Health inspection·June 28, 2024

F 0575 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to display in a public and accessible location, the [NAME] and [NAME] Retaliation Hotline poster informing residents of their right to explore or decline community transition, and their right to be free from retaliation. The facility also failed to submit a monthly list of voluntary and involuntary discharge residents to the [NAME] and [NAME] program. This failure has the potential to affect all 42-residents residing in the facility. Findings Include: On 6/26/24 at 11:00am, the first-floor bulletin board observation was conducted with surveyor, V1 (Administrator) and V3(Admissions) for the [NAME] and [NAME] Retaliation poster. All parties verified that there was no visible poster of the mentioned advocacy group in the facility. On 6/26/24 at 11:30am, the dining and activity rooms were observed. There was no signage of [NAME] and [NAME] poster posted in these rooms. On 6/26/24 at 12:30pm V1 (Administrator), V3(Admissions) and V8 (Social Services) stated that they were not aware of a poster/signage that needs to be posted and visible to residents and family members in the facility. V1 stated I didn't know about this poster, but I will post it now on the facility's bulletin's board. On 6/26/24 at 1:00pm, V1 and V8 both stated that they are not aware that they must submit a monthly list of voluntary and involuntary discharge residents to the [NAME] and [NAME] program. V8 stated that an email is sent to the agency when residents request to be transferred into the community. There is no monthly list of residents on the program that is sent out. Facility document titled; Health Care Council of Illinois reads: Resident admission Packet revised 12/2023. Statement of Resident Right. 5. The facility must post in a form and manner accessible and understandable to resident and resident representative: (i) A list of names addresses and telephone number of all pertinent state agencies and advocacy groups such as the state Survey Agency, the State licensure office, adult Protective Services where law provides for jurisdiction in long term care facility, the office of the State Long-Term Care on Page 1 of 4 146013 146013 06/28/2024 Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302

F 0575 Ombudsman program, the protection and advocacy network, home and community-based services programs . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 146013 Page 2 of 4 146013 06/28/2024 Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow the Wound Care Plan by not implementing effective interventions to prevent further alteration in skin integrity. This failure affected 1 resident (R44) of 3 residents reviewed for wounds in a total sample of 15. Residents Affected - Few Findings Include: On 6-25-24 at 8:03 AM, R44 was noted laying on a low air loss mattress with the mattress setting at static. On 6-27-24 at 11:00 AM, R44 was noted laying on a low air loss mattress with mattress set at static and verified with V11 (Assistant Director of Nursing/ADON). On 6-27-24 at 11:00 AM, V11 (ADON) said the low air loss mattress helps with wound healing by alternating pressure relief. V11 said the alternating pressure setting is based on the resident's weight. V11 said static setting is when all chambers are full and there is no alternating pressure relief for the resident. V11 said it is the nurse's responsibility to check the settings on the air mattress. On 6-27-24 at 11:28 AM, V2 (Director of Nursing) said the low air loss mattress can promote wound healing by alternating pressure relief for the resident. V2 said staff will use the static setting when changing position or providing care for a resident. V1 said static setting on the air mattress does not deliver the intended benefit of the air mattress. R44's wound care plan documents: Pressure reducing/relieving mattress and wheel chair (w/c) cushions as needed. Pressure Ulcer Prevention Protocol (no date) documents: Procedure: 4.C. Use of Pressure Reducing Devices, such as pressure reducing mattresses, mattress overlays, w/c cushioning devices, if needed. Manufacturer's Instructions (no date) documents: 2. Therapy Modes: A. Static - Redistribute body mass over a greater surface area at a constant low pressure. All of the air cells are equally inflated at lower pressures when compared to the respective comfort level in alternating mode. B. Alternate Pressure- 1 in 2 alternating cell cycle achieves period pressure relief. There are four selectable cycle time available. Caregivers can select one of the four cycle times based upon patient comfort and desired outcome. 146013 Page 3 of 4 146013 06/28/2024 Berkeley Nursing & Rehab Center 6909 West North Avenue Oak Park, IL 60302

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to follow the Medication Policy by not labeling medication bottles with the opened date. This failure affected 3 residents (R24, R34, and R18) of 15 residents reviewed for medications. Findings Include: On 6-26-24 at 1:10 PM surveyor found R24's Ketoconazole Shampoo 2%, R34's levocarnitine Oral Solution, and R18's liquid Ondansetron were opened without any opened date on the label. On 6-26-24 at 1:13 PM, V10 (Licensed Practical Nurse/LPN) said the opened date is important because staff can tell when it expires and how long the medication can last. V10 said the opened date lets staff know when to discard. On 6-26-24 at 1:45 PM, V9 (LPN) said when accessing medications she would label with the opened date and note the expiration date. On 6-26-24 at 9:00 AM, V2 (Director of Nursing) said nurses are responsible for labeling medication with the opened date. V2 said the opened date of medications is important to determine how long the medication can be used. V2 said the nurses will also honor the medication expiration date on the medication as well. Medication Policy (no date) documents: Procedure: 1. Each prescribe medication medication label includes: h. Date medication dispensed. 146013 Page 4 of 4