Health inspection·October 19, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review the facility failed to ensure a resident's lower extremity and incontinence brief were covered for dignity. This failure affected 1 (R142) resident reviewed for dignity in the total sample of 59 residents. Findings include: On 10/16/2023 at 3:45pm, R142 was on a highback chair across the 1st floor South nurse's station. R142's right thigh and incontinence brief were exposed. There was a blanket between R142 legs. R104 was also seated on a wheelchair across the nurse's station with R142. At this time, two staff were by the nurse's station. One of the staff was V12 (Registered Nurse) who was writing on a piece of paper. This surveyor inquired who the nurse assigned to R142 was. V12 (Registered Nurse) stated I (V12) am the nurse for (R142). Surveyor inquired what's with R142's exposed right thigh and incontinence brief. V12 lifted his (V12) eyes and stated (R142) has Huntington's disease; she (R142) moves a lot. After this statement, V12 continued what he (V12) was doing. On 10/16/2023 at 3:47pm, two staff tried to cover R142's exposed thigh and incontinence brief. V11 (Certified Nursing Assistant) stated she (R142) moves a lot and we can't keep the blanket on her (R142). I (V11) usually have a blanket over her (R142) to keep her (R142) covered for dignity. This surveyor inquired if the intervention was effective. V11 stated no, it is not effective. She (R142) can't keep the blanket on her (R142). On 10/18/2023 at 9:27am, V3 (Director of Nursing) stated, in reference to providing privacy and dignity to R142, to make sure she (R142) is covered for dignity. Everybody can monitor her (R142) safety and dignity. This surveyor informed V3 that during the observation on 10/17/2023 with R142, V12 (Registered Nurse) was at the nurse's station and this surveyor gestured to V12 of R142's exposed right upper thigh and incontinence brief and V12 informed surveyor R142's diagnosis of Huntington's disease without covering R142's exposed right thigh and incontinence brief. V3 stated he (V12) should have covered her (R142) for dignity. R142's (Active Order As Of: 10/17/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) dementia, Huntington's disease, restlessness and agitation. R142's (09/08/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99 - unable to complete the interview.C0700. Short Term memory OK. 1. Memory problem. C0800. Long-term memory OK. 1. Memory problem. Section G. I. toilet use- how resident changes pad and adjust clothes. 3/3 coding extensive assistance/Two +persons physical assist. Page 1 of 14 145838 145838 10/19/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The (05/05/15) Registered Nurse Job Description documented, in part Summary/Objective. In keeping with our organization's goal of improving the lives of the Guests we serve, the Registered Nurse (R.N.) plays a critical role in providing superior customer service and nursing care to all Guests and guests. The R.N. provides supervision of staff and will safeguard the health, safety and welfare of all Guests/guests under their care by following applicable laws, regulations and established nursing policies and procedures. Essential Functions. Reasonable accommodations may be made to enable individual with disabilities to perform the essential functions. 19. Maintains the comfort, privacy and dignity of Guests/guests and interacts with them in a manner and displays warmth, respect and promotes a caring environment. 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. 145838 Page 2 of 14 145838 10/19/2023 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 observation, interview and record review, the facility failed to ensure a homelike environment for two residents (R164 and R18) in the sample of 59 residents. Residents Affected - Few Findings include: On 10/16/23 12:17 PM surveyor observed brown stain approximately one square foot in size in the ceiling located adjacent to the room door. R164 stated it has been like that since I moved into this room. R164 stated I have not seen water dripping from the ceiling area where the brown spot is located. On 10/16/23 12:37 PM survey observed the baseboard near the floor behind R18's bed hanging off the wall. On 10/18/2023 at 11:35am V23(Maintenance Director) observed the brown stain in the ceiling of R164's room and stated when the heavy rain came earlier this year there were some water leaks from the main roof. V23 stated I patched the main roof and stopped some of the leaking. V23 stated