Health inspection·November 29, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow the Resident Assessment Instrument (RAI) manual to reflect an accurate assessment for one (R109) out of six residents' Minimum Data Set (MDS) assessment reviewed in a total sample of thirty-seven. Findings Include:R109's face sheet shows he is [AGE] years old, admitted to the facility on [DATE] with diagnoses not limited to personal history of transient ischemic attack (TIA) and cerebral infarction, Gastrostomy status, adult failure to thrive, essential hypertension, type 2 diabetes mellitus, developmental disorder of scholastic skills, and unspecified asthma. On 11/25/25 at 1:18 PM, R109 is seated in his wheelchair with limitations to his left hand.On 11/26/25 at 12:41 PM, V22 (Certified Occupational Therapist Assistant/COTA) stated that she has been in the facility since March 2019, and she provided exercises for R109's arms/legs due to weaknesses upon initial admission from 6/6/24 to 6/18/24. He was referred to therapy again on 6/27/24 to 7/23/24 due to diagnosis of adult failure to thrive, he was not working, with limitation to bilateral upper, lower extremities, and with more limitation to left arm/hand. On 11/26/25 at 12:59 PM, V12 (Restorative Nurse) stated that he completed R109's functional limitation in range of motion assessment (section GG0115) of the MDS on 6/30/24. R109 was readmitted with diagnosis of adult failure to thrive on 6/26/24, he was weak and unable to perform activity of daily living (ADL). Surveyor and V12 reviewed R109's hospital discharge records dated 6/26/24 which shows limitation to all his four extremities. V12 stated that he coded no limitation to bilateral upper and lower extremities because he did not notice the limitation during R109's physical assessment.On 11/26/25 at 1:36 PM, V31 (Clinical Care Coordinator/CCC) stated that she has been in the facility since 2015, and it is her expectation that all sections of the MDS are coded accurately. R109's hospital physician's notes of 6/20/24 document in part: admitted from nursing home due to failure to thrive, is barely able to move his right arm. He is not able to move his left hand or lower extremities.Restorative Nurse job description, document in part completes assigned MDS portions accurately and on time.Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, 2025. page GG-5 document read in part: definition of functional limitation in range of motion, limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living). Residents Affected - Few Page 1 of 5 145838 145838 11/29/2025 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0695 Provide safe and appropriate respiratory care 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 date/label and maintain proper storage of nebulizer tubing and mask when not in use for one (R3) out of one resident reviewed for respiratory care in a final sample of 37.Findings Include:On 11/25/25 at 10:01 AM, R3's resting comfortably in bed. R3's nebulizer machine was not being used, not inside a clear bag, was sitting on top of R3's nightstand. R3's nebulizer tubing mask was sitting on top of the nebulizer machine and was not inside a clear bag. R3's nebulizer tubing and mask had dates labeled 10/22/25. R3 stated he gets nebulizer treatment as needed for COPD (Chronic Obstructive Pulmonary Disease).On 11/25/25 at 10:10 AM, V6 (Assistant Director of Nursing) stated that nebulizer tubing and mask are changed weekly and as needed. V6 said the tubing and the mask should be dated when it was last changed. V6 stated that it's important to change it weekly to prevent infection and prevent fluid accumulation in the tubing. V6 said it should be stored inside a clear plastic bag and labeled with the date also to prevent infection and contamination. On 11/25/25 at 10:14 AM, Surveyor and V6 entered R3's room. V6 confirmed R3's nebulizer tubing and mask were dated 10/22/25 and should be inside the clear bag because it's not being used, and the bag should also be dated. R3's clinical records show an admission date of 1/4/23 with included diagnoses but not limited to Chronic Obstructive Pulmonary Disease, End Staged Renal Disease, and Hypertensive Heart Disease with Heart Failure. R3's order summary report with active orders as of 11/25/25 reads in part: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 6 hours as needed for shortness of breath/congestion (ordered 10/22/25). The facility's Respiratory Therapy Equipment Use policy dated 7/3/25 documents in part: All oxygen equipment including nasal cannula, humidifier, and nebulizer mask will not be reused. Once opened, this equipment will be dated and discarded after 7 days of use, whether used continuously or on a prn (as needed) basis. Residents