Health inspection·December 12, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide dignity for two (R41, R226) residents in a total sample of 25 residents reviewed. Findings include: 1. On 12/09/2024 at 10:19 AM, R226 observed lying in bed inside of his room in a left lateral position. R226 observed with a shirt on with a white blanket half-way covering the mid-section of his body. R226 is observed without any under briefs on and his buttocks exposed. R226 states a staff member took his incontinence briefs off because they were too small. R226 states the facility does not have any incontinence briefs that are his size to place on him. On 12/09/2024 at 10:22AM, V4 (Certified Nursing Assistant/CNA) now located inside of R226s' room. V4 observes that R226 is not wearing any incontinence briefs. V4 stated she offered to place reusable incontinence briefs on R226 but R226 stated that he was not comfortable wearing the diaper. V4 stated the facility uses reusable incontinence briefs for residents who are mostly bed bound. V4 stated some residents have disposable incontinence briefs in their own rooms in the closet and are purchased by their own family. Surveyor toured the 1st floor unit with V4. There were four linen carts observed on the first floor. Surveyor did not observe any disposable incontinence briefs located on any of the linen carts. Surveyor observed several reusable cloth incontinence briefs on the shelves of the linen carts. R226s' Face sheet documents that R226 has diagnoses not limited to: unspecified dementia, major depressive disorder, schizophrenia, delusional disorders, and chronic kidney disease. R226s' MDS/Minimum Data Set, dated [DATE] documents that R226 has a BIMS/Brief Interview for Mental Status score of 13/15, which indicates that R226 is cognitively intact. R226 is incontinent of bowel and bladder and has an indwelling urinary catheter. R226s' care plan dated 12/09/2024 documents that R226 is care planned for Activities of Daily Living/ADL self-care deficit related to weakness. 2. On 12/09/2024 at 12:17 PM, R41 observed lying in bed inside of his room in a supine position. R41 observed with a white blanket covering his body. R41 observed moving around and attempting to get out of bed. Surveyor observes that R41 does not have on any clothes on underneath the blanket. R41 was completely naked without a gown or incontinence briefs on. R41 is not alert and unable to make Page 1 of 16 145806 145806 12/12/2024 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0557 his needs known. R41 was also observed to have multiple finger contractures on both of his hands. Level of Harm - Minimal harm or potential for actual harm On 12/09/2024 at 12:17PM, V7 (Certified Nursing Assistant/CNA) also located inside of R41s' room. V7 acknowledged that R41 was not wearing any clothing and was completely naked underneath the blanket. V7 stated she is not R41s' assigned CNA today. V7 stated she is assigned to care for residents on the third floor but came to the first floor to help assist some of the residents with their care. V7 stated the facility uses reusable incontinence briefs for residents who are mostly bed bound. V7 stated she was informed by her supervisor to use the reusable incontinence briefs for R41 also. V7 stated residents who are mobile and able to get out of bed are the residents who use the disposable incontinence briefs. V7 stated it is a dignity issue for R41 not to have on any clothing underneath his blanket. V7 stated she will gather supplies to help clothe R41. Residents Affected - Few R41s' Face sheet documents that R41 has diagnoses not limited to: External constriction of unspecified finger, abnormalities of gait and mobility, unsteadiness on feet, muscle weakness, lack of coordination, and extrapyramidal and movement disorder. R41s' MDS/Minimum Data Set, dated [DATE] documents that R41 has a BIMS/Brief Interview for Mental Status score of 09/15, which indicates that R41 is cognitively impaired. R41 requires partial/moderate assistance with ADL/Activities of Daily Living care. R41 is incontinent of bowel and bladder. R41s' care plan documents that R41 is care planned for incontinence. On 12/11/2024 at 1:42PM, V2 (Director of Nursing/DON) stated if residents are left without any clothes or incontinence briefs on, then this is a dignity issue and does not promote dignity for the resident. Facility policy undated, titled Resident Rights documents in part, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. b. be treated with respect, kindness, and dignity. Facility's document, undated, titled Residents' Rights for People in Long-Term Care Facilities documents in part You have a right to make your own choices. