Health inspection·February 23, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to provide a dignified dining experience to residents and failed to provide privacy during incontinence care. Residents Affected - Few This applies to 3 of 3 residents (R9, R60, R77) reviewed for dignity in a sample of 38. The findings include: 1. On 02/20/24 at 11:50 AM, V13 (Certified Nursing Assistant/CNA) started to provide incontinence care for R9 when the state surveyor came into the room. V13 then stopped providing care and said, I need to get more help. She then left the room with the resident with her gown up over her chest, the sheet and blanket pulled down to the end of the bed, and the curtain and door open. R9 was left exposed to anyone walking in the hallway. At 11:54 AM, V13 return to the room with V14 (CNA). On 02/21/24 at 10:31 AM, R9 said it bothered her to be left exposed with the door and curtain open. I'm not for their show and tell. R9 said it has happened before and that staff should be more in tuned to what the patient is feeling and how leaving the door open makes them feel. On 02/20/24 at 12:03 PM, V13 said she should have closed the curtain and door before leaving the room for the residents' privacy. On 02/22/24 at 10:08 AM, V2 (Director of Nursing) said the staff should have pulled the sheets up and pulled the curtain before getting help. V2 said this should be done for dignity and privacy of the resident. The facility's Perineal Care policy (date 1/10/2023) showed, while providing perineal care provide privacy by pulling privacy curtain or closing the door in a private room. 2. On 2/20/24 at 12:57 PM, V5 (3rd floor Unit Manager) was observed feeding R60 and R77 at the same time during lunch on the 3rd floor. V5 was standing while feeding both residents. R60's MDS of 1/3/24 shows that R60 requires assistance while eating. R77's MDS of 11/30/23 shows that R77 requires assistance while eating. On 2/22/24 at 9:18 AM, V2 said staff should sit or be at the same level while assisting with feeding residents for dignity reasons. The facility's Resident Rights Promoting and Maintaining Resident Dignity during Mealtimes Page 1 of 16 145878 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0550 (4/26/2023) states that all staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. All staff will be seated while feeding a resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145878 Page 2 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide an appropriate size wheelchair for a resident. This applies to 1 of 1 resident (R70) reviewed for wheelchairs in a sample of 38. Residents Affected - Few The findings include: On 2/20/24 at 10:42 AM, during initial tour of the facility, surveyor asked R70 if she had any concerns. R70 stated, Yes, I do have a concern. I'm missing my wheelchair. This wheelchair here is not mine. Mine had my name on it and it was bigger. It was black. This wheelchair is too small. It's too low to the ground and too tight across my hips. I don't remember when it was exactly missing. I've told everyone that has come to my room that it's missing. I've told them the new wheelchair is uncomfortable, but no one is doing anything about it. I need my old one back. I can't use this one because it's just not the right size and it's uncomfortable. On 2/20/24 at 11:00 AM, surveyor tried to locate R70's Certified Nursing Assistant/CNA. V23 (CNA) stated R70's CNA was on her break. Surveyor asked V23 if R70 ever complained to her that her wheelchair was not the appropriate size. V23 stated no and said she doesn't normally work on the unit full time and that she floats all over the facility. Surveyor asked V23 if she could transfer R70 into her wheelchair. After transferring R70 in the wheelchair, surveyor was unable to slide a finger in between the sides of the wheelchair. It was too tight. R70 stated, It's too tight on the sides and it's causing pain. It's too low on the ground. This isn't going to work. On 2/20/24 at 11:13 AM, V22 (LPN/Licensed Practical Nurse/ 2nd floor Unit Manager) stated, Yes, I'm aware that (R70's) own wheelchair is missing. We are looking for it, but we can't find it. We did provide her with another one. She didn't mention it to me that it's too small. I did rounds this morning and she never said anything. I will go talk to (R70). On 2/20/24 at 11:17 AM, V22 came back to surveyor and stated, I talked to (R70), and she said her wheelchair causes pain. I told her she doesn't have to use it. We are looking for her wheelchair. I will try to find it. Thanks for telling me. On 2/21/24 at 10:08 AM, V21 (RN/Registered Nurse/Restorative Nurse) stated, I will have therapy evaluate (R70) today and get the correct wheelchair. We are actively looking for her old wheelchair. They personally didn't tell me it was missing. If we knew