I need to repatch this part of the ceiling. V23 stated maintenance is responsible for fixing the plastic baseboard hanging from the wall. R18's diagnosis include but are not limited to Unspecified Convulsions ,Personal History Of Covid-19 , Schizophrenia, Unspecified, Dysphagia, Unspecified, Morbid (Severe) Obesity Due To Excess Calories, Major Depressive Disorder, Recurrent, Unspecified, Blindness Left Eye Category 3, Normal Vision Right Eye, Unspecified Dislocation Of Left Hip, Sequela, Pseudobulbar Affect, Allergic Rhinitis, Unspecified, Constipation, Unspecified, Unspecified Asthma, Uncomplicated, Bipolar Disorder, Unspecified , Hypothyroidism, Unspecified , Neuromuscular Dysfunction Of Bladder, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis , Mild Intellectual Disabilities. R164's's diagnosis include but are not limited Hemiplegia And Hemiparesis Following Other Cerebrovascular Disease Affecting Right Dominant Side, Aphasia, Muscle Wasting And Atrophy, Not Elsewhere Classified, Multiple Sites, Other Lack Of Coordination, History Of Falling, Other Abnormalities Of Gait And Mobility, Restlessness And Agitation, Unspecified Fall, Subsequent Encounter, Cerebral Edema, Facial Weakness Following Other Cerebrovascular Disease, Diabetes Insipidus, Compression Of Brain, Type 2 Diabetes Mellitus With Hyperglycemia, Malignant Neoplasm Of Brain, Unspecified, Other Specified Disorders Of Brain, Obesity, Unspecified, Sleep Apnea, Unspecified, Personal History Of Other Diseases Of The Digestive System, Unspecified Intellectual Disabilities, Tachycardia, Unspecified, Acute Embolism And Thrombosis Of Right Popliteal Vein, Acute Embolism And Thrombosis Of Unspecified Deep Veins Of Right Lower Extremity , Encounter For Antineoplastic Radiation Therapy, Personal History Of Other Diseases Of The Respiratory System, Heart Failure, Unspecified, Other Pulmonary Embolism Without Acute Cor Pulmonale. On 10/18/2023 reviewed the facility's Maintenance Work Order Lists from 7/2023 to 10/2023, no work was received for R164's brown stain on the ceiling in the room nor the baseboard hanging from the wall in R18's room. On 10/18/2023 reviewed the job description dated 12/1/2019 for Maintenance Director which documents, in part underneath Essential Functions 1. Responsible for all service and repair tasks as assigned. 145838 Page 3 of 14 145838 10/19/2023 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 Based on observation, interview and record review the facility to provide nail care to two residents (R7, R77) out of a sample size of 59. Residents Affected - Few R7 has a diagnosis of but not limited to Parkinson's Disease without Dyskinesia, Nonexudative Age-Related Macular Degeneration, Type 2 Diabetes Mellitus, and Dysphagia. Brief Interview of Mental Status score is 13 that indicates cognitively intact. R77 has a diagnosis of but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Vascular Dementia, Type 2 Diabetes Mellitus with Hyperglycemia and Cerebral Infarction. R77's Brief Interview of Mental Status score is 13 that indicates cognitively intact. Findings: On 10/16/2023 at 11:00am surveyor observed R7 with long fingernails on the right hand. R7 stated that she would like her fingernails cut, but staff say they will cut them but they don't ever come back to cut them. On 10/18/2023 at 11:55am surveyor observed R77 fingernails long on both hands. R77 stated that they cut his nails sometimes and he would like them to be cut. On 10/18/2023 at 12:33pm V27 (CNA) stated that nail care is done during baths or showers and as needed. On 10/18/2023 at 12:37pm V3 (Director of Nursing) stated that nail care should be done during bathing or showering and as needed. R7's care plan ADL focus Self Care Deficit dated 4/22/2017 documents check nail length and trim and clean on bath day and as necessary. Nail Care Policy with a revised dated of 7/28/2023 documents, in part, the purposes of this procedure are to keep nails trimmed and to prevent infections and trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 145838 Page 4 of 14 145838 10/19/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide foot care/podiatry care for a resident. This failure affects one resident (R92) in a sample of 59 residents, reviewed for foot care. Residents Affected - Few Findings include: On 10/16 23 at 11:10am on the first floor, R92 was observed in the hallway with the toenails on both feet very thick and yellow with dry scaly skin on both feet and around the toes. On 10/17/23 at 12:30pm, R92's feet were still in the same