Health inspection·February 8, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to date oxygen tubing per resident's physician order. This failure affected one resident (R24) reviewed for oxygen equipment, in a total sample of 30 residents. Residents Affected - Few Findings include: On 02/05/2024 at 11:41 am, surveyor observed R24 sitting in the chair in R24's room, awake and alert. R24 was observed with oxygen concentrator machine set at 3 ½ liters oxygen. The nasal cannula was observed placed in R24's nares, nasal cannula was connected to oxygen tubing and tubing was connected to the oxygen concentrator machine, the tubing was not dated. When R24 was asked regarding R24's oxygen tubing, R24 stated, I have been on oxygen for a while and the staff changes the tubing once a month. On 02/07/2024 at 10:30 am V2(DON/Director of Nursing) stated the nurses are responsible for changing the oxygen tubing. V2 stated the oxygen tubing should be changed every Sunday, at least weekly on the 11pm to 7am shift. V2 stated the nurses should label the oxygen tubing with a date which would indicate when the oxygen tubing was changed. V2 stated the oxygen tubing is labeled for infection control purposes and as a reminder for the nursing staff to change the oxygen tubing every seven days. R24's Face Sheet documents that R24 has the following diagnosis that include, but are not limited to, type 2 diabetes mellitus with diabetic neuropathy, unspecified, chronic obstructive pulmonary disease, unspecified, essential (primary) hypertension, myocardial infarction, pure hypercholesterolemia, unspecified, personal history of transient ischemic attack , and cerebral infarction without residual deficits, atherosclerotic heart disease of native coronary artery without angina pectoris, cervicalgia, simple chronic bronchitis and unspecified asthma, uncomplicated. R24's Brief Interview for Mental Status (BIMS) dated 01/08/2024 documents that R24 has a BIMS score of 15, which indicates that R24's cognition is intact. R24's MDS (Minimum Data Set) Section O. dated 01/08/2024 documents, in part, 00100.Special Treatments, Procedures, and Programs, Respiratory Treatments C1. Oxygen Therapy 2. While a resident. R24's Physician Order Summary Report dated 02/07/2024 documents, in part, Titrate Oxygen 2-5L(liters)/min(minute) via N/C (nasal cannula) to maintain O2(oxygen) above 90% every shift for COPD (Chronic Obstructive Pulmonary Disease). R24's Physician Order Summary Report dated 02/07/2024 documents, in part, change oxygen tubing and nebulizer tubing/mask, mark with date at bedtime every Sunday, every evening shift, mark date on the Page 1 of 7 146185 146185 02/08/2024 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0695 tubing. Level of Harm - Minimal harm or potential for actual harm Surveyor requested a facility policy regarding Oxygen Therapy and Administration from V2(DON). V2 was unable to provide surveyor a facility policy regarding Oxygen Therapy and Administration. Residents Affected - Few 146185 Page 2 of 7 146185 02/08/2024 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 observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of <5% for 2 (R16 and R31) residents of 6 residents reviewed for medication administration. There were 28 opportunities and 2 errors resulting in 7.14% medication administration error rate. Residents Affected - Few Findings include: 1.) On 02/06/2024 at 9:09am, during the medication administration task with V3 (Registered Nurse), observed V3 dispensed O** D**** Multivitamins with mineral 1 tablet for R31. On 02/06/2024 at 9:45am, this surveyor requested V3 to check the container of the O** D*** and stated it is multivitamins with minerals. The color is light orange. This is an error. R31's (Active order as of: 02/06/2024) documented, in part Multivitamin Oral Tablet give 1 tablet by mouth one time a day. R31's (Active order as of: 02/06/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) cerebral infarction, age-related cognitive decline. Order Summary: Multivitamin Oral Tablet 1 tablet by mouth. R31's (Schedule date: 02/06/2024 - 02/06/2024) Medication Admin (administration) Audit Report documented, in part Multivitamin Oral Tablet give 1 tablet one time a day. Schedule date: 02/06/2024. Administration Time: 02/06/2024 10:49 (am). R31's (11/13/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 04. Indicating R31's mental status as severely impaired. 