Inspection·April 10, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review the facility failed to ensure resident rooms were clean and repairs were performed in a timely manner for 11 of 13 residents (R1, R4, R5, R7-R14) reviewed for clean, comfortable and homelike in the sample of 14. The findings include: 1. On 4/10/23 at 10:25 AM, R4 was sitting in bed. R4's right siderail was broken. If pushed on, the siderail frame would pull away from the inner electrical component of the siderail. R4 had crushed up pretzels on the floor near her bed. R4's nightstand did not have a handle on the top drawer. R4's window valance had a layer of white dust on it. R4's walls had cobwebs on them. R4's window did not have a screen in it and there was a blanket on the windowsill that had brown/dirt debris and leaves on it. R4's white blinds had multiple colored splatters on them. R4's air conditioning/heating unit had brown/green spots on the vents of the unit. On 4/10/23 at 10:25 AM, R4 said that she has been in her room for about 9 years. R4 said that she notified staff about 3 weeks ago about her bed being broken. R4 said that the pretzels have been on her floor for about 3-4 days and the staff just step all over them when providing care. R4 said that her nightstand has not had a handle since her admission. R4 said that she does not think that the curtains have ever been taken down and cleaned. R4 said that the air conditioning unit was cleaned once that she can remember. R4 said, I feel disgusting in here. I don't like having visitors because it is embarrassing. A Compliment and Concern/Response Form dated 1/28/23 shows that R4 was asking for her room to be deep cleaned. 2. On 4/10/23 at 8:45 AM, R1 was sitting on the side of the bed. R1's floor was not clean. R1 had multiple pieces of tissue (including under the bed), a spoon, a cup, two pills, a white powdery substance and a black/brown dried debris spot on the floor. R1's wall had multiple large nicks along the lower portion of the wall. 3. On 4/10/23 at 10:32 AM, R5 was lying in bed. R5's garbage cans were full. R5's floor was sticky under her bedside table. R5 had a fork on the floor. R5's wall had multiple large nicks along the lower portion of the wall. On 4/10/23 at 10:32 AM, R5 said that they have not cleaned her room in about 3 days. R5 said that she would like it cleaned more often. (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 3 Event ID: 145868 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 04/10/2023 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)