Health inspection·January 6, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain a Physician order and update the resident record with the correct code status for 4 of 4 (R7, R12, R33, R42) residents in a sample of 13. Findings include: 1. R7 was admitted to the facility on [DATE] with diagnoses not limited to Atrial Fibrillation, Major Depressive Disorder, Spinal Stenosis, Rheumatoid Arthritis, Hypothyroidism, Mild Cognitive Impairment, Essential (Primary) Hypertension, Venous Insufficiency and Rhabdomyolysis. R7's MDS (Minimum Data Set) Section C Cognitive Pattern BIMS (Brief Interview for Mental Status) score of 15 indicates intact cognition. Order Summary Report dated [DATE] has no documented Physician order for a Code Status. Order Summary Report dated [DATE] Order Status: Discontinued document in part: DNR (Do Not Resuscitate) order date [DATE] order discontinued [DATE], DNR order date [DATE] order discontinued [DATE], DNR order date [DATE] order discontinued [DATE] and DNR order date [DATE] order discontinued [DATE]. Care Plan documents in part: Focus: Code Status: R7 and Family request DNR order to be in effect. Date initiated [DATE]. Interventions: Discuss with resident or annually quarterly during care plan meeting to ensure wishes are to be continued. Date initiated [DATE]. On [DATE] at 10:35 AM during the review or R7's Advance Directives it was noted that there was no Physician order or code status on R7's Face Sheet. POLST (Physician Order for Life Sustaining Treatment) Form dated [DATE] documents in part: Do Not Attempt Resuscitation/DNR. Limited additional interventions. Only use medical treatment antibiotics, IV (Intravenous) Fluids and cardiac monitor as indicated. Treatment Plan: Provide Basic Medical Treatments. 2. R12 was admitted to the facility on [DATE]. On [DATE] during review of physician orders it was noted that R12 had no physician order for the code status. Order Listing Report dated [DATE] document in part: DNR, revision date [DATE]. R12's POLST (Physician Orders for Life Sustaining Treatment) Form dated [DATE] documents in part: Do Not Attempt Resuscitation/DNR. Care Plan documents in part: Focus: R12 and/or family request DNR order to be in effect. Date initiated [DATE]. Page 1 of 17 146185 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0578 Level of Harm - Minimal harm or potential for actual harm 3. R33 was admitted to the facility on [DATE]. On [DATE] during the review of R33's Advance Directives it was noted that there was no Physician order for a code status or code status documented on R33's Face Sheet. On [DATE] DNR was entered on R33's face for the Advance Directive by V2 (Director of Nursing). Order Listing Report dated [DATE] documents in part: DNR, revision date [DATE]. Residents Affected - Some R33's POLST (Physician Order for Life Sustaining Treatment) Form dated [DATE] document in part: Do Not Attempt Resuscitation/DNR. Comfort-Focused Treatment. Care Plan documents in part: Focus: Code Status: reads in part: R33 and POA (Power of Attorney) request DNR with comfort-focused treatment order to be in effect. Date initiated [DATE]. 4. R42 was admitted to the facility on [DATE]. On [DATE] during the review of R42's Advance Directives it was noted that there was no Physician order for a code status or code status documented on R42's Face Sheet. POLST (Physician Order for Life Sustaining Treatment) Form dated [DATE] documents in part: Do Not Attempt Resuscitation/DNR. Comfort-Focused Treatment. On [DATE] at 09:10 AM V3 (Director of Social Service) stated I make sure the advance directives are correct, ask the residents if they are a full code or DNR (Do Not Resuscitate), get the POLST (Physician Order for Life Sustaining Treatment) form and fill it out. The family is involved, we get the doctor to sign the POLST form and we upload it in the resident medical record. After I am done the doctor signs the POLST form and the nurse puts in the chart as a DNR or full code. It is somewhere that they can type the code status in there. When the resident's medical record is opened in the computer it should have DNR or full code where it has code status. I think nursing enters the code status. We scan the POLST form into the medical records. I am responsible for whatever the code status is, I put it in the care plan. If there is a green piece of tape on the resident door that mean they are a full code. We discuss the Advance Directives with the resident every quarter during the care plan meeting to see if they want to remain a DNR or full code. If there is no order and there is a POLST form the staff should get the order. There was a binder on the floor with the POLST forms, but I don't think it is anymore. R42 is from our apartments for short term rehab. The nurses wanted me ask R42 if she (R42) wanted to be a full code or DNR and R42 chose to be a DNR. Since R42 chose to be a DNR it should be in the care plan. R42's POLST form was uploaded into the computer and there is no order for the code status. On [DATE] at 10:42 AM V14 (Registered Nurse) looked in the computer and stated R7 does not have a code status. I do not see a code status order, care plan or a code status on R7's face sheet. If there is no order for the code status and the resident has a POLST (Physician Order for Life Sustaining Treatment) form for DNR, if CPR (Cardiopulmonary Resuscitation) is started it would be started in error. The code status should be entered in the physician orders. On [DATE] at 11:03 AM R7 was asked by the surveyor what were her (R7) wishes for the Advance Directive and R7 responded DNR (Do Not Resuscitate). On [DATE] at 11:07 AM V15 (Licensed Practical Nurse) stated