Health inspection·December 19, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were nine (3) medication errors out of 30 medication opportunities, resulting in a 10% medication error rate. This applies to 2 residents (R20, R42) of 4 residents observed during medication administration. Residents Affected - Few Findings included: 1. On 12/17/2024 at 9:50 AM Medication observation with V17 (Agency Registered nurse) completed for R20. R20 has a diagnosis of anemia, benign prostatic hyperplasia, elevate prostate antigen and failure to thrive. V17 omitted giving Cyanocobalamin Tablet 1000 MCG and finasteride 5mg 1 tab was missing from the medication cart, medication not given. Per Physician order sheet dated: December 2024 reads: a-Cyanocobalamin Tablet 1000 MCG Give 1 tablet by mouth one time a day scheduled for 9:00AM b- Finasteride Tablet 5MG Give 1 tablet by mouth one time a day scheduled for 9:00AM 2. On 12/17/2024 at 9:36 AM Medication observation with V17 (Agency Registered nurse) completed for R42. R42 has a diagnosis of anemia, nausea, vomiting, acquired absence of parts of the digestive tract, volvulus, and gastric-esophageal reflux disease with esophagitis. Pantoprazole Sodium 1 Tablet Delayed Release 40 MG scheduled for 8:00AM given at 9:36AM. Per Physician order sheet dated: December 2024 reads: Pantoprazole Sodium Tablet Delayed Release 40 MG Give 1 tablet by mouth one time a day scheduled 8:00AM. On 12/17/2024 at 9:36 AM during medication administration V17 left medications unattended on the table for R42 to go to her medication cart outside of the dinning room to pick-up a straw for R42 to take his medication with water. R359 was sitting next to R42 during the incident and other residents were in the dining room as well. Surveyor remained by the R42's table. On 12/17/24 at 09:40AM V17 said that she was not supposed to leave medication on the table unattended and go to the medication cart to pick up a straw outside the dining room. V17 said that the facility medication administration Page 1 of 7 145942 145942 12/19/2024 Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few policy states that medication must be under the nurse's supervision at all the times and V17 needs to observe R42 to swallowing medications. On 12/17/2024 at 11:32 AM V2(Director of Nursing) said that medications times are 9:00AM, 1:00PM, 5:00PM, 7:00PM, and 9:00PM. Nurses have one hour before and on hour after to administer medications. The first floor has 31 residents and 34 residents for the second floor. Nurse on the first floor can get extra assistance of the unit manager and second floor V2 stated that she can assists the nurse as needed and nurses are aware to call for assistance. V17 is agency nurse and V2 said that earlier today she offered help to V17 who said that she was fine. V2 said not being aware that V17 had medications not administered-on time. On 12/18/24 at 11:14 AM V2 said, nurses are expected to pass medications one hour before and one hour after the scheduled time. If a medication is schedule for 8:00AM and giving at 9:30AM, it is late, and nurse will have to notify the physician, or the in-house nursing practitioner of the medication was given late. If medication is not available in the facility or emergency convenience box, nurse will have to select number 9 under the electronic medication administration record, and it will trigger a response and will require a nurse to chart under the progress notes and call physician or in-house nursing practitioner for directions. V2 said, nurses are expected to keep medications under their supervision at times and observe residents swallowing medications. Facility does not have any resident on self-administration program currently. On 12/18/2024 at 12:00 PM V1(Administrator) presented: Facility Policy titled: 5.2: Medication Administration, undated, reads: 16. Give the resident the medication. 17. Remain with the resident to ensure that the medication is swallowed. 19. Circle initials on MAR if medication is not administered as ordered and record reason in the PRN/Omission Medication section of the MAR or as appropriate in electronic medication administration record. Facility Policy titled: Policy and Procedure, Medication Administration, undated, reads: Unless otherwise specified by physician, medications will be administered within 60 minutes before or after the facility's dosing scheduled, expect before and after meals orders and non-routine orders medications. 145942 Page 2 of 7 145942 12/19/2024 Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453

