Health inspection·January 16, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess, identify, and document a resident's skin lesion. The facility also failed to follow physician orders to consult a dermatologist for skin lesions. This applies to 1 of 4 residents (R18), reviewed for skin conditions in the sample of 34. Residents Affected - Few The findings include: R18's face sheet showed her to be a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include Vascular Dementia with mild anxiety, Chronic Diastolic Heart Failure, Chronic Kidney Disease, Personal history of Cerebral infarction, and Long Term Use of Anticoagulants. On January 13, 2025 at 10:21 AM, R18 was observed with a red lesion on the top of her nose and forehead. On January 14, 2025 at 2:27 PM, R18 was in the dining room and the red lesions to her nose and forehead were still present. V19 (Registered Nurse/RN) stated the lesions to R18 nose and forehead were skin cancer. V19 stated there are no treatments for the lesions. V19 stated they are applying A & D ointment to the area and keeping the areas from getting dry. On January 15, 2025 at 1:07 PM, V13 (Family member of R18) stated that he saw R18 yesterday and last week on Tuesday or Friday and R18 had the same lesion to her nose last week and yesterday. V18 stated that he is not aware of his mother going to the Dermatologist while residing at the facility. R18 stated she has reoccurring lesions to her nose. On January 14, 2025 at 4:25 PM, V2 (Director of Nursing) stated she wasn't aware of any wound on R18's nose and was only aware of the wound to R18's forehead. On January 15, 2025 at 10:37 AM, V7 (Wound Care Doctor) stated she was just made aware of the wound to R18's nose. V7 stated she is not sure what the wound was on R18's nose. V7 stated she saw that R18 had an order for a Dermatology consult in 2023, but she was not sure if R18 saw the Dermatologist. V7 stated she recommends that R18 visit a Dermatologist. V7 stated the Dermatologist can do a biopsy to determine if the lesions are cancerous. V7 stated in the meantime, they will keep it moist with Vaseline, and A & D ointment. V7 stated that reoccurring wounds might be suspicious for cancer. R18's Initial Wound Evaluation & Management Summary dated January 15, 2025 by V7, showed the following: Diagnosis: Nodular lesion of skin or subcutaneous tissue, Location: nose and face, Duration at least 7 days. History: scabby lesion on tip of nose, staff reports that it comes and goes, patient has been observed scratching the lesion at times. There is verbal history that the lesion on the Page 1 of 10 145878 145878 01/16/2025 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few forehead was previously diagnosed as a skin cancer (no known details). Patient was advised to go to dermatology in 2023, unclear per records if she saw a Dermatologist. No reported pain, pruritus, or drainage from nose lesion. Lesion measures 0.5 x 0.9 x 0.2 cm (centimeter). Treatment recommend referral to Dermatology. Additional Treatment information: Recommend Vaseline ointment to lesion daily. Recommend dermatology consult for biopsy if family is agreeable due to the thin skin and location of the lesion. R18 has an order dated July 8, 2023 that showed the following: Dermatology consult for nose lesion. Another order dated November 9, 2024 showed the following. Monitor skin on shower days. Document abnormal findings in progress notes. R18's care plan, shower sheets, and progress notes were reviewed for last week and this week, and there was no documentation of R18's nose lesion as of January 14, 2025 at 4:30 PM. On January 15, 2025 at 1:00 PM, V2 stated she has no knowledge of R18 seeing a Dermatologist. On January 15, 2024 at 2:35 PM, V20 (Medical Records) stated she is responsible for making doctor appointments for residents. V20 stated she was not aware of any appointment for Dermatology being made for R18 before today. On January 16, 2025 at 10:26 AM and 11:08 AM, V2 stated if the staff notices a new skin issue, the nurse should assess the skin, update the doctor and family, and document it in the medical record. V2 stated the staff should be documenting new skin tear or skin issues in the nursing progress note and detailing the assessment, who they notified, and any ordered treatments. V2 stated that she expects the staff to follow the doctor's orders. The facility's Wound and Skin Care-Wound Assessment and Documentation policy dated June 5, 2024 showed the following: 14. Progress note should be completed initially when a new wound is identified and whenever there is a change in the wound that indicates potential infection or deterioration, and as needed. 145878 Page 2 of 10 145878 01/16/2025 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

