Health inspection·December 15, 2022

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement resident specific fall prevention interventions for a resident with severe cognitive impairment for 1 (R6) of 5 residents reviewed for falls in the sample of 42. This failure resulted in R6 being transferred to the hospital's emergency department where he was diagnosed with a hip fracture and had subsequent hip surgery. Findings include: R6 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Unspecified Asthma, Hypertension, Alzheimer's Disease, Major Depressive Disorder, and Dementia. According to MDS (Minimum Data Set) dated 05/18/2022 under section C, R6 has BIMS (Brief Interview of Mental Status) score of 4 indicating severely impaired cognition. According to MDS (Minimum Data Set) dated 05/18/2022 under section G, all shows R6's functional status for transfers requires extensive assistance with one-person staff assist to transfer, walk in the room, and toilet use. Fall risk assessment dated [DATE] shows R6's fall risk evaluation score of 12, indicating very high risk for falls. On 12/12/22 at 01:17 PM Surveyor observed R6 in his room. Bed placed against the wall, fall mat present on the right side of the bed. Bed in the lowest position with upper side rails up. Call light within R6's reach. R6's speech unintelligible, surveyor unable to conduct interview. On 12/14/22 at 11:51 AM Surveyor interviewed V16 (Registered Nurse/ fall preventionist), V16 stated, One of the reasons why R6 suffered multiple falls withing this year (2022) is that R6 has gait imbalances and is very impulsive. R6 is often displaying unpredictable behaviors, like trying to remove his clothes while being assisted to the bathroom. R6 was evaluated for urinary tract infections several times; however, all came back with negative result. V16 stated, When R6 was on the initial unit, he was placed right across from the nursing station. Additionally, R6 was encouraged to participate in day-care program to keep him occupied with multiple activities throughout the day. V19 (Psychiatrist) and the family were also involved in R6's care. Evenings and nights appeared to be the culprit of R6's fall problem. R6 had 12 fall incidents from the beginning of 2022. The hip fracture was suffered during one of his episodes of impulsiveness on 06/14/2022. R6 was attempting to get up without assistance. V17 (Certified Nursing Assistant) just rounded on R6 and offered toileting; around Page 1 of 6 145667 145667 12/15/2022 Avantara Park Ridge 1601 North Western Avenue Park Ridge, IL 60068