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Facility policy dated 02/2020, titled Quality of Life- Dignity documents in part, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 145806 Page 2 of 16 145806 12/12/2024 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. Based on observation, interview, and record review, the facility failed to ensure that reusable cloth incontinence briefs intended for resident use were in good condition, this failure has the potential to affect 40 incontinent residents residing in the facility. Findings include: On 12/10/2024 at 12:23PM, a tour of the laundry room was conducted with V13 (Laundry Aide). Surveyor observed the following inside of the laundry room in the basement of the facility: One cloth incontinence brief with multiple, permanent dark colored stains folded on a linen cart intended for resident use. V13 stated she is aware that she should throw the stained incontinence briefs away when the facility receives new cloth incontinence briefs. V13 stated she washed the cloth incontinence brief twice and since it is not ripped/torn, she assumed it was okay for residents to continue to use it. On 12/10/2024 at 12:47PM, V14 (Housekeeping Director) now located in the laundry room and observes the multiple, permanent dark stains on the incontinence brief. V14 states the permanent stains on the incontinence briefs appears to be a result of urine and feces. V14 stated V13 (Laundry Aide) is responsible for notifying him when incontinence briefs and other linen need to be reordered in the facility. V14 stated V13 is also responsible for discarding old, stained, and worn linen in the facility that can no longer be used for resident use. V14 stated the multiple, permanently dark stained incontinence brief should not be on the linen cart to be distributed for resident use in the facility. Facility policy dated 10/2022, titled Laundry and Bedding documents in part, Policy Statement: Soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control. Mattresses, Pillows and Overlays: 5. Pillows that are torn, damaged, or permanently stained are discarded. Facility policy dated 05/2020, titled Quality of Life-Homelike Environment documents in part, Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2. e. Clean bed and bath linens are in good condition, Residents' Rights for People in Long-Term Care Facilities documents in part, Your facility must be safe, clean, comfortable, and homelike. Facility document undated, titled Incontinence List documents that there are a total of 40 incontinent residents residing in the facility. 145806 Page 3 of 16 145806 12/12/2024 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 12/10/24 at 11:10 AM, interviewed V10 (Social Service Director) and stated that the resident's PASARR Level I or II should be completed prior to admitting in the facility to make sure that resident being admitted is eligible and meet the requirements to come to the nursing facility. V10 stated that the facility does not run or re-run the residents' PASARR until instructed by the outside agency in charge of PASARR screenings. Residents Affected - Some R72's clinical records show an original admission date of 6/07/19 with included diagnoses but not limited to Schizoaffective Disorder and Major Depressive Disorder. The facility provided R72's OBRA - I INITIAL SCREEN completed by outside agency and is dated 10/22/18. R72's screen shows there is a reasonable basis for suspecting DD (Developmental Delay) or MI (Mental Illness). R72's Level II Preadmission Screening and Resident Review (PASARR) was not completed. Based on interview and record review, the facility failed to refer four (R41, R66, R72, R90) residents with serious mental illness to the appropriate state-designated authority for PASARR (Pre-admission Screening and Resident Review) level II evaluation and determination in a total sample of 25 residents reviewed. Findings Include: R41s' Face sheet documents that R41 was admitted to the facility on [DATE] with diagnoses not limited to: bipolar disorder and anxiety disorder. R41s' PASARR screening dated 05/25/2005 titled OBRA-1 Initial Screen documents that there is reasonable basis to suspect a mental illness for R41. There is no documentation to show that R41 was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. R66s' Face sheet documents that R66 was admitted to the facility on [DATE] with diagnoses not limited to: schizophrenia, schizoaffective disorder, and bipolar disorder. R66s' PASARR screening dated 10/28/2013 titled Assessment Summary Information documents that R66 has a mental illness diagnosis of paranoid schizophrenia. There is no documentation