Health inspection·November 15, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure a resident's call light device was within reach for one resident (R107) to call for staff assistance. This failure affected one resident (R107) in the sample of 58 residents reviewed for accommodation of needs. Residents Affected - Few Findings include: R107 has a diagnosis of but not limited to Chronic Atrial Fibrillation, Protein-Calorie Malnutrition, Vascular Dementia, Low Back Pain, Age Related Osteoporosis, Cognitive Communication Deficit. R107's has a Brief Interview of Mental Status score of 10 that indicates moderate cognitive impairment. On 11/12/2023 at 11:25am surveyor observed R107's call light device on the left side of the pillow underneath another pillow where R107 could not reach. On 11/12/2023 at 11:26am R107 said, I ((R107) cannot reach it. Surveyor observed R107 attempting to reach for the call light, but R107 was unable to reach the call light. On 11/12/2023 at 11:28am V15 (CNA) stated, no R107 cannot reach the call light and it (referring to call light) should be attached to the resident. On 11/14/2023 at 11:47am V2 (DON) stated, the call lights should be attached to the resident's gown or pillow and be within reach of the resident. Call Policy dated 10/2020 documents, in part, call light is within easy reach. Job description for Certified Nursing Assistant dated 2015 documents, in part, answer residents' call lights promptly and courteously and respond to inquiries relating to requests from residents within given time frames and established policy. R107 Care plan focus for falls documents, in part, re-oriented resident to use of call light (7/24/2023) and be sure the residents call light is within reach and encourage the resident to use it for assistance as needed. Page 1 of 21 145806 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide room identifiers on residents' room in an effort to provide a safe environment to residents. This failure affected six (R24, R34, R43, R73, R101, and R323) residents reviewed for home like environment in the total sample of 58 residents. Findings include: On 11/12/23 10:46 AM, R34, R43, R101, and R323's room had no room number/identifier. On 11/12/23 10:47 AM, R24 and R73' room had no room number/identifier. On 11/12/23 11:02 AM, V9 (Certified Nursing Assistant) stated, that is room [ROOM NUMBER] and 104. The room numbers are missing. Maybe the maintenance put it somewhere. On 11/14/2023 at 10:20am, surveyor pointed out to V27 (Maintenance and Housekeeping Supervisor) R24, R73's, R34, R43, R101, and R323's room are missing room number/resident identification. V27 stated, someone stole the numbers 2-3 weeks ago. I (V27) informed (V1) already. I (V27) am not sure if she (V1) already ordered the 'room numbers'. On 11/14/2023 at 10:31am, V1 (Administrator) stated, I (V1) reached out to the company that (V27) gave me. I (V1) left a voicemail 2-3 weeks ago. It's on me, I (V1) did not follow up. I (V1) have not ordered anything yet because I (V1) was not able to talk to them. On 11/14/2023 at 2:11pm, V2 (Director of Nursing) stated, some of the room numbers are missing. The reason to put the room number so staff and residents can identify the room. During the medical codes like code blue, when resident is unconscious, staff will know where to go. When there is a code, whoever is doing the overhead page will mention the room number and staff will go to the right room. R24's (07/19/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R24's mental status as cognitively intact. R34's (08/22/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 04. Indicating R34's mental status as severely impaired. R43's (09/12/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R43's mental status as cognitively intact. R73's (08/07/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R73's mental status as cognitively intact. R101's (08/31/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 05. Indicating R101's mental status as severely 145806 Page 2 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0584 impaired. Level of Harm - Minimal harm or potential for actual harm R323's (10/06/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06. Indicating R323's indicating mental status as severely impaired. Residents Affected - Some The (undated) Residents' Rights for people in Long-Term Care Facilities documented, in part Your rights to dignity and respect. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your rights to safety. Your facility must provide services to keep your physical and mental health, at their highest practicable levels. Your facility must be safe. 145806 Page 3 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident was free from physical abuse which affected one (R70) in the sample of 58 residents reviewed for abuse. This failure caused harm to R70 who was physically struck, fell, and suffered a laceration to R70's left forehead which required 4 sutures as treatment in the hospital. Findings include: On 11/12/23 at 11:14 am, R70 observed in wheelchair propelling self out of R70's room using R70's right arm to move the wheelchair wheel and right foot to move on floor. R70's left arm laying on R70's lap. This surveyor noted a healed, pink laceration, approximately 3 centimeters (cm) in length. When asked about the laceration, R70 stated, I (R70) fell and hit my head. R70 stated, it was in the basement in the dining room by the vending machine (on 10/12/23). R70 said R49 and R70 were in the dining room with no one else there. R70 said, R70 doesn't remember exactly what R49 said to R70 but that all of a sudden, I (R70) fell and hit my head. R70 said, R70 yelled, and the nurses and CNAs came and helped R70. R70 stated, I (R70) was bleeding from above my eye pointing to R70's left eyebrow. R70 stated, I (R70) went to hospital and got stitches. R70's admission Record documents, in part, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pseudobulbar affect, schizophrenia, hypertension, chronic obstructive pulmonary disease, unsteadiness on feet, lack of coordination and reduced mobility. R70's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicates R70 is cognitively intact. In R70's hospital records, V38 (Emergency Hospital Physician) documents, in part, R70 presenting to the emergency department with forehead laceration after a fall. Per EMS (emergency medical system), (R70) was in physical altercation with another member (R49) of nursing home. (R70) was