R12's code status is DNR (Do Not Resuscitate). There should be an order for the code status because everything that is done for the resident needs a physician order. Surveyor and V15 proceeded down the hallway to R12's room. Upon standing in front of R12's door surveyor asked V15 how she (V15) would respond if entering R12's room R12 was found unresponsive. V15 responded The green tape on R12's door would make R12 a full code and I 146185 Page 2 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would have to start CPR according to the green piece of tape. The green piece of tape should be removed because R12 is a DNR. V15 proceeded to remove the green piece of tape from the R12's door frame. V15 looked at the nurses station and nurse office to fine the first-floor binder titled Names and Numbers and Social Facts Good to Know containing the resident POLST forms and was unable to locate the binder. On [DATE] at 11:51 AM V2 (Director of Nursing) stated The code status order should be put in the Physician orders immediately, as long as the POLST (Physician Order for Life Sustaining Treatment) form is signed by the doctor. The POLST form is uploaded into the medical records under the miscellaneous tab. The admitting nurse puts the order in the computer for the code status. If we do not have an order for the code status the resident have to be a full code. The resident and physician sign the POLST form. The code status should be entered in the care plan immediately. Entering the code status on the face sheet is a little tricky depending on who enters the code status in PCC (Point Click Care). If the code status is entered in as an order you have to go under advance directives for it to show on the face sheet. There is no order for R7's code status on the physician order sheet and the code status is not showing on the face sheet. If a resident is found unresponsive, we would look at the residents' door and see if there is a green sticker there. If the resident is a full code, there would be a green sticker. If there is an immediate situation we rely on the green sticker on door or run and go check the order. R7 was admitted to the hospital and when R7 came back someone did not put the code status order in. When a resident is admitted to the facility part of the nurse's responsibility is to contact the doctor for clarification of orders and get a code status order. If the resident does not have the green sticker on the door, you cannot start CPR (Cardiopulmonary Resuscitation). We use the green sticker, face sheet or order for the code status. If we do not have the order or don't know the code status, we do CPR. If there was a green piece of tape on R12's door I would start CPR and I would have started CPR in error because R12 is a DNR (Do Not Resuscitate). On [DATE] at 12:15 PM V2 (Director of Nursing) stated The code status for the residents should match the face sheet, physician orders, POLST form and Care plan. If the code status does not match there is a potential for confusion and staff doing CPR when they are not supposed to or not doing CPR when they are supposed to CPR. FacilityCardiopulmonary Resuscitation CPR policy (revised 06/17) documents in part: If there is a written advance directive to resuscitate, if the Resident has no advance directive, or if the Resident does not have a valid Do Not Resuscitate order, the Resident will be administered cardiopulmonary resuscitation (CPR) when a sudden episode of unconsciousness with no pulse, no heartbeat, or no respiration occurs. Procedure: 1. Upon admission, the Home's staff shall verify the presence of advance directives or the Resident's wishes with regard to CPR; this may be done while conducting the admission assessment. While awaiting a physician's order to withhold CPR, the Home's staff will immediately document discussions with the resident and/or representative, including the Resident's wishes regarding CPR. At a minimum, verbal declination of CPR by a Resident, or if applicable by the Resident's representative, will be witnessed by two staff members. While a physician's order is pending the Home's staff will honor the documented verbal wishes of the Resident or the Resident's representative regarding CPR. 2. Resident's preferences/choices regarding CPR are documented in their advance directives (unless they decline to execute an advance directive). Those choices are reflected also in the physician's orders. Each resident's choice regarding CPR is also readily available in a hard-copy binder in each Resident's care area, where the face sheet of each resident who has elected resuscitation is clearly marked with a green sticker indicating that choice, and the face sheets of those who have decided against resuscitation do not have the green CPR sticker. The entrance to the private room of each resident who has chosen resuscitation is also 146185 Page 3 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0578 clearly marked with a green sticker. Level of Harm - Minimal harm or potential for actual harm Facility Do Not Resuscitate policy dated 07/05 documents in part: 1. The home will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. 2. Do Not Resuscitate Order (DNR) is a written order to nursing staff not to resuscitate from cardiac or respiratory arrest when the Resident is in the last phases of dying, or when resuscitation would result in severe pain or damage from the aggressive invasion of the Resident's bodily person. Purpose 1. To respect the wishes of a Resident. Procedure: 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the Resident's medical record. 