to show that R66 was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. R90s' Face sheet documents that R90 was admitted to the facility on [DATE] with diagnoses not limited to: schizoaffective disorder, panic disorder, and major depressive disorder. R90s' PASARR screening dated 06/05/2020 titled Interagency Certification of Screening Results documents R90s' serious medical issues as a primary focus. There is no documentation to show that R90 was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. Facility Policy dated 03/2022, titled admission Criteria documents in part, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. c. upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and 145806 Page 4 of 16 145806 12/12/2024 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0645 whether placement in the facility is appropriate. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 145806 Page 5 of 16 145806 12/12/2024 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to correctly set air loss mattress based on weight for one (R75) of 8 residents reviewed for pressure wound treatment services in a total sample of 25 . Residents Affected - Few Findings include: On 12/09/24 at 1:25 PM, R75 was observed lying in bed on an air loss mattress. Air loss mattress dial setting was in the middle of the 240-320-pound weight per the low air mattress' display panel. Surveyor felt the pressure of R75's low air loss mattress and it was hard and very firm to touch. On 12/09/24 at 1:30 PM, V2 (Director of Nursing) stated the low air loss mattress is set based on the resident's weight. V2 observed R75's low air loss mattress setting and stated R75 must weigh between 240-320 pounds since that is what the air loss mattress is set at. On 12/11/24 at 8:40 AM, V31 (Restorative Nurse/Fall Coordinator/Wound Coordinator) stated the purpose of low air loss mattress is to eliminate pressure from concentrating in one area so the pressure is distributed to the whole body and is used to prevent a pressure wound from getting worse and/or to prevent a pressure wound from developing. V31 stated the mattress should not be hard and should have some bounciness to it because if the mattress is too hard it would prevent the pressure from being evenly distributed which would defeat the purpose of the air loss mattress causing the mattress to function like a regular mattress. V31 stated the air low mattress setting is based on the resident's weight. V31 stated the nursing staff should be monitoring the setting on a daily to make sure it is on the correct setting based on the resident's weight. V31 stated R75 has a stage IV pressure wound on sacrum and is under hospice care. V31 stated R75 weighs between 100-110 pounds, not between 240-320 pounds. V31 stated R75's low air loss mattress should not have been set between 240-320 pounds. V31 stated V2 notified V31 about the error of R75's weight setting, and it was corrected, and training was done with the nursing staff to ensure the air low mattress is set properly to minimize pressure on the skin. V31 stated the potential of the low air loss mattress not being set correctly is that it could make the pressure wound worse and impair wound healing. R75 has diagnosis which includes but not limited to Dementia, Adult Failure to Thrive, Weakness, Need for Assistance with Personal Care, Muscle Wasting and Atrophy, Muscle Weakness (Generalized), Unsteadiness on Feet, Lack of Coordination, Reduced Mobility, Abnormalities of Gait And Mobility, Abnormal Posture, Schizoaffective Disorder, Drug Induced Subacute Dyskinesia. R75's Braden Risk Assessment History printed 12/10/24 documents in part, R75's at high risk for acquiring pressure wounds based on Braden Score of 10. R75's MDS (Minimum Data Set) from 10/16/24 documents in part, R75 has functional limitation in range of motion impairments to both sides of upper and lower extremities and is dependent on staff for all self-care activities except feeding and is dependent on staff for mobility. R75's MDS also indicates R74 has a pressure ulcer/injury over bony prominence stage 4 and skin treatments include pressure reducing device for bed and pressure ulcer/injury care. R75's Wound Rounds assessment dated [DATE] documents, facility acquired identified 12/05/23 145806 Page 6 of 16 145806 12/12/2024 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0686 pressure ulcer to coccyx (0.5x0.5x0.1). Level of Harm - Minimal harm or potential for actual harm R75's Order Summary Report dated 12/10/24 documents in part, clean coccyx area with Normal Saline, apply alginate dressing cover with Hydrocolloid dressing every other day and PRN (as needed) every 8 hours as needed for wound care with order date 10/29/24. Residents Affected - Few R75's Monthly Weight Report printed 12/11/24 documents December 2024 weight 104 pounds, November 2024 weight 108 pounds. Facility provided policy titled, Support Surface Guidelines dated September 2022 documents in part, the redistributing support surfaces are to promote comfort for al bed or chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Facility provided Owner's Manual for R75's air loss mattress documents in part, this product is intended to help and reduce the incidence of pressure ulcers while optimizing patient comfort and operation according to the weight and height of the patient. 