Health inspection·September 20, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review the facility failed to place a hand splint to the left hand for contracture management for 1 (R145) resident reviewed for range of motion in a sample of 35. Residents Affected - Few Findings Include: R145 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Cerebral Infarction due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery, Aphasia Following Cerebral Infarction, Dysphagia Following Cerebral Infarction, Dysarthria Following Cerebral Infarction, Facial Weakness Following Cerebral Infarction, Occlusion and Stenosis of Unspecified Carotid Artery and Essential (Primary) Hypertension. R145's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Order Summary Report dated 09/18/24 document in part: Apply resting hand splint and elbow on left hand and PRAFO (pressure relief ankle foot orthosis) on BLE (Bilateral lower extremities) for 4 hours daily as tolerated. Care Plan document in part: Focus: R145 has an ADL (activities of daily living) self-care deficit related to limited mobility in left hand d/t (due/to) hemiplegia. Resident is on a splint and/or brace assistance program Date Initiated: 12/10/23. Interventions: I am on a Splint Program. Staff will provide Passive Range of Motion daily before application of R145 splint. Date Initiated: 12/10/23. I am on a Splint Program. I would like staff to check for skin integrity, circulation, and motion before and after removal of splint and note condition of the skin Date Initiated: 12/10/2023. Restorative Splint/Brace Program: Please provide/use left resting hand brace for 4-6 hours daily or as tolerated. Date Initiated: 12/10/23. On 09/17/24 at 11:14 AM R145 was observed lying in bed on a low air loss mattress. R145 left hand was observed contracted with the left arm bent up and laying on R145's chest. There was no splint observed to the left upper extremity. R145 stated I have been here about a year. They exercise my left arm, but they haven't come today yet. On 09/19/24 at 09:45 V21 (Restorative Nurse) stated R145 has a splint to the left upper extremity. R145 had a stroke, is alert and oriented x3. R145's splint should be applied daily at least 4 hours. They have the charting in Point Click Care for that. If R145 refuses the splints the restorative aide or certified nurse assistant should document. The purpose of the splint is to prevent the worsening of a contracture or stiffness. R145 has a contracture to the left upper extremity and the splint Page 1 of 19 145838 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0688 is for the prevention of further contracture. Level of Harm - Minimal harm or potential for actual harm On 09/18/24 at 10:12 AM V21 (Restorative Nurse) presented the surveyor with Documentation Titled Follow Up Question Report dated 09/12/24 - 09/18/24 with V22 (Certified Nurse Assistant) entry that document in part: 09/17/24 09:18 AM Was brace/splint applied? Yes. However, on 09/17/24 at 11:14 AM R145 was observed lying in bed with no splint in place to the left upper extremity. Residents Affected - Few On 09/19/24 at 10:13 V22 (Certified Nurse Assistant) stated I was assigned to R145 on Tuesday 09/17/24. I provide total care, change, wash her face and on days that R145 want to get up I get her up. On Tuesday it was a normal day, I checked, changed, would go in when R145 put on the call light and turn her. I document the brace/splint because I see them applied but restorative applies the splints. I do not apply the splints myself. On 09/17/24 I saw R145 legs I don't remember if the left arm splint was on there. R145 is alert and oriented x3. I know for sure that R145 had the brace on her legs, but she did not get a bath on Tuesday. On 09/18/24 at 09:18 AM surveyor entered R145 room and observed R145 lying in bed with the left-hand splint in place. When asked did the staff ever come and apply the left-hand splint on Tuesday 09/17/24. R145 responded, they did not put it on at all yesterday and they just put it on about forty minutes ago. It is used to stretch my fingers out and they leave it on until lunch time. On 09/19/24 at 10:40 AM V21 (Restorative Nurse) stated my restorative aides put the residents' splints on. If they had applied the splints they would have charted. There is no proof that R145's splints were applied other then V22 (Certified Nurse Assistant) documentation. On 09/17/24 we only had two restorative aides for that day, and it is generally four restorative aides, one on each unit. I only had two restorative aides to cover the whole building. Generally, all of the residents should have some type of restorative program. If there are two restorative aides, I can't expect for them to cover the whole building. That is why we implemented the group program for about 3 months. Policy: Titled Restorative Nursing Program revised 08/19/24 document in part: It is the policy of this facility to assess for comprehensive nursing and restorative needs upon admission. Procedure: 2. Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. 3. Nursing and Restorative Services may include the following: c. Contracture Prevention and Management. ii. Splint/Orthotic Management. 6. Restorative Programs shall be reflected and indicated in the resident's electronic restorative log in order to document the provision of services and the frequency by the nurses, cnas (certified nurse assistants) and/or restorative aides. 