Health inspection·March 18, 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 interview and record review the facility failed assert the right of the resident by failing to ensure a resident's personal belongings were inventoried upon readmission to the facility. This failure affects one (R1) resident out of three residents reviewed for resident rights. Findings include: R1's Facesheet documents that R1 was admitted to the facility on [DATE] and readmitted to the facility from the hospital on [DATE]. R1 was discharged from the facility on [DATE], R1 expired on [DATE]. On [DATE] at 1:40PM, V12 (Activities Director) states she has been working at the facility since [DATE]. V12 states when a resident is admitted to the facility, their belongings are inventoried and documented in their electronic health record. V12 states all residents who are admitted to the facility should have a resident inventory form placed in their electronic health record. V12 states not one person is responsible for handling the resident's belongings when they are admitted . V12 states she has seen staff such as nurses, housekeepers, receptionists, social services, CNAs, and administration bring resident belongings to the activity department in the basement to be inventoried. V12 states she has never personally performed an inventory of resident's belongings and have three other staff members who are responsible for resident inventories. V12 states the activities department work in collaboration with social services to perform the inventories for resident belongings. V12 states the activities department does not usually inventory resident valuable belongings and mainly inventory items such as hearing aids, eyeglasses, clothing, and shoes. V12 states the activities department mainly focuses on labeling the resident clothing to help prevent lost clothing items. On [DATE] at 2:01PM, V13 (Social Services/Dementia Coordinator) states she has been working at the facility for 5 years. V13 states when a resident is admitted to the facility, the activities department goes to the resident's room to retrieve the resident belongings to be inventoried. V13 states resident belongings are also taken down to the activities department in the basement. V13 states the activities department is responsible for inventorying all resident belongings such as phones, wallets, and jewelry. V13 states if the activities department discovers an item that is considered valuable or if a resident chooses, the items are placed in the facility safe that is kept in the social services office located in the basement. V13 states when a resident is admitted to the facility, they should have their belongings inventoried and documented in their electronic health record; V13 states since she has been working at the facility, this has been the process. V13 states the social services department will then place the valuable item in the safe. V13 states the social services department, maintenance department, and V1 (administrator) all have the code to the safe where resident Page 1 of 5 145838 145838 03/18/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few belongings are kept. V13 states all residents should have an inventory list even if they do not have any belongings. V13 states it should be documented in the resident's electronic medical record that the resident does not have any belongings. V13 states she is aware that R1 had some clothing items and a ring that was inventoried when R1 was admitted to the facility. V13 states she remembers seeing R1 wearing a gold ring on her left ring finger and believe it was R1's wedding ring. V13 states she was made aware of R1's missing ring when R1's daughter called the facility after R1 expired and inquired about the whereabouts of R1's ring. V13 states R1 was hospitalized prior to R1 expiring and V13 believes R1 went to the hospital with the ring on. V13 states the facility filled out a concern form and performed a search for R1's missing ring and did not find it. V13 states she also interviewed the nurse and CNA and asked if they recalled seeing R1's ring when R1 returned from the hospital and they said no. V13 describes R1's ring as a gold ring with diamonds. V13 states she has seen R1 with the ring on her finger before. V13 states she informed V1 (Administrator) and V1 stated he would call R1's daughter. V13 states if the facility receives a report of a resident missing their belongings and the item is not inventoried, then the facility performs a search for the item. V13 states she believes the item is reimbursed if it is not found. V13 states she believes V1 is the person responsible for reimbursing the residents for lost items. On [DATE] at 10:03AM, V1 (Administrator) states he was made aware six weeks ago about R1's missing ring.V1 states the facility called the hospital to see if R1's ring was located there but the hospital stated R1's ring was not inside the hospital. V1 states R1's ring is invaluable and irreplaceable and is not sure how to continue with handling the process regarding R1's lost ring as it relates to legal issues. V1 states he called R1's daughter and she informed V1 that she was getting a lawyer. V1 states R1 had a legal guardian who is not R1's daughter. Social Services progress note written by V13 on [DATE] at 11:32AM documents Writer emailed R1's Guardian and attorney on this date d/t R1 leaving behind a wallet in SS safe. Attorney responded Any belongings of R1's can be given to R1's daughter. Writer will call R1's daughter regarding belongings. Social Services progress note written by V13 on [DATE] at 3:27PM documents R1's daughter called writer regarding a gold ring and a necklace with a Jewish [NAME] pendant. Writer recalls R1 wearing a ring before recent hospitalizations. Writer checked inventory and only a gold ring w/6 diamonds was inventoried. R1's daughter called local hospital and no ring in the lost and found. Writer