pushed and fell onto the ground. (R70) hit (R70's) head on the ground and sustained a laceration of (R70's) left forehead and (R70) has left-sided deficits from prior stroke. R70's hospital records indicate that R70's laceration repair to the left forehead, 3-centimeter laceration was performed with 4 sutures. On 11/13/23 at 12:26 pm, R49 observed in room, dressed, groomed, and ambulatory. Surveyor asked about an incident with R70 on 10/12/23. R49 said, R49 was by R49's self in basement by the vending machine with R70. R49 stated, I (R49) was just doing this as R49 is demonstrating that R49 was smacking on R70's forearm when R70 was in the wheelchair in front of the vending machine. R49 said, then R70 hit me (R49) on my face, and R49 hit R70 to the point that (R70) fell. R49 showed this surveyor again that R49 hit R70 on the left arm. R49's admission Record documents, in part, diagnoses of type 2 diabetes mellitus, asthma, paranoid schizophrenia, bipolar disorder, heart failure, hypertension, acute kidney failure, major depressive disorder, altered mental status, and cognitive communication deficit. R49's MDS, dated [DATE], documents, in part, a BIMS score of 12 which indicates R49 has moderate cognitive impairment. 145806 Page 4 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0600 Facility document undated and titled Emergency Codes, documents, in part, that a Code White is for resident is alert but has fallen. Level of Harm - Actual harm Residents Affected - Few On 11/14/23 at 1:40 pm, V33 (Receptionist) stated, while monitoring the video camera footage of the facility from the receptionist front desk, V33 observed (on 10/12/23 after lunch) R70 on the floor in the basement dining room with R49 off to the side of the room. V33 stated, V33 called the code white on the overhead paging system to alert staff to attend to R70. On 11/14/23 at 12:39 pm, V18 (Psychotropic Nurse, Licensed Practical Nurse, LPN) stated, R70 is oriented times 2 to 3 (person, place, and time) and R70 uses a wheelchair to be mobile due to left sided weakness. V18 stated, R49 is oriented times 2 to 3, is ambulatory and can be feisty with being verbally aggressive with peers. V18 stated, on 10/12/23 in the afternoon, V18 was in the office in the basement hallway and heard that commotion coming from the basement dining room; so V18 went running to see what was happening. When asked what V18 was hearing, V18 stated, V18 heard R70 screaming. V18 stated, on V18's way in the basement hallway, V18 heard the Code White to the lower-level dining room announced on the overhead paging system. V18 stated, a code white is when a resident has fallen but is still alert, and V33 (Receptionist) was the staff member who paged the code white. V18 stated, As I (V18) got closer (to the basement dining room), I heard (R70) screaming. I didn't hear (R49) at all. V18 stated, V18 observed no other residents or staff in the basement dining room or coming from the basement dining room. V18 stated, V18 observed R70 face down on the floor with blood on the floor coming from (R70, and R49 was walking away from (R70). V18 stated, R49 went to sit on a bench in the basement dining room, and R70 was on the floor, laying the middle of the room in front of the vending machine with R70's wheelchair behind R70. V18 stated, R70 was saying, my arm, my arm, because R70 was laying on R70's left weak arm (from the hemiplegia). V18 stated, other staff then arrived and retrieved gauze dressings for V18 to provide initial first aide to R70's facial laceration. Facility document titled Resident/Employee Statement signed by V18 and dated 10/12/23, V18 documents, in part, I (V18) arrived to the main dining room in basement because I heard yelling. When I entered dining room, I saw (R70) on the floor face down. When I approached (R70), I saw (R49) walking away from (R70). I saw blood coming out of (R70) left eye brown and on opening. I applied pressure to opening and other staff assisted me to get (R70) to seated position then lifted to be seated in wheelchair. On 11/14/23 at 9:47 am, surveyor asked about the incident on 10/12/23 with R49 and R70. V23 (Psychological Rehabilitation Services Coordinator, PRSC) stated, V23 was present in the facility and responded to the basement dining room. V23 stated, Basically, (R70) was using the vending machine and (R49) asked for soda and they had an altercation together. V23 stated, when V23 arrived to the dining room, R49 and R70 were the only two residents in there. V23 stated, V18 was present tending to R70 and that R70's eyeglasses were broken on the floor with R70 bleeding from R70's face with blood on the floor around R70's head. V23 stated, R70 was face down with body on the floor with R70's wheelchair by R70. On 10/12/23 at 2:30 pm, V23 (PRSC) documents, in part, in R70's progress notes, (R70) made contact with (R49) in the basement dining area. Staff immediately intervened and separated residents. On 10/12/23 at 2:45 pm, V23 (Psychological Rehabilitation Services Coordinator, PRSC) documents, in part, in R49's progress notes, (R49) made contact with co-peer in basement in the dining area. On 11/14/23 at 11:28 am, V21 (Registered Nurse, RN) stated, V21 was R70's nurse on 10/12/23 for the 145806 Page 5 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0600 Level of Harm - Actual harm Residents Affected - Few day shift. V21 stated, V21 heard the code white to the lower level called overhead on the paging system, and V21 responded immediately. V21 stated, when V21 entered the basement dining room, R70 was bleeding from R70's face and R49 moved away from R70 in the dining room. V21 stated, R70 didn't want to talk about what had just happened with R49 as V21 was tending to R70's care. V21 stated, when R70 was brought upstairs, V21 talked to R70, and R70 said, I (R70) was pushed and (R49) started it. R70 said, R49 pushed R70 out of the wheelchair. R70's incident report, prepared by V21 (RN), documents, in part, Nursing Description: (R70) was in physical altercation with (R49). (R70) with the receiver in the contact, at the lower-level dinning (dining) hall. On 10/12/23 at 3:11 pm, V21 (RN) documents, in part, in R70's progress notes, Responded to code white in the dinning (dining) room, (R70) found on the floor, noted with laceration on upper left lid, (R70) assisted back to wheelchair, wheeled back to (R70) room for further assessment. (R70) stated, I (R70) got tired of being bordered by (R49), told (R49) to stop and we got in