4. Do not resuscitate orders (DNR) will remain in effect until the Resident (or surrogate) provides the Home with a signed and dated request to end the DNR order. 5. The interdisciplinary care planning team will review advance directives with the Resident during quarterly care planning sessions to determine if the Resident wishes to make changes to such directives. Residents Affected - Some On [DATE] at 11:20 AM, R42's electronic health record (EHR) was reviewed. Review of R42's physician order sheet, face sheet, and comprehensive care plan do not document code status for R42. R42's POLST form shows R42 is DNR. 146185 Page 4 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, the facility failed to follow its abuse policy by not providing necessary care inservices, resulting in a female resident physically assaulting another male resident for two (R3 and R29) out of four residents reviewed for physical abuse. Findings include: On 01/03/23 at 01:35 PM, surveyor observed R29 in R29's room. R29 stated he (R29) was kicked and punched by R3. R29 stated that R3 resides down the hall. R29 stated, Multiple times she (R3) hits me (R29). On 01/03/23 at 01:40 PM, V1 (Administrator) stated that she (V1) is aware of the abuse altercation between R3 and R29. She (V1) stated R3 hit R29 first. On 01/05/23 at 10:00 AM, V2 (Director of Nursing) stated that she (V2) is aware of the abuse from R3 hitting R29 first. V2 stated, This is not the first time this has happened. R3's care plan is not updated. We told the family but no interventions were put in place or at least it is not documented. On 01/05/2023 at 10:00 AM, V3 (Director of Social Services) stated V3 was standing by the reception desk on the day of the incident and heard a loud commotion. V3 stated, R29 stated 'She (R3) hit me (R29) and I (R29) hit her (R3) back.' The abuse was witnessed by the CNAs. R3 hit R29 first on 12/2/2022. This is not the first time this incident. The first incident happened before I (V3) started here. I (V3) just know there was a history of them not liking each other. There were no interventions put in place. If there are no interventions put in place, then the incident could happen again and escalate to a worse situation. I am not sure if this incident was reported to IDPH. R3's care plan documents in part: R3 has a tendency of hitting one particular resident on occasion without provocation. R3 will make false statements that the resident hit her (R3) to legitimize her (R3) hit towards him. Interventions: Daughter is aware of R3 hitting a resident. Daughter has a tendency to believe R3 when she (R3) says the other resident hit her (R3) but is aware that R3 has poor memory/impulse control. Progress note by V3 (12/2/2022) documents in part: This writer was standing by the receptionist desk when a loud argument began. This writer went to see what was going on and this writer was told by two witnesses who are CNAs, who informed this writer that they witnessed R3 hit a fellow resident and the resident hit her back. Reviewed R3 and R29's progress notes from 12/1/2022 to 1/3/2023. No documentation was found of interventions to separate the two residents. Facility's Incident Report (12/2/2022) documents in part: R3 alleged that R29 gave her (R3) a look first. R3 then admits that she (R3) did a circular motion with her arms towards R29 and hit him (R29). Interventions: keep both residents apart from each other and to monitor their whereabouts often. Facility's abuse policy (11/2016) documents in part: Every resident of our Home is entitled to respectful and courteous treatment. The facility will not tolerate rude, threatening or abusive behavior 146185 Page 5 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0600 Level of Harm - Minimal harm or potential for actual harm toward any resident or any other mistreatment of a resident. No resident, regardless of age, ability to comprehend, disability or comatose status is immune from abuse, neglect, and mistreatment. All residents must be protected from abuse, neglect, and mistreatment. All of the following are examples of possible abuse: Any observation of a staff member, resident, family member, or other individual hitting, striking or otherwise injuring a resident. Residents Affected - Few 146185 Page 6 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, failed to follow their Abuse policy by failing to report to Illinois Department of Public Health an incident between two residents (R3 and R29) in a sample of 4 residents reviewed for abuse. Findings include: On 01/03/23 at 01:35 PM, surveyor observed R29 residing in R29's room. R29 stated he (R29) was kicked and punched by R3. R29 stated that R3 resides down the hall. R29 stated, Multiple times she (R3) hits me (R29). On 01/03/23 at 01:40 PM, V1 (Administrator) stated that she (V1) is aware of the abuse altercation between R3 and R29. She (V1) stated R3 hit R29 first. She (V1) stated that she (V1) did not report the abuse incident to Illinois Department of Public Health. On 01/05/2023 at 10:00 AM, V3 (Director of Social Services) stated on the date of the incident, V3 was standing by the reception desk and heard a loud commotion. V3 stated, R29 stated 'She (R3) hit me (R29) and I (R29) hit her (R3) back.' The abuse was witnessed by the CNAs. R3 hit R29 first on 12/2/2022. This is not the first time this incident occurred. The first incident happened before I (V3) started here. I (V3) just know there was a history of them not liking each other. There were no interventions put in place. If there are no interventions put in place, then the incident could happen again and escalate to a worse situation. I am not sure if this incident was reported to IDPH. Progress note by V3 (dated 