Health inspection·February 24, 2025

F 0679 Provide activities to meet all resident's needs. 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 residents were notified, invited, and engaged to attend meaningful activities that incorporate residents' interests for 2 (R1, R4) out of 3 residents reviewed for residents' rights. Residents Affected - Few Findings Include: On 2/23/25 at 8:55 AM, R1 was observed lying in bed alert and able to verbalize needs. R1 is blind and can't read. R1 can only see contrast and forms. R1 stated R1 would like to go to activities like bingo but staff does not tell R1 of what activities are going on in the facility each day. R1 stated that R1 also likes to go to church and listens to gospels. R1 stated staff used to hand out a sheet about activities, but it's been a while since R1 gotten one. R1 stated R1 does not know what other things are going on in the facility for today. On 2/23/25 at 10:30 AM, R4's up in bed alert and able to verbalize needs. R4 was interviewed about activities in the facility. R4 stated, Since I've been here nobody tells me what activities are going on in the facility. I've been here for 3 months. I would like to do some activities if something interests me. On 2/23/25 at 11:01 AM, Surveyor observed V11 (Activity Aide) conducting yoga/meditation session on the third floor for activities. R1 and R4 were not in attendance. On 2/23/25 at 11:06 AM, interviewed V11 and stated that there are activities in the facility every day held on third floor or fourth floor. The calendars are posted on the board. V11 stated, We go around to all residents and invite residents of what activities I'm doing. We let them know every morning. V11 stated V11 did not stop by this morning to notify and invite R1 about today's activities. V11 stated V11 did not stop by this morning to invite R4 to activities either. On 2/23/25 at 11:46 AM, interviewed V2 (Activity Director) and stated that R1 refuses to go to activities. V2 stated activity calendars are posted on every floor. V2 stated V2's staff and [V2] invite the residents to activities and encourage them to attend every day. V2 stated V2 did not invite R1 to go to activities this morning. V2 stated there's one activity staff [V11] in the facility today and not sure if V11 invited R1 to activities. V2 stated, That is the goal is to invite each resident to attend activities every day. We visit [R1] we encourage [R1] to attend activities. [R1] said [R1] likes bingo. We explain to [R1] that we have bingo some days. Normally [R1] just refuses to go to activities. We don't have other things for [R1] to do besides the one on the calendar. V2 stated that R4 does not attend activities either. V2 stated, I can't remember if I invited [R4] for activities this morning. Page 1 of 4 145336 145336 02/24/2025 Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/23/25 at 2:07 PM, Surveyor observed V11 (Activity Aide) conducting activities of gospel hour and puzzles on the third floor. R1 and R4 were not in attendance. V11 stated V11's the only activity aide in the building doing activities. On 2/23/25 at 2:22 PM, R1's still in bed alert and awake. R1 stated V2 (Activity Director) just left and just gave R1 a sheet of the week about activities. R1 stated, [V2] told me that there are activities from 10:30 AM to 3:00 PM. Surveyor asked R1 if R1 is aware of the activity gospel hour that started at 2:00 PM listed on the activity calendar for today. R1 stated, I would like to do gospel hour. I didn't know about that. Nobody invited me to that. I would have had them get me dressed and attend to that one. R1 stated that R1 would also have attended Zumba and daily chronicles this morning if staff had invited R1 to attend. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15 and is total dependent on staff assistance for transferring from bed to chair. R1's progress notes dated 2/3/25 at 12:55 PM documented by V13 (Licensed Clinical Social Worker) reads in part: R1 has diagnosis of adjustment disorder with mixed anxiety and depressed mood. R1 continues to have depression and anxiety due to being in the facility and loss of independence and home. R1 has significant mobility decline. Specific goal for R1 is to engage in at least one facility activity one time per week to reduce isolation and depression. R4's MDS dated [DATE] shows R4 is cognitively intact with BIMS of 15 and can walk with supervision. R4's activity care plan initiated 2/23/25 shows R4 engages in leisure/recreation pursuits: Music, Social interaction, Television, Movies with one intervention documents in part: Encourage R4 to pursue formal and informal leisure interest opportunities. The facility's February Activities calendar shows on the 23rd activities include Zumba mix at 10:30 AM, daily chronicles at 11:00 AM, gospel hour at 2:00 PM, puzzle mania at 3:00 PM, and pop in visits at 4:00 PM. The facility's Activity Policy dated 7/12/24 documents in part: It is the facility's policy to provide meaningful activity to residents. Provide group activities to residents that appeal to their interest on a daily basis. Activities may be based on specific needs, or interests, or culture, or background, etc. Program of Activities includes a combination of large and small group, one-to-one, and self-directed activities. 