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 interview and record review, the facility failed to follow their policy to notify the physician of a resident's significant weight loss and to consult the dietitian to evaluate a resident with significant weight loss. This applies to 1 of 5 residents (R98) reviewed for nutrition in the sample of 34. Residents Affected - Few The findings include: The EMR (Electronic Medical Record) showed R98 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, congestive heart failure, dementia, and major depressive disorder. R98's Weights and Vitals Summary dated January 16, 2025, showed on July 13, 2024, R98 weighed 158 pounds and on January 13, 2025, R98 weighed 127.7 pounds resulting in a 19.18 % (percent) weight loss in six months. The documentation continued to show on October 1, 2024, R98 weighed 138.6 pounds and on November 2, 2024, R98 weighed 128.2 pounds resulting in a 7.5% weight loss in one month. As of January 15, 2025, at 10:00 AM, the facility does not have documentation to show R98 was evaluated by the dietitian for R98's significant weight loss in November 2024, or January 2025. On January 14, 2025, at 4:21 PM, V12 (Dietitian) said V12's last evaluation documented for R98 was in August 2024. V12 continued to say R98 has not been on V12's radar for weight loss monitoring. V12 said R98 needs to be evaluated to see if she needs fortified foods or supplements. V12 continued to say R98 is not currently receiving supplements. On January 14, 2025, at 4:38 PM, V5 (Unit Manager) said she reviewed R98's progress notes and does not see any progress notes regarding staff notifying R98's physician regarding R98's significant weight loss. V5 said facility staff are expected to document a progress note when a physician is notified of significant weight loss. On January 15, 2025, at 9:46 AM, V2 (Director of Nursing) said when a resident experiences significant weight loss, the physician and dietitian should be notified. V2 continued to say the dietitian would complete a nutrition evaluation for the resident. V2 said V12 had not completed an evaluation for R98's significant weight loss in November or in January. V2 said it should be documented in the medial record. On January 16, 2025, at 10:21 AM, V2 said a significant weight loss is a 5% or greater weight loss in one month and a 10% or greater weight loss in six months. V2 continued to say V12's standard of practice for significant weight loss is to document and care plan on a monthly basis. The facility does not have documentation to show R98 has had monthly care plan updates or documentation since R98's significant weight loss in November 2024. R98's Nutrition Comprehensive Assessment dated August 29, 2024, by V12 showed R98 weighed 165.8 pounds and R98's goal weight was to maintain weight. The documentation continued to show the goal for R98 was for no unplanned weight changes and R98 was at risk for malnutrition. R98's nutrition care plan dated July 26, 2024, showed [R98] is at risk for inadequate intake of 145878 Page 3 of 10 145878 01/16/2025 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nutrition and/or hydration related to diuretic therapy and diagnosis including diabetes mellitus type 2, congestive heart failure, chronic kidney disease stage 4, depression and dementia . The care plan continued to show multiple interventions dated February 15, 2024, including Registered Dietitian to evaluate and make recommendations as needed. The facility's policy titled Weight Monitoring dated October 6, 2024, showed Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem . 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. b. The physician should be encouraged to document the diagnosis or clinical that may be contributing to weight loss . e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. f. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. g. The interdisciplinary plan of care communicates care instructions to staff. 145878 Page 4 of 10 145878 01/16/2025 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders for laboratory tests for a resident receiving intravenous hydration. This applies to 1 of 1 resident (R149) reviewed for laboratory services in the sample of 34. Residents Affected - Few The findings include: The EMR (Electronic Medical Record) showed R149 was admitted to the facility on [DATE], with multiple diagnoses including hyperosmolality (fluid and electrolyte imbalance disorder) and hypernatremia (elevated sodium levels), Alzheimer's disease, dementia, and chronic kidney disease. On January 13, 2025, at 10:50 AM, R149 was sitting in her wheelchair. R149 had intravenous fluids infusing. R149's Order Summary Report dated January 15, 2025, showed an order dated January 12, 2025, for laboratory tests every Monday. The report continued to show an order dated January 12, 2025, Sodium