Health inspection·July 14, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to perform assessment to determine safe self-administration for one of one resident (R95) reviewed for self-administration of medication in a sample of 26. Residents Affected - Few Findings include: On 07/11/2023 at 10:58 AM, during observation rounds, R95 was observed lying on the bed with bedside table in front of him. Bedside table was observed with R95's Fluticasone Furoate/Vilanterol Inhaler 100/25 micrograms (mcg)/inhalation (inh) and R78's Fluticasone proprionate 50 mcg/actuation (act). On 07/12/2023 at 10:31AM during observation with V23 (Registered Nurse), R95's Fluticasone Furoate/Vilanterol Inhaler 100/25 micrograms (mcg) and R78's Fluticasone proprionate 50 mcg/actuation (act) was again observed at the bedside table. On 07/12/2023 at 10:31AM, V23 removed the medications and stated that it should not be there. On 07/12/2023 at 11:02 AM, V2 (Director of Nursing) stated that if the resident gets anxious and prefers to have their inhalers at bedside, they obtain an order from the physician and leave it at the bedside. She said that no assessment is being done or completed for self-administration of medication. On 07/13/2023 at 11:14 AM, V3 (Assistant Director of Nursing) said that to determine if the resident can safely self-administer medication, the resident has to be assessed first, provide education, and return demonstration has to be done and document the findings and determine that the resident is safe to self-administer. She also mentioned that self-administration has to be included in the care plan. On 07/13/2023 at 12:36 PM, V17 (Care Plan Coordinator) stated that if the resident is self-administering medication, it has to be included in the care plan. V17 reviewed R95's care plan and said that R95 did not have care plan for medication self-administration. R95's Order Summary Report dated 7/13/2023 indicated admission date of 02/03/2023 and diagnoses including unspecified glaucoma and unqualified vision loss of both eyes, and order for Fluticasone Furoate/Vilanterol Inhaler 100/25mcg/inh with order date of 5/12/2023. Order Summary Report did not indicate order for fluticasone propionate for R95. Care plan revised 6/25/2022 did not indicate self-administration of medication. Page 1 of 12 145208 145208 07/14/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0554 Facility Policy: Level of Harm - Minimal harm or potential for actual harm Title: Self - Administration of Medications Revised 4/2017 Residents Affected - Few Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's; a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. 5. The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. 13. The staff and practitioner will periodically (for example, during quarterly MDS [Minimum Data Set] reviews) reevaluate a resident's ability to continue to self-administer medications. 145208 Page 2 of 12 145208 07/14/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on interview and record review, the facility failed to follow its policy in displaying prominently in the medical record whether a resident has executed an advance directive for one resident (R2) reviewed for code status in a sample of 26 residents. Findings include: During record review on 7/12/23 at 10:30 am, R2's electronic record was noted with no code status. The DNR (Do Not Resuscitate) binder and R2's chart was also not with no code status for R2. On 7/12/23 at 11:30 am. V2 (Director of Nursing) stated that the code should be in the resident's record. V2 also stated that the code status can be found in the DNR binder and patient's chart. V2 updated the medical record during the interview process. On 7/12/23 at 1:00 pm, both V29 (RN) and V30 (LPN) both stated that the code status should be in the resident's chart, binder or in the computer. Facility policy titled Advance Directive revised 11/2020 reads; Policy Statement: Advance directive will be respected in accordance with the state law and facility policy. Policy Interpretation and Implementation. 7. information about whether the resident has executed an advance directive shall be displayed prominently in the medical record. 