Health inspection·August 18, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record review, the facility failed to follow their call light policy. The facility failed to place call light within reach. This deficient practice affects three residents (R15, R41 and R71) of three residents reviewed for call light placement in a total sample of 25 residents. Residents Affected - Few Findings Include: On 8/15/23 at 10:30AM, Observed R71 in bed, observed call light placement not within reach. Call light was on the floor on the right side of R71's bed. R71 stated that she does not know where her call light is. Also stated that when her call light is not within reach, R71 will yell or call for help. On 8/15/23 at 10:35AM, V13 (RN) confirmed that the call light of R71 is on the floor and not within R71's reach. V13 also stated that she will inform the maintenance that the call light needs a clip. On 8/15/23 at 10:45AM, R15 in bed, observed call light wrapped in left upper side rail, No clip. R15 said she don't know where her call light is at that moment. Pointed at the left side rail, and R15 said I cannot see or reach it. On 8/15/23 at 10:50AM, V13 also confirmed that the fall light placement is not within reach of R15. State surveyor asked R15 if she is able to reach the call light, R15 said No. V13 again said she will let the maintenance know that the clip is not available. On 08/15/23 11:27AM, surveyor asked R41 to activate her call light. R41 said she cannot activate her call light because she cannot reach the call light. On 08/15/23 11:27AM, R41's call light was not accessible and was on the floor in back of R41's wheelchair. R41's left arm is in a splint and was not able to reach the call light on the floor. V30 (CNA) noted R41's call light on the floor and in back of R41's wheelchair. V30 was able to reach behind and attach the call light to the side rail and ensure call light is R41's in reach. On 8/17/23 at 1:45PM, V28 (DON) stated that call light should be within residents' reach. Use of Call Light Policy reads in part: To respond promptly to resident's call for assistance. When providing care to residents, position the call light continently for the resident's use. Tell the residents where the call light is and show him/her how to use the call light and provide reminders to use the call light as needed. Be sure call lights are placed within resident reach at all times. Page 1 of 11 145557 145557 08/18/2023 Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to follow their prevention and treatment of pressure injury policy and failed to implement preventative measure appropriately by not following the operation manual for a pressure injury preventative mattress. This deficient practice affected one resident (R38) of three residents reviewed for skin alterations in a total sample of 25 residents. Residents Affected - Few Findings Include: On 8/15/23 at 11:00AM, observed R38 in bed, using a low air loss mattress (pressure injury preventative mattress). Machine checked and it is set on 230lbs (pound in weight). On 8/15/23 at 11:10AM, V14 (LPN) confirmed that the machine is set for 230 lbs. Stated that the low air loss mattress is supposed to be set to the weight of R38 and that she will check the weight of the resident and change the setting as necessary. On 8/16/23 at 10:00AM, observed R38 in bed, using a low air loss mattress (pressure injury preventative mattress). Machine checked and it is set on 280lbs (pound in weight). Machine for the low air loss mattress had six lights for weight by lbs. The light goes in 80lbs, 130lbs, 180lbs, 230lbs, 280lbs, and 340lbs. On 8/16/23 at 10:35AM, V5 (Wound Care Coordinator) stated that the mattress machine setting check is done randomly by her wound care team and they make adjustments when needed. The light should be close to the weight of the resident. The weight light lit in the machine should show closer to the weight of R38. R38 had a history of pressure injuries but they are already healed and we are using the special mattress as preventative measure for R38. R38 is assessed as moderate risk for skin alteration. We follow the recommendation setting of the manufacturer of the mattress, which to set it for the weight of the resident using the machine. It defeats the purpose of the machine if the recommendation is not followed. I will in-service the staff and educate them about the importance of the low air loss mattress in the right setting. R38's weight in July 2023 was 144.6lbs and in August of 2023 was 146.6lbs. Braden Scale Assessment (predicting pressure injury risk) dated 6/3/23 shows R38 scored 14 (Moderate Risk). R38 has a care plan for alteration of skin integrity related to moisture to under breast and a history of pressure wounds to bilateral buttocks. R38 requires extensive assist in ADL care, bed mobility, and transfers. R38 has occasional incontinece of bowel and bladder and intentional friction of buttocks against bed. Intervention initiated: pressure redistribution support-low air loss mattress in bed. Operation Manual for low air loss mattress provided by the facility, reads in part: Pressure set up: users can adjust the pressure level of the air mattress to the desired firmness by themselves or according to the suggestions from a health care professional. Note: It is recommended to press auto firm on the panel when the mattress is first inflated. Users can easily adjust the air mattress to a desired firmness according to the patient's weight and comfort. 145557 Page 2 of 11 145557 08/18/2023 Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Braden Scale for Predicting Pressure Injury Risk policy, reads in part: To be completed for all residents to assess level of risk for developing pressure injury. Regardless of the resident's total risk score, eacj risk factor and potential cause(s) should be reviewed individually. Implement intervention according to the resident's Braden Score and/or individual risk factors identified. Prevention and Treatment of Pressure injury and Other Skin Alterations policy, reads in part: identify residents at risk for developing pressure injuries. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Identify residents at risk for developing pressure injuries utilizing the Braden scale. 145557 Page 3 of 11 145557 08/18/2023 Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 label the enteral tube feeding bags with the date and time it was initiated for four of thirteen residents (R24, R32, R52, R323) reviewed for tube feeding in a sample of 25. Findings include: On 08/15/2023 at 10:32AM during observation, R52 was observed with enteral tube feeding attached to her gastrostomy tube labeled with initiation date of 8/14/2023 with no time indicated. At 11:06 AM during observation, R32 was observed with enteral tube feeding attached to her gastrostomy tube labeled with initiation date of 8/14/2023 with no time indicated. At 11:10 AM during observation, R323 was observed with enteral tube feeding attached to her gastrostomy tube without label indicating the resident's name, and date and time it was initiated. At 12:13 PM during observation, R24 was observed with enteral tube feeding attached to her gastrostomy tube labeled with initiation date of 8/14/2023 with no time indicated. On 08/15/2023 at 12:02PM, V33 (Registered Nurse/RN) stated that they only write the date the feeding was initiated on the enteral feeding not the time because they go by the electronic medication administration record (eMAR). On 08/15/2023 at 12:19PM, V34 (RN) said that she is not sure if the time has to be written down on the enteral feeding. R52's admission record indicated admission date of 07/08/2023 and diagnoses including dysphagia oropharyngeal phase. R52's order listing report dated 08/17/2023 indicated active order of enteral feeding with order date of 08/04/2023. R32's admission record indicated admission date of 07/24/2020 and diagnoses including dysphagia and encounter for attention to gastrostomy. R32's order listing report dated 08/17/2023 indicated active order of enteral feeding with order date of 06/05/2023. R323's admission record indicated admission date of 10/08/2021 and diagnoses including dysphagia and encounter for attention to gastrostomy. R323's order listing report dated 08/17/2023 indicated active order of enteral feeding with order date of 08/11/2023. R24's admission record indicated admission date of 06/13/2023 and diagnoses including encounter for attention to gastrostomy. R24's order listing report dated 08/17/2023 indicated active order of enteral feeding with order date of 06/14/2023. Facility Policy: Title: Enteral Nutrition Feeding Date: 09/2020 Procedure: 145557 Page 4 of 11 145557 08/18/2023 Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 13. Change enteral feeding solution and bag/bottle per manufacturer guidelines. Nestle: Enteral feeding closed system can hang up for up to 48 hours. Enteral feeding in an open system bag should be changed every 24 hours (bag itself). A carton/can (250 milliliters/ml) should be used/infused within an 8 hour hang time. Label bag/container with name, date, time. Change spike set with each new ready to hang bottle. Change irrigation set and/or piston syringe weekly and prn (as needed). Label with name, use and date. Shake formula well and check for expiration date prior to administration. 