12/2/2022) documents in part: This writer was standing by the receptionist desk when a loud argument began. This writer went to see what was going on and this writer was told by two witnesses who are CNAs, who informed this writer that they witnessed R3 hit a fellow resident and the resident hit her (R29) back. Facility's Incident Report (12/2/2022) documents in part: R3 alleges that R29 gave her (R3) a look first. R3 then admits that she (R3) did a circular motion with her arms towards R29 and hit him (R29). Interventions: keep both residents apart from each other and to monitor their whereabouts often. Facility's abuse policy (11/2016) documents in part: As soon as possible, but within no more than two hours in the case of serious bodily injury, or within twenty-four hours for all other situations of suspected abuse, neglect or mistreatment, the state's Department of Public Health shall be notified of the suspected abuse, neglect or mistreatment. The results of the investigation shall be described in a written report which shall be provided to the State survey agency. The report shall be provided within five working days of the incident. 146185 Page 7 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a comprehensive care plan was in place for the Advance Directives for 3 (R39, R40, R42) of 3 residents reviewed for code status in a sample of 13. Findings include: On 01/05/23 during the record review of Advance directives it was noted by the surveyor that (R39, R40, R42) had no documented care plan for Advance Directives or code status. R39 was admitted to the facility on [DATE]. On 01/05/23 during review of R39 there was no Advance Directive Care Plan. R39's POLST (Physician Orders for Life Sustaining Treatment) Form dated 09/14/22 documents in part: Do Not Attempt Resuscitation/DNR. Selective Treatment. R40 was admitted to the facility on [DATE]. On 01/05/23 during review of R40 there was no Advance Directive Care Plan. R39's POLST (Physician Orders for Life Sustaining Treatment) Form dated 11/06/20 documents in part: Do Not Attempt Resuscitation/DNR. Selective Treatment. R42 was admitted to the facility on [DATE]. On 01/05/23 during the review of R42's Advance Directives it was noted that there was no Physician order for a code status or code status documented on R42's Face Sheet. POLST (Physician Orders for Life Sustaining Treatment) Form dated 12/09/22 documents in part: Do Not Attempt Resuscitation/DNR. Comfort-Focused Treatment. On 01/05/23 at 09:10 AM V3 (Director of Social Service) stated I make sure the advance directives are correct, ask the residents if they are a full code or DNR (Do Not Resuscitate), get the POLST (Physician Order for Life Sustaining Treatment) form and fill it out. The family is involved, we get the doctor to sign the POLST form and we upload it in the resident medical record. After I am done the doctor signs the POLST form and the nurse puts it in the chart as a DNR or full code. I am responsible for whatever the code status is, I put it in the care plan. We discuss the Advance Directives with the resident every quarter during the care plan meeting to see if they want to remain a DNR or full code. On 01/05/23 at 10:42 AM V14 (Registered Nurse) stated V14 looked in the computer and stated R7 does not have a code status. V14 stated, I do not see a code status order, care plan or a code status on R7's face sheet. On 01/05/23 at 11:07 AM V15 (Licensed Practical Nurse) stated R12's POLST form has Do Not Attempt Resuscitation. One other place to look for the code status is the care plan under social services. R12 care plan is DNR. On 01/05/23 at 11:51 AM V2 (Director of Nursing) stated The care plan should be initiated within 24 hours of admission. The code status should be entered in the care plan immediately. On 01/05/23 at 12:15 PM V2 (Director of Nursing) stated The code status for the residents should match on the face sheet, physician orders, POLST form and Care plan. Facility Care Plan policy dated 05/06 documents in part: Every Resident has a comprehensive care 146185 Page 8 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plan as part of their medical record. Purpose: to develop quantifiable objectives for the highest level of functioning the Resident may be able to attain. 1. The comprehensive care plan includes measurable objectives and timetables to meet the Resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment. 2. The care plan is initiated within 48 (forty-eight) hours of admission and is written within seven (7) days after the completion of the Resident assessment; it reflects intermediate steps for each outcome objective. The care plan is updated following the admitting MDS (Minimum Data Set). On 1/04/23 at 11:20 AM, R42's electronic health record (EHR) was reviewed. R42's physician order sheet, face sheet, and comprehensive care plan do not document code status for R42. R42's POLST form shows R42 is DNR. 146185 Page 9 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to a.) ensure staff obtained a physician order for the code status for 5 (R7, R12, R33, R37, R42) residents, and b.) ensure staff knew how to confirm the residents' code status in an emergency. Findings include: On [DATE] at 10:35 AM during the review of R7's Advance Directives it was noted that there was no Physician order for a code status or code status documented on R7's Face Sheet. POLST (Physician Orders for Life Sustaining Treatment) Form dated [DATE] documents in part: Do Not Attempt Resuscitation/DNR. Limited additional interventions. Only use medical treatment antibiotics, IV (Intravenous) Fluids and cardiac monitor as indicated. Treatment Plan: Provide