Health inspection·November 8, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to respond promptly to an activated call light for one of three residents (R33) reviewed for call light in a sample of 30. The facility also failed to ensure to knock before going inside the resident's room for one of one resident (R50) observed for privacy and dignity in a sample of 30. Findings include: 1. On 11/07/2024 at 10:14AM during observation, R33 was observed lying on her bed. R33 showed R33's phone indicating the facility's phone number on the top of the list with number 3 enclosed in a parenthesis and time across it as 9:47AM, which indicates that she has called the facility three times with the last call made at 9:47AM. R33's call light was observed within R33's reach and R33 was observed activating it at 10:15AM. On 11/07/2024 between 10:15AM - 10:30AM, eight staff were observed passing by R33's room but no staff stopped by to check on R33 and what R33 needs. On 11/07/2024 at 10:25AM, R33 was observed calling R33's daughter to ask if R33's daughter can call the facility and ask if a Certified Nursing Assistant/CNA can come in to change her. On 11/07/2024 at 10:26AM, an overhead page was heard stating that a CNA is needed in R33's room. The overhead page was heard twice. On 11/07/2024 at 10:15AM, R33 stated that she has called the facility's main line three times to ask for nursing staff because she had a bowel movement and has been sitting on it since she first tried calling. R33 stated that she rarely uses the call light because no one is answering the call light. On 11/07/2024 at 10:18AM, R33 stated that R33 did not understand that being able to go to the toilet is a privilege until R33 cannot do it anymore. This statement was made by R33 three more times in a sad, regretful tone. On 11/07/2024 at 10:28AM, R33 started crying and stated that she'd rather be dead than lay on her own feces. On 11/09/2024 at 11:08AM during interview with V1 (Administrator), V1 stated that he expects any of the facility staff passing by a resident's room with a call light on to respond and check on what Page 1 of 21 145197 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0550 the resident needs. Level of Harm - Minimal harm or potential for actual harm On 11/09/2024 at 11:13AM during interview with V2 (Director of Nursing), V2 stated that she expects the nursing staff to respond to call light in not more than 10 minutes. V2 also stated that if the assigned staff to the resident is doing patient care, other nursing staff can answer or respond to call light and ask what the resident needs. V2 also stated that if any staff is passing be a room with a call light on, she expects staff to answer and check on what the resident needs. Residents Affected - Few Review of R33's Order Summary Report dated 11/08/2024 indicated admission date of 02/17/2022 and diagnoses of not limited to bilateral primary osteoarthritis of knee and arthropathy. Review of R33's Minimum Data Set (MDS) dated [DATE] indicated in Section C that R33 has Brief Interview Mental Status (BIMS) score of 13, in Section E that R33 did not exhibit any behavioral symptoms and rejection of care, in Section GG that R33 is dependent with toileting hygiene, and in Section H that R33 is frequently incontinent of urine and bowel. Review of R33's Care Plan revised on 10/12/2024 indicated that R33 has bowel/bladder incontinence r/t (related to) physical limitation and disease process with goal on R33 will be clean and dry, and interventions that includes ensuring call light is within reach and answer promptly and providing pericare after each incontinent episode. Review of R33's Progress Notes from 09/21/2024 up to 11/09/2024 did not indicate any behavioral symptoms, or rejection of care. Review of facility's policy entitled Call Light revised on 02/02/2018 indicated the following: Purpose: To respond to resident's requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered. 4. Requests shall be responded to in a courteous and professional manner. 2. On 11/7/24 at 10:40AM, observed V10 and V11 (Certified Nursing Assistants) entering R50's room without knocking. On 11/7/24 at 10:43AM, V10 said she did not knock on door before entering R50 room. On 11/7/24 at 10:44AM, V11 said she did not knock on door before entering R50 room. On 11/7/24 at 11:38AM, V2 (Director of Nursing) said that all staff should knock on resident door and wait for response before entering resident room. Facility's Policy on Dignity, Revised 4/23/18 Guidelines 145197 Page 2 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0550 Level of Harm - Minimal harm or potential for actual harm The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Residents Affected - Few Maintaining a resident's dignity should include but not limited to the following: -Protecting and valuing resident's private space (for example, knocking on doors and requesting permission before entering, closing doors as requested by the resident). 