145806 Page 7 of 16 145806 12/12/2024 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate assistance and supervision to 2 (R50, R84) out of 2 high fall risk residents reviewed for accidents and hazards in a final sample of 25. Findings Include: On 12/09/24 at 12:05 PM, R50 was sitting in [R50's] wheelchair in the dining room alert and able to verbalize needs. R50 stated R50 has pain everywhere. R50 stated [R50] went to the bathroom by himself around 9:00 AM this morning, and while [R50] was washing [R50's] hands, R50 slipped and hit [R50's] head on the sink. R5 stated [R50] was able to lift himself back up and went back in bed. R50 stated [R50] notified the nurse but does not know the name of the nurse. On 12/9/24 At 12:10 PM, Surveyor notified V9 (Registered Nurse) of what was reported by R50. V9 stated that V9 was not made aware of R50's incident. V9 stated, I will assess and send [R50] out. On 12/9/24 At 12:31 PM, interviewed V33 (Certified Nursing Assistant) and stated that R50 can go to the bathroom on his own and can stand up and transfer by himself without assistance. V33 stated that R50 is high risk for fall and staff needs to monitor R50. V33 stated V33 was not made aware of R50's incident. At 12:36 PM, V9 stated R50 was assessed and R50's vital signs were: 121/68 (Blood Pressure), 66 (Heart Rate), 95% oxygen saturation (Room Air), 97.5 (Temperature), and 18 (Respiration). V9 stated R50 had no injuries and V35 (Nurse Practitioner) ordered neuro check and to continue to monitor R50. V9 stated that R50 should not be going to the bathroom by himself. V9 stated R50 requires staff assistance for toileting and transfers. On 12/10/24 at 2:52 PM, V31 (Restorative Nurse/Fall Coordinator/Wound Coordinator) stated the facility uses a Morse Fall Assessment as a tool to identify residents at risk for falls and to prevent/anticipate falls to avoid falls and injuries. V31 stated some of the criteria used as part of the Morse Fall Assessment include history of falls, ambulation ability, and cognition status/self-awareness. V31 stated the Morse Fall Assessment gives a score and the higher the score the higher chance they are at risk for falls. V31 stated that if the functional assessment and the Minimum Data Set coded that the resident requires supervision, then this means the resident needs to be monitored and may need for you to guide them when walking to give them more balance and support. V31 stated that partial/moderate assistance means is when the resident needs more physical assistance from the staff including more holding, being part of the task, and substantial/maximal assistance means the staff is providing more of the care than the resident. V31 stated that whatever level of assistance is needed based on the functional assessment must be always provided to the resident. V31 stated that it is important to provide the required assistance to the resident for the resident's safety, and residents at risk for falls should be provided with the required assistance to try to prevent falls from occurring. V31 stated R84 is at high risk for falling based on the Morse Fall Assessment due to impulsive behaviors and impaired cognitive function. V31 stated based on R84's functional assessment R84 can ambulate with supervision and since R84 is at high risk for falls the staff should be within eye distance so that they can monitor R84 and intervene as needed with touch assistance. V31 stated R84 should be supervised by staff at all times. V31 stated another resident (R44) was sitting in the 1st floor 145806 Page 8 of 16 145806 12/12/2024 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dining room when R84 fell and R44 did not say there was any staff in the room when R84 fell. V31 stated none of the staff V31 has spoken to said they were in the room when R84 fell. V31 stated there should be a staff member in the common areas like the dining room when residents are in there especially if the resident is at a high risk for falling and it is possible R84's fall could have been