the wheelchair that we gave her was causing issues, therapy or the restorative nurse (me) would come and assess that new wheelchair. On 2/21/24 at 10:56 AM, V20 (Social Services) stated, We received an email from this family on Friday 2/16/24 stating that her wheelchair has been misplaced. On Monday, we started searching for her wheelchair. Yesterday, I was informed that she was uncomfortable in the new wheelchair that was provided. I talked with our supply manager, and we provided a new wheelchair to her. It was much more comfortable and suitable. V20's email from R70's son dated 2/16/24 documents: I did tell mom's (R70) nurse about this today, but I guess she was brought back to her room in the wrong wheelchair after her shower earlier this week. Her chair has special brake extensions, and it says (R70's last name) and (room number) on the white tag hanging off the back of the seat. Just wanted to help tracking it down and returning it to her room. Thank you. 145878 Page 3 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V20's email to R70's son dated 2/20/24 after surveyor brought it to the facility's attention documents: Your mom (R70) reported that the current wheelchair that she has was uncomfortable. Our supplies manager switched it out with one that she states is more comfortable until her chair has been located. On 2/21/24 at 1:55 PM, V19 (Director of Mission Integration) stated, When residents come in, they are given a wheelchair based on height and weight. If at any time, they are uncomfortable with their wheelchair, we will get physical therapy and/or occupational therapy involved and have them assess the resident with the wheelchair. Sometimes, they need longer footrests, or the wheelchair is too snug or too wide or we may have to provide them with different brake extenders. I don't have a policy regarding this. R70's face sheet shows diagnoses of cerebral infarction, chronic obstructive pulmonary disease (COPD), and wedge compression fracture of T5-T8 vertebra. R70's MDS (Minimum Data Set) dated 1/24/24) shows a BIM's (Brief Interview for Mental Status Score) of 14, which means she is cognitively intact. It also shows she uses a wheelchair. R70's care plan dated 11/3/23 shows a problem that she has limited physical mobility related to weakness, chronic back pain (Kyphoplasty due to compression fractures T5-T6 and T7-T8) in 12/2023, pathological fracture T12-L1), osteoporosis, COPD, and coronary artery disease. Approach: Locomotion: Wheelchair. Facility was unable to provide concerns/grievance form for R70's missing wheelchair and they were unable to provide a policy on wheelchairs. 145878 Page 4 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R107's face-sheet showed, R107 was admitted to the facility on [DATE] and her diagnoses included inflammation of the gallbladder and laparoscopic cholecystectomy. R107's MDS (Minimum Data Set) dated 4/14/23 showed, R107 is cognitively intact (BIMS-Brief Interview of Mental Status-score of 15) and required extensive assist for ADLs (activities of daily living). R107's progress notes dated 4/17/23 at 7:51 PM showed R107 was sent to the hospital for investigation and confirmation of fracture of the right hip. Records lacked documentation to show that the notice of transfer or discharge was given in writing to the resident or her representative upon transfer or discharge or as soon as practicable. Records lacked documentation to show, the facility sent a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman within 30 days. On 2/22/24 at 12:15 PM, V19 (Director of Mission Integration) stated, notice of transfer or discharge was not given in writing, to the resident or her representative upon transferring R107 to the hospital on 4/17/23. On 2/22/24 at 12:18 PM, V1 (Administrator) stated, notice of transfer or discharge was not given in writing to a representative of the Office of the State Long-Term Care Ombudsman upon transferring R107 to the hospital on 4/17/23. Based on interview and record review, the facility failed to provide a resident and/or his family/power of attorney in writing for the reason of transfer to the hospital. They also failed to notify the ombudsman of the transfer. This applies to 3 of 3 residents (R41, R107, R208) reviewed for discharge in a sample of 38. The findings include: 1. On 2/22/24 at 11:56 AM, V19 (Director of Mission Integration) stated, We didn't inform (R41) or his representative of the reason for transfer in writing at the time of discharge to the hospital or afterwards. R41's face sheet shows an admission date of 10/5/23 to the facility. R41's progress notes document the following: On 12/23/23 at 11:40 AM, (R41) had a scant amount of pink tinged sputum. On 12/23/23 at 3:48 PM, Spoke with nurse practitioner. Verbal order read back to send out (R41) to the