145557 Page 5 of 11 145557 08/18/2023 Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 provide an extra tracheostomy (trach) cannula at the bed side and failed to have enough water in the aerosol bottle at the bed for two residents (R58 and R322) of nine residents reviewed for Trach care in a total sample of 25 residents. Residents Affected - Few Findings Include: 1. On 8/15/23 at 11:30 am during screening R58's humidifier was observed with approximately 2 milliliters of water in the bottle, no bubbles were seen in the aerosol bottle or in the large bore corrugated tubing while still connected to R58's tracheostomy (trach) collar. There was no extra emergency tracheostomy cannula at the bedside. V23 (LPN) was observed going out to request an extra cannula from the respiratory therapist, V23 was informed by V24 (Respiratory Therapist) that there was an extra piece of cannula in R58's cupboard. V23 did not know where to find the extra emergency tracheostomy cannula. On 8/15/23 at 11:35 am, V23 and V24 both stated that there should be an extra tracheostomy cannula at the bedside in case of an emergency. Both stated that, the humidifier bottle should have enough water to keep the tracheostomy moist. V24 stated that the humidifier is used to prevent plug formation. R58 was admitted on [DATE] with multiple sclerosis, functional quadriplegia, and dependence on supplemental oxygen. Care plan dated 7/28/23 reads, adjust oxygen to maintain saturation with adequate parameters, R58 has alteration due to Trach and has potential for complications secondary to tracheostomy . Facility policy dated 09/2020 titled, Oxygen Therapy Devices High Humidity. Policy: Oxygen delivered with high humidity or high humidity without O2 will be set up to enhance humidification of mucous membrane . Procedure: 3. High humidity -with oxygen, can be provided using an aerosol bottle, large bore corrugated tubing, 02 device and 100% source . 2. On 08/15/2023 at 11:33AM during observation with V36 (Registered Nurse), R322 was observed with tracheostomy attached to wall oxygen with no extra emergency tracheostomy kit and artificial manual breathing unit (AMBU) at bedside. On 08/15/2023 at 11:33AM, V36 said that residents on tracheostomy tubes usually have a spare tracheostomy kit and AMBU at bedside but she does not know why R322 did not have one. R322's face sheet indicated admission date of 07/10/2023, and diagnoses including paralysis of vocal cords and larynx, bilateral, encounter for attention to tracheostomy and dependence on supplemental oxygen. R322's order listing report dated 8/17/2023 indicated and active order for in case of emergency, trained nurse may reinsert outer cannula of tracheostomy as needed with order date of 145557 Page 6 of 11 145557 08/18/2023 Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010

F 0695 7/10/2023. Level of Harm - Minimal harm or potential for actual harm Facility unable to provide policy. Residents Affected - Few 145557 Page 7 of 11 145557 08/18/2023 Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to discard expired house stock medications and label multi-dose medications with open date for three of four medication carts and one of one medication room observed for medication storage and labeling. This deficiency can affect all 126 residents residing in the facility. Findings include: On [DATE] at 1:20PM during observation with V33 (Registered Nurse/RN), Cart 4 in C-wing was observed with the following: 1. Opened house stock Lactobacillus acidophilus bottle with expiration date 7/23 2. R67's budesonide 0.5 milligrams (mg)/2 milliliters (ml) nebules in an open foil pouch with no open date 3. R9's budesonide 0.5 milligrams (mg)/2 milliliters (ml) nebules in an open foil pouch with no open date At 2:05PM during observation with V14 (Licensed Practical Nurse/LPN), Cart 2 in B-wing was observed with the following: 1. R22's opened 10ml vial of Heparin sodium 5000 units/ml with no open date 2. R12's opened 10ml vial of Heparin sodium 5000 units/ml with no open date At 2:40PM during observation with V31 (LPN), B-wing medication room was observed with opened multidose vial of tuberculin purified protein derivative (PPD) with no open date. At 2:51PM during observation with V7 (LPN), Cart 1 of C-wing was observed with the following: 