145197 Page 3 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/7/24 at 12:19PM, Observed R10 on right side lying position in bed. The water pitcher placed on top of the bedside tray table is away from her. R10 asked the surveyor to call the CNA (Certified Nurse Assistant). R10 said that she does not have her call light and she want water. Observed call light on the floor on the left side of the bed. Called V3 (Assistant Director of Nursing) and showed observation made. Informed V3 that call light was on the floor and the water pitcher is away from R10. V3 picked up the call light on the floor and clipped on top R10's top sheet accessible to R10. V3 said that call light should be placed within resident's reach. V3 moved the bedside tray table located on the foot part right side of the bed closer to R10. V3 said that water pitcher is empty. V3 said that water pitcher is placed with resident's reach and CNA should check and refill it at the beginning on the shift. V3 said that she will refill it. Residents Affected - Few R10 is admitted on [DATE] with admitting diagnosis listed in part but not limited to Transient ischemic attack and Cerebral infarction, Parkinson disease, Age related physical debility, Moderate protein calorie malnutrition. Comprehensive care plan indicated that she has ADL (activity of daily living) self-care/ mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day related to activity intolerance, confusion, dementia, disease process, limited mobility, limited ROM, musculoskeletal impairment, right AKA (above the knee amputation). On 11/7/24 at 1:19PM, Informed V2 (Director of Nursing) of above concerns. Facility's policy on Call light revisions: 2/18/18 Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in timely manner. 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. Based on observation, interview, and record review the facility failed to ensure a residents call light was within reach for 2 of 4 residents (R10 and R232) reviewed for accommodation of needs in a sample of 30. Findings include: 1. On 11/7/2024 at 10:30am R232 was heard yelling for help upon walking in the room R232 was observed with a water pitcher that was spilling over in the bed. R232 said I can't find my call light and my water is going to spill, I need help. R232 call light was observed on the floor behind the bed. On 11/7/2024 at 10:35am V9(Licensed Practical Nurse) said the R232 call light should be within reach. 145197 Page 4 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0558 On 11/7/2024 at 12:30pm V2 (Director of Nursing) said all call lights should be in reach of all residents. Level of Harm - Minimal harm or potential for actual harm An order summary report dated 11/8/2024 indicates that R232 has a diagnosis of dysphagia oropharyngeal phase, need for assistance with personal care. Residents Affected - Few A care plan dated 10/28/2024 with an intervention of encourage fluid intake. A focus of fall related to confusion, deconditioning, gait, and balance problems incontinence, unaware of safety needs, and intervention dated 10/15/2024 be sure to keep call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 145197 Page 5 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the advance directive is indicated in the resident's health records for one of one resident (R1) reviewed for advanced directives in a sample of 30. Findings include: On [DATE] at 12:15PM during observation, a list of residents with active DNR (Do not Resuscitate) was observed on the South nurse's station. R1's name was not observed on the active DNR list. On [DATE] at 1:00PM during record review, R1's clinical dashboard indicated R1 is full code status. R1's physician's orders indicated R1 has an order for full code. R1's care plan revised on [DATE] indicated R1 is full code, attempt resuscitation, CPR (cardiopulmonary resuscitation), including intubation and mechanical ventilation. R1's scanned documents indicated R1 has a signed DNR/Practitioner Orders for Life-Sustaining Treatment (POLST) form on [DATE] with Do Not Attempt Resuscitation/DNR and Selective Treatment marked. On [DATE] at 11:08AM during record review with V13 (Social Service Director), R1's clinical dashboard indicated R1 is full code status. R1's scanned documents indicated R1 has a signed DNR/Practitioner Orders for Life-Sustaining Treatment (POLST) form on [DATE] with Do Not Attempt Resuscitation/DNR and Selective Treatment marked. V13 reviewed R1's Social Service and Care Plan Progress Notes since her admission on [DATE] to check if there was any note indicating change on R1's advance directives. On [DATE] at 11:08AM during interview with V13, V13 stated that she cannot find any documentation indicating change on R1's advance directives. V13 also stated that if R1 has a signed DNR/Practitioner Orders for Life-Sustaining Treatment (POLST) form with Do Not Attempt Resuscitation/DNR and Selective Treatment marked, R1 should be considered DNR status and should be included on the active DNR list. V13 stated that if R1's code status in R1's electronic record shows full code and R1 is DNR, staff might accidentally attempt resuscitation on R1 against her will. Review of R1's admission Record printed on [DATE] indicated R1 has advance directive of full code. Review of R1's Order Summary Report dated [DATE] indicated R1 was admitted on [DATE], R1 has diagnoses of not limited to Chronic Diastolic (Congestive) Heart Failure, Unspecified Asthma and Chronic Obstructive Pulmonary Disease, and R1 has an order for full code with order date of [DATE]. Review of facility's policy entitled Advance Directives revised on [DATE] indicated the following: Guidelines: For the purpose of this policy and procedure Advanced Directives means a written instrument, such as living will or life prolonging procedure declaration, appointment of health care representative or power of attorney for health care purposes. These directives are established under state law and relate to the provision of medical care when the individual is incapacitated. 