145336 Page 2 of 4 145336 02/24/2025 Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to serve adequate food portions as documented on the menu and meal tickets. This failure has the potential to affect all 213 residents receiving food prepared in the facility's kitchen. Findings Include: On 02/23/25 at 8:45 AM, surveyor entered kitchen and observed the breakfast tray line still in progress. Observed a 4-ounce ladle being used to portion out the grits and oatmeal for all of the diet (regular, ground and pureed) and a number 12-scoop used to portion out pureed toast. On 02/23/25 at 8:50 AM, V14 (Cook) stated she is the one who sets up the tray line with the serving utensils which should be used to portion out the resident's food. V14 stated she looks at the meal tickets to determine the correct portion sizes to be served. V14 stated the meal tickets do not say which serving utensil should be used, it only gives portion measurements. V14 stated for example, the meal ticket will read ¾ cup portion for grits/oatmeal, it does not say to use a 6-ounce ladle which is what we use to serve the hot cereal. V14 stated because she has been working in the kitchen for a long time, she knows which serving utensil gives what portion. V14 stated there used to be a diagram/poster guide which listed the different scoop numbers and the servings they each yielded but that is not up anymore. V14 stated, it must have fallen off the wall. On 02/23/25 at 8:57 AM, reviewed with V14 the serving utensils being used on the tray line. V14 observed the 4-ounce ladle being used to portion out the grits and oatmeal. V14 stated that is a 4-ounce ladle and it should be a 6-ounce ladle. V14 observed all of the pureed food items being portioned out with a number 12-scoop. V14 stated those are not the correct serving utensils and they are a mistake. V14 stated the kitchen should be using the correct serving utensils so the residents can get the full portion of food they are supposed to base on the menu created for them. On 02/23/25 at 9:00 AM, observed large container of different serving utensils including number ten scoops and six-ounce ladles. On 02/23/25 at 1:22 PM, V23 (Dietary Director) stated it is the cook's responsibility to set up the tray line with the correct serving utensils to be used to portion out the food. V23 stated they should be looking at the Diet Manual Spreadsheet to check which serving utensils are needed and that these are kept in a binder in the kitchen for their reference. V23 stated the Diet Manual Spreadsheets are based on menus which are created by and approved by a corporate Registered Dietitian. V23 stated it is important for the kitchen to follow the Diet Manual Spreadsheets to determine which serving utensil should be used to make sure the resident's nutritional needs are being met. V23 stated if the kitchen staff is using the wrong serving utensil when portioning out the resident's food then the residents may not be receiving enough food which as the potential to lead to malnutrition and weight loss. Facility provided list of resident's diet orders based on census on 02/23/25. There are six residents who receive nothing by mouth (NPO). Facility provide policy titled, Menus dated October 2019 which documents in part, 145336 Page 3 of 4 145336 02/24/2025 Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610

F 0803 1.) Level of Harm - Minimal harm or potential for actual harm it is the center policy that menus are planned in advance, and to meet the nutritional needs of the residents/patients, will be developed utilizing an established national guideline. Residents Affected - Many 2.) The Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus. 3.) Menus are served as written. Facility document titled in part, Illinois Diet Guide Sheet Sunday (Day 15) Breakfast documents in part for ¾ cup grits to be served to regular, chopped, and ground consistencies and for pureed diet consistencies to receive number 6-scoop of grits and number 10-scoop of pureed toast. Facility provided document titled, Portion Control Chart dated 12/29/2021 which documents in part, number 6-scoop to provide 5.33 ounces, number 10-scoop to provide 3.2 ounces and number 12-scoop to provide 2.58 ounces. Facility provided recipe titled, Great Grits which documents portion size as ¾ cup. 145336 Page 4 of 4