hospital ER (Emergency Room) Spoke with (R41's) POA. He is aware of the situation and transfer to the hospital. Left facility via 911 at 3:43 PM. On 12/23/23 at 9:02 PM, Spoke with staff at hospital ER. (R41) will be admitted with a diagnosis of pneumonia and hemostasis. On 12/28/23 at 7:40 PM, (R41) arrived with 2 ambulance personnels via stretcher from the hospital at 7:40 PM. (R41) was transferred to his bed. 145878 Page 5 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0623 Level of Harm - Minimal harm or potential for actual harm Review of R41's electronic medical record shows nothing was uploaded regarding the discharge letter to the resident/POA. Review of R41's January POS (Physician Order Sheet) does not show a physician's order to be transferred to the hospital. Residents Affected - Few 2. On 2/22/24 at 12:01 PM, V19 (Director of Mission Integration) stated, We didn't inform (R208) or her representative of the reason for transfer in writing at the time of discharge to the hospital or afterwards. R208's face sheet documents an admission date of 11/10/23. R208's progress notes document the following: On 1/2/24 at 8:01 AM, (R208) observed on right side in his room at 6:55 AM. Noted with alarm sound in (R208's) room. (R208) stated, I was trying to hurry and go to the bathroom. I'm just humiliated that I have to use the bathroom by myself. Noted with stating again during assessment, I'm just clumsy and not careful. Encouraged to use call light to allow staff to assist with needs. She verbalized of having pain to left leg/hip. Bruise noted below the right elbow. Express with flexing extremities of having pain to left leg/hip. Notified medical doctor and informed. New orders received for x-rays of right arm and elbow, left hip, pelvis, and femur. Spoke with daughter and informed. On 1/2/24 at 10:00 AM, (R208) seen and evaluated by medical doctor with order to send (R208) to hospital (ER) due to pain on left lower trochanter post fall and irregular heartbeat. (R208)'s daughter at bedside. (R208) sent to emergency room for further evaluation and treatment. (R208)'s daughter to follow. Report given to nurse at emergency room. Informed of urine culture specimen result with positive UTI (Urinary Tract Infection). On 1/2/24 at 4:00 PM, (R208) sent back from the hospital. (R208) sent out due to pain after fall and irregular heartbeat. Per report, (R208) was administered with Rocephin IV while in hospital. New order for oral antibiotics for UTI from hospital received. (R208) is allergic to prescribed antibiotic. Medical doctor informed with order to change to Macrobid 500 MG (Milligrams) orally twice a day x 5 days. Noted and carried out. On 1/5/24 at 6:33 PM, CNA (Certified Nursing Assistant) alerted this nurse that (R208) is on the floor. Upon assessment, (R208) observed lying supine, both legs straight down with head tilted down with occiput against the bedside table next to her bed .Unable to recall how she fell on the floor. Complained of pain on left hip. Body assessment done and showed no break in skin. 911 called due to complaint of left hip pain without moving resident from the floor other than placing a pillow on head for comfort. (R208) has recent history of left hip fracture with displaced intertrochanteric fracture of left femur. Daughter (POA) informed and will follow resident in hospital. Medical doctor and supervisor informed. Report called into hospital and spoke with ER nurse. On 1/5/24 at 11:05 PM, (R208) returned from hospital via ambulance at 8:50 PM will continue to monitor. Review of R208's electronic medical record shows nothing was uploaded regarding the discharge letter to the resident/POA. R208's January 2024 POS does not show an order for transfer to the hospital on 1/5/24. 145878 Page 6 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V19 provided an email of a list residents that were discharged in December and emailed to the ombudsman. R208's name was not on the list. V19 stated that if R208's name is not on the list, then the ombudsman was not made aware of the discharge to the hospital. Facility's policy titled Discharge and Transfer from the Facility (10/15/22) documents: B. Timing of The Notice-1. Before the facility will transfer or discharge a resident, the facility will provide a written notice to the resident and resident representative in a manner and language understandable to the party. 2. For facility-initiated transfer or discharge of a resident, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long Term care (LTC) Ombudsman. If information changes prior to the resident's discharge, the notice will be update and distributed to all required parties. 5. Emergency Transfers-When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers must also be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. 