145838 Page 2 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, and record reviews, the facility failed to provide supervision of residents during a smoking break and demonstrate competency and knowledge related to safety measures and equipment for the smoking patio and failed to secure first and second floor soiled utility rooms that contained sharps and infectious waste containers. These deficient practices have the potential to affect all residents who are identified as smokers (R15, R26, R40, R59, R75, R87, R93, R95, R111, R112, R117, R125, R128, R129, R137, R149, R151, R154, R159, R160, R163, R170, R171) and all ambulatory residents that reside on the first and second floors, in the sample of 35. Findings include: On 9/19/2024 at 9:35 AM, approximately 10 residents observed on the Smoking Patio. V26 (Activity Aide) observed helping wheelchair bound residents on to and off the smoking patio; no staff observed stationed on the patio to monitor residents during smoking break. On 9/19/2024 at 9:42 AM, V24 (Activity Aide) said we don't stay on the patio the whole time, we go out there periodically. V24 said I can find out where the smoking blanket is, I don't know what it is. I have not received any training related to what to do if resident's clothing catches on fire, I would call for help immediately. On 9/19/2024 at 9:52 AM V25 (Activity Director) said there is no training related to what to do if resident's clothing catches on fire. V25 said, we don't stay on the patio (duration of smoke break), we go out there periodically. On 9/19/2024 at 09:58 AM, V28 (Activity Aide) said staff do not stay on smoking patio for duration of smoking break; periodically go out and monitor. On 9/19/2024 at 10:08 AM, V1 (Administrator) said Activity Staff sit at door (first floor dining room) during smoking breaks. They periodically go out on the patio and check residents for paraphernalia when returning from smoking patio. V1 said, I would expect staff to call for help if resident's clothing catches on fire. V1 acknowledged Surveyor's concern that staff may not be able to see entire smoking patio if they are sitting inside the building.) V1 said Activity Staff would be provided with fire safety training for smoking patio. Fire Drill Evaluation Worksheets dated 5/28/2024, 6/11/024, 7/31/2024, and 8/27/2024, do not document any drills/training specific to the facility's smoking patio/smoke breaks. Employee Inservice Sign-In Sheets document Activity Staff received the following training: Location and how to use fire blanket. Safety of residents during smoke breaks. Monitor residents that are smoking at all times. Follow the facility('s) smoking policy. How to use the fire blanket safely. Where it is located. All sign-in sheets are dated 9.19.2024. Smoking Policy (revised 8.19.2024) documents: It is the facility's policy to monitor and assess residents that smoke to promote smoking in a safe manner. Smoking Policy (undated) does not document safety measures to be implemented if a resident's clothing catches on fire or monitoring of smoking patio. 145838 Page 3 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/17/24 approximately 12:15 PM, observed R11 sitting in the day/dining room coloring. R11 was alert and oriented and had no concerns with the facility. R11 endorsed quitting smoking. On 9/17/24 at 12:42 PM, During review on the 2nd floor, surveyor/writer observed R11 come out of a room carrying a new trash bag. On the wall next to the room there was a sign that read Utility Room. On the door of the room there was a sign that read CAUTION Infectious Waste Storage Area Unauthorized Persons Keep Out and an entry code keypad. Writer asked R11 what was R11 doing in the room. R11 said R11 went to throw out trash and get a trash bag. Writer asked R11 how did R11 get inside of the room. R11 proceeded to press a series of buttons on the entry code keypad, turned a knob and opened the door. Multiple times, writer attempted to open the door without even pressing buttons on the entry keypad and the door opened each time. Inside of the room were two garbage cans with bags of trash inside, one red biohazard can with bags of trash inside, two red sharps containers that contained sharps, a hopper with standing water, a utility sink, a broom, and the room had a foul stench. On 9/17/24 at 12:55 PM, Writer reviewed the Utility Room with V28 (MDS/Clinical Care Coordinator). Writer opened the door of the room without entering a code. V28 verified the room was not locked and stated the room is supposed to be locked and entry is with a code. V28 stated residents should not be in the room. V28 picked-up and shook the sharps containers to verify they were full of sharps. V28 stated the sharps containers located in the room should not be accessible to residents. V28 stated the hopper is used to pour urine into. On 9/17/24 at 1:05 PM, V23 (Housekeeping Manager/Laundry/Central Supplies) stated red isolation bags, trash from resident rooms, full sharps containers are kept in the Utility Room. Housekeeping throws the trash in dumpsters at the end of shift. Maintenance takes the red isolation bags and sharps containers to a special area outside of the building. V23 stated the door to the Utility Room should be locked at all times. Residents should not be in the room and should not have the code to the door to the room. Residents should not be in the room because of the risk of infection from the garbage and sharps that are kept in there. On 9/18/24 at 2:54 PM, During review on the 1st floor, two surveyors, including writer, discovered an unlocked room. On the wall next to the room there was a sign that read Utility Room. On the door of the room there was a sign that read CAUTION Infectious Waste Storage Area Unauthorized Persons Keep Out and an entry code keypad. Writer opened the door to the room without entering a code into the entry code keypad. Inside of the Utility Room was a hopper, a biohazard box with at least one red isolation bag inside, a cube refrigerator, empty, with a sign on the door stating the Refrigerator is for Specimens, and two garbage cans. On 9/18/24 at 3:05 PM, V2 (Director of Nursing) stated urine and stool specimens are kept in the refrigerator in the Utility Room on the 1st floor. On 9/19/24 at 11:55 AM, V27 (Registered Nurse) stated residents should not be in the Utility Room. That