Chloride Intravenous Solution 0.45% (percent), use 1000 mL (milliliters) intravenously one time a day every Monday for IVF (Intravenous Fluids), HANG AFTER MORNING LABS HAVE BEEN DRAWN! R149's January 2025 MAR (Medication Administration Record) showed R149 received the ordered intravenous fluids on January 13, 2025, at 6:00 AM. R149's Laboratory Results Report showed R149's laboratory tests were collected on January 14, 2025. On January 15, 2025, at 1:29 PM, V2 (Director of Nursing) said R149's laboratory tests were ordered to be drawn before the intravenous fluids were started on January 13, 2025, but the laboratory tests were performed the day after. V2 said it is the expectation for physician orders for laboratory tests to be followed as ordered. 145878 Page 5 of 10 145878 01/16/2025 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility's Arbitration Agreement failed to have the required language in the Arbitration Agreement Contract. This applies to all 170 residents residing in the facility. Residents Affected - Many The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 13, 2025, by V1 (Administrator) showed the facility census was 170 residents. The facility provided their Facility's admission Contract Between Resident and [Facility] (Short-Term Rehabilitation Care and Long-Term Care Services) contract. On pages 17-18, the contract explained the arbitration agreement, but failed to let the resident and /or the resident representative know that signing this contract was not a condition of their admission to this facility or that after signing the agreement, that they had 30 days to rescind the agreement. On January 13, 2025 at 9:32 AM, during entrance conference, V1 (Administrator) said the arbitration agreement is part of the admission packet. V1 said she has not had any newly admitted resident or their representative refuse to sign the Admission/Arbitration agreement. On January 14, 2025, at 3:53 PM, V3 (Assistant Administrator) said the current admission packet with the arbitration agreement in it, is from 2018. 145878 Page 6 of 10 145878 01/16/2025 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review the facility's Arbitration Agreement failed to have a process for selecting a neutral arbitrator. The facility also failed to provide a selection of venues that is suitable for residents or their representatives. This applies to all 170 residents residing the facility. Residents Affected - Many The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 13, 2025, by V1 (Administrator) showed the facility census was 170 residents. On January 14, 2025, at 3:03 PM, the facility's admission Packet which included the facility's Arbitration Agreement showed under General (q) Alternative Dispute Resolution: (i) Arbitration Agreement: .The Parties will cooperate with one another in selecting an arbitrator from the arbitration company panel of arbitrators and pursue diligently the arbitration . (Name of Association) Dispute Resolution Service will Administer the arbitration . If (Name of Association) or it's successor is not available to administer the arbitration, then the Facility will select another arbitration service to administer the arbitration . The arbitration hearing will be in the county in which the facility is located. On January 13, 2025 at 9:32 AM, during entrance conference, V1 (Administrator) said the arbitration agreement is part of the admission packet. V1 said she has not had any new admissions or their representative refuse to sign the arbitration agreement. On January 14, 2025, at 3:53 PM, V3 (Assistant Administrator) said the current admission packet with the arbitration agreement in it, is from 2018. 145878 Page 7 of 10 145878 01/16/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R34's EMR (Electronic Medical Record) showed R34 was admitted to the facility on [DATE], with diagnoses that included fracture of left pubis, history of falling, weakness, and overactive bladder. Residents Affected - Many R34's MDS (Minimum Data Set) dated January 2, 2025 showed R34 had severely impaired cognition and R34 required substantial/maximal assistance with toileting and showering. R34's care plan showed R34 had functional bowel and bladder incontinence related to impaired mobility and staff are to clean R34's perineal area with each incontinence episode. On January 15, 2025, at 9:27 AM, V8 (CNA/Certified Nurse Assistant) and V9 (Nurse Manager) assisted R34 to the bathroom. Both V8 and V9 put on clean gloves. V8 positioned R34's wheelchair so R34 was facing the wall with the grab bar. R34 held onto grab bar and V8 and V9 assisted R34 to stand and pivot so the toilet was behind her. V8 pulled down R34's pants and soiled incontinence brief. While R34 was sitting on the toilet, with the same gloves, V8 combed R34's hair and then