145878 Page 7 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide in writing to residents and their families/POA (Power of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 3 of 3 residents (R41, R107, R208) reviewed for discharge in a sample of 38. The findings include: 1. On 2/22/24 at 12:02 PM, V1 (Administrator) stated R41 was not given a bed hold notice at the time of discharge to the hospital. She stated that during the time of admission, the residents are given a contract regarding bed holds, but not at discharge. R41's face sheet shows an admission date of 10/5/23 to the facility. R41's progress notes document the following: On 12/23/23 at 11:40 AM, (R41) had a scant amount of pink tinged sputum. On 12/23/23 at 3:48 PM, Spoke with nurse practitioner. Verbal order read back to send out (R41) to the hospital ER (Emergency Room) Spoke with (R41's) POA. He is aware of the situation and transfer to the hospital. Left facility via 911 at 3:43 PM. On 12/23/23 at 9:02 PM, Spoke with staff at hospital ER. (R41) will be admitted with a diagnosis of pneumonia and hemostasis. On 12/28/23 at 7:40 PM, (R41) arrived with 2 ambulance personnels via stretcher from the hospital at 7:40 PM. (R41) was transferred to his bed. Review of R41's electronic medical record shows nothing was uploaded regarding the bed hold to the resident/POA. Neither was anything mentioned in the progress notes. 2. On 2/22/23 at 12:08 PM, V1 stated that R208 was not given a bed hold notice at the time of discharge to the hospital. R208's face sheet documents an admission date of 11/10/23. R208's progress notes document the following: On 1/2/24 at 8:01 AM, (R208) observed on right side in his room at 6:55 AM. Noted with alarm sound in (R208's) room. (R208) stated, I was trying to hurry and go to the bathroom. I'm just humiliated that I have to use the bathroom by myself. Noted with stating again during assessment, I'm just clumsy and not careful. Encouraged to use call light to allow staff to assist with needs. She verbalized of having pain to left leg/hip. Bruise noted below the right elbow. Express with flexing extremities of having pain to left leg/hip. Notified medical doctor and informed. New orders received for x-rays of right arm and elbow, left hip, pelvis, and femur. Spoke with daughter and informed. On 1/2/24 at 10:00 AM, (R208) seen and evaluated by medical doctor with order to send (R208) to hospital (ER) due to pain on left lower trochanter post fall and irregular heartbeat. (R208)'s daughter at bedside. (R208) sent to emergency room for further evaluation and treatment. (R208)'s daughter 145878 Page 8 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to follow. Report given to nurse at emergency room. Informed of urine culture specimen result with positive UTI (Urinary Tract Infection). On 1/2/24 at 4:00 PM, (R208) sent back from the hospital. (R208) sent out due to pain after fall and irregular heartbeat. Per report, (R208) was administered with Rocephin IV while in hospital. New order for oral antibiotics for UTI from hospital received. (R208) is allergic to prescribed antibiotic. Medical doctor informed with order to change to Macrobid 500 MG (Milligrams) orally twice a day x 5 days. Noted and carried out. On 1/5/24 at 6:33 PM, CNA (Certified Nursing Assistant) alerted this nurse that (R208) is on the floor. Upon assessment, (R208) observed lying supine, both legs straight down with head tilted down with occiput against the bedside table next to her bed .Unable to recall how she fell on the floor. Complained of pain on left hip. Body assessment done and showed no break in skin. 911 called due to complaint of left hip pain without moving resident from the floor other than placing a pillow on head for comfort. (R208) has recent history of left hip fracture with displaced intertrochanteric fracture of left femur. Daughter (POA) informed and will follow resident in hospital. Medical doctor and supervisor informed. Report called into hospital and spoke with ER nurse. On 1/5/24 at 11:05 PM, (R208) returned from hospital via ambulance at 8:50 PM will continue to monitor. Review of R208's electronic medical record shows nothing was uploaded regarding the bed hold to the resident/POA. Neither was anything mentioned in the progress notes. On 2/22/24, surveyor requested the policy regarding the bed hold notice and it was not provided. On 2/22/24 at 12:15 PM, V19 (Director of Mission Integration) stated she just created a policy on bed hold notice. She confirmed that the bed hold notice should be given at the time of discharge. 