Inspection·June 28, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 06/28/23 at 08:48 AM, V10 Housekeeping said the resident rooms are cleaned every other day. V10 said the bathrooms, floors, tables are cleaned, and the garbage is taken out. V10 said there is 1 housekeeper for the 200 hall and there is no housekeeper after 2:30 PM. On 06/28/23 at 11:07 AM, V11 Housekeeping Director said they are short staffed and only have one housekeeper per unit. V11 said staff is supposed to clean half the rooms in the unit one day and the other half the next day. V11 said staff should clean rooms if needed even if not on the scheduled day. V11 said there is housekeeping staff on weekends that should clean the resident rooms. The facility's General Housekeeping Policy dated 7/28/22 shows facility will ensure that the facility and resident rooms will be clean, orderly, and sanitary through housekeeping services. The housekeeping staff will clean the resident rooms and bathrooms daily using approved sanitizing agents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 2 of 11 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 06/28/2023 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure R162 was provided with incontinent care as directed by her care plan and failed to ensure R50 was positioned and provided with care planned interventions during mealtimes for two of thirty-two residents reviewed for ADL's-Activities of Daily Living. Residents Affected - Few The findings include: On 06/27/23 at 1:19PM, R162 was lying in bed on her back. R162 had a strong smell of urine. V14 CNA-Certified Nursing Assistant turned R162 without the assistance of another staff. R162 yelled out, made facial grimace, and grabbed her left arm when V14 CNA rolled R162 to her right side by himself. V14 CNA removed R162's incontinent brief, it was saturated with urine and loose stool. R162 had redness to her labia, redness to her right medial thigh, and multiple 1-centimeter red circular areas diffusely spread throughout her inner thighs and posterior buttocks. On 06/27/23 at 1:19PM, V14 CNA said, I last changed R162 at 9:00AM, (over 4 hours). On 06/27/23 at 1:34PM, V4 Wound Care Nurse said, R162 was seen by the Wound Nurse Practitioner yesterday for a wound on her abdomen. I was not aware R162 had any other skin issues. This looks like a fungal infection; it can be caused by a variety of things including moisture. R162's MDS-Minimum Data Set, dated [DATE], shows, Bed Mobility: Extensive Assistance of two-person physical assist. Toilet use: Total dependence-full staff performance every time with two-person physical assist. Urinary Continence: Always incontinent. Bowel Continence: Always incontinent. R162's Current Care Plan on 06/27/23 shows, R162 displays frequent occasional bladder incontinence related to impaired mobility; I will remain free from skin breakdown due to incontinence and brief use; I would like the staff to check me for incontinence episode every 2 hours. The facility's Skin Care Treatment Regimen policy revised 07/28/22 shows, residents who are not able to turn and reposition themselves will be turned and repositioned every 2 hours. 2. On 6/26/23 at 12:30 PM, the head of R50's bed was elevated 30 degrees. R50 was lying on her back with her shoulders and hips flat on the mattress. R50's neck was hyper-flexed with the back of her neck in the crease of the mattress where the head of the bed elevates. R50 said, I usually sit up in bed to eat. R50 attempted to sit-up further in bed but was unable to. R50's meal tray consisted of chicken noodle soup, chicken and biscuit, mashed potatoes, broccoli, and ice cream. R50 did not receive a grilled cheese sandwich with lunch. No staff were present to assist R50 with eating. R50 could not reach the ice cream on her tray that is listed in her Care Plan as an intervention to prevent weight-loss. On 06/27/23 at 2:05PM, V5 Restorative Nurse said, R50 can move from side to side in bed but cannot push herself up in the bed. R50 requires set up and supervision for eating, staff to set up food, ensure correct diet, cut food as needed, and the head of the bed should be elevated 45 to 90 degrees to eat. On 6/28/23 at 10:47 AM, V13 (Registered Dietitian) said, R50 should have received a grilled cheese (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 3 of 11 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 06/28/2023 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)