a fight. On 10/12/23 at 2:30 pm, V21 (RN) documents, in part, in R49's progress notes, (R49) was in a physical altercation with (R70). (R49) initiated the contact, at the lower-level dinning (dining) hall. No injuries on (R49). R49's Care Plan, dated 10/12/23, documents, in part, a focus of (R49) has potential to be physically aggressive towards others, such as hitting others . history of harm to others . (R49) made contact with (R70) in basement dining area. On 11/14/23 at 2:19 pm, V2 (Director of Nursing, DON) stated, V2 was not a witness or did not respond to the code white called in the facility on 10/12/23 for R49 and R70's physical altercation due to V2 responding to another code white incident (in a different location in facility) that occurred near the same time on 10/12/23. V2 stated, with reports from staff and R70's hospitalization records, V2 stated, R70's fall was a result from the physical altercation. (R70) came back with sutures. That is a serious injury. On 11/15/23 at 3:00 pm, when asked what are V37's (Medical Director) expectations of the facility staff to ensure that residents are safe from physical harm. V37 stated, residents should have a safe environment in the facility, and residents must be free from abuse. When speaking to V37 about R49 and R70's incident on 10/12/23 with R70 falling from a wheelchair after physical hitting from R49 and suffering a forehead laceration requiring suture repair in the hospital, V37 stated, That's a serious injury. When asked how staff are to ensure that residents don't experience physical harm from other residents, V37 stated, An altercation like this should never happen. Of course, they (staff) should be watching the residents. And they should know who starts to fight. Facility policy dated 10/2022 and titled Abuse Prevention Program, documents, in part, Policy: This (facility) affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: . Establishing an environment that promotes resident sensitivity, resident security, and prevention 145806 Page 6 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0600 Level of Harm - Actual harm Residents Affected - Few of mistreatment; identifying a current says and patterns of potential mistreatment . Implementing says stones to prompt away and aggressively investigate all reports in allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment . Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury . Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking. 145806 Page 7 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

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 post the daily nursing staffing. This failure has the potential to affect all 125 residents residing in the facility. Residents Affected - Many Findings include: On 03/05/23 V1 (Administrator) present facility's census of 125 residents. On 11/12/23 at 9:10 am, upon entrance to the facility, the facility's daily staff posting was observed posted at the receptionist desk dated 11/9/23. On 11/14/23 at 1:40 pm V2 DON (Director of Nursing) stated, the staffing sheet should be posted daily. V2 stated, I (V2) give the staffing to the HR (Human Resource), and they are responsible for the posting for Monday to Friday. I do not know who HR give the sheets to for the weekends. On 11/14/23 at 1:50 pm, V33 (Receptionist) stated, the staffing sheets is given for the whole week, and I post the sheets daily. Surveyor inquired if V33 had the sheets for November 10th,11th, and 12, 2023. V33 stated, yes. I (V33) had the sheets for the whole week and the sheets are to be posted daily. On 11/14/23 at 2:34 pm, V39 HR (Human Resource) stated, I print the staffing sheets out and give the staffing sheets to the front desk. I give the receptionist the staffing sheets for the whole week. The purpose for the posting of the staffing sheets is for people who come in will know what staff is here. Surveyor inquired to V39 if it is acceptable to have the staffing sheet for the November 9, 2023, posted on November12, 2023. V39 stated, No it is not acceptable to have the 9th posted on the 12th. The (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) State Operations Manual documented, in part §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. 145806 Page 8 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0732 (iv) Resident census. Level of Harm - Minimal harm or potential for actual harm §483.35(g)(2) Posting requirements. Residents Affected - Many (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. GUIDANCE §483.35(g) The facility ' s staffing data document may be a form or spreadsheet, as long as all the required information is displayed clearly and in a visible place. 145806 Page 9 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, 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 label/date food items, failed to store food items/goods six inches off the floor, failed to dispose of food items after the use by date, and failed to ensure staff kept personal belongings in appropriate location in an effort to prevent food borne illnesses These failures have the potential to affect all 124 residents receiving oral nutrition at the facility. Findings include: The (11/11/2023) Midnight Census report documented that there were 125 residents at the facility. The (undated) List of residents not taking oral nutrition indicated there was one resident on the list. On 11/12/23 9:29am, during the initial tour of the Kitchen with V7 (Cook); there were 2 bottles of Purified Drinking Water inside the reach in cooler. V7 (Cook) stated, these should not be here. The Reach in cooler is not for staff. On 11/12/23 09:35 AM, there was a pair of black shoes on the floor inside the dry storage room. V7 (cook) stated, these are not supposed to be here; the food in the kitchen might get contaminated. On 11/12/23 9:39am, there was a bin of powder juice labeled 6/10/22 with 'use by date by 6 months'. The individual container of the powder juice has no date. V7 checked the powder juice for manufacturer's expiration date and stated, I (V7) don't see it. On 11/12/23 at 9:46am, there was 1 box of Idahoan sliced scallop potatoes and a box of Devils food mix with no label. V7 stated, these should be labeled with delivery date so we know how long it would last. On 11/12/23 at 9:48am, the rice bin was dated 7/9/21. The bag of rice inside the bin was not dated. V7 checked the bag of rice for date and stated, there is no label, rice bin should be dated. ON 11/12/23 at 