Basic Medical Treatments. Review of health records read as follows: R7 was admitted to the facility on [DATE], Order Summary Report dated [DATE] has no documented Physician order for a Code Status. Order Summary Report dated [DATE] Order Status: Discontinued documents in part: DNR (Do Not Resuscitate) order date [DATE] order discontinued [DATE], DNR order date [DATE] order discontinued [DATE], DNR order date [DATE] order discontinued [DATE] and DNR order date [DATE] order discontinued [DATE]. Care Plan documents in part: Focus: Code Status: R7 and Family request DNR order to be in effect. Date initiated [DATE]. Interventions: Discuss with resident or annually quarterly during care plan meeting to ensure wishes are to be continued. Date initiated [DATE]. R12 was admitted to the facility on [DATE]. On [DATE] during review of physician orders it was noted that R12 had no physician order for the code status. Order Listing Report dated [DATE] documents in part: DNR, revision date [DATE]. R12's POLST (Physician Orders for Life Sustaining Treatment) Form dated [DATE] documents in part: Do Not Attempt Resuscitation/DNR. Care Plan documents in part: Focus: R12 and/or family request DNR order to be in effect. Date initiated [DATE]. R33 was admitted to the facility on [DATE]. On [DATE] during the review of R33's Advance Directives it was noted that there was no Physician order for a code status or code status documented on R33's Face Sheet. On [DATE] DNR was entered on R33's face for the Advance Directive by V2 (Director of Nursing). Order Listing Report dated [DATE] documents in part: DNR, revision date [DATE]. R33's POLST (Physician Orders for Life Sustaining Treatment) Form dated [DATE] documents in part: Do Not Attempt Resuscitation/DNR. Comfort-Focused Treatment. 146185 Page 10 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Care Plan documents in part: Focus: Code Status: reads in part: R33 and POA (Power of Attorney) request DNR with comfort-focused treatment order to be in effect. Date initiated [DATE]. R37 was admitted to the facility on [DATE]. On [DATE] during the review of R37's Advance Directives it was noted that there was a conflicting code status. Physician order documents in part: DNR code status order date [DATE], DNR code status documented on R37's Face Sheet, POLST (Physician Orders for Life Sustaining Treatment) Form dated [DATE] document in part: Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation) and Care Plan document in part: R37 requests FULL CODE order to be in effect. Date initiated [DATE]. R42 was admitted to the facility on [DATE]. On [DATE] during the review of R42's Advance Directives it was noted that there was no Physician order for a code status or code status documented on R42's Face Sheet. POLST (Physician Orders for Life Sustaining Treatment) Form dated [DATE] documents in part: Do Not Attempt Resuscitation/DNR. Comfort-Focused Treatment. On [DATE] at 09:10 AM V3 (Director of Social Service) stated I make sure the advance directives are correct, ask the residents if they are a full code or DNR (Do Not Resuscitate), get the POLST (Physician Order for Life Sustaining Treatment) form and fill it out. The family is involved, we get the doctor to sign the POLST form and we upload it in the resident medical record. I think nursing enters the code status. If there is a green piece of tape on the resident door that mean they are a full code. If there is no order and there is a POLST form the staff should get the order. There was a binder on the floor with the POLST forms, but I don't think it is there anymore. The nurses wanted me to ask R42 if she (R42) wanted to be a full code or DNR and R42 chose to be a DNR. R42's POLST form was uploaded into the computer and there no order for the code status. On [DATE] at 10:42 AM survey asked V14 (Registered Nurse) how she (V14) would respond if she (V14) were to enter a resident room and found them unresponsive. V14 stated I would not leave the resident and press the call light for staff to come. I would start CPR if there was a green piece of tape on the door. There is red on the door if the resident is a DNR (Do Not Resuscitate). V14 looked in the computer and stated R7 does not have a code status. I do not see a code status order, care plan or a code status on R42's face sheet. If there is no order for the code status and the resident has a POLST (Physician Order for Life Sustaining Treatment) form for DNR, if CPR (Cardiopulmonary Resuscitation) is started it would be started in error. The code status should be entered in the physician orders. V14 presented the surveyor with a Binder located in the second floor Nurse office titled Names and Numbers and Social Facts Good to Know containing the resident POLST forms. On [DATE] at 11:07 AM V15 (Licensed Practical Nurse) stated R12's code status is DNR (Do Not Resuscitate). Surveyor asked V15 how she (V15) would respond if she (V15) were to enter a resident's room and found the resident unresponsive. V15 stated I would look at the door because everyone that is a full code has a green piece of tape. If there is a green piece of tape I would start CPR (Cardiopulmonary Resuscitation). The POLST (Physician Order for Life Sustaining Treatment) form is located in the computer under the miscellaneous tab. R12's POLST form has Do Not Attempt Resuscitation. One other place to look for the code status is the care plan under social services. R12's care plan is DNR. There should be an order for the code status because everything that is done for the resident needs a physician order. Surveyor and V15 proceeded down the hallway to R12's room. Upon standing in front of R12's door surveyor