Avantara Lincoln Park

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

intermittent pressor support. Unfortunately, she did not improve, and palliative care was consulted. Family ultimately elected to proceed with palliative extubations and transition to comfort measures only. She is treated with a morphine drip for air hunger and/or pain. An order was placed to consult inpatient hospice, who reached out to the family, but inpatient hospice was not established prior to the patient expiring. The patient expired on [DATE REDACTED] at 11:34pm. Facility's job description titled RN Floor Nurse dated [DATE REDACTED] documents in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Registered Nurse plays a critical role in providing superior customer service and nursing care to all Guests and guests. The RN provides supervision of staff and will safeguard the health, safety and welfare of all Guests under their care by following applicable laws, regulation, and established nursing policies and procedures. Essential Functions: 9. Responsible for all nursing care of assigned Guest while on duty. Must notify appropriate persons if there is any significant change in a Guest's condition or any transfer to hospital. 10. Ensure that Guest care plans are being followed and assess each Guest's status in accord with their care plan. Facility's undated job description titled Certified Nursing Assistant documents in part, Job Summary: The primary purpose of your job position is to provide residents of this facility in you nursing unit with nursing and personal care under the supervision of a Charge Nurse, and to safeguard the health, safety , and welfare of all resident of the facility, in accordance with the facility's established policies and procedures and applicable laws and regulation, and the directions your supervisors, who include the Administrator, Director of Nursing, Assistant Director of Nursing, House Supervisor, Charge Nurse, Rehabilitation Director, and other members of the facility's management to whom such persons report, in order to assure that the highest degree of quality care is maintained at all times. Main Duties: P. Detect and report situations that have a high probability of causing accidents or injuries to residents and/or staff. U. Report all equipment malfunctions and breakdowns to the charge nurse as soon as possible and keep his/her informed of supply needs and equipment needing replacement.

Facility's policy titled Fall Prevention Program Guidelines revised date [DATE REDACTED] documents in part, Policy Statement: Fall prevention program guidelines shall be implemented to promote safety of all residents in the facility. This program shall include measures to determine the individual needs of each resident by assessing the risks for fall and the implementation of evidence-based prevention interventions. Procedure.

1. 2. Safety interventions shall be initiated and implemented for each resident identified at risk for fall. 3. All

assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. 7. An individualized evidence-based plan of care shall be created to reflect fall prevention interventions which could be but not limited to h. Residents shall be observed to ensure the resident is safely positioned in bed or chair. Provide care as assigned in accordance with the plan of care. k. May utilize personal alarms when appropriate such as bed alarms, chair alarms and motion sensor alarm and floor mat alarms.p. Ensure equipment is properly functioning and maintained. If malfunctioning, equipment must be removed immediately and reported to maintenance department for repair or replacement.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avantara Lincoln Park

1366 West Fullerton Avenue Chicago, IL 60614

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on interview, and record review, the facility failed to administer covid 19 vaccine to one resident (Resident R5) that consented for the covid 19 vaccine. The facility also failed to document the administration or declination of covid 19 vaccine for the same resident. This failure affected one resident (Resident R5) in a sample of four residents reviewed for covid 19 vaccine administration. Resident R5 admitted to facility on 11/17/2025 with diagnosis that documents in part; Cerebral infarction, hyperlipidemia, essential hypertension, chronic atrial fibrillation, insomnia, protein calorie malnutrition, covid 19 (12/1/25).On 12/29/25 at 3:15pm, V2 (Director of Nursing) stated that she expects the infection control nurse to obtain consents for resident vaccinations and schedule a vaccine clinic to ensure that vaccinations are administered and recorded in the immunization tab in chart.On 12/30/25 at 1:05 pm, V19 (family member of Resident R5) stated that he did give consent for Resident R5 to receive the covid 19 vaccine on 11/18/2025 and that he wanted Resident R5 to have the covid vaccine administered.On 12/30/25 at 09:45 am, V30 (Infection Control Nurse/LPN) stated the covid outbreak started 11/23/25 which was a Sunday and we started testing based on contact tracing with guidance from Chicago Department of Public Health (CDPH), it was one case on 2nd floor and one case on the 5th floor.

By 11/26/25 we had so many cases around 18 that CDPH stated to begin unit base testing. One of our staff aides tested positive who worked directly with Resident R5 on 11/28/25, this was discovered thru contact tracing.

V30 stated the purpose of consents and declination forms is to ensure that residents and staff are educated on benefits and risk of vaccines. I feel it is important for residents and staff to sign the consent and declination forms and also receive their vaccine if they consent to be vaccinated. Currently we have two residents that are on isolation for covid 19 in the facility.Review of facility contact tracing log for residents displays that Resident R5 tested positive for Covid 19 on 12/1/25 and is no longer a resident in the facility.Review of facility policy titled Infection prevention control with revision date of 6/30/25 documents in part: Policy statement; the facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for the identified infection.;29.) The facility shall comply with infection control recommendations provided by the IDPH or certified local health department, including, but not limited to, testing plans, infection control assessments, training or other measures designed to reduce infection rates and disease outbreaks.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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