9:56am, inside the 'Food Storage' room observed one blue and one black jackets hanging by the door. V7 stated, staff are not supposed to put their jackets here. We have a locker room. There is food here and food may get contaminated. On 11/12/23 at 9:58am, there were 2 big water bottles on the floor on the hallway. V7 stated, these should be six inches off the floor. On 11/13/2023 at 10:19am, in reference to the bottled water inside the reach in cooler, V17 (Dietary Manager) stated, no staff are allowed to bring their personal items in the kitchen including bottled water. There could be something in their personal items. This surveyor reiterated to define 'something'. V17 something from the outside that is not good for the residents. On 11/13/2023 at 10:21am, in reference to a pair of shoes inside the dry storage room, V17 stated, shoes are not supposed to be in the kitchen. Shoes could be dirty, staff use them on the street, shoes could bring the dirt inside the kitchen. 145806 Page 10 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 11/13/2023 at 10:22am, in reference to the powdered juice bin dated 6/10/22 use by 6 months, V17 stated, the powdered juice should be disposed of if the bin is labeled 6/10/22 and use by 6 months. The powdered juice is no longer good for the health of the resident. On 11/13/2023 at 10:24am, in reference to a box of sliced scallop potatoes and a box of Devil's food without labels, V17 stated, whoever received the delivery should write the date these were delivered so we'll know when to dispose them of. On 11/13/2023 at 10:26am, in reference to the 2 jackets hanging inside the 'Food Storage' room, V17 stated, again there should be no personal items inside the food storage because there could be dirt and all on their personal items. On 11/14/2023 at 12:30pm, the 'Food Storage' room was open. A big bottle of water was used to prop it open. There was a blue jacket hanging by the door. These were pointed out to V17. V17 stated, I (V17) already did an in-service to the staff and they are still doing it. The (revised 2017) Storage of Dry goods/foods documented, in part Policy: Non refrigerated foods and other dry goods are stored in a clean, dry area, which is free from contaminants. Procedure: Foods and goods are at least six inches above the floor. Food stored in bins is removed from original packaging. Bins are labeled and dated. Opened products are labeled, dated with the use by date. The (undated) Labeling and Dating of foods documented, in part Policy: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded. Procedure: Packaged or containerized bulk food may be removed from the original package and stored in an ingredient bin labeled with the common name of the food, the date the item was opened and the date by which the item should be discarded or used by. The (undated) Use by Date Recommendations documented that the recommended maximum storage period if opened and expiration date not exceeded for white rice is 1 year on shelf and brown rice is 3-6 months. The (undated) Sanitation & Foods documented, in part Policy: The facility provides a designated area or locker rooms where employees are to keep personal belongings away from food production areas. Procedure: 1. Employees should leave personal belongings that include coats, shoes to their assigned locker rooms before going to their assigned work areas. 145806 Page 11 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure the outside dumpster lid was closed to prevent pest and rodents from migrating into the dumpster. This failure has the potential to affect all 125 residents at the facility. Residents Affected - Many Findings include: On 11/12/23 at 10:00am, two out of 6 lids of the outside dumpster were open. V7 (Cook) stated, the dumpster should be closed at all times to avoid attracting bees, flies, cockroaches and rats. On 11/13/2023 at 10:26am, in reference to the outside dumpster's lids that were open, V17 (Dietary Manager) stated, the dumpster should be close at all times. There's food in the dumpster, food will attract rodents, insects, flies, and roaches to get into the dumpster. On 11/14/2023 at 10:33am, in reference to the outside dumpster, V27 (Maintenance/Housekeeping Supervisor) stated, the dumpster should be closed at all times so pest will not go there, pest like rodents. The (undated) facility provided document Safe food handling - Dumpster upon request of dumpster policy in reference to dumpster lids and overflowing garbage did not include policy and procedure about dumpster lids and overflowing garbage. The (11/15/2023) email correspondence with V1 (Administrator) upon request of expectation whether dumpster should be left open or close documented, in part The dumpster lid should be open when in use and closed after. To dispose of trash and maintain a clean environment and avoid overflow. 145806 Page 12 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: Residents Affected - Some On 11/12/23 at 11:03 am, V14 (Housekeeper) observed in the 2nd floor hallway outside of R105 and R107's room with the housekeeping supply cart noted outside the room. V14 walks in the hallway with gloves on V14's hands to the alcohol based hand rub (ABHR) mounted on the hallway wall, pumps the ABHR on V14's gloved hands, rubs the ABHR on V14's gloved hands and returns back to the housekeeping supply cart outside R105 and R107's room. V14 then takes the broom handle with the sanitized, gloved hands and enters the room to mop the floor. R105's admission Record documents, in part, diagnoses of chronic kidney disease, type 2 diabetes mellitus, hypertension, COVID-19, major depressive disorder, schizoaffective disorder, and muscle weakness. R107's admission Record documents, in part, diagnoses of cognitive communication deficit, vascular dementia, reduced mobility, osteoporosis, hypertension, major depressive disorder, schizoaffective disorder, and muscle weakness. On 11/12/23 at 12:54 am, V14 observed walking in the 2nd floor hallway while wearing gloves on hands and carrying a clean roll of brown paper towels. V14 then walked back down the hallway to the Janitor Closet and placed the clean paper towel roll on the storage shelf with V14's gloved hands. On 11/14/23 at 1:58 pm, surveyor asked the expectations of when the housekeeping staff should be for donning gloves for housekeeping work. V27 (Maintenance/Housekeeping Supervisor) stated, the housekeeping staff should put on gloves right before going into the resident's room, then