Health inspection·November 22, 2024

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to complete performance review evaluations for 5 of 5 CNAs (Certified Nursing Assistants). This applies to all 79 residents in the facility. Residents Affected - Many The findings include: Facility's CMS (Centers for Medicare and Medicaid Services) Form 671 titled Long Term Care Facility Application for Medicare and Medicaid (11/19/24) shows the facility has a current census of 79. On 11/20/24 at 9:35 AM, V9 (Business Office Manager) stated, Corporate did rate changes for the CNAs and when that happens you are supposed to do a performance evaluation for the staff member. I was supposed to do the performance reviews, but I didn't do them. I'll be honest with you. I started here in April 2023. The supervisors are really supposed to do the performance evaluation, but I'm actually doing them because they are so busy. I'm trying to help them out. But I forgot to do them. On 11/20/24 at 9:42 AM, V2 (Director of Nursing) stated, I do performance evaluations for my nurses. (V9) is not supposed to do the performance evaluations for the CNAs. She's not their supervisor. Currently, our CNA supervisor is V10. She's supposed to do it for this year. But before it was V11 (CNA) supervisor. He quit in October 2024. He should have done them. On 11/20/24 at 9:45 AM, V9 and surveyor reviewed the personnel files for 5 CNAs that were currently working in the facility. The following were noted: 1.V4's (CNA) Employee Personnel Form shows a hire date of 11/16/2021. There were no annual performance reviews for 2022, 2023 and 2024. 2.V5's (CNA) Employee Personnel Form shows a hire date of 4/18/21. There were no annual performance reviews for 2022, 2023, and 2024. V9 did provide an annual performance review for 7/18/21. 3.V6's (CNA) Employee Personnel Form shows a hire date of 11/11/2014. There were no annual performance reviews for 2015, 2016, 2017, 2018, 2020, 2021, 2022, 2023, and 2024. V9 did provide an annual performance review for only 11/11/2019. 4.V7's (CNA) Employee Personnel Form shows a hire date of 12/20/22. There was no annual performance review for 2023. 5.V8's (CNA) Employee Personnel Form shows a hire date of 6/5/2017. There were no annual performance reviews from 2018 to 2024. Page 1 of 7 146153 146153 11/22/2024 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0730 Level of Harm - Potential for minimal harm Residents Affected - Many Facility's policy titled Performance Evaluations (1/2009) shows Procedure: 1. The Personnel Director will utilize the monthly reports from the Payroll Department as they related to evaluations to determine the employees who are due to annual evaluation or for a probationary evaluation 3. The Personnel Director will maintain a list of all evaluation reports which have been sent to the employee's supervisor and require them to be returned by a predetermined date set by the Personnel Director. 4. If the evaluation report is done in tandem with a rate change, then the evaluation report must be returned to the Personnel Director before the evaluation report is discussed with the employee 8. Annual performance evaluations will be completed from the original date of employment or annually from a position change 11. Performance evaluations will be completed by the employee's department supervisor and reviewed by the Administrator. 15. Completed performance evaluations will be placed in the employee's personnel file. 146153 Page 2 of 7 146153 11/22/2024 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain orders for resident medications and failed to have orders for medications at the bedside. The facility failed to make sure residents took all their medication in the presence of the nurse. The facility also failed to make sure that residents had their own personal medications instead of someone else's in their room. This applies to 5 of 5 residents (R10, R19, R57, R65, R127) reviewed for medications in a sample of 23. The findings include: 1. On 11/19/24 at 10:30 AM, during initial tour, R10 was sitting in her wheelchair in her room. On her bedside table, there was an Atrovent inhaler. R10 stated, This is my inhaler from home. It's usually kept in my purse. I don't know why it's here. The nurse gives me another one. On 11/20/24 at 2:35 PM, on R10's bedside table, the Atrovent inhaler continued to be there. R10 stated, Yeah, it's still here. It should be in my purse. I can't find my purse. R10's face sheet shows diagnoses of chronic obstructive pulmonary disease with (acute) exacerbation and acute respiratory failure with hypoxia. R10's POS (Physician Order Sheet) shows an order for Atrovent HFA Inhalation Aerosol Solution 17 MCG (Micrograms)/ACT-1 puff inhale orally one time a day related to chronic obstructive pulmonary disease with acute exacerbation. There is no order for R10 to use her inhaler from home or for it to be at the bedside. R10's MDS (Minimum Data Set) dated 10/25/24 shows a BIMS (Brief Interview for Mental Status) score of 13, which means she is cognitively intact. 