Health inspection·April 27, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 provide a timely response to an activated call light for one resident (R38) and failed to provide a call device for one resident (R60) in the total sample of 40 residents. Residents Affected - Few Findings include: On 4/24/23 at 11:41 AM, R38 stated It's awful. It takes them a long time to answer, regarding call light responsiveness. R38 added that it can take staff up to an hour to respond, and R38 has had to call the receptionist to forward the call to the nurse's station in order to get a hold of someone. On 4/24/23 at 11:50 AM, R38 activated her call light. A red light was observed flashing on the wall behind R38's bed indicating the call light was on. At 11:52 AM, a staff member walked in and introduced himself as V23 (Medical Doctor/Physiatrist). V23 stated that he (V23) is from therapy and will be back to work with R38. V23 left the room without addressing why R38 had her (R38) call light on. At 12:08 PM, 18 minutes after the call light was activated, V8 (CNA/Certified Nursing Assistant) arrived in the room stating, I just came back upstairs from downstairs and saw it goin' off. On 04/25/23 at 2:21 PM, V2 (DON/Director of Nursing) stated, We would like it to be within 5 minutes, regarding the timeframe to respond to a call light. V2 added that anyone can respond to a call light but if that person is non-clinical, then he or she can ask what is needed and relay that information to the appropriate clinical staff member Anyone who is trained to interact with residents. Whoever happens to be on the floor. Sometimes we have staff who isn't patient care, they can notify other staff. The surveyor inquired why timely response to call lights is important. V2 responded, If there is a time sensitive situation that needs to be addressed immediately. R38's admission Record documents diagnoses including but not limited to pain in thoracic spine, chronic obstructive pulmonary disease (COPD), unsteadiness on feet, and osteoporosis. R38's 4/6/23 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating R38's cognition is intact. R38's 4/11/23 care plan documents, in part, Focus: (R38) is at risk for falls r/t (related to) Gait/balance problems, COPD, HTN (hypertension), angina, arthritis, endocarditis and medication regimen and requires assistance with ADLs (Activities of Daily Living). Interventions include but are not limited to . (R38) needs prompt response to all requests for assistance. The 6/8/22 Answering the Call Light Policy documents, in part, The purpose of this procedure is to Page 1 of 16 145776 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0558 Level of Harm - Minimal harm or potential for actual harm ensure timely responses to the resident's requests and needs .Identify yourself and politely respond to the resident by his/her name (e.g., This is Mrs. [NAME]. Mr. [NAME], how may I help you?). If the resident needs assistance, indicate the approximate time it will take for you to respond. If the resident's request requires another staff member, notify the individual. If the resident's request is something you can fulfill, complete the task within five minutes if possible. Residents Affected - Few R60's admission record includes but not limited to Encephalopathy, Schizophrenia, Osteomyelitis left ankle and foot, Obesity, Obstructive Sleep Apnea, Diabetes and Hypertension. R60's (2/6/23) cognitive assessment determined a score of 14 (cognitively intact). R60's functional status for bed mobility, Dressing, and toilet use document 2/2. (Requires limited assistance/ one-person physical assist). On 4/24/23 at 11:15 am Surveyor inquired to R60 where is the call light? R60 stated the call light only have one string so I share it with my roommate. Surveyor observed one orange string that was on the roommate's side. R60 did not have a string for the call light. On 4/24/23 at 11:44 am, surveyor inquired to V7 CNA (Certified Nursing Assistant) if R60 has a call light. V7 went into R60's room and left the room without answering the surveyor to get V6. V6 came to R60's room and stated to V7, You either see a call light or you don't, why you afraid to answer? V7 stated no I did not see a call light for R60. Surveyor inquired from V6 whether every resident should have a call light. V6 stated Yes, every resident should have a call light and not be sharing a call light. On 4/25/23 at 11:50 am observed no call light in R60's room. R60's care plan (11/6/22) documents in part, R60 is at moderate risk for falls related to gait/balance problems. Psychoactive drug use secondary to diagnosis schizophrenia, morbid obesity, cellulitis of left lower foot, resident is up to wheelchair. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. On 4/25/23 at 2:24 pm V2 DON (Director of Nursing) stated every resident should have a call light, so they have a way to communicate with nursing staff. No resident be sharing a call light. On 4/25/23 at 2: 45 pm V9 (Building Manager) stated every resident should have a call light. On 4/26/23 at 11:20 am V1 Administrator stated that every resident should have their own call light and not share call lights with other residents. Facility Policy (undated) titled, Accommodation of Needs, documents in part, Policy Interpretation, and Implementation: The need and preferences, including the need for adaptive devices and modification to the physical environment shall be evaluated upon admission and reviewed on an ongoing basis. 145776 Page 2 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

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. Based on observation, interview and record review, the facility failed to ensure the cleanliness of a personal refrigerator, failed to provide a thermometer and maintain a temperature log for the personal refrigerator, and failed to ensure food stored in the personal refrigerator was dated to prevent foodborne illness for one resident (R21) out of 4 residents reviewed in the total sample of 40 residents. Findings include: On 4/24/23 at 11:30AM, the surveyor observed a personal refrigerator in R21's room with no temperature log or thermometer inside. The inside of the refrigerator appeared dirty with spilled brown rice from a carton of Chinese food. On 4/24/23 at 11:31 AM, this observation was brought to the attention of V4 (LPN/Licensed Practical Nurse). The surveyor inquired about a temperature log. V4 stated, I don't see one. Inside the refrigerator, V4 found a bottle of pop, Chinese food, and pickles. V4 stated, No, I (V4) don't see a date on them. He's (R21) alert and oriented so he (R21) will throw it out himself. V4 added, I see some little crumbs in here. On 4/24/23 at 12:09 PM, V10 (Housekeeping Supervisor) stated, We usually try to clean them (personal refrigerators) on a regular basis. V10 stated that the maintenance department is responsible for maintaining the temperature log. After looking inside of R21's personal refrigerator, V10 stated, I didn't see one, regarding a thermometer. On 4/24/23 at 12:21 PM, the surveyor observed V9 (Building Manager) bring a thermometer and temperature log into R21's room. V9 stated, We were unaware that (R21) had a personal refrigerator. The surveyor inquired what is the importance of ensuring that there is an appropriate temperature in a personal refrigerator. V9 replied, Infection control. Like if something spoils, we don't want them (residents) to get sick. On 4/26/23 at 9:39 AM V1 (Administrator/RN, Registered Nurse) stated that residents' personal food is expected to have a date placed on it when it's put in the refrigerator. V1 added that the nurses and CNAs (Certified Nursing Assistants) are expected to check the date and throw out the food if it's expired. On 04/26/23 at 11:33 AM, R21 stated that he (R21) has had the personal refrigerator for About a year. R21 added that housekeeping would come to clean the refrigerator if he (R21) asked them to, but no one ever checked the temperature or provided a thermometer. On 4/27/23 at 8:27 AM, V1 acknowledged that the facility policy provided to the surveyor on refrigerators and freezers pertains to personal refrigerators as well. R21's admission Record documents diagnoses including but not limited to morbid obesity due to excess calories, type 2 diabetes mellitus, hypertension and hemiplegia and hemiparesis affecting right dominant side. R21's 3/16/23 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating R21's 145776 Page 3 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0584 cognition is intact. Level of Harm - Minimal harm or potential for actual harm The 2/1/22 Personal Property policy documents, in part, .7. Residents are allowed to have a personal refrigerator in their room if there is space. The resident will be educated on keeping the temperature log and who to report to if the temperature is out of range and or the facility staff will keep track of the daily temperature log and report temperatures out of range to the nursing and or building staff. Residents Affected - Few The 5/20/22 Refrigerators and Freezers policy documents, in part, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines . 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 3. Monthly tracking sheets will include time, temperature, initials, and action taken. The last column will be completed only if temperatures are not acceptable . 7. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. Refrigerators and freezers will be kept clean, free of debris, . on a scheduled basis and more often as necessary. 145776 Page 4 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 clip or trim the fingernails of one resident (R54) out of three residents reviewed for fingernail care. Residents Affected - Few Findings include: R54 has the following diagnose which include, but are not limited to cerebral infarction due to embolism of left middle cerebral artery, anemia, unspecified, flaccid hemiplegia affecting right dominant side, benign prostatic hyperplasia with lower urinary tract symptoms, essential (primary) hypertension, neuromuscular dysfunction of bladder, unspecified, obstructive and reflux uropathy, unspecified, major depressive disorder, single episode, unspecified, retention of urine, unspecified, malignant neoplasm of colon, unspecified, unsteadiness on feet, aphasia, other lack of coordination, chronic viral hepatitis c, other psychoactive substance abuse, uncomplicated, other hydronephrosis. R54's Minimum Data Set (MDS) dated [DATE] Section C, documents, in part, BIMS (Brief Interview for Mental Status) Score of 08, which indicates R54 has moderately impaired cognition. Section G-Functional Status J. Personal hygiene is coded as a 3/2-Extensive assistance/one-person physical assist. On 4/24/2023 at 10:48am surveyor observed R54 with long fingernails on the left hand. R54 stated he has requested for fingernails to be clipped or trimmed. On 4/26/2023 at 11:31am surveyor observed R54 with long fingernails on the left hand. On 4/26/2023 at 11:49am V22(CNA/Certified Nursing Assistant) stated the certified nursing assistants are responsible for clipping the resident's fingernails. On 4/26/2023 at 11:54am V5(LPN/Licensed Practical Nurse) stated the certified nursing assistants are responsible for clipping the resident's fingernails, if the resident does not have diabetes. On 4/26/2023 at 3:37pm V2(DON/Director of Nursing) stated the certified nursing assistants would be responsible for being the first staff to observe that a resident's long fingernails require clipping. V2 stated the nurses always keep clippers on their person to clip a resident's fingernails. V2 stated the certified nursing assistants can clip the resident's fingernails at any time they observe that the resident's fingernails are long and dirty. R54's care plan dated 4/26/2023 documents, in part, Focus: R54 requires limited to extensive assistance with all grooming/ hygiene activities secondary to DX (diagnoses): CVA (cerebrovascular accident) right hemiparesis, aphasia, anemia, CA (cancer) colon, BPH (benign prostatic hyperplasia) major depression, obstructive uropathy, chronic viral Hepatitis C. Goal: R54 will maintain current self-care abilities daily through the next review date. Reviewed facility's policy on Nail Care dated 6/8/22 and titled Care of Fingernails/Toenails which documents, in part, Purpose: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. Reviewed facility's policy titled Activities of Daily Living(ADLs), Supporting dated 6/8/22 which 145776 Page 5 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documents, in part, residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. Reviewed Certified Nursing Assistants job description dated 3/24/16 which documents, in part, Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Reviewed Registered Nurse job description dated 3/25/16 which documents, in part, Summary: The Registered Nurse is responsible for providing direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Reviewed Licensed Practical Nurse job description dated 04/01/17 which documents, in part, Summary: The LPN/Licensed Practical Nurse is responsible for providing direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. 145776 Page 6 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

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, interviews, and record review the facility failed to ensure that a resident's (R84) blood pressure was measured before administering a heart medication as ordered by the Physician and failed to ensure that the resident's (R84) Heart rate was properly measured as ordered by the Physician. This failure has the potential affect all residents that reside in the facility and who relies on a Nurse to follow Doctor's orders pertaining to their care and treatment. Residents Affected - Few Findings include: R84 is [AGE] year old with diagnosis including but not limited to: Hypertension, Cerebral Infarction due to Occlusion or Stenosis of Right Posterior Cerebral Artery, Hemiplegia and Hemiparesis, and Chronic