asked V15 how she (V15) would respond if entering R12's room R12 was found unresponsive. V15 responded The green tape on R12's door would make R12 a full code and I would have to start CPR according to the green piece of tape. The green piece of tape should be removed because R12 is a DNR. V15 proceeded to remove the green piece of tape from R12's door frame. V15 looked at 146185 Page 11 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the nurses' station and nurses' office to find the first-floor binder titled Names and Numbers and Social Facts Good to Know containing the resident POLST forms and was unable to locate the binder. On [DATE] at 11:51 AM V2 (Director of Nursing) stated The code status order should be put in the Physician orders immediately, as long as the POLST (Physician Order for Life Sustaining Treatment) form is signed by the doctor. The admitting nurse puts the order in the computer for the code status. If we do not have an order for the code status the residents have to be a full code. The resident and physician sign the POLST form. There is no order for R7's code status on the Physician Order Sheet and the code status is not showing on the face sheet. If a resident is found unresponsive, we would look at the resident's door and see if there is a green sticker there. If the resident is a full code, there would be a green sticker. If there is an immediate situation we rely on the green sticker on door or run and go check the order. R7 was admitted to the hospital and when R7 came back someone did not put the code status order in. When a resident is admitted to the facility part of the nurse's responsibility is to contact the doctor for clarification of orders and get a code status order. If the resident does not have the green sticker on the door, you cannot start CPR (Cardiopulmonary Resuscitation). We use the green sticker, face sheet or order for the code status. If we do not have the order or don't know the code status, we do CPR. If there was a green piece of tape on R12's door I would start CPR and I would have started CPR in error because R12 is a DNR (Do Not Resuscitate). On [DATE] at 12:15 PM V2 (Director of Nursing) stated The code status for the residents should match on the face sheet, physician orders, POLST form and care plan. If the code status does not match there is a potential for confusion and staff doing CPR when they are not supposed to or not doing CPR when they are supposed to do CPR. Facility Cardiopulmonary Resuscitation CPR policy (revised 06/17) documents in part: If there is a written advance directive to resuscitate, if the Resident has no advance directive, or if the Resident does not have a valid Do Not Resuscitate order, the Resident will be administered cardiopulmonary resuscitation (CPR) when a sudden episode of unconsciousness with no pulse, no heartbeat, or no respiration occurs. Procedure: 1. Upon admission, the Home's staff shall verify the presence of advance directives or the Resident's wishes with regard to CPR; this may be done while conducting the admission assessment. 2. Resident's preferences/choices regarding CPR are documented in their advance directives (unless they decline to execute an advance directive). Those choices are reflected also in the physician's orders. Each resident's choice regarding CPR is also readily available in a hard-copy binder in each Resident's care area, where the face sheet of each resident who has elected resuscitation is clearly marked with a green sticker indicating that choice, and the face sheets of those who have decided against resuscitation do not have the green CPR sticker. The entrance to the private room of each resident who has chosen resuscitation is also clearly marked with a green sticker. Facility Do Not Resuscitate policy (dated 07/05) documents in part: 1. The home will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. 2. Do Not Resuscitate Order (DNR) is a written order to nursing staff not to resuscitate from cardiac or respiratory arrest when the Resident is in the last phases of dying, or when resuscitation would result in severe pain or damage from the aggressive invasion of the Resident's bodily person. Purpose 1. To respect the wishes of a Resident. Procedure: 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the Resident's medical record. 4. Do not resuscitate orders (DNR) will remain in effect until the Resident (or surrogate) provides the Home with a signed and dated request to end the DNR order. 146185 Page 12 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide assistive device to maintain hearing abilities for 1 (R5) of 1 resident who has hearing impairment in a sample of 13 residents reviewed for hearing. Residents Affected - Few Findings include: On 1/03/23 at 11:09 AM, R5 was sitting on a wheelchair alert and verbally responsive. Surveyor attempted to interview R5. R5 stated, What? What are you saying? I can't hear you. Surveyor observed R5 with no hearing aids or any type of assistive device for hearing. On 1/03/23 at 11:10 AM, during interview V6 (Certified Nursing Assistant/CNA) stated that V6 is in charge of R5. V6 stated R5 is still able to verbalize needs but is very hard of hearing. V6 stated R5 has no hearing aids. V6 stated, R5 has no hearing aids. I haven't seen (R5) with hearing aids. Sometimes (R5) doesn't understand when I talk so I use hand gestures. On 1/03/23 at 11:22 AM during interview V7 (Licensed Practical Nurse) stated that R5 is hard of hearing and should have hearing aids to communicate. V7 stated, R5 should have 2 hearing aids. She's (R5) had them for a while. The hearing aids are kept in (R5's) room. The CNAs take them