8. the plan of care for each resident will be consistent with his or her documented treatment preference and /or advance directive. Physician order dated 7/12/23 reads; Do not Intubate, POLST (Physician Orders for Life Sustaining Treatment): Do Not Attempt Resuscitation/DNR. All updated during the interview process. Care plan reads; Code Status: DNR. 145208 Page 3 of 12 145208 07/14/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed to comprehensively assess at the time of the required comprehensive assessment for one of six residents (R9) reviewed for resident assessment in a sample of 26. Findings include: On 07/11/2023 at 11:37 AM during observation rounds, R9 was observed sitting on bed and stated that she feels like she is losing weight and has never met the dietitian. On 07/13/2023 at 2:05 PM, V22 (MDS [Minimum Data Set] Coordinator) said that all comprehensive assessments are usually done between 3-5 days before the assessment date. On 07/14/2023 at 10:20 AM, V25 (Registered Dietitian) said that she tries to within the 7 days before and after the assessment date, comprehensive assessment is done on residents. V25 reviewed R9's electronic health record and stated that she should have an assessment for 5/3/2023. R9's Order Summary Report dated 7/13/2023 indicated admission date of 4/29/2022, and diagnoses including iron deficiency anemia unspecified and anxiety disorder unspecified. Dietary Progress Notes from 08/11/2022 to 7/12/2023 were reviewed and the last progress note noted from the dietitian was 2/4/2023. MDS Assessment was reviewed and noted last assessment date of 5/3/2023 which was label as annual assessment. Facility unable to provide policy. 145208 Page 4 of 12 145208 07/14/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to provide ongoing assessment and revise care plan for a resident who has hearing impairment. This deficiency affects one (R8) of one resident in the sample of 26 reviewed for Sensory impairment. Findings include: On 7/11/23 at 11:30 am, R8 is alert and oriented, able to verbalize needs to staff but because R8 is hard of hearing, he requires speakers to adjust their tone and volume and speak distinctly to be heard and understood. He said that he has had hearing problems for a while. He said he went to audiologist last month and failed the test. He said that he is scheduled for follow up appointment soon for possible hearing aid device. He said that he has been in the facility for 7 months. On 7/12/23 at 1:28 pm, V1 Administrator said that R8 is the one making his own medical appointment and will inform the nurse for his transportation arrangement. She said that they don't have copy of his medical record from his audiologist. They will call R8's audiologist and have them fax it to the facility. Review R8's audiology record dated 6/27/23 given by V1 Administrator indicated: History: The patient, a male, [AGE] year-old, presents to audiology for an initial evaluation of hearing due to patient report of hearing loss. Patient reports gradual hearing loss bilaterally over the last few months. Patient noted that he has needed the volume loud on the television. Patient reports occupational noise exposure (meat packing factory) without use of hearing protection for 10 years. Impressions: Mild to profound sensorineural hearing loss bilaterally with poor word recognition scores. Recommendations: 1. Follow up the referring provider. 2. Utilize good listening skills including reducing background noise when possible and emphasizing face to face conversation for maximum use of visual cues. 3. Audiologic re-evaluation if a change in hearing is noted or if medically indicated. 4. Consider trial with amplification, pending medical clearance. Patient to be provided IDPH list pending medical clearance given asymmetric hearing loss. Discussed given poor word recognition scores, patient may have limited success with traditional amplification. On 7/12/23 at 11:53 am, V17 Care Coordinator said that she formulated the nursing care plan for all resident in the facility. She said that she hasn't seen or spoken with R8 for a while. She can't remember when she assessed him. Review R8 comprehensive care plan with V17. No care plan for hearing impairment was formulated. Informed her that R8 complained of hard of hearing and was sent out for 145208 Page 5 of 12 145208 07/14/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0657 Level of Harm - Minimal harm or potential for actual harm audiologist evaluation last 6/27/23. R8 has mild to profound sensorineural hearing loss bilaterally. Recommendation of ear amplification. V17 said she is not aware that R8 has hearing impairment and had audiologist consultation. She said that usually in their morning meeting they discussed who goes to the doctor for follow up, but she was not notified. She said that R8's hearing impairment should be care planned. Residents Affected - Few On 7/13/23 at 10:50 am, V21 RN said that she is the assigned nurse for R8. She does not have problem with communication with R8 because she speaks louder and closer in front so she could have a face-to-face conversation with him. On 7/13/23 at 10:58 am, V11 CNA said that she does not have a problem communicating with R8 because she speaks louder to him. On 7/13/23 at 12:49 pm, V22 MDS/ Resident assessment Coordinator said that she does the MDS/Resident assessment Section B Hearing for R8 dated 1/5/23 (Admission) and 4/26/23 (Significant change) both assessments indicated that R8 has adequate hearing. V22 said that she speaks loudly when she talks to him, and he needs more time to response. She does not find him having hard of hearing. She said that she is not aware that R8 has difficulty hearing and has appointment with audiologist on 6/27/23. She said that if they notified her, she will re-assess him and will have a revision in MDS section B. Facility's policy on Comprehensive person-centered care plan indicates: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional need is developed and implemented for each resident. Policy interpretation and implementation: 8. The comprehensive, person-centered care plan will: m. Aid in preventing or reducing decline in the resident's functional status and or functional levels 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process. 