Health inspection·September 29, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to a.) monitor the call light system and answer call lights within a timely manner for two residents (R1, R5), b.) provide incontinence care for two (R5, R8) residents, and c.) ensure one (R1) resident have access to their personal belongings. These failures affect three residents in a sample of six residents reviewed. Findings include:1.) On 09/26/2025 at 1:20PM, R1 states when he pulls his call light string, it is connected to a light switch and the switch remains in the same position when he activates his call light. R1 states it takes staff a long time to answer his call light, and he's waited up to 30 minutes for someone to answer his call light. R1 states he was recently transferred to his current room and his heart monitor was left in his old room. R1 states he informed V4 (Psychiatric Rehabilitation Service Coordinator/PRSC) that he was missing his heart monitor, which looks like a cell phone, and is black in color. R1 states V4 told him that she would go and look for his heart monitor, but V4 never returned or followed up with him about this matter.On 09/27/2025 at 11:16AM, V4 (Psychiatric Rehabilitation Service Coordinator/PRSC) states she remembers R1 telling her about his missing heart monitor about one to two days ago. V4 states she spoke to the nurse and CNA (Certified Nursing Assistant) staff on the (XXX) floor and asked them the location of R1's belongings. V4 states she does not recall which nurse or CNA she spoke with, but they were unaware of where R1's belongings were. V4 states she never asked staff on the (YYY) floor the location of R1's belongings because she wanted the staff on the (XXX) floor to go and find R1's belongings. V4 states when R1 experienced a room change, she expected the staff to take all R1's belongings to his new room. V4 states she did not know that R1 had a heart monitor and does not know what it looks like. V4 states she has not followed up with the matter of R1's missing heart monitor. Record review documents that R1 was transferred to his new room on 08/22/2025.R1's progress note dated 08/30/2025 at 2:33AM documents Received a [AGE] year-old African American male, readmitted from hospital with Dx: of bradycardia. R1 arrived on the stretcher accompanied with two EMTs at approximately 8:40 pm. R1 is A&OX3 (alert and orientated), able to make needs known. Head to toe assessment was completed, Skin is intact. Vitals sign are as follows BP 117/78 P 69 T 97.7 R 16 SPO2 97% room air. No s/s (signs and symptoms) of discomfort or distress noted. Denied pain at this time. R1 has a left-side implantable Loop Recorder for one year now. ER (Emergency Room) nurse reported that the loop recorder interrogation was completed by the device company, no abnormality or blockage were noted. R1 is advised to avoid Beta Blockers. All medications were verified and confirmed with Dr (doctor). and order received to continue with medications from the hospital. Noted and carried out. R1 on regular heart diet. DON/ADON (Director of Nursing/Assistant Director of Nursing) made aware. R1 is lying comfortably in bed, fall precautions are maintained per facility policy, call light placed within reach. plan of care ongoing.During record review, R1's inventory list dated 09/10/2025 does not document that R1's heart monitor was inventoried in the facility. There is no documentation to Residents Affected - Few Page 1 of 4 145730 145730 09/29/2025 Continental Nursing & Rehab Center 5336 North Western Avenue Chicago, IL 60625