1. At the time of admission each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law. 145197 Page 6 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0578 Level of Harm - Minimal harm or potential for actual harm 3. The resident, the legal representative, or the individual who has been authorized as the resident's health care representative will be asked if an Advanced Directive, as recognized under the state law, has been executed. Documentation concerning this inquiry and the individual response shall include the date the entry was made and the individual making this inquiry. This information shall then be included in the resident's medical record. Residents Affected - Few 9. A written physician's order is required in response to the resident's Advanced Directive(s). Physician's orders shall be specific and address each Advanced Directive(s). 10. Advanced Directive(s) shall be included in the resident's plan of care and will be reviewed during the care plan meeting with the resident and/or the resident's legal representative when present. 145197 Page 7 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

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** Based on observation, interview, and record review the facility failed to follow standard care practice of utilizing minimal layer of linens and not utilize a disposable brief when using low air loss mattress to resident who has stage 4 pressure ulcer. This deficiency affects one (R10) of three residents in the sample of 30 reviewed for pressure ulcer management. Residents Affected - Few Findings include: On 11/7/24 at 12:19 PM, Observed R10 on right side lying position in bed. R10 is on LAL (low air loss) mattress with flat sheet and cloth pad over the mattress. Called V3 (Assistant Director of Nursing) and showed observation made. R10 is wearing disposable brief. V3 said that she is not sure what is their policy regarding multilayers of linen in using LAL mattress. On 11/7/14 at 1:19PM, Informed V2 (Director of Nursing/DON) of above observation. V2 said, resident on LAL mattress should have only flat sheet over the mattress. R10 is admitted on [DATE] with admitting diagnosis listed in part but not limited to Transient ischemic attack and Cerebral infarction, Parkinson disease, Age related physical debility, Moderate protein calorie malnutrition, Stage 4 sacral pressure ulcer, Type 2 Diabetes Mellitus, Vascular Dementia. Active physician order sheet indicates Air mattress in use, apply protective dressing to right ischial every Monday, Wednesday and Friday, Sacrum: cleanse with normal saline solution pat dry apply calcium silver cover with dry dressing daily and as needed. Comprehensive care plan indicates she has stage 4 on sacrum. Intervention: Pressure reducing mattress. Skin assessment/Braden scale indicates that she is at risk for developing pressure ulcer. R10's most recent wound assessment dated [DATE] indicated Sacrum, active stage 4 pressure ulcer, present on admission 4/19/24, 70% pink or red non-granulating tissue, 10% bright beefy red tissue, 20% slough loosely adherent, light serosanguineous exudate, distinct and attached wound edge, measures 6cmx 5cm x 1cm. R10 is currently seen by wound care physician. On 11/8/24 at 9:30AM, V2 (DON) said that they don't have policy for LAL mattress usage. Facility's policy on Pressure Ulcer Prevention revision date 1/15/28 indicates: Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 9. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple stage 4 or one or more stage 3 or stage 4 wounds. 145197 Page 8 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 no intravenous medication and hazardous pesticides were left at resident's bedside. The facility also failed to follow physician order in implementing fall precaution measures. This deficiency affects all four (R10, R23, R37 and R52) residents in the sample of 30 reviewed for Residents' safety. Findings include: 1. On 11/7/24 at 12:19PM, Observed R10 on right side lying position in bed. Observed call light on the floor on the left side of the bed. No floor mat observed. R10 is admitted on [DATE] with admitting diagnosis listed in part but not limited to Transient ischemic attack and Cerebral infarction, Parkinson disease, Age related physical debility, Moderate protein calorie malnutrition, Stage 4 sacral pressure ulcer, Type 2 Diabetes Mellitus, Vascular Dementia. Fall assessment indicated she is at risk for fall. Most recent unwitnessed fall incident dated 7/29/24 in the bedroom. R10 was observed in the floor. R10 attempting to move over and slipped out of bed to the floor. Active physician order sheet indicates floor mat when resident in bed- check for placement. Comprehensive care plan indicates that she is at risk for fall/injury from