Health inspection·January 5, 2024

F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure resident's buttocks were not exposed, provide dignified care while feeding the residents and failed to remove resident's urinal during mealtime. This applies to 4 of 4 residents (R85, R5, R91 and R113) reviewed for dignity in a sample of 32. Findings include: 1. On 1/3/24 at 12:45 PM, R85 was sitting along with many other residents in the dining room for lunch with his buttocks fully exposed. On 1/3/24 at 12:50 PM, V5 (CNA-Certified Nursing Assistant) stated that leaving R85 exposed like that violates his dignity. On 1/3/24 at 3:00 PM, V4 (RN-Registered Nurse) stated, residents must be well groomed and the clothing they wear should cover their body appropriately to maintain their dignity. Facility policy on 'Quality of life - Dignity' dated 1/2024 showed, ' . A. Residents shall be treated with dignity and respect at all times .' 2. On 1/2/24 at 1:02 PM, R91 was observed in her room in bed, with the head of the bed elevated about 45 degrees. R91's lunch tray was on her bedside table in front of her. V8 (Business Office Manager) came in to R91's room and said that she was going to assist R91 with her lunch. V8 said that R91 was nonverbal and had her health had recently declined. V8 informed R91 that she would be feeding her the lunch and instead of sitting down level with R91 to assist her to eat, V8 stood up over R91 at her bedside and began feeding her ice cream. The facility's Assistance with Meals policy (revised 11/2019) states that feeding assistants will not stand over residents while assisting with meals. R91's EMR (Electronic Medical Record) showed diagnoses of dementia and gastro-esophageal reflux disease without esophagitis. R91's Minimum Data Set, dated [DATE] showed that resident was unable to complete the cognition interview. 3. On 1/2/24 at 1:09 PM, R5 was observed in her room, in bed, sitting up. R5's lunch tray was on her bedside table, in front of her. V6 (CNA/Certified Nurse Aide) came in the room, and asked if R5 needed assistance with her meal, R5 said yes. V6 came and stood by R5's bedside and began to cut up Page 1 of 6 145956 145956 01/05/2024 Citadel at Casa Scalabrini 480 North Wolf Road Northlake, IL 60164

F 0550 Level of Harm - Minimal harm or potential for actual harm the roasted pork loins in small pieces and began to feed her the pork loins, roasted potatoes and carrots. V6 remained standing while feeding R5 her lunch. R5's EMR showed diagnoses of spinal stenosis lumbar region, abnormal posture and lack of coordination. R5's MDS dated [DATE] showed that R5's cognition is moderately impaired. Residents Affected - Some 4. On 1/2/24 at 1:16 PM, R113 was sitting up by the side of the bed in the room eating his lunch. There was a urinal that had 200 ml (milliliters) of urine on the bedside table next to his lunch tray. Surveyor asked R113 if there was a reason he had the urinal on his bedside table while eating, he shook his head no; surveyor asked if he would like it emptied, he nodded his head yes. R113's EMR showed the following diagnosis of chronic obstructive pulmonary disease, asthma, and benign prostate hyperplasia. R113's MDS dated [DATE] showed that R113's cognition is moderately impaired. On 1/4/24 at 10:15 AM, V3 (DON/Director of Nursing) said that staff should sit next to residents while assisting with feeding, due to dignity and the urinal with urine should not be on the bedside table along with the meal trays as it is a dignity issue as well. 145956 Page 2 of 6 145956 01/05/2024 Citadel at Casa Scalabrini 480 North Wolf Road Northlake, IL 60164

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 have call lights accessible to dependent residents. Residents Affected - Few This applies to 1 of 4 residents (R26) reviewed for accommodation of needs in a sample of 32. The findings include: On 01/02/2024 at 11:44 AM, R26 was in his room, lying on bed. The room's right window was open. The room felt cold. R26's call light was on the floor on the right side of the bed. R26 said he was transferred from his previous room to his current room at 10:30 AM on 01/02/2024. R26 said he has been looking for his call light since his transfer because the room was too cold. He said he was upset because his old room had everything he needed, and his new room did not even have a call light. He said he has been calling out for help but nobody came to his room. On 01/04/2024 at 11:44 AM, V3 (DON-Director of Nursing) said after a resident transfers room, she expects staff to orient resident to set up of new room and make sure call light is within reach. She said call light should always be within reach for safety purposes. Facility's Policy on Answering the Call Light dated 10/2017 and revised on 12/2017 stated the following: .General Guidelines .E. When the resident is in bed or confined to a chair be sure the call light is within reach of the resident. 145956 Page 3 of 6 145956 01/05/2024 Citadel at Casa Scalabrini 480 North Wolf Road Northlake, IL 60164