F 0677 with lunch on 6/26/23. Level of Harm - Minimal harm or potential for actual harm R50's MDS dated [DATE] shows, R50 requires one-person physical assistance and supervision during meals. R50 requires extensive assistance of one person for bed mobility. Residents Affected - Few R50's Meal Ticket dated 06/26/23 shows, Note: Send: Ice-Cream, Grilled Cheese Sandwich, Soup. (R50 did not receive a grilled cheese sandwich with her lunch tray.) R50's Dietary Notes dated 04/14/23 shows, R50 experienced a 10.2% significant weight loss between October 2022 and April 2023. R50's current Care Plan on 06/26/23 shows, R50 has an ADL self-care performance deficit related to impaired mobility, weakness, and fatigue. Bed Mobility: extensive two staff participation to reposition and turn in bed. Unintended Weight Loss: R50 has the following conditions and risk factors that put her at risk for unintended weight loss. Diagnosis of dementia, bilateral primary osteoarthritis of knee, muscle wasting and atrophy, cognitive communication deficit .History of significant weight loss related to varied oral intake. Body Mass Index low for age. Intervention: Provide ice cream at lunch and dinner, extra sandwich at lunch. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 4 of 11 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 06/28/2023 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/26/23 at 10:29 AM, R147's Pressure reduction heel boots were sitting in a chair at the foot of R147's bed. R147's right and left lateral heels were resting on the bed. No off-loading interventions were in place. Residents Affected - Few On 6/27/23 at 9:03 AM, V18 Restorative Aide said, pressure to the heel of the foot is reduced by elevating the feet off the bed with pillows or applying heel protectors. On 6/27/23 at 11:30 AM, R147 was in bed lying on his back. R147's heels were resting on the bed. R147 did not have heel boots or a pillow to off-load pressure from his heels. R147's current Care Plan on 6/26/23 shows, R147 has potential for pressure injury related to assessed as moderate risk (for pressure ulcers), limited joint mobility, incontinent, diabetes, Cerebral Vascular Accident with hemiplegia, anemia, sacral to groin moisture acquired skin disorder, history of a Stage three pressure ulcer. Intervention: Off-loading of bilateral heel when in bed every shift and as needed. Based on observation, interview and record review the facility failed to assess, identify and provide treatment for an open area on a resident with a history of pressure ulcer and failed to ensure pressure relieving interventions were in place for residents with pressure ulcer injuries and residents who a high risk for developing pressure. This applies to 2 of 5 residents (R98, R147) reviewed for pressure ulcer in the sample of 32. The findings include: 1. R98's face sheet shows he is [AGE] year old male with diagnosis including osteoarthritis of knee, muscle wasting, type 2 diabetes, morbid obesity, peripheral vascular disease and cellulitis of right lower limb. R98's Minimum Data Set assessment dated [DATE] shows his cognition is intact, requires extensive assist with bed mobility and toileting and total dependent with two person assist for transfers. R98's Braden Score dated 6/12/23 shows he is HIGH risk for acquiring pressure wounds. On 6/26/23 at 9:28 AM, R98 was observed lying in bed. He said he has a pressure sore on the back of his right leg from being in bed and new wounds on his groin. He said he has not been out of bed in 10 days. At 9:45 AM V7 (Certified Nursing Assistant-CNA) was providing incontinence care to R98. R98 was soiled with urine. Excoriation and redness were observed to his scrotum and groin. R98 moaned in discomfort while being cleansed he stated, my skin is really sore. An open area was observed under his right gluteal fold with skin discoloration and without a dressing in place. On 6/26/23 at 12:51 PM, R98 remained in bed, a wheelchair was observed in his room without a pressure relieving cushion. He said he would like to get out of bed. His wheelchair does not have a cushion, they lost it. They brought me a different wheelchair because the previous one broke and lost my cushion. On 6/27/23 at 10:43 AM, V4 (Wound Nurse) said R98 has moisture associated skin damage (MASD) on his right posterior thigh, that he was informed of yesterday 6/26/23. R98 has a history of pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 5 of 11 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 06/28/2023 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ulcers but did not have MASD prior. He said R98 would like to get out of bed but does not have a pressure relieving cushion. Restorative should know where his cushion is. At 11:33 AM, V4 said his moisture is related to incontinence issues and he should be changed frequently. Staff should report any skin concerns right away. On 