weakness and tiredness related to history of falling, psychotropic medication usage, pain, contracture on left lower extremity, right above the knee amputation and behavior. Fall care plan was not updated after fall incident on 7/29/24. On 11/7/24 at 2:00PM, Observed R10 still did not have floor mat. Called V5 (Licensed Practical Nurse/LPN) and showed observation. V5 said that R10 does not used floor mat. Informed V5 that R10 has physician order of floor mat. V5 said that she will review R10's chart. On 11/7/24 at 2:18PM, Informed V2 (Director of Nursing/DON) and V7 (Restorative Nurse/Fall Coordinator) of above concerns. Both said that R10 should have floor mat as ordered by physician. On 11/8/24 at 11:08AM, Review R10's fall care plan with V2 (DON) and V7 (Restorative Nurse). Both said that R10's fall care plan was not updated when he had fall incident last 7/29/24. Both said that fall care plan should be updated after each fall incident based on root cause analysis. 2. On 11/7/24 at 12:23PM, Observed R52 lying in bed. Observed Intravenous (IV) medication (Daptomycin 500mg/100ml 0.9%) on top of the bedside table. Called V3 (Assistant Director of Nursing/ADON) and informed observation made. V3 said that no IV medication should be left at bedside. On 11/7/24 at 1:19PM, Informed V2 (DON) of above observation. V2 said that no IV medication should be left at bedside. R52 is admitted on [DATE] with diagnosis listed in part but not limited to Cellulitis of left breast, Granulomatous Mastitis left breast, Type 2 Diabetes Mellitus, Obstructive sleep apnea, Chronic obstructive pulmonary disease, Chronic respiratory failure. Active physician order indicates Cubicin solution reconstituted 500mg (Daptomycin) use 500mg intravenously every 24 hours for infection (cellulitis of left breast) for 7 days. 145197 Page 9 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. On 11/7/24 at 12:30PM, Rounds made with V3 (ADON) to R37's room. Showed observation made to V3 that R37 does not have Non-slip material in his wheelchair. Informed V3 that R37 has an order for non-slip material as part of fall preventive measures. V3 said that they should be following and implementing physician order. R37 is admitted on [DATE] with diagnosis listed in part but to limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Hypotension, history of falling, Age-related physical debility. Active physician order sheet indicates use of non-slip material in his wheelchair. Fall assessment indicated that R37 is at risk for fall. Most recent fall unwitnessed fall dated 10/29/24 indicated that R37 was observed lying on the floor in front of wheelchair. R37 attempting to repositioned himself and slid out of chair on the floor landing on his back. Comprehensive care plan indicates he is at risk for falls related to history of falls, impaired mobility, weakness, pain, and behavior. Intervention: Nonslip material under the chair. Fall care plan was not updated after fall incident on 10/29/24. On 11/8/24 at 11:08AM, Review R37's fall care plan with V2 (DON) and V7 (Restorative Nurse). Both said that R10's fall care plan was not updated when he had fall incident last 10/29/24. Both said that fall care plan should be updated after each fall incident based on root cause analysis. On 11/8/24 at 11:15AM, V2 (DON) said that they don't have policy on resident's medication safety. Facility's policy on Fall Prevention Program revision dated 11/21/24 indicates: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. 4. On 11/7/24 at 10:17AM, a pesticide spray was observed on R23's bedside table. On 11/7/24 at 10:17AM, V7 (Restorative Nurse) said she unsure if pesticide spray can be at bedside. On 11/7/24 at 11:04 AM, V2 (Director of Nursing) said that no pesticide spray is allowed to be at bedside. On 11/7/24 at 11:54AM, V1 (Administrator) said that no pesticide spray should be kept at bedside table. Facility's Policy on Chemical Labeling & Storage Revised 1-31-18. Purpose: To ensure proper and safe labeling, handling and storage of chemicals used in the facility. Guidelines: 5. Hazardous chemicals shall be maintained in a locked area. Examples include, but not limited to 145197 Page 10 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0689 housekeeping storage closet, Soiled Utility Room, medication room, or locked cabinet in shower room. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 145197 Page 11 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review the facility failed to ensure physician order is followed for tube feeding administration. This deficiency affected 1 of 3 residents (R121) reviewed for tube feeding administration in a sample of 30. Findings include: On 11/7/2024 at 10:35 AM during facility round, observed R121 tube feeding bottle hanging on a pole but not connected to R121 and machine was off. R121 said he gets feeding during the day and staff puts it on. On 11/7/2024 at 10:37 AM, V8 (Registered Nurse) said feeding for R121 should have been on according to physician order. On 11/8/2024 at 11:15 AM, V2 (Director of Nursing) said physician order should be followed and feeding of R121 should have been on at 10AM. Order Summary Report: Diagnoses: Dysphagia, Oropharyngeal, Gastrostomy Status Enteral Feed Order every shift Administer via enteral feeding pump; (Brand Name Enteral Feeding) 1.5 70ml/hr x 20hrs; total volume 1400ml. Start at 10am Stop at 6am. Care Plan: R121 have a G tube in place and at risk for complications related to use. Intervention: Tube feeding as ordered. Policy and Procedure: Policy Title: Medication Administration General Guidelines, no revision date Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). Administration: 2. Medications are administered in accordance with written orders of the prescriber. 