Health inspection·February 11, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide sufficient fluid intake to maintain proper hydration for one of four (R1) residents reviewed for therapeutic diets in the sample of four. Residents Affected - Few Findings include: R1 was admitted to the facility with diagnoses including but not limited to Anemia; Hyperkalemia; Pressure Ulcer of Sacral Region, stage 4; Personal History of Immunosuppression Therapy; Other Reduction Deformities of Brain; Kidney Transplant Status; Gastrostomy Status; Severe Intellectual Disabilities; Hyperosmolality and Hypernatremia; Unspecified Severe Protein-Calorie Malnutrition; and Chronic Kidney Disease, stage 3a. On 2/10/2025 at 10:02 AM, R1 was sitting in the specialty chair in her room. R1 had a calm disposition, was clean, appropriately dressed, and well-groomed. Non-interviewable. R1 does not appear neglected. R1 appears thin. R1 observed wearing a left leg stabilizing boot. No tube feeding set up observed at this time. R1's gastrostomy tube site clean, dressing changed with date 02/10/2025. On 2/10/2025 at 11:21 AM V4 (Family Member) said, From what I heard, it seemed like after one of R1's hospitalizations, the tube feed water flush order was entered wrong. I brought it up to the nurse's attention, don't remember the name, during one of the feedings, and the facility took care of it. On 2/10/2025 at 11:43 AM V2 (Director of Nursing) said, R1 was hospitalized on [DATE] for anemia and discharged the next day (12/31/2024). First page of the hospital record (provided to the surveyor by V2) is a form that the facility nurse uses to take verbal hand-of-report, before resident is readmitted to the facility. V5 (Licensed Practical Nurse/LPN) wrote on R1's hand-off-report form that R1 should receive 200 ml (milliliters) water flush QID (four times a day). V5 (LPN) did not include that water flushes are to be done four times a day before and after each meal. The report is verbal, not always detailed, and not final. The actual discharge hospital record was supposed to be reviewed thoroughly after R1 was readmitted to the facility. R1's discharge hospital record showed that R1 is to receive increased free water flush to 200 ml QID before and after meals. The nurse on duty transcribes all new orders to electronic medical record upon residents' return to the facility. V6 (LPN) was the one who put in all new orders upon R1's readmission on [DATE]. V6 (LPN) transcribed inaccurate order. V6 (LPN) put it in an order as: water flush 200 ml/four times a day instead of 200 ml four times a day before and after meal. Nurses' assumption was to flush feeding tube with 100 ml of water before and 100 ml of water after each of R1's four meals. When in fact, it was supposed to be 200 ml water flush before and after meals four times a day. R1 was hospitalized again on 1/2/2025, and that's when the hospital called me and asked how many flushes R1 is getting. We told the hospital staff the mistake was on our part. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145839 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Healthcare Center 665 Busse Highway Park Ridge, IL 60068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)