put a new brief on R34 and loosely fastened it. When R34 said she was done, V8 and V9 assisted R34 to stand there was a small amount of stool on the toilet seat. V8 cleaned R34 from front to back. V8 sprayed the toilet seat with the same cleaner used to clean R34. V8 wiped the toilet seat clean and then pulled R34's incontinence brief and pants up. V8 and V9 assisted R34 back into her wheelchair. V8 sprayed R34's hands with the spray. V9 asked V8 to help R34 wash her hands with soap and water. V8 moved R34 in front of the sink and R34 washed her hands with soap and water. R34 was wheeled out of the bathroom and into her room. V8 had the same gloves on during the entire incontinence care. On January 15, 2025, at 10:46 AM, V2 (Director of Nursing) said the staff need to clean from dirty to clean. The staff should wash hands, put on gloves, assist resident to bathroom, once standing in front of the toilet, the staff can pull the resident's pants and incontinence brief down and remove the soiled brief. While the resident is using the bathroom, the staff needs to remove gloves, sanitize their hands, and put on new gloves. When resident is done, the staff need to clean both the front groin area especially if the incontinence brief was soiled and gloves need to be changed after cleaning the front area and before moving to the back area. The back area (buttock) needs to be cleaned from front to back. After cleaning the staff needs to remove their gloves, perform hand hygiene (soap and water or hand sanitizer), and put on new gloves before putting on and pulling up the incontinence brief and pants. 3. R168's face sheet showed her to be a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include Heart Failure, Chronic Kidney Disease, Major Depressive Disorder, Pain in Left and Right Legs, and Adult Failure to Thrive. On January 14, 2024 at 10:20 AM during wound rounds with V7 (Wound Care Doctor), V6 (Certified Nursing Assistant) and V4 (Wound Care Nurse), V4 removed dressing from R168's right ankle, and sprayed the wound with wound cleaner, and dried it with a 4x4 gauze. While the V6 held R168 on her right side, V4 then pulled the foam dressing off R168's left ischium and sacrum. V4 pulled up R168's buttocks up to visualize and clean part of the left ischium wound. V4's gloves were touching between R168 buttocks on the white barrier cream substance. V4 then sprayed the left ischium wound with wound cleaner and wiped it with 4X4. Without removing her gloves or performing hand hygiene, V4 applied skin prep and grabbed alginate and tore it with her hands, placed it on the left ischium wound, and then a foam dressing on top of that. V4 then sprayed the sacral wound and wiped it with a 4x4 gauze. Without 145878 Page 8 of 10 145878 01/16/2025 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many removing her gloves or performing hand hygiene, V4 applied skin prep, tore another piece of alginate, and put it on the sacral wound then put a foam dressing on top of that. On January 14, 2024 at 11:45 AM, during wound care, R168 had a right heal wound covered in black necrotic tissue right bunion wound covered in black necrotic tissue, a right inner ankle wound covered in grayish slough, and a sacral wound covered in grayish slough. V4 (Wound Care Nurse) sprayed the right foot wounds with wound cleanser and wiped dry with 4x4 gauze. Without removing her gloves, and performing hand hygiene, V4 applied skin prep to the 2 right foot wounds and the right inner ankle wound. V4 then place alginate and a new foam dressing on top of the right inner ankle wound. V4 then removed the dressing from R168's sacrum and right ischium, sprayed the wound with wound cleaner, wiped the wounds with 4x4 gauze, and then without removing her gloves or performing hand hygiene, V4 placed alginate and foam dressing on to R168's sacral wound. On January 15, 2025 at 10:32 AM, V4 stated she should remove her gloves and perform hand hygiene when moving from dirty to clean areas during wound care. V4 stated she probably forgot to remove gloves and perform hand hygiene because she was nervous. On January 16, 2025 at 10:26 AM, V2 stated when performing wound care and moving from dirty to clean areas, the staff should remove gloves and perform hand hygiene. V2 stated not removing gloves and performing hand hygiene could contaminate the wound and increase the risk of infection. The facility's hand hygiene policy dated May 2024 showed the following: 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached table. When, during resident care, moving from a contaminated body site to a clean body site. Based on interview and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to perform hand hygiene during provisions of care. This applies to all 170 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 