Health inspection·May 31, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. 3. R15's admission Record documents an admit date of 4/19/2016. This admission record includes the following diagnoses: visual hallucinations with an onset date of 7/11/23 and bipolar disorder with onset date of 4/26/23. R15's current PASARR (Preadmission Screening and Resident Review) level one was completed as an OBRA (Omnibus Budget Reconciliation Act)-1 initial screen on 4/19/16 documenting that R15 was not suspected for Mental Illness or Developmental Disease. On 5/31/24 at 10:30 AM, V12 (Bookkeeper) stated that she was unaware of the added diagnoses for mental illness so she will submit for a level 2 PASARR today. The policy Preadmission Screening and Annual Resident Review (PASARR) dated 11/28/2012 with a revision date of 11/13/2018 documents The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals. Based on interview and record review the facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASARR) for 3 (R40, R15 and R43) of 3 residents reviewed for PASARR's in the sample of 33. Findings Include: 1. R40's admission Record documents an admission date of 11/02/2021 and documents diagnoses including: Bipolar disorder, current episode mixed, unspecified, with diagnosis date of 5/25/22, Major Depressive Disorder, single episode unspecified, with diagnosis date 11/02/2021, and Unspecified Dementia with a diagnosis date of 11/02/2021. R40's current Level 1 PASARR dated 11/03/2021 documents long term care placement was appropriate. 2. R43's admission Record documents an admission date of 02/19/2019 and documents diagnoses including: Major Depressive Disorder recurrent, unspecified with diagnosis date of 04/21/2019, and Psychotic disorder with delusions due to known physiological condition with diagnosis date of 06/12/2019. R43's current Level I PASARR dated 05/10/2023 documents a diagnosis of Major Depression but did not include Psychotic disorder with delusions. The document goes on to say No Level II Required. Page 1 of 8 145918 145918 05/31/2024 The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/30/2024 at 2:25 P.M. V1 (Administrator) stated that she was unaware that R40 and R43 needed a Level II Screen. V1 stated that V12 (Bookkeeper) and V13 (Social Service) do the screens. On 5/30/24 at 2:30 P.M., V12 and V13 were interviewed. V12 stated that she was not aware that R40 and R43 had a diagnosis that would need a Level II. V12 stated that she was not aware that R40 had a new diagnosis but would go run new screens immediately. V13 stated that she would ensure it get completed as she was unaware of his diagnosis. 145918 Page 2 of 8 145918 05/31/2024 The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417

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 interview and record review the facility failed to ensure dependent residents received timely assistance for toileting needs for 2 of 2 residents (R48 and R55) reviewed for Activities of Daily Living in the sample of 33. Residents Affected - Few The findings include: 1. R48's admission Record documented an original admission date to the facility as 11/30/2022. R48 is documented with diagnoses including Parkinson's Disease, Blindness, one eye, Difficulty walking, Pain in right knee and unsteadiness on feet. R48's Minimum Data Set (MDS) with an Assessment Reference Date of 05/26/2024 documented a Brief Interview for Mental Status Score of 15, indicating R48 is cognitively intact. The same MDS documented in Section GG0130, toileting assistance is documented as substantial / maximal assistance. Section GG0170 also documented substantial / maximal assistance status for toileting transfers. Section H0300 documented R48 as being occasionally incontinent. R48's Plan of Care documented a focus area of ADL (Activities of Daily Living) Self Care / Mobility Performance Deficit with a date initiated as 12/10/2021. Interventions listed for this focus area document, (R48's) usual performance for toileting is substantial / maximal assistance. On 05/28/24 at 10:59 AM, R48 was observed sitting in her wheelchair in her room. R48 was observed being alert and oriented to person, place, and time. R48 stated she has concerns with the facility and the amount of time it takes staff to answer call lights. R48 stated that the average time it takes for call lights to be answered is 30 minutes up to one hour. R48 stated she can confirm these times by the use of the clocks in her room, which were visualized during this interview. R48 stated it isn't a specific day or time when this occurs. R48 stated she has experienced incontinence episodes waiting for staff to take her to the restroom. R48 stated she finds it frustrating and embarrassing when she experiences incontinence and has to have her clothes changed. 