F 0689 Level of Harm - Actual harm Residents Affected - Few 1:50am V17 (CNA) and V18 (Licensed practical Nurse) found him on the floor. V16 stated, R6 would ask at times to take him to the bathroom, and he used his call light, but it was inconsistent. V16 further indicated that R6 was transferred to secured memory care unit for more effective monitoring. On 12/14/22 at 12:54 PM Surveyor interviewed V14 (LPN/ secured memory care unit staff), V14 stated, R6 was transferred to the secured memory care unit about six months ago. R6 is on fall preventions that include bed in lowest position, fall mats, upper side rails up, frequent monitoring, at least every 2 hours but with him it's usually every 45 minutes to 1 hour, bed and chair alarm in place, and call light within reach. Additionally, R6 resides in the room right across from the nursing station. On 12/14/22 at 12:54 PM Surveyor interviewed V15 (Certified Nursing Assistant/ secured memory care unit staff), V15 stated, R6 is on fall precautions. I check on him every 10 min, the door to his room is almost always open, so we can look at him pretty much constantly. R6 has fall mat beside his bed and chair alarm and bed alarm are in place. Fall care plan dated 03/10/2020 reads in part, R6 is at risk for falls, with interventions: educate R6 of the importance of calling staff if he needs assistance, create signs with instruction reminding R6 to use call light for assistance, keep call light within reach, remind R6 to ask for assistance. Resisting Care care plan dated 09/16/2020 reads in part, R6 exhibits symptoms of resisting care which is manifested by: getting up to go to the bathroom, with interventions: educate and remind resident to utilize call light, remind resident to ask for assistance form staff. Per record review, R6 fell on [DATE], 02/18/2022, 03/10/2022, 03/14/2022. 04/28/2022, 05/07/2022, 05/13/2022, 06/10/2022, 06/14/2022 while in the initial unit. R6 suffered hip fracture during 06/14/2022 fall incident. Additionally, R6 fell on [DATE], 07/22/2022, and 10/10/2022 while in the secured memory care unit. Per record review, hospital records dated 06/14/2022 at 01:01 PM reads in part, [R6] sustained mechanical fall at nursing home earlier today resulting in left hip fracture. Orthopedic surgery has been consulted and plan is for operative repair later today. On 12/15/2022 at 09:49 AM, 10:54 AM, and 12:44 PM Surveyor attempted to interview V17 (Certified Nursing Assistant) via phone, no answer, voicemail left. On 12/15/2022 at 09:51 AM, 10:56 AM, and 12:46 PM Surveyor attempted to interview V18 (Licensed Practical Nurse) via phone, no answer, voicemail left. On 12/15/2022 at 09:53 AM Surveyor attempted to interview V19 (Psychiatrist), message left with receptionist, waiting for a call back. On 12/15/2022 at 10:16 AM Surveyor received call back from V19 (Psychiatrist), V19 stated, R6 is not cognitively appropriate to respond to fall preventions such as [but not limited to] educating of the importance of calling staff if he needs assistance, creating signs with instruction reminding to use call light for assistance, or reminding to ask for assistance. R6 is not cognitively aware and cannot retain information and process through what's appropriate and what's not. 145667 Page 2 of 6 145667 12/15/2022 Avantara Park Ridge 1601 North Western Avenue Park Ridge, IL 60068

F 0689 Level of Harm - Actual harm Residents Affected - Few Legacy Healthcare Fall Occurrence Policy dated August 3, 2016, reads in part, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Ultimately, the Falls Coordinator may change the interventions provided by the nurse if the Falls Coordinator's investigation identifies a more appropriate intervention for the individual fall. The interventions will be reevaluated and revised as necessary. 145667 Page 3 of 6 145667 12/15/2022 Avantara Park Ridge 1601 North Western Avenue Park Ridge, IL 60068

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow pharmacy medication labeling policy by not noting and implementing open date labels. This applies to 8 of 54 (R6, R27, R40, R51, R54, R68, R266, and R318) residents' medications in four of five medication carts during the medication storage and labeling task. Findings Include: On [DATE] at 03:00 PM Surveyor conducted inspection of medication cart (1-9) on Friendship unit. Surveyor observed opened and undated or dated inappropriately medications for: R54 - Ventolin HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) - open date 03/28 (no year) R27 - ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) - no open date R51 - Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT - no open date On [DATE] at 03:50 PM Surveyor conducted inspection of medication cart on Love Pod unit. Surveyor observed opened and undated or dated with expired date medications for: R40 - Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT (Fluticasone Furoate Vilanterol) - No open date Insulin Glargine Solution 100 UNIT/ML vial no open date - [NAME] R266 R68 - HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML - dated [DATE]-[DATE] (expired) and Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML - no open date On [DATE] at 12:02 PM Surveyor conducted inspection of medication cart on Pathways unit. Surveyor observed opened and undated medications for: R318 - Anoro Ellipta Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/ACT (Umeclidinium-Vilanterol) - no open date On [DATE] at 12:16 PM Surveyor conducted inspection of medication cart on Faith Place unit inspected. Surveyor observed opened and undated medications for: R6 - Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT - no open date On [DATE] at 12:37 PM Surveyor interviewed V14 (Licensed Practical Nurse), V14 stated, Medications like insulin should be dated upon opening because there is a limited time to use it, for insulin it is 28 days. I'm not sure about inhalers and other medications. 145667 Page 4 of 6 145667 12/15/2022 Avantara Park Ridge 1601 North Western Avenue Park Ridge, IL 60068