out at night and put them on her (R5) in the morning. They are kept in (R5's) room at night. V7 stated that R5 has not been seen by an audiologist recently. On 1/03/23 at 11:30 AM, surveyor entered R5's room with V6 (CNA). V6 checked R5's room and looked through R5's drawers but no hearing aids were found. V6 stated, I don't think she's (R5) got hearing aids. On 1/04/23 at 9:23 AM, during interview V10 (Certified Nursing Assistant) stated R5 is hard of hearing and never had hearing aids. V10 stated, I think (R5) refused hearing aids a long time ago. R5's electronic health record (EHR) shows an initial admission date of 5/4/2015. R5's audiology consultation progress notes dated 2/8/16 indicates R5 has moderate hearing loss recommending hearing aids. R5's progress note dated 3/11/16 at 3:09 PM documents R5 not wearing R5's hearing aids because they were too loud. This progress note does not document any education provided to R5 and no indication of a follow up with the audiology. R5 was last seen by an audiologist on 2/8/16 and no follow up after that. R5's Minimum Data Set (MDS) with an assessment reference date of 12/12/22 shows R5 has moderate difficulty with hearing, and able to sometimes understand others. R5's comprehensive care plan does not document any refusals in wearing assistive devices for hearing. R5's current physician order sheet (POS) reads in part, Schedule hearing aid evaluation and obtain a hearing aid if needed. Facility's Audiology services policy dated 10/2017 reads in part: Audiology services will be provided upon request. 146185 Page 13 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

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 ensure a medication error rate less than 5% for 3 of 9 residents (R10, R38, R18) in the sample reviewed. There were 25 opportunities and 3 errors resulting in a 12% medication error rate. Residents Affected - Few Findings include: On 01/03/23 at 11:57 AM Medication pass observation was conducted with V11 (Registered Nurse). V11 was observed preparing Humalog KwikPen Solution Pen-injector for R10. V11 was observed immediately setting the dose dial to 15 units as ordered without priming the insulin pen. V11 was observed injecting the Humalog insulin pen to R10's right lower side of abdomen. On 01/03/23 at 12:28 PM V11 was observed preparing Ventolin HFA inhaler for R38. V11 was observed giving instructions to R38 and administered the first puff of Ventolin inhaler. V11 shook the inhaler for about 3 to 5 seconds and administered the 2nd puff of Ventolin inhaler to R38 without waiting for at least 1 minute between puffs. On 01/03/23 at 12:50 PM V11 was observed preparing Ventolin HFA inhaler for R18. V11 was observed giving instructions to R18 and administered the first puff of Ventolin inhaler. V11 shook the inhaler for about 3 to 5 seconds and administered the 2nd puff of Ventolin inhaler to R38 without waiting for at least 1 minute between puffs. On 01/04/23 at 1:20 PM V2 (Director of Nursing) was interviewed and stated that nurses should follow the 6 rights (right resident, medication, dose, time, route, documentation) in giving medications. V2 stated that pen insulin should be primed before administering the dose ordered. V2 stated that the potential effect of not priming the pen insulin prior to administration could result to a lesser dose delivered to the resident. V2 stated that in administering inhalers, the nurse should follow the doctor's order and nurses need to wait for at least a minute in between puffs. V2 stated that medication might not be properly absorbed into the lungs if the nurse is not waiting for at least a minute between puffs. Record review of R10's physician order sheet reads in part: HumaLOG KwikPen Solution Pen-injector 100 UNIT/ML (Insulin Lispro (1 Unit Dial) Inject 15 unit subcutaneously with meals for Type 2 DM. Record review of R38's physician order sheet reads in part: Ventolin HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA) 2 inhalation inhale orally every 6 hours. Record review of R18's physician order sheet reads in part: Ventolin HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA) 2 puff inhale orally every 6 hours. Facility's policy for insulin injection, subcutaneous - pen device revised date 6/2019 reads in part: 11. Turn dose dial to two (2). Tap gently on the pen device then fully push delivery button as far as it will go. You should see the insulin the chamber or a drop on the needed. If you do not, you may repeat up to six (6) times. After the air shot the dial should return to zero (0). Facility's policy for Inhalers - Oral dated 5/2006 reads in part: Albuterol inhaler - 1 minute between puff (minimum timeframe between each puff). 146185 Page 14 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

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. Based on observation, interview and record review, the facility failed to (a) properly discard multi-dose inhaler 30 days of opening for 1 resident (R27); and (b) properly store medications in the refrigerator separate from food items and supplement drinks that can potentially affect 18 residents (R37, R42, R10, R39, R19, R22, R32, R9, R24, R18, R30, R35, R40, R27, R7, R38, R4, R11) inspected for medication storage and labeling. Findings include: On 01/03/23 at 12:34 PM 2nd floor medication cart was inspected with V11 (Registered Nurse/RN) and found R27's Advair multi-dose inhaler was observed to had been opened on 12/3/22 with an expiration date of 1/2/23. This medication was still in medication cart (1/3/23). V11 stated that the Advair inhaler was already ordered from the pharmacy and awaiting delivery. At 12:40 PM 2nd