avoidable. V31 stated that if a resident is in the room and is known to do things by himself but does not call for help then the staff should be providing assistance during the task and anticipate the resident's needs. V31 stated that R50 is at high risk for falls due to impulsive behaviors and the staff should be monitoring R50 during ADL (Activities of Daily Living) care because R50 does need assistance to prevent R50 from falling. V31 stated staff should be monitoring R50 until the ADL task is completed, R50 should not be doing it alone. V31 stated R50 needs one staff assistance for transfer and to go to the bathroom. R50's clinical records show R50 has included diagnoses but not limited to epilepsy, unsteadiness on feet and muscle weakness. R50's MDS and functional assessment dated [DATE] shows R50 is cognitively impaired and requires partial/moderate assistance with transfers and toileting. R50's MORSE FALL SCALE dated 11/01/24 shows R50 is high risk for falling. The facility's Safety and Supervision of Residents policy dated 07/22 reads in part: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The facility's Activities of Daily Living (ADLs), Support/Care policy dated 03/23 reads in part: 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: Hygiene, Mobility, Elimination, Dining, Communication. On 12/09/24 between 9:30-9:45 AM, during medication pass administration observation surveyor standing in the hallway observed R84 in the 1st floor unit dining room lose R84's balance, and stumble towards the floor. Surveyor heard other residents calling for help and then heard a loud sound and then heard CODE WHITE being called over the loudspeaker. Per surveyor there were no staff present in the dining room when the fall occurred. On 12/09/24 between 12:35 PM-1:35 PM, surveyor interviewed the following staff working on the 1st floor including V4 (Certified Nursing Assistant), V7 (Certified Nursing Assistant), V23 (Registered Nurse), V25 (Certified Nursing Assistant), V26 (Certified Nursing Assistant), V27 (Certified Nursing Assistant), V28 (Certified Nursing Assistant, V29 (Certified Nursing Assistant) who all stated none of them witnessed R84's fall in the dining room. Per record review, on 12/09/24 incident note completed by V23 (Registered Nurse) documented in part writer responded to code white in 1st floor dining room, head to toe assessment performed, resident denied pain, skin intact, resident alert and orientated within baseline, resident denied hitting head, vital signs are stable, and resident's MD notified and ordered labs and message left with resident's emergency contact. On 12/10/24 at 3:30 PM, R44 stated R44 was sitting in the dining room on the 1st floor yesterday 145806 Page 9 of 16 145806 12/12/2024 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when R84 fell. R44 stated R84 entered the dining room talking loudly and yelling so R44 was ignoring R84 and then R44 saw R84 on the floor. R44 stated there were no staff in the dining room when R84 fell. R84 admitted to the facility 05/24/24 with diagnosis included but not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Major Depressive Disorder, Recurrent, Muscle Weakness (Generalized), Unsteadiness on Feet, Unspecified Lack of Coordination, Other Reduced Mobility, Other Lack of Coordination, Abnormal Posture, Unspecified Psychosis Not Due to A Substance Or Known Physiological Condition. R84's MDS (Minimum Data Set) from 11/29/24 BIMS (Brief Interview for Mental Status) documents in part, resident is rarely/never understood and has long/short term memory problems and functional abilities included R84 requires supervision or touch assistance for all mobility including walking, sit to stand, chair/bed to chair transfer. R84 has fall risk care plan which documents in part, R84 Is at risk for falls related to confusion, gait/balance problems and unaware of safety needs due to diagnosis of dementia. Goal is for resident to be free of falls through next review and interventions include but not limited to anticipate and meet resident's needs. R84's MORSE Fall Scale dated 11/29/24, signed 12/03/24 documents in part, score 65.0, high risk for falling. Facility document titled; High Risk Resident dated 11/28/24 Need Extra Monitoring per Staff which includes R50's and R84's names listed. Facility Post Fall Investigation dated 12/09/24 documents in part, involving R84 type of fall unwitnessed. Facility policy document titled, Emergency Codes undated which documents in part, Code White: Resident is alert, but has fallen. 