Inspection·April 5, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a dressing was changed to a resident's pressure ulcer and failed to ensure the dressing was in place to a resident's pressure ulcer. This applies to 1 of 5 residents (R46) reviewed for pressure ulcers in a sample of 27. Residents Affected - Few The findings include: On 4/3/23 at 1:28 PM V13(Certified Nurse Assistant/CNA) transferred R46 to bed using a mechanical lift. R46 had a dressing on right outer knee dated 3/29/23. V13 stated, That is her bone under there. R46's Wound Evaluation and Management Summary dated 3/29/23 shows that R46 has a 1 cm x 0.7 cm x not measurable full thickness wound to her right knee. It is documented as Other viable tissue- 100% (Bone). The objective for this wound is: control infection, palliation. R46's March Treatment Administration Record shows that R46 has an order for: Right Knee: Cleanse with Normal Saline/wound cleanser and pat dry gently. Apply sure-prep skin protectant to the peri wound, apply (petroleum gel) gauze to the wound bed, cover with bordered foam. Every day shift every Monday, Wednesday, and Friday for wound care watch for signs and symptoms of infection. This order is signed out as having been done on 3/29/23 and 3/31/23. On 4/5/23 at 10:10 AM V1 (Administrator) stated that she had talked to the nurse that worked on 3/31/23 and the nurse told her that she had gotten busy and was not able to change the dressing to R46's knee on 3/31/23. On 4/4/23 at 9:30 AM V13 (CNA) took R46 to her room. V13 lifted R46's pant leg and there was no dressing in place over R46's right knee wound. The area appeared dry and scabbed/calloused with a white, solid, thin piece of tissue protruding through the skin. V13 stated, That is her bone. V13 explained that V14 (Agency CNA) was assigned to R46 today. V14 entered the room and stated that R46's bandage was on the blanket when she came in this morning to get R46 up for breakfast. V15 (Registered Nurse/Wound Care Nurse) was present and reached in the garbage to find the old dressing dated 4/3/23. V15 stated she was did not know that the dressing had come off this morning. V15 then cleaned R46's right knee wound and applied a new dressing. The undated facility policy entitled Clean Dressing Change states, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and /or cross contamination. Physician's orders will specify type of dressing and frequency of changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145878 If continuation sheet Page 2 of 10 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 145878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 4/3/23 at 10:19 AM R35 stated, I don't get therapy anymore they say there is a limitation for it related to Medicare. No one has ever come in and done exercises with me. R35 also stated that he prefers to stay in his room most of the time and does not usually participate in activities. R35's EMR (Electronic Medical Record) shows an order dated 5/4/22 (11 months ago) Restorative AROM program, resident will participate in group exercise or individual exercise 6-7 times per week x's 15 mins. When viewed on 4/4/23 this same order is marked as canceled. R35's Physical Therapy Discharge Instructions dated 4/2/21 state, DC(Discharge) to facility with restorative program. R35's Occupational Therapy Discharge Instructions dated 3/14/23 state, Patient to stay as a long-term care resident at (facility). Patient educated in thera-band exercises for both upper extremities strengthening to be done in his room by tying the band on the bed rail. Patient has red thera-band in his room and verbalized understanding. On 4/5/23 at 10:10 AM the facility presented a statement dated 4/4/23 that reads, Met with resident in his room to discuss exercises. Resident states he prefers to not have group exercises with activities or 1:1 active range of motion and passive range of motion exercises with CNA in room. Resident stated he prefers to perform his own exercises while up in the wheelchair while in his room. Offered to add short exercise videos (sit down low exertion) on desktop computer and for staff to remind him to perform exercises. (R35) in agreement with this plan. Exercise tools to be provided for resident to use. At this time V1 (Administrator) stated, (R35) prefers not to have one on one or group exercises- he prefers to be in his room. We decided we could download different exercises on his computer that he could do on his own and he was agreeable to that. The AROM (Active range of motion should be incorporated into the ADLs (activities of daily living) with the CNAs. 2. R60's Face Sheet shows diagnoses of: multiple sclerosis and contracture of left hand. R60's Minimum Data Set assessment dated [DATE] shows that her cognition is intact and has limited range of motion on both sides of her upper and lower extremities. On 4/3/23 at 1:54 PM, R60 was lying in bed. R60 was unable to move her left upper extremity or her bilateral lower legs. R60 said that she has multiple sclerosis. R60 said when she went to the neurologist in November, they wanted her to start physical therapy. R60 said that she did not get approved for therapy. R60 said that they used to come in a do exercise with her arms and legs and it would help a lot with her pain and stiffness. R60 said that she no longer gets any exercises, and they told her that they no longer have that program. On 4/4/23 at 1:35 PM, V18 (Certified Nursing Assistant) said that R60 is