floor medication room inspected with V11 (RN). A white refrigerator was observed with the following items: applesauce, chocolate pudding, supplemental dietary drinks, juices (cranberry, apple, orange), 2 bottles of beer (V11 stated those are for residents). The following medications were also inside the white refrigerator including insulins (Lantus pen and Humalog pen for R10; Lantus vial and Insulin lispro pen for R27); Trulicity injections for R10, Probiotic capsules for R19; and open box of stool softener suppositories. V11 stated that suppositories are house stock. On 01/04/23 at 1:20PM during interview V2 (Director of Nursing) stated that the 2nd floor refrigerator in unit station/medication room is for medications that should be refrigerated and is intended for all residents residing on the 2nd floor. V2 stated that medications kept in fridge should be separate from food items. V2 further stated that it is ideal to separate food and medications and temperature should be maintained. V2 stated that expired medication should not be kept in the medication cart and should be returned to pharmacy. Facility's daily census printed on 01/03/23 indicated 18 residents residing on the 2nd floor. Facility Medication Storage and Administration policy (revision date 8/29/20) reads in part: 5. All expired medications either prescribed or house supply shall be removed immediately upon discovery and placed in the appropriate holding receptacle for pick up and destruction by the DON / Designee. 10. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. 146185 Page 15 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

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 follow their policy on food storage to ensure food items in the coolers were discarded within the recommended dates after the best by dates, to maintain freshness and prevention of apparent signs of spoilage for fruits and vegetables, and to date food items after being opened. These failures have the potential to affect all 41 residents residing in the facility who are receiving oral diets. Findings include: On 1/03/23 at approximately 9:36 AM, an initial kitchen tour was conducted with V5 (Dietary Manager). The following were observed: Cooler 4 with a temperature of 39 degrees Fahrenheit (F): An opened pineapple juice bottle with no label when it was opened. An opened half and half creamer with no label when it was opened. A container of large curd cottage cheese with best by date of 12/19/22. V5 stated that food items should be dated after opening. V5 also stated that facility does not discard food items on the best by dates. V5 stated, We go by days beyond the best by because it's what's recommended. Cooler 1 with a temperature of 38 degrees F: A large container of cabbage with date labeled 10/26. The leaves were very limp with greyish black discoloration. A large container with date labeled 12/13 with spots, mushy and wrinkled skins. A large container of kale with date labeled 12/20. The leaves were very limp with greyish black discoloration. A small container of pears with date labeled 12/20, rotten and very mushy with brown spots and holes. V5 stated, Those need to be thrown out. A large container of butter lettuce with date labeled 12/27. The leaves were very limp. A large container of cauliflower with date labeled 12/6 with mold. V5 stated, It's trash. V5 stated that the dates on the containers specify when the vegetables came in. Cooler 2 with a temperature of 38 degrees F: A box of artisan rolls with best by dates of 12/23/22. 146185 Page 16 of 17 146185 01/06/2023 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0812 A large pack of flour tortillas with best by date of 12/2/22. Level of Harm - Minimal harm or potential for actual harm 2 boxes of bagels with best by dates of 12/16/22. Residents Affected - Many On 1/03/23 at 11:21 AM, a survey team member conducted an interview with R7. R7 stated, I am only eating a whole lot of mashed potatoes and fresh fruit that is not fresh, so I don't eat them. At 1:03 PM, a survey team member conducted an interview with R4. R4 stated that the fruits and vegetables from the kitchen appear to be rotten. On 1/04/23 at 1:51 PM, a follow up interview was conducted with R7. R7 stated that sometimes the breads that the facility give are old, stale, hard to chew, and comes really dry. On 1/05/23 at 10:43 AM, a phone interview was conducted with V13 (Registered Dietitian). V13 stated that V13 does not inspect the facility's coolers. V13 stated that vegetables typically can be stored up to 7 days. V13 stated that best by dates mean that that's the date where that product would be at the best quality until that date. Facility Food Storage Policy dated 1/2017 reads in part: Cold Storage Foods that will be stored for more than 24 hours must be labeled with a discard date. Refrigerated commercially prepared food that are dated with best by or sell by or pull by dates, have be used or discarded within 7 days of additional storage unless otherwise specified by the manufacturer .Fresh produce, whether fruit or vegetable, also have a shelf life that is dependent upon quality characteristics of freshness and apparent signs of spoilage. Foods such as refrigerated baked goods and fresh produce must be sorted and evaluated for freshness and acceptability upon removing from storage, prior preparation. Donated Bakery and Bread Items - Local bakery items such as bread and cake should be used or frozen within 3 days of the best by date. Refrigerate bread, cakes, sweet rolls, muffins, coffee cakes. Commercially prepared bakery items can be used or frozen within 5 days for bread/cakes. 146185 Page 17 of 17