Health inspection·June 14, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate a new Level I screen for residents with known mental illness for one (R12) resident reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 12 residents reviewed. Residents Affected - Few Findings include: R12's Facehsheet documents that R12 was admitted to the facility on [DATE]. R12's Facesheet documents that R12 was diagnosed with other bipolar disorder on 05/17/2022, and diagnosed with major depressive disorder, recurrent, unspecified on 05/17/2022. R12's Interagency Certification of Screening Results OBRA-I Initial Screen dated 04/11/2018 indicates that R12 has no reasonable basis for suspecting MI (mental illness). R12's Minimum Data Set (MDS) Section I dated 03/15/2024 indicates active diagnoses of depression and bipolar disease. There is no documentation to show that R12 has a Level II PASARR screening. On 06/12/2024, surveyor inquired to V1 (Administrator) about level PASARR screenings for residents who are admitted to the facility. V1 (Administrator) provided surveyor with R12's PASARR and V1 stated he is not aware of who is specifically responsible for performing the resident PASARR screenings at the facility. On 06/12/2024, V3 (Social Services Director) stated she is not responsible for performing the PASARR screenings in the facility. Facility policy dated 06/01/2023 titled PASARR, Preadmission, Screening & Resident Review-SNF documents in part, Policy: PASARR requires that all people entering Medicaid-certified nursing communities are evaluated for: Serious Mental Illness (SMI); Intellectual Disability (ID); Developmental Disabilities (DD); .This is a federal requirement to ensure that individuals are not inappropriately placed in nursing homes for long term care. Protocol: The PASARR process requires that all Medicaid-certified nursing communities, regardless of payer, be given a preliminary assessment to determine whether they might have SMI, ID, DD. This is called a Level I screen. The NF is ultimately responsible for ensuring that the (Level I) is completed and the determination is on file. Page 1 of 6 145637 145637 06/14/2024 St Joseph Village of Chicago 4021 West Belmont Chicago, IL 60641

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to follow policy to reconcile controlled medications in order to prevent loss or diversion for one of two carts reviewed for medication labeling and storage. Findings include: On 6/11/24 at approximately 10:00 AM, reviewed 1st floor medication cart: -Observed the number of pills in three bingo cards did not match the corresponding number of pills left on the Controlled Drug Receipt/Record/Disposition forms. The controlled substance was not signed out by the nurse when administered. R150 POS (Physician Order Summary) documents in part: hydromorphone HCL tablet 5mg. R150 Hydromorphone HCL 4mg bingo card indicates 19 pills remaining. R150 Controlled Drug Receipt/Record/Disposition Form for Hydromorphone HCL 4mg indicates amount left is 20. R24 POS documents in part: oxycodone HCL tablet 5mg and pregabalin capsule 75mg. R24 Pregabalin 75mg bingo card indicates 2 pills remaining. R24 Controlled Drug Receipt/Record/Disposition Form for Pregabalin 75mg indicates amount left is 3. R24 Oxycodone HCL 5mg bingo card indicates 21 pills remaining. R24 Controlled Drug Receipt/Record/Disposition Form for Oxycodone HCL 5mg indicates amount left is 22. Reviewed Controlled Substances Count Verification forms for the months of April, May, and June. Found multiple lapses in documentation of nurse initials for multiple days and shifts. On 6/13/24 at 2:28 PM, V2 (Infection Preventionist, Acting Director of Nursing, Restorative Nurse) stated when the nurse administers a controlled substance/narcotic, they remove the controlled substance from the box and the bingo card and document the removal in the narcotic log and on the MAR (medication administration record) right after administration. The nurse should not wait until later after all medications have been passed to document removal in the narcotic log. The previous nurse and the next nurse should count the narcotics together to confirm the number of pills in the bingo card match the number of pills left on the sheet. This is done because they are controlled substances and to verify that they are not diverted somewhere else. The narcotics log has to be signed by both of the nurses to know that the count was done. If the sheet is not signed, I don't know that the count was done. On 6/13/24 at 4:14 PM, V27 (Registered Nurse) stated at the change of each shift, outgoing and oncoming nurse should count the narcotics together, so we know that the count is right, and nothing is 145637 Page 2 of 6 145637 06/14/2024 St Joseph Village of Chicago 4021 West Belmont Chicago, IL 60641

F 0755 missing. Both nurses sign the form to verify that we counted. Level of Harm - Minimal harm or potential for actual harm Controlled Substances, 11/2022, documents in part: Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. Residents Affected - Some Preparation and General Guidelines, Controlled Substances, 3/2021, documents in part: Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration (MAR, Controlled Drug Receipt/Record Disposition Form) 2) Amount administered (Controlled Drug Receipt/Record Disposition Form) 3) Remaining quantity (Controlled Drug Receipt/Record Disposition Form) 4) Initials of the nurse administering the dose, completed after the mediation is actually administered (MAR, Controlled Drug Receipt/Record Disposition Form). 145637 Page 3 of 6 145637 06/14/2024 St Joseph Village of Chicago 4021 West Belmont Chicago, IL 60641