13. Assessment of residents are ongoing and care plan are revised as information about the residents and the resident conditions change. 14. The IDT (interdisciplinary team) must review and update the care plan Facility's policy on Clinical protocol sensory impairments indicates: Assessment and recognition: 1. As part of the initial screening, the staff and physician will help identify individuals with sensory impairment, scope of hearing taste, vision, smell, and touch. 145208 Page 6 of 12 145208 07/14/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0657 Level of Harm - Minimal harm or potential for actual harm a. Relevant details would include, for example, the nature of visual impairment, scope of hearing loss, whether taste deficit is specific for sweet, sour, or salty foods, response to pinprick and light touch on neurological exam Residents Affected - Few 145208 Page 7 of 12 145208 07/14/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow its Providers Orders for Infusion Therapy policy by not obtaining intravenous flush orders at the time intravenous medication is ordered. This failure effects 1 of 2 residents (R112) reviewed for Intravenous administration in a sample of 26. Residents Affected - Few Findings Include: On 7/11/2023 at 12:00 pm, V20 (Nurse) was observed flushing intravenously, 10 milliliters of normal saline, administering R112 intravenous antibiotic therapy, flushing with 10 milliliters of normal saline in the left antecubital by (peripherally inserted central catheter-PICC) line. R112 did not have an order for intravenous flushes. V20 said I thought it was an order for flushing. On 7/11/2023 at 1:00 pm, V3 (Assistant Director of Nursing - ADON) said the intravenous flush orders should be obtained when the antibiotic orders where given. An Order Summary Report dated 7/7/2023 indicates R112 has an order for Piperacillin Sodium-Tazobactam Solution Reconstituted with 3.375 grams intravenously every six hours for urinary tract infection for 7 days. Facility Policy: Provider Orders for Infusion Therapy 1/8/2023 Policy: The purpose of this policy is to provide guidelines for infusion therapy to be administered with principles of safe and effective order writing so that all prescribed medications are administered safely and accurately. General Guidelines: 6. Orders for flushing protocols should also be written at the time of the intravenous medication order writing if not already present in the resident's medical record. 145208 Page 8 of 12 145208 07/14/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

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 Based on interview and record reviewed, the facility failed to follow its policy in developing a post-discharge plan with the resident's family for one resident (R130) reviewed for discharge planning in a sample of 26 residents. Residents Affected - Few Finding include. During review of closed records on 7/13/23 at 1:30 pm, R130's progress note was noted to still have R130 as out on pass. On 7/13/23 at 2:15 pm, V8 (Social Service Director) stated that R130 went out on a pass with family and decided not to return to the facility. V8 updated the resident's chart after surveyor made V8 aware during the interview. On 7/13/23 at 12:45 pm, V22 (MDS Coordinator) unable to be reached. Nursing notes dated 4/10/23 at 7:41 am, reads; Resident noted out on pass with family, writer spoke with resident sister and stated resident would like to stay overnight and will return in AM, nursing supervisor made aware. Facility policy dated 11/2020 reads: Discharge Summary and Plan. Policy statement: When a resident discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Policy Interpretation and implementation. 