3. R107's face-sheet showed, R107 was admitted to the facility on [DATE] and her diagnoses included inflammation of the gallbladder and laparoscopic cholecystectomy. R107's Minimum Data Set (MDS) dated [DATE] showed R107 is cognitively intact (BIMS-Brief Interview of Mental Status-score of 15) and required extensive assist for ADLs (activities of daily living). R107's progress notes dated 4/17/23 at 7:51 PM showed R107 was sent to the hospital for investigation and confirmation of fracture of the right hip. Records lacked documentation to show that the facility provided the resident and the resident representative written notice of bed-hold policy and return. On 2/22/24 at 12:25 PM, V1 (Administrator) and V19 (Director of Mission Integration) stated, notice of bed-hold policy was not given in writing, to the resident or her representative, when R107 was transferred to the hospital on 4/17/23. 145878 Page 9 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents dependent upon staff for ADLs (Activities of Daily Living) received nail grooming for 4 of 38 residents (R18, R101, R139, & R146) reviewed for ADLs in a sample of 38. Residents Affected - Some The findings include: 1. On 02/20/24 at 11:05 AM, R18 was observed with long jagged nails, with brown substances under the nails. R18 said that she didn't like them that way and wanted them cut and filed. R18 has diagnoses including, cerebral atherosclerosis, and polyarthritis osteoporosis. R18's 11/5/24 Care plan showed an ADL self-care performance deficit related to Activity Intolerance, Dementia, Impaired balance, Limited Mobility. She was admitted to hospice services and the goal is comfort with interventions including, check nail length and trim and clean on bath day and as necessary. R18's 12/28/23 Minimum Data Set (MDS) showed that R18 cognition is severely impaired, and in Section GG I. Personal hygiene R18 needs substantial/maximal assistance. 2. On 02/20/24 at 10:49 AM, R101 was observed with her fingernails long, jagged, and brown substances under nails. R101 said I asked about a month ago for them to cut them and nobody has helped me. R101 has diagnoses including, Parkinson's disease, osteoarthritis, and muscle weakness. R101's 1/3/24 MDS section C showed that her cognition is intact. Section GG I. of the MDS showed that R101 needs setup or clean up assistance for personal hygiene. R101's 1/3/24 care plan showed that R101 has an ADL self-care performance with interventions including, Check nail length and trim and clean on bath day and as necessary, and personal hygiene - supervision maximal 1 assist. 3. On 02/20/24 at 11:00 AM, R139 was observed with his fingernails long, jagged, and brown substances under nails. R139 said, The last time they cut them was a couple of weeks ago. I would rather they be cut short. R139's diagnoses include, Cerebral infarction, weakness, need for assistance with personal care, Dementia, and Alzheimer's disease. R139's 1/2/24 care plan showed he has an ADL self-care performance deficit related to a history of Cerebral Vascular Accident (CVA), dementia, and weakness. The care plan interventions included, check nail length and trim and clean on bath day and as necessary, and personal hygiene with moderate to maximal 1 person assistance. R139's MDS showed that his cognition is moderately impaired and in section GG I. He is to receive substantial maximal assistance with personal hygiene. 4. On 02/20/24 at 11:14 AM, R146 was observed with her fingernails long, jagged, and with brown substances under nails. R146 said that it was probably about a month since the last time they were cut, and that staff does not offer to cut them. On 02/21/24 at 10:58 AM, R146 was observed with her fingernails long, jagged, and with brown substances under nails. R146 has diagnoses including hemiplegia and hemiparesis, dementia, and weakness. R146's 1/23/24 care plan showed she has an ADL self-care performance deficit related to weakness, left hemiparesis post Cerebral Vascular Accident (CVA), osteoarthritis, and activity intolerance .with approaches including, personal hygiene - moderate to maximal to dependent 1 person assistance. R146's 1/29/24 MDS section GG I. personal hygiene showed that she needs substantial/maximal assistance. 145878 Page 10 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 02/22/24 at 09:59 AM, V2 (Director of Nursing) said that the residents' nails should be clean and short, and staff should be providing ADL care routinely and as needed. V2 said this should be done for infection control, to prevent skin tears, cleanliness, and dignity. The facility's Activities of daily living (ADL) policy (1/18/2023) showed, that care and services will be provided for the following activities of daily living, bathing, dressing, grooming, and oral care. The policy's Explanation and Compliance guidelines showed, 3. a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 145878 Page 11 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to provide interventions and supervision to 2 of 2 residents (R9, R29) who were at risk