145806 Page 10 of 16 145806 12/12/2024 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, 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 ensure medications were locked and secured while unattended. This failure has the potential to affect all 68 residents residing on the 1st and 3rd floors. Findings Include: On 12/09/2024 at 11:15AM, surveyor located on the first floor of the facility. Surveyor observes a medication cart unlocked and unattended with medication cart keys left inside of the medication carts' lock. V6 (Registered Nurse/RN) states she is responsible for the unlocked and unattended medication cart. V6 states this medication cart stores medications for residents on the 1st and 3rd floors of the facility. V6 states she must have gotten busy with other things and forgot to lock the medication cart and retrieve the keys. V6 states that residents can potentially get access to the medications if the cart is left unlocked and unattended. V6 states residents could potentially overdose, have an adverse reaction, or other life-threatening complications if they get access to the medications. Surveyor observes inside of V6s' medication cart that a total of 35 residents have medications stored inside the medication cart. On 12/11/20224 at 1:42PM, V2 (Director of Nursing/DON) states it is dangerous to leave medication carts unlocked and unattended. V2 states residents can remove the medications, self-administer the wrong medications, and have life threatening and adverse reactions. Facility policy dated 04/2021, titled Storage of Medications documents in part, 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts should not be left unattended unless, it is within visible supervision of the nurse. 14. Access to controlled medications is limited to authorized personnel. Facility census dated 12/09/2024 documents that a total of 19 residents reside on the 3rd floor of the facility and 49 residents reside on the 1st floor of the facility. 145806 Page 11 of 16 145806 12/12/2024 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 observations, interviews, and record reviews, the facility failed to discard expired food based on use by guidelines and labeled use by date, failed to ensure food items were labeled and dated with use by date, and failed to sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 123 residents receiving food prepared in the facility's kitchen. Findings include: On 12/09/24 at 9:15 AM, V19 (Dietary Manager) stated all items should be labeled with an open and use by date and prepared items should be thrown out after seven days. V19 stated day one is the day the item was prepared and day seven is the date the item must be discarded on. V19 stated the purpose of labeling, dating, and discarding items after seven days is to ensure food is safe for the residents to eat and that there is a potential to make residents sick if they are served expired foods. On 12/09/24 at 9:45 AM, during initial kitchen tour observed found container of tuna salad dated 11/03/23 in the reach-in refrigerator. The tuna salad had areas of white material pooling with liquid. V19 stated the tuna fish was mixed with mayonnaise and that it was mislabeled because the item has not been in the cooler for over one year. V19 stated the tuna fish salad should have been discarded seven days from the day it was prepared on 11/03 and that the item should have been labeled with a use by or discard date of 11/10. V19 stated the kitchen would not serve that to the residents based on the date it was prepared because it has the potential to make the residents sick if that was served to them. Observed V19 discard the tuna salad into the trash. On 12/09/24 at 9:48 AM, observed sliced deli turkey in metal container labeled 12/08/24. There was no use by date on the item. V19 stated the turkey should be labeled with a use by date of 12/14/24 so the staff knows when to throw out the item. On 12/09/24 at 9:54 AM, observed V20 (Dishwasher) at three-compartment sink washing pots and pans with a collection of cleaned items being stored on the side of the sink to air dry. V19 stated the kitchen uses a Quat (Quaternary) solution to disinfect the kitchen equipment being cleaned in the three-compartment sink and that the concentration of the third sink containing the sanitation solution should be between 150-400 ppm (parts per million) per the manufacturer guidelines. V19 stated any concentration less than that means the items are not being sanitized 100% which is important to prevent cross contamination and food borne illness. V19 checked the three-compartment sink concentration using a test strip and it read 100 ppm. V19 stated the concentration is not high enough which means that the items are not being disinfected properly. V19 stated that all the items that have been washed will need to