Health inspection·September 22, 2023

F 0572 Give residents a notice of rights, rules, services and charges. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide and complete admission contracts to three of five residents (R1, R3, and R5) upon admission to the facility. Residents Affected - Few Findings include: On 9.14.2023 at 11:51 AM, V5 and V6 (Family Members) said, they did not sign any paperwork (Admissions Contract) when R3 was admitted to the facility. On 9.14.2023 at 3:11PM, V1 (Administrator) said, I don't know what's up with her (R3) contract. Either V19 (Administrative Assistant/Guest Relations/Admissions) did not upload it, or it wasn't done. There should be a contract; we can't find it, were looking for it. Facility was unable to provide a contract for R3. On 9.20.2203 at 10:15 AM, V19 (Administrative Assistant/Guest Relations/Admissions) said, the Admissions Department is responsible for obtaining a signed contract for each resident, when the resident comes in, we obtain a contract, The contract is signed by the resident's family or whoever is their responsible party. The contract is signed within 72 hours but if not then as soon as possible. We put it into the admission file. The family or the resident is given a copy. V19 said, I haven't spoken with R3's family about the admission contract yet. The contract contains information such as choice of physician, advanced directives, vaccines, bed hold policies, storage polices, benefits as it relates to Medicare and Medicaid, and resident rights are included. Those who don't have family involved, those who are homeless, they might not understand the policies of how things work. R1's medical record (Face Sheet) documents R1 was admitted to the facility on 9.17.2022. R1's contract was not completed until 9.21.2023. R5's medical record (Face Sheet) documents R5 was admitted to the facility on 5.23.2023. R5's contract was not completed until 8.30.2023. Page 1 of 5 145838 145838 09/22/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0584 Level of Harm - Minimal harm or potential for actual harm 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 interview and record review, the facility failed to ensure that facility staff did not store their personal belongings in a resident's closet for one (R3) of five residents reviewed for homelike environment. Residents Affected - Few Findings include: On 9.13.2023 at 2:21 PM, V2 (DON-Director of Nursing) said, DON said, V8 (CNA-Certified Nursing Assistant) left her belongings in R3's closet. V2 said there is a locker room in the basement where staff can place their belongings; staff should not place their belongings in a resident's room. On 9.14.2023 at 11:51 AM, V5 (Family Member) said during telephone interview, there were items in her closet that were not hers. I sent pictures to V4 (Social Service Designee). On 9.14.2023 at 12:24 PM, V4 (Social Service Designee) said, yes, I was sent a picture (of R3's closet). In the picture there was a wig, a few belongings, some clothing items that were in a folded pile. R3's previous roommate had a wig. V5's (Family Member) concern was that the wig and clothing belonged to an employee. Surveyor noted a wig, water bottle, jacket and backpack in the picture of R3's closet. On 9.14.2023 at 2:29 PM, V7 (LPN-Licensed Practical Nurse) said, there were no clothes in R3's closet. That's all we found, the backpack, water bottle and jacket belonging to V8 (CNA-Certified Nursing Assistant). She, V8, admitted they were her belongings; I spoke with her, and she removed them immediately. Staff should not be storing their belongings in a resident's closet. It's for the residents' belongings. We do have a locker room in the basement. On 9.14.2023 at 3:59 PM, V8 (CNA-Certified Nursing Assistant) said during telephone interview, I put my belongings in R3's closet. It was for just a moment; I was caught up in doing something. After it was pointed out to me, I removed my belongings. We have a locker in the basement where we can store our belongings while working. Staff's personal belongings should not be placed in a resident's closet. 145838 Page 2 of 5 145838 09/22/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 remove a faulty power cord resulting in a series of orange-red sparks accompanied by puffs of smoke and a series popping noises. This deficient practice has the potential to affect one of two residents (R3) reviewed for faulty power cords and could affect all residents in the entire building, as well as an indeterminable number of staff and visitors. The Immediate Jeopardy began on 9.4.2023. V1 (Administrator) was notified on 9.19.2023 at 2:14 PM of the Immediate Jeopardy. The facility presented the removal plan on 9.19.2023 at 3:14 PM. The plan was accepted on 9.20.2023 at 8:29 AM. The surveyor conducted onsite observations, interviews, and record reviews to confirm the removal plan was implemented. V1 (Administrator) was informed on 9.20.2023 that the Immediate Jeopardy was removed. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: R3's Face Sheet documents R3 is a [AGE] year-old admitted to the facility on 5.11.2022 with diagnoses including but not limited to: Chronic Atrial Fibrillation, Type 2 Diabetes Mellitus, Dysphagia, and Pressure Ulcer of Sacral Region, Stage 4. R3's MDS (Minimum Data Set of 8.9.23) Section C (Cognitive Patterns) documents R3 is mildly cognitively impaired. Section G (Functional Status) documents R3 requires extensive assistance of two plus persons physical assist for bed mobility, is totally dependent with two plus persons physical assist for transfers and requires extensive assistance of one person for toilet use. Section M (Skin Conditions) documents R3 is at risk for developing pressure ulcers/injuries, was admitted with one unstageable pressure ulcer, and has a pressure relieving device for the bed. R3's Order Summary Report (Active Orders as of 9.21.2023) documents: Skin: Mattress: [Low Air Loss Mattress] due to very limited mobility and presence of pressure injury. On 9.14.2023 at 8:35 AM, V11 (Long Term Care Support Specialist) said R3's son (V5) provided her pictures, including one of a cord with exposed frayed wires. On 9.14.2023 at 11:00 AM, Surveyor and V3 (Maintenance Director) entered