Health inspection·October 5, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who depends on staff's assistance for ADL (Activities of Daily Living) care call device was responded to in a timely manner. This failure affected one resident (R1) out of four residents reviewed for ADL care. Residents Affected - Few Findings include: R1's Brief Interview for Mental Status (BIMS) dated 07/10/23 shows that R1 has a BIMS score of 15 which indicates that R1 is cognitively intact. R1 has a diagnosis which includes but not limited to: Left knee resistance to unilateral primary osteoarthritis, lymph edema, asthma, anemia, major depression non rheumatic aortic valve stenosis, liver disease, atrial fibrillation, and hyperlipidemia. On 10/02/23 at 11:39 am, R1 was observed in bed awake and alert with R1's call device activated. Surveyor observed V12 (License Practical Nurse, LPN) R1's nurse in the 1 south unit hallway outside of R1's room at V12's medication cart while R1's call device was activated and sounding for assistance. R1 stated, R1 had soiled R1's incontinence brief with urine and had been waiting to be changed by staff for over 30 minutes. R1 stated staff last changed R1's incontinence brief around 5:00 am on 10/02/23. At 11:50 am, Surveyor observed V12 remain in the hallway outside of R1's room at V12's medication cart while R1's call device remained activated and sounding for assistance. At 12:05 pm, V13 (Certified Nursing Assistant, CNA, Agency Staff) responded to R1's call device for assistance. When V13 was asked regarding the last time V13 rounded on R1 or provided incontinence care to R1, V13 stated around 9:00 am on 10/02/23. When V13 was asked regarding how long R1's call device was activated and sounding for assistance V13 stated, V13 responded to R1's call device when V13 saw R1's call device activated. V13 stated, staff should respond to the residents call devices as soon as possible for the residents safety. At 12:10 pm, V13 performed incontinence care with R1 and R1's incontinence brief was observed lightly saturated with yellow amber urine. On 10/02/23 at 12:30 pm, V12 (Licensed Practical Nurse, LPN) was asked regarding the facility's expectation for answering call lights and rounding on the residents and V12 stated, I (V12) am new to the facility. I (V12) do not know the residents and was trying to pass my (V12) medication. On 10/03/23 at 3:15 pm, V2 (Director of Nursing, DON) stated, it is the facility's expectation for all staff to answer the call lights. V2 stated, all staff is expected to answer call lights within a timely manner of 5 minutes or less of the call light being activated for the safety of the resident. Page 1 of 4 145838 145838 10/05/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's Minimum Data Set (MDS) dated [DATE] shows that R1 requires extensive assistance from staff for ADL care. The facility's policy dated 10/31/20 and titled ADL Care documents, in part: ADL care is provided for each resident in the facility in accordance too the resident's comprehensive assessment and care plan in order to identify, evaluate, and intervene to, maintain, improve or prevent an avoidable decline in the ADL's. The facility's policy dated 07/27/23 and titled Call Light Policy documents, in part: Policy Statement: It is the policy of the facility to ensure that there is prompt response to the residents call for assistance. Procedures: 1. Facility shall answer call lights in a timely manner. The facility's job description dated 05/05/2019 and titled Certified Nursing Assistant documents, in part: Summary/Objective: In keeping with our organization's goal of improving the lives of the Guest we serve, the Certified Nursing Assistant (C.N.A.) plays a critical role in providing superior customer service and nursing care to all Guest. The C.N.A. safeguards the health, safety, and welfare of all guests under their care by following applicable laws, regulation, and established nursing policies and procedures. Essential Functions: 14. Must answer and respond to call lights promptly and courteously. The facility's undated job description undated titled Licensed Practical Nurse documents, in part: Summary/Objective: In keeping with our organization's goal of improving the lives of the Guest we serve, Licensed Practical Nurse (L.P.N.) plays a critical role in providing superior customer service and nursing care to all Guest. The L.P.N. provides supervision of staff and will safeguard the health, safety, and welfare of all Guest/guest under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: 20. Answer and respond to call lights promptly and courteously. 