Obstructive Pulmonary Disease. R84's BIMS (Brief Interview of Mental Status) score is 10, which indicates Severe Cognitive Impairment. On 4/23/23 at 10:45 am, V4 (Licensed Practical Nurse) was observed handing R84 a medication cup that contained the following heart medications: Amlodipine 10 MG, Hydralazine HCl 10 MG, Lisinopril 40 MG, and Carvedilol 25 MG. Surveyor inquired about R84's last blood pressure. On 4/24/23 at 10:47 am, V4 said, R84's blood pressure was last taken this morning at around 6 am. She (R84) is ok to take her medication. After R84 had swallowed all of her blood pressure medication given by V4, Surveyor asked V4 where the blood pressure results were recorded. V4 logged into R84's chart on a computer and accessed the vitals page. R84's last recorded blood pressure was the night before (on 4/23/23). V4 said, I was told the blood pressure was already taken this morning. That's why I didn't take V4's blood pressure before giving the heart medication. Surveyor inquired about the importance of checking a patient's blood pressure before administering certain heart medications. On 4/24/23 at 11:03 am, V4 said, I usually check before to see if it's (R84's blood pressure) high or low. If it's too low we (Nurses) would hold the medication because the medication could lower the blood pressure even more. The risks of taking blood pressure medication if the blood pressure is already low is, it could kill them. I (V4) will recheck and monitor R84's blood pressure. On 4/24/23 at 11:05 am, V4 attempted to measure R84's pulse manually. V4 placed two fingers on R84's right wrist to obtain a radial pulse. V4 continued to hold her fingers in place on R84's wrist for 45 seconds and said, Her pulse is 74. 145776 Page 7 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0684 Surveyor asked how V4 measured R84's pulse without a watch or a clock. Level of Harm - Minimal harm or potential for actual harm V4 said, I do it all the time. I don't have a watch and there is no clock here in the patients room so, I count to 100 in my head. Residents Affected - Few Surveyor inquired why V4 counted to 100 and V4 said, I meant, I counted to 60 in my head. I counted to 60 and counted the pulse at the same time. Surveyor inquired about the correct way to measure a patient's Heart rate/ Pulse. On 4/24/23 at 11:10 am V4 said, Checking the pulse with a watch or a monitor is more accurate than manually counting without a watch. On 4/25/2023, Surveyor inquired about the expectations when administering medications with Doctor ordered parameters such as certain heart medication. On 4/25/23 at 1:15 pm, V2 (Director of Nursing) said, For most residents that takes Blood Pressure medication, the Doctor orders parameters depending on that resident. When parameters are ordered, the blood pressure should be taken prior to administering the medication. Surveyor asked what the purpose of Doctor ordered parameters were. V2 said, The purpose of the parameters is to ensure that we do not medicate a patient who may be hypotensive (with low blood pressure) because they could 'bottom out' (a sudden drop in blood pressure). The risk could be a possible syncope episode (temporary loss of consciousness). In the worst case, if the heart is not working properly, the patient could have a cardiac arrest. Surveyor inquired about the proper way to check a patient's Pulse / Heart rate. V2 said, The standard for checking a pulse is to use a clock, watch, or timer. The pulse is to be checked between 30 and 60 seconds depending on the patient's heart condition. We (Nurses) measure the Heart rate in beats per minute. It (heart rate/ pulse) cannot be measured without a watch, clock or timer. R84's Physician Order sheet documents an order the reads, Carvedilol 25 MG Give 1 tablet by mouth two times a day for Hypertension. (Parameters): Hold and notify MD/NP (Medical Doctor/ Nurse Practitioner) if SBP<110 (Systolic Blood Pressure is less than 110) or DMP <60 (pulse less than 60). R84's Medication Administration Record documents, Carvedilol 25 MG administered by V4 at 10:45 am (as observed by Surveyor). R84's Care Plan documents, Monitor for side effects such as orthostatic hypotension and increased heart rate. Obtain blood pressure readings. R84's Vital history documents, the last blood pressure prior to taking the blood pressure medication (Carvedilol) was taken on 4/23/23 at 7:53 pm. R84's Blood pressure was not measured prior to the administration of R84's morning medication as 145776 Page 8 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0684 ordered. Level of Harm - Minimal harm or potential for actual harm The Facility's policy titled Job Description: Registered Nurse (RN) documents, Essential Duties and Responsibilities (includes but not limited to), Prepare and administer medications as ordered by the Physician. Residents Affected - Few The RN job description excludes monitoring vital signs of assigned patients and following Physicians orders. The Facility's policy titled Job Description: Licensed Practical Nurse (LPN) documents, Essential Duties and Responsibilities (includes but not limited to), Prepare and administer medications as ordered by the Physician. The LPN job description excludes monitoring vital signs of assigned patients and following Physicians orders. The Facility's policy titled, Blood Pressure Measuring documents, Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. The Facility's policy titled, Administering Medications, excluded any verbiage related to the nurse following Physicians orders. 145776 Page 9 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress was not layered with multiple linens for one resident (R63). This failure affected one resident reviewed for pressure ulcer/injury prevention and treatment in a sample size of 40. Residents Affected - Few Findings include: R63's admission record includes but not limited to Osteoarthritis, Spinal Stenosis, Pressure Ulcer, Diabetes, Gas Gangrene, Thoracic Aortic, Dementia, Osteoarthritis, Acute Kidney Failure, and Hypertension. R63's (2/14/23) cognitive assessment determined a score of 8 (moderately impaired). On 4/24/23 at 10:56 am, R63 was lying on a low air loss mattress with multiple layers between R63 and the low air loss mattress. The layers observed on R63 consisted of a flat sheet, a flat sheet folded multiple times for a draw sheet that was positioned under R63's lower back and buttock, and an incontinent brief. On 4/24/23 at 11:10 am, V6 LPN (License Practical Nurse) checked the layers of linen between R63 and the low air loss mattress, per surveyor's request, and stated, there is a flat sheet, draw sheet and incontinent brief. It should only be one layer, to prevent further skin breakdown. V6 stated, having multiple layers defeats the purpose of the air mattress. On 4/27/23 12:32 pm, V27 (Wound Care Nurse) stated that the purpose of the air mattress is to relieve the pressure. Layering on an air mattress could potentially worsen the wounds. There should only be a flat sheet no padding but can have an incontinent brief on. R63's (2/8/23) Active Order Summary Report documented, in part, Low Air Loss Mattress. R63's care plan (1/30/23) documented, in part, R63 is at risk for pressure injury base on Braden scale score of 9, Hx (history) of pressure injury. R63 was admitted with a stage 4 pressure injury to sacrum. Interventions: The resident requires air loss mattress and wheelchair cushion. Facility Policy (undated) titled Low Air-Loss Mattress/Bed, documented, in part, A specialty bed will be obtained upon provider order. The low air-loss mattress/bed will be utilized according to manufacturer's recommendations. The (undated) Protekt Aire 3000/3500/3600 Operation Manual documented, in part, Instructions step 2. You may place a thin cotton sheet over the mattress top cover. Operation Instructions 5. Patients can directly lie on the mattress or cover with a sheet and tuck loosely to increase the comfort of the patient. 145776 Page 10 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure that the (Facility) Daily Staffing was up to date and posted in a prominent location that is readily accessible to staff and visitors. This failure has the potential to affect all 88 residents residing in the facility. Residents Affected - Many Findings include: On 4/25/2023 at 9:11 AM, a nurse and CNA (Certified Nursing) staffing schedule was observed at the receptionist desk on a clipboard, but it did not include the actual time worked for each category (licensed or non-licensed) and type of nursing staff but rather it listed the shift and units each nurse or CNA was assigned to. On 4/25/23 at 3:05 PM, the surveyor asked V15 (Staffing Coordinator) to show the surveyor where the Daily Staffing is posted. V15 walked the surveyor to the lobby and asked the receptionist where the Daily Staffing is posted. Initially, V16 pointed to the clipboard, but V15 then explained that she (V15) needs the staffing sheet with the hours worked on it. V16 (Receptionist) turned around in her (V16) chair and grabbed a hard, plastic paper cover that was leaning against the back of the receptionist area wall near a couple of binders. V16 stated that the Daily Staffing used to be on the wall by the facility licenses (to the left of the entry doors when walking into the facility), but the cover broke. The surveyor asked V15 to read the