1. R110's opened 10ml vial of Heparin sodium 5000 units/ml with no open date 2. R110's opened latanoprost solution 0.05% eye drops with no open date with label that reads Discard 42 days after opening 3. Two opened 10 ml vials of R95's Heparin sodium 5000 units/ml with no open date On [DATE] at 1:30PM, V33 said that the house stock lactobacillus bottles should have been discarded and the budesonide foil pouch should indicate an open date once opened. On [DATE] at 2:15PM, V14 said that she does not know why the vials did not have open dates. She added that they should have an open date, so they know when to stop using it. On [DATE] at 2:45 PM, V31 said that the PPD vial should have an open date so other nurses would 145557 Page 8 of 11 145557 08/18/2023 Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010

F 0761 know when to discard it and not use it. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 3:10PM, V7 said all multidose vials should have an open date and the eye drops that has a specific instruction of when to discard should be labeled with open date as well. Residents Affected - Many Facility Documents: Title: Medicine Information Leaflet (Budesonide) Patient Information and Instruction for Use: How should I store budesonide inhalation suspension? · Budesonide inhalation suspension vials can be stored for 2 weeks after opening the protective aluminum foil envelope. Patient Instructions for Use: 1. Budesonide inhalation suspension vials come in a sealed protective aluminum foil envelope. · Do not open the sealed pouch until you are ready to use a dose of budesonide inhalation suspension. · Record the date that you opened the foil in the space provided on the envelope. Policy Title: Medication Pass Guidelines Date: 09/2022 16. House stock medications · Check expiration dates of all medications before administration. 19. Eye medications · Eye drops/ointments/gels are considered safe and effective for use until the manufacturer ' s expiration date when stored according to manufacturer guidelines, unless otherwise specified by the manufacturer or pharmacy. Policy Title: Multi-Dose Vials, Use of Date: 01/2022 C. Policy: Multi-dose vials (MDVs) contain preservative, so they may be used multiple times. The opened and beyond-use (expiration) dates will be noted and initialed at the time the vial cap is removed. D. Procedure: 145557 Page 9 of 11 145557 08/18/2023 Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 4. If this is a previously opened vial, check that the opened and expiration dates are noted and initialed and that the vial has not expired. a. If the vial has been opened longer than 28 days, or has expired per the manufacturer ' s guidance, it should no longer be used and should be discarded in a sharp container and a new vial of medication should be obtained. 5. If this is a new vial, remove the cap from the vial. Using an ink pen, write the opened and expiration dates, as well as the nurse ' s initials, on the vial ' s label or pharmacy-provided sticker. 145557 Page 10 of 11 145557 08/18/2023 Alden Estates of Barrington 1420 South Barrington Road Barrington, IL 60010

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to properly store Bi-pap masks and Nebulizer mask and left masks open to air on bedside table. This failure affected 2 residents (R8 and R88) of 3 reviewed for oxygen equipment in a total sample of 25. Residents Affected - Few Findings include: On 08/15/23 at 10:30 AM, observed R88's Bi-pap mask on the bedside table exposed to the air (not stored in plastic bag) as observed by V14 (LPN). On 08/15/23 at 10:49 AM, observed R8's nebulizer mask on the bedside table open to air (not stored in a plastic bag) as verified by V29 (CNA) and V29 immediately placed nebulizer mask in plastic bag in front of surveyor. On 8/17/23 at 11:48 AM, V2 (DON) said Bi-pap masks and nebulizer masks are stored in plastic bags. The masks are kept in a bag to keep masks clean after being cleaned per policy. On 08/15/23 at 10:30 AM, V14 (LPN) said the CNA is to inform the nurse and the nurse will place the Bi-pap mask in the bag. V14 said she will place the Bi-pap mask in a bag to keep it clean. On 08/15/23 at 10:49 AM, V29 (CNA) said it is the nurse's job to store nebulizer masks in a bag to keep it clean. On 08/15/23 at 11:01 AM, V31 (LPN) said the face mask is stored in a plastic bag for infection control. Bi-Pap Policy (dated 9-20), Nebulizer Policy (dated 9-20), and Infection Control Policy were reviewed but there was no guidance provided on mask storage. 145557 Page 11 of 11