13, 2025, by V1 (Administrator) showed the facility census was 170 residents. The facility's Water Management Plan dated September 17, 2024, showed Overview: Scope: The Water Management Plan (WMP) outlines procedures for minimizing the risk of Legionnaires' disease for persons at [the facility] site. The water systems on the site are described in tables and flow diagrams; the systems requiring control measures are noted in the Hazard Analysis . Objective: The objective of the WMP is to minimize the risk of Legionnaires' disease by managing certain building water systems for the control of Legionella bacteria. Organization: The WMP will be overseen by the team leader and members listed in the 'Team' section. The team's duties are listed in the 'Management' section . Cooling Towers: Sample cooling towers for Legionella testing within two weeks of start-up following shutdown (whether shutdown for the season or for maintenance) and at least once every three months (ideally monthly) during operation . Decorative Fountains: Test decorative fountains for Legionella at least once every three months during operation . Risk Assessment Per Hazard Analysis: The risk assessment report is based on an analysis of the building water systems for the hazards outlined in the Overview (Cope) of the WMP. The 'Significant Risk' column shows the team's determination as to whether the system/device presents a significant risk potential for one of the hazards outlined in the WMP scope . The Water Management Plan continued to show multiple areas at significant risk for 145878 Page 9 of 10 145878 01/16/2025 St Patrick's Residence 1400 Brookdale Road Naperville, IL 60563

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Legionella growth, including: the cooling tower systems, the domestic hot water systems, and the decorative fountain. The Water Management Plan showed, Control Measures: Cooling Tower Maintenance: Monitoring: .4. Test for Legionella before fans are started following a shutdown (whether shut down for the season or for maintenance)-no less than one hour and no more than 14 days after water has been circulating with routine chemical treatment-and at least once every 90 days during operation. Test sample(s) of water from the cooling tower basin or water returning to the cooling tower from the load per the WMP validation program and any applicable regulations . Control Measure: Domestic Water System Maintenance. Monitoring: Check the hot water return pumps to make sure they are running. Log date and time of inspection. Frequency of control measure task: Every one day . Control Measure: Domestic Water System Maintenance. Monitoring: Record hot water temperatures at a few faucets annually. For each measurement, record the number of seconds it took to reach the peak temperature. Log temperature complaints. Frequency of control measure task: Every one day . Control measure: Domestic Water System Maintenance. Monitoring: Record thermostatic mixing valve outlet temperature gauge readings at least once weekly, preferably daily .Control Measures: Domestic Water System Maintenance. Monitoring: Record water heater and hot water storage tank outlet temperature gauge readings at least once weekly, preferably daily . On January 15, 2025, at 9:38 AM, V10 (Chief Engineer) provided the facility's documentation of control measures for the facility's Water Management Plan for Legionella. V10 said the decorative fountain was cleaned and started on March 13, 2024, and shut down on October 8, 2024. V10 said the cooling tower was started on June 10, 2024. V10 said the only maintenance on the cooling tower at that time was cleaning and chemicals were added. V10 provided a calendar and said calendar included the dates the cooling tower was cleaned and started, when the fountain was cleaned and started, when the cooling tower was shut down and drained, when the decorative fountain was shut down and drained, and hot water temperatures from a few residents' rooms on Mondays through Fridays. V10 said the facility tested for Legionella once in 2024, on August 15, 2024. The facility does not have documentation to show Legionella testing was performed every three months on decorative fountain, Legionella testing was performed on the cooling tower within 14 days of the cooling tower starting for the year, daily hot water temperature readings including the time to reach the temperature, weekly readings of the thermostatic mixing valve outlet temperature gauge, weekly readings of the water heater and hot water storage tank outlet temperature gauge, or daily monitoring of the hot water return pumps. On January 15, 2025, at 12:55 PM, V1 (Administrator) said it is the expectation V10 perform the monitoring listed in the control measures of the facility's Water Management Plan. 145878 Page 10 of 10