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 (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 2 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 11/02/2023 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)