Health inspection·February 10, 2023

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** Based on observation, interview and record review, the facility failed to have call lights accessible to dependent residents. This applies to 3 of 3 residents (R37, R55, R61) reviewed for accommodation of needs in a sample of 22. Residents Affected - Few The findings include 1. R55's face sheet dated 2/8/23 showed that R55 had diagnoses of spondylosis with myelopathy cervical region, fatigue fracture of vertebra lumbar region, radiculopathy lumbar and cervical region, major depressive disorder, seizures, fibromyalgia and right hip pain. R55's Minimum Data Set (MDS) dated [DATE] showed that R55's cognition is moderately impaired, R55 needs extensive assistance with two or more persons assist with bed mobility, total dependence with transfers and extensive assistance with one person assist with toilet use. R55's care plan dated 9/19/22 showed that R55 has self-care deficit (ADL/Activities of Daily Living and mobility) with the intervention to have call light within reach and to encourage resident to use prior to attempting self-care. On 2/7/23 at 11:41 AM during initial tour rounds on the 2nd floor, R55 could be heard in the hallway asking for help. R55 was observed in bed in her room. R55 said that she needed adjusted in bed. R55's feet were slightly off the bed. Surveyor was unable to locate R55's call light; it was not next to her in bed. Surveyor left R55's room and informed V5 (Restorative Aide) who was in the hallway. V5 found R55's call light hanging off the left side of R55's bed. V5 then repositioned R55 in bed. At 12:07 PM, R55's call light was observed dangling on the left side of R55's bed, not within R55's reach. At 12:30 PM, R55 was observed eating lunch in bed, call light was still dangling on the left side of bed, not within R55's reach. R55 asked for her tray to be moved closer. V8 (Certified Nursing Assistant/CNA) was in the hallway and came in assisted R55. On 2/8/23 at 9:15 AM, R55 was in bed resting, call light observed hanging on left side of bed, not within reach. Surveyor asked R55 if she knew where her call light was, R55 said it was somewhere around here but could not locate it. At 12:19 PM, R55 asked surveyor for a cup of water. R55's call light was still hanging on the left side the bed, not within reach. Surveyor asked R55 about her call light. R55 said she had not seen it and could not reach her call light. 2. R37's face sheet dated 2/8/23 showed that R37's had diagnoses of other sequelae following unspecified cerebrovascular disease, hemiplegia affecting left non dominant side, contracture of left wrist, left hand, left knee and left ankle and other chronic pain. Page 1 of 8 145358 145358 02/10/2023 Arista Healthcare 1136 North Mill Street Naperville, IL 60563

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R37's MDS dated [DATE] showed that R37's cognition is moderately impaired, R37 needs extensive assistance with two or more persons assist with bed mobility, extensive assistance with one person assist with transfers and toilet use. R37's care plan (revised 6/30/22) showed that R37 has a functional and self-care deficit in performing ADLs with the intervention to always have call light within reach. On 2/8/23 at 9:17 AM, R37 was observed in bed watching TV. R37's call light was on the floor by the right side of the bed. R37 was asked where the call light was. R37 said she did not know where it was. R37 was asked what she would do if she needed assistance; R37 said she does not know. At 12:18 PM, R37's call light was still on the floor by the right side of the bed. On 2/8/23 at 12:23 PM, surveyor showed V6 (Licensed Practical Nurse/LPN) R37's call light on the floor. V6 picked it up and clipped it to R37's bed. V6 said that R37 and R55 can use their call lights and it should be within reach so that the residents can use it if they need assistance. On 2/8/23 at 2:50 PM, V2 (Director of Nursing/DON) said call light should be accessible to residents so they can use it anytime if they need assistance. On 2/9/23 at 8:25 AM, V1 (Administrator) said they do not have call light assessment for the residents, but it is in their care plan for call lights to always be within reach. Facility Call Lights policy (November 2022) documents, 1. All residents shall have the nurse call light system available and within easy accessibility to the resident at the bedside or other reasonable accessible location. 3. Per MDS dated [DATE], R61's Brief Interview for Mental Status (BIMS) score was 6, indicating severely impaired cognition. R61 requires total staff assistance with transfers, locomotion and toileting. On 2/7/23 at 10:46 am, R61 was noted lying in bed. R61's call light was out of his reach. The call light was on the floor behind the refrigerator located to the right of his bed. 145358 Page 2 of 8 145358 02/10/2023 Arista Healthcare 1136 North Mill Street Naperville, IL 60563