145197 Page 12 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure the medications are stored safely, securely, and properly following manufacturer/supplier recommendations. This deficiency affects one (1) of two (2) medication storage rooms and one (1) of three (3) medication carts reviewed for Medication Storage. Findings include: On 11/7/24 at 12:34 PM, observed East side hallway medication cart opened with keys attached to cart lock and unattended. On 11/7/24 at 12:36 PM, V15 (Licensed Practical Nurse) said that medication carts should not be opened, the medication carts should be locked when not in use. V15 said if the nurse on duty goes to break then the cart key is given to the other nurse on duty for safe keeping. On 11/7/24 at 12:37 PM, V15 opened East side medication cart and three (3) medication cups were observed with pre-poured medications unlabeled. V15 said that no pre-filled medication cups should be left inside the medication cart. On 11/7/24 at 12:42 PM, V15 opened East side medication room storage and medication room refrigerator lock was observed unlocked. V15 said that the medication refrigerator should be always locked due to some controlled substance medications are kept refrigerated and refrigerator should be kept locked. On 11/7/24 at 12:56PM, V2 (Director of Nursing) said that medication cart keys should not be left on cart and medication room refrigerators should have a lock pad and kept locked at all times. Facility's Policy on Storage of Medications Policy#4.1 Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Temperature 3. Controlled-substance that require refrigeration are stored within a locked box within the 145197 Page 13 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0761 refrigerator. This box must be attached to the inside of the refrigerator. Level of Harm - Minimal harm or potential for actual harm Facility's Policy on Medication Administration General Guidelines Policy#7.2 Residents Affected - Few Policy Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). Administration 3. When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. 145197 Page 14 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 follow the Food Storage (Dry, Refrigerated, and Frozen) Policy by not labeling 2 bowls of gelatin with the date which has the capacity to affect 109 residents on an oral diet. The facility also failed to maintain resident personal refrigerators which affected 2 of 2 residents (R42 and R106) reviewed for refrigerators of a total sample of 30. Findings include: 1. On 11/07/24 at 10:20 AM, surveyor and V15 (Dietary Manager) observed the walk-in refrigerator and noted 2 bowls of gelatin without any label or date. V15 immediately removed the 2 bowls and said the gelatin will be discarded. On 11-8-24 at 11:00 AM, V16 (Dietary Director) said the food label indicates when the food has been made and the staff can determine how long the food is good for. V16 said the unlabeled gelatin found in the refrigerator will be discarded. V16 said the facility has 109 residents on oral diets. Food Storage (Dry, Refrigerated, and Frozen) Policy (no date) documents: a. All food items will be labeled. 2. On 11/07/2024 at 10:54AM during observation with V5 (Licensed Practical Nurse), R106's refrigerator in the room was observed with multiple unlabeled and undated plastic containers of food and opened and undated container of salsa. At the same time, R106's freezer in the refrigerator was observed with thick ice surrounding it. R106's refrigerator temperature log for October 2024 indicated temperature was last checked on October 21st. On 11/07/2024 at 10:57AM during interview with V5, V5 stated that as far as V5 knows, housekeeping department are responsible for checking the temperature of R106's refrigerator. V5 also stated that maintenance department are responsible for cleaning and maintaining R106's refrigerator. V5 also stated that nursing staff do not touch anything on R106's refrigerator. V5 stated that they do not check, label, or date any of R106's food items, only if there is an unusual odor already, then they will ask permission from the R106 or R106's family to clean up R106's refrigerator. On 11/07/2024 at 11:13AM during observation with V22 (Maintenance Director), R106's refrigerator in the room was again observed with multiple unlabeled and undated containers of food, and the freezer part was observed with thick ice surrounding it. On 11/07/2024 at 11:15AM during interview with V22, V22 stated that R106's refrigerator temperature should be checked daily, and V22 tries to check the residents' refrigerators daily but it is impossible for him to do it daily that's why he checks it at least once a week. V22 also stated that R106's refrigerator needs to be de-iced and cleaned. R106's Order Summary Report dated 11/08/2024 indicated R106 was admitted in the facility on 07/04/2023 with diagnoses of not limited to Vascular Dementia and Iron Deficiency Anemia. 