for falls in a sample of 38. Residents Affected - Few The findings include: 1. On 02/20/24 between 11:50 AM to 11:54 AM, R9 was observed in her bed that was in a high position. At 11:50 AM, V13 (Certified Nursing Assistant/CNA) had started to provide incontinence care for R9, when V13 stopped and said she needed to go get assistance, leaving R9 in her bed, with the bed in a high position. At 11:54 AM, V13 and V14 (CNA) returned to R9's room to continue incontinence care. On 02/20/24 at 12:03 PM, V13 said she had meant to put R9's bed back in a low position. V13 said that R9's bed should not have been left in a high position because it is a fall risk. On 02/22/24 at 10:06 AM, V2 (Director of Nursing/DOM) said the staff should not have left R9 in a high position when she went to go get help because it is a fall risk and possible injury. 2. On 02/20/24 at 10:45 AM, R29 was observed in bed with the bed in a high position. On 02/21/24 at 11:53 AM, R29 was observed in bed and awake. R29's bed was in a medium height position. R29 said, I'm all mixed up today. R29 was confused and unable to use the bed control. On 02/21/24 at 12:00 PM, R29's bed was still in a medium height position and V15 (CNA) came into the room. The state surveyor asked V15 if R29's bed was in the lowest position and V15 said no and then lowered the bed about 24 inches. V15 said that she was R29's CNA for the day and was not sure if her bed is to be in the lowest position while she is in it. R29's 1/5/24 care plan showed R2's has an increased risk for falls related to poor balance, history of falls, receiving antipsychotic which could cause dizziness, and incontinence. R29's care plan showed interventions including, The facility will strive to prevent a major injury, and bed locked in lowest position when care not being provided. R29's 12/14/23 Minimum Data Set (MDS) showed that R29 cognition is severely impaired. On 02/22/24 at 10:02 AM, V2 said that R29's bed should be in a low position when she is in bed. V2 said this should be done because if she does fall, there is more of a risk for injury if she falls from a high area. V2 said the staff should have known that R29's bed should be in a low position and should have looked at R29's (plan of care) for her care needs. The facility's Fall Risk Assessment Policy (11/2/2022) showed that it is the policy of the facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. 145878 Page 12 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

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 properly label, date, and store food items and maintain a clean kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 2/20/24 documents that the total census was 162 residents. On 2/22/24 at 12:24 PM, V18 (Diet Office Assistant) said there is only 1 NPO (Nothing by Mouth) resident, and the other 161 residents eat from the facility kitchen. On 2/20/24 from 9:14 AM through 10:21 AM, the facility kitchen was toured in the presence of V3 (Director of Food and Nutrition), and the following was found: In the Cook's refrigerator: 1. A small bin of pureed ham with expiration date of 2/15. 2. A small bin of ground ham with expiration date of 1/31. 3. An unlabeled and undated opened package of what V3 said was baloney. 4. A 4 Quart bin of processed ham dated opened on 2/18 and expiration on 2/29. V3 said those dates were not correct, processed meats are not good for 11 days. 5. A medium sized plastic bin of tuna salad dated 2/18 and expiration of 2/29. V3 said that expiration date was wrong, that tuna salad, or any salad mixed with mayonnaise is only good for 3 days. 6. A 2-quart bin of processed turkey labeled opened on 2/18 and expiration of 2/29. In the Dry Storage: 7. Four 48-ounce glass jars of grape jelly with best by date of 9/27/23. 8. Two 9-ounce taco seasoning mixes with expiration date of 12/6/23. 9. A 1 quart bottle of foam free liquid oven cleaner spilled on the floor, with the contents white and dried up on the floor. V3 said she did not know how or when the cleaner spilled. In Walk-In refrigerator #2 10. A pink liquid spill on the floor under the chicken cutlets rack. 11. On 2/20/24 at 9:14 AM in the kitchen in front of the 3-compartment sink there was a sheet of plywood on the floor with a lot of dust surrounding it. V3 said a pipe in the floor was dug up on 2/19/24 because of a blockage. On 2/20/24 at 10:16 AM the kitchen floor was still dirty from the pipe 145878 Page 13 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0812 Level of Harm - Minimal harm or potential for actual harm work and the dust/dirt had shoe prints in it and was being tracked through the kitchen. V3 said we were going to mop it, but maintenance told us to leave it because they were coming back again tonight to continue repairs. We can mop it up, because we are tracking it