2. R55's admission Record documented an original admission date to the facility as 01/10/2022. R55 is documented with diagnoses including Morbid Obesity, Chronic Kidney disease, Difficulty walking, and unsteadiness on feet. R55's Minimum Data Set (MDS) with an Assessment Reference Date of 03/13/2024 documented a Brief Interview for Mental Status Score of 15, indicating R55 is cognitively intact. The same MDS documented in Section GG0130, dependent status for toileting. Section GG0170 also documented dependent status for toileting transfer. Section H0300 documented R55 as being frequently incontinent. R55's Plan of Care documented a focus area of ADL (Activities of Daily Living) Self Care / Mobility Performance Deficit with a date initiated as 04/22/2022. Interventions listed for this focus area document, (R55's) usual performance for toileting is dependent, may use sit to stand with 2 people. On 05/28/2024 at 10:59 AM, R48 was observed in her bed, and was alert and oriented. R48 stated she has experienced incontinence episodes waiting for staff to take her to the restroom. R48 stated that she has noted it taking up to 30 minutes for staff to respond to the call lights. R48 stated she finds it frustrating and embarrassing when she experiences incontinence episodes while waiting to be placed on the bed pan. 145918 Page 3 of 8 145918 05/31/2024 The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417

F 0677 Level of Harm - Minimal harm or potential for actual harm On 5/31/2024 at 9:30 AM, V1 (Administrator) stated that her expectation is that call lights be acknowledged by staff within 10-15 minutes. V1 stated that she is aware of the call light complaints from resident council and has started QA (Quality Assurance) rounds on call light monitoring. V1 stated that call light times are monitored, and staff are educated regarding call light answering. V1 stated that any staff member can answer a call light. Residents Affected - Few On 05/31/2024 at 12:35 PM, V2 (Director of Nursing) stated it is her expectation that call lights are answered within 5 minutes of them being pushed. Review of the Resident Council meeting minutes for December 2023 to April 2024, as provided by the facility document the following concerns: 12/27/23 - Nursing: Ignore Lights. 1/24/24 - Nursing: Passing up call lights. 2/28/24 - Nursing: Residents stated at times call lights are not being answered in a timely manner. 4/27/24 - Nursing: Call lights, sometimes have to wait to be answered. The facility policy titled Call Light with a revision date of 02/02/2018, documents under Guidelines that Resident call lights will be answered in a timely manner. 145918 Page 4 of 8 145918 05/31/2024 The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417

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 interview and record review the facility failed to implement interventions to prevent falls with injuries for 1 of 1 (R169) residents reviewed for falls in a sample of 33. Residents Affected - Few The Findings Include: R169's admission Record documents an admission date of 5/24/24. The admission record also includes the following diagnoses: unsteadiness on feet, abnormalities of gait and mobility, and lack of coordination. R169's admission MDS (Minimum Data Set) dated 5/27/24 documents that R169 has a BIMS (Brief Interview of Mental Status) score of 15, indicating that R169 is cognitively intact. This same MDS documents in Section GG that R169 needs supervision/touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R169's Care Plan under the focus area of I have an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day related to recent history of closed fracture of neck of left femur. The Interventions for this focus area include for sit/lying and toileting that partial/moderate assistance is needed. These interventions have an initiation date of 5/28/24. The initial fall occurrence dated 5/27/24 at 22:00 (10:00 PM) documents that the location of the fall occurred in the resident's room and that the nurse was called down to the resident's room to assess a fall that occurred as he was being assisted to the restroom by V11 with his walker when he lost his balance and fell backwards. R169 hit his head on the edge of the bed in the room causing a 3 centimeter laceration on the back of his head, and hit his left elbow causing a large skin tear to both areas. The action taken immediately per this report was that R169 was sent to emergency room for evaluation. On 5/30/24 at 1:50 PM, V2 (Director of Nursing) stated that V11 (Certified Nurse Assistant) let go of R169 to turn the call light off and when she did that he fell backward. V2 went on to state that he had a line placement that day and still may have been groggy from that. V2 stated that she has since educated the staff on proper transfers with a 'hemi' walker. V2 stated that R169 was not admitted to the hospital after evaluation he was sent back with no injuries or new orders. V2 stated that R169 returned to the facility at 5:00 AM on 5/28/24. V2 stated that R169 has the skin tear to his elbow and his head required no orders other than to keep clean and dry. On 5/30/24 at 2:00 PM, V11 stated that she went to assist R169 to the bathroom and let go of him to turn on the bathroom light. When she did he fell and hit his head on the bed and scratched his arm. V11 stated that she thinks maybe his slip on shoes may have been part of the problem, but it happened so fast she isn't sure why he slipped and fell. V11 stated that she has never worked with R169 prior to this day, nor