Health inspection·October 27, 2022

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow physician's order to apply medicated cream to relieve discomfort and itching for one (R15) of one resident reviewed for quality of care in the sample of 18. Residents Affected - Few Findings include: R15 was admitted to the facility on [DATE] with diagnosis including but not limited to Essential Hypertension, Primary Osteoarthritis, Muscle Weakness, Open-Angle Glaucoma Left Eye, and Bilateral Hearing Loss. According to MDS (Minimum Data Set) dated 09/07/2022 under section C, R15 has BIMS (Brief Interview of Mental Status) score of 11 indicating moderately impaired cognition. On 10/24/22 at 11:08 AM the surveyor observed R15 lying in bed, dressed in a hospital gown. The surveyor asked if R15 usually stays in bed past breakfast. R15 stated, I usually stay in the common area and participate in activities, but I have had a rash in my private area for months now and it itches terribly. I stayed in bed because of it in the last two days because it gets worse when I'm sitting down. I would like to know more about it. V7 (Certified Nursing Assistant) told me that I talk about it too much. Nobody cares about what I say here. This condition keeps me up at night and it causes pain and itchiness. On 10/24/22 at 11:38 AM V7 (CNA) stated, I didn't see any rash on her skin. I changed her this morning, around 7.30 AM. I usually change her every two hours. Surveyor asked if R15 usually stays in bed at this time. V7 stated, R15 wasn't feeling good yesterday, so today she still didn't feel good and wanted to stay in bed. Surveyor clarified if V7 discouraged R15 from talking about itchiness in her private area. V7 stated, I never told her to stop talking about itching, when she mentions something, I always tell her that the nurse will put some medication on. On 10/24/22 at 11:45 AM V7 changed R15's briefs and called V6 (Register Nurse) to apply skin barrier cream into affected area. The surveyor did not note any rash in R15's private area. V7 washed and dressed R15 and put her into a wheelchair. V7 proceeded to propel R15 into a common area for upcoming lunch. On 10/24/22 at 12:07 PM V6 (RN) stated, R15 just told me about the itching this morning. I'll notify the doctor when they do rounds on the unit. We've been using skin barrier cream every time R15 gets her briefs changed. V6 indicated that she forgot that there was an order of antipruritic cream for R15 private area itchiness. On 10/24/2022 at 02:05 PM Surveyor observed V8 (Nurse Practitioner) at R15's bedside. V8 completed (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145026 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Place 3200 Grant Street Evanston, IL 60201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)