through the kitchen. On 2/21/24 at 11:08 AM, V3 said the construction company was in the kitchen working on the pipe until 2/20/24 at 4:30 AM and they still had to concrete and re-tile the floor to finish the repair. Residents Affected - Many 12. For the duration of the kitchen tour on 2/20/24 from 9:14 AM to 10:21 AM, V3's hairnet was only covering half of her head. V3's hair was not restrained from the top middle of her head forward. V3's hair net was only covering the top middle of her head back down to her neck. On 2/22/24 at 9:37 AM, V3 (Director of Food and Nutrition) said all food items in the kitchen should be labeled and dated to make sure the food is safe for the residents to eat. V3 said expired food items should be thrown away because they would be a health hazard if consumed by the residents. V3 said processed meats are good for 3 days once opened. V3 said the kitchen staff slice their own deli meats and she was not sure if deli meats sliced on site last longer than pre-sliced and packaged meats. V3 said she would refer to the facility policy for expiration of deli meats. V3 said the risk with serving expired processed meats is foodborne illness. V3 said prepared salads like tuna salad are good for 3 days in the refrigerator. V3 said hairnets need to be worn covering all hair on the head while in the facility kitchen because hair could potentially fall in the food and contaminate it. V3 said the floors in the kitchen and storage areas should be mopped after each meal. The facility's policy titled, Expired/Recalled Product revised 12/18 states, Procedure: .3. Outdated or recalled product will be discarded . The facility's policy titled, Food Storage and Expiration Dates revised 11/23 states, Policy: All opened food that is placed into storage shall be labeled with the product name, date opened and/or expiration, or use by date. If a product has a manufacturer expiration or use by date, follow that date unless removed from the original container .The day the product is opened is counted as day one. Procedures: Foods that expire 3 days after opening: leftover foods, prepared salads (egg, tuna, etc.), leftover deli meats .The dining service manager will: .2. Assure labeling guidelines are followed . The facility's policy titled, Labeling & Dating for Food Storage revised 11/30/22 states, Storage and packaging practices help assure proper ingredient usage and food safety. All foods that require time and temperature control (TCS) should be labeled with the following: common name of the food, date the food was made, and use by date . Any unopened items with a printed manufacturers use by date may be used until the date listed on the product . The facility's policy titled, Hair Restraints revised 11/30/22 states, Employees shall use effective hair restraints to prevent the contamination of food or food contact surfaces .Hair shall be covered at all times while in the kitchen and during service of food . The facility's policy titled, Cleanliness and Sanitation of Service Area effective 1/2023 states, Policy: The cleanliness and sanitation of the serving area is to be maintained. Procedures: Employees involved in the service of food in the serving area must observe the following procedures to ensure safety: .After Service: 1 .Monitor racks, carts, and coolers, checking for any spillage. 2. Sweep and clean floors after meal service . 145878 Page 14 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 5. On 02/20/24 at 12:30 PM, V17 (RN/Registered Nurse) was observed feeding 2 residents R98 and R1 at the same time. V17 was observed using only her right hand and used R98's and R1's spoons, forks, and cups, never cleaning her hands. At 12:39 PM, V16 (CNA) took over feeding R98 and R1. V16 was observed using only her right hand and using R98's and R1's spoons, forks, and cups, never cleaning her hands. Residents Affected - Some On 02/20/24 at 12:32 PM, V17 said that she had cleaned her hands before she started serving the lunch trays and felt that should have been enough. V17 said that it is not ideal to keep cleaning your hands while feeding two people. V17 said that it is possible for cross contamination if you feed two people at the same time and don't clean your hands in-between. On 02/22/24 at 09:48 AM, V2 (Director of Nursing) said that staff should not be feeding two residents at the same time because there can be cross contamination, it is for infection control. 