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 . Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure aspiration precautions were followed in accordance with professional standards of practice and provider recommendations. This applies to 1 of 1 resident (R75) reviewed for dysphagia in a sample of 32. Findings include: On 1/2/24 at 2:15 PM, R75 was eating lunch in bed with head of bed raised at 45 degrees angle. No staff was near R75. R75 drank juice with straw. At the head-end of the bed, a notice showed 'swallow strategies' that included for R75 to sit up at 90 degree angle for meals, use no straws, and alternate food solids and liquids. The next day on 1/3/24 at 10:00 AM, R75 was sitting in her bed at a 45 degree angle and had a nutritional shake with a straw in front of her and she had finished the carton. R75 also had a straw in her water jug. No staff were near R75. On 1/4/24 at 11:30 AM, the Surveyor visited R75 with V3 (DON-Director of Nursing) and observed R75 was in her bed, again at a 45 degree angle, and she had an empty nutritional shake carton in front of her with a straw in it. V3 (DON) stated, the swallow precaution instructions are put up on the wall for staff to follow so that R75 will not aspirate. V3 (DON) stated that R75 should not have had straw in her liquids, she should be sitting upright at a 90 degree angle, and staff must watch to ensure R75 alternates solid and liquid food. R75's January 2024 Physician Orders showed, [R75] must be in upright position for all meals due to aspiration precaution. The facility's 1/2024 Aspiration Precautions policy showed, encourage resident to sit upright when taking anything by mouth Follow speech pathology recommendations from swallow assessments . R75's 10/13/21 Speech Therapist's swallow and discharge summary showed, [R75] will safely swallow thin liquids via teaspoon . R75's 6/2/23 Speech Therapist Progress notes showed . Patient will demonstrate the ability to safely and efficiently consume thin liquid trials via straw with clinician only without overt s/s aspiration or any noted difficulty . 145956 Page 4 of 6 145956 01/05/2024 Citadel at Casa Scalabrini 480 North Wolf Road Northlake, IL 60164

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review, the facility failed to verify placement of gastrostomy tube (G-tube) prior to administering medications through the G-tube and failed to flush the G-tube in between medication administration. This applies to 1 of 4 (R82) residents reviewed for medication administration via G-tube in a sample of 32. The findings include: On 1/3/24 at 1:12 PM, V7 (RN/Registered Nurse) went to R82's room to administer medications via G-tube. V7 informed R82 of the medication administration. R82 was on continuous g-tube feeding; V7 paused R82's feeding and the feeding tubing remained connected. A second lumen was present on R82's G-tube and it was capped. Without uncapping R82's second lumen or disconnecting the feeding, V7 used her stethoscope to listen to R82's lower abdomen. V7 proceeded to flush the G-tube with 10 ml (Milliliters) of water, administered Diltiazem 120 mg (milligrams) without flushig with water, then administered liquid Metoclopramide 5 ml, then flushed the G-tube with 10 ml of water after medication administration. R82's EMR (Electronic Medical Record) showed the following diagnoses of hemiplegia following cerebral infarction affecting right dominant side, dysphagia following unspecified cerebrovascular disease and aphasia following cerebral infarction. R82's POS (Physician Order Sheet) had the following orders of Diltiazem 120 mg tablet administer one tablet by g-tube route three times daily; Metoclopramide 5 mg/5 ml solution administer every 8 hours by g-tube three times daily. Check for G-tube patency/placement at med pass and as needed. On 1/3/24 at 1:19 PM, V7 said she should have checked for the G-tube placement prior to administering medications and she should have flushed the G-tube between each medication administration. On 1/4/24 at 10:20 AM, V3 (DON/Director of Nursing) said the nurses are to check for G-tube placement by checking residual prior to medication administration to prevent complications and aspiration, and the nurse should flush the G-tube in between each medication. The facility's Administering Medications Through an Enteral Tube policy (revised 1/2020) states to verify placement of the feeding tube; if administering more than one medication, flush with 15 ml of warm water (or prescribed amount) between medications. 145956 Page 5 of 6 145956 01/05/2024 Citadel at Casa Scalabrini 480 North Wolf Road Northlake, IL 60164

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review, the facility failed to remove lint from the facility's clothes dryers. Residents Affected - Many This has the potential to affect all residents residing in the facility, staff, and visitors. Findings include: The facility's 1/2/24 Centers for Medicare and Medicaid Services Form 671 form showed a resident census of 156 residents. On 1/4/24 at 9:46am, all the facility's five dryers were observed not in use and with lint in the lint basket/catchers. The baskets all had lint on the sides and bottom of the baskets, and the lint in each basket was about ½ inch thick. On 1/04/24 at 9:46am, V9 (Laundry Staff) said that she did not remember if she had cleaned out the dryers today or not. V9 said that she does not log it when she cleans out the lint baskets and she did not know how often she should clean the lint out- maybe once a day or a few times a day. At 9:52 am, V10 (Laundry Supervisor) verified there was lint in all five dryers and the staff are not logging when they clean out the lint traps and they are supposed to. V10 said she did not know that the lint baskets are supposed to be cleaned out after each load. V10 said she thought the last time the staff logged cleaning out a lint trap was in July 2023. On 1/04/24 at 10:23 am, V11 (Director of Facilities Management.) said that the lint should be removed after every load because it could be a fire hazard, even after one load. On 1/04/24 at 10:23 am V10 (Laundry Supervisor) said that it is a fire hazard if the lint is not cleaned out of the dryer after each load. On 1/04/24 at 11:35 PM V1 (Assistant Administrator) said that her expectations are that the staff clean out the lint from the dryers after each load and to log it on the sheet for safety issues and to eliminate a fire hazard. On 1/04/24 at 1:28pm V11 said that on average the facility does 20 loads a day, every day. The facility's Daily Dryer lint logs showed only three pages, May (no year shown)- total 23 entries, May/June (no year shown)- 22 entries, & July (no year shown)- 9 entries. A review of the facility's Logbook Documentation [company name] Tels. forms dated 1/3/2024, 12/26/23, 12/18/23, 12/11/23 & 12/4/23 showed, under Steps: Confirm that the lint is removed from the stack and inside the dryer. It is a fire hazard and a code violation if this is not maintained. The forms showed under Lint Catch/Screen - Lint catchers should be cleaned AFTER EACH LOAD. The facility's undated dryer manual, (ADG-758 [Gas DSI] Installation Manual) showed, Routine Maintenance- A. CLEANING Warning: lint from most fabrics is highly combustible. The accumulation of lint can create a potential fire hazard . 145956 Page 6 of 6