enter into the room to perform duties. V27 stated, housekeeping staff must doff (remove) gloves before coming out of the room and then perform hand hygiene. V27 stated, housekeeping staff should not be wearing gloves in the hallway. V27 stated, housekeeping staff should not sanitize their hands while wearing gloves. V27 stated, staff need to remove the gloves, do hand hygiene on the bare hands to disinfect and put new gloves on. Surveyor asked the purpose of not wearing gloves in the hallway. V27 stated it's to prevent COVID-19 from spreading, and V27's housekeeping staff is there to keep the facility clean and disinfected. On 11/14/23 at 2:19 pm, V2 (Director of Nursing, DON) stated, no staff should wear gloves while out in the hallway, and there's even a sign posted. V2 said, gloves can be contaminated then the staff is touching other surfaces, so the gloves must be removed before coming out in the hallway. V2 stated, ABHR is to clean hands only. Facility policy dated August 2019 and titled Handwashing/Hand Hygiene, documents, in part, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% (percent) of alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . l. After contact with objects (e.g. {for example}, medical equipment) in the immediate vicinity of the resident; m. After removing gloves . 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene . 10. Single-use disposable gloves should be used: . b. When anticipating contact with blood or body fluids; and 145806 Page 13 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some c. When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions . Using Alcohol-Based Hand Rubs: 1. Apply generous amount of product to palm of hand and rub hands together. 2. Cover all surfaces of hands and fingers until hands are dry. Facility job description (undated) titled Housekeeper, documents, in part, Housekeeper. Qualifications: Must show the ability to comprehend and follow directions in order to complete assigned tasks . Awareness/knowledge of basic sanitation/infection control practices is desired . Position Responsibilities: . Uses proper sanitation and safety procedures - including proper infection control techniques, hand washing. Facility document printed 11/12/23 and titled Midnight Census Report, documents, in part, that 57 residents reside on the 2nd floor in the facility. Findings include: R18 has a diagnosis of but not limited to Acute and Subacute Endocarditis, Chronic Obstructive Pulmonary Disease, Rheumatic Mitral Insufficiency, Type 2 Diabetes, Hypertension and Type 2 Diabetes. R30 has a diagnosis of but not limited to Acute Respiratory Failure, Cognitive Communication Deficit, Hypertension, Dependence on Dialysis, Respiratory Failure and Type 2 Diabetes. R30 has a Brief Interview of Mental Status score of 08 indicates severe cognitive impairment. R118 has a diagnosis of but not limited to Obstructive Sleep Apnea, Hypothyroidism, Type 2 Diabetes Mellitus, BiPolar Disorder, Difficulty Walking, Hypertension and Muscle Weakness. R118 has a Brief Interview of Mental Status score of 15 indicates cognitive intactness. Resident Covid-19 positive listed dated 11/12/2023 list R30 and R118 as having contract Covid-19 on 11/06/2023 and R18 on 11/08/2023. On 11/12/2023 at 12:02pm surveyor observed V15 (CNA) enter into a resident room without a face shield on. On 11/12/2023 at 12:04pm V15 stated, she should have had a face shield on when entering a droplet/contact isolation room. V15 stated, she has to go downstairs to get a face shield. On 11/12/2023 at 12:44pm surveyor observed V5 (Infection Preventionalist/RN) enter R18, R30 and R118's room without donning a gown or gloves. R18, R30 and R118 were on droplet/contact isolation. On 11/12/2023 at 12:45pm V5 stated, she should have on a gown and gloves when entering an isolation room, but she just went to drop off the lunch tray. On 11/14/2023 at 11:47am V2 (DON) stated, staff should wear N95 masks, gown, gloves and face shield on when entering contact and droplet rooms. Job description titled Registered Nurse dated 2015 documents, in part, participate in maintenance of the infection control program for monitoring communicate and/or infectious diseases among the residents and personnel and ensure that your assigned personnel follow established infection control procedures when isolation precautions become necessary and ensure that nursing personnel follow established procedures in the use and disposal of personal protective equipment. 145806 Page 14 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0880 Policy titled Assisting the Resident with In-Room Meal with a revised date of December 2013 documents, in part, follow transmission based precautions, as appropriate. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Some The (11/11/2023) Midnight Census report documented that there were 50 residents on the first floor. The Updated Positive Covid list: 11/12/23 include R2. On 11/12/2023 at 10:38am, V13 (Licensed Practice Nurse) stated (R2) is on isolation due to Covid-19. On 11/12/2023 at 11:06am, there were Droplet Precaution and Contact Precaution signs posted by R2's room. On 11/12/23 at 12:12 PM, during dining observation of the first floor, V12 (Certified Nursing Assistant) was wearing a mask, took a food tray from the food cart and went inside R2's room without donning additional appropriate PPE (Personal Protective Equipment), came out R2's room, poured coffee from the beverage cart and went back to R2's room. On 11/12/23 at 12:13 PM, upon exit of V12, this surveyor requested V12 to read the signs posted by R2's door. V12 stated, contact and droplet precautions. I (V12) have gowned up early, but I (V12) removed it. I (V12) was not wearing any of the PPE when I (V12) entered (R2)'s room. On 11/12/23 at 12:21 PM, V36 (Laundry Aide) was wearing a mask, went inside R2's room without donning additional appropriate PPE. This surveyor requested V36 to read the signs posted by R2's room and stated contact and droplet precautions, I (V36) am not sure what PPE to wear. On 11/14/2023 at 11:43am, V18 (IP Nurse/Psychotropic nurse/LPN) stated, for residents on contact precaution, we place them on isolation room, put signage up, PPE bins should have mask, gowns, gloves, red bags, and hand sanitizer. Prior to entering the room, staff are supposed to don gown and gloves and doff prior to exiting. Surveyor inquired if staff are supposed to done PPE when passing tray to isolation room. V18 stated, no matter what care they are providing; staff are expected to don and doff PPE appropriately. On 11/14/2023 at 11:46am, V18 stated for residents on droplet precaution expectation is to have signage, PPE bin; staff are expected to have a mask and face shield or goggles prior to entering the room. if residents are on contact and droplet precautions, staff is supposed to don gown, gloves, mask, and face shield. On 11/14/2023 at 11:48 V18 stated, the purpose of donning appropriate PPE is to protect staff member entering the room so they don't contract whatever the resident has and passing it to other residents or staff. On 11/14/2023 at 11:49am, V18 stated, for residents who tested positive with Covid-19, we quarantine our residents for 10 days: either symptomatic or asymptomatic. R2's (11/14/2023) Medication Review Report documented, in part Diagnoses: (include but not limited to) COPD (chronic obstructive pulmonary disease), gastritis, seizures. Order summary. 