Health inspection·January 26, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide incontinence care and catheter care in a manner that would prevent infection and maintain hygiene. This applies to 3 of 6 residents (R26, 42 and R113) reviewed for incontinence care and urinary catheter care in the sample of 18. The findings include: 1. R113 was admitted to the facility on [DATE]. R113 had multiple diagnoses which includes, cerebral infarction due to unspecified occlusion or stenosis of the right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, generalized muscle weakness and retention of urine, based on the face sheet. R113's admission MDS (minimum data set) dated January 10, 2023 showed that the resident is cognitively intact. The MDS showed that R113 required extensive assistance from the staff with most of his ADL (activities of daily living) including bed mobility, dressing, toilet use and personal hygiene. The same MDS showed that R113 had indwelling urinary catheter. On January 24, 2023 at 2:25 PM, R113 was in bed, alert, oriented and verbally responsive. R113 had a urinary catheter in place. V5 (Treatment Nurse) with the assistance of V6 (CNA/Certified Nursing Assistant) was about to provide treatment on R113's pressure injuries. V5 and V6 turned R113 on his right side. R113 had a small amount of stool. With gloved hands, V5 cleaned R113's anal and bilateral buttock areas and then proceeded to provide pressure injury treatment. V6 then applied a new disposable brief to R113 and then both V5 and V6 fastened the resident's disposable brief. R113's front perineal area, including the urinary catheter insertion site and urinary catheter tubing were not cleaned. To reposition R113 in bed, V6 unhooked the resident's privacy bag (containing the urinary catheter draining bag and part of the catheter tubing) from the bed frame and placed it on top of R113's bed. While V5 and V6 were attempting to turn and reposition R113, the urine that was inside the catheter tubing was visibly noted flowing back towards the urinary catheter insertion site and then back towards the urinary drainage bag. V6 was informed of this observation and was prompted to hang back the privacy bag containing the urinary catheter bag on the bed frame. R113's active order summary report showed an order dated January 4, 2023 for Indwelling urinary catheter care daily and PRN (as needed). R113's care plan initiated on January 10, 2023 regarding indwelling urinary catheter showed Page 1 of 9 146153 146153 01/26/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few multiple interventions including, Position collection bag below the level of the bladder and Catheter care per orders. 2. R42 has multiple diagnoses which includes, acute and chronic respiratory failure with hypoxia, generalized muscle weakness, stage 3 chronic kidney disease, infection, and inflammatory reaction due to indwelling urethral catheter and history of urinary tract infection, based on the face sheet. R42's admission MDS dated [DATE] showed that the resident is cognitively intact. The same MDS showed that R42 required extensive assistance from the staff with most of her ADL including, bed mobility, dressing, toilet use and personal hygiene. On January 24, 2023 at 1:14 PM, R42 was in bed, alert, oriented and verbally responsive. R42 had an indwelling urinary catheter in place. V5 (Treatment Nurse) with the assistance of V6 (CNA/Certified Nursing Assistant) was providing treatment to R42's upper back area. V5 and V6 turned R42 on her left side. R42 had a small amount of stool. With gloved hands, V6 cleaned R42's anal and bilateral buttock areas and then proceeded to provide pressure injury treatment to the resident's sacrococcygeal and buttocks. When the treatment was completed, V5 and V6 applied a new disposable brief to R42 and then fastened the resident's disposable brief. R42's front perineal area, including the urinary catheter insertion site and urinary catheter tubing were not cleaned. R42's active order summary report dated January 19, 2023 showed an order for, Indwelling urinary catheter care daily and PRN (as needed). Further review of R42's active order summary report showed an order dated January 20, 2023 for, Cephalexin oral capsule 500 mg. Give 1 capsule by mouth three times a day related to urinary tract infection, for 14 administrations. R42's urinalysis collected on January 14, 2023 showed that Proteus Mirabilis organisms were identified. R42's active care plan initiated on December 6, 2023 regarding indwelling urinary catheter showed multiple interventions which includes, Provide catheter care and Catheter care per order. On January 25, 2023 at 8:20 AM, V2 (Director of Nursing) stated that when staff are providing bowel incontinence care to a resident, full perineal care should be provided to include, both the resident's front and back private areas as well as