Health inspection·April 6, 2022

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide incontinence care in a manner to prevent infection to 1 of 3 residents (R87) reviewed for incontinence care in the sample of 35. On 4/4/22 at 9:57 AM, R87 was in bed with a strong urine odor. V6 (Certified Nursing Assistant-CNA) removed R87's incontinent pad, which was totally soiled with urine. V6 (CNA) took a disposable incontinent wipe, and wiped R87's frontal area once. Then V6 turned R87 to her side and wiped R87's buttocks. There were no further cleansing to R87's thighs and peri areas. On 4/5/22 at 1:45 PM, V3 (License Practical Nurse- LPN) said when providing incontinence care, cleanse peri areas and thighs thoroughly to prevent skin breakdown and infection. R87's facility assessment dated [DATE] show's R87 is always incontinent of urine. R87's latest care plan show-toilet use- Provide prompt peri care shift and as needed. A facility document entitled Incontinence Care Competency (undated) show, b.wash the perineum moving from inside outward to and including thighs, alternating side to side . The Facility Policy entitled Incontinent and Perineal care dated 7/28/21 show's provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation and to observe resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 2 of 6 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 145868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Long Grove 1666 Checker Road Long Grove, 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure medications were dispensed according to standards of practice for 1 of 4 residents (R59) reviewed for pharmacy services in the sample of 35. The findings include: On 4/4/2022 at 9:48 AM, there was a plastic medication cup with 1 orange pill inside it sitting on R59's bed side table. R59 said the nurses bring her medications in and some of them just leave them in the room for her to take and others watch her take them. On 4/4/2022 at 10:11 AM, V9 Registered Nurse/RN said sometimes we can let residents take their own medications. I know ones I need to watch take them and others I stand, and spoon feed their medications to them. On 4/5/2022 at 8:45 AM, V8 Licensed Practical Nurse/LPN said they have no residents who have current orders to self-administer their own medications. V8 said nurses have to watch the residents take their medications. On 4/6/2022 at 8:14 AM, V2 (Director of Nursing) said nurses are not supposed to leave medications at the bedside for a resident to take, they have to stand and watch them take their medications. R59's active physician order summary shows there is no current order for her to self -administer her own medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 3 of 6 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 145868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Long Grove 1666 Checker Road Long Grove, 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 - Few 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 medications were secured for 2 of 35 residents (R52 and R38) reviewed for medications in the sample of 35. The findings include: 1. A facility assessment done on 1/14/22 showed R52 was mentally intact. R52's Order Summary Report showed an order for an ipratropium-albuterol inhaler to be given 6 times a day as needed and an order for glycopyrrolate nebulizer to be given two times a day. On 04/04/22 at 12:01 PM, R52 had an ipratropium-albuterol inhaler and two glycopyrrolate nebulizer ampules sitting on his bedside table. R52 said the medications are kept at his bedside. On 04/06/22 at 09:39 AM, V3 (LPN) said medications are kept secured by keeping them in the locked medication cart and if medications are kept at bedside they are not secured. On 04/05/22 at 09:12 AM, V4 (Licensed Practical Nurse - LPN) said R52 has not been assessed to keep medications at bedside or to self-administer medications. R52's Order Summary Report printed on 4/5/22 at 10:49 AM showed an order to self-administer 6 AM medications and may keep medication at bedside. This order was entered on 04/05/22 after the medications were observed at bedside on 04/04/22. 2.) On 4/4/2022 at 8:45 AM, there was a bottle of multivitamins sitting on R38's bedside table. R38 said he keeps the bottle in his room and takes 1 tablet per day. On 4/5/2022 at 8:45 AM, V8 (Licensed Practical Nurse/LPN) said medications should not be stored at the bedside and no residents have current orders to keep their oral medications at their bedside. R38's Order Summary Report printed on 4/6/2022 at 9:28 AM, shows an order dated 4/5/2922 for Multivitamin Tablet own supply may leave at beside. This order was entered after the medication was observed at the bedside on 4/4/2022. The facility's Medication Storage and Labeling policy revised on 7/28/21 shows, It is the facility's policy to comply with federal regulations in storage and labeling of medications .4. Medications will be secured in locked storage area . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 4 of 6 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 145868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Long Grove 1666 Checker Road Long Grove, 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review the facility failed to ensure the noon meal was thoroughly pureed for 21 of 21 residents (R54, R128, R98, R176, R116, R25, R19, R78, R27, R129, R162, R41, R34, R72, R169, R146, R123, R84, R120, R69 and R107) reviewed for pureed diet in the sample of 35. The findings include: On 04/04/22 at 01:27 PM, the noon pureed meatballs and buttered noodles contained pieces of meat and noodle that required chewing. On 04/04/22 at 01:48 PM, V12 Dietary Manager said puree foods should be smooth with no bits of food to chew. The facility's Puree Diet Type Report dated 4/4/22 shows there are 21 residents in the facility on a pureed diet. The facility's undated Texture Progression Policy shows Pureed: eliminates the need for chewing. All foods must be presented in a form that is homogenous and cohesive in nature foods will be pureed to ensure a smooth cohesive quality without lumps. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 5 of 6 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 145868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Long Grove 1666 Checker Road Long Grove, 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to wash hands and change gloves to prevent the spread of infection to 1 of 35 residents (R99) reviewed for infection control in the sample of 35. Residents Affected - Few The findings include: On 04/04/22 at 10:15 AM, V6 (Certified Nursing Assistant-CNA) provided incontinence care to R99 . R99 had large amount of stool that soaked thru her incontinent pad, her bed sheets and blankets. V6 (CNA) cleaned large amount of loose stool from R99. With visibly soiled gloves on, V6 touched multiple surfaces, applied incontinent pad to R99, turned R99 side to side, changed R99's bed sheets, adjusted R99 in bed, touched her pillows, applied new covers to R99. V6 did all these tasks without washing her hands and changing her gloves. At 1:00 PM, V6 CNA said she was not sure when to change her gloves or wash her hands when providing care. On 4/5/22 at 1:45 PM, V3 (LPN) said that gloves should be removed and then staff should wash hands or sanitize after providing care to the residents. Then apply new gloves before touching anything else for infection control reasons. The facility policy entitled Hand Hygiene dated 7/8/21 show Hand Hygiene is important in controlling infections- before moving from work on soiled body site to a clean body site on the same resident. The facility policy entitled Glove Use show. Wash Hands after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 6 of 6