be re-sanitized. V19 stated the concentration should be checked prior to cleaning items in the three-compartment sink, On 12/09/24 at 10:00 AM, V20 was asked if V20 checked the concentration of the sanitizer in the three-compartment sink and V20 stated I didn't check it this morning. On 12/09/24 at 10:04 AM, V21 (Dietary Aide) stated V21 filled up the third sink with water and added three pumps of sanitizing solution and then checked the concentration using the test strip. V21 stated the test strip reading was 100 ppm at 6:30 AM. 145806 Page 12 of 16 145806 12/12/2024 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 12/09/24 at 10:07 AM, observed V22 (Cook) empty and refill the third compartment sink with water and then add four pumps of sanitizing solution. V22 checked the concentration using a test trip and the reading obtained was 200 ppm. On 12/09/24 at 10:09 AM, this surveyor heard V19 tell V20 to sanitize all the items V20 had previously cleaned because they were not sanitized correctly. Facility provided list of diet orders for all residents in the facility as of 12/09/24. The diet order list indicates there are total of 125 residents of which 2 residents are receiving nothing by mouth (NPO) and 123 residents are receiving diets (not NPO). Facility provided policy titled Labeling and Dating dated 2017 documents in part, to decrease the risk of food borne illness and to provide the highest quality, food is labeled with the date received, the date opened and the date by which the item should be discarded and refrigerated food prepared is labeled with the date to discard or to use by. This includes leftovers. The discard/use by date will be a maximum of six days after preparation. The day of preparation is counted as day 1. Facility provided policy titled Time/Temperature Control for Safety Food (TCS) dated 2021 documents in part, foods that require time and temperature control to prevent the growth of microorganisms (bacteria) which cause foodborne illness are known as TCS foods and some foods are more likely than other to be TCS foods including but not limited to milk/dairy products, eggs, and fish. Facility provide policy titled Manual Sanitizing in Three-Compartment Sink dated 2017 which documents in part, a sink with three compartments is used for manually washing, rinsing, and sanitizing utensils and equipment and manufacturer's instructions on the wall poster above the three-compartment sink are followed. Facility provided copy of manufacturer's signage posted above the three-compartment sink titled Sanitizer Test Procedures documents in part, for Quaternary test paper reading 150-400 ppm. 145806 Page 13 of 16 145806 12/12/2024 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 Based on observations, interviews and record review, the facility failed to ensure shared equipment was cleaned and decontaminated between each use for 4 [R27, R92, R104, R116] of 6 residents reviewed for medication administration observation. Residents Affected - Some Findings included: On 12/9/24 at 9:38 AM, V23 obtained R116's blood pressure with a wrist blood pressure cuff device. V23 placed the device on R116 left wrist, blood pressure measured 134/99, heart rate 90. After use, V23 did not sanitize the blood pressure device, placed the device inside the top drawer of the medication cart and proceeded to prepare R116 medications. On 12/9/24 at 9:52 AM, V23 obtained R104's blood pressure with same wrist blood pressure device. Prior to use, V23 did not sanitize the device. V23 placed the blood pressure device on R104's left wrist, blood pressure measured 127/87, heart rate 82. After use V23 did not sanitize the device and placed it on top of the medication cart. On 12/9/24 at 10:10 AM, V23 obtained R92's blood pressure with same wrist blood pressure device. Prior to use, V23 did not sanitize the device and placed it on R92's left wrist. R92's blood pressure measured 112/86 and heart rate 80. After use V23 did not sanitize the device and placed the device inside the top drawer of the medication cart and proceeded to prepare R92's medications. During the same medication pass observation, prior to use, V23 did not sanitize the device and placed it on R27's left wrist, blood pressure measured 120/72, heart rate 62. After use V23 did not sanitize the device and placed it on top of the medication cart. On 12/9/24 at 10:42 AM, V23 [Registered Nurse] stated, Between each resident I should have used the sanitizing wipes to disinfect the wrist blood pressure device to prevent the spread of infection. I was nervous and forgot to clean off the device. On 12/11/24 at 12:30 PM, V2 [Director of Nursing] stated, All shared medical equipment