Affected - Few 145838 Page 2 of 5 145838 11/29/2025 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to provide honey thickened liquids as ordered by the physician for one resident (R138) during an activity function in a total sample of 37.Findings Include: On 11/25/25 at 12:30 PM, observed R138 sitting at table next to V23 (Activity Aide). R138 had mechanical soft items on her lunch plate, a closed container of honey thickened milk, an opened container of honey thickened juice and an opened can of soda next to her plate of food. R138's meal ticket read mechanical altered/ground, honey thick milk. On 11/25/25 at 12:32 PM, V23 stated R138 can only drink honey thickened liquids. V23 stated the soda can is in front of R138 because R138 requested it, but R138 is not drinking it. V23 stated the soda is not thickened. On 11/25/25 at 12:35 PM, observed R138 pick up the can of soda, bring it to her mouth and take several sips of soda. Surveyor pointed this out to the V23 and V26 (Social Worker) who also observed R138 drinking the soda from the soda can. V23 and V26 stated R138 should only be drinking honey thickened liquids. On 11/25/25 at 12:45 PM, V26 stated that a family member had donated pizza and soda for the residents to eat after the mass which ended around 12:00 PM which was right before the lunch trays were delivered. V26 stated that R138 asked for one of the cans of soda and one of the staff must have gotten it for R138 and then opened it up for her because R138 could not have opened the soda can up on her own. V26 stated that is how she was able to drink the soda. On 11/25/25 at 12:47 PM - R138 stated her liquids need to be thickened so that she does not cough. R138 said, all my liquids have to be thickened even water. R138 stated someone gave her the soda and a staff member opened it for her. She does not remember which staff member opened it for her. R138 said, I only coughed a few times while drinking the soda. R138 stated no one offered to thicken the soda for her and that she would have accepted the soda mixed with thickener. R138 said, the staff must have forgot to thicken it. On 11/25/25 at 12:53 PM, V27 (Registered Nurse) viewed R138's electronic health record (EHR) and stated that R138 is on a mechanical soft with honey thickened liquids diet order due to swallowing difficulties. V27 stated all R138's liquids must be thickened to honey consistency because otherwise she will cough. V27 stated R138 is at high risk for aspiration. V27 showed surveyor a large container of commercial thickener stored in the nurse's medication cart. V27 stated that he did not know R138 wanted or was given soda during activities/lunch and that no one asked him to provide thickener. V27 stated the staff should have asked him to put thickener in the soda to get the soda to a honey consistency so that it could be safely consumed by R138. On 11/26/25 at 11:10 AM, V23 stated she knows which residents require thickened liquids. V23 stated R138 is not allowed to drink any thin liquid and all her liquids always have to be thickened to honey consistency. V23 stated if R138 requests water or coffee or some other type of liquid that is being served at an activity function, then she would tell the nurse because the nurse has the thickener in their medication cart, and they are the ones who thicken the liquid to the right consistency for R138. V23 stated yesterday, there was a lot going on in the dining room and that after religious services a family brought in pizza and soda to share with everyone. V23 stated she did put the soda in front of R138, but she did not open it for her. V23 stated she told R138 that she had to wait and V23 was planning on letting the nurse on duty know that the soda needed to be thickened. V23 said, it was too busy, there was a lot going on. I don't know who opened the soda for her. It was busy. V23 stated the can of soda should not have been opened for R138 and R138 should not have been allowed to drink the soda. V23 said, I know this because all her liquids need to be thickened by the nurse.On 11/26/25 at 1:05 PM, V24 (Speech Language Pathologist) stated R138 requires mechanical soft solids with honey thickened liquids due to a history of a stroke, and dysphagia. V24 stated all the liquids R138 drinks must be thickened to 145838 Page 3 of 5 145838 11/29/2025 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few honey consistency. V24 stated if R138 is given non-honey thick liquids this would place her at risk for increased coughing, choking and aspiration pneumonia. V24 stated thin liquids could slip down quickly without giving R138 time to react and go directly into her lung. V24 stated it is important for the staff to act on the resident's behalf and ensure R138's diet