145838 Page 2 of 4 145838 10/05/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident (R1) who depend on staff's assistance for their ADL (Activities of Daily Living) care received showers/bed baths. This failure affected one out of four residents reviewed for ADL care and showers. Residents Affected - Few Findings include: R1's Brief Interview for Mental Status (BIMS) dated 07/10/23 shows that R1 has a BIMS score of 15 which indicates that R1 is cognitively intact. R1 has a diagnosis which includes but not limited to: Left knee resistance to unilateral primary osteoarthritis, lymph edema, asthma, anemia, major depression non rheumatic aortic valve stenosis, liver disease, atrial fibrillation, and hyperlipidemia. On 10/02/23 at 11:39 am, R1 was observed in room in bed awake and alert. R1 was asked regarding the last time R1 received a shower at the facility. R1 stated, R1 last received a shower on 09/11/23. R1 explained, on 09/11/23 was the last time that staff at the facility offered and gave R1 a shower. R1 stated, R1 has refused a shower when R1's leg is hurting too much for R1 to get out of bed and R1 is not offered a bed bath or for R1's shower to be given on another day. On 10/02/23 at 12:11 pm, V13 was asked regarding R1's shower schedule. V13 stated, I (V13) do not know. I (V13) am from the agency. This is my (V13) first time caring for her (R1).) V13 stated that R1 was not scheduled for V13 to give a shower or bed bath to on 10/02/23. On 10/02/23 at 12:30 pm, V12 (Licensed Practical Nurse, LPN) was asked regarding the residents shower schedules. V12 stated, I (V12) do not know. I (V12) just started working at this facility. The CNA's make the residents shower schedule. On 10/03/23 at 3:15 pm, V2 (Director of Nursing, DON) V2 stated, residents are given showers twice a week according to the units shower schedule. V2 stated, R1 requires extensive assistance from staff and that R1 is known for refusing showers. V2 stated, every resident has a shower schedule on each unit at the facility and that residents should be offered a shower or bed bath twice a week at the facility to maintain the residents hygiene and make sure the resident is clean. V2 stated, residents are given showers as needed per the residents' or family's request. R1's Minimum Data Set (MDS) dated [DATE] shows that R1 requires extensive assistance from staff. R1's care plan dated 07/10/23 documents, in part: Interventions: R1 requires extensive one staff participation with bathing. The facility's document dated 03/15/23 and titled 1 South Shower Schedule documents, in part: R1 is scheduled for a shower on the PM shift on Mondays and Thursdays at the facility. The facility's document dated 09/01/23- 10/03/23 titled ADL - Bathing & Skin Monitoring shows that from 09/01/23 through 10/03/23 R1 receive a shower only on 09/11/23. The facility's policy dated 10/31/20 and titled ADL Care documents, in part: ADL care is provided 145838 Page 3 of 4 145838 10/05/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for each resident in the facility in accordance too the resident's comprehensive assessment and care plan in order to identify, evaluate, and intervene to, maintain, improve or prevent an avoidable decline in the ADL's. The facility's policy dated 07/28/23 and titled Shower and Hygiene documents, in part: Policy Statement: It is the policy of this facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident, and observe the condition of the resident's skin. Procedure: 1. Administer resident shower once weekly and/or as often as necessary. Any resident who needs hygienic care will be provided care to promote hygiene (facial, body, perineal care, etc.). 2. If reasonably practicable, try to accommodate resident's preference in the shower schedule. 3. Shower refusal by the resident shall be relayed by the assigned CNA to the charge nurse. 4. Nursing staff to provide bed bath daily and PRN as needed. 11. Documentation (Shower Log/ CNA Assignment Sheet): . d. If the resident refused the shower and / or if shower was not administered and interventions taken e.g., bed bath/ re-scheduling the shower schedule consistent to facility protocol. The facility's job description dated 05/05/2019 and titled Certified Nursing Assistant documents, in part: Summary/Objective: In keeping with out organization's goal of improving the lives of the Guest we serve, the Certified Nursing Assistant (C.N.A.) plays a critical role in providing superior customer service and nursing care to all Guest. The C.N.A. safeguards the health, safety, and welfare of all guests under their care by following applicable laws, regulation, and established nursing policies and procedures. Essential Functions: 3. Carry out assignments required for the Guest's activities of daily living (ADL's) which include but not limited to bathing, dressing, grooming, toileting, and feeding. 145838 Page 4 of 4