room is where we put the sharps containers when they are full, biohazard/isolation waste, garbage including used diapers, garbage from medication administration, garbage from resident rooms. The specimen refrigerator in the room is for urine, stool samples, Covid tests. The lab picks up samples daily. The door to the room should be locked. Its dirty in the room and don't want residents in there. The residents can hurt themselves with the sharps, they can mess with the samples. On 9/19/24 at 12:10 PM, V8 (Infection Control Nurse) stated residents should not be in the Utility Room. It can be a safety hazard. They can be exposed to harmful bacteria. Without proper hand 145838 Page 4 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hygiene when they come out of the room, that can lead to cross contamination with staff and other residents. There can be biohazard waste, full sharps containers, dirty diapers, waste from resident rooms, waste from the medication carts in the room. The door to the room should be locked. The refrigerator is for urine, and stool specimens. The access to the refrigerator is for nurses and lab personnel. Facility policy Hazards, 7/30/24, documents in part: Policy Statement: It is the facility's policy to ensure the safety of each resident in the building and remove hazardous items and correct situations to prevent accidents. Procedures: 1. Ensure that residents have no access to medications, sharps, and chemicals that would be hazardous to them. 145838 Page 5 of 19 145838 09/20/2024 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 - Some 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 observations, interviews, and record review, the facility failed to provide appropriate treatment and services to prevent complications from enteral feeding for 2 (R35, R132) of 6 residents reviewed for enteral feedings. The facility also failed to ensure expired enteral feeding products were removed and unavailable to be administered to residents. This failure has the potential to affect 2 (R29, R36) residents that receive enteral nutritional feedings. Findings Include: 1. R35 has diagnosis not limited to Essential (Primary) Hypertension, Hyperlipidemia, Adult Failure to Thrive, Type 2 Diabetes Mellitus with Hyperglycemia, Bilateral, Indeterminate Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease, Restlessness and Agitation, Dysphagia, Dementia, unspecified Severity, with Agitation, Severe Protein-Calorie Malnutrition, Gastrostomy Status, Ulcer of Esophagus, Vitamin D Deficiency, Type 2 Diabetes Mellitus with Foot Ulcer, Pressure Ulcer of Sacral Region and Personal History of other Diseases of the Digestive System. R35's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicate resident is rarely/never understood. R35's Order Review Report dated 09/18/24 document in part: NPO (Nothing by mouth) diet NPO texture, NPO consistency, for PEG (percutaneous endoscopic gastrostomy) tube. Enteral Feed Order every shift Enteral feeding- Tube type: Peg tube, Glucerna 1.5 Rate: 60 ml/hr. (milliliter/hour), start at 6 am and infuse x20 hours or until 1200 ml formula is reached per day. Care plan document in part: R35 is NPO d/t (due/to) dysphagia. S/p (status/post) PEG tube placement on 2/7/24. R35 is on therapeutic enteral formula dt (due to) dx (diagnosis) DM (Diabetes Mellitus) Date Initiated: 09/14/20. R35 has the following conditions and risk factors that puts her at risk for dehydration: increased risk of confusion and delirium, cognitive impairment, Senile Degeneration of the Brain, on diuretic therapy, on NPO and on enteral feeding via gastrostomy tube (s/p GT placement (02/07/24), s/p Explore Lap, Partial Gastrectomy of greater curvature of body of stomach (02/12/24), Dx of Dysphagia, Adult Failure to Thrive, Malnutrition, Type 2 DM w/ Hyperglycemia, Diabetic Neuropathy. Interventions: Administer fluids per doctor's order via appropriate routes (Nothing by Mouth, G- (gastric) tube). R35's currently on NPO and on enteral feeding of Glucerna 1.5 via gastrostomy tube given as scheduled. Observe aspiration precaution. Monitor for tolerance and effectiveness. Date Initiated: 09/08/20. On 09/17/24 at 12:28 PM R35 was observed in bed on a low air loss mattress positioned in a low Fowler position receiving an enteral feeding of Glucerna at 60 ml/hr. On 09/17/24 at 12:34 the surveyor entered R35 room with V15 (Licensed Practical Nurse) then asked the position of R35 head of the bed. V15 responded, it looks like R35 head of bed should be up a little more because she could aspirate. On 09/19/24 at 12:45 PM V2 (Director of Nursing) presented a care plan that documents in part: R35 is at risk for alteration in nutritional status related to her Dx (diagnosis) of Adult Failure to Thrive, Dysphagia, Type 2 Diabetes mellitus w/ Hyperglycemia, Diabetic Neuropathy and Foot Ulcers, Gastrostomy Status. Interventions: Elevate head of the bed during enteral feeding. Observe aspiration precaution. Monitor for tolerance and effectiveness. 145838 Page 6 of 19 145838 09/20/2024 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 - Some 2. R132 has diagnosis not limited to Type 2 Diabetes Mellitus, Altered Mental Status, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Gastrostomy Status, Hyperlipidemia, Chronic Obstructive Pulmonary Disease, Emphysema, Anxiety Disorder, Restlessness and Agitation, Personal History of other Diseases of the Respiratory System, Dysphagia. R132's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 06 indicating severe cognitive impairment. R132's Order Summary Report dated 09/18/24 document in part: NPO (Nothing by mouth) diet NPO texture, thin liquid consistency. Enteral Feed Order every shift Enteral feeding- Tube type: Peg tube, Glucerna 1.5 Rate: 80 ml/hr. (milliliter/hour), start at 6 am and run 20 hours or until 1600 ml formula is administered daily. Care plan document in part: R132 is NPO, on PEG tube feeding d/t dysphagia and the inability to meet his nutritional/fluid needs. Presence of PEG tube places him at risk of infections, fluid overload, dehydration, and aspiration. -R132 is at increased nutrition risk d/t recent NPO status requiring enteral feeding to support nutrition, on NPO and on enteral feeding via gastrostomy tube s/p placement (04/01/24), Interventions: Administer fluids per doctor's order via appropriate routes (PEG-tube). R132 currently on NPO and on enteral feeding via gastrostomy tube. Observe aspiration precaution. Monitor for tolerance and effectiveness. Date Initiated: 05/10/23. On 09/17/24 at 12:21 PM R132 was observed in bed in a low Fowler position receiving an enteral feeding of Glucerna at 80 ml/hr. (milliliters/hour). On 09/17/24 at 12:33 the surveyor entered R132 room with V15 (Licensed Practical Nurse) then asked the position of R132 head of the bed. V15 responded, I'd say 30 degrees. However, R132 head of the bed was observed positioned in a low fowlers position. On 09/19/24 at 11:53 AM V2 (Director of Nursing) stated A resident with a Gastric tube should be position at 30-to-45-degree angle, slightly elevated as long as they are not flat in the bed. There is a potential for aspiration if the resident is not properly positioned. On 09/19/24 at 12:45 PM V2 (Director of Nursing) presented a care plan that documents in part: R132 has/have a Dx of COPD related to Nicotine Dependence (cigarettes) in remission. Interventions: Head of bed elevated (semi-Fowlers to fowlers) secondary to shortness of breath while lying flat and difficulty breathing as needed. Head of bed to be elevated (semi-Fowlers to fowlers) or out of bed upright in a chair during episodes of difficulty breathing (Dyspnea). Document titled Diet Type Report dated 09/19/24 document in part: Eleven residents with a diet type of NPO. Policy: Titled Enteral Tube Feeding Care revised 07/26/24 document in part: Enteral Tube is an avenue of feeding and hydration nutritional support via gastrostomy route. Procedure: 9. Residents on enteral feeding must be positioned in a fowler's position at all times while the feeding is running. Titled General Care revised 07/30/24 document in part: It is the facility's policy to provide care for every resident to meet their needs. Procedures: 1. Upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs, etc. Psychosocial needs would include 145838 Page 7 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0693 Level of Harm - Minimal harm or potential for actual harm but are not limited to areas of mental and psychosocial well-being. The facility will assist the resident to meet these needs. 3. 9/17/24 at 3:15 PM, reviewed 2 North medication room with V29 (Licensed Practical Nurse) and V30 (Registered Nurse) and observed: Residents Affected - Some -Osmolite Complete Balanced Nutrition; 1.5 CAL; with use before date Nov (November) 1, 2023; 2 bottles -TwoCal HN 2.0 CAL Calorie and Protein Dense Nutrition; with expiration date Sep (September) 1, 2024; 2 cartons According to face sheet printed 9/19/24, R29 diagnoses include but are not limited to quadriplegia, encounter for attention to gastrostomy, gastrostomy status, cerebral infarction. R29 physician order summary printed 9/20/24 reads in part: enteral feed order every shift enteral feeding-tube type: G-tube, Osmolite 1.5, Rate: 70 ml/hr, start at 5am and infuse until 1400 ml formula is reached per day. According to face sheet printed 9/19/24, R36 diagnoses include but are not limited to acquired absence of other specified parts of digestive tract, encounter for attention to gastrostomy, gastrostomy status, chronic diastolic (congestive) heart failure. R36 physician order summary printed 9/20/24 reads in part: enteral feed order six times a day enteral feeding-tube type: PEG tube, Bolus: 1 carton of TwoCal (240 ml), 6x/day. On 9/19/24 at 11:55 AM, V27 (Registered Nurse) stated there should not be expired medications in the medication carts or medication rooms. If a resident is given an expired medication, it can harm the resident. The G-tube feedings and bolus feedings and oral feedings should not be expired. On 9/19/24 at 12:10 PM, V8 (Infection Control Nurse) stated there should not be expired medications in the medication carts or medication rooms. It can be dangerous to the residents to have expired products administered to them. On 9/19/24 at 1:54 PM, V2 (Director of Nursing) stated there should be no expired medications or enteral feedings in the medication carts or medication rooms. Residents could have an adverse reaction to expired medications or enteral feedings. Central supply should be checking the supply for expiration dates. When the supply comes upstairs then the nurses should be checking dates. List of Residents with G-tubes and are on Enteral Feedings provided by facility 9/19/24 documents in part: R29, Osmolite 1.5; R36, TwoCal 240 ml. Facility policy Enteral Tube Feeding Care, 7/26/24, documents in part: 2. Check for feeding formulas expiration date. 145838 Page 8 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to change an intravenous catheter dressing timely for 1 (R33) resident reviewed for intravenous catheter care in a sample of 35. Residents Affected - Few Findings Include: R33 has diagnosis not limited to Essential (Primary) Hypertension, Personal History of Malignant Neoplasm of Thyroid, Personal History of Malignant Neoplasm of other Parts of Uterus, Type 2 Diabetes Mellitus, Morbid (Severe) Obesity due to Excess Calories, Hypothyroidism, Hyperlipidemia, Spinal Stenosis, Cervical Region, Osteophyte, Vertebrae, Disorder of Bone, Adult Failure to Thrive, Restlessness and Agitation, Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarction, Intervertebral Disc Degeneration, Lumbar Region, Spinal Stenosis, Lumbar Region , Adjustment Disorder with Anxiety, Bilateral Primary Osteoarthritis of