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 verify gastrostomy tube (G-tube) placement prior to administering medications through the G-tube. This applies to 1 of 1 resident (R76) reviewed for medication administration via G-tube in the sample of 22. The findings include: On 2/8/23 at 12:05 PM, V7 (Registered Nurse) went to R76's room to administer his noon medications via the G-tube. V7 placed her stethoscope on R76's abdomen and injected 5 ml (millimeters) of air using the piston syringe through the port. V7 checked the placement of the g-tube by auscultating. V7 flushed the tube and then began administering R76's medications. After administering the medications, V7 flushed the tube again. V7 failed to check placement of the g-tube by aspirating gastric content. V7 said V7 checked R76's placement of the g-tube by pushing the 5 ml of air and auscultating. On 2/8/23 at 2:54 PM, V2 (Director of Nursing) said the nurse should check for g-tube placement by checking the gastric residual. Facility Policy and Procedure Tube Feeding: Checking Gastric Residual policy (November 2022) documents: 10. Gently pull the piston of the syringe back, aspirating for gastric contents. 11. Note the amount, color, and consistency of the gastric contents. 12. Return any aspirated gastric contents back into the stomach. 145358 Page 3 of 8 145358 02/10/2023 Arista Healthcare 1136 North Mill Street Naperville, IL 60563

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 label all stored food items and remove expired food items. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: Facility Resident Census and Condition of Residents (Form CMS- Centers for Medicare and Medicaid Services-672) documents that the total census was 85 residents. Out of the 85 residents, there were three residents on gastric tube feedings. On 2/7/23 starting at 9:52 AM, the facility kitchen was toured in the presence of V13 (Dietary Manager). On 2/7/23 at 9:57 AM in dry storage room, four plastic containers of cereal (labeled bran, oat, rice, and corn) were found without dates. Three chocolate pudding dry mix packets, two vanilla pudding dry mix packets, one lime gelatin dry mix packet, one muffin mix bag, and one devil's food cake mix bag were all found opened without dates. On 2/7/23 at 10:08 AM in the dry storage room, six bags of unopened tortilla chips were found with expiration date of January 18, 2023. V13 removed the tortilla chips from the shelf. One cheddar cheese sauce mix packet was found opened without date. On 2/7/23 at 10:11 AM in the dry storage room, one bag of opened pasta noodles was found unlabeled without date. On 2/7/23 at 10:18 AM in walk-in refrigerator, pulled pork leftovers were found with an expiration date of 2/6/23. V13 threw away the expired pulled pork. Two bricks of cheese were found opened, without label or date. Two buckets filled with liquid dated 1/31/23 were found without labels. V13 said one bucket was nectar thick juice and one bucket was nectar thick milk. V13 discarded contents of both buckets. One bag of diced white chicken bag was found opened without a date. On 2/7/23 at 10:31 AM in the walk-in refrigerator, three plastic containers of food were found unlabeled and undated. V13 said the containers had apple sauce, mandarin oranges, and peaches in them. V13 then labeled and dated the apple sauce and mandarin orange containers and threw away the peaches. V13 said he did not know when the peaches were opened. In the walk-in freezer two turkeys were found without dates. V13 said the turkeys came in November and there were so many of them that V13 didn't get the chance to label them all. One bag of frozen corn on the cob without label or date was found with freezer burn. V13 said he was going to throw them out. On 2/8/23 at 10:53 AM in the first floor unit refrigerator, an unlabeled and undated half gallon jug with R89's name on it was found with orange liquid in it and dark brown sediment in the bottom. Also in the first floor unit refrigerator, an apple pie with expiration date of 2/4/23 and a cherry pie with expiration date 2/3/23 were found. V7 (Registered Nurse) threw away the unlabeled and undated half gallon jug and said she was going to ask staff who the pies belonged to. V7 said the half gallon jug should have a label on it describing what it is and an expiration date. 145358 Page 4 of 8 145358 02/10/2023 Arista Healthcare 1136 North Mill Street Naperville, IL 60563