condition. On 10/18/23 at 1:40pm, V3(Director of Nursing) was asked about how a resident gets to see a Podiatrist for foot care. V3 stated that the nurses usually put down the names of the residents in a book at the nursing station for the Podiatrist. The surveyor went with V3 to the nursing station on the first floor, and V3 stated that the Podiatrist list is somewhere in her(V2's) office. V3 explained that R92 was admitted in the past 3 weeks (9/27/23) and that she(V3) will add R92 to the list for the Podiatrist. R92's POS (Physician Order Sheet) dated 9/27/23 states: May see Podiatrist as needed. Facility's policy on Nail Care dated 7/28/23 states: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. #6 states: CNA (Certified Nurse Assistant) to report to the nurse if there is evidence of ingrown toenails, infections, pain, or if nails are too hard or too thick to cut with ease. #7 states: Refer to podiatrist for podiatric care and treatment of toenails. Facility's policy on Podiatry consult dated 7/28/23 states: The facility will observe the following policy for coordinating Podiatry care. #2 states: Residents will be referred to Podiatrist based on the foot assessment. 145838 Page 5 of 14 145838 10/19/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. On 10/17/2023 at 11:39am, during the controlled medication storage task observation with V18 (Licensed Practice Nurse) of the medication cart labeled 1 South back, there was one pill left on R167's Oxycodone dispensing card and R167's Controlled Drug Administration Record Tablet for Oxycodone IR 10mg indicated 2 tablets left on the dispensing card; and there were 23 pills left on R124's Briviact 50mg dispensing card and R124's Controlled Drug Administration Record tablet for Briviact 50mg indicated there were 24 tablets left on the dispensing card. V18 stated I (V18) signed in the PCC (EHR -electronic health record) but I (V18) forgot to sign in their (R167 and R124) controlled sheets that I (V18) dispensed their (R167 and R124) medications. On 10/18/2023 at 9:53am, V3 (Director of Nursing) stated the expectation is to initial the resident's controlled sheet after the staff dispensed the controlled medication to ensure controlled medications are accounted for. R124's (Active Order As Of: 10/18/2023) Order Summary Report documented, in part Briviact Oral Tablet 50mg Active 07/06/2023. R124's (Schedule Date: 10/17/2023 - 10/17/2023) Medication Admin (Administration) Audit Report documented, in part Briviact Oral tablet 50MG. Administration time: 10/17/2023 08:17 (am). R167's (Active Order As Of: 10/18/2023) Order Summary Report documented, in part Oxycodone HCl Oral tablet 10MG Active 08/29/2023. R167's (Schedule Date: 10/17/2023 - 10/17/2023) Medication Admin (Administration) Audit Report documented, in part Oxycodone HCl oral tablet 10MG. Administration Time: 10/17/2023 09:19(am). The (undated) Controlled Substance Storage documented, in part Policy. The medications included in the drug enforcement administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures. 4. The following information is completed on the accountability form upon dispensing or receipt of a controlled substance: e) quantity received. The (05/05/15) Registered Nurse Job Description documented, in part Summary/Objective. In keeping with our organization's goal of improving the lives of the Guests we serve, the Registered Nurse (R.N.) plays a critical role in providing superior customer service and nursing care to all Guests and guests. The R.N. provides supervision of staff and will safeguard the health, safety and welfare of all Guests/guests under their care by following applicable laws, regulations and established nursing policies and procedures. Essential Functions. Reasonable accommodations may be made to enable individual with disabilities to perform the essential functions. 5. Administer medications within the scope of practice of the R.N. Licensure. Maintain a current report of narcotics received and used. 6. Review daily documentation of the dispensing of the controlled substances and narcotics. Ensure that drugs covered by controlled substances laws are verified by inventory. Based on observation, interview, and record review the facility staff failed to document on the individual residents controlled drug administration record for 5 residents (R124, R167, R75, R67 and R159). This failure has the potential to affect all 172 residents in the facility. 