3. On 11/07/2024 at 10:56AM during observation, R42's refrigerator at bedside was observed with multiple unlabeled and undated plastic containers of food, and the freezer part was observed with thick 145197 Page 15 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many ice surrounding it. R42's refrigerator temperature log for October 2024 indicated temperature was last checked on October 21st. On 11/07/2024 at 10:57AM during interview with V5, V5 stated that as far as V5 knows, housekeeping department are responsible for checking the temperature of R42's refrigerator. V5 also stated that maintenance department are responsible for cleaning and maintaining R42's refrigerator. V5 also stated that nursing staff do not touch anything on R42's refrigerator. V5 stated that they do not check, label or date any of R42's food items, only if there is an unusual odor already, then they will ask permission from the R42 or R42's family to clean up R42's refrigerator. On 11/07/2024 at 11:14AM during observation with V22 (Maintenance Director), R42's refrigerator in the room was again observed with multiple unlabeled and undated containers of food, and the freezer part was observed with thick ice surrounding it. On 11/07/2024 at 11:15AM during interview with V22, V22 stated that R42's refrigerator temperature should be checked daily, and V22 tries to check the residents' refrigerators daily but it is impossible for him to do it daily that's why he checks it at least once a week. V22 also stated that R42's refrigerator needs to be de-iced and cleaned. R42's Order Summary Report dated 11/08/2024 indicated R42 was admitted in the facility on 02/02/2023 with diagnoses of not limited to Type 2 Diabetes Mellitus with Diabetic Dermatitis and Gastro-esophageal reflux disease. Review of facility's policy entitled Food - Resident Pantry - Safe Storage revised on 6-3-19 indicated the following: Purpose: To ensure that resident food items are stored in a manner that is sanitary and safe for consumption and to prevent contamination and spoilage. Guidelines: - Other staff, such as Housekeeping will be assigned to cleaning resident's personal refrigerators and documenting refrigerator temperatures. - All resident foods and beverages, including alcoholic beverages shall be labeled with resident's name and dated. - Food items, condiments and liquids that are not in the original containers should be discarded 3 days after the date labeled on the container. - Foods which are outdated or are not labeled and dated shall be discarded daily when cleaning. 145197 Page 16 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 11/7/24 at 10:56 AM, surveyor noted R105's canister and oxygen tube were not labeled. This was verified by V15 (Licensed Practical Nurse/LPN). Residents Affected - Some On 11/8/24 at 9:00 AM, V2 (Director of Nursing) said the canister (with tubing) is dated to know when the system was changed. It is changed weekly to prevent bacteria growth. V2 said an assigned nurse will change the system weekly. On 11/7/24 at 11:00 AM, V15 (LPN) said the water canister (and oxygen tubing) is changed weekly by staff. V15 said the date is significant because it tells you how old it is and if it needs to be changed. V15 said the c-pap mask and nebulizer masks should be stored a plastic bag to prevent contamination. 4. On 11/7/24 at 10:50 AM, surveyor noted no date on R432's water canister and oxygen tubing, c-pap mask not stored in plastic bag, nebulizer mask not stored in plastic bag. These findings were verified by V15 (LPN). On 11/7/24 at 10:50 AM, R432 said he was unaware of labeling or proper storage of nebulizer and c-pap equipment. On 11/8/24 at 9:00 AM, V2 (Director of Nursing) said the canister (with tubing) is dated to know when the system was changed. It is changed weekly to prevent bacteria growth. V2 said an assigned nurse will change the system weekly. V2 said nebulizer mask and C-pap masks are stored in plastic bag when not in use to prevent contamination. On 11/7/24 at 11:00 AM, V15 (LPN) said the water canister (and oxygen tubing) is changed weekly by staff. V15 said the date is significant because it tells you how old it is and if it needs to be changed. V15 said the c-pap mask and nebulizer masks should be stored a plastic bag to prevent contamination. Oxygen & Respiratory Equipment - Changing/ Cleaning Policy (revised 1/7/19) documents: b. A clean plastic bag with a zip loc or draw string, etc. will be provided with each new set up, and will be marked with the date the setup was changed. Nebulizer-Medication Administration Policy (revised 10/9/18) documents: 23. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 5. On 11/7/24 at 12:23PM, Observed R52 lying in bed with oxygen at 2.5LPM (liter per minute) via nasal cannula (NC). Observed CPAP (Continuous Positive Pressure) mask on the floor. Called V3 (Assistant Director of Nursing/ADON) and informed observation made. V3 said that CPAP mask should be placed on plastic bag inside the drawer after use. V3 picked up the CPAP mask on the floor and placed it inside the bedside drawer. V3 said that she will have it clean. R52 is admitted on [DATE] with diagnosis listed in part but not limited to Obstructive sleep apnea, Chronic obstructive pulmonary disease, Chronic respiratory failure. Active physician order sheet indicated BIPAP (Bilevel positive airway pressure)/CPAP via mask with 12/5/10 CWP at bedtime for sleep apnea. Oxygen at 3LPM via NC continuous for bronchitis. Comprehensive care plan indicated use of 145197 Page 17 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0880 BIPAP/CPAP machine while sleeping and risk of its use related to sleep apnea. Level of Harm - Minimal harm or potential for actual harm 6. On 11/17/24 at 12:28PM, Observed R15 lying in bed. Observed CPAP nasal mask exposed and uncovered placed on top of bedside dresser. Showed observation to V3 (ADON). V3 said that CPAP should be placed on plastic bag inside the drawer after use. No IV medications should be left at bedside. Residents Affected - Some R15 is admitted on [DATE] with diagnosis listed in part but not limited to Chronic Obstructive Pulmonary Disease, Acute respiratory failure with hypoxia, Morbid obesity, Congestive heart failure. Active physician order sheet indicated BIPAP/CPAP on at 10PM and off at 6AM, Pressure between 8-20cm of water every night shift. Once during the night check heart rate, respiration, and oxygen saturation. Comprehensive care plan indicates use of CPAP/BIPAP machine while sleeping. On 11/7/24 at 1:19PM, Informed V2 (DON) of above concerns. Facility's policy on CPAP Therapy indicates: Purpose: CPAP is used to treat obstructive sleep apnea. The goals of this therapy include improve ventilation, improve quality of sleep, decrease hospitalizations, improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing and improve lung compliance. 7. On 11/7/2024 at 10:40am R85 was observed in bed with an antibiotic intravenous tubing attached to R85 right arm midline. R85 said this IV stopped about an hour ago. On 11/7/2024 at 10:45 V9 (LPN) said I started the antibiotic at 9am. On 11/7/2024 at 10:50 this surveyor observed V9 put on gloves and disconnect the intravenous tubing and flush R85 midline with sodium chloride, then covered the resident's arm with a blanket. On 11/7/2024 at 12:30pm V2(Director of Nursing-DON) said I expect all nurses to follow the enhanced barrier precautions and wash their hands before and after removing an intravenous antibiotic and to clean the resident's midline port. An order summary report indicates that R85 has osteomyelitis in the vertebra and sacral wound. An intravenous antibiotic of piperacillin 3.375-gram last dose was administered at 9am a saline flush of sodium chloride 5 millimeters intravenously every shift and after each antibiotic. An order for enhanced barrier precautions every shift for midline and wound dated 10/24/2024. 8. On 11/07/2024 at 10:56AM during observation, R42's CPAP (Continuous Positive Airway Pressure) mask was observed placed on the right, upper side of the bed without any cover. On 11/07/2024 at 11:10AM during observation with V5, R42's CPAP mask was again observed placed on the right, upper side of the bed without any cover. On 11/07/2024 at 11:06AM during interview with V5 (LPN), V5 stated R42 puts on and removes her CPAP mask herself. V5 also stated that R42's CPAP mask should be placed in bag after each use. On 11/07/2024 at 11:10AM during interview with R42 while making rounds with V5, R42 stated that no staff educated her on how to store her CPAP mask after each use. 145197 Page 18 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0880 Level of Harm - Minimal harm or potential for actual harm On 11/08/2024 at 9:45AM during interview with V2 (Director of Nursing), V2 stated that CPAP masks are considered respiratory equipment, and it should be cleaned and placed in a bag covering it after each use. Review of R42's Order Summary Report dated 11/08/2024 indicated that R42 was admitted in the facility on 02/02/2023 and an active order for CPAP use with order date of 04/28/2023. Residents Affected - Some Review of R42's Care Plan revised on 10/09/2024 indicated that R42 use a sleep apnea machine while sleeping and have a potential complication related to it, and a diagnosis of not limited to sleep apnea. Review of facility's policy entitled CPAP Therapy indicates the following: Purpose: CPAP is used to treat obstructive sleep apnea. The goals of this therapy include improve ventilation, improve quality of sleep, decrease hospitalizations, improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing and improve lung compliance. 9. On 11/07/2024 at 10:42AM during observation, R93's CPAP (Continuous Positive Airway Pressure) mask was observed placed on the nightstand without any cover. On 11/07/2024 at 10:43AM during observation with V15 (Licensed Practical Nurse), R93's CPAP mask was again observed placed on the nightstand without any cover. On 11/07/2024 at 10:42AM during interview, R93 stated that R93 puts on and removes her CPAP mask herself. R93 also stated that she has not seen any staff clean her CPAP machine, and staff only puts water in it. On 11/07/2024 at 10:43AM during interview with V15, V15 stated that R93's CPAP mask should be covered after each use. On 11/08/2024 at 9:45AM during interview with V2 (Director of Nursing), V2 stated that CPAP masks are considered respiratory equipment, and it should be cleaned and placed in a bag covering it after each use. Review of R93's Order Summary Report dated 11/08/2024 indicated that R93 was admitted in the facility on 06/21/2024 with diagnoses of not limited to Obstructive Sleep Apnea and an active order for CPAP use with order date of 06/21/2024. Review of R93's Care Plan revised on 10/02/2024 indicated that R93 use a CPAP machine while sleeping r/t (related to) sleep apnea. 