R3's room. Surveyor observed R3 awake, alert, and sitting up in on a low air loss mattress. The power cord to the mattress pump was plugged in electrical outlet on the wall behind R3's bed; the pump was in the on position. V3 crouched down, picked up the electrical cord and said to the Surveyor: look at this. The black power cord had a small slit (approximately ¼ inch long) with frayed, exposed wires. As V3 was showing Surveyor the power a cord, several orangish-reddish sparks and puffs of white smoke were observed; several popping noises were heard. On 9.14.2023 at 11:15 AM, V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the issue with power cord. 145838 Page 3 of 5 145838 09/22/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 9.14.2023 at 11:51 AM, V5 (R3's Family Member) said, regarding frayed, exposed wire of power cord, I took a picture on 9.4.23 at 11:44 AM. I reported it to her (R3's) nurse.'' On 9.14.2023 at 2:29 PM, V7 (LPN-Licensed Practical Nurse) said, after reviewing Daily Nursing Schedule for 9.4.2023, she was working 7:00 AM to 7:00PM on that day; was assigned to Team One and was the nurse responsible for R3's care on that day. I don't remember anything about the cord (frayed cord with exposed wires). It could be a problem, it's a short circuit, there could be a fire, it's hazardous. 9.14.2023 at 4:05 PM, V3 (Maintenance Director) said, I already changed the power cord. What we should have done, is inspect it (low air loss mattress power cord) when it was delivered (to the facility). So now we will inspect any equipment that we rent when it is delivered. We have a checklist now. On 9.15.2023 at 9:26 AM, V3 (Maintenance Director) said, I did not know about it (frayed cord with exposed wires) until you and I found it. If someone here knew about it, they should have reported it to me. V5 (Family Member) never told us about the exposed wires. It should be fixed because it's a hazard, you don't want anyone to die. V3 said, I do rounds in the morning. I ask the residents if everything is okay, then I check the logbook. Every day I go into every resident's rooms. Do I visually inspect every cord, no. I don't visually inspect every day, I ask the resident. I depend on the Nurses and CNAs to let me know if there is a problem. If I inspected every remote control, bed cord, it would take me six hours per day. V13 (Maintenance Assistant) changed the power cord around 11:15 AM yesterday. On 9.15.2023 at 8:14 AM, V5 (R3's Family Member) said, I showed her (V7-LPN) the cord; she was in the room with me and (R3). I informed V4 (Social Service Designee) on Tuesday September 12, 2023, at 10:55 AM when she called me. 9.15.2023 at 12:35 PM, V4 (Social Service Designee) said, I was not informed about the exposed wires. R5 did not mentioned any exposed wires when I spoke with him. I would have mentioned the exposed wires to the Administrator and Maintenance. On 9.19.2023 at 11:51 AM, V5 emailed pictures of cord for R3's low air loss mattress pump. The black outer sheath was frayed with exposed wires. On 9.19.2023 at 12:45 PM, V5 (R3's Family Member) said, I found the frayed power cord when I was looking for the bed control (R3's) bed. It always seems to be missing. So, that's the first thing I do when I come to visit her, I look for the bed control. I saw the exposed wires when I was looking for her bed control. Facility's Maintenance policy (Revised 7.28.2023) documents, It is the facility's policy to maintain equipment and the building environment. All resident care equipment and the building environment will be maintained by the maintenance department. Any staff who is made aware of a malfunctioning equipment or any part of the building that is in disrepair will report the issue to the maintenance department. The maintenance department will address the issue as soon as possible. Any equipment that cannot be fixed will be replaced accordingly. On 9.15.2023, V12 (Vice President of Marketing and Sales Durable Medical Equipment Company) emailed Surveyor LS900 True Low Air Loss Operating Instructions Manual (undated) which documents, Care 145838 Page 4 of 5 145838 09/22/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0689 Level of Harm - Immediate jeopardy to resident health or safety should be taken such that the power cord of the control unit is not pinched or any objects placed on the power cord, and also ensure it is not located where it can be stepped on or tripped over. United States Department of Labor - (OSHA) Occupational Safety and Health Administration webpage discussing Electrical - Hazards/Flexible Cords, reads: A flexible cord may be damaged by door or window edges, by staples and fastenings, by abrasion from adjacent materials, or simply by aging. If the electrical Residents Affected - Few conductors become exposed, there is a danger of shocks, burns, or fire. Abatement Plan Accepted on 9.20.2023. These are the steps that (Facility) took to remove the immediacy from the alleged deficient practice: -On 9/14/23, low air loss mattress pump identified by (V3 Maintenance Director) as being frayed with exposed wires was immediately removed from resident (R3). -On 9/19/23, Facility staff of (V3 Maintenance Director), (V1 Administrator), (V2 Director of Nursing), and (V17 Assistant Administrator) conducted facility wide search for air mattresses to ensure cords attached to the pump are intact with no deficiencies (ex. no cuts, frayed wires, exposed wires). No other issues were noted during this audit -On 9/17/23, Administrator in-serviced Maintenance staff Preventative Maintenance Policy. This was completed on 9/19/23. -On 9/14/23, Maintenance Director and Assistant Administrator initiated facility-wide in-service on recognizing damaged cords, reporting them and removing power source in order replace with a properly working unit. The facility will ensure that new hires, staff on leave, and agency staff will be in-serviced prior -QA tool titled F689 QA Tool was initiated on 9/19/23. This audit tool will be utilized to monitor air mattresses and ensure they are intact. This will be carried out by the Maintenance Director or Maintenance Assistant daily for 4 weeks until 10/17/23, followed by twice a week for 4 weeks until 10/30/23. 145838 Page 5 of 5