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 a) remove medications from the top of the cart when unattended, b) lock the cart when unattended and c) remove expired medications from the cart for one of two medication carts reviewed for medication labeling and storage. Findings include: On 6/11/24 at approximately 10:00 AM, reviewed 1st floor medication cart: -During medication administration with V14 (Nurse), a medicine cup of approximately 10 loose tablets and capsules for a resident was observed on the top of the medication cart that was unattended. -During medication administration with V14, V14 walked away from the medication cart and went into a resident room leaving the medication cart out of view of V14. The cart was observed not locked. -Observed Lantus (insulin glargine) injection pen 100unit/ml, not sealed, labeled with date opened 5/6 and date expire 6/3/24. R23's POS (Physician Order Summary) documents in part: Lantus SoloStar subcutaneous solution pen-injector (insulin glargine). -Observed a controlled substance, a bottle of Hydromorphone 4mg/ml liquid, labeled expired 4/26/24 and the Controlled Drug Receipt/Record/Disposition Form marked expired 4/26/24. R41's POS documents in part: hydromorphone HCL solution 4mg On 6/11/24 at 10:15 AM, V14 (Registered Nurse) stated I poured the cup of medications and when I went into the room the resident was not in there. They had taken the resident to therapy already. Medications should not be left on the top of the medication cart. They should not be left on top of the cart because anybody could come and take them. Some of the residents on this floor have psychiatric diagnoses. I could have trashed the medications since I was not able to administer them. I should have locked the medication cart before I left it unattended. It should be locked so it is not accessible. According to the label, the insulin is expired. It should be discarded. If a resident was administered an expired medication, there is potential for medical issues and for the medication not to work. It may not have the effect as it would if it were not expired. There should not be expired medications in the medication cart. On 6/13/24 at 2:28 PM, V2 (Infection Preventionist, Acting Director of Nursing, Restorative Nurse) stated the expired hydromorphone should have been discarded long ago. The medication cart should not be left unlocked. The medication cart should be locked when the nurse is not at the cart. If the nurse is in the resident room and the cart is out of sight of the nurse the cart should be locked. It should be locked so no one but the nurse has access to it. A cup of medications should not be left on the cart if the cart is not attended. Anyone can pass by and grab and take the medications. The medications should be wasted if the resident is not available to take the medications if already poured. There should not be expired medications on the medication cart. The insulin should have been disposed of on the expiration date. There is potential for harm if a resident is administered an expired 145637 Page 4 of 6 145637 06/14/2024 St Joseph Village of Chicago 4021 West Belmont Chicago, IL 60641

F 0761 medication. Level of Harm - Minimal harm or potential for actual harm On 6/13/24 at 4:14 PM, V27 (Registered Nurse) stated the medication cart should be locked when left unattended. There should be no medications, no sharps, no scissors left on top of the cart. Somebody might grab and take it. It's dangerous especially if it's not their medication. Expired medications should be removed from the cart and wasted for safety of the resident. It's not good to the resident if its expired. Residents Affected - Some Medications with shortened Expiration Dates, 5/26/23, reads in part: Lantus Solostar shortened expiration date is 28 days from open or out of refrigerator. Medication Labeling and Storage, 2/2023, documents in part: The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 145637 Page 5 of 6 145637 06/14/2024 St Joseph Village of Chicago 4021 West Belmont Chicago, IL 60641

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 observations, interview, and review of record the facility failed to properly store and label fruits and vegetables inside walk-in cooler. And failed to seal properly burger patties and processed turkey chili inside walk-in freezer in accordance with policy of the facility. These failures are potential to affect all 42 residents taking food by mouth. Findings include: On 06/11/2024 at 09:45 AM, with V23 (Food Services Director) at the walk-in cooler 1 discolored cantaloupe not dated. V23 said, I do not think this is mold, but I see what you mean. I will discard it. V23 took the discolored cantaloupe out of the walk-in cooler. Celery labelled as received May 15 with no other date when to discard. There are onions and carrots on a plastic container (not the original package) not dated. At the walk-in freezer turkey chili and around 27 burger patties on a large metal tray, at the bottom plastic wrap not attached from three sides exposing the food to the environment. V23 was asked if these patties are intended to be prepared for residents' consumption. V23 took the metal tray out of the walk-in freezer. Placed it on the table, and V23 said, I will tell my staff, to seal food in the freezer properly. V23 also said that staff are expected not to use food in the freezer that is not properly sealed. Policy of the facility for Storage of Food and Supplies dated 12/7/2020 reads: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain safety and wholesomeness of the food for human consumption. Under fruit and vegetable storage: All perishable fruits and vegetables placed in refrigeration as soon as received. They should remain in the original container until empty. Watch closely to prevent the possibility of decay. Sort and produce daily to remove spoiled pieces. Under freezer foods, wrap food tightly to prevent cross contamination. Per V1 (Administrator) facility does not have any resident that does not take the food by mouth. 145637 Page 6 of 6