145806 Page 15 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0880 Contact/Droplet isolation d/t (due to) positive Covid result x 10 days until 11/12/23. Order Date: 11/03/2023. Level of Harm - Minimal harm or potential for actual harm R2's (08/07/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R2's mental status as cognitively intact. Residents Affected - Some R2's (11/03/2023) Care Plan documented, in part Focus: on contact/droplet isolation related to Covid-19 until 11/12/23. Goal: will have no complications. Interventions: Contact /droplet precautions. The (11/15/2023) email correspondence with V2 (Director of Nursing) upon request of R2's Covid test result on 11/03/2023 documented in part Rapid Antigen done on the 11/3/23 with positive result. The (2015) Certified Nursing Assistant Job Description documented, in part The Primary purpose of your position is to provide quality nursing care to residents; implement specific procedures and programs related to resident care. Staff Development and Safety. Ensure that you follow established infection control procedures when isolation precautions become necessary. The (10/2018) Isolation - Categories of Transmission-Based Precautions documented, in part Policy Statement. Transmission-Based Precautions are initiated when resident develops signs and symptom of a transmissible infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to the other residents. Policy Interpretation and Implementation. 2. Transmission-Based Precautions are additional measures that protect staff, visitors and other residents from becoming infected. 5. When a resident is placed on Transmission-Based Precautions, appropriate notification is placed on the room entrance. Contact Precautions. 1. Contact precautions may be implemented for residents know or suspected to be infected. Staff will wear gloves when entering the room. 5. Staff will wear disposable gown upon entering the room and remove before leaving the room. Droplet precautions. 3. Masks will be worn when entering the room. 4. Gloves, gown, and goggles should be worn if there is a risk of spraying respiratory secretions. The facility provided (03/30/2020) CDC (Centers for Disease Control and Prevention) pamphlet for Use Personal Protective Equipment (PPE) when caring for Patients with Confirmed or Suspected Covid-19 documented, in part Before caring for patients with confirmed or suspected COVID-19, healthcare personnel (HCP) must: remember: PPE must be donned correctly before entering the patient area (e.g. isolation room) PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. Based on observation, interview and record review, the facility failed to appropriately don and doff personal protective equipment (PPE) for isolation rooms; failed to perform proper hand hygiene, failed to doff gloves in the hallway; failed to post the proper isolation sign for positive COVID 19 isolation rooms in efforts to prevent the spread of microorganism including COVID 19; failed to provide accessible PPE for isolation rooms; failed to properly transport COVID 19 isolation linen; and failed to follow the facility's COVID-19 policy and procedures. These failures affected R2, R16, R18, R30, R33, R38, R94, R105, R107, and R118 and has the potential to affect all 50 residents on the first floor, all 57 residents on the second floor and all 18 residents on the third floor at the facility. Findings include: 145806 Page 16 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0880 On 11/12/23 V2 (Director of Nursing, DON) presented the facility census of 125 residents. Level of Harm - Minimal harm or potential for actual harm On 11/13/23, V18 (Infection Preventionist Licensed Practical Nurse, LPN) provided a document titled Updated Positive COVID list 11/13/23 documenting R16, R33, R38, and R94's on isolation for COVID in the facility. Residents Affected - Some On 11/12/23 at 10:30 am, Surveyor toured the third-floor unit and observed an orange droplet precautions isolation sign posted on R16, R33, R38, and R94's isolation room doors without accessible PPE (an isolation bin set up with gown, N95 mask, face protection, and gloves) available for visitors and staff to use. On 11/12/23 at 10:51 am, Surveyor observed V3 (Certified Nursing Assistant, CNA) enter and exit R16, R38, and R94's isolation room without donning or doffing appropriate PPE (No gown, N95 mask, gloves, and eye protection). V3 was asked if R16, R38, and R94 was on isolation. V3 stated, Yes. For COVID 19. V3 was asked if V3 should be wearing PPE when going into R16, R38, and R94's room. V3 stated, V3 did not need to wear PPE when entering R16, R38, and R94's isolation rooms because V3 was only checking to see if R16, R38, and R94 needed anything. On 11/12/23 at 10:55 am, Surveyor observed V14 (Housekeeper) wearing a blue isolation gown while on the third-floor unit cleaning R16, R33, R38, and R94's isolation rooms and then enter into the third-floor hallway without V14 changing V14's blue isolation gown in between entering and exiting R16, R33, R38, and R94's isolation rooms and the third-floor hallway. On 11/12/23 at 11:00 am, these observations were brought to V2 (Director of Nursing, DON). V2 stated, V2 received a SIRENS notification from the department of Public Health on 11/09/23 that stated staff at the facility was no longer was required to wear isolation gowns and mask inside of COVID 19 isolation rooms. V2 was asked if staff are required to wear isolation gowns when entering the residents rooms during care with the residents. V2 