date on the paper that was inside the plastic cover. V15 stated, December 31, 2022. That's old. V16 looked through one of the binders and stated, I'll have to reprint it. I (V16) can't find it. On 4/25/23 at 3:20 PM, the surveyor inquired what the expectation is with posting the daily staffing. V2 (DON/Director of Nursing) stated, It should be visible to everyone. On 4/26/23 at 9:35 AM, V1 (Administrator) stated, We had April's (Daily Staffing) in there (binder) but there were a couple missing so we printed them out. The 4/23/23 Midnight Census Report documented 88 occupied beds in the facility. The 1/1/23 Posting Direct Care Daily Staffing Numbers policy documents, in part, Policy Statement: Our facility will post, on a daily basis, for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation: 1. Within two (2) hours of the beginning of each shift, the number of licensed nurses [RNs (Registered Nurses), LPNs (Licensed Practical Nurses), and LVNs (Licensed Vocational Nurses)] and the number of unlicensed personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format . 3. Shift staffing information shall be recorded and the Daily Nursing Schedule. The information recorded on the form shall include the following: . g. The actual time worked during that shift for each category and type of nursing staff. 145776 Page 11 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to maintain shift change accountability records for controlled substances that enables periodic reconciliation and accounting for residents' controlled medications. This failure has the potential to affect all 42 residents on the second floor of the facility. Findings include: The Facility census shows that there are 42 residents on the second floor of the facility. On 4/6/23 at 10:30am on the second floor with V5(Agency LPN/Licensed Practical Nurse), the Shift change accountability records for controlled substances for the second floor for April 2023 was reviewed. This record shows several missing entries of nurses' signatures, interpreted to mean that there were some shifts that no nurse was accountable or responsible for the narcotics on the floor. Some of the missing entries include 4/4/23, 4/8/23, 4/9/23, 4/15/23, 4/20/23, 4/22/23, and 4/23/23. V5 was asked why some nurses did not sign the records and if they counted the narcotics before taking over from the previous nurse. V5 responded that she is from the agency and does not know whose signatures were missing, but that she(V5) always signs the narcotic sheet at the beginning and at the end of the shift. Facility's policy titled Controlled Substances with review date 3/1/22 says in #12a: Controlled Medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. The facility did not follow this policy. 145776 Page 12 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to follow the medication labeling and storage policy by not documenting an open date on eye drops. This failure affected two residents (R37 and R75). This failure was identified on two medication carts reviewed for medication labeling and storage out of four carts. Findings include: R37 is a [AGE] year old with diagnosis including but not limited to: Idiopathic Peripheral Neuropathy, Type 2 Diabetes Mellitus, Dementia, Hypertension, Anxiety disorder, and Major Depressive Disorder. On [DATE] at 12:25 pm, Carboxymethylcellulose Sodium Solution 1% was observed on the third floor medication cart A for R37. R37's Physician Order Sheet dated [DATE], documents an order for Carboxymethylcellulose Sodium 1%, instill one drop in both eyes every six hours as needed for dry eyes. R75 is a [AGE] year old with diagnosis including but not limited to: Dementia, Disorientation, and Hypertension. On [DATE] at 12:35 pm, the following eye drops were observed opened and without an expiration date on the third floor medication cart B: Dorzolamide/ Timolol 22.3 MG/ 6.8Ofloxacine 0.3% ; and Prednisolone Acetate 1% for R75. R75's Physician Order Sheet dated [DATE], documents orders for: Dorzolamide HCl/ Timolol 22.3 MG/ 6.8, instill one drop in each eye twice a day for Blurred vision; Ofloxacine solution 0.3% instill one drop in right eye four times a day for Prophylaxis; and Prednisolone Acetate Ophthalmic Solution 1% instill one drop in right eye four times a day for preoperation. On [DATE] at 12:37 pm, V6 (LPN/ Licensed Practical Nurse) said; without labeling the eye drops with an open date, the eye drops could possibly be given while it is expired. We should not be using the eye drops if there is no expiration or open date on it. The risk of using the unlabeled eye drops is, the eye drops could introduce bacteria and cause infection to the resident. The manufacturer's expiration date is not the expiration date. The expiration dated changes once the eye drops are opened. I cannot determine when they expire. (Referring to eye drops noted without expiration dates on carts A and B). Surveyor inquired about the regulatory requirements related to labeling patient's eye drops. On [DATE] at 1:20 pm, V2 (Director of Nursing) said, We (Nurses) are to label the eye drops upon opening. By labeling the eye drops with and opening date, it could be determined when the eye drops expire. Best practice would be to label the eye drops as soon as it is opened. If an expired eye drop is given, foreign bodies into the eye and possible infection. 