not on a restorative program. V18 said that the facility got rid of the restorative program a while ago. On 4/4/23 at 1:50 PM, V2 (Director of Nursing) said that they do not have a restorative program. R60's Restorative Care Plan shows, The resident has a potential for decline in range of motion due to ROM and mobility limitations, progressive MS (multiple sclerosis) disease process, and pain AAROM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145878 If continuation sheet Page 3 of 10 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 145878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm (active-assist range of motion) to BUE (bilateral upper extremities), 10 reps x 2 sets, with 1-staff limited assist, daily, 6-7 days per week Restorative PROM (passive range of motion: Altered functional range of motion of bilateral lower extremities r/t (related to) MS disease process. At risk for joint deformities/contractures. Contractures present in left shoulder, elbow, and left 3rd, 4th, and 5th fingers PROM to BLE (bilateral lower extremities), 6 reps x 2 sets, with 1-staff assist, daily, 6-7 days per week . Residents Affected - Few The facility's undated Prevention of Decline in Range of Motion Policy shows, Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion Care plan interventions will be developed and delivered through the facility's restorative program, or through specialized rehabilitative services as ordered by the attending practitioner. Based on observation, interview, and record review the facility failed to ensure a resident with a contracture had a splint applied and failed to provide restorative services for 3 of 5 residents (R35, R60, R131) reviewed for restorative/range of motion in the sample of 27. 1. On 04/03/23 at 10:13 AM, R131 was in sleeping in bed with her right hand resting on her chest. R131's fingers were slightly bent in towards the palm of her hand. There was a blue splint on the nightstand in R131's room. On 04/03/23 at 2:20 PM, R131 was up in a reclining wheelchair in the lounge area. R131 did not have a splint on her right hand. On 04/04/23 at 08:53 AM, R131 was in bed. R131's hand splint was on the nightstand in her room. On 04/04/23 at 9:32 AM, V10 (Registered Nurse) stated R131 has a right-hand contracture. She should have a brace on when she gets up and off at nights. We put it on when she gets in chair in the afternoon. On 04/05/23 at 11:21 AM, V11 (Occupational Therapy) stated R131 has a right-hand contracture. At first, we only did a palm protector. Then we were able to open her hand up more and we were able to use a resting hand splint. It is used to keep her hand open and prevent her hand from contracting further. According to the order, it should be on in morning and off at night to help keep her hand open. R131's Physician Orders shows, and order dated 2/9/23 for Patient to wear right resting hand splint during the daytime, off at night, in the morning APPLY. R131's Care Plan shows R131 has deficit related to hemiparesis post cerebrovascular accident Right resting hand splint: On in morning. Off at bedtime. The facility's Splint/Brace Policy dated 11/9/22 shows that any resident who has been assessed by a Rehabilitation Therapist and determined to demonstrate the medical necessity for the use of a splint/brace, to obtain an order for the device and provide care and services for maintaining joint mobility and for contracture care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145878 If continuation sheet Page 4 of 10 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 145878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to transfer a resident in a safe manner for 1 of 27 residents (R23) reviewed for safety in the sample of 27. The findings include: On 04/03/23 at 10:34 AM, R23 was sitting up in her wheelchair, slowly propelling herself down the hall. At 10:36 AM, V6 (Certified Nursing Assistant) assisted R23 to the bathroom in her room. R23 said she didn't want to go to the bathroom, she just wanted to go to bed. V6 than moved R23's wheelchair to the bed. R23 grabbed onto the rail of the bed and half stood up. V6 (with the gait belt around V6's waist) grabbed the back of R23's pants and helped R23 to stand, pivot, and sit down in bed. On 04/04/23 at 01:42 PM, V7 (Registered Nurse) said R23 is a one person for transfers. V7 said everyone should use a gait belt during transfers for safety. R23's Minimum Data Set, dated [DATE] shows R23 is cognitively impaired and requires extensive assistance of two persons for transfer. The facility's Safe Lifting and Movement of Residents Policy dated 7/2017 shows Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents staff responsive for direct resident care will be trained in the use of manual gait/transfer belts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145878 If continuation sheet Page 5 of 10 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 145878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to ensure appropriate care and services were performed to prevent a urinary tract infection or to prevent a urinary tract infection from worsening and failed to ensure an indwelling urinary catheter bag was kept below the level of the bladder to prevent infections for 2 of 27 residents (R42 and R81) reviewed for continence/catheters in the sample of 27. The findings include: R42's Physician Progress Notes from 3/31/23 shows that she has a history of urinary tract infections. R42's Nursing