145838 Page 6 of 14 145838 10/19/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0755 Findings include: Level of Harm - Minimal harm or potential for actual harm On 10/17/2023 at 2:27PM surveyor with V22(LPN/Licensed Practical Nurse) reviewed the two north medication cart Controlled Drug Administration Records for the following residents R159, R75 and R67(these forms are used by the facility for accountability of controlled substances after the controlled substance medication is administered to the individual resident). The controlled drug administration records were not signed after the administration of the controlled substance to the resident. Residents Affected - Some On 10/17/2023 at 2:28PM R159's MAR(medication administration record) documents R159 was administered one tablet of Hydrocodone-Acetaminophen Oral tablet 5-325mg(milligrams)- Give 1 tablet by mouth every 6 hours as needed on 10/17/2023 at 12:14. Upon review of R159's controlled drug administration record the tablet had not been documented as administered to R159 on 10/17/2023 at 12:14, which made the amount of tablets remaining in the bingo card not match the number of tablets documented on the controlled drug administration record. R159's diagnosis include but are not limited to Metabolic Encephalopathy, Major Depressive Disorder, Recurrent, Moderate, Generalized Anxiety Disorder, Primary Insomnia, Unspecified Severe Protein-Calorie Malnutrition, Unspecified Abdominal Pain, Anemia, Unspecified, Thrombocytopenia, Unspecified, Elevation Of Levels Of Liver Transaminase Levels, Myalgia, Unspecified Site, Calculus Of Gallbladder Without Cholecystitis Without Obstruction, Alcoholic Liver Disease, Unspecified, Alcohol Abuse, Uncomplicated, Alcohol Use, Unspecified With Withdrawal Delirium, Other Pulmonary Embolism Without Acute Cor Pulmonale, Iron Deficiency Anemia, Unspecified, Alcohol Abuse, In Remission, Alcoholic Hepatitis Without Ascites, Cholecystitis, Unspecified, Localized Edema. R159's MDS section C dated 07/06/2023 documents a BIMS of 15, which indicates R159 is cognitively intact. On 10/17/2023 at 2:30PM R75's MAR (medication administration record) documents R75 was administered one tablet of Hydrocodone-Acetaminophen Oral tablet 5-325mg(milligrams)- Give 1 tablet by mouth every 8 hours on 10/17/2023 at 1400. Upon review of R75's-controlled drug administration records the tablet had not been documented as administered to R75 on 10/17/2023 at 1400, which made the number of tablets remaining in the bingo card does not match the number of tablets documented on the controlled drug administration record. R75's diagnosis include but are not limited to Spondylosis Without Myelopathy Or Radiculopathy, Cervical Region, Urinary Tract Infection, Site Not Specified , Unspecified Severe Protein-Calorie Malnutrition, Adult Failure To Thrive, Neuromuscular Dysfunction Of Bladder, Unspecified, Pressure Ulcer Of Sacral Region, Stage 4 , Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Alzheimer's Disease, Unspecified, Unspecified Fall, Subsequent Encounter, Spinal Stenosis, Cervical Region, Unspecified Atrial Fibrillation, Heart Failure, Unspecified, Anemia, Unspecified, Thrombocytosis, Unspecified, Age-Related Osteoporosis Without Current Pathological Fracture, Hypotension, Unspecified, Other Cervical Disc Degeneration, Unspecified Cervical Region. R75's MDS section C dated 7/20/2023 documents a BIMS score of 03, which indicates R75's cognition is severely impaired. On 10/17/2023 at 2:32PM R67's MAR (medication administration record) documents R67 was administered one capsule of Floricet Oral Capsule 50-300-40 mg(milligrams)- Give 1 tablet by mouth every 4 hours 145838 Page 7 of 14 145838 10/19/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as needed on 10/17/2023 at 1302. Upon review of R67's-controlled drug administration records the capsule had not been documented as administered to R67 on 10/17/2023 at 1302, which made the number of capsules remaining in the bingo card not match the number of capsules documented on the controlled drug administration record. R67's diagnosis include but are not limited to Fibromyalgia, Muscle Wasting And Atrophy, Not Elsewhere Classified, Other Site, Difficulty In Walking, Not Elsewhere Classified, Other Lack Of Coordination, History Of Falling, Unspecified Asthma, Uncomplicated, Hypothyroidism, Unspecified, Other Specified Disorders Of Urethra, Hyperlipidemia, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Obesity, Unspecified, Major Depressive Disorder, Recurrent, Unspecified, Anxiety Disorder, Unspecified, Insomnia, Unspecified, Calculus Of Kidney, Suicidal Ideations, Nonrheumatic