Health inspection·November 16, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an environment that was clean and free of pervasive odor by failing to clean a resident's room per facility policy and protocols. This failure affected one resident (R64) of one resident reviewed for housekeeping on the sample list of 50. Findings include: R64 is a [AGE] year-old female who was originally admitted to the facility on [DATE], with past medical history of Heart failure, type 2 diabetes, weakness, need for assistance with personal care, sepsis, morbid (severe) obesity due to excess calories, major depressive disorder, psoriasis, weakness, anxiety disorder, etc. On 11/13/23 at 12:00PM R64's door was closed with contact isolation sign on the door and an isolation bin with personal protective equipment (PPE). After opening the door, R64 was sitting on her bed, awake, alert and oriented and stated that she is doing okay. R64's room was very dirty with pervasive odor, paper towel was littered all over the bathroom floor and garbage can was overflowing with garbage. R64 said, I am sorry my room is dirty, no one comes in to clean the room because they said I have a disease. I came back from the hospital on Friday and since then, no housekeepers have entered the room. R64 stated that it is very frustrating to her, they act as if they will die if they come into her room. On 11/13/23 at 12:20PM, R64 was standing at her door with her walker and complaining to the nurse (V5) who was in the hallway passing medication about her room that has not been cleaned. V5 (nurse) told resident that her room was cleaned yesterday but resident insisted that no housekeeper has been in her room since Friday. Review of medical record showed that resident was sent to the hospital for fever and chills, was treated for sepsis, cellulitis and leg wound infection, was readmitted to the facility on Friday, 11/10/2023 and on contact isolation for MDRO in wounds. The facility's grievance/concern log showed a concern filed on 9/21/2023 by a resident regarding improper cleaning of her room. On 11/13/23 at 12:08PM, V20 (Housekeeper) was observed cleaning resident's rooms on the low side of unit 3 near R64's room, V20 was asked whether she cleaned the resident's room, and she said not yet. V20 added that she is scared of going into the room because she has cancer but she thinks the room was cleaned by the 3 to 11pm shift the previous day. Page 1 of 6 145696 145696 11/16/2023 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/14/2023 at 2:10PM, V21 (Housekeeping Director) said that V20 did not clean the resident's room because she was afraid, she relied on V20 to switch the room with another housekeeper. There are nine housekeepers on day shift, two on each floor (2, 3, 4, and 5) and one on the first floor. V21 said that she can move V20 to another floor to avoid a repeat of what happened yesterday, she added that she saw resident's room after concerns were noted and it was filthy. V21 said the room was cleaned right away and that the resident being on isolation is not an excuse not to clean her room. Housekeeping policy (undated) provided by V2 (Assistant Administrator) stated its purpose as to provide a clean, attractive, and safe environment for residents, visitors, and staff. The section of the policy titled infectious area cleaning policy and procedure daily cleaning states the same purpose as above, responsibility indicated housekeeping staff/laundry staff. Under protective equipment, the policy states in part to check with nursing staff on requirements for entering isolation room and ensure there is a sign on the door. Wear proper PPE and any other item recommended by the manufacturer. Daily cleaning procedures item 4 states, empty trash and put the filled liner in the isolation garbage within the room. 7. Using cleaning cloths impregnated with a disinfectant cleaner, start at one side of the door and working around the entire room, clean all surfaces of cabinets, lockers, bedside tables, overbed tables, IV poles, wheelchairs, commode, call bell/cord, blood pressure cuff, medical apparatus, etc. Follow manufacturer's guideline or product supplier recommendation. Daily cleaning of infectious area section of the policy under Note for Viruses stated in part, for MRSA, Noro virus influenza, or Covid 19, use Clorox clean up disinfectant cleaner with bleach, Clorox healthcare bleach wipes with a dwell time of 5 minutes, 30 seconds to be left on the surface. 145696 Page 2 of 6 145696 11/16/2023 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review the facility failed to follow their policy and procedures for making efforts to ensure resident's grievances regarding late mealtimes were resolved promptly and to the resident's satisfaction. This failure affects three of three residents (R80, R165 and R22). This failure has the potential to affect all 283 residents in the facility who receive meals. Findings include: Per facility census provided during the course of this survey, there are currently 283 residents in the facility. The Facility's Meal Schedule documents lunch times for 4th and 5th floors are from 12:10 PM - 12:30 PM. On 11/13/23 from 12:30 PM - 1:29 PM Observed several residents waiting in the 4th floor dining area for lunch to be served. V8 (Dietary Director) stated the lunch meal was delayed due to a dietary staff being