Knee, Primary Osteoarthritis, Left Hand, Arthropathy, Atherosclerotic Heart Disease of Native Coronary Artery, Ankylosing Spondylitis of Multiple Sites in Spine, Spondylosis, Polyarthritis, Major Depressive Disorder, Adjustment Disorder with Depressed Mood, Ventral Hernia, other and Unspecified Ventral Hernia With Obstruction, Personal History of Covid-19, Primary Osteoarthritis, Left Shoulder, Intervertebral Disc Degeneration, Thoracic Region, Vascular Dementia, Unspecified Severity, with Agitation, Diverticulosis of Large Intestine, Intestinal Obstruction, Gastro-Esophageal Reflux Disease, Slow Transit Constipation, Carrier of Carbapenem-Resistant Enterobacterales. BIMS (Brief Interview for Mental Status) 11. Care plan documents in part: R33 has potential for infection related to presence of midline catheter on right upper arm. Date Initiated: 09/05/24. Interventions: Initiate proper precaution per facility policy. R33 on Antibiotic Therapy related to elevated WBC (Leukocytosis) and ESBL in urine. R33 received Meropenem Intravenous Solution Reconstituted 1 GM (gram) intravenously every 8 hours for leukocytosis for 5 Days -Start Date- 09/05/24 2200. On 09/17/24 at 11:26 AM R33 was observed lying on a low air loss mattress. The Midline observed to R33's right arm was dated 09/05/24. On 09/17/24 at 11:50 AM V16 stated facility policy on PICC (Peripheral Inserted Central Catheter)/Midline dressing change was the PICC/Midline dressing is changed every 7 days, but wound care changes the dressing and take care of it. On 09/17/24 at 01:35 PM surveyor entered R33's room with V16 (Registered Nurse) then asked what date was on R33's Midline dressing. V16 looked at the PICC line dressing using the flashlight on her (V16) cell phone and stated, it's dated 09/05/24. On 09/19/24 at 11:53 AM V2 (Director of Nursing) stated The Midline dressing is changed every 7 days once a week and as needed. If the Midline dressing is not changed as ordered there is a potential for infection. We need to check the site when doing the dressing changes, look at the skin condition during dressing changes make sure there is not any redness. Policy: Titled Intravenous Therapy revised 08/16/24 document in part: it is the facility's policy to ensure 145838 Page 9 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0694 Level of Harm - Minimal harm or potential for actual harm that intravenous policy and procedure are compliant to federal standard of care. Procedures: b. All midline catheter dressing are to be done every 7 days while following the procedure for dressing change of central lines. vii. The outside of the dressing will then be labeled with dressing change date and time. Residents Affected - Few 145838 Page 10 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

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 expired medications were removed and unavailable to be administered to residents. This failure has the potential to affect all residents receiving medications from the 2 North Front medication cart. Findings include: On 9/17/24 at 3:07 PM, reviewed 2 North front medication cart with V2 (Director of Nursing) and observed: -Gas Relief Simethicone 80mg chewable tablets with expiration date 8/24. On 9/19/24 at 11:55 AM, V27 (Registered Nurse) stated there should not be expired medications in the medication carts or medication rooms. If a resident is given an expired medication, it can harm the resident. On 9/19/24 at 12:10 PM, V8 (Infection Control Nurse) stated there should not be expired medications in the medication carts or medication rooms. It can be dangerous to the residents to have expired products administered to them. On 9/19/24 at 1:54 PM, V2 (Director of Nursing) stated there should be no expired medications or enteral feedings in the medication carts or medication rooms. Residents could have an adverse reaction to expired medications or enteral feedings. Central supply should be checking the supply for expiration dates. When the supply comes upstairs then the nurses should be checking dates. Facility policy Medication Storage, Labeling, and Disposal, 8/16/24, documents in part: 2. House stocks designed for multiple administration will be labeled with the name of the medication, the strength, instruction, and expiration. The information from the manufacturer is enough to meet this requirement. The facility does not date this medication when opened. And the medication automatically expires based on the expiration date based on the manufacture's guidelines. 145838 Page 11 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to follow the menu for residents receiving a pureed diet. This failure has the potential to affect 19 residents receiving a pureed diet. Residents Affected - Some Findings Include: On 09/18/24 at 11:29 AM the kitchen staff began plating from the steam table. Staff was observed plating pureed ravioli, pureed medley mixed vegetable and mash potatoes to be served for the residents that receive a pureed diet. There was no pureed bread served. On 09/19/24 at 03:25 PM V20 (Registered Dietician) stated If it says a pureed bread item on the meal ticket the resident should be receiving it. The residents on the pureed diet should have received ravioli, mixed vegetables, French garlic bread and pineapple upside down cake. The residents could receive mashed potatoes in place of the bread. That would not be following the menu. The mashed potatoes would be a substitution and be marked in the substitution binder. There is a binder in the kitchen if there is not enough of an item, I need to give this as a substitution and I would have to sign off on it. I was not notified that they were serving mashed potatoes. The bread would be the first option. On 09/19/24 at 09:21 AM V14 (Dietary Manager) stated on 09/18/24 Beef Ravioli, California blend vegetable medley, garlic bread and pineapple upside down cake was served for lunch. All of the residents should have received bread, even the residents that receive a pureed diet. The Register Dietician let me know mashed potatoes were served instead of the garlic bread. When I spoke to the V14 (Cook) she said that she forget the pureed bread. The menu was not followed for the residents that receive a pureed diet. The mashed potatoes being substituted for the pureed bread there is a potential the residents could not have received the same calories. That should not have happened unless the dietician is aware of the substitution. Document titled Diet Type Report dated 09/18/24 document in part: Nineteen residents that receive a Pureed Diet. Policy: Titled Kitchen revised 08/16/24 document in part: The facility will comply with state and federal regulations in operating facility's kitchen. 