Health inspection·September 20, 2023

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 Based on interview and record review the facility failed to follow their practice of identifying the name of the resident with the transportation company to ensure that the correct resident was sent to the correct appointment for one of three residents (R5) reviewed for right resident This failure resulted in R5 being dropped off at a non-dialysis clinic. R5 was subsequently taken to hospital for evaluation, Residents Affected - Few Findings include: R5's face sheet shows R5 has diagnosis of hypertensive chronic kidney disease with stage 5 chronic kidney disease, type 2 diabetes with neuropathy, asthma, fluid overload, acute respiratory failure with hypoxia, pleural effusion, anemia, unspecified dementia, acute on chronic systolic heart failure, end stage renal disease, dependent on renal dialysis. MDS dated 7.28.23 denotes in-part BIMS score 10 (cognitive deficits). Section G for functional status denotes extensive assist and 1-person physical assist. R5 progress notes dated 8.24.23 completed by V2 (Director of Nursing) denotes in-part this writer was notified by the receptionist that the resident was taken to a doctor's office by transportation instead of dialysis. Transportation company was contacted to pick up the resident and refused. Author personally went with a second nurse to pick up the