Health inspection·May 3, 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. Based on observation, interview and record review the facility failed to maintain resident rooms in a clean and sanitary manner for 4 residents R1, R2, R4, R6 reviewed for clean, comfortable, homelike environment in the sample of 21. The findings include: The Facility Data Sheet dated 5/3/24 showed a resident census of 104 residents. On 5/3/24 at 7:40 AM, R2 was seated in bed. A urinal, filled with 600 milliliters (mls) of urine, was on his beside table. No lid was noted on the urinal bottle. Directly next to the urinal, was a sandwich. R2 pointed at the sandwich next to the urinal, I won't eat that. That's terrible. Gross. R2's garbage container, on the floor next to his bed, was overflowing with garbage. On 5/3/24 at 8:00 AM, this surveyor walked down the 200 unit hallway with V3 Certified Nursing Assistant (CNA). This surveyor's shoes stuck to the floor walking down the hallway. V3 wore shoe coverings over her shoes. V3 stated she wore shoe coverings over shoes because I don't like my shoes sticking to the floor either. On 5/3/24 at 8:02 AM, R6 laid in bed. A urinal, half-filled with urine, was noted directly next to R6's glass of drinking water. No lid was noted on the urinal. On 5/3/24 at 8:20 AM, R1 was seated on his bed. R4 was asleep in the bed next to R1. A pungent, foul odor was noted in R1 and R4's room. R1's black bed sheet was soiled with food debris. [NAME] sticky, food debris was noted on R1's floor, around his bed. Cookie wrappers, tissues, and an empty potato chip bag laid on R1's floor. The garbage container next to R1's bed was overflowing. R1 stated, My room is filthy. R4 laid in bed. No sheet was noted on R4's bed. Stool was noted leaking out of R4's incontinence brief, directly onto R4's bare mattress. A facility concern form dated 1/24/24 showed a resident request for his room to be swept. A concern form dated 2/14/24 showed a request for a resident's furniture to be cleaned. A form dated 4/10/24 showed a complaint related to food leftovers being left all over the bed and on the rails. The facility's 4/29/24 Resident Council Minutes showed concerns related to sticky floors and dirty dining rooms were identified. On 5/3/24 at 11:47 AM, V7 Housekeeping Supervisor stated each resident room is to be cleaned, daily, which included emptying garbage, sweeping and mopping floors, wiping down furniture, and cleaning Page 1 of 4 145660 145660 05/03/2024 Aperion Care Westchester 2901 South Wolf Road Westchester, IL 60154

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some each bathroom. V7 stated housekeeping was currently short-staffed. We have a position open on days and evenings. The facility's Housekeeping Services Policy (undated) showed, It is the policy of the facility to maintain a clean, odor free, comfortable and orderly environment in all health care and public areas, which meet the sanitation needs of the facility and residents right for a clean, comfortable homelike environment . The Housekeeping Department employs and trains sufficient numbers of personnel to meet the residents and to carry out the responsibilities . 145660 Page 2 of 4 145660 05/03/2024 Aperion Care Westchester 2901 South Wolf Road Westchester, IL 60154

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide ADL (activities of daily living) assistance to residents that required staff assistance for toileting/incontinence care, nail care, and oral hygiene for 3 of 7 residents (R4, R3, R2) reviewed for activities of daily living in the sample of 21. Residents Affected - Few The findings include: 1. R4's current care plan showed R4 required staff assistance with toileting and incontinence care related to his diagnosis of CVA (cerebrovascular accident) The care plan showed R4 was incontinent of urine and stool. The plan showed R4 also required staff assistance for nail care with a care plan intervention of check nail length and trim and clean on bath day and as needed. R4 was cognitively impaired due to his diagnosis of dementia. On 5/3/24 at 8:20 AM, R4 was asleep in bed. No sheet was noted on R4's bed. Stool was noted leaking out of R4's incontinence brief, directly onto R4's bare mattress. All of R4's fingernails had thick, black debris under his nails. On 5/3/24 at 8:33 AM, V3 Certified Nursing Assistant (CNA) entered R4's room to provide cares. V3 stated she was unsure when R4 was provided with incontinence care last. V3 stated, I started at 6:00 AM today. This is my first time doing cares on him. V3 CNA removed R4's incontinence brief that was saturated with urine and mushy stool. R4's buttocks and perineal area appeared red. R4's Bowel and Bladder Elimination record dated 4/20/24-5/3/24 showed no documentation that R4 received incontinence care anytime between 12:00 AM-8:33 AM on 5/3/24. 2. R3's current care plan showed R3 required staff assistance for toileting and incontinence care related to his diagnoses of altered mental status, weakness, and vision loss. The plan showed R3 was at risk for bowel and bladder incontinence. The plan showed R3 will be kept clean and dry. On 5/3/24 at 8:02 AM, V3 CNA entered R3's room to provide cares. An odor of urine was noted in the room. R3 asked V3 CNA to Take me to the shower. I need to get up. R3's incontinence brief was wet with urine. The weight/heaviness of R3's brief was pulling the brief down towards R3's knees. V3 CNA stated, I don't know when he was changed last. Maybe sometime on nights? He can get up to the bathroom if someone helps him. 3. R2's current care plan showed R2 required staff assistance for personal hygiene/oral care related to his diagnosis of CVA. On 5/3/24 at 7:45 AM, R2 was in bed. R2's lips were dirty with a food debris. R2 was missing teeth. R2 stated, The last time someone helped me brush my teeth was months ago. The only time they get cleaned is when the dentist is here. I don't even know if I have a toothbrush in my bathroom. I can't get into the bathroom without someone helping me. I just try to use mouthwash every day. R2 pointed to a bottle of mouthwash on his bedside table. On 5/3/24 at 10:15 AM, V2 Director of Nursing stated staff should toilet and/or provide residents with incontinence care every two hours and as needed. V2 stated oral care should be provided to residents daily unless a resident does not require assistance with those cares. 145660 Page 3 of 4 145660 05/03/2024 Aperion Care Westchester 2901 South Wolf Road Westchester, IL 60154

F 0677 Level of Harm - Minimal harm or potential for actual harm The facility's Incontinence Care policy dated 1/16/2018 showed, Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode. Residents Affected - Few 145660 Page 4 of 4