2.) On 02/06/2024 at 9:58am, V3 dispensed and crushed R16's Metoprolol 25mg ER (extended release) tablet. R16's (02/2024) MAR (Medication Administration Record) documented, in part Metoprolol Succinate Oral Capsule ER (Extended Release) 24 Hour Sprinkle 25 MG (Metoprolol Succinate). Start Date: 05/26/2023. This is an error. R16 was given crushed Metoprolol 25mg ER 1 tablet. R16's (Active order as of: 02/06/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) essential primary hypertension. Medication may be crushed and/or opened unless contraindicated. Order Date: 11/12/2018. Metoprolol Succinate Oral Capsule ER (Extended Release) 24 Hour sprinkle 25 mg. Order Date: 05/25/2023. R16's (Schedule date: 02/06/2024 - 02/06/2024) Medication Admin (administration) Audit Report documented, in part Metoprolol Succinate Oral Capsule ER 24 Hour Sprinkle 25MG. Schedule date: 02/06/2024. Administration Time: 10:00(am). R16's (11/28/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 05. Indicating R16's mental status as severely impaired. On 02/07/2024 at 1:04pm, V2 (Director of Nursing) stated the expectation for the nurse is to follow the 5 rights of medication administration: right patient, route, dose, strength, and time. The form 146185 Page 3 of 7 146185 02/08/2024 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0759 of the medication whether capsule or table is included in the right dose or right strength. Level of Harm - Minimal harm or potential for actual harm On 02/07/2024 at 1:07pm, V2 we (facility) cannot crush Extended-Release medication in tablet form. If the medication needs to be crushed, nurse should have called the doctor and inform the doctor that the resident could not take the medication whole. The doctor will give the recommendation and change the order to what the resident can take crushed. Residents Affected - Few On 02/07/2024 at 1:10pm, V2 stated extended-release medication is coated and takes time to dissolve and gives resident longer coverage. If the nurse crushed extended-release medication, it defeats the purpose of making the medication extended release and it makes the resident not covered longer. Crushed medication works faster, and it will not cover the resident in 24 hours. The potency of the medication will be shorter in duration. On 02/07/2024 at 1:14pm, V2 stated the nurse expectation is to give the medication according to the doctor's order. The (undated) Staff Nurse Licensed Practical Nurse job description documented, in part Summary/Objective: The LPN (Licensed Practical Nurse) is responsible for the provision and supervision of medical and personal care services in assigned area to assure resident attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care in conjunction with the Unit Supervisor. Essential Functions: 5. Administer and document prescribed medication/treatments accurately and timely and in compliance with policies and procedures. The (undated) Staff Nurse Registered Nurse job description documented, in part Summary/Objective: The RN (Registered Nurse) is responsible for the provision and supervision of medical and personal care services in assigned area to assure resident attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Essential Functions: 5. Administer and document prescribed medication/treatments accurately and timely and in compliance with policies and procedures. The (08/2017) Medication, Administration documented, in part Policy: All medications are administered by licensed nurses. A physician order that includes dosage, route, duration, and other required consideration for administration of medication. It is the responsibility of the nursing professional to be to be aware of the classification, action, correct dosage, and side effects of a medication before administration. Purpose: To aid Residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. 146185 Page 4 of 7 146185 02/08/2024 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 discard food items that were beyond their use by dates. This failure has the potential to affect all 42 residents that receive oral nutrition residing in the facility. Finding include: On 2/5/2024 at 9:20am surveyor observed 3 unopened 1/2 gallons of buttermilk with a yellow sticker dated 11/03/2023 and an unopened one gallon of 2% milk with a use by date of 1/16/2024. On 2/05/2024 at 9:28am V8 (Dietary Manager) stated that it (the milk) should have been thrown out. On 2/05/2024 at 9:30am surveyor observed 2 aluminum pans of cooked Lasagna with a date of 1/18/2024 in the freezer. On 2/5/2024 at 9:35am V8 stated that it was donated on that date, but it should have been discarded by now. On 2/5/2024 at about 9:45am surveyor observed 5 unopened and 1 open box of Chocolate frosting mix with a date of 7/4/2022. On 2/5/2024 at 9:50am V8 stated these items should have been tossed a while ago. Reception and use of Food Items with a review date of 