician order dated 9/26/23 showed an order for R5 to receive one drop to each eye, twice a day, for treatment of his glaucoma. One opened bottle of Brimonidine Tartrate-Timolol eye drops for R10. No expiration date had been documented on the bottle. A physician order dated 5/21/21 showed an order for R10 one drop to each eye, every twelve hours. 3. On 2/21/24 at 9:15 AM, an additional second floor med cart was reviewed with V10 LPN. One opened vial of Levemir insulin for R6 was found with no expiration date noted on the vial. V10 LPN stated, All insulin should be labeled with the date it's opened to make sure staff knows when it expires. A physician order dated 12/23/23 showed an order for R6 to receive 95 uts of Levemir insulin, daily, at 8:00 AM. The facility's Medication Storage, Labeling, and Disposal policy dated 8/24/23 showed, House stocks designed for multiple administration will be labeled with the name of the medication, the strength, instruction, and expiration . The facility's Medication Pass policy dated 7/28/23 showed, Insulin vials are to be discarded 28 days after opening, except for Levemir insulin which are to be discarded 42 days after opening . The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145816 If continuation sheet Page 4 of 5 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 145816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047 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 0761 policy also showed all opened medication vials should be labeled with the date it was opened and discarded within 28 days of opening. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145816 If continuation sheet Page 5 of 5