providing catheter care by cleaning the urinary catheter insertion site and the (outside) catheter tubing to ensure cleanliness, maintain hygiene and to prevent potential infection. When placing the drainage bag and the catheter tubing, the staff must ensure that it is positioned below the bladder to prevent back flow of urine. According to V2, the staff should have not placed the drainage bag and tubing on the bed to prevent potential back flow. V2 added that the staff should make sure to observe while doing care, that the urine from the catheter tubing will not flow back towards the catheter insertion site, to prevent potential infection. Review of the facility's catheter care policy and procedure dated September 2020 showed in-part, Daily and PRN (as needed) catheter care will be done to promote comfort and cleanliness.3. The EMR (Electronic Medical Record) showed R26 was admitted to the facility on [DATE], with multiple diagnoses including urinary tract infections, retention of urine, and dementia. The MDS dated [DATE], showed R26 was cognitively intact and was totally dependent on facility staff for transfers between surfaces. The MDS continued to show R26 had an indwelling urinary catheter. 146153 Page 2 of 9 146153 01/26/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On January 25, 2023, at 10:32 AM, R26 was lying in bed. V6 (CNA/Certified Nursing Assistant) took R26's indwelling urinary catheter collection bag from the side of R26's bed and placed the collection bag on R26's lower abdomen. Yellow urine was back flowing in the drainage tubing towards R26. R26's indwelling urinary catheter collection bag was on R26's lower abdomen while V6 and V13 (CNA) transferred R26 from the bed to the recliner using a total body mechanical lift. A R26 sat in the recliner, V6 removed R26's indwelling urinary catheter collection bag from R26's abdomen, and had R26's urine collection bag above the level of R26's bladder as V6 made R26 comfortable in the chair. On January 25, 2023, at 2:30 PM, V2 (DON/Director of Nursing) said indwelling urinary catheter collection bags should be kept below the level of the bladder during resident transfers. 146153 Page 3 of 9 146153 01/26/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy for tracking behaviors for residents receiving psychotropic medications. This applies to 2 of 5 residents (R44 and R27) reviewed for unnecessary medications in a sample of 18. The findings include: 1. On January 23, 2023, at 1:00 PM, R44 was lying in bed, sleeping. On January 24, 2023, at 1:50 PM, R44 was lying in bed, sleeping. On January 25, 2023, at 9:35 AM, R44 was lying in bed, sleeping. The EMR (Electronic Medical Record) showed R44 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, anxiety, and depression. The EMR continued to show the following targeted behaviors for R44: low moods, sadness, and anxiousness. R44's Order Summary Report dated January 25, 2023, showed the following orders initiated on January 6, 2023, for R44: Alprazolam tablet (antianxiety medication) disintegrating 0.25 mg (milligram), give one tablet by mouth at bedtime related to anxiety disorder, Duloxetine capsule (antidepressant medication) delayed release particles 30 mg, give one capsule by mouth one time a day related to depression. R44's MDS dated [DATE], showed R44 had moderate cognitive impairment. On January 25, 2023, at 2:15 PM, V2 (DON/Director of Nursing) said the CNAs (Certified Nursing Assistants) are responsible for charting whether a resident is exhibiting behaviors or note. V2 continued to say the CNAs should be documenting this every shift. The facility does not have documentation to show R44's behavior tracking was completed while R44 was receiving psychotropic medications. 2. The EMR showed R27 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, depression, and mild intellectual disabilities. The EMR continued to show the following targeted behaviors for R27: low moods and sadness. R27's Order Summary Report dated January 25, 2023, showed the following order initiated on September 28, 2022, fluoxetine capsule (antidepressant medication) 20 mg, give two capsule by mouth one time a day related to depression. 146153 Page 4 of 9 146153 01/26/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0758 R27's MD dated January 4, 2023, showed R44 had moderate cognitive impairment. Level of Harm - Minimal harm or potential for actual harm The facility does not have documentation to show R27's behavior tracking was completed for the last 30 days. Residents Affected - Few The facility policy titled, PSYCHOTROPIC MEDICATIONS - USE OF, dated 09/2020 showed, PURPOSE: To establish a standardized system to inform residents and/or their responsible parties about psychotropic medications and their side effects . DOCUMENTATION: Prior to the administration of an antipsychotic medication, the following must be documented . 4. Residents who display target behaviors or who take psychotherapeutic medications will have their behaviors quantitatively and objectively documented on the behavior tracking form . 146153 Page 5 of 9 146153 01/26/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