stated, staff should be wearing the appropriate PPE when inside isolation rooms. V2 was asked regarding accessible PPE (an isolation bin set up with gown, N95 mask, face protection, and gloves) for the isolation rooms on the third floor unit. V2 stated, I'm (V2) not sure why there are no isolation bins with PPE for the isolation rooms on this floor you have to ask my IP nurse (referring to V18 (Infection Preventionist, IP, Licensed Practical Nurse, LPN). On 11/12/23 at 11:12 am, Surveyor questioned V14 regarding wearing a blue isolation gown while on the third-floor unit cleaning R16, R33, R38, and R94's isolation rooms and then enter into the third-floor hallway without V14 changing V14's blue isolation gown in between entering and exiting R16, R33, R38, and R94's isolation rooms and the third-floor hallway. V14 stated, I (V14) keep the blue gown on because of COVID. I (V14) wore the same gown because there are no bins to use a different gown. V14 was asked regarding PPE usage for isolation rooms. V14 stated, I (V14) should change the gown whenever I (V14 ) leave out of COVID rooms so that I (V14) do not spread the COVID. When I (V14) finish cleaning one room, I (V14) should change my (V14) gown before I (V14) leave the room. On 11/12/23 at 11:30 am, V6 (Certified Nursing Assistant, CNA, CNA Supervisor) was observed bringing yellow isolation gowns, gloves, and N95 mask to the third-floor unit nursing station. V6 was asked regarding isolation bin set with PPE supplies for the isolation rooms on the third-floor unit. V6 stated, I (V6) don't know why there are no isolation bins on this floor. I (V6) was just asked to bring isolation supplies up here (referring to the third-floor unit). 145806 Page 17 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/13/23 at 10:42 am, Surveyor and V35 (Laundry Aide) conducted a tour of the laundry area. Surveyor observed a grey barrel with red biohazard bags of soiled linen and clear bags with soiled linen across from the washing machines in the laundry area. V35 stated, The laundry all comes down together in one barrel from each floor with COVID linen in red bags and regular soiled linen in clear bags. V35 explained, all the COVID isolation linen and regular soiled linen is transported to the laundry department in the same barrel and V35 separates the COVID linen from non-COVID linen into two separate barrels once the linen arrives to the laundry room. V35 was asked the facility policy for transporting COVID 19 soiled linen and non-COVID 19 soiled linen. V35 stated, the linen is all placed in one barrel at the same time and V35 brings the linen down to the laundry to separate the COVID 19 soiled linen bags for wash. V35 was asked regarding the disinfecting and cleaning of the barrels used for transporting the linen to the laundry department. V35 stated, V35 does not know. On 11/13/23 at 10:45 am, Surveyor requested to speak with the housekeeping supervisor and V27 stated, the facility housekeeping supervisor was not working and V35 could answer questions regarding the facility's laundry department. On 11/14/23 at 10:42 am, V18 (Infection Preventionist, IP, Licensed Practical Nurse, LPN) was interviewed regarding the facility's infection prevention program. V18 stated, R16, R33, R38, and R94's were on droplet and contact isolation for COVID 19 at the facility. V18 explained, once a residents test positive for COVID 19 the resident is placed on contact and droplet precautions and away from residents who are not positive for COVID 19. V18 also explained, residents who are on isolation for COVID 19 should have an isolation sign for droplet and contact on the residents door and an isolation bin outside of the residents door with access to PPE (gowns, gloves, N95 mask, and eye protection). V18 stated, residents who test positive for COVID requires staff to wear (don) gown, gloves, N95 mask and face protection when the staff is entering the isolation room and that the staff should remove (doff) the PPE prior to exiting the isolation room. V18 was asked regarding the facility's process for transporting residents who are on isolation for COVID 19 linen. V18 stated, residents who are on isolation for COVID linen should be placed in a red biohazard bag and brought down in the laundry barrel separate from residents linen who is not on isolation for COVID. V18 also explained, the housekeeping department at the facility is responsible for sanitizing and cleaning the linen barrels after each removal of COVID linen from the linen barrels. V14 was asked regarding the isolation bins and the Contact isolation signs for R16, R33, R38, and R94's room. V14 stated, V14 does not know what happen to the contact isolation signs and bins for R16, R33, R38, and R94's isolation rooms. V14 was asked regarding the importance of the infection prevention program and following the facility's COVID 19 policy and procedures. V18 stated, it is important to follow the facility's COVID 19 policy and procedures and infection prevention program so that diseases are not spread, and the residents and staff do not get sick. R16's face sheet shows R16 has a diagnosis which includes but not limited to : COVID-19, chronic obstructive pulmonary disease, essential hypertension, and schizoaffective disorder. R16's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 14 which indicates R16 is cognitively intact. R16's Physician Order Sheet (POS) dated 11/06/23 shows that R16 has Contact/Droplet isolation due to positive COVID result for ten days until 11/15/23 one time only for COVID until 11/15/23. R16's care plan documents in part: Focus: Contact/Droplet isolation related to COVID-19 as of 11/06/23. 