8. All food items in the menu and recipe will be followed. In the event that change is needed, the dietician may be consulted first to approve the change and ensure that the change is appropriate. 145838 Page 12 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

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 observation, interview, and record review the facility failed to ensure kitchen tongs and measurement pitchers were properly cleaned and sanitized and food was removed and discarded from the prep refrigerator by the use by date This failure has the potential to affect all the residents in the facility. Findings Include: On 09/17/24 at 09:34 the surveyor entered the kitchen for the initial tour with V14 (Dietary Manager). Red rice/chicken was observed in the prep refrigerator dated 07/12/24 - 07/16/24. V14 stated the wrong month was written on there but today is 09/17/24. On 09/18/24 at 09:35 AM the surveyor entered the kitchen. The Menu dated Wednesday 09/18/24 consisted of Beef Ravioli, Italian Parmesan, Medley Mixed Vegetables, French Garlic Bread and Pineapple Up-side Down Cake. On 09/18/24 at 09:47 AM V18 (Cook) place Steak burgers in a pan using tongs on top of stove. On 09/18/24 at 10:14 AM V18 (Cook) removed a green bucket from under the prep table near the sink, used a sponge that was in the green bucket and washed the tongs. On 09/18/24 at 10:16 AM V18 (Cook) used the tongs to remove the steak burgers from the pan and placed them on the hamburger buns. On 09/18/24 at 10:35 AM V18 (Cook) washed the strainer, small and large measurement pitcher using the sponge that was in the green bucket, then placed them to the right side of the sink. On 09/18/24 at 10:39 AM V18 (Cook) obtained the small measurement pitcher then dipped it into the pot Italian parmesan sauce then poured it into two pans before placing them on the steam table. On 09/18/24 at 10:45 AM V18 (Cook) washed the tongs and the pitcher with the sponge that was in the green bucket. On 09/18/24 at 10:49 AM Surveyor asked V14 (Dietary Manager) the contents of the red and green bucket. V18 stated the red bucket has the sanitizer; the green bucket has soap and water. On 09/18/24 at 11:03 AM V18 (Cook) used the small pitcher that she washed with the sponge from the green bucket to dip and remove excess water from the ravioli that was on the stove top. On 09/19/24 at 09:21 AM V14 (Dietary Manager) stated The green bucket had soap and water and it is used for towels after the counters are sanitized. The soiled towels are placed in the bucket then we have a large bucket that the towels are put in so they can be washed. The tongs and measurement pitchers should be taken to the three-compartment sink to be washed. V14 should have grabbed a clean pitcher each time she uses a dish. V14 should put the dishes in the three-compartment sink and get a new measurement pitcher, we have plenty of measurement pitchers. There is a potentially using the measurement pitcher and tongs could contaminate the food. The dishes should be washed, sanitized and air dry before using again. 145838 Page 13 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Document titled In-Service Sign in Sheet dated 09/17/24 document in part: In-service topic: Sanitation buckets concentration. Document titled In-Service Sign in Sheet dated 09/17/24 document in part: In-service topic: Label and dating. Temperature Control for Safety foods can grow harmful bacteria if stored or labeled incorrectly. Labeling Temperature Control for Safety foods we prepare helps us know when they were made and when they might spoil. We must label and us Temperature Control for Safety foods within 7 days from preparation or opening to stay safe. Proper labeling ensures the food we serve is fresh and safe to eat. If we use food labels incorrectly it could lead to us serving unsafe food. Labeling errors that can lead to unsafe food: incomplete labels or inaccurate information, incorrect use-by-dates. Document titled In-Service Sign in Sheet dated 09/19/24 document in part: In-service topic: Cleaning and Sanitizing, Preventing Cross Contamination. Cleaning removes dirt and soil, while sanitizing reduces bacteria and viruses on surfaces. Cleaning and sanitizing does not eliminate the need for disinfection. Both activities prevent contamination and keep our employees, locations, food, and customers safe. Cross contamination occurs when harmful bacteria move or transfer from one person, place, or surface to another. Preventing cross-contamination is an important step to preventing foodborne illness - protecting our employees, customers, and company's reputation. Conditions that can cause cross-contamination: Improper cleaning and sanitizing, Improper storing food. Behaviors that can contribute to cross contamination: Preparing food on or serving with unclean items. Policy: Titled Kitchen revised 08/16/24 document in part: The facility will comply with state and federal regulations in operating facility's kitchen. 1. Food Storage: h. Open containers or potentially hazardous food or leftovers should be dated and used within 3-5 days in the refrigerator. 