among residents must be sanitized before and after each use on each resident. If the shared equipment is not sanitized between residents, it could potentially spread infection from one resident to another. Policy document in part: Cleaning and Disinfection of Resident Care Items and Equipment Resident care equipment including reusable items and durable medical equipment will be cleaned and disinfected according to the current CDC recommendations for disinfection of blood borne pathogens standards noncritical items are those that come in contact to scan but not mucus membranes noncritical resident care items include bed pants, blood pressure cuffs, crutches and computers. Reusable resident care equipment will be decontaminated and or sterilized between residents according to the manufacturer's instructions. 145806 Page 14 of 16 145806 12/12/2024 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, 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 follow its policy and offer pneumonia vaccines prior to or upon admission to the facility. This failure affects three (R9, R72, R75) out of five residents reviewed for pneumonia vaccines in a total sample of 25 residents. Residents Affected - Few Findings include: R9s' Facesheet documents that R9 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses not limited to: Chronic Obstructive Pulmonary Disease/COPD, Anemia, unspecified open wound to left leg, and chronic multifocal osteomyelitis. Review of R9s' electronic health record/EHR reveals that there is no documentation to show that a pneumonia vaccine was administered to R9. Facility is unable to provide documentation to show the pneumonia vaccine was offered to R9 prior to 11/20/2024. R72s' Facesheet documents that R72 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses not limited to: Stage 4 Chronic Kidney Disease, Diabetes Mellitus, dependence on renal dialysis, anemia, and acquired absence of kidney. Review of R72s' electronic health record/EHR reveals that there is no documentation to show that a pneumonia vaccine was administered to R72. Facility is unable to provide documentation to show the pneumonia vaccine was offered to R72 prior to 08/26/2024. R75s' Facesheet documents that R75 is an [AGE] year-old male admitted to the facility on [DATE] with diagnoses not limited to: adult failure to thrive, drug induced subacute dyskinesia, muscle wasting and atrophy, fracture of left femur, and dementia. Review of R75s' electronic health record/EHR reveals that there is no documentation to show that a pneumonia vaccine was administered to R75. Facility is unable to provide documentation to show the pneumonia vaccine was offered to R77 prior to 11/20/2024. According to the Centers for Disease Control and Prevention/CDC, People are more likely to get pneumonia at certain ages. For adults, those 65 years or older are at increased risk. Risk continues increasing as age increases: an [AGE] year-old has a higher risk than a [AGE] year-old adult. People who have chronic (ongoing) medical conditions are at increased risk for pneumonia. These can include chronic heart disease, chronic liver disease, chronic lung disease, diabetes, and people with a weakened immune system are at greatest risk for pneumonia. Many different conditions and medicines can weaken the immune system. On 12/10/2024 at 2:41 PM, V3 (Infection Preventionist/IP), states R9, R72, and R75 have all consented to the pneumonia vaccine but have not yet been vaccinated in the facility. V3 states residents should be offered the pneumonia vaccination upon admission to the facility. V3 states she is awaiting a date from the outside contracted company to visit the facility and vaccinate the residents. On 12/11/2024 at 1:42PM, V2 (Director of Nursing/DON) states she expects all residents to be offered the pneumonia vaccine upon admission to the facility. V2 states once consent is obtained, the vaccine is ordered from their contracted pharmacy and arrives to the facility within three days. V2 states once the vaccine arrives, she expects the nursing staff to administer the vaccine as soon as possible to the resident. 145806 Page 15 of 16 145806 12/12/2024 Warren Park Health & Living Ctr 6700 North Damen Avenue Chicago, IL 60645

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Facility policy dated 10/2022, titled Pneumococcal Vaccine documents in part, Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series on admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted on residents' admission if not conducted prior to admission. 6. For residents who receive the vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the residents' medical record. 145806 Page 16 of 16