145806 Page 18 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R16's progress note dated 11/06/23 at 4:54 pm, authored by V5 (Registered Nurse, RN) documents R16 was updated regarding recent COVID-19 rapid positive result. Strict contact and droplet isolation protocols are in place. R33's face sheet shows R33 has a diagnosis which includes but not limited to : COVID-19, paranoid schizophrenia, essential hypertension, type 2 diabetes, asthma, and herpes viral infection. R33's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates R33 is cognitively intact. R33's Physician Order Sheet (POS) dated 11/07/23 shows R33 has Contact/Droplet isolation due to positive COVID result for ten days until 11/15/23 one time only for COVID until 11/15/23. All care rendered in private room. R33's care plan documents in part: Focus: Contact/Droplet isolation related to COVID-19 as of 11/06/23. R33's progress note dated 11/06/23 at 4:56 pm, authored by V5 (Registered Nurse, RN) documents R33 was updated regarding recent COVID-19 rapid positive result. Strict contact and droplet isolation protocols are in place. R38's face sheet shows R38 has a diagnosis which includes but not limited to : bipolar disorder, schizophrenia, convulsions, dysphagia, and reduced mobility. R38's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates R38 is cognitively intact. R38's Physician Order Sheet (POS) dated 11/06/23 shows that R38 has Contact/Droplet positive result for ten days. R38's care plan documents in part: Focus: Contact/Droplet isolation related to COVID-19 due to positive result. R38's progress note dated 11/07/23 at 10:02 pm, authored by V18 (Licensed Practical Nurse) documents R38's stated guardian informed resident tested positive for COVID R38 will remain on contact/droplet isolation for 10 days. R94's face sheet shows that R94 has a diagnosis which includes but not limited to : schizoaffective disorder, Bipolar type, unspecified psychosis, heart failure, chronic obstructive pulmonary disease, essential hypertension, and anemia. R94's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates R94 is cognitively intact. R94's Physician Order Sheet (POS) dated 11/06/23 shows R94 has Contact/Droplet isolation due to positive COVID result for ten days until 11/15/23 one time only for COVID until 11/15/23. R94's care plan documents in part: Focus: Contact/Droplet isolation related to COVID-19 as of 11/06/23 till 11/16/23. 145806 Page 19 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R94's progress note dated 11/06/23 at 4:30 pm, authored by V5 (Registered Nurse, RN) documents R94 was updated regarding recent COVID-19 rapid positive result. Strict contact and droplet isolation protocols are in place. The facility's document dated April 2020 and titled Infection Prevention and Control Program documents, in part: Policy: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 10. Outbreak Management: 3. Preventing the spread to other residents . 11. Prevention of Infection: 7. Implementing appropriate isolation precautions when necessary. The facility's document dated 06/14/2023 and titled Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID 19) documents, in part: Personal Protective Equipment: Health Care Personal (HCP) who enter the room of a patient with suspected or confirmed SARS- CoV-2 (COVID 19) infection should adhere to Standard Precautions and use a NIOSH (National Institute for Occupational Safety and Health)- approved particulate respirator with N95 filters or higher, gown , gloves and eye protection (i.e., goggles or face shield that covers the front and side of the face . Supplies: The following are additional measures that will be taken to identify the correct type of PPE: Post signs on the door or wall outside of the resident room to clearly describe the type of precautions needed and required PPE. The facility's document dated January 2014 and titled Departmental (Environmental Services) Laundry and Linen documents, in part: Purpose: The purpose of this procedure is to provide a process for the save and aseptic handling, washing, and storage of linen. The facility's document dated October 2018 and titled Laundry and Bedding, Soiled documents, in part: Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. The facility's document dated October 2018 and titled Isolation Categories of Transmission Based Precautions documents, in part: Policy Statement: Transmission Based Precautions are initiated when a resident develops signs and symptoms of transmissible infection; arrives for admission wit symptoms of infection, or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation: 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution . Contact Precautions: 5. Staff and Visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed . Droplet Precautions: 4. Gloves, gown, and goggles should be worn if there is risk of spraying respiratory secretions. 145806 Page 20 of 21 145806 11/15/2023 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure the facility is free of roaches. This failure has the potential to affect all 125 residents in the facility. Residents Affected - Some Findings include: On 11/12/23 at 10:00am, two out of 6 lids of the outside dumpster were open. V7 (Cook) stated, the dumpster should be closed at all times to avoid attracting bees, flies, roaches, and rats. On 11/13/2023 at 10:26am, in reference to the outside dumpster that was open. V17 (Dietary Manager) stated, the dumpster should be close at all times. There's food in the dumpster, food will attract rodents, insects, flies, and roaches to get into the dumpster. On 11/12/23 at 11:25 AM, there was a live roach inside the shower room. This observation was pointed out to V12 (Certified Nursing Assistant). V12 stated, there is a small live roach in shower 3. On 11/14/2023 at 10:22am, in reference to the live roach seen on the 1st floor shower room, V27 (Maintenance and Housekeeping Supervisor) stated, I (V27) just came in today and nobody told me (V27) about the live roach that was seen on the shower room. Staff usually report to me by word of mouth. We (facility) do not have forms where staff could report sighting of roach. In this situation, 'word of mouth' is not effective of letting me (V27) know there was a roach sighting on the shower room. I (V27) have not sprayed the shower room with roach spray. We (facility) do not want roaches inside the facility. It is not good for the health of the residents. On 11/14/2023 at 10:33am, in reference to the outside dumpster V27 (Maintenance/Housekeeping Supervisor) stated, the dumpster should be closed at all times so pest will not go there; pest like rodents, not roaches. Roaches come here when residents are admitted . They (residents) brought roaches in. The (11/13/2023) Service Inspection Report documented, in part Pest Activity. German Roaches. Area: Main Kitchen Area Stoves/equipment. Status: Activity. Pest Findings: German Roaches - Exoskeleton. The (undated) Policy on Pest Control documented, in part General: It is the policy of the facility will be free of pest/rodents. Policy. 1. All reports of pest or rodents will be followed up by maintenance department. 2. Staff will notify and report any sightings within the facility. 6. Effected area will be thoroughly cleaned and treated. 145806 Page 21 of 21