Mitral (Valve) Prolapse, Vitamin D Deficiency, Unspecified, Chronic Migraine Without Aura, Not Intractable, Without Status Migrainosus, Interstitial Cystitis (Chronic) Without Hematuria, Irritable Bowel Syndrome Without Diarrhea, Personal History Of Other Diseases Of The Digestive System. R67's MDS section C dated 9/28/2023 documents R67 has a BIMS score of 15, which indicates R67 is cognitively intact. On 10/17/2023 at 2:27PM V22(LPN/Licensed Practical Nurse) stated I just gave the residents their medications. V22 stated I am supposed to sign out the medication on the individual residents-controlled drug administration record immediately after I administer the medication to the resident. On 10/18/2023 at 12:52 PM V29(ADON/Assistant Director of Nursing) stated the nurse on duty is responsible for completing the controlled drug administration record. V29 stated the purpose of the nurse completing the controlled drug administration record is to track the total number of each controlled substance remaining in the bingo card. V29 stated if the nurse discovers the count documented on the controlled drug administration record does not match the number of tablets or capsules in the bingo card, the nurse is to call the director of nursing or the assistant director of nursing so that we can investigate why the count is off. On 10/18/2023 reviewed the facility's policy (revision date of 07/27/2023) titled Controlled Medications Count which documents, in part, Policy Statement: It is the policy of the facility to maintain an accurate count of Scheduled II (2) controlled medications. Procedure 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication was taken. On 10/18/2023 reviewed the facility's job description for RN (Registered Nurse) Floor Nurse dated 12/01/2019 which documents, in part, underneath Essential Functions 5. Administer medications within the scope of practice of the RN (Registered Nurse) Licensure Maintain a current report of narcotics received and used. 6. Review daily the documentation of the dispensing of the controlled substances and narcotics. Ensure that drugs covered by controlled substances laws are verified by inventory. 145838 Page 8 of 14 145838 10/19/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of <5% for 1 (R68) of 4 (R68, R91, R132, and R161) residents reviewed for medication administration. There were 32 opportunities and 4 errors resulting in 12.5% medication administration error rate. Residents Affected - Few Findings include: On 10/17/2023 at 8:51am, V10 (Registered Nurse) started dispensing the following medications for R68: 1. Pro-Stat 30ml. 2. Arginaid 4.5grams orange flavor mixed well with 180ml of water 3. Vitamin C. 500mg tablet 4. Eliquis 5mg tablet 5. Iron tablet 325/65mg tablet 6. Furosemide 40mg tablet 7. Losartan 100mg tablet 8. Valproic Acid 250mg/5ml dispensed 10ml. On 10/17/2023 at 9:00am, V10 counted the medications and stated there are five tablets and 3 liquid medications for a total of 8 medications. On 10/17/2023 at 9:27am, V10 administered R68's medications via g-tube. 145838 Page 9 of 14 145838 10/19/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0759 Level of Harm - Minimal harm or potential for actual harm R68's (Schedule date 10/17/2023 - 10/17/2023) Medication Administration Audit Report documented that R68 was also administered the following medications at 9:59am and was documented at 10:00am by V10. These are errors as R68 did not receive these medications during the medication pass observation with V10. Residents Affected - Few 1. Multivitamins liquid 5ml 2. Amlodipine besylate tablet 5mg 3. Senna Oral capsule 8.6mg 2 capsules and 4. Zinc sulfate 220mg R68's (10/2023) Medication Administration Record documented that R68 was administered amlodipine Besylate 5mg, multivitamin liquid 5ml, Zinc Sulfate capsule 220MG, and Senna Oral Capsule 8.6mg 2 capsules on 10/17/2023. On 10/17/2023 at 3:40pm, this surveyor with V1 (Administrator) reviewed the camera located at R68's unit. V10 was observed pouring water on a plastic cup and entered R68's room. Did not observe V10 dispensing and crushing medications prior to entering R68's room. On 10/18/2023 at 10:25am, V10 stated I (V10) was not able to give his (R68)'s multivitamins, Zinc 220mg, Senna and amlodipine. It is expected of staff to give the medications as scheduled and we have to document accurately that the medications were given. I (V10) called the doctor 10 minutes ago today and informed of the missed medications. I (V10) should have called right away, yesterday, that (R68) missed some of his (R68) medications. I (V10) should have not documented that the medications were given. Instead, I (V10) should have documented that the medications were not available at that time. On 10/18/2023 at 9:51am, V3 (Director of Nursing) stated expectation with medication administration is to give or administer the medication one hour before and after scheduled time and to observe the Rights of medication administration like the right patient, right dose, right medications, right route, right refuse, and right time or frequency and to document medication administration right after the staff administered the medication. To acknowledge that the medications are given. On 10/18/2023 at 10:08am, V3 stated staff are not expected to document medication was administered if not given. If medications are not given, staff are expected to document the reason why the medications were not given. R68's (Active Order As Of: 10/18/2023) Order Summary Report documented, in part amlodipine Besylate oral tablet 5mg Active 10/07/2023, Multivitamins Liquid give 5ml via G-tube Active 10/09/2023, 145838 Page 10 of 14 145838 10/19/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0759 Senna Oral Capsule 8.6mg Active 10/07/2023, Zinc Sulfate Capsule 220MG Active 10/07/2023. Level of Harm - Minimal harm or potential for actual harm The (05/05/15) Registered Nurse Job Description documented, in part Summary/Objective. In keeping with our organization's goal of improving the lives of the Guests we serve, the Registered Nurse (R.N.) plays a critical role in providing superior customer service and nursing care to all Gusts and guests. The R.N. provides supervision of staff and will safeguard the health, safety and welfare of all Guests/guests under their care by following applicable laws, regulations and established nursing policies and procedures. Essential Functions. Reasonable accommodations may be made to enable individual with disabilities to perform the essential functions. 5. Administer medications within the scope of practice of the R.N. Licensure. Residents Affected - Few The (10/18/23) Employee Inservice Sign-In Sheet documented, in part If medication is not available, inform MD (medical doctor) and document. The (7/28/23) Missed Medication documented, in part Policy Statement. It is the facility's policy to administer medications to the residents and promote resident's rights of refusal at the same time. This policy will address missed medications. Procedures. 1. Administer medications as ordered to the residents. 2. Sign the eMAR (electronic Medication Administration Record) after the medications have been given to the resident. 5. If the medication is not available, administer the medication once available if it is a medication that is ordered daily. 6. If the medication that is missed is ordered more than once daily, call the physician to determine if the physician would like to order anything related to the missed dose, or would want to have the missed dose administered to the resident, when it becomes available. 145838 Page 11 of 14 145838 10/19/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to properly log refrigerator temperatures for two resident's (R91, R16) personal refrigerators. This failure has the potential to affect all 59 residents in the sample. Residents Affected - Few R16 has a diagnosis of but not limited to Cerebral Infarction, Non-Pressure Chronic Ulcer of Right Calf with Fat Layer Exposed, Obesity, Type 2 Diabetes Mellitus, and Hypertension. R16's Brief Interview of Mental Status score is 15 that indicates cognitively intact. R16's admission date is 8/01/2022. R91 has a diagnosis of Atrioventricular Block, Mild Cognitive Impairment, Hypothyroidism, Type 2 Diabetes Mellitus and Psychosis. R91 has a Brief Interview of Mental Status score of 14 that indicates cognitively intact. R91 admission date is 10/08/2020. Findings: On 10/16/2023 at about 11:15am surveyor observed R16's Daily Refrigerator Log for 2023 with only 3 temperatures on it. R16 stated, no, the refrigerator temperature is not being checked every day. On 10/16/2023 at 11:47am surveyor observed R91's Daily Refrigerator Log for 2023 with no temperatures logged for January 2023-June 2023, July 1-July 25 and 09/04, 09/10, 9/10, 10/01, 10/02, 10/07, 10/8, and 10/14-10/16 were blank. Surveyor also checked R91's thermometer inside of the refrigerator and it read 52 degrees. R91 stated that she has had to throw away the milk she keeps in her refrigerator because it spoils and the freezer unthaws and has water on the top shelf. On 10/16/2023 at 11:53am V29 (ADON) stated that a temperature of 52 degrees is a problem for a resident's personal refrigerator. On 10/18/2023 at 11:51am surveyor checked the thermometer for R91's refrigerator again and it read 52 degrees. On 10/18/2023 at 10:27am V34 (Housekeeping Director) stated refrigerator logs, for resident's personal refrigerators should be completed every day by the housekeeping staff. Undated Daily Refrigerator Log Policy, documents, in part, refrigerators should be check daily. 