2. On 11/20/24 at 10:36 AM, R127 was not in her room. On her bedside table, there was (Brand name eye drops). On the label, it shows her name, and it documents Carboxymethyl Cellulose Sodium 0.5 MG (Milligrams) Ophthalmic Solution. Put 2 drops in both eyes 4 times a day. On 11/20/24 at 2:43 PM, R127 was sleeping on her bed. On her bedside table, the Refresh Tears continued to be there. R127's face sheet shows a diagnosis of glaucoma. Review of 127's POS shows she has no orders for (Brand name eye drops). R127's MDS dated [DATE] shows a BIMS score of 15, which means she is cognitively intact. On 11/20/24 at 3:02 PM, V2 (Director of Nursing/DON) stated, I don't have any residents that have meds at the bedside. All meds should have an order and there should be an order for it to be at the bedside. On 11/21/24 at 11:58 AM, V12 (Licensed Practical Nurse/LPN) stated, If residents bring meds from home, we lock it up in the medication cart. If they want to use it, then we need to get an order or script from the doctor for them to use it and to be stored at the bedside. Facility's policy titled Self-Administration of Medications: 2. The IDT (Interdisciplinary Team) 146153 Page 3 of 7 146153 11/22/2024 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0761 Level of Harm - Minimal harm or potential for actual harm must also determine who will be responsible (the resident or nursing staff) for storage and documentation of the administration of drugs as well as the location of the drug administration. 3. When such is ordered, the following conditions will apply: a. The manner of storage will prevent access by other residents. 4. Storage of legend drugs at the bedside will meet the conditions of the above, and will additionally: a.) Be specifically ordered by the prescriber of the drugs. Residents Affected - Some 4. On 11/19/24 at 10:59 AM, R57 was on his bed sleeping and found a medication cup with seven pills in it. On 11/19/24 at 11:09 AM, V13 (LPN) stated that she shouldn't have left R57's 9:00 AM medications at his bedside and should have stayed with him until he took all his medications. A record review on the Medication Administration Record (MAR) for November 2024 documented that R57 received 7 medications at 9:00 AM on 11/19/24, including Gabapentin 300 milligrams (mg), Duloxetine 30 mg, Ferrous Sulfate 325 mg, Finasteride 5 mg, a Multivitamin tablet, Colace 100 mg, and Potassium Chloride 20 milli-equivalent. On 11/19/24 at 1:08 PM, V2 (DON) stated that none of their residents were assessed for self-administration of medications, and the nurse should have stayed with R57 to ensure R57 took all his medications. 3. R19 was admitted to the facility with diagnoses that includes displaced intertrochanteric fracture of left femur, chronic obstructive pulmonary disease, asthma, type 2 diabetes, hypertension, heart failure and poly-osteoarthritis. On 11/19/24 at 12:51 PM, a 2.5-ounce bottle of pain relief cream and 3.53-ounce jar of vaporizing ointment was on R19's over bed table. R19 stated she puts the vaporizing ointment in her nose. On 11/21/24 at 11:38 AM, V16 (LPN) assigned to R19 stated she did not have any residents that were assessed to keep medications at the bed side. On 11/21/24 at 1:49 PM, V2 (DON) stated there are no residents in the facility that can keep medications at the bed side. Staff should have seen R19's medications if they were sitting out. R19 does not have a physician's order for vaporizing ointment or pain relief cream. Review of R19's current physician's order does not include pain relieving cream or vaporizing ointment. 5. On 11/19/24 at 10:31 AM during initial tour, R65's room was observed to have (Brand name eye drops) in a plastic bag and a medication cup with a white cream, which R65 said was cortisone cream. On 11/21/24 at 12:47 PM, R65 said the eye drops on her bedside table were not hers. R65 said she also used all the cream in the medication cup. V17 (Family Member) said she took the eye drops to the front desk and thought they may have belonged to the resident who was previously in R65's room. On 11/21/24 at 12:51 PM, V15 (Registered Nurse) said R65 was not allowed to have medications at the bedside, including the cortisone cream. V15 said she was not made aware of the resident having eye drops in her room, and there should be an order if the residents were allowed to keep medications at bedside. 