Health inspection·December 13, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to adequately supervise a high fall risk resident for one of four residents (R26) reviewed for accidents in the sample of 14. Residents Affected - Few Findings include: On 12/10/2024 at 10:09AM during facility rounds, V15 (Certified Nursing Assistant) was observed coming out of R26's room and R26 was observed sitting on the toilet with R26's wheelchair in front of her with no staff present. On 12/10/2024 at 10:15AM during interview with V15, V15 stated that he went out of R26's room because he needs to grab another pair of gloves because what he had was the wrong size. V15 stated that he does not usually leave the resident but R26 is not a fall risk so he trusts R26 will not fall. On 12/12/2024 at 9:30AM during interview with V2 (Interim Director of Nursing), V2 stated that staff is expected to gather all their needed supplies before proceeding to resident's room and before starting to provide care to any resident. V2 stated that staff cannot leave any resident unattended until the task is completed. V2 also stated that if the resident wants some privacy, the staff can stay outside the bathroom with the door slightly opened to be able to hear or peek as needed. V2 stated that supervision means that one staff must be present to oversee and monitor the resident while performing the task. V2 stated that extensive assistance means that the resident cannot really do the task for themselves, so one or two staff must be present to provide support and assistance to the resident during care. Review of R26's Fall Risk Review dated 11/18/2024 indicated R26 has fall risk score of 13 which is considered a high risk for falls. Review of R26's Progress Notes dated 06/12/2024 indicated a fall incident was noted. Review of R26's Minimum Data Set (MDS) Section GG - Functional Abilities dated 11/18/2024 indicated R26 needs supervision or touching assistance with toileting hygiene, and partial/moderate assistance with toilet transfer. Review of R26's care plan revised on 11/22/2024 indicated that R26 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness d/t (due to) dx (diagnoses) of dementia, cerebral infarction, depression, adult failure to thrive. R26 is an extensive assistance of one staff member for toileting, bed mobility, transfer. Page 1 of 5 145786 145786 12/13/2024 Lincolnwood Place 7000 North McCormick Blvd. Lincolnwood, IL 60645

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility's policy entitled Activities of Daily Living (ADL) Supporting - Skilled last revised 3/13/2023 indicated the following: Protocol: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: c. Bowel and Bladder Elimination (toileting); 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: b. Supervision - oversight, encouragement or cueing provided 3 or more times during the last 7 days. c. Limited Assistance - Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 3 or more times during the last 7 days. d. Extensive Assistance - while resident performed part of the activity over the last 7 days, staff provided weight-bearing support. 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Review of facility's policy entitled Falls Program - Skilled last revised 09/13/2022 indicated the following: Avoidable Accident: The Community failed to: - Implement interventions, adequate supervision (consistent with the resident's needs), goals, plan of care, and current standards of practice in order to reduce the risk of an accident. An evaluation of the factors includes reviewing for previous falls and if so, are there any similarities. Intrinsic Risk Factors: - Previous fall Supervision - The Community is obligated to provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards in the resident environment. 145786 Page 2 of 5 145786 12/13/2024 Lincolnwood Place 7000 North McCormick Blvd. Lincolnwood, IL 60645

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observation, interview, and record review, the facility failed to monitor the temperature of two of two medication refrigerators reviewed for medication storage. This failure has the potential to affect six of six Residents (R2, R3, R8, R14, R17, and R182) reviewed for medication storage in a sample of 14 residents. Findings include: On 12/11/24 at 9:30am, during a tour of the medication storage room, surveyor observed log A (Patient medication fridge) with a missing temperature date for 12/2/24, 12/3/24 and 12/10/24. Log B (House stock control substance fridge) was also missing temperature on 12/11/24. Surveyor, V2 (Director of Nursing/DON) and V13 (Registered Nurse/ RN) also observed medications for six residents in the fridge. (R2, R3, R8, R14, R17, and R182). On 12/11/24 at 9:30am, both V2 (DON) and V13 (RN) stated that, the night shift is responsible for checking the refrigerator at the end of the shift in the morning before leaving. Both stated that the temperature should have been checked. V2 stated that if the fridge is not in the right temperature it can affect the efficacy of the medications. The facility was unable to provide policy on medication refrigerator temperature monitoring. 145786 Page 3 of 5 145786 12/13/2024 Lincolnwood Place 7000 North McCormick Blvd. Lincolnwood, IL 60645