injured and informed she had to assist with meal prep and service. V19 (Certified Nursing Assistant) and V11 (Transportation Coordinator) stated lunch is normally served at 12:30 PM. On 11/13/23 at 1:29 PM Observed lunch being delivered to 4th floor dining area. On 11/14/23 at 11:33 AM during resident council meeting, R80 and R165 stated meals are frequently late. R165 stated this happens about 40% of the time. R80 and R165 stated there's a dietary staff shortage. R165 stated about 2-3 months ago he documented 7 weeks' worth of observations of late meals and turned it in to the facility. R165 stated he reported the times meals were served as opposed to when they should have been served. Resident Council Concern Form dated 08/17/2023 documents R165 expressed concern about meals being served late. Resident Council Meeting Report from August 08/17/2023 documents residents are concerned about meals being late. A grievance form dated 09/21/2023 documents a concern regarding MDR (Main Dining Room) issues stating 90% of these problems would be solved with proper staffing. Resolution includes assigning department managers along with a certified nursing assistant to monitor and assist for all meals and assistant administrator continuously overseeing as well. The facility's Grievance Policy reviewed 11/16/2023 states: The Grievance Official will: If necessary, take any required immediate action to prevent further potential violations of any resident right while the violation is being investigated.R225's physician orders for diet indicate 4/19/23 general diet mechanical soft with pureed meat texture, thin liquids consistency, Korean food, super cereal @ breakfast. Whole milk BID. The 10/19/23 care plan indicates R225 with potential for nutritional risk related to new CVA Cerebrovascular Accident; Dysphagia, Dementia. Diet downgraded to pureed. Needs assistance with eating. 145696 Page 3 of 6 145696 11/16/2023 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interventions indicate prepare/serve the resident's nutritional diet as ordered. Prescribed diet is: general/pureed. Mechanical soft with pureed meat. On 11/13/23 at 01:14 PM, lunch arrived to the 5th floor dining room. At 1:45 PM, R225 does not have a lunch tray prepared. R225 is a mechanical soft diet with puree meat. V4 ADON (Assistant Director of Nursing) in the dining room who were preparing lunch trays. V4 and staff were unable to locate R225's lunch meal. V4 ADON placed a call to the kitchen from her cell phone informing them to prepare a lunch tray for R225. V4 said, I just called the kitchen, they're going to make R225 a tray and bring it up. On 11/16/23 at 10:00 AM , V8 Dietary Manager said, Our food is fresh, it's a challenge. We are working on managing our time better. I had a cook that was injured so I helped out on Monday. We're not late all the time. Lunch for 5th floor didn't arrive until 1:14 PM. V8 said, We have a sheet that we mark when the food leaves the kitchen. Once it leaves it's out of our control. The 5th floor lunch times for the high side is 12:20 PM and low side 12:40 PM. It was late on Monday. We have staff on the units to help serve. V8 said, I missed a couple resident council meetings. I received a grievance from R165, he's from the 1st floor. I signed off on it. The staff didn't bring it up to me about other resident concerns about late meals. Moving forward today I'm going to in-service my staff on meal times. That's my solution. V8 did not have an answer to how the late meals could affect residents. On 11/16/23 at 10:09 AM, V4 ADON Assistant Director of Nursing said, The kitchen supervisor is trying hard to prepare it. The preparation is from fresh food, it's Korean. It's like home cooked, it takes time. R225's tray wasn't in his room at the time. V4 said, One of the CNA's Certified Nurse Assistant found it after you left. It was on one of the other carts. When V4 was asked, Why was the tray not found while staff were looking for it on the carts? V4 said, I don't know. V4 said, We address it in our stand up meetings, we say it's a problem. It's addressed through leadership to the Kitchen Supervisor, the Administrator and Director of Nursing to communicate. We offer to help pick up the trays from the kitchen. We help pass trays to residents. Each manager has a floor to help everyday. I'm on 5th floor. I help make sure everything is organized and everyone is practicing infection control. V4 said, It affects the residents, they get upset when they're hungry. It frustrates them. 145696 Page 4 of 6 145696 11/16/2023 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement care plan interventions addressing behaviors of anxiety, agitation, and physical aggression for a resident with cognitive impairment and mental disorder. This failure applied to one (R87) of one resident reviewed for behavior management on the sample list of 50. Findings include: R87 is a [AGE] year-old, male, initially admitted in the facility on 03/14/2014 with diagnoses of Huntington's Disease; Bipolar Disorder, Current Episode Depressed, Mild or Moderate Severity, Unspecified; Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance; Schizoaffective Disorder, Unspecified; Schizophrenia, Unspecified; Unspecified Psychosis Not Due To A Substance Or Known Physiological Condition and Degenerative Disease of the Basal Ganglia, Unspecified. R87's