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 1.follow their policy on hand washing by not performing hand hygiene when entering the kitchen, 2. failed to follow their policy on use of gloves by not performing hand hygiene prior to putting on gloves and when removed, 3. failed to follow their policy on use of hair restraints by staff entering the kitchen without putting on a hair net, 4. failed to follow their policy on use of wipe cloths by leaving cloths on the food preparation table and not ensuring they are in a sanitation bucket, 5. failed to follow their policy on use of sanitizing buckets by failing to maintain the sanitizing solution at 200 ppm (parts per million) of quaternary solution , 6. failed to follow their policy on use of thermometers by failing to sanitize a thermometer prior to obtaining food temperatures, and 7. failed to follow their policy on use of standardized recipes by not using a recipe during food preparation for lunch. These failures have the potential to affect all 63 residents who receive oral meals from the facility's kitchen. Findings include: On 12/17/27 at 9:55 AM, V13 [NAME] in Training was observed in the food preparation area cooking the lunch meal. Review of the menu for lunch states: beef taco, Spanish rice, seasoned corn, fruit mix, and flour tortilla. V13 [NAME] removed her gloves after touching multiple surfaces, threw them in the garbage and put on a new pair of gloves without performing hand hygiene in the handwashing sink. On 12/17/24 at 10:04 AM, V13 [NAME] removed the thermometer from the holder, rinsed it off under the faucet with water in the food preparation sink, then wiped it off with a wet wiping towel that was lying on the food preparation table. V13 inserted the thermometer into the cooked ground beef then rinsed it off again in the prep sink and laid the thermometer on the food prep table uncovered. V13 did not clean the thermometer with an alcohol wipe and did not put the wet wiping towel into the sanitation bucket. On 12/17/24 at 10:06 AM, V13 [NAME] removed her gloves from cooking, threw them in the garbage, and opened the kitchen door for the delivery person. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink. V13 continued to prepare the lunch meal wearing the gloves touching multiple surfaces. On 12/17/24 at 10:08 AM, V13 [NAME] poured the ground beef in a colander and transferred it to another pan. She removed her gloves, threw them in the garbage, and put on a clean pair of gloves without performing hand hygiene in the handwashing sink. On 12/17/24 at 10:12 AM, V13 [NAME] filled a pitcher with water and poured it into the ground beef with a package of taco seasoning. V13 did use a recipe for the measurement of the water put into the ground beef. On 12/17/24 at 10:15 AM, V13 [NAME] removed her gloves from cooking, threw them in the garbage, and opened the kitchen door for the delivery person. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 10:20 AM, V12 Dietary Manager was asked to test the sanitation bucket in the food preparation area. V12 dipped a chemical test strip into the sanitation bucket which indicated 100 ppm 145942 Page 3 of 7 145942 12/19/2024 Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (parts per million) of quaternary solution. V12 was asked what the chemical solution concentration should indicate for proper sanitation. V12 said, It should be 200. Quaternary sanitizer solution concentration range is 150-200 ppm. On 12/17/24 at 10:22 AM, V13 [NAME] removed her gloves from cooking, threw them in the garbage, and opened the kitchen door for the delivery person. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 10:28 AM and at 10:31 AM, V13 [NAME] removed her gloves from cooking/ touching multiple surfaces and threw them in the garbage. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 10:34 AM, V6 Activity CNA (Certified Nurse Assistant) entered the kitchen and put the lunch substitution list on the food prep table. V6 did not perform hand hygiene and put on a hair net upon entering the kitchen. V6 was inquired of entering the kitchen. V6 said, I don't come in here often, I should put on a hair net and wash my hands. On 12/17/24 at 10:37 AM, V12 DM Dietary Manager said, It's been down since I started. Will follow up with administrator regarding maintenance. On 12/17/24 at 10:39 AM, V13 is cleaning the thermometer in the food preparation sink. V13 poured a liquid cleaning substance on a wet wiping towel, wiped the thermometer with the towel, rinsed the thermometer and put the cover on it. V13 placed the wet wiping towel on the food preparation table. V13 did not clean the thermometer with alcohol wipes. V13 did not put the wet wiping towel in the sanitation solution. On 12/17/24 at 10:41 AM, V15 Dietary Aide is removing dishes from the dishwasher and touching multiple surfaces while wearing gloves. V15 removed his gloves, threw them in the garbage, and put on a clean pair of gloves without performing hand hygiene in the handwashing sink. On 12/17/24 at 10:50 AM, V13 [NAME] is preparing two beef burgers for lunch substitutions. V13 put an unmeasured amount of lemon pepper salt on each burger. V13 did not follow a recipe or determine if the residents had any dietary restrictions on salt intake prior to using the unmeasured seasoning. On 12/17/24 at 10:56AM, 10:59 AM, and 11:01 AM, V13 [NAME] removed her gloves from cooking/ touching multiple surfaces and threw them in the garbage. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 11:07 AM, while wearing the same gloves during cooking, V13 [NAME] took the food processor over to the dishwasher machine and washed it. V13 returned to the food preparation area removed her gloves and threw them in the garbage. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 11:09 AM, V12 Dietary Manager is putting away the food delivery in the refrigerator. V12 picked up the wet wiping towel off the food preparation table and wiped the handles and door of the refrigerator. V12 put the wet wiping towel back on the food preparation table. V12 did not put the wet wiping towel in the sanitation solution. On 12/17/24 at 11:14 AM, V13 [NAME] is preparing the tortilla shells in the food processor for the 145942 Page 4 of 7 145942 12/19/2024 Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453

F 0812 Level of Harm - Minimal harm or potential for actual harm pureed diet residents. V13 [NAME] put pieces of tortilla shells into the food processor and poured two 236 ml (milliliter) cartons of milk on top of them during the process. V13 is not using a recipe with measurements for the puree entrée. V13 [NAME] removed her gloves and threw them in the garbage. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. Residents Affected - Many On 12/17/24 at 11:31 AM and 11:33 AM, V13 [NAME] washed her hands in the handwashing sink and returned to the food preparation area while drying her hands with a paper towel. V13 placed the paper towel down on the food preparation table, put on clean gloves and continued to prepare the food. V13 did not dispose of the used paper towel in the garbage. By V13 placing the used paper towel on the food preparation table caused it to become contaminated. V13 did not clean and sanitize the food preparation table. On 12/17/24 at 11:36 AM, V13 [NAME] removed her gloves from cooking/ touching multiple surfaces and threw them in the garbage. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 11:37 AM, V15 Dietary Aide prepared sandwiches, removed his gloves, put them in the garbage and put on a clean pair of gloves. V15 did not perform hand hygiene in the handwashing sink before putting on a clean pair of gloves. On 12/17/24 at 11:39 AM, V13 [NAME] removed the cover from the thermometer and placed it into a pan of rice to read the temperature. V13 placed the thermometer on the food prep table. V13 did not use an alcohol wipe to clean the thermometer before and after its use. On 12/17/24 at 11:41 AM, V13 [NAME] wiped the thermometer with a wet wiping towel under the faucet in the food preparation sink. V13 removed a pan from the oven. V13 placed the thermometer inside the food and took the temperature. V13 laid the thermometer on the food preparation table. V13 did not use an alcohol wipe to clean the thermometer before and after its use. On 12/17/24 at 11:52 AM, V13 [NAME] picked up the thermometer from the food preparation table and placed it into a pan of broccoli. V13 put the thermometer back onto the food preparation table. V13 did not use an alcohol wipe to clean the thermometer before and after its use. V13 poured an unmeasured amount of lemon pepper salt, garlic powder, and black pepper onto the broccoli. V13 did not follow a recipe or determine if the residents had any dietary restrictions on salt intake prior to using the unmeasured seasonings. On 12/17/24 at 12:00 PM, V13 put water into a container on the stove and poured an unmeasured amount of iodized salt into the water. V13 said, I'm making mashed potatoes. V13 did not follow a recipe or determine if the residents had any dietary restrictions on salt intake prior to using the unmeasured seasonings. On 12/17/24 at 12:12 PM, V16 Dietary Aide is scooping sour cream into condiment cups for lunch on the dishwashing area table. V16 was inquired of his location while preparing food. V16 said, I didn't know where else to go. They wash dishes here; I shouldn't do it here. On 12/17/24 at 12:24 PM, V13 [NAME] was inquired of food preparation concerns. During food preparation when gloves are removed what should be done? V13 said, Wash hands and put on another pair. 145942 Page 5 of 7 145942 12/19/2024 Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453