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 administer medications as ordered by the physician. There were 25 opportunities with 5 timing errors, resulting in 20% medication error rate. Residents Affected - Few This applies to 3 of 10 residents (R42, R114 and R116) observed during the medication pass in the sample of 18. The findings include: On January 23, 2023 at 4:40 PM, State agency representative asked V4 (Nurse) who was seated inside the second floor nursing station, if she will be doing the afternoon medication pass. V4 responded that V3 (Nurse/Assistant Director of Nursing) will be doing the medication pass. During this conversation V3 was walking pass the nursing station. V3 stated, I thought I am just supposed to give the 2:00 PM medications. V4 responded, You now have the keys to the medication cart. During this point, V3 went to the team 1 medication cart and started preparing medications to the residents. 1. On January 23, 2023 at 5:22 PM, V3 stated that she will prepare and administer the 2:00 PM scheduled medications for R42. V3 prepared and administered the following medications to R42: 1 tablet of Hydralazine 100 mg (milligram) , 1 tablet of Cephalexin 500 mg and injected 1 ml (milliliter) of Heparin 50,000 units/ml. R42 has multiple diagnoses which includes, chronic diastolic (congestive) heart failure, hypertensive and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, urinary tract infection and long term (current) use of anticoagulants, based on the face sheet. R42's active order summary report showed orders dated January 20, 2023 for Hydralazine HCl (hydrochloride) 50 mg. Give 2 tablets by mouth three times a day related to hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease or unspecified chronic kidney disease, 100 mg total, Cephalexin 500 mg. Give 1 capsule by mouth three times a day related to urinary tract infection for 14 administrations and Heparin Sodium injection solution 5000 unit/ml. Inject 1 applicator subcutaneously every 8 hours for DVT (deep vein thrombosis) Prophylaxis. R42's January 2023 MAR (medication administration record) for Hydralazine HCl 50 mg showed that this medication was scheduled to be given three times a day, every 6:00 AM, 2:00 PM and 9:00 PM. R42's January 2023 MAR for Cephalexin 500 mg showed that this medication was scheduled to be given three times a day, every 6:00 AM, 2:00 PM and 9:00 PM. R42's January 2023 MAR for Heparin Sodium injection showed that this medication was scheduled to be given every 8 hours at 6:00 AM, 2:00 PM and 10:00 PM. On January 25, 2023 at 11:36 AM, V11 (Physician) stated that he expects the facility to administer any residents medications as ordered and as scheduled. 2. On January 23, 2023 at 5:40 PM, V3 stated that she will prepare and administer the 2:00 PM scheduled IV (intravenous) medication for R116. V3 prepared and administered the Meropenem & Sodium Chloride 500 mg, at 100 ml/hr (milliliter/hour) rate over 30 minutes to R116. 146153 Page 6 of 9 146153 01/26/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R116 has multiple diagnoses which includes, urinary tract infection and ESBL (Extended Spectrum Beta Lactamase) resistance, based on the face sheet. R116's active order summary report showed an order dated January 18, 2023 for Meropenem-Sodium Chloride Intravenous Solution Reconstituted 500 mg/50 ml. Use 500 mg intravenously every 8 hours for ABT/ESBL (antibiotic/Extended Spectrum Beta-Lactamase) in urine for 14 Days. R116's MAR for Meropenem-Sodium Chloride 500 mg, showed that this medication was scheduled to be given every 8 hours at 6:00 AM, 2:00 PM and 10:00 PM. On January 25, 2023 at 2:57 PM, V12 (Physician) stated that the physician's orders should be followed, including the timing of the intravenous medications. 3. On January 23, 2023 at 5:46 PM, V3 stated that she will prepare and administer the 3:00 PM medication for R114. V3 prepared and administered, 1 tablet of Methocarbamol 500 mg to R114. R114 has multiple diagnoses which includes, fracture of the upper end of the right humerus, displaced supracondylar fracture with intracondylar extension of the lower end of the left femur and Parkinson's disease, based on the face sheet. R114's active order summary report showed an order dated January 4, 2023 for, Methocarbamol 500 mg. Give 1 tablet by mouth three times a day for pain management. R114's MAR for Methocarbamol 500 mg, showed that this medication was scheduled to be given three times a day, every 9:00 AM, 3:00 PM and 9:00 PM. On January 25, 2023 at 11:36 AM, V11 (Physician) stated that he expects the facility to administer any residents medications as ordered and as scheduled. Review of the facility's medication administration policy and procedure dated September 2020 showed, Policy: Medications will be administered in accordance with the established policies and procedures. Under the procedure, it showed in-part, 1. Drugs must be administered in accordance with the written orders of the attending physician. 