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few show that R1's personal items and clothing were inventoried upon admission on [DATE] or when R1 was hospitalized on [DATE].During record review of R1's inventory sheet on 09/27/2025 at 10:42AM, the CNA and nurse's name is not legible to read. Surveyor then asks V2 (DON) if he is aware of who completed and signed R1's inventory sheet. V2 states the form is also not legible for him to read.2.) On 09/26/2025 at 1:05PM, R5 states about two weeks ago, he pressed his call because he was soiled and needed to have his incontinence briefs changed. R5 states this incident occurred at approximately 4:00PM and facility is terrible at answering the call lights during the 3:00PM to 11:00PM shift. R5 states he waited approximately 1.5 hours to have his incontinence briefs changed. R5 states by the time V5 (CNA) came to change his incontinence briefs, he was already on the phone with the state agency reporting the incident.On 09/26/2025 at 2:04PM, surveyor exits the elevator and is located on the (YYY) floor of the facility and hears an audible call light sound. At 2:06PM, surveyor located at the (YYY) floor nurses' station and observes that R5's call light is illuminated. Surveyor observes V10 (CNA) sitting in a chair at the nurses' station facing the call light system. V10 has her cell phone in her hand and observed looking down and scrolling on her phone. Once V10 observes surveyor, V10 puts her phone away, gets up out of the chair, and begin walking away from the nurses' station.On 09/27/2025 at 12:44PM, V5 (CNA) states about two weeks ago, he was assigned to care for R5 during the 3:00PM to 11:00PM shift. V5 states R5 pressed his call light, and he went to R5's room to see what R5 needed. V5 states R5 informed him that he was soiled and needed to be changed. V5 states he told R5 he would be back to assist him soon. V5 states when he left R5's room, the was approached by another colleague who informed him that it was his turn to monitor another resident for 1:1 monitoring. V5 states he made a mistake by not updating R5 because he forgot. V5 states after performing his 1:1 monitoring for the other resident, he saw that R5's call light was illuminated. V5 states when he went inside of R5's room, R5 was on the phone with the state agency and complained that he had to wait 4 hours to be changed. V5 states R5 did not wait 4 hours to be changed and instead, only waited 1 hour to be changed. V5 states he apologized to R5 and then changed R5's incontinence briefs. 3.) On 09/26/2025 at 2:09PM, R8 observed sitting in a wheelchair in the (YYY) floor hallway wearing a gown. R8 states he has been asking staff to take him to the bathroom for the past 30 minutes and no one has taken him yet. On 09/26/2025 at 2:11PM, V8 (Licensed Practical Nurse/LPN) states it is unacceptable for a CNA staff member to be using their cell phone and ignoring a resident's call light. V8 states even if a resident is not assigned to a particular CNA, it is still everyone's responsibility to answer all resident's call lights. V8 states it's important to answer resident call light due to the potential of there being an emergency. V8 states she was just made aware of R8 needing to use the restroom. Surveyor observes V8 (LPN) instruct V10 (CNA) to assist R8 to use the restroom. V10 is observed transporting R8 via wheelchair away from the nurses' station. On 09/26/2025 at 2:19PM, V10 observed transporting R8 back to the nurse's station. R8 then states V10 never took him to the restroom and brought him right back to the nurse's station. R8 states he still needs to use the restroom, otherwise he will urinate on himself.Facility policy undated, titled Call Lights documents in part, It is the policy of the facility to have a system in place to allow the staff to respond promptly to a resident's call for assistance. Procedure: 2. Call lights are to be answered promptly by staff who see that the call light has been activated. 6. Answer the call light in a prompt, courteous manner; turning off the call light upon entrance to the room. 7. NEVER TURN OFF A CALL LIGHT THEN FAIL TO SEE THAT THE RESIDENT'S REQUEST WAS ADDRESSED.Facility policy undated, titled Incontinence Care documents in part, It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily 145730 Page 2 of 4 145730 09/29/2025 Continental Nursing & Rehab Center 5336 North Western Avenue Chicago, IL 60625

F 0684 Level of Harm - Minimal harm or potential for actual harm care.Facility policy undated, titled Resident Personal Clothes and Belongings Handling documents in part, Procedure: upon admission and annually the following will be done: Personal belongings are to be listed as well.When a resident is transferred to another room, nursing staff and housekeeping staff will transfer the resident's clothing and belongings. Residents Affected - Few 145730 Page 3 of 4 145730 09/29/2025 Continental Nursing & Rehab Center 5336 North Western Avenue Chicago, IL 60625

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on interview and record review, the facility failed to ensure that menus are followed when staff did not use the appropriate utensil to serve/plate the food. This deficient practice has the potential to affect all residents that receive meals from the kitchen.Findings include:On 9/28/2025 at 11:16 AM, V15 (Traveling Chef Manager) said, yesterday I observed kitchen staff not following the menu. They were not using the appropriate utensils to plate food. I told them that they must follow the menu and use the appropriate utensils to plate food.On 9/28/2025 at 12:08 PM, R14 said, a lot of the times, the portions are small like what you would feed to a toddler.On 9/28/2025 at 11:58 AM, R4 said food portions are small.On 9/28/2025 at 2:28 PM, R12 said food portions are small.On 9/28/2025 at 4:15 PM via telephone, V4 (Psychiatric Rehabilitation Service Coordinator/PRSC) said, they (the residents) always complain about the food. There's new staff in the kitchen. The portions look small, but I don't know.On 9/29/2025 at 12:25 PM via telephone, V22 (Registered Dietitian) said, I have heard from residents that portions are small. It could be a problem (if the appropriate utensils are not used to plate food). Residents may not get the proper nutrition or protein. That could lead to residents not getting the right amount of calories and protein which could lead to weight loss. 8/27/2025, Resident Council Meeting Minutes documents: residents requested larger portion sizes.Policy related to plating of food requested, not received at time of survey. 145730 Page 4 of 4