1/2015 documents, in part, documents commercially packaged goods will be used or discarded by the expiration date and used within 3 months of a sell by or best by date and commercially produced dry goods will not be dated more than 9 months beyond the receiving date. 146185 Page 5 of 7 146185 02/08/2024 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to check and document the temperature of residents' personal refrigerators daily. This failure affected 2 (R7 and R8) residents reviewed for personal food in the total sample of 30 residents. Residents Affected - Few Findings include: 1.) On 02/05/24 at 10:45 AM, there was a personal refrigerator inside R8's room. There were ice cream bars and concentrated juice inside the refrigerator. R8's personal refrigerator temperature log has missing entries. On 02/05/24 at 10:55 AM, these observations were pointed out to V3 (Registered Nurse). V3 stated there are 2 ice cream bars and 2 concentrated apple juice in (R8)'s refrigerator. I (V3) don't know who checks the temperature of the resident's personal refrigerator. Looking at (R8) temperature log, V3 stated there is a lot of temperatures missing for January. On 02/07/2024 at 1:19pm, V2 (Director of Nursing) stated the 3-11 pm shift CNA is supposed to check the temperature of the resident's refrigerator. The importance of checking the refrigerator temperature is to make sure residents have safe food inside the refrigerator. Temperature should be kept between 36F-41F. R8's (Active order as of: 02/06/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) type 2 Diabetes Mellitus. R8's (11/20/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R8's mental status as cognitively intact. R8's (Year: 2024) Refrigerator Temperature Record had missing entries on days 1/5/24, 1/6/24, 1/8/24, 1/10/24, 1/13/24, 1/14/24, 1/15/24, 1/16/24,1/17/24, 1/18/24, 1/22/24, 1/23/24, 1/25/24, 1/26/24, 1/27/24, 1/28/24, 1/29/24, 1/30/24, and 1/31/24. The (08/23/23) Personal Refrigerators policy and procedure documented, in part Residents who desire to have a personal refrigerator in their rooms, and who are able to maintain the refrigerator and its contents in a sanitary and safe condition, are welcome to have on brought to the home and placed in their room. Purpose. The purpose of this policy is to help promote a home like environment and to support residents' independence both in choices and daily functioning. Procedure: 4. Facility will provide a thermometer to check temp every day. A daily temperature log will be kept. Temperature will be maintained for food at 40°. 6. The evening shift Certified Nursing Assistant assigned to the resident will monitor the refrigerator to assure that the resident (with or without the help of family/friends) is maintain it in a clean and sanitary condition and is following safety requirements. 2.) R7's diagnosis includes but are not limited to type 2 diabetes mellitus with hyperglycemia, major depressive disorder, recurrent, unspecified, chronic obstructive pulmonary disease, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, nondisplaced fracture of head of unspecified radius, initial encounter for closed fracture, anemia, unspecified, gastro-esophageal reflux disease without esophagitis, 146185 Page 6 of 7 146185 02/08/2024 Little Sisters of the Poor 2325 North Lakewood Avenue Chicago, IL 60614

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified urinary incontinence, other specified glaucoma, essential (primary) hypertension, heart failure, unspecified, hyperlipidemia, unspecified, and unspecified atrial fibrillation. R7's Brief Interview for Mental Status (BIMS) dated 12/20/2023 Section C -C0500 documents that R7 has a BIMS score of 06 which indicates that R7's cognition is severely impaired. On 02/05/2024 at 11:06 am observed R7 with a white colored refrigerator on top of a stand in R7's room, with food items stored inside. Surveyor observed a temperature log titled Refrigerator Temperature Record affixed on the front of R7's refrigerator with missing documentation of a temperature for the following dates: 1/8/24, 1/13/24, 1/14/24, 1/16/24, 1/17/24, 1/20/24, 1/25/24, 1/30/24 and 1/31/24. On 02/08/2024 at 1:18 pm V1(Administrator) stated the certified nursing assistants are responsible for maintaining the temperature logs for resident's personal refrigerators. V1 stated the temperatures are checked once a day for resident's personal refrigerators. V1 stated the purpose of checking the temperatures in the resident's personal refrigerators is to make sure the refrigerator is working properly and to prevent illness to the residents from contaminated or expired foods. 146185 Page 7 of 7