6/27/23 at 10:50 AM, R98 was lying in bed, he said he has reported the sore on his bottom several times to the staff. His sore feels better with the dressing on. On 6/27/23 at 11:59 AM, V5 (Restorative Nurse) said he changed R98's wheelchair about a week ago because it was broken. I'm not sure what happened to his cushion, but he should have it. Maybe the cushion was taken with the broken wheelchair. If the staff cannot find the cushion, they should notify nursing. On 6/27/23 at 1:06 PM, V7 (CNA) said R98 is alert and oriented, he is incontinent and should be changed every two hours. He said R98's had skin issues to his bottom. He said he's had that area on his right leg/bottom since last week and he was applying the barrier cream, it's hard to keep him dry. R98's Wound assessment dated [DATE] documents Right Posterior Thigh facility acquired moisture associated skin damage, classification incontinence measuring 0.5 cm (centimeters) x 0.4 cm x 0.10 with new orders, dressing initiated. R98's current care plan shows he has a potential for pressure ulcer development related to high Braden score, edema, morbid obesity, frequent incontinence and limited joint mobility. R98 has a history of right gluteal deep tissue injury with interventions including he requires a wheelchair cushion and low air loss mattress, notify nurse immediately of any new skin breakdowns, such as redness ., turning and repositioning . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 6 of 11 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 06/28/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure aspiration precautions were maintained for a resident with dysphagia, failed to provide thicken liquids and failed to ensure fall interventions were in place for a resident at risk for falls. This applies to 2 of 32 residents (R151, R10) reviewed for safety in the sample of 32. The findings include: 1. On 6/26/23 at 9:21 AM, R151 was observed lying in bed during the breakfast meal. The head of the bed was not positioned upright. It was approximately at a 45 degrees angle. A cup of non-thicken orange juice was on his tray half consumed. A bright colored sign was posted on the wall Aspiration Precautions with instructions to have the head of the bed upright. At 12:55 PM, during the noon meal, R151 was positioned at a 45 degree angle. He was served a mechanical ground tray with regular liquids. R151's diet card on his tray shows a mechanical ground and nectar thicken liquids. On 6/27/23 at 1:06 PM, V7 (Certified Nursing Assistant-CNA) said R151 is a little confused, he can have regular liquids. On 6/28/23 at 9:11 AM, V6 (Speech Therapist) said R151 has moderate to severe dysphagia, he has poor bolus control and aspirates on thin liquids. He was discharged from speech and referred to hospice and is now on a mechanical diet with nectar thick liquids. It is not safe for him to have thin liquids. R151's Physician Order Sheets shows he is an [AGE] year old male with diagnosis including pneumonia, unspecified psychosis, dysphagia oral phase, cognitive communication deficit, and encephalopathy. The P.O.S. shows orders for mechanical soft texture and nectar thick liquids. R151's Barium Swallow Study dated 4/26/23 documents moderate to severe oropharyngeal dysphagia .he is at extremely HIGH RISK of Aspiration due to severe amounts of pharyngeal residue . The report shows the recommendations include strict aspiration precautions, multiple swallows per bite/sip, meds crushed . R151's current care plan and does not show he is at risk for aspiration and does list his precautions in place. 2. On 6/27/23 at 9:15 AM, R10 was sitting in a wheelchair in the dining/activity area. R10 moved his wheelchair from the table then towards the center of the room using his arms and feet. R10 was wearing socks that did not have non-skid soles. On 6/27/23 at 9:16 AM, V21 CNA-Certified Nursing Assistant said, R10 is a fall risk, he does not need non-slip footwear in the wheelchair. On 6/27/23 at 2:05 PM, V5 Restorative Nurse said, R10 is a fall risk. He needs to wear shoes or non-skid socks when up in the wheelchair. R10's Fall Report dated 4/19/23 at 2:25 AM, shows, resident half sitting half lying with head up, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 7 of 11 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 06/28/2023 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)