modifications are being met even when food/liquid is being served at activity functions. V24 stated the nursing units have thickener so they can manually thicken any liquid the resident would like, and any liquid can be thickened including soda. V24 stated if R138 wanted to drink soda the staff should have added thickener to make it the correct honey thickened consistency. V24 stated R138 does not mind having to use the thickener or complain about it, and she does not refuse liquids that have been thickened with thickener. R138's Order Summary Sheet dated 11/25/25 documents in part, diet order as mechanical soft texture, honey thick liquids consistency order date 04/23/25. R138's Speech Therapy Evaluation and Plan of Treatment certification period 10/21/25 - 11/19/25 documents in part with recommendations for honey thick liquids. Facility provided document titled, Census List dated 11/25/25, 11:52 AM which list R138's diet order as mechanical altered/ground - honey. Facility provided copy of R138's meal ticket dated 11/25/25 listing mechanical altered/ground, honey at the top of each meal for breakfast, lunch, and dinner. Facility provided kitchen policy titled, Thickened Liquids dated 10/01/25 which documents in part, thickened liquids will be made available to meet the nutritional and fluid needs of residents with dysphagia as ordered, to ensure residents receive thickened liquids meeting swallowing and fluid requirements and Dining Services will provide a powder or gel thickening agent to nursing to thicken thin liquids as needed. Facility provided kitchen policy titled, Therapeutic Diets dated October 2019 which documents in part, it is the center policy to insure (ensure) that all residents have a diet order, including regular, therapeutic, and texture modified, prescribed by the attending physician, physician extender or credentialed practitioner in accordance with applicable regulatory guidelines. 145838 Page 4 of 5 145838 11/29/2025 Peterson Park Health Care Ctr 6141 North Pulaski Road Chicago, IL 60646

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide and maintain an effective pest control program. These failures have the potential to affect 174 resident's residing in the facility. Findings Include: On 11/25/2025 at 9:53 AM, surveyor observed R159 laying on his bed free of pain. R159 is alert and oriented to person, place or time. R159 stated he has seen roaches today in the bathroom. Surveyors open the bathroom door and observe one small roach on the ground. R159 stated he has not seen an exterminator from the pest control company come in to spray medication to get rid of the roaches. On 11/25/2025 at 10:04 AM, Surveyor observed R70 sitting on the edge of the bed. R70 appears to be comfortable and free of pain. R70 is alert and oriented to person, place and time. R70 stated he has seen roaches in his bathroom, dresser, and nightstand. R70 opened his dresser, and there was live activity present of three different size roaches: small, medium and large. The roaches scattered away when the dresser door was opened. R70 stated this is nothing, I see them all the time everywhere. R70 stated he has not seen an exterminator from the pest control company come in to spray medication. On 11/25/2025 at 10:32 AM, surveyor observed R19 sitting on the edge of the bed while reading a magazine. R19 is alert to person, place and time, with occasional forgetfulness. R19 stated she has seen roaches in her bathroom. R19 stated when I saw the roach in my bathroom I stepped on it, then I called the nurse. R19 continued by stating the nurse then called the housekeeper, and she cleaned up the dead roach from the floor. R19 stated I don't recall seeing an exterminator come in to get rid of the roaches. On 11/25/2025 at 12:00 PM, surveyor observed activity of a small roach in the conference room table while it landed on the table. On 11/25/2025 at 9:48 AM, V17 (Maintenance Director) stated he has seen roaches in the past typically in the hallways but has seen improvement since the facility hired an exterminator. V17 stated the exterminator comes to the facility two times per month, and during that time he will let the exterminator know where he last seen any activity of roaches. Policy titled Pest Control documents in part it is the facility's policy to ensure that there is an effective pest control process in the building. If there is a suspicion or actual problem with pests, the facility will contact a pest control company to inspect presence of a pest control problem. If a pest problem or infestation is identified, the pest control company will treat the problem. It is the discretion of the pest control company if follow-up treatment or inspection is needed. Residents Affected - Many 145838 Page 5 of 5