POS (Physician Order Sheet) dated 08/29/23 documented: Physical Aggression every shift. Resident has signs and symptoms of physical aggression at times. Anxiety every shift. Clonazepam (Benzodiazepine) tablet 0.5mg (milligrams) give one tablet by mouth three times a day, Haloperidol (Antipsychotic) tablet 2mg give 2 tablets by mouth two times a day, Seroquel (Antispychotic) tablet 400mg give 1 tablet by mouth at bedtime. On 11/15/23 at 12:25 PM, R87 was observed in the dining room, sitting in his wheelchair. There were other residents observed in the dining room eating lunch. Suddenly, R87 stood up, his chair alarm went off. V17 (Certified Nurse Assistant, CNA) went to R87 to stop him from standing up. He (R87) sat down but stood up again. V5 (Registered Nurse, RN) went to R87 and assisted V17 to stop him (R87) and have him sit in his wheelchair. R87 insisted to stand up and walk away but V5 and V17 were holding his (R87) arms and hands suppressing him (R87) to walk and made him sit in the wheelchair. Both V5 and V17 stated, You need to sit down, you might fall. What do you need? R87 did not respond but kept on standing up while both (V5 and V17) staff insisted him to sit in the wheelchair. At this time, as V5 and V17 restricting him to stand up and walk, R87 became more agitated and started pushing V5 and V17. V5 stated in a quite loud manner, You need to let go of me, you need to sit down. He (R87) sat down in the wheelchair but still insisted on standing up and pushing V5 and V17 again in an aggressive manner. At this time, R87 became uncontrollable. V5 left to get some assistance by calling code gray. V17 tried to make R87 sit in the wheelchair but he kept on standing up, walked towards the chair in front of him (R87) and sat down, while V17 tried to ask what he needs, he (R87) responded that he wants to go back to his room. V17 was asked regarding R87's behavior. V17 stated, He do that at times. We try to call somebody for help. He is really strong. V5 was interviewed regarding R87's behavior. V5 replied, Recently yes, he's standing up from his wheelchair or from bed. That is why he has a chair and bed alarm. He was on Clonazepam and Haldol. We just redirect him to sit down and ask what he needs. He is too heavy, so we need a second person. We make sure he is not getting harm. If he is not listening and might be harmful to others, we have anti-anxiety medication to give. On 11/15/23 at 12:50 PM, V18 (Social Services Director) was asked regarding R87. V18 mentioned, He 145696 Page 5 of 6 145696 11/16/2023 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0740 Level of Harm - Minimal harm or potential for actual harm has a history of that behavior but has not done it in a while. He usually yells out. We make sure he has bed alarm and chair alarm on. We watch and stay with him. Report to CNA and RN. If he calms down, it's okay and continue to monitor. If he does not calm down, reach out to physician. R87's care plan on behavioral distress dated 06/01/22 documented the following interventions: Residents Affected - Few If the resident becomes verbally or physically abusive attempt to calm the resident by explaining that ladies and gentlemen do not talk/behave this way. We do not touch other people. If talking to the resident is not successful in stopping the behavior, try to walk with the resident to a quiet area, away from other individuals. Intervene by speaking calmly and professionally in a soft tone of voice. Staff should avoid raising own voice, since this tends to make the resident more upset. This may cause the situation to escalate. Ask the resident to calmly explain what is causing this upsetting behavior. Praise the resident to speaking calmly and appropriately. On 11/15/23 at 2:05 PM, V3 (Director of Nursing) was asked on the right approach to R87 to prevent behavior escalation. V3 stated, Sometimes he is verbally abusive and physically aggressive. He could swing. There was an incident before that he wants to get coffee, he stood from wheelchair, and he swung his arms at staff. It happened in the hallway. He gets agitated when tries to get something and thinks staff is preventing him to do so. We have to talk to him on a clear soft tone. At times he could be aggressive, at times he could be redirected. If not able to redirect him, speak to him and bring him to his room. Separate from other residents by bringing him back to his room. Then, ask him what he needs. With the incident today, code gray was announced, which means violent resident. I went there and approached him in a calm manner. I redirected him and took him to his room. He told me that he wants to go to bed. We laid him down to bed. After two minutes, he said he wanted to go to the toilet. I asked the CNA for assistance. I also asked Social Services to provide one on one. Facility's policy titled Behavior Management Psychotropic Medication Protocol undated, stated in part but not limited to the following: Procedure: 3. Established resident receiving psychotropic/psychoactive medications/behavior management program: d. The interdisciplinary care team will update the care plan to include the problem behavior goals and approaches. e. The planned interventions for each individual resident's behavior will be communicated to the appropriate staff members, interventions and response will be documented. 145696 Page 6 of 6