Notes dated 4/2/23 shows, Observed resident calling for bathroom multiple times since this morning more than usual received orders .UA (Urinalysis) with reflex to culture .orders carried out. R42's Nursing Notes dated 4/3/23 shows, Urine collection is still pending. Tried urine collection using specimen hat this afternoon, resident put toilet paper with the specimen. On 4/3/23 at 1:37 PM, R42 was sitting on the toilet. V17 (Certified Nursing Assistant/CNA) lifted her from the toilet using a mechanical sit to stand devices. There was a specimen hat on the toilet and urine in the hat. V17 cleaned R42's front perineal area by wiping from back to front x 3. On 4/4/23 at 11:15 AM, R42 was sitting in a wheelchair in the hallway. R42 said that she feels weak and has no energy. R42 said that she has to constantly go to the bathroom and the staff are getting mad at her. This surveyor notified V18 (CNA) that she had to use the restroom. V18 said that the other CNA already took her to the bathroom a few times this morning and it is all in her head and then told her that he was bringing her to lunch. R42 said that she did not feel good. V18 then brought her to the nurse and the nurse took R42's vitals and then she was brought to the dining room. On 4/4/23 at 1:30 PM, V17 said that he has taken R42 to the restroom a few times and two of the times she did urinate. V17 said that he was not aware that R42 needed a urine specimen collected. On 4/4/23 at 1:40 PM, V19 (Registered Nurse) said that if a urinalysis is ordered, it should be collected right away. V19 said that she spoke with the supervisor earlier about R42's urinalysis that was ordered. R19 said that it had not been obtained yet but she will straight cath her later to get the sample. On 4/4/23 at 1:50 PM, V2 (Director of Nursing) said that if a urinalysis is ordered, it should be collected within the nurse's shift. V2 said that if a resident can use the bathroom, the staff could collect the specimen by using a collection hat on the toilet. V2 said that if a resident is unable to use the toilet, the nurse can straight cath the resident to get the specimen. V2 said that it is important to get the specimen right away so treatment can be started immediately if they have an infection. The facility's Bathroom, Assisting a Resident to Policy shows, If the resident needs help in cleaning himself or herself, put on gloves. Clean the perineum from front to back with toilet tissue . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145878 If continuation sheet Page 6 of 10 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 145878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. On 04/03/23 at 10:07 AM, V8 and V9 (CNA) used a sit to stand mechanical lift machine to transfer R81 from the wheelchair to the recliner. As R81's mechanical lift sling was attached to the mechanical lift, V8 was holding R81's urinary catheter bag up in air at her waist level while R81 remained seated in the wheelchair. R81's urinary catheter tubing was filled with yellow urine with some sediment. V8 continued to hold R81's catheter bag and her waist level (above the level of R81's bladder) while R81 was assisted to stand with the machine and then lowered to the recliner. V8 than draped R81's catheter bag over the arm of the recliner. V9 than picked up R81's urinary catheter bag and held it up in the air (above the level of R81's bladder) while V8 went to get basin to put catheter bag in. At 10:10 AM, when V9 put R81's urinary catheter bag into a basin on the floor, there was air bubbles in tubing rising upwards as urine drained into the bag. On 04/03/23 at 11:55 AM, V6 (CNA) and V8 (CNA), assisted R81 to transfer from the recliner to the wheelchair with a sit to stand mechanical lift. R81's mechanical lift sling was attached to the lift and the lift machine would not work. V8 placed R81's urinary catheter bag on floor and went to get a new mechanical lift machine. V8 then picked up R81's urinary catheter bag and held it at her waist height. (Above the level of R81's bladder) V8 than clipped the urinary catheter bag onto the rail of the sit to stand and R81 was lifted and then lowered into his wheelchair. V8 than clipped R81's urinary catheter bag onto the bottom of R81's wheelchair. Yellow urine with some sediment was seen throughout the tubing. On 04/04/23 at 9:32 AM, V10 (Registered Nurse) stated urinary catheter bags should be below the resident's knee to allow the urine to flow by gravity. There is less chance of infection if the urine is not backing up in tubing and into the resident. R81's Care Plan dated 1/5/23 shows R81 has an indwelling urinary catheter due to obstructive uropathy with an intervention to maintain integrity of drainage system. The facility's Catheter Care Policy dated 2022 shows Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145878 If continuation sheet Page 7 of 10 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 145878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure that a resident received his medication at the ordered time. This applies to 1 of 27 residents (R38) reviewed for medication administration in a sample of 27. The findings include: On 4/3/23 at 10:51 AM R27 (R38's wife) stated, I don't care for agency nurses. Last night 11-7 the nurse came in and gave me my medicine walked out-never came back for (R38). He still never got his morning medications and that concerns me. (R27 was not aware of what medications R38 was supposed to get.) On 