146153 Page 4 of 7 146153 11/22/2024 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0761 Level of Harm - Minimal harm or potential for actual harm R65's face sheet showed she was admitted to the facility with diagnoses including hypertension, spinal stenosis, polyosteoarthritis, anxiety disorder, gout, cognitive communication deficit, and muscle weakness. R65's POS (Physician Order Sheet) did not have orders for cortisone cream or (Brand name eye drops). Residents Affected - Some 146153 Page 5 of 7 146153 11/22/2024 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to utilize an appropriate standardized tool/system to justify or warrant the necessity of an antibiotic at the time the antibiotic was ordered. This applies to 4 of 4 residents (R4, R43, R65, R66) reviewed for antibiotic stewardship in a sample of 23. Residents Affected - Some The findings include: 1. R43's face sheet shows she was admitted to the facility on [DATE]. R43's POS (Physician Order Sheet) showed an order dated October 28, 2024, for Nitrofurantoin Monohyd Macro Oral capsule 100 MG (Milligram) Give 1 capsule by mouth two times a day for UTI (Urinary Tract Infection) for 5 days. R43's October 2024 MAR (Medication Administration Record) showed she received the antibiotic from October 28, 2024, through November 2, 2024. R43's Criteria for Infection Report Form-Urinary Tract Infections (UTIs) dated November 1, 2024, showed R43 did not meet criteria to be prescribed antibiotic. R43's labs dated October 28, 2024, showed urine culture results which came back showing 70,000 to 90,000 CFU/ml (Colony-Forming Unit/Milliliters) of E. coli (Escherichia Coli). On November 20, 2024, at 2:31 PM, V2 (Director of Nursing/Infection Preventionist) said R43's urinalysis was collected on October 26, 2024, because she had increasing confusion, which showed she had E. coli. V2 said R43 would not have gotten antibiotics because she only had increasing confusion, which was her baseline. 2. R65's face sheet showed she was admitted to the facility on [DATE]. R65's POS showed orders dated October 22, 2024. The first order was for Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth one time only related to urinary tract infection, site not specified for 1 day beginning October 22, 2024, and completed October 23, 2024. The second order was for Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day related to urinary tract infection, site not specified for 9 administrations beginning October 22, 2024, and completed October 27, 2024. R65's October 2024 MAR showed she received the antibiotic on October 22, 2024, through October 27, 2024. R65's Criteria for Infection Report Form-Urinary Tract Infections (UTIs) dated November 1, 2024, showed R65 did not meet criteria to be prescribed antibiotic. On November 20, 2024, at 2:02 PM, V2 said R65 did not present with any symptoms but was flagged for a UTI. 3. R66's face sheet showed she was admitted to the facility on [DATE]. R66's POS showed an order dated October 22, 2024, for Nitrofurantoin Monohyd Macro Oral capsule 100 MG (Milligram) Give 1 capsule by mouth two times a day for UTI (Urinary Tract Infection) for 5 days. R66's October 2024 MAR shows she received the medication from October 23, 2024, through October 27, 2024. R66's Criteria for Infection Report Form-Urinary Tract Infections (UTIs) dated November 1, 2024, showed R66 did not meet criteria to be prescribed antibiotic. R66's labs dated October 21, 2024, showed urine culture results which came back showing 70,000 to 90,000 CFU/ml (Colony-Forming Unit/Milliliters) of E. coli (Escherichia Coli). 146153 Page 6 of 7 146153 11/22/2024 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On November 20, 2024, at 2:26 PM, V2 said R66's symptoms were increasing confusion, and a UA (Urinalysis) was done on October 19, 2024. V2 said R66's UA showed she had E. Coli but did not think the doctor gave an order for an antibiotic because the only symptom she had was increased confusion which was her baseline. 4. R4's face sheet showed she was admitted to the facility on [DATE]. R4's POS shows an order dated September 26, 2024, for Cephalexin Oral capsule 500 MG Give 1 capsule by mouth one time a day related to urinary tract infection, site not specified for prophylaxis. R4's November 2024 MAR shows she received Cephalexin 500 MG with a start date of September 26, 2024, and was receiving it through November 22, 2024. The MAR also showed she received Ciprofloxacin HCl Tablet 250 MG Give 1 tablet by mouth every 12 hours for prophylactic treatment, [possible] UTI for 10 days, which was administered from November 11, 2024, through November 20, 2024. On November 20, 2024, at 3:28 PM, V2 said they completed the McGeer tool after the month was over. V2 said she had not done any of the McGeer tracking tool for any of the residents who were on antibiotics for November 2024. V2 said the McGeer tool was done for tracking the use of antibiotics. The facility's Infection Prevention and Control Manual Antibiotic Stewardship [and] MDROs (Multi Drug Resistant Organisms) policy dated April 2021 showed It is the policy of this facility to provide systematic efforts to optimize the use of antibiotics in order to maximize their benefits to residents, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. The facility will communicate resident assessment information and relation to constitutional criteria for infection (i.e. as outlined in Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria) to the practitioner, including non-pharmacological interventions that can be accomplished in the facility based on resident assessment. 146153 Page 7 of 7