146153 Page 7 of 9 146153 01/26/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to provide nutrition supplements and nectar thick liquid as ordered by the Physician. This applies to 3 of 3 residents (R8, R12, R45) reviewed for dining in the sample of 18. The findings include: 1.R12's face sheet included diagnoses of unspecified kyphosis, other lack of coordination, dysphagia, oropharyngeal phase, difficulty in walking, not elsewhere classified personal history of other malignant neoplasm of large intestine. R12's 5 day admission MDS (minimum data set) dated 12/28/2022 showed that R12 was cognitively intact. On 01/23/23 12:15 PM, R12 was seen eating in room and appeared thin. R12 was served a room tray by V8 (Dietary Hostess). R12 received mechanical soft diet consisting of tuna salad sandwich, cup of tomato juice, pasta salad and fruit punch. V8 stated that she has finished serving R12 her meal. Diet list titled Diet Type Report available in the dining room showed that R12's diet included mighty shake at breakfast lunch and dinner. When asked if she normally receives a health shake, R12 replied Sometimes they give me one, but they haven't in the last couple days. R12 stated that she would like a mighty shake with her lunch, and this was relayed to V8. R12's diet order on POS (Physician Order Sheet) showed mighty shake at breakfast, lunch and dinner. Start date 12/21/2022 at 14:31 (status: active). 2.R8's face sheet includes diagnoses of hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, dementia in other diseases classified elsewhere, moderate, with agitation, other lack of coordination, other abnormalities of gait and mobility, epilepsy, unspecified, not intractable, without status epilepticus. R8's 5 day MDS (minimum data set) dated 11/05/22 showed that R8 was cognitively intact. On 01/23/23 at 12:26 PM, R8 was seen eating in the dining room assisted by staff. R8 received 1 cup soup, 1/2 a sandwich and 2 servings of mixed fruit. Facility Diet Type Report showed that R8's diet included mighty shake with lunch and dinner. On 1/23/23 at 12:49 PM, R8 visited in room and R8 stated that she is blind and that the staff assist her at meals. R8 stated that she did not get a health shake at lunch. R8 remarked I was wondering why I did not get that. This information was relayed to V9 (Dietary Hostess). R8's diet order on POS showed Mighty Shake, No Sugar Added two times a day. Start date 1/18/2023 at 12:00 (status: active). 3. R45's face sheet included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, aphasia following cerebral infarction, dysphagia following unspecified cerebrovascular disease, dysarthria following cerebral infarction. R45's Quarterly MDS dated [DATE] showed that R45 was intact in cognition. 146153 Page 8 of 9 146153 01/26/2023 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/24/23 at 12:53 PM, R45 was seated in dining room feeding self. R45 was seen eating barbecue beef on bun with a plastic fork and also received apple sauce. R45 was also noted to receive a liquid in a red colored glass. The liquid appeared clear on the top half and slightly dense at the bottom of the cup. R45's diet order on facility Diet Type Report showed magic cup for lunch and dinner and nectar fluid consistency. This information was relayed to V7 (Dietitian) who was in the vicinity. When V7 asked R45 whether he wants ice cream/magic cup, R45 nodded yes. V9, who was also in the area stated that she was not aware that R45's diet list showed magic cup. When V9 was asked if the liquid was nectar thick, she stated that she added 1 and a half tablespoons of thickener to cranberry juice in the glass and that she should have added 2 tablespoons. R45's diet order on POS included Regular texture, nectar consistency, magic cup for lunch and dinner. Start date 10/26/2022 at 17:20 (status active). Instructions for thickener mixing chart on the container with thickener showed to use 2 tablespoons + 2 teaspoons for 8 fluid ounces for nectar thick liquids. The glass that cranberry juice was served in was verified by V10 (Corporate Chef) to be a 10-ounce glass with 8 ounces of fluid. On 01/25/23 at 11:27 AM, V7 (Dietitian) stated that the residents should receive the nutrition supplements as ordered as they are recommended to provide extra protein and calories to meet supplemental needs. V7 stated that magic cup is a thickened ice cream and that nectar thick liquids is recommended by Speech Language Pathologist for residents with swallowing problems. 146153 Page 9 of 9