10. On 11/07/2024 at 10:14AM during observation, R124's CPAP (Continuous Positive Airway Pressure) mask was observed placed on the bedside table without any cover. On 11/07/2024 at 11:10AM during observation with V5, R124's CPAP mask was again observed placed on the bedside table without any cover. On 11/07/2024 at 10:14AM during interview with R124, R124 stated that R124 puts on his CPAP mask himself at night and R124 removes it himself in the morning. 145197 Page 19 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0880 Level of Harm - Minimal harm or potential for actual harm On 11/07/2024 at 11:06AM during interview with V5 (LPN), V5 stated that R124's CPAP mask should be placed in bag after each use. On 11/08/2024 at 9:45AM during interview with V2 (Director of Nursing), V2 stated that CPAP masks are considered respiratory equipment, and it should be cleaned and placed in a bag covering it after each use. Residents Affected - Some Review of R124's Order Summary Report dated 11/08/2024 indicated that R124 was admitted in the facility on 09/21/2024 with diagnoses of not limited to Obstructive Sleep Apnea. Review of R124's Care Plan revised on 10/09/2024 indicated that R124 use a CPAP/Bi-PAP (Bi-level Positive Airway Pressure) machine while sleeping. 11. On 11/7/2024 at 10:20 AM R38 nebulizer machine was on bedside table. Nebulizer is not in use. The set up, mask and tubing, were not dated and not stored in a plastic bag. R38 said he uses the machine so he can breathe better. On 11/7/2024 at 10:25 AM V8 (Registered Nurse) said nebulizer treatment set up should be in a bag when not in used and labeled with date so staff would know when to change it. Set up is changed once a week on Sunday. On 11/7/2024 at 11:40 AM V2 (Director of Nursing) said nebulizer treatment mask and tubing should be stored in a clear plastic bag when not in used to for infection control and labeled with date of when it was last changed. Based on observation, interview, and record review the facility failed to ensure appropriate infection control practices in proper handling of oxygen & respiratory equipment. The facility also failed to ensure proper hand hygiene/handwashing is performed during resident care. This deficiency affects all eleven (R15, R23, R38, R42, R50, R52, R85, R93, R105, R124, R432) residents in the sample of 30 reviewed for Infection control. Findings include: 1. On 11/7/24 at 10:17AM, observed R23's nebulizer mask hanging from drawer without plastic covering or date and nebulizer machine on floor. On 11/7/24 at 10:17AM, V7(Restorative Nurse) said she is unsure if nebulizer mask should have a plastic covering, V7 said the nebulizer mask should not be hanging from dresser or touching the floor. On 11/7/24 at 11:04AM, V2 (Director of Nurse) said that all nebulizer masks should be covered when not in use and have labeling of date when the mask was last changed. Facility's Policy on Oxygen & Respiratory Equipment-Changing/Cleaning Revised 1/7/19. Purpose: 1. To provide guidelines to employees for changing all disposable respiratory supplies. 145197 Page 20 of 21 145197 11/08/2024 Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453

F 0880 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. Level of Harm - Minimal harm or potential for actual harm 3. To minimize the risk of infection transmission. Procedure: Residents Affected - Some Hand Held Nebulizer (HHN) and Mask, if applicable b. A clean plastic bag with a zip loc or draw string, etc. will be provided with each new set up, and will be marked with the date the set up was changed. Facility's Policy on Nebulizer- Medication Administration Revised 10/9/18. Nebulizer- Administering Medications through a Small Volume (Handheld) Nebulizer. 23. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 2. On 11/7/24 at 10:40AM, observed V10 (Certified Nursing Assistant/CNA) removing gloves and exiting R50's room an Enhanced Barrier Protection prevention room without performing hand hygiene. On 11/7/24 at 10:41AM, V10 said that when she removed gloves and exited room, she did not perform hand hygiene, she said she forgot. On 11/7/24 at 11:04AM, V2 (Director of Nursing/DON) said that all staff should follow facility policy on hand hygiene/handwashing. V2 expectations are for staff to perform hand hygiene before and after entering room/ before and after glove usage. Facility's Policy on Hand Hygiene/Handwashing Revised 1-10-18. Definition: Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e., alcohol-based hand sanitizer including foam or gel). When to perform hand hygiene (Either Alcohol Based Sanitizer or Handwashing): -Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed). -After glove removal. 145197 Page 21 of 21