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 follow the food storage policy by not labeling food products with (cook or open) dates. This failure has the potential to affect 36 residents with oral diets. Findings include: On 12/10/24 at 9:56 AM, Surveyor and V6 (Chef) noted 1 metal pan of cooked mixed vegetables without a date, 1 metal pan of meat sauce without a label or date, 1 metal pan of marinara without a label or date, 1 metal pan of barbeque sauce without a label or date, and 1 metal pan of beef base without a label or date, 7 trays of uncooked tilapia without a label or date, 1 pan of lasagna without a label or date, 1 tray of dinner rolls without a label or date, 1 open bag of tortellini without a label or date, 1 open bag of tater tots without a label or date, 1 open bag of sweet potato fries without a label or date, 1 open bag of raisin bran without a label or date, and 1 open bag of wheat cereal without a label or date. Surveyor noted V6 immediately labeling numerous food items with dates. On 12/11/24 at 9:45 AM, V6 (Chef) said food labels let you know when the food was handled and you can determine how long the food is good for. V6 said all (dietary) staff are responsible for labeling food items. On 12/11/24 at 9:55 AM, V7 (Dietician) said food is labeled and dated before and after food is handled. Dates let you know when food was prepared and when it was used. V7 said depending on the food, food can last 3-5 days. V7 said all dietary staff should label and date food items. On 12/12/24 at 9:44 AM, V8 (Cook) said food is labeled to say how long it has been there. V8 said all food should be labeled and all kitchen staff is responsible for labeling food. Food Storage Policy (revised 9-2016) documents: 1. All products should be dated upon receipt and upon use when the entire amount of a product is not prepared. Where requires by state regulations, use by dates are put on products. Leftovers should be date according to the leftovers policy. Dietary Spreadsheet documents 36 residents on oral diets. 145786 Page 4 of 5 145786 12/13/2024 Lincolnwood Place 7000 North McCormick Blvd. Lincolnwood, IL 60645

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to administer immunizations to 3 of 5 residents (R15, R28 and R132) reviewed for immunization in a sample of 14 residents. Residents Affected - Few Findings include: During record review on 12/12/24 at 11:00am, R15's record was noted with a consent for influenza dated 11/22/24. The vaccine was not administered as of 12/11/24. R28 consented to pneumococcal vaccine on 11/13/24 and the vaccine was not administered as of 12/11/24 and R132 consented for influenza on 12/4/24 and did not receive the vaccine as of 12/11/24. The surveyor, V2(Director of Nursing/DON) and V13(Registered Nurse/RN) observed a house stock of 20 pre-filled (0.5ml (millimeter)) Influenza Vac Adjuvanted Fluad ([AGE] years of age and older) in the fridge during medication storage inspection. On 12/11/24 at 11:30am, Both V2(DON) and V4(infection Prevention) stated that the vaccines should have been given. V2 stated that the nurse who took the consent should have given the vaccines. V2 stated that residents' vaccine status is checked upon admission and given if they have not received any immunization. V4 stated that she is responsible for checking that residents' immunizations are up to date once admitted into the facility. V4 stated that she took over the position nine months ago. Facility policy dated 6/4 /2024 reads, title Resident Immunization policy: 3. Procedure: As appropriate residents will be offered the opportunity to receive the immunizations annually (October 1 - March 31st) for influenza. 4. As appropriate, residents will be offered the opportunity to receive a one-time dose of vaccine for pneumococcal pneumonia after the age of 65, or a second dose for those who received their first dose when they were under 65; or if 5 or more years have passed since that dose. Facility policy dated 7/14/2022 titled, Offering Pneumococcal. Policy: All residents will be offered the pneumococcal vaccine PCV 13 and PP SV23 to aid in preventing pneumococcal infection (e.g pneumonia) Protocol: 1.Upon admission residents will be assessed for eligibility to receive the pneumococcal vaccine (PCV 15 and PPSV23 one year later, or RPP SV20) and when indicated will be offered the vaccination within 5 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 145786 Page 5 of 5