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 2/8/23 at 12:15 PM in the second floor unit refrigerator, an unlabeled and undated plastic food container was found with food inside. V13 said he did not know what the food was or who it belonged to. V13 emptied the container in the garbage and said he was going to bring plastic container downstairs to the kitchen to wash it. On 2/7/23 at 10:10 AM, V13 said all food items are supposed to be labeled and dated with expiration dates as soon as they are opened. On 2/8/23 at 11:08 AM, V1 (Administrator) said it is V13's responsibility to check the unit refrigerators daily and throw away all expired and unlabeled food. On 2/8/23 at 11:10 AM, V13 said he checked the unit refrigerators already and did not see any expired, unlabeled, or undated foods. On 2/8/23 at 12:23 PM, V13 said he threw away the pies from the first floor unit refrigerator because they were expired and not labeled with a name. V13 said the facility staff know that all food is supposed to be labeled in the refrigerator. Food Safety and Sanitation Policy titled 'Dating and Labeling' (4/2017) states, All items not in their original containers will be labeled. Food labels should include the common name of the food or a statement that clearly and accurately identifies it. Food Safety and Sanitation Policy titled 'Storage of Dry Foods/Supplies' (4/2017) states, Opened products will be labeled and stored in tightly covered containers. Storage bins used will be kept clean, labeled, and dated. Food Safety and Sanitation Policy titled 'Storage of Refrigerated/Frozen Foods' (4/2017) states, Foods in the refrigerator will be covered, labeled, and dated. Foods will be used by its use-by-date, frozen or discarded. Facility 'Food Brought into the Facility by Friends/Family/Others (Outside Sources) For Residents' policy (11/28/2017) states, Procedure: 1. Any food or beverage brought into the facility by friends/family/others for resident consumption will be encouraged to be checked by a nursing staff member. Any suspicious or obviously contaminated items (due to appearance/odor or expiration date that has passed-if the food is packaged by the manufacturer) will be discarded immediately. 145358 Page 5 of 8 145358 02/10/2023 Arista Healthcare 1136 North Mill Street Naperville, IL 60563

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 2/7/23 at 11:02 AM, R15's refrigerator had several items inside. There were no temperature logs posted on his refrigerator. Residents Affected - Some On 2/8/23 at 1:21 PM, surveyor reviewed the refrigerator temperature log binder provided by maintenance. There were no refrigerator temperature logs at all for R15 since January 2023 to present. 7. On 2/7/23 at 11:15 AM, R84's refrigerator had several items inside. There were no temperature logs posted on her refrigerator. On 2/8/23 at 1:25 PM, surveyor reviewed the refrigerator temperature log binder provided by maintenance. There were refrigerator temperature log sheets R84 for the following dates: January 2023-1/2, 1/12, 1/19, and 1/26. December 2022-12/5, 12/14, 12/22, and 12/31. There was no log sheet started for the month of February 2023. Based on observation, interview, and record review, the facility failed to have a thermometer, monitor resident's refrigerator temperature, label and date food items, and remove expired food items to ensure safe, sanitary storage and consumption of personal food items. This applies to 9 of 9 residents (R10, R22, R25, R63, R83, R15, R84, R68, R40) reviewed for personal food storage and refrigerator use in a sample of 22. Findings include: 1. On 02/07/23 at 10:50 AM, the surveyor observed R10 in his room having a personal refrigerator stored with pasta sauce, gelatin and {Name Brand} nutritional supplement drink. No temperature log was available with the fridge. 2. On 02/07/23 at 10:55 AM, R22 was observed in his room having a personal refrigerator without having a temperature log available with the fridge. 3. On 2/7/23 at 10:31 AM, R25 was observed in her room having a refrigerator packed full of food items, including garlic chutney, milk, cheese, daal (lentil curry), pickle, butter, yogurt, etc. No temperature log was available with the resident's refrigerator. R25 stated that her son brings these food items on weekends. On 02/08/23 at 11:51 AM, V2 (Director of Nursing) stated, The housekeeping is in charge of checking on resident personal refrigerators daily and filling out the temperature log. They are keeping the log somewhere outside the resident's room. The resident refrigerator should be monitored daily and should fill out the temperature log. Record review on the January temperature log indicates that the log was filled out only on 1/1/23, 1/6/23, and 1/16/23 for R10, R22, and R25. Record review on the February temp log (as of 2/7/23) indicates that the log was completed only on 2/7/23 (as of 2/7/23). Facility 'Food Brought into the Facility by Friends/Family/Others for Residents' policy documents: All refrigerators in use in the facility have their internal temperature recorded daily. 145358 Page 6 of 8 145358 02/10/2023 Arista Healthcare 1136 North Mill Street Naperville, IL 60563

