Health inspection·May 14, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 a resident with eczema was assessed and treated in a timely manner. This applies to 1 of 6 residents (R1) reviewed for quality of care in the sample of 6. Residents Affected - Few The findings include: On May 14, 2024, at 10:10 AM, R1 was lying in bed. The entire top of her head/scalp was dry with yellow/red crusty scabs. Her hair appeared greasy and/or wet. She stated, They say it's eczema on my head. It's been there for a while. On May 14, 2024, at 10:56 AM, V3 Certified Nursing Assistant (CNA) stated, R1's head has been like that for 2-3 months. They are not doing anything for it. She has been putting A&D ointment on it until R1's friend (V5 power of attorney of financial (POA)) brought her a medicated shampoo. She was washing her hair with regular shampoo, but it was drying it out more. She didn't know what it was on her head. It started off small and has gotten bigger. When she tries to scrape off the crusty scabs, R1 says it hurts so she doesn't scrub it too hard. On May 14, 2024, at 10:58 AM, V5 R1's POA was visiting her. She stated, her head has been like this since December. She showed this surveyor a picture taken on December 13, 2023, of R1's head. It had a small round yellow crusty scab on the top of her head. It was approximately the size of a quarter. (The yellow crusty area now covers the entire top of her scalp/head). There were two red/purple lines on each side of the yellow scab. It looked like scratches. She stated, they told her it was psoriasis. So, she went and bought her a medicated shampoo. R1 had a bottle of [NAME] psoriasis shampoo in her room that was purchased by V5. They have only been putting on ointment (A&D ointment) and using the medicated shampoo V5 bought her last week. V5 also showed this surveyor another picture she took last Thursday (May 9, 2024) of R1's head. R1's head had a thick yellow, red crusty scabs all over the top of her head. On May 14, 2024, at 11:00 AM, V8 Wound Care Nurse and V7 Wound Care Nurse Practitioner (WCNP) were seeing residents in the facility. V8 stated, he didn't know about R1's head until last week when V10 Social Services reported it to him. V7 stated, he first saw R1's head last week on May 8th. He recommended a medicated shampoo (Ketoconazole). V7 stated, he has been seeing her weekly because she has a rash on her back and coccyx. He has not been seeing her for her head/scalp. At 2:15 PM, V7 stated, A&D ointment is a petroleum ointment. He would not recommend that because it acts like a barrier. She needs the medicated shampoo. On May 14, 2024, at 11:10 AM, V9 Registered Nurse (RN) stated, she was the full-time nurse on day (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 05/14/2024 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)