F 0812 Level of Harm - Minimal harm or potential for actual harm How should a thermometer be cleaned and used? V13 said, Clean it with sterilized water and soap, then sterilize with sanitized water every time I use it. Where should wet wiping towels be kept and why? V13 said, Should be in the green (soap) bucket. After using put back for cross contamination of area. They shouldn't be on the prep table. Residents Affected - Many What should be used when preparing food to ensure accurate measurements and ingredients? V13 said, A recipe. I didn't have the recipe, but I'd use the measuring cups and spoons. It's important for the resident's health. What is the food preparation sink used for? V13 said, It's only for rinsing stuff off. The three compartment sink doesn't work. When you wash and dry your hands, what should be done with the paper towel? V13 said, Throw it away because of cross contamination. On 12/17/24 at 12:37 PM, V12 Dietary Manager was inquired where wet wiping towels are to be kept and why? V12 said, Put it back into the sanitation or soap bucket for sanitation reasons. On 12/17/24 at 2:23 PM, V1 Administrator was inquired of the three compartment sink not working and maintenance. V1 said, It's been at least a month. We did order some parts. We had the plumber come in, there was a leakage. On 12/18/24 12:02 PM, V12 Dietary Manager was inquired of the kitchen concerns. During food preparation when gloves are removed what should be done? V12 said, Wash your hands for sanitation and stop germs for infection control. How should a thermometer be cleaned and used? V12 said, It should be cleaned with an alcohol pad. It should be inserted into food for thirty seconds. Each time it's put into food it should be cleaned with an alcohol pad. What should be used when preparing food to ensure accurate measurements and ingredients? V12 said, Use measuring cups and spoons, a recipe book tells what and how much to use. What is the food preparation sink used for? V12 said, Just to run water in it to cook with. It's only for food purposes. Not for cleaning. When you wash and dry your hands, what should be done with the paper towel? V12 said, Dispose of it in the garbage. And you shouldn't touch the garbage can. V12 was inquired of having the menu recipes available during food preparation. V12 said, I came in on Sunday and changed out the new recipes for the winter menu. I put the recipe book on top of the cook table in the morning. V13 didn't ask me for any recipes. V12 was inquired of which residents received the broccoli and mashed potatoes prepared by V13 [NAME] and the number of residents who receive mechanical soft and pureed meals. V12 said, Now we have 14 residents with mechanical soft diets and 6 residents with pureed diets. They both received the broccoli. There are 5 residents that don't get rice, they got mashed potatoes. 145942 Page 6 of 7 145942 12/19/2024 Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453

F 0812 The 4/2017 Food Safety & Sanitation Handwashing policy states in part: Level of Harm - Minimal harm or potential for actual harm Policy: The facility will practice safe food handling and avoid cross contamination through proper and adequate handwashing techniques. Residents Affected - Many Procedure: The Food & Nutrition Department Manager or designee will ensure that employees practice proper hygiene and handwashing at all times. The 4/2017 Food Safety & Sanitation Glove Use policy states in part: Policy: The facility will practice safe food handling and avoid cross contamination through proper use of gloves. Procedure: Employees are required to wash hands before using gloves. The 4/2017 Food Safety & Sanitation Employee Health & Personal Hygiene policy states in part: Policy: Food service employees shall maintain good personal hygiene and free from communicable illnesses and infections while working in the facility. Procedure: Hair restraints will be worn at all times. The 4/2017 Food Safety & Sanitation Sanitizing Buckets policy states in part: Policy: The facility will use sanitizing buckets with wipe cloths to sanitize preparation and food service areas. Procedure: The Food and Nutrition Department Manager or designee will ensure that sanitizing buckets are used in food preparation and service areas and are changed often. Sanitizer concentration range for quaternary 150 - 200 ppm (parts per million). The 4/2017 Food Safety & Sanitation Thermometer Calibration & Use policy states in part: Policy: Thermometers will be calibrated before use. Procedure: Food thermometers will be sanitized between taking food temperatures. Alcohol swab may be used to clean the thermometers between each use. It is recommended to have more than one thermometer available. The 4/2022 Food Safety & Sanitation Standardized Recipes policy states in part: Policy: Standardized recipes will be available in the kitchen and used for food preparation. Procedure: All foods will be prepared using standardized recipes on the menu cycle spreadsheets. Standardized recipes include number of servings, serving sizes, ingredients and preparation instructions. 145942 Page 7 of 7