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On [DATE] at 09:24 AM Surveyor interviewed V2 (Director of Nursing), V2 stated, Open dates should be placed on medications because we don't always use expiration dates as a guide to dispense those medications. One of the examples would be insulin; insulin is good for 28 days. If medication is used past its approved use date, it can lose its potency. Nurses should not administer medications that go beyond approved use date. Other medications, like inhalers, may have different time windows to use them, for example, it could be 30, 45, or 60 days. My expectation for the nurses is to date medications upon opening. Medications with Shortened Expiration dates policy dated [DATE] reads in part, Fluticasone propiante inhalation powder should be discarded 2 months (100- and 250- strengths) after removal from moisture-protective overwrap pouch. Albuterol [should be discarded] 12 months after removal from protective pouch. Insulin lispro injection KwikPen expires 28 days after first use or removal from refrigerator. Insulin Glargine injection - Lantus vial expires 28 days after first use or removal from refrigerator. Insulin Glargine injection - SoloStarPen expires 28 days after first use or removal from refrigerator. The opened date should be noted on each container/vial of medication known to have a shortened beyond use date or expiration date. 145667 Page 5 of 6 145667 12/15/2022 Avantara Park Ridge 1601 North Western Avenue Park Ridge, IL 60068

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. FACILITY Based on observations and interview, the facility failed to safely maintain proper freezer and food temperatures, failed to follow facility policy and department regulations for safe food temperatures to prevent food-born illness. This failure has the potential to affect all 134 residents who reside at the facility. Findings include: On 12/12/22 at 10:54 AM, observed temperature log on freezer labeled ice cream freezer for December 2022 that showed from 12/1-12/8, the logged AM and PM temperatures were all above 0 degrees Fahrenheit, and the AM temperature logged on 12/13/2022 showed 10 degrees F. Temperature log also showed acceptable freezer temps as below 0 degrees F. Also observed a Temperature Requirements For Potentially Hazardous Foods that showed for Hot Food Holding, temperature of 135 degrees F and freezing temperatures of 0 degrees F. At 10:56 AM, V6 opened ice cream freezer door and said the internal freezer temperature read 18 degrees F. Surveyor began checking food items within freezer and noted 2 opened boxes of ice cream cups that were soft to touch and not frozen. V6 then said he will have maintenance look at the freezer and/or thermometer. On 12/12/22 at 11:05 AM, food temperatures for lunch meal items on steam table were checked with V8 (Dietary Supervisor) as follows: Pan of roast beef temperature showed 140.6 degrees F. V8 said the temperature should be 160 degrees F. V8 then said there was a temperature issue with a second pan of roast beef which was previously placed back in the oven. On 12/13/22 at 10:42 AM, V6 (Temporary Dietary Manager) said the ice cream freezer has a compressor issue and he is awaiting a quote to repair/replace from the outside vendor. Freezer temperature at this time read 16 degrees F. V6 then said he had an in-service that morning with V8 (Dietary Supervisor) regarding previous day food temperatures. On 12/13/2022 at 11:00 AM, lunch food items were temped again with V8 (Dietary Supervisor) that showed honey ham temperature at 202.5 degrees F. At 12:22 PM, test tray plated by V8 and placed on the unit cart. At 12:31 PM, the test tray left the kitchen and taken to the unit per caregiver. At 12:43 PM, test tray temped by V8 (Dietary Supervisor) that read 131.3 degrees F (holding temperature). Per V8, holding temperature for the honey ham should be at 135 degrees F. Reviewed kitchen policy last revised 07/28/22 provided by V6 (Temporary Dietary Manager) that showed under policy statement, the facility will comply with state and federal regulations in operating facility's kitchen. Under procedures, policy showed, food storage: frozen food frozen and hard. Under food temperature, policy showed, hot food temperature should be 135 degrees F and above. 145667 Page 6 of 6