145776 Page 13 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0761 Level of Harm - Minimal harm or potential for actual harm V1 (Administrator) presented Storage of Medications Policy dated [DATE] reads, Certain medications of package types, such as IV solutions, multiple dose injectable vials, ophthalmics (eye drops), once opened require an expiration date shorter than the manufacturer's expiration date to insure purity and potency. Residents Affected - Few 145776 Page 14 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to document temperature readings on the freezer and cooler temperature logs. This has the potential to affect 85 residents in the facility who receive an oral diet. Findings include: On 4/24/2023 at 9:35am upon initial tour of the kitchen, observed the temperature logs for cooler #1, cooler #2, cooler #3, freezer #1 and freezer #2. All temperature logs were missing documentation of a temperature reading for the following dates and times: 1. Cooler #1 missing documentation of a temperature reading for the PM shift on 4/21/2023, 4/22/2023 and 4/23/2023. 2. Cooler #2 missing documentation of a temperature reading for the PM shift on 4/1/23, 4/2/23, 4/3/23, 4/4/23, 4/5/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/10/23, 4/11/23, 4/12/23, 4/13/23, 4/14/23, 4/15/23, 4/16/23, 4/17/23, 4/18/23, 4/19/23, 4/20/23, 4/21/23, 4/22/23 and 4/23/23. 3. Cooler #3 missing documentation of a temperature reading for the PM shift on 4/1/23, 4/2/23, 4/3/23, 4/4/23, 4/5/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/10/23, 4/11/23, 4/12/23, 4/13/23, 4/14/23, 4/15/23, 4/16/23, 4/17/23, 4/18/23, 4/19/23, 4/20/23, 4/21/23, 4/22/23 and 4/23/23. 4. Freezer #1 missing documentation of a temperature reading for the PM shift on 4/21/23, 4/22/23 and 4/23/23. 5. Freezer #2 missing documentation of a temperature reading for the PM shift on 4/21/23, 4/22/23 and 4/23/23. On 4/24/2023 at 9:45am V3(Dietary Manager) stated the cooks are responsible for documenting the temperature on the temperature logs for the coolers and freezers. V3 stated a temperature reading for the coolers and freezers are to be documented for the 6am and 12noon shifts. On 4/26/2023 at 10:40am V3(Dietary Manager) stated the purpose of checking the temperatures for the coolers and freezers is to make sure the coolers are 41 degrees or below 41 degrees and that frozen products stay frozen in the freezers. V3 stated if the temperatures in the coolers and freezers are not correct the foods in the coolers and freezers could spoil. V3 stated if resident eats spoiled food, the resident could end up with a food borne illness. On 4/26/2023 at 10:42am V18(Dietary Aide) stated the cooks are responsible for checking the temperature logs for the coolers and freezers. On 4/26/2023 at 10:59am V19(Cook) stated the cooks are responsible for checking and documenting the temperature on the temperature logs for the coolers and freezers. V19 stated I check the temperatures for the coolers and the freezers and document the temperature readings on the log when I come in to work at 6am. V19 stated the evening cook is to check the temperature readings for the coolers and freezers and document on the temperature log when coming into work at 12noon. V19 stated the foods in the coolers and freezers could spoil if the temperatures are off or not checked at all for 145776 Page 15 of 16 145776 04/27/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many changes. V19 stated if the residents eat spoiled foods the residents can get sick or get a food borne illness. V19 stated I received training on how to properly check and document on the freezer and cooler logs when I started working at this facility in 2021. Review of facility's Refrigerators and Freezers Policy with a reviewed date of 5/20/22 documents, in part, Policy Statement: The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation 4. Food service supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at the closing in the evening. 145776 Page 16 of 16