F 0689 on the floor at bedside, leaning on his right arm. Level of Harm - Minimal harm or potential for actual harm R10's Care Plan updated 4/20/23 shows, R10 is high risk for falls, ensure that R10 is wearing appropriate footwear, non-skid shoes/socks, when mobilizing in wheelchair. Residents Affected - Few The facility's Fall Occurrence policy revised 5/17/23 shows, those identified as high risk for falls will be provided fall interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 8 of 11 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 06/28/2023 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)

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 ensure perineal care was provided in a manner to prevent infections for a resident with a history of urinary tract infections. This applies to 1 of 9 residents (R98) reviewed for bladder services in the sample of 32. The findings include: 1. On 6/26/23 at 9:45 AM, V7(Certified Nursing Assistant) was providing incontinence care to R98. V7 cleansed R98's penile area from the base towards to the tip of the penis and used the same area of the contaminated wipe cleansing his scrotum and groin. On 6/28/23 at 9:33 AM, V2 (Director of Nursing) said staff should be cleansing the top of the penile area downward to prevent infections and should be using a different area of the wipe for cleansing. R98's face sheet shows he is an [AGE] year old male with diagnosis including morbid obesity, chronic kidney disease with heart failure, congestive heart failure, benign prostatic hyperplasia and history of malignant neoplasm of the bladder. R98's care plan initiated on 6/13/23 shows he has a urinary tract infection with interventions including check at least every two hours for incontinence care. Wash, rinse and dry soiled areas and caregiver teaching should include good hygiene practices. The care plan also shows he is incontinent and would like the staff to check for incontinence care every two hours and requires extensive assist with toileting The Facilities Incontinent and Perineal Care Policy revised 7/2022 states, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition maintain clean techniques . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 9 of 11 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 06/28/2023 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a resident with significant weight loss was provided nutritional supplements at meals for 1 of 12 residents (R78) reviewed for weight loss in the sample of 32. Residents Affected - Few The findings include: On 6/26/23 at 12:35 PM, R78 was eating lunch in the dining room. R78 was served puree chicken, mashed potatoes with gravy, puree broccoli, juice, and strawberry ice cream. There was no fortified pudding on R78's tray. On 6/27/23 at 12:45 PM, R78 was eating in dining room. R78 was not served magic up or fortified pudding or ice cream. On 6/27/23 at 1:00 PM, V12 Certified Nursing Assistant said the kitchen is supposed to send up magic cup and fortified puddings on the residents trays. On 6/28/23 at 9:31 AM, V13 Dietician said R78 is on supplements due to poor appetite. The supplements should be given as ordered to help with weight loss. R78's Dietician Note dated 6/13/23 shows R78 significant weight loss times 3 months and 6 months which is unplanned. Current diet regular diet, puree texture, thin liquid, receiving soup at lunch, ice cream and chicken broth at dinner, fortified pudding at lunch and dinner. Resident with diagnosis of severe protein calorie malnutrition. Continue to honor food preferences. Recommend magic cup at lunch. R78's Physician Orders dated 6/13/23 shows Regular diet puree texture, thin liquids consistency, fortified pudding at lunch and dinner, magic cup at lunch-ok to substitute. The facility's Weights Policy dated 6/20/23 shows significant weight changes will be assessed and addressed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 10 of 11 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 06/28/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure cookware was handled in a sanitary manner. This applies to all 163 residents residing at the facility. Residents Affected - Many The findings include: The Resident Census and Conditions of Residents Form (CMS-672) dated 6/26/23 shows there were 163 residents residing at the facility. On 6/26/23 at 11:52 AM, V9 (Cook) loaded soiled pans into a tray and ran them through the dishwasher. With the same gloves on, V9 took the cleaned pans from the dishwasher rack and placed them on the storage shelf. On 6/27/23 at 2:00 PM, V8 (Dietary Manager) said that gloves should be removed, and hands should be washed after loading dirty dishes and before touching the clean dishes. The facility's undated Dishwashing Machine Use Policy shows, Wash hands before and after running dishwashing machine, and frequently during the process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145868 If continuation sheet Page 11 of 11