5. 3 Compartment Sink (Wash, Rinse, Sanitize). a. The 1st compartment is water and soap for washing. b. The 2nd compartment is water for rinsing. c. The 3rd sink used for sanitizing pots and pans. d. The 3rd compartment for sanitizing has to comply with the sanitizer's manufacturer's recommendation. 8. All food items in the menu and recipe will be followed. In the event that change is needed, the dietician may be consulted first to approve the change and ensure that the change is appropriate. 11. Miscellaneous Areas: b. Food brought by the resident's family will be labeled to identify the date the food from the outside was brought in by the representative. c. Perishable food items brought in by the resident's representative will be discarded within 3-5 days after brought in and refrigerated in the resident's room. 145838 Page 14 of 19 145838 09/20/2024 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 ensure food items in a residents personal refrigerator was labeled and dated for one resident (R143) reviewed in a total sample of 35 residents. Residents Affected - Few Findings include: R143 has diagnosis not limited to Essential (Primary) Hypertension, Spastic Hemiplegia Affecting Right Dominant Side, Hyperlipidemia, Type 2 Diabetes Mellitus with other Diabetic Neurological Complication and Aphasia Following Cerebral Infarction. R143's Care plan document in part: R143 has a diagnosis of Type 2 Diabetes Mellitus. Interventions: Monitor compliance with diet and document any problems. On 09/17/24 at 12:03 PM surveyor entered R143 room and asked it was okay to check his refrigerator. R143 responded, yes. Two undated sandwiches and 2 undated chocolate chip cookies wrapped in clear plastic wrap were observed in R143's refrigerator. On 09/17/24 at 12:07 PM surveyor asked V15 (Licensed Practical Nurse) who is responsible for checking the resident refrigerators and discarding undated and expired items. V15 responded, any nurse can check the resident's refrigerator. Things in the resident refrigerator should be dated and if it is not dated, we discard it. On 09/17/24 at 12:10 PM surveyor entered R143 room with V15 (Licensed Practical Nurse) and asked to check R143's refrigerator. V15 opened R143's refrigerator and when asked what she observe in the refrigerator V15 responded, two cheese and turkey sandwiches and 2 chocolate chip cookies, both do not have a date on them. On 09/19/24 at 11:53 AM V2 (Director of Nursing) stated the checking of the resident refrigerators is done by housekeeping. If there is something unlabeled in the resident's refrigerator the nurses are made aware and social service talk to the resident. The food items in the resident refrigerators should be dated. If there is a sandwich in the resident refrigerator that is unlabeled, we offer another sandwich and we need to educate the resident. 145838 Page 15 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

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 reviews, the facility failed to ensure contracted staff wore appropriate Personal Protective Equipment (PPE) while caring for a resident (R34) on Enhance Barrier Precautions (EBP) and failed to ensure proper linen storage/handling. These failures have the potential to affect all 171 residents that reside in the facility. Residents Affected - Many Findings include: R34's admission Record documents in part medical diagnoses of gastrostomy status and encounter for attention to gastrostomy. R34's care plan documents in part that R34 is on Enhanced Barrier Precautions (initiated 7/13/2023). Interventions include Ensure that gown and gloves are used during high-contact resident are activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use for those with central line, urinary catheter, feeding tube, tracheostomy/ventilator, and Wound care for any skin opening requiring a dressing) that provide opportunities for transfer of MDROs [multi-drug resistant organisms] to staff hands and clothing (initiated 7/13/2023). On 9/17/2024 at 11:08 AM, there was an Enhanced Barrier Precautions (EBP) sign posted outside of R34's bedroom door. It documents in part to wear gloves and a gown for High-Contact Resident Care Activities including dressing, bathing/showering, changing linens, providing hygiene, and changing briefs or assisting with toileting. Inside R34's room, V11 (Hospice Certified Nurse Aide - CNA) was bagging dirty linen. V11 wore gloves but no gown. V11 stated finishing R34's bed bath. V11 stated [V11] comes five times a week to care for R34. V11 stated facility did not inform V11 of any precautions for R34. Showed V11 the EBP sign outside of R34's door. V11 stated doesn't know what the sign is for and wasn't told to gown up while doing care for R34. V11 flagged down V12 (CNA) who was walking down the hall and asked what the EBP meant. At 11:13 AM, V12 stated EBP was for residents who were at risk. V11 stated they kind of are like easier for them to catch stuff. V11 stated staff are supposed to wear gloves and gown when doing contact stuff with the skin. On 9/18/2024 at 2:03 PM, V8 (Infection Preventionist) stated EBP is usually for residents with central lines, catheters, tracheostomy's, gastrostomy tubes (R34), and wounds. V8 stated staff are to don gloves and a gown for contact care including personal hygiene, changing linen, and bathing. Facility's Infection Prevention and Control policy, last revised 7/31/2024, documents in part that Enhanced Barrier Precautions (EBP) is an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDROs). The goal is to prevent transmission of MDROs to others. It involves the use of gloves and gowns during high contact resident care activities for residents infected or colonized with MDROs as well as residents with wounds and/or indwelling medical devices. On 9/18/2024 at 10:33 AM, surveyor conducted laundry observations in