and housekeeper cleaned R1's room and did not find a ring. Spoke with NOD and said they may have removed ring in hospital d/t swelling. Concern form completed and will continue to look out for a gold ring/necklace. No other concerns; R1's daughter expressed appreciation. Guardian and attorney also informed of missing jewelry and expressed appreciation for the update. Concern logs reviewed; concern form dated [DATE] documents a concern related to R1's missing ring and necklace. R1's resident inventory lists during R1's entire time of residing in the facility were requested from V3 (Assistant Administrator). Two resident inventory lists were provided to surveyor by V3 and were dated [DATE] and [DATE]. R1's resident inventory dated [DATE] documents a gold ring with six diamonds was inventoried in the facility. There is no documentation to show that R1's belongings were inventoried upon R1 being readmitted from the hospital to the facility on [DATE]. 145838 Page 2 of 5 145838 03/18/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ombudsman Program Residents' Rights for People in Long Term Care Facilities dated 11/2018 documents in part, Your facility must try to keep your property from being lost or stolen. Facility policy dated [DATE] titled Personal Belongings List documents in part, Policy statement- It is the policy of the facility to protect the resident's belongings from being misplaced and from theft. In order to prevent this, the facility will ensure that resident's belongings are tracked accurately. Procedures- 1. Upon admission or readmission , the CNA will list all of the resident's belongings in the Resident Inventory UDA. 4. When a resident or family reports that a personal item is missing, the Resident's Resident Inventory UDA will be checked to rule out false claims. 145838 Page 3 of 5 145838 03/18/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure staff providing care and services to a resident who has a feeding tube is competent in and utilize facility protocols regarding feeding tube nutrition and care. This failure affects one (R2) resident receiving enteral nutrition feedings out of three residents reviewed. Findings include: On 03/16/2024 at 11:13AM, surveyor enters R2's room and observes V10 (Wound Care Technician) providing care for R2. R2's enteral feeding pump observed off while V10 is providing care to R2. V10 states R2 does not have any wounds but V10 is applying bandages and cushioning to R2's legs to prevent pressure ulcers. Surveyor observes R2's right leg contracted and folded over R2's left leg. V10 observed placing padding and bandages in between where R2's right leg comes in contact with R2's left leg. V10 observed completing applying bandages and is observed putting R2's head of bed at 90 degrees. V10 observed turning R2's enteral feeding pump on. V10 states he is not a nurse. V10 states he is the person who turned R2's enteral feeding pump off prior to providing care for R2. V10 states he also turned R2's enteral feeding pump back on because he knows that R2 has certain times when R2's enteral feeding should be turned off and on. V10 states he is not certain of the exact times when R2's feeding should be turned on or off and he would have to check with the nurse. Surveyor asks V10 if he is authorized to operate R2's enteral feeding pump. V10 states he does not think that he is authorized to operate R2's enteral feeding pump. Surveyor asks V10 why did he operate R2's enteral feeding pump if he is not certain of the correct times when R2's enteral feeding should be turned on or off. V10 states he is not sure why he operated R2's enteral feeding pump because usually V10 would call the nurse to turn R2's enteral feeding back on. On 03/16/2024 at 11:21AM, V11 (Wound Care Nurse/RN) enters R2's room. Surveyor makes V11 aware of V10 operating R2's enteral feeding pump. V11 states she does not think that V10 is authorized to operate R2's enteral feeding pump. V11 states the nurses are authorized to operate resident's enteral feeding pumps. On 03/16/2024 at 11:53AM, V2 (Director of Nursing/DON) states V10 is not authorized to operate resident's enteral feeding pumps and V10 should have asked the nurse to operate R2's enteral feeding pump instead. R2's Physician Order Sheet/POS dated 03/05/2024 documents in part the following order: Enteral feed: every shift Enteral feeding- Tube type: G-tube, Glucerna 1.5, Rate: 60ml/hr (milliliters/hour), start at 6am and infuse until 1200 ml is reached per day. Turn off for ADLs (activities of daily living) and PRN (as needed). May give Glucerna 1.2 @ 75 ml/hr x20 hrs (1500 ml formula total) if Glucerna 1.5 unavailable. AND one time a day every Tuesday, Thursday, Saturday Turn tube feeding OFF at 9am. AND one time a day every Tuesday, Thursday, Saturday Turn tube feeding ON at 11am. AND one time a day every Monday, Wednesday, Friday, Sunday Turn tube feeding OFF at 11am. 145838 Page 4 of 5 145838 03/18/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0693 AND one time a day every Monday, Wednesday, Friday, Sunday Turn tube feeding ON at 1pm. Level of Harm - Minimal harm or potential for actual harm AND one time a day Turn tube feeding OFF at 4pm. AND one time a day Turn tube feeding ON at 6pm. Residents Affected - Few AND every night shift Total Volume Infused within 24 hrs: 1200 ml (Tube feeding expected to end during 11pm-7am shift) Facility policy dated 01/14/2017 titled Enteral Nutrition Care documents in part, Procedures- 4. Nurse shall identify proper French size, balloon volume, monitor and check that feeding tubes is in the right location in order to verify proper placement; 5. Before beginning of a feeding and before administering medications. 10. Nurse shall perform proper calibration of enteral feeding pumps to ensure that pump settings accurately provide the rate and volume consistent with the physician's order and plan of care. 145838 Page 5 of 5