Health inspection·December 5, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the fall care plan interventions for a resident (R18) with a history of falls. This applies to 1 of 3 residents (R18) reviewed for falls in a sample of 35.The Findings include:R18 is a [AGE] year-old female admitted on [DATE] with an admitting diagnosis including dementia, walking difficulty, and vertebral fracture.On 12/2/25 at 10:22 AM, R18 was observed in her bed with the floor mat folded and kept behind the headboard.A review of the facility-provided fall log documented two falls for R18 on 5/10/25 and 8/19/25, with no injuries.A review of the fall care plan document intervention, including a floor mat on the side of the bed.On 12/03/2025 1:57 PM, V3 (Director of Nursing/DON) stated, our staff should follow the care plan interventions. The floor mat should be at the bedside when a resident who is at risk for falls is in bed.A review of the facility presented guidelines for the document on incidents/accidents/falls:15. Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place. Page 1 of 5 145696 145696 12/05/2025 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its indwelling catheter care policy by not applying leg anchors/stabilizers to prevent tugging on the catheter and by not wiping the catheter from the insertion site. This applies to 2 of 2 residents (R10 and R237) reviewed for indwelling catheter care in a sample of 35.The findings include:1.R10 is an [AGE] year-old female admitted on [DATE] with an admitting diagnosis including dementia, acute kidney failure, and elevated white blood cells.On 12/04/2025 9:33 AM, observed V21 (Certified Nursing Assistant/CNA) providing indwelling catheter care to R10 and completed without wiping down the catheter from the insertion site.On 12/04/2025 at 10:33 AM, during an infection control interview, V22 (Infection Preventionist/IP) stated, The staff should wipe down the indwelling catheter from the insertion site to prevent infection.2.R237 is an [AGE] year-old female admitted with an admitting diagnosis including neuromuscular dysfunction of the bladder, anxiety, and malnutrition.On 12/04/2025 at 9:15 AM, during wound care observation, R237 was observed with an indwelling catheter tubing under her leg without securing with a stat lock.On 12/04/2025 9:25 AM, V23 (Wound Care Nurse) stated, The stat lock should be there with the resident's thigh to prevent tension/tugging on the catheter. The floor nurse has to apply the stat lock to reduce tension. I will apply the stat lock.A review of the facility presented the Guidelines for Indwelling Catheter Care document:15. Use a fresh, soapy, wet washcloth for each swipe. Clean peri area and at least 4 inches of the catheter, moving in only one direction, away from the body.18. Ensure tubing is not under the resident. Apply a leg anchor/stabilizer to prevent tugging on the catheter. 145696 Page 2 of 5 145696 12/05/2025 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow their Policy on Unit Refrigerators regarding labeling, storage, and monitoring of expiration dates for foods brought by family members to ensure resident safety. This deficient practice affects 2 of 2 residents (R258 and R15) reviewed for food safety in a total sample of 35.R258 is a [AGE] year-old female resident with diagnoses of but not limited to Displaced simple supracondylar fracture of left humerus, multiple fractures of ribs left side, Diabetes, Osteoarthritis, Acute cystitis, hypertensive heart disease, dysphagia. R258 was re-admitted to the facility on [DATE].On 12/2/2025 at 10:45 AM during resident room rounds, R258 granted permission to inspect her personal refrigerator. The thermometer inside the fridge displayed a temperature of 40 degrees Fahrenheit, however no temperature monitoring log was observed for the refrigerator. There was multiple food item inside the refrigerator that were expired and lacked labels. 2 packages of hard candy - Expiration date 7/31/20251 pack of (smoothie snack) 3.2 oz - Expiration date 1/3/20251 small container of unopened pound cake - No label1 small container of soup (1/3 full) - No label 1 medium glass container of Kimchi No label2 bottles of Korean Kangjam- No label3 pieces of boiled purple yam in a ziplock bag, observed with patches of grayish-green discoloration and a raised texture, suggestive of spoilage - No label1 medium piece of pound cake stored in a see-through plastic container. The cake had patches of brownish-black raised texture, indicative of spoilage, and no label was present. Upon observing the condition of the cake, R258 immediately stated, Uh-oh, this is old. R258 appeared visibly disgusted and proceeded to discard the item in the garbage.2 cans of peach juice, 240 ml each can. Expiration date 11/2/20251 orange pineapple juice 10 oz. Expiration date 12/16/20242 black plums in a ziplock bag, very soft and mushy with [NAME] juice collected inside the bag - No label5 packs of High-calcium black soy milk 180 ml each bag - No expiration date written on the package R15 is [AGE] year-old male resident admitted to the facility on [DATE]. R15 has diagnosis of, but not limited to diabetes, end stage renal disease, cerebral infarction, dysphasia, hypertensive heart disease, speech and language deficit, arthritis, seizure.On 12/2/2025 at 11:25 AM, R15 was observed sitting in bed and resting. R15 refused to engage in conversation. V9 (Certified nursing assistant/CNA) stated that R15 speaks when he chooses to but may also refuse at times. R15's personal refrigerator was inspected with V9. The following items were noted:Yogurt: 2 containers, 4 oz each - Expiration date 11/30/2025Organic roasted chestnut, 3.5 oz, 1 pack - Expiration date 9/11/2025Dried fish in a ziplock bag - No labelBoiled purple potatoes, 2 pieces - No labelGrapes in a ziplock bag - No labelCherry tomatoes in a ziplock bag - No labelBoiled corn, 1 piece in a ziplock bag - No labelV9 stated that housekeeping maintains the personal refrigerator log. V9 also reported that R15's family regularly brings him food. V9 acknowledged that food needs to be checked for expiration because consuming expired food is not safe. V9 also said that food brought in should be labeled.On 12/3/2025 at 8:48 AM, V10 (CNA) who has worked at the facility for 17 years, was interviewed. V10 was asked regarding the facility's process in handling food brought in by family members. According to V10, one of her resident's family regularly brings food to the facility, usually in the evening prior to dinner. When V10 was asked whether staff are required to check and label food when it is received, V10 stated, Yes, we need to, and if I am the one who receives it, then I label it. But other people, I do not know if they do. We check the food if it's still okay, and ‘okay' means if it is still fresh. I only work the 7-3 shift, so food is usually brought in the evening when I am not around. When informed that unlabeled and expired food items were found in some residents' room, V10 responded, Oh, all foods need to have a label to be safe. Yes, it is important to check the food in Residents Affected - Few 145696 Page 3 of 5 145696 12/05/2025 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few their personal fridge to see if they are still edible and fresh. It is okay to keep food for 1-2 days. If they are expired and they eat them, they will get sick.On 12/3/2025 at 9:19 AM, V4 (Licensed practical nurse/LPN) was interviewed regarding staff practices for handling and storing food brought in by residents' families. V4 stated that food items kept in a resident's personal refrigerator must be checked daily by the CNAs and housekeeping. V4 added that the housekeeping department is responsible for maintaining the temperature log of the personal refrigerators. V4 further stated, food items should be labeled, and that old ones we throw away. Expired or spoiled food can pose a health risk to residents, as consuming such items may lead to illness. V4 was informed that during the inspection conducted the previous day, 12/2/2025, multiple unlabeled and expired food items were found in R258's personal refrigerator. V4 is observed proceeded to R258's room and open the refrigerator and inspect the contents. V4 removed a ziplock bag containing three pieces of purple yam. Upon seeing the contents, she stated, Oh no, this is spoiled, this needs to be thrown away! Grayish-green patches with a raised texture were pointed out to V4, and she appeared visibly disgusted. Next, V4 examined a package of hard candy and read the expiration date on the bag as 7/31/2025. V4 then picked up a plastic bottle of orange pineapple juice, which displayed an expiration date of 12/16/2024. A ziplock bag containing two black plums was shown to V4. V4 noted that the fruits felt very soft and mushy, and the bag lacked a label. V4 also removed two unopened cans of peach juice (240 mL each) and read the printed expiration date as 11/2/2025. Additionally, unlabeled containers of kimchi and kangjam were identified inside the refrigerator. Finally, V4 inspected two packages of roasted seaweed (4 grams each) and read the expiration date as 9/24/2024.V4 then said that she will continue to inspect each item later. On 12/04/2025 at 8:47 AM, V3 (Director of nursing) was interviewed regarding food brought in by residents' families. V3 stated that staff are responsible for labeling and dating packages of food brought in by family members. V3 stated that the housekeeping department is responsible for checking the food stored in residents' refrigerators for freshness and expiration. V3 added that sometimes CNAs ask family members to write the date on the food items themselves. V3 stated that staff follow the expiration dates written on the packaging. V3 also said that spoiled or expired food can cause discomfort if a resident consumes it. On 12/4/2025 at 10:05 AM, V16, (Housekeeping supervisor) was interviewed regarding the process for maintaining personal refrigerator temperature logs and food handling brought by family members. V16 stated that the housekeeping department is responsible for maintaining temperature logs for personal refrigerators on all floors. According to V16, refrigerator units are checked daily for temperature accuracy, and the food inside is inspected for freshness and expiration dates. V16 explained that all food items should be labeled to indicate when they were opened, and that opened food may be kept for no more than 72 hours. Opened items must also be sealed properly. V16 said that family members often bring food for residents and stated, sometimes we don't have any control. V16 added that family members are advised about food labeling requirements by the admissions staff. When asked about the potential consequences of residents consuming spoiled or expired food, V16 responded that residents can have stomach ache and can make them sick.On 12/4/2023 R258's family was reached via phone call at 2:32 PM. R258's family was interviewed regarding food brought into the facility. The family stated that the facility did not advise them to label any food they bring for R258. Also stated that they bring food for R258 whenever they are in town to visit. R258 said that labeling is important for safety reasons. Review of the facility's Policy and Procedures on Unit Refrigerators (Revised 11/2011): Purpose: To assure that perishable food does not have prolonged storage and is stored at the proper temperature. Policy: All unit refrigerators will be maintained regarding temperature and cleanliness. Each refrigerator will be provided with 145696 Page 4 of 5 145696 12/05/2025 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few thermometer to ensure that refrigerators are maintained at 36-41 degrees temperature.The resident's temperature will be cleaned by the housekeeping department every three days to assure that all food stored in the refrigerator is palatable and not beyond expiration date.Refrigerator temperatures will be checked daily to ensure sanitary conditions. Policy on Cleanliness and Food Management: 1. Food Assessment: Housekeeping staff will: Remove and discard any food item that is visibly spoiled or unpalatable. Check all items for expiration date and discard any items that are expired. 2. Resident/Staff Responsibility: Residents and/or their designated caregivers are responsible for ensuring that all perishable food items are properly sealed, dated upon opening, and stored promptly. 145696 Page 5 of 5