Health inspection·April 18, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure six (R5, R13, R23, R26, R32 R37) residents rights were maintained. This failure affected six (R5, R13, R23, R26, R32 and R37) of six residents reviewed for resident rights out of a total sample of 22. Finding include: R23 is a [AGE] year-old resident most recent admission to the facility on [DATE] with diagnoses of but not limited to severe intellectual disabilities, down syndrome, and Alzheimer's dementia. On 04/15/24 at 10:03AM, during random observation, R23 was in TV area with activity staff. R23 was observed sleeping in geriatric chair with mechanical lift sling visible underneath resident. On 04/15/24 at 10:34 AM R23 was observed in room sleeping in geriatric chair and mechanical lift sling visible underneath resident. R5 is a [AGE] year-old resident admitted to facility on 09/16/20 with diagnoses of but not limited to Alzheimer's disease, dementia and down syndrome. On 04/15/24 at 10:06 AM, R5 was observed in geriatric chair in TV area with activity staff V3. R5 was observed sleeping in geriatric chair with mechanical lift sling visible underneath resident. On 04/15/24 at 10:24 AM, R5 was observed awake in TV area watching television with mechanical lift sling visible underneath resident. R32 is a [AGE] year-old resident re-admitted to facility on 04/14/2023 with diagnoses including but not limited to profound intellectual disability, Alzheimer's disease, autism, dementia, and down syndrome. R13 is a [AGE] year-old resident admitted to facility on 07/15/2022 with diagnoses including but not limited to Alzheimer's disease and down syndrome. R26 is a [AGE] year-old resident admitted to facility on 06/07/2022 with diagnoses including but not limited to down syndrome and Alzheimer's disease. R37 is a [AGE] year-old resident admitted to facility on 09/13/2023 with diagnoses including but not limited to bipolar disorder, down syndrome, profound intellectual disability, and Alzheimer's Page 1 of 4 145839 145839 04/18/2024 Park Ridge Healthcare Center 665 Busse Highway Park Ridge, IL 60068

F 0550 disease. Level of Harm - Minimal harm or potential for actual harm On 04/17/24 at 09:27 AM R5, R13, R23, R26, R32, and R37 identified by V3 (Social Services) were all observed in small activity room. R5, R13, R23, R26, R32, and R37 were sitting in geriatric chairs with mechanical lift slings visible beneath them in the chair. Residents Affected - Some On 04/17/24 at 11:34 AM, V2 (Director of nursing) stated, mechanical lift slings being left in geriatric chair underneath residents is typical practice here. The reason is because it would be hard to lift them and replace the sling and cause friction and shearing to residents. V2 agreed mechanical lift slings being left under residents and visible could be a dignity issue as well. Anyone who walks through this facility can see the resident is transferred using a mechanical lift by seeing the sling. On 04/17/24 at 1:37 PM, V4 (Licensed Practical Nurse) stated, mechanical lift slings being left under patients is typical practice here. Our patients have osteoporosis, weakness and are cognitively impaired residents so I feel this is a safer practice. We leave the mechanical lift slings underneath residents for ease of staff to transfer our residents. Resident rights policy dated 08/23/2017 states: Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to: Privacy and confidentiality Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules as long as those rules do not violate a regulatory requirement. 145839 Page 2 of 4 145839 04/18/2024 Park Ridge Healthcare Center 665 Busse Highway Park Ridge, IL 60068

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to ensure that dietary staff are properly certified for food handling. This failure has the potential to affect all 37 residents who receive food by mouth from the kitchen. Facility census provided by V1 (Administrator) upon entrance is 38 minus 1 resident that gets nothing by mouth (NPO). Findings include: On 04/16/24 at 11:30AM, conducted a second visit in the kitchen and requested the certification for all dietary staff from V5 (Dietary manager). V5 presented 3 food handing certificates for the dietary aides. Review of facility employee list showed 6 dietary aides currently work at the facility. V5 stated, three dietary staff that are missing the food handling certificate are working at another place and are going to send V5 their certificates. V5 later presented certificates for 2 additional staff, stating the remaining staff (V9) is still looking for his own and will send it over. On 04/17/24 at 1:177PM, V5 stated, he did not receive the food handling certificate. The staff could not find it and is taking the test right now and he will send over the certificate after completion. V5 added, V9 has worked at the facility for months now, he had a certificate in another place before he started working at the facility but could not find. On 04/17/24 at 3:00PM, V1 (Administrator) said, V9 has worked at the facility for about one year. V1 was told that V9 had a certificate that expired and is now taking the test again. V1 stated, V9 works part time for a couple of hours a week but should still have a current food handling certificate on file. Surveyor requested the expired copy of V9's license. V1 stated that they could not find it, and the facility does not have any policy regarding required qualifications for dietary staff. Illinois Food Handling Regulation Enforcement Act (410 ILCS 625) amended by SB1495, (in part) requires all food handlers in Illinois to receive training in basic food safety concepts from an ANAB-Accredited provider. Food Handlers must complete a food safety training within 30 days of beginning of employment. 145839 Page 3 of 4 145839 04/18/2024 Park Ridge Healthcare Center 665 Busse Highway Park Ridge, IL 60068

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to have measures in place to minimize the risk of Legionella and other opportunistic pathogens in building water systems and failed to have corrective actions for temperature variances outside control limits. This failure has the potential to affect all 38 residents residing at the facility. Residents Affected - Many Findings include: Facility census provided by administrator upon entrance was 38. On 4/16/2024 at 2:32PM, V2 (DON) said he is the infection prevention nurse and has worked at the facility for about 25 years. V2 stated she does not know anything about facility water management or Legionella prevention, the administrator and maintenance director takes care of that. On 04/16/24 at 3:02PM. V1 (administrator) stated, the facility does not do any testing for Legionella disease. If they did any testing it was in the past. V1 has been at the facility for 5 years and they have not done any testing. The facility only takes temperatures and do routine flushing. V1 stated the only time they will do any testing is if there is an indication of legionella or during construction, otherwise they are not required to test. On 04/17/24 at 10:13 AM, V1 presented documentation for the facility's Legionella prevention temperature log from July 2023 to April 2024. Documents show the temperature in the water heater storage tank and the circulating water exiting the mixing valve does not meet the temperature parameters. The section of the documents for corrective action taken for variance outside parameters were left blank. V1 was presented with this observation and V1 stated, We don't have any corrective action, we do not take any measures unless there is an indication of a problem. On 04/17/24 at 10:13 AM, V7 (Maintenance Director) who was present during the interview stated, he just started at the facility about 6 months ago and has never done any testing at the facility or in his previous job. V7 just checks the temperatures and does not do anything additional for temperatures that do not meet stated range. On 04/17/24 at 11:30 AM, V1 stated, she told the maintenance director to change the temperature setting in the water heater to match the parameter. V1 stated, V7 was supposed to do the testing today and the reading from today is okay. Water management policy revised 12/28/2017 stated its purpose as to identify and reduce the risk of Legionella growth and spread. Under guidelines, the policy states that preventive maintenance will be performed ss applicable, including, but not limited to hot water temperatures to be obtained at the domestic hot water boiler and at the mixing valve at least 5 times a week. Environmental services will monitor the identified areas of risk per guidelines above and implement corrective action as indicated. Additional monitoring or actions may need to be implemented for the following: Data shows control measures are persistently outside of control limits. 145839 Page 4 of 4