Health inspection·February 14, 2025

F 0660 Plan the resident's discharge to meet the resident's goals and needs. 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 identify and develop a discharge plan for resident (R1) with a discharge goal to return to the community. Residents Affected - Few This applies to 1 out of 3 residents (R1) reviewed for discharge services. R1's Medical Record showed R1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease, asthma, congestive heart failure, generalized muscle weakness, and syncope. On 2/07/2025 at 11:40 AM, R1 was sitting in her wheelchair receiving 2 L (liters) of continuous oxygen via a nasal cannula. R1 stated she was frustrated because there had been delays with her discharge the prior week and now her discharge date was changed to 2/11/2025. On 2/07/2025 at 3:30 PM, V10 (R1's daughter) was interviewed via telephone. V10 stated she contacted the facility on 1/27/2025 to initiate a discussion regarding R1's discharge planning to return to her supportive living facility in the community. V10 stated during the meeting it was identified R1 required DME (Durable Medical Equipment) for her new oxygen and nebulizer therapies. V10 stated R1's original discharge date was scheduled for 2/04/2025 but then was cancelled when it was identified R1 needed additional training on how to use her wheelchair with her oxygen safely. On 2/13/2025 at 9:00 AM, V11 (R1's Supportive Living Facility Director of Nursing/DON) stated she had made multiple attempts prior to contact the facility to ensure R1 was ready for a safe return but was unsuccessful. V11 stated V10 then contacted her to inform her of R1's scheduled return date of 2/04/2025. V11 stated she was concerned because on 1/30/2025 she identified the facility had not made proper arrangements for home health services and DME ordering. V11 stated the facility thought R1's family would be obtaining R1's respiratory DME on their own, which was incorrect. V11 continued to say she then became more concerned when informed R1 now required the use of a wheelchair. V11 stated the facility was unable to show her documentation that R1 was trained on the use of her new wheelchair and oxygen equipment. V11 stated she informed V10 and V4 (Social Services) that R1 was not ready to safely return to her supportive living facility. V11 stated R1's delayed discharge could have been avoided if her goals had been identified and addressed appropriately by the facility at the time of admission and during her discharge planning. On 2 /11/2025 at 11:10 AM, V4 (Social Service) stated she was contacted by R1's family to discuss R1's discharge planning on 1/27/2025. V4 stated R1's original discharge date was scheduled for 2/04/2025. V4 stated R1's discharge date was then changed to 2/11/2025 after V11 assessed R1 at the facility. V4 stated discharge planning should be initiated by the facility's staff within 24-48 hours of a Page 1 of 3 145029 145029 02/14/2025 Avantara Joliet 210 North Springfield Avenue Joliet, IL 60435

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's admission to identify the resident's discharge goals and needs. V4 stated appropriate discharge planning should be reviewed to ensure the resident is safely discharged . R1's care plan showed a R1 required discharge planning and teaching for a safe discharge initiated on 1/13/2025. The care plan had multiple discharge interventions including Assess needs of resident/family beginning on day of admission and continuing throughout stay. Anticipate needs/services .Involve the resident/family in the discharge process .Assess of community resources should be utilized and contact appropriate personnel . V4's Social Service note dated 1/27/2025 (20 days after R1's admission) stated Writer spoke with patient's daughter [V10] via telephone to discuss patient's discharge .A Care conference was scheduled for Tuesday 1/28/2025 at 10 am via phone to discuss transfer back to [R1's Supportive Living Facility]. R1's Discharge Communication Sheet updated showed R1's original discharge date was scheduled on 2/04/2025. The facility's policy titled Transfer or Discharge, Preparing a Resident for dated 01/2025, stated Policy Statement Residents will be prepared in advance for discharge. Policy Interpretation and Implementation A. When a resident is scheduled for transfer or discharge, the social worker, or designee, will notify nursing services of the transfer of discharge so that appropriate procedures can be implemented. 145029 Page 2 of 3 145029 02/14/2025 Avantara Joliet 210 North Springfield Avenue Joliet, IL 60435

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 obtain an oxygen therapy order for a resident (R1) who required the use of continuous oxygen. Residents Affected - Few This applies to 1 out of 3 residents (R1) reviewed for oxygen therapy. R1's Medical Record showed R1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease, asthma, congestive heart failure, and syncope. R1's MDS (Minimum Data Set) dated 1/13/2025 showed R1 was admitted with continuous oxygen therapy. On 2/07/2025 at 9:25 AM, R1 was sitting in her wheelchair receiving 2 L (liters) of continuous oxygen via a nasal cannula. R1 stated she had recently been admitted to the facility with oxygen. R1 continued to say her oxygen therapy was new and was explained by the facility's staff that she now required the use of continuous oxygen. On 2/07/2025 at 2:20 PM, V8 (Agency Registered Nurse/RN) stated she was told on report that R1 required the use of 2-3 L continuous oxygen. V8 was asked to review R1's orders and stated she was unable to find an order for R1's oxygen therapy. V8 stated that residents receiving oxygen required a physician's order to indicate how much oxygen should be administered. On 2/11/2025 at 10:15 AM V3 (Assistant Director of Nursing/ADON) stated R1 was admitted with 2 L of oxygen therapy. V3 stated she also reviewed R1's orders and was unable to find an order for oxygen. V3 stated the facility expects nurses to review, obtain, and transcribe admission orders, accordingly, including oxygen orders. V3 stated residents receiving oxygen should be monitored to ensure they are safely receiving oxygen therapy as ordered. R1's care plan showed a nursing problem of impaired gas exchange initiated on 1/20/2025. The care plan had multiple interventions including R1's need for oxygen use and to maintain her oxygen administration as ordered. R1's Physician Orders report dated February 2025, showed R1's oxygen order was obtained on 2/07/2025 (during the survey). R1's oxygen order O2 2 LITERS PER NASAL CANNULA CONTINOUS TO KEEP O2 SAS >90%. MONITOR O2 SATS QSHIFT. The facility's policy titled Procedure: Oxygen Administration dated 12/2024, indicates The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation A. Verify that there is a physician's order for this procedure. Review the physician's orders or community protocol for oxygen administration. B. Review the resident's care plan to assess for any special needs of the resident. 145029 Page 3 of 3