the basement. Outside the laundry room there were blue bins lined up against the wall. One blue bin had bundles of flat sheet. The bin was uncovered. Another bin contained white/blue incontinence pads. The bin was also uncovered. V9 (Laundry Aide) stated linens were clean and delivered that morning. V9 stated linen bins should 145838 Page 16 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many remain covered. Laundry room door was propped open. There were two bins of dirty resident clothing on the right side waiting to be washed. To the left there was a metal rack of clean linen. On one of the metal racks there was a portable fan blowing directly on the clean linen. Fan intake was towards the door and dirty linen and fan output was to the clean linen (wind current going from dirty to clean). At 10:39 AM, V9 opened the laundry chute room. The bin inside was overflowing and there were multiple bags of linen/resident clothing backed up the chute. At 2:03 PM, V8 (Infection Preventionist) and V10 (Assistant Director of Nursing) stated linens are supposed to be covered to keep them protected from potential contamination. Linens in the blue carts should be covered with plastic. On 9/19/2024 at 11:01 AM, V23 (Housekeeping/Laundry/Central Supplies) stated an outside company delivers clean linen in blue bins. The blue bins need to be covered in plastic until time for use. V23 stated that laundry chute should be checked every two hours or as needed. V23 stated the laundry chute should not be overflowing. Facility's Linen Handling by Laundry Staff policy, last revised 8/16/2024) documents in part: Clean linen may be placed in a clean linen room or left in the cart that is protected from the environment. Facility did not have a policy pertaining to laundry chute. 145838 Page 17 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 functioning call light system for one (R14) resident in a total sample of 35 residents reviewed. Residents Affected - Few Findings include: On 09/17/2024 at 11:50AM, surveyor located inside of R14's room. R14 asks surveyor to assist her with finding her television remote control referring to it as the clicker. R14 states she wants her remote control so that she can change the channel on her television. Surveyor informs R14 that she should press her call light for staff assistance with her remote control. R14 then picks up her call light pad and continuously press her call light pad while stating that she has been pressing it for a long time already and no one has come to her room to assist her. Surveyor observes that when R14 presses her call light several times, the call light does not illuminate above R14's room door and no audible sound is heard. Surveyor observes that R14's call light is plugged into the wall. On 09/17/2024 at 11:53AM, surveyor makes V3 (Licensed Practical Nurse/LPN) aware of R14's call light status. V3 states she is the nurse responsible for caring for R14 today. V3 now located inside of R14's room and return demonstrates the use of R14's call light. V3 is observed pressing R14's call light pad and states she does not see a light illuminated above R14's door and does not hear an audible call light sound. V3 observes R14's call light and confirms that R14's call light is plugged into the wall. V3 states R14's call light should illuminate above R14's room and a call light sound should be audible. V3 states staff would not be able to respond to R14's call light to assist with her needs because R14's call light is currently not working. V3 states she needs to call maintenance and make them aware that R14's call light is not working. On 09/17/2024 at 12:04PM, surveyor makes V4 (Certified Nursing Assistant/CNA) aware of R14's call light status. V4 states she is the CNA responsible for caring for R14 today. V4 located inside of R14's room and return demonstrates the use of R14's call light. V4 is observed pressing R14's call light pad and states she does not see a light illuminated above R14's door and does not hear an audible call light sound. V4 observes R14's call light and confirms that R14's call light is plugged into the wall. V4 states staff would not be able to respond to R14's call light to assist with her needs because R14's call light is currently not working. R14's call light assessment dated [DATE] documents that V32 (Restorative Nurse/LPN) documented that R14 is not able to cognitively use her call light. On 09/19/2024 at 10:59AM, V32 (Restorative Nurse/LPN) states she performs call light assessments by going into resident rooms and asking them to return demonstrate the use of their call light button by having them press their call light button. V32 states if a resident is not able to use the call light button, she assesses them for the call light touch pad instead. V32 states R14 uses the call light touch pad to call for staff assistance. Surveyor makes V32 aware of R14's call light assessment dated [DATE]. V32 observes R14's call light assessment and states she must have made a mistake when documenting R14's call light assessment because R14 is able to use her call light although R14 can be cognitively confused at times. R14's care plan dated 07/05/2024 documents that R14 has an ADL self-care performance deficit and documents CALL LIGHT Encourage R14 to use call light to call for assistance. May use touch pad. 145838 Page 18 of 19 145838 09/20/2024 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0919 Level of Harm - Minimal harm or potential for actual harm Facility policy dated 07/26/2024, titled The facility also ensures that the call system is in proper working order. 3. Nursing staff shall check all call lights daily and report any defective call lights to the administrator/maintenance immediately for repair. 6. Be sure that when the call light is triggered, it will either alert the staff visually or audibly or both. Residents Affected - Few 145838 Page 19 of 19