Health inspection·March 15, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure comfortable temperatures for 3 of 8 residents (R1, R2, and R3), a comfortable bed mattress for 1 of 8 residents (R1), and odorless air for all 93 residents third-floor residents. Findings include: On 03/14/2024, during the investigation, the writer entered the third floor via elevator five different times from 11:00 AM to 3:00 PM. The third-floor entrance from the elevator, dining room, and 300 wing had a strong urine odor. Though the facility's third-floor flooring, residents' rooms, and bathrooms were clean, the mentioned areas had a strong odor of urine. 1. R1's face sheet showed R1 was admitted to the facility on [DATE] with diagnoses including catatonic disorder, schizophrenia, depression, encephalopathy, and urinary retention with acute kidney failure. At 11:28 PM, R1 was in bed, withdrawn, staring at the writer, and did not respond to the writer's interview. R1's bed was sagging in the center, urine odor was present by his door entry, and the room temperature was 85 degrees Fahrenheit. R1 got up and left the room. On 03/14/2024, around 2:00 PM, V14 (R1's volunteer and vice President of United Cerebral Policy (USP) said they provided support to R1 at home, and since 03/10/2024, staff has been volunteering to visit R1 at the facility. V14 said R1's room had a urine odor, and her staff also told her about R1's room and floor's urine odor. V14 said V12 (R1's family member) reported to V5 (Registered Nurse) on 03/10/2024 about his bed since R1 reported to V12 that he had neck pain due to the uncomfortable bed. On 03/14/2024 at 1:45 PM, V6 (Registered Nurse) said she saw in the nursing report that V12 (R1's family member) reported on 03/10/2024 to V5 (Registered Nurse) that R1's bed mattress had issues. V6 said the maintenance staff changed the bed mattress. At 2:42 PM, V5 said V12 (R1's family member) told her the head end of the bed was not rising and was uncomfortable. She endorsed it in the nursing report and was unaware of what happened afterward. On 03/14/2024 at 1:18 PM, V3 (Director of Maintenance) said no one placed the work order for R1's bed concerns and no one reported to him about R1's room's high temperature. V3 said the facility's temperature was checked daily. V3 said the facility runs on a water system, and even shutting off the water system takes a while to cool down the temperature as water pipes remain hot for a while. On 03/14/2024, around 1:30 PM, the writer toured the facility with V3 (Director of Maintenance), Page 1 of 2 145329 145329 03/15/2024 Norridge Gardens 7001 West Cullom Norridge, IL 60634

F 0584 Level of Harm - Minimal harm or potential for actual harm checking the temperature of R1-R8 rooms. R1-R3's rooms showed a temperature of 85 degrees Fahrenheit, V3 said the ideal temperature is between 71- and 81-degrees Fahrenheit. V3 checked the bed mattresses of R1-R8. V3 stated that if R1 is uncomfortable in his bed he will talk with V2 (Director of Nursing) and change the mattress. When the writer asked about the urine odor, V3 acknowledged it and said it could be due to the carpet. Residents Affected - Some On 03/15/2024 at 12:46 PM, V4 (Housekeeping Manager) said the facility makes all efforts to keep it clean and odor-free. V4 said her housekeeping staff attends to spills and urination as soon as the staff reports them. V4 said some residents are ambulatory and urinate wherever they want, and it goes unnoticed. So, the management discussed removing it and replacing it with regular flooring. 2. R2's face sheet showed that R2 was admitted to the facility initially on 04/1/2022 with diagnoses including dementia, pulmonary embolism, depression, and under palliative care. R2's room smelled of urine, and the temperature was 85 degrees Fahrenheit. R2 was in bed and not interviewable. On 03/14/2024 at 11:30 AM, V13 (R2's family member) said that the urine smell in the room was due to R2's briefs and bed soaking in urine when she arrived at the facility around 7:00 AM. She changed his briefs and bedding and reported her concerns to the management. V13 said she always feels warm and doesn't know if she feels warm due to room temperature or if that is her. V13 said R3 (R2's roommate) also had the same situation when she came to the facility. 3. R3's face sheet showed [AGE] year-old R3 was admitted to the facility initially on 11/22/2013 with diagnoses including dementia, traumatic brain injury, depression, and schizophrenia. At 12:30 PM, R3 was in the dining room and not interviewable. R3 was sharing the room of R2, where the temperature was 85 degrees Fahrenheit. On 03/14/2024, V7 (student Nursing Assistant) was in the dining room at 12:00 PM, V9 (Certified Nursing Assistant) in the 300 hallway, V10 (Laundry Aide) in the 300 wing at 12:48 PM, and V11 (Dietary Aide) entered the floor via elevator at 1:29 PM acknowledged that the floor had urine odor when the writer asked them. V9 said this odor might be due to carpets. On 03/14/2024, V1 (Assistant Administrator) and V2 (Director of Nursing) said the facility is making all efforts to keep residents safe and happy, and no one reported concerns about temperature and bed mattresses. V1 and V2 said the facility would follow up on all current concerns. A review of the facility policy with a revised date of March 2020, titled Homelike Environment, in part shows residents are provided with a safe, clean, and comfortable homelike environment, including comfortable room temperatures near the range of 71-81-degree Fahrenheit, maintenance of the device, and elimination of odors. 145329 Page 2 of 2