4/3/23 at 11:00 AM R38 returned from a dentist visit. R38 stood up using walker and assist from V12 (Certified Nurse Assistant/CNA). R38 had a lidocaine patch on his left hip patch that was dated 4/2/23. R38's April Medication Administration Record shows that R38 has orders for Aspercreme Lidocaine Patch 4%, Apply to back topically every 12 hours. Apply patch to back at 6:00 AM and remove patch at 6:00PM. On 4/4/23 at 9:54 AM V21 (2nd Floor Nursing Supervisor) stated, I was doing rounds yesterday and (V2 Director of Nursing) texted me about the medication. I looked in the med cart and all the meds were gone from that day, and they were signed out. I wasn't sure if the patch was put on (he didn't have a patch on), so I changed it about 10:30 AM- 11:00 AM. R38's Progress notes dated 4/3/23 state, Lidocaine patch to lower back fell off. Applied new one to lower back. Resident tolerated well. No complaints of pain or discomfort. The undated facility policy entitled Administering Medications states, Medications must be administered in accordance with the orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145878 If continuation sheet Page 8 of 10 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 145878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563 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)

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 a multi-dose vial was dated when opened. This has the potential to affect 22 of 22 residents (R17, R65, R67, R72, R73, R78, R82, R122, R123, R127, R135 & R290-R300) reviewed for medication storage in the sample of 27. The findings include: On April 4, 2023, at 2:02 PM, 2 TB (tuberculosis) multi dose vials were in the first-floor refrigerator. The vials were opened and not dated. V16 (Registered Nurse) stated, they are supposed to date medications when they open the vial/bottle. Both labels on the TB vials show, discard 30 days after opening. The facility's roster provided on April 5, 2023, shows, R17, R65, R67, R72, R73, R78, R82, R122, R123, R127, R135 & R290-R300 reside on the first floor. The facility's administering medications policy (no date) shows, 8. When opening a multi-dose container, the date shall be recorded on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145878 If continuation sheet Page 9 of 10 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 145878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563 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)

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review the facility failed to have a Certified Infection Preventionist to oversee the Infection Control Program of the facility. This applies to all residents residing in the facility. Residents Affected - Many The findings include: The Census and Condition report dated 4/4/23 show there are 137 residents residing in the facility. On 4/4/23 at 9AM, V2 (Director of Nursing/DON) and V4 (Infection Control Nurse) both said they are not Certified Infection Control Preventionist (IP) and have not taken the required training to become an IP. V4 said the facility's IP was the previous DON. V5 (QA, Payroll Staff) is serving as the IP at the facility and had taken the training. Both V2 and V4 said they were not familiar with V5's qualifications. V2 said V21 (Nurse Supervisor) also went through the IP Nurse training but was not the Infection Control -IP nurse at this time. At 11:10 AM, V5 said she has a degree with Civil Engineer but no degree in Health Sciences. V5 said she has no degree with public health, epidemiology, microbiology, medical technology, or any related fields. V5 said her work is focused on data collection. V5 said she knows numbers and when the number is up then she tells the Infection Control Nurse or DON that they need to be looked into and provide in-services to the staff. V5 said V2 (DON) is the one coordinating the Infection Control program of the facility. On 4/5/23 V1 (Administrator) said she knows the importance of having an IP nurse at the facility and V4 (Infection Control Nurse) was now in the process of completing the IP training. The facility job description qualification for Infection Control Nurse show, Policy: It is the policy of this home to designate one or more (individual (s) with appropriate education and training to act as the infection preventionist (IP) (s) to be responsible for the home's Infection Prevention and Control Program. Qualifications: Education, Experience: Registered Nurse (preferred) or an individual with public health, epidemiology, clinical laboratory science, medical technology, or related fields. The primary purpose of the Infection Preventionist (IP) is to be responsible for coordinating the infection prevention and control program. The individual will develop, implement and evaluate the .infection prevention program, perform surveillance, develop an annual surveillance plan based on the population served, evaluate services provided and analyze the surveillance data, utilize epidemiologic principle to conduct surveillance and investigation; evaluate and modify the surveillance plan as necessary, develop, interpret and assist with implementation of infection prevention and control policies and protocols, communicate infection prevention and control information and data to various committee and health care workers across the home as assigned and monitor the program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145878 If continuation sheet Page 10 of 10