Inspection·May 3, 2024

F 0698 nurse recommendation and agreed. Order to send out to emergency room for the catheter line to be changed. Level of Harm - Actual harm Residents Affected - Few R1's nursing note dated 3/16/24 at 10:27 PM showed, Writer called for (non-emergency transportation company) for transport to [acute care hospital]. ETA (estimated time of arrival) 2 hours. R1's nursing note dated 3/17/24 at 1:55 AM showed, Resident out to [acute care hospital] for dialysis catheter exchange on stretcher accompanied by family and 2 paramedics. Resident alert, oriented to self, verbally responding and in NAD (no acute distress) at time of departure. R1 Nursing Note dated 3/18/24 showed, Followed up [Acute Care Hospital] per admitting nurse on the floor - admitted with sepsis. R1's Acute Care Hospital documentation printed 3/20/24 showed, Date/Time of admission: [DATE] at 2:02 AM . history of hypertension, end-stage renal disease on peritoneal dialysis history of bacterial peritonitis received IV antibiotics sent in from subacute rehab to emergency room . patient was found sepsis Leukocytosis and lactic acidosis and was started on IV antibiotics and is being admitted to the medical floor, also has electrolyte imbalance with hypokalemia, hypomagnesemia, and hypercalcemia and CT scan of the abdomen showed possible esophagitis, gastritis, enteritis, and stercoral proctitis . Assessment: Sepsis with leukocytosis and lactic acidosis, possible recurrent peritonitis . Plan: Admit to medical floor with Infectious Disease and nephrology on consult started on IV antibiotics . [AGE] year-old female with hypertension, dyslipidemia, End Stage Renal Disease . She was recently getting her PD (peritoneal dialysis) at subacute rehabilitation. PD stopped. Plan to remove PD catheter due to infection. Permacath placed 3/19 and got HD (hemodialysis) that day . On 4/29/24 at 11:55 AM, V9 (R1's Home Dialysis Company) stated, [R1] was our patient before she went into the facility and we continue to provide supplies while the patient is in the facility . Our company provides training to the facility, but it is the facility's responsibility to make sure that their staff attend the training and that they have someone in the building providing the dialysis that has been trained Some facility's hire a PD specialist to handle the patient and help reduce infections . When dialysis is completed, each day there is a sterile cap that goes onto the end of the peritoneal dialysis catheter. There is absolutely an increased risk of infection if the cap is mishandled, misplaced, or the tubing is mishandled. The end of the peritoneal catheter must stay sterile. We teach all our patients about this. If the cap is not there, we automatically treat for infection prophylactically . [R1's] infection would likely be from the missing cap . On 4/28/24 at 9:45 AM, V13 (R1's granddaughter) stated R1 was admitted to the acute care hospital from the facility on 3/17/24 with diagnoses of sepsis. V13 stated R1's dialysis port that was in her abdomen had to be removed due to the infection and R1 had a new port put into her chest. V13 stated due to the abdominal infection R1 can no longer do peritoneal dialysis overnight while she is sleeping but now has to go to an outpatient facility and receive hemodialysis which requires R1 to have transportation coordinated and requires her to be in the dialysis chair for 4 hours several times a week. On 4/28/24 at 9:55 AM, V22 (R1's daughter) stated her mother had been doing peritoneal dialysis for many years herself prior to coming into the facility. V22 stated R1 told her the nurses were not handling her dialysis in a sanitary way and she was well aware of how to perform it due to her handling her dialysis herself for many years. V22 stated she went into the facility on the morning of 3/16/24 at approximately 11:00 AM and her mother was in her bed and her dialysis tubing was still (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Chicago Ridge 10300 Southwest Highway Chicago Ridge, IL 60415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Actual harm Residents Affected - Few attached to the dialysis machine. V22 stated the machine was beeping. V22 stated she notified the nurse, and they were going to take care of it. V22 stated her sister contacted her when she went into the facility on 3/16/24 at approximately 5:30 PM and she found her mother still connected to the dialysis tubing. V22 stated R1 should have been disconnected from the dialysis machine at around 8:00 AM. V22 stated she contacted the facility and asked to speak with the charge nurse. V22 stated she was told that they were not going to do R1's dialysis because they noticed the cap was missing from R1's catheter tubing. V22 stated the charge nurse asked the nurse on the floor (V7 Registered Nurse) about the cap and she said she didn't know when it went missing. V22 stated R1 was nauseous and there was vomitus on her bed linens. On 4/28/24 at 11:13 AM, V2 ADON (Assistant Director of Nursing) stated, . On 3/16/24, from my understanding, when they disconnected [R1] from the dialysis machine there was no sterile cap. Can't say for sure how long the cap was gone . If they are disconnected and the clamp isn't properly closed and there is no cap you run an increased risk of peritonitis . [R1] wasn't having symptoms of infection, the family was present and was going to do patient care and notified that the cap was not in place. From 4/28/24 through 5/1/24, the surveyor made several attempts to get into contact with V7 RN (Registered Nurse) who provided R1's cares on 3/6/24, with no return calls received. The facility's policy and procedure reviewed 7/28/23 showed, Peritoneal Dialysis, Purpose: The facility will comply with the standard of practice for care of resident with Peritoneal Dialysis before, during, and after the procedure. Procedure: 1) Inspect peritoneal catheter sit daily for any signs of redness, drainage, tenderness or swelling that could indicate infection. If there is any change in the catheter site, the physician will be notified immediately. 2) When not in use, ensure that the peritoneal catheter is capped. 3) Prior to peritoneal dialysis, wash hands and put mask on . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145700 If continuation sheet Page 3 of 3