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 8. On 2/7/23 at 10:41 AM, during the initial tour on the 2nd floor, R40 and R68 were in their room. R40 was observed opening the small personal refrigerator in the room. The refrigerator had several cans of cola and a jug of water with no date on it. R40 said he shares the room with his wife R68. There was no temperature log noted on the refrigerator. On 2/7/23 at 2:08 PM, V2 (Director of Nursing) gave surveyor the refrigerator temperature log for R40 and R68. Review of the temperature log for January and February log showed that form was only filled out on 1/3/23, 1/10/23, 1/17/23, 1/24/23, 1/31/23 and 2/7/23. 4. R63 is a sixty-four-year-old male with a primary diagnosis of early onset Alzheimer's Disease. R63 is cognitively intact with a BIMS (Brief Interview for Mental Status) Score of 15 as per the Minimum Data Set, dated [DATE]. R63 requires staff supervision with his activities of daily living. On 2/7/23 at 11:17 AM, R63's refrigerator was viewed by surveyor. Fifteen cartons of expired milk were noted in R63's refrigerator - 2% milk dates: 10/22/22, 1/15/22, 1/31/23, 11/9/22, 10/24/22, 10/9/22, 11/ 20/22, 11/20/22, 12/10/22, 1/27/22, 12/4/22, 11/27/22, 1/28/23, 11/6/22, 12/17/22. Three cartons of 1% milk were noted with an expiration date of 11/16/22. A zip lock bag of meat was observed as not dated. Two take out containers of unidentified food had no date, and an opened bag of teriyaki pork and beef meat sticks were observed with no noted expiration date. On 2/7/23 at 1:19 PM, R63 stated he cleans his refrigerator himself. On 2/7/23 at 3:16 PM, R63 stated the bag of meat in in refrigerator has three different kinds of meat he saved from dinner a few days ago. R63 stated he eats and drinks the items in his refrigerator including the milk. 5. R83 is a seventy-six-year-old female with a primary diagnosis of Atrial Fibrillation. R83 is cognitively intact with a BIMS (Brief Interview for Mental Status) Score of 15 per the Minimum Data Set, dated [DATE]. R83 requires extensive assistance with transfers, dressing, toileting and personal hygiene On 2/7/23 at 12:44 PM, R83's refrigerator noted with six cups of partially drank red liquid with no date or cover, a bag of unidentifiable food and bottle of ranch dressing. Items in the refrigerator felt warm. No thermometer was noted in the refrigerator. R83 stated no one had ever checked her refrigerator temperature. On 2/7/23 at 12:31 PM, V9 (Certified Nursing Assistant/CNA) stated housekeeping and CNAs help clean the resident refrigerators. Housekeeping looks at the refrigerators' temperatures. On 2/8/23 at 9:59 AM, V1 (Administrator) stated he spoke with the housekeeping manager about the refrigerator checks being daily per facility policy. Housekeeping is responsible for completing the refrigerator checks. Review of refrigerator temperature logs for November 2022, December 2022, January 2022 and February 2023 indicate R63 and R83's refrigerator were done once per week. On 2/9/23 at 9:17 AM, V10 (Housekeeping Supervisor) stated he is responsible for tracking and documenting refrigerators' temperatures for the entire facility. V10 stated he's been the housekeeping supervisor 2 1/2 years. V10 stated for 2 1/2 years he's been completing the temperature log and 145358 Page 7 of 8 145358 02/10/2023 Arista Healthcare 1136 North Mill Street Naperville, IL 60563

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cleaning the refrigerators once weekly as the previous Director of Nursing had instructed. V10 stated he didn't know what the facility policy said about checking the refrigerators. V10 stated the facility did give him a binder with the facility policies when he started. V10 stated his understanding now is that it should be done daily. V10 stated, If the refrigerator falls outside of the normal temperature range, we notify the resident and we throw away the food. The refrigerator is put it in the basement to check the temperature for one day. If it's still out of range we notify the resident and their family when the refrigerator is no longer operational. V10 stated when he checks the refrigerator temperatures, he also checks the expiration date of food items. V10 stated if there is new item, he notifies the resident it needs to be dated. V10 stated he checks the date on juice and milk if there are expired items, he throws it out. V10 stated R63 gives him a hard time, but expired items are thrown out. V10 stated he threw expired items away this week for R63 and put a thermometer in the refrigerator for R83 on Tuesday. 145358 Page 8 of 8