6. On 02/20/24 at 11:54 PM, V13 and V14 (CNAs) were observed providing incontinence care for R9. V14 removed R9's soiled brief, did not remove her gloves or clean her hands, and put her hands on R9's hip stabilizing R9 as V13 cleaned R9's buttock area. After V13 provided perineal care to R9, V13 removed her gloves but did not clean her hands before putting on clean gloves. V13 then assisted in putting on R9's new brief, and repositioning R9 in the bed. V14 also assisted with putting on R9's new brief, repositioned her in the bed, adjusting R9's sheet and blanket and touching the bed control to adjust R9's bed, still with the dirty gloved hands. On 02/20/24 at 12:03 PM, V13 (CNA) said she should have cleaned her hands before putting on new gloves. V13 said she should have cleaned her hands after going from a dirty area to clean for infection control. On 02/20/24 at 12:04 PM, V14 said she should have removed her gloves and cleaned her hands after going from a dirty area. V14 said she forgot to do it after removing the brief. V14 said this should be done for infection control. On 02/22/24 at 9:50 AM, V2 said that staff should clean their hands and change gloves when going from dirty to clean. V2 said this should be done for infection control to prevent the spread of infections. The facility's Infection Control - Hand Washing policy (11/30/2022) showed that the facility considers hand hygiene the primary means to prevent the spread of infections. Based on observation, interview, and record review, the facility failed to maintain infection control while entering isolation, while feeding residents, and during incontinent care. This applies to 10 of 10 residents (R1, R9, R59, R60, R76, R77, R89, R98, R104 and R109) reviewed for infection control in a sample of 38. The findings include: 1. On 2/22/24 at 10:39 AM, V6 (Social Services) was observed entering R59's room without gown and gloves. At 10:41 AM, V6 came out of R59's room. V6 said she went to issue R59 a notice of discharge. V6 only had on her N95 mask and goggles on when she entered the room. V6 said thought that all the PPE (Personal Protective Equipment) she was on was sufficient, she did not look at the isolation sign on the door. There was a sign for Contact Precautions and Droplet Precautions on the door. For the contact precaution sign, providers and staff must put on gloves and gown before entering the room, discard gloves and gown before exiting the room. 145878 Page 15 of 16 145878 02/23/2024 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R59's lab result of 2/14/24 showed that R59 tested positive for RSV (Respiratory Syncytial Virus). R59's EMR (Electronic Medical Record) showed that R59 was placed on contact/droplet precaution for RSV on 2/14/24 and end of isolation will be 2/23/24. On 2/22/24 at 10:43 AM, V9 (Agency LPN/Licensed Practical Nurse) said that R59 was on isolation for RSV and staff requires full PPE before going in the resident's room. On 2/22/24 at 10:47 AM, V2 (DON/Director of Nursing) said staff should have full PPE (gown, gloves, N95, face shield) prior to entering the room. On 2/22/24 at 12:15 PM, V10 (Infection Preventionist) said RSV is a respiratory infection and requires droplet isolation, staff are to wear full PPE to prevent possible spread of infection. 2. On 2/20/24 at 12:38 PM, during lunch on the 3rd floor, V8 (Volunteer) was observed feeding R104 and R109 at the same time. V8 used the same hand to feed both residents and did not perform any hand hygiene in between feeding both residents. R104's MDS (Minimum Data Set) of 1/5/24 shows that R104 requires assistance with meals. R109's MDS of 12/29/23 shows that R109 requires assistance with meals. 3. On 2/20/24 at 12:50 PM, V4 (MDS/Minimum Data Set Coordinator) was observed feeding R76 and R89 at the same time during lunch on the 3rd floor. V4 used the same hand to feed both residents and did not perform any hand hygiene while feeding both residents. On 2/21/24 at 12:15 PM, V7 (CNA/Certified Nurse Aide) was observed feeding R76 and R89 at the same time, using the same hand. V7 failed to perform any hand hygiene while feeding both residents. R76's MDS of 12/13/23, shows that R76 requires assistance with meals. R89's MDS of 2/1/24 shows that R89 requires assistance with meals. 4. On 2/20/24 at 12:57 PM, V5 (3rd floor Unit Manager) was observed feeding R60 and R77 at the same time during lunch on the 3rd floor. V5 failed to perform any hand hygiene while feeding both residents. R60's MDS of 1/3/24 shows that R60 requires assistance while eating. R77's MDS of 11/30/23 shows that R77 requires assistance while eating. On 2/22/24 at 9:18 AM, V2 (DON) said staff should wash their hands before, after, and in between feeding every resident. The facility's Infection Control- Management of Respiratory Syncytial Virus (RSV) policy (2/16/24) states that infection control principles will be followed to decrease the risk of transmission, based on federal, state or local guidance. The principle includes, hand hygiene, respiratory and cough etiquette, transmission-based precautions, appropriate personal protective equipment as indicated, cleaning and disinfecting of high-touched surfaces. 145878 Page 16 of 16