145838 Page 12 of 14 145838 10/19/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a sanitary shower room and bathroom for residents on the north wing of the first floor. This failure has the potential to affect all 46 residents on the north wing of the first floor. Findings include: On 10/16/23 at 10:30am after the entrance conference, V1(Administrator) presented the facility's census that show that 46 residents reside on the north wing of the first floor. On 10/16/23 at 11:10am, the bathroom in room [ROOM NUMBER] was observed with dried brownish material on the edges and on the top of the toilet, and with the garbage full and overflowing with some material on the floor of the bathroom. R92 (a resident from room [ROOM NUMBER] on the north wing of the first floor) told the surveyor in the hallway that he could not use the bathroom because it was filthy. The surveyor tried to look around for a housekeeper. Again, on 10/16 23 at 11:53am, the bathroom was still in the same condition. At this time, V32(Certified Nurse Assistant/CNA) was called to observe the bathroom and V32 stated, I will call them now to clean it. On 10/17/23 between 11am and 12pm during the Resident Council Group Interview, the 3 residents on unit 1 North (R129, R130, and R139) all stated that the community shower room on unit 1 North was always filthy with feces, soiled towels and wash cloths all over the floor in the mornings, and sometimes they had to wait for long before taking a shower. The surveyor immediately went to observe the shower room and found soiled wash cloths on the floor with some unpleasant odor. On 10/18/23 at 10:10am, V34(Housekeeping Director) stated the shower room should be clean because a housekeeper is always assigned to the unit. V34 also explained that he(V34) did not expect room [ROOM NUMBER]'s garbage to be so full of garbage on the floor. V34 later presented the Housekeeping Schedule for unit 1 North which was reviewed. V34 also presented General Housekeeping Policy. This policy dated 8/18/2016 with revision date 9/29/23 states in part, #1: The housekeeping staff will clean and sanitize the resident's rooms and bathrooms daily using the sanitizer and keep surfaces clean. 145838 Page 13 of 14 145838 10/19/2023 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide an environment free of cigarette odor and failed to consider nonsmoking residents on the first floor of the facility. This failure has the potential to affect all 55 non-smoking residents on the first floor. Residents Affected - Some Findings include: On 10/16/23 at 10:30am after the entrance conference, V1(Administrator) presented the facility's census that show that 74 residents reside on the first floor. On 10/19/23 at 11:01am, V1 presented a list that shows that there are 19 smokers and 55 nonsmokers on the first floor. On 10/17/23 between 9:45am and 10:15am, the surveyor smelled a strong cigarette odor in the front lobby, and in the dining room and in the hallway of the whole first floor. The surveyor called V1(Administrator) to confirm the strong cigarette odor. V1 stated that it was due to some residents leaving the door to the smoking area open after they finish smoking. V1 stated that he(V1) would educate the staff that supervise smoking to ensure that the door is always closed to prevent cigarette smoke from spreading to other areas. On 10/19/23 at 10:53am, V38(R227's family) stated Always, if you go into that dining room after they finish smoking, you will smell a strong cigarette odor all over everywhere, and that is not fair for other people who don't smoke. Facility's Smoking Policy with latest revision date 7/28/23 states in #6: If a facility changes its policy to prohibit smoking, it should allow current residents who smoke to continue smoking in an area that maintains the quality of life for those residents and considers non-smoking residents. The smoking area may be an outside area provided that residents remain safe. The facility did not follow this policy. 145838 Page 14 of 14