Health inspection·December 17, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review the facility failed to resolve resident grievances for 5 of 6 residents (R1, R3, R4, R5 R6) reviewed for grievances in the sample of 6. Residents Affected - Some The findings include: On 12/17/24 at 9:55 AM, R1 stated he has seen R2 standing at the lunch time steam cart in the hall. R1 said R2 continually touches the trays and removes plate lids with his bare hands. R1 said it is unsanitary and spreads germs. R1 said it has been discussed at group meetings when staff members are present. Nothing is being done about it. On 12/17/24 at 12:37 PM, R4 stated she has seen R2 pick food off resident trays and hovers over the steam carts to find his tray. R4 said she has seen R2 pick food off used trays and then touch fresh food trays. R4 said R2 touches the warming covers with his dirty hands. R4 said it was discussed at the last food focus meeting and staff know about the issue. R4 said no one is doing anything about it. On 12/17/24 at 11:21 AM, V3 (Registered Nurse) said R2 does touch the food trays at mealtimes. R2 is alert and has OCD (obsessive compulsive disorder). Timing is important to him. If his tray is not delivered to his room at the same time each meal, R2 will go to the steam cart and look for it. He touches trays and tickets to find his own. R2 picks up warming lids to see if the trays have been eaten or not. On 12/17/24 at 11:42 AM, V5 (Registered Nurse) said R2 can independently walk up and down the halls. V5 stated he was aware of R2 looking at the food trays in the past but thought that concern had been corrected. V5 said R2 does carry his used tray back to the hall steam cart after he is done eating. On 12/17/24 at 12:17 PM, V6 (Social Service Director) stated he heard R1 and R2 arguing outside his door about one week ago. V6 said R1 was telling R2 to stop touching food trays. V6 said he interviewed both residents and determined the issue had been brought up by several residents at past food focus meetings. On 12/17/24 at 1:35 PM, V7 (Food Service Manager) stated residents have been complaining at food focus meetings regarding R2 picking at food on the steam carts. Residents said he touches the trays and snack items. V7 said R1, R3, R4, R5 and R6 were the residents that had witnessed R2 and voiced their concerns. V7 said they are all alert and oriented with no memory issues. V7 said she reported the complaints to the DON (Director of Nurses) but was not sure how it was followed up. Page 1 of 2 145689 145689 12/17/2024 Pearl of Elk Grove, The 1920 Nerge Road Elk Grove Village, IL 60007

F 0585 R1, R3, R4, R5 and R6's facility assessments showed no cognitive impairment. Level of Harm - Minimal harm or potential for actual harm The food focus meeting notes dated 12/11/24 (six days ago) showed R2 still messing with the food trays and interfering with staff passing the trays. The notes showed R2 takes snacks, sandwiches, and checks the food trays himself. Residents Affected - Some On 12/17/24 at 2:20 PM, V2 (Director of Nurses) stated residents are not allowed to pass food trays and should not be anywhere near the steam carts. There is the potential for germs to be spread or residents get the wrong food tray. V2 said she was told by V7 about the complaints at past food focus meetings. V2 said she did speak with R2 about the concerns but unfortunately did not document the follow up or resolution anywhere. The facility's Grievance Program policy last review dated 5/15/24 states: 7. b. The grievance will be logged on the facility grievance log .h. All facility grievance investigations will be initiated as soon as possible after the grievance is filed. Completed and timely follow up will be conducted by the department supervisor, the Grievance Office and/or the Administrator. 145689 Page 2 of 2