4. the post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: c. a description of the resident 's stated discharge goals. C. when a resident is discharge home, a post-discharge plan of care will be completed to convey continuity of care to the resident, family and/or home agency 145208 Page 9 of 12 145208 07/14/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation interview and record review the facility failed to ensure residents who were dependent on staff for shaving and fingernail care received those services for 1 of 5 residents (R112) reviewed for (Activities of Daily Living- ADL) assistance in a sample of 26. Residents Affected - Few Findings include: On 7/11/2023 at 11:30 am, V19 (Certified Nursing Assistant-CNA) observed with writer R112 face unshaved and fingernails long. V20 said R112 should be shaved and fingernails should be cut down. On 7/11/2023 at 12:00 pm, V20 observed with writer R112 face unshaved and fingernails long. V20 said R112 should be shaved and his fingernails should be cut down. On 7/11/2023 at 1:00 pm, V3 (Assistant Director of Nursing-ADON) observed with writer R112 face unshaved and fingernails long. V3 said R112 should not look like this and said he should be shaved and his fingernails should be cut down. A care plan dated 11/2/2022 indicates that R112 has focus of ADL self-care performance deficit related to diagnosis of Dementia, right above the knee amputation, and hypertension. An intervention of personal hygiene: The resident requires extensive assistance by (1) staff with personal hygiene and oral care. Facility Policy: 11/2015 A.D.L CARE (Activity of Daily Living) Policy: To meet the grooming and hygiene needs of residents with dignity and privacy. To encourage residents to achieve independence while providing the assistance needed. The basis of ADL care should be implemented whenever a procedure or task occurs. Basics for ADL care: Ask the resident for permission to assist with or perform ADL care. 145208 Page 10 of 12 145208 07/14/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to follow orders per their Order Summary Report to off load heels while in bed. This failure effects 1 of 8 residents (R112) reviewed for prevention of pressure ulcers in a sample of 26. Residents Affected - Few Findings include: On 7/11/2023 at 11:30 am, R112 was observed with V19 (Certified Nursing Assistant-CNA) with his left heel laying on the bed, V19 said I don't know if R112 foot should be elevated on pillows or not. On 7/11/2023 at 12:00 pm, V20 (Nurse) said R112 left heel should be elevated on pillows to prevent any skin breakdown. On 7/11/2023 at 1:00 pm, V3 (Assistant Director of Nursing-ADON) observed R112 left heel laying on the bed and said his left heel should be off loaded while in bed to try and prevent a pressure ulcer. On 7/13/2023 at 8:00 am, R112's left heel was observed laying on the bed. R112 said the pillow was there only one day. An Order Summary Report dated 7/14/2023 indicated that R112 has an order to off load heels while in bed every shift prescribed on 12/20/2022. Facility Policy: 1/20/2019 Prevention of Pressure Ulcers/Injuries Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcers/injuries risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Mobility/Repositioning: 10. When in bed, every attempt should be made to float heels (keep heels off the bed). 145208 Page 11 of 12 145208 07/14/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide range of motion (ROM) exercises to one resident (R34) out of eight residents reviewed for ROM in a sample of 26. Finding includes: On 07/11/23 11:34 AM, R34 was observed in her room with V10 (RN). R34 has bilateral hand contractures with no split on. V10 reviewed both R34 physician order and care plan; no split was ordered. V10 said that R34 should have a splint to prevent further contractures. On 7/12/2023 at 10:30 am, V8 (Physical Therapy Director) said that R34 was discharged from occupational therapy and referred to restorative program on 5/25/2023 while awaiting for bilateral hand splints. V8 said that restorative nurse should have carried out the recommendation of ROM from Occupational therapy. On 7/12/2023 at 10:35 am, review of care plan with V2 (DON/Restorative Nurse) and V8 did not indicate that R34 should be on bilateral progressive hand splints. Rather, the care plan indicated that R34 wears right hand splint daily 6-7 days per week which was not applied either. R34 is an [AGE] year old female who was admitted on [DATE] with a diagnosis not limited to primary hypertension, anemia, anxiety, and muscle wasting and atrophy. Restorative Nursing: Policy: Each resident admitted to the facility shall be assessed by a nurse within the first 72 hours of admission regarding rehabilitative nursing care to be administered. Based on the individual resident needs the following programs are available: AROM Splint assistance. Range of Motion: Range of motion may be done on each resident every day during bath time without a physician's order. Restorative Assessment Procedure The following will be restorative assessment procedure: Upon admission of a new resident: - Need to complete a transfer assessment, ROM assessment, motorized wheelchair assessment, any ADL assessments needed, and a Functional Endurance Assessment. 145208 Page 12 of 12