Health inspection·November 2, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review the facility failed to supervise a resident with dementia and a history of wandering for 1 of 9 residents (R2) reviewed for safety in the sample of 9. Residents Affected - Few The findings include: On 11/1/23 at 9:45 AM, R2 was sitting in a dining room chair sleeping. R2 had dark purple bruises above his left eyebrow, on his left eyelid, and below his left eye. R2 had gauze wrapped around both hands and wrists. V10 Central Supply was sitting next to R2 and said he was asked to sit with R2 today. On 11/1/23 at 9:52 AM, V6 Licensed Practical Nurse said no one really knows what happened to R2's eye, it happened on the weekend. V6 said R2 wanders around the hallway and goes into other residents rooms. V6 said staff usually follows R2 and redirects him. V6 said R2 has had 1:1 observation since he moved down here from the unit upstairs. V6 said R2 ambulates but can't follow commands and is very confused. V6 said when R2 starts roaming around you really have to watch him. V6 said staff are supposed to be with him at all times when the family is not here. On 11/1/23 at 11:10 AM, V1 Administrator said R2's daughter noticed bruises on R2's left eye and hand and notified the nurse. V1 said the nurse was not sure how the bruises happened, and the resident wasn't able to tell her. V1 said the injury happened sometime Saturday morning. V1 said a staff member was assigned to sit with R2 on the evening but V1 was not sure if someone was assigned to monitor R2 on Saturday morning. V1 said we knew from admission reports that R2 needed supervision and extra help. On 11/1/23 at 11:45 AM, V12 Certified Nursing Assistant said he worked on Saturday morning and was providing care to R2's roommate when he saw R2 get up out of bed by himself and walk to the bathroom. V12 said there was no 1:1 person in the room with R2 and the nurses were passing medications in other resident rooms. V12 said he was not sure what happened to R2, but he did notice a red area under R2's eye around breakfast time. On 11/1/23 at 1:30 PM, V1 Administrator said there was no sitter assigned to R2 for 1:1 on Saturday. On 11/1/23 at 1:39 PM, V13 Licensed Practical Nurse (LPN) said she was the nurse on duty Saturday morning, and she was not aware of a person being assigned to be the 1:1 with R2. V13 said staff reported to her, bruising to R2's eye and some bruising to his hand. V13 said she had no idea where the Page 1 of 2 145868 145868 11/02/2023 Avantara Long Grove 1666 Checker Road Long Grove, IL 60047

F 0689 injuries came from. Level of Harm - Minimal harm or potential for actual harm On 11/2/23 at 9:04 AM, V3 LPN said R2 wanders all over the unit. V3 said R2 has been on 1:1 monitoring ever since he moved down to this unit. Residents Affected - Few R2's Progress Note dated 10/28/23 at 7:42 AM, shows R2 slept well the entire night with one and one caregiver, fall precaution observed, will continue to monitor. R2's Change in condition form dated 10/28/23 shows Notified by a staff member, noted bruise on the left eyebrow and above the eyelid, abrasion on the right hand with some bruise. Unwitnessed skin alteration, no fall or no physical altercation noted with other resident. 145868 Page 2 of 2