had she worked with any resident that used this type of walker. V11 stated that R169 didn't have a gait belt on either because of the type of walker that he uses. On 5/30/24 at 2:30 PM, V15 (Therapy Director) stated that a resident who is coded as a supervision/or touching assistance should not be left unattended for the potential of a fall. V15 also stated at 145918 Page 5 of 8 145918 05/31/2024 The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few this time that a gait belt should be used on R169 when he is up walking with his 'hemi' walker or at any time due to his unsteadiness. The Fall Prevention Program policy, dated 11/21/17, documents the purpose of this policy is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Transfers-Manual Gait Belt and Mechanical Lift policy, with a revision date of 1/19/18, documents 9. use of gait belt for all physical assists transfers is mandatory . 145918 Page 6 of 8 145918 05/31/2024 The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure therapeutic diets were provided as ordered for 1 of 2 residents (R18) reviewed for therapeutic diets in the sample of 33. Residents Affected - Few The Findings Include: R18's admission Record documents an admission date of 01/30/2024. admission diagnoses listed include: Atrial Fibrillation, Atherosclerotic heart disease if native coronary artery, heart failure, and essential hypertension. R18's Physician's Order Sheet documents a dietary order of NAS (No Added Salt), regular texture, regular consistency dated 1/30/24. On 05/28/2024 at 11:57 A.M. R18 stated that she never receives the diet that is on the card. R18 stated that she always gets other foods not on the card. Tray diet card documents R18's diet as Heart Healthy. The tray card stated R18 should receive Meatballs with spiral noodles, Italian blend vegetables, garlic bread, beverage and butterscotch bars. At this time, R18 received Ravioli, Italian blend vegetables, garlic bread, and pudding. The facility Diet Spreadsheet documents on day 24, Tuesday (5/28/24), the Regular Diet for lunch served is beef ravioli w/ (with) marinara sauce, Italian blend vegetables, butterscotch bars, garlic bread, and beverage. The Heart Healthy Diet served for lunch on the same date documents Meatballs w/ spiral noodles, Italian blend vegetables, butterscotch bars, bread, and beverage. On 05/29/2024 at 12:09 P.M. R18's tray card documented she should receive Hot pork on bun, Sweet potato fries, fiesta blend vegetables, glazed applesauce cake, and beverage. R18's lunch tray observed at this time contained the following items: Bratwurst on bun, potato wedges, fiesta blend vegetables, applesauce cake, and beverage. The facility Diet Spreadsheet documents on day 25, Wednesday (5/29/24), the Regular Diet for lunch is Bratwurst on a bun, sweet potato fries, fiesta blend vegetables, glazed apple sauce cake, and beverage. The Heart Healthy Diet served for lunch the same date documents hot pork on a bun, fiesta blend vegetables, glazed applesauce cake, and beverage. On 05/29/2024 at 12:16 P.M. V2 (Director of Nursing) stated that the residents should receive the diet that is printed on the card. V2 stated if the menu had changed the residents should have been notified. V2 stated in the past the diets served has been the same as what the diet card shows. V2 stated that there has been a change in leaders in the dietary department that happened recently and this could have caused some confusion. On 05/29/2024 at 12:21 P.M. V14 (cook) stated the menu was different today because the proper food items were not ordered by the dietary manager who recently quit. V14 stated they made substitutions with alternatives they have until a new order comes in. 145918 Page 7 of 8 145918 05/31/2024 The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417

F 0812 Level of Harm - Minimal harm or potential for actual harm 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/cover food items and prevent cross contamination. This failure has the potential to affect all 67 residents residing in the facility. Residents Affected - Many The Findings Include: On 5/28/24 at 10:00 AM, during the initial tour of the kitchen, the following items were found not to be labeled and/or covered in the refrigerators: drink pitchers not labeled, desert bowls that were covered but not labeled, shredded cheese not labeled, and salad not labeled. The cake was found to be uncovered on a tray and not labeled. During the initial kitchen tour, the bulk sugar container had a cup with no handle in the container. Other food debris that was brown in color was seen in a bulk sugar container, and the lid to sugar container was sticky and had dust and food substance stuck to it. On 5/28/24 at 11:00 AM, V12 (Cook) stated that she will correct these concerns as they have recently lost their dietary manager and they are working through that. The food storage policy dated 2020 documents .1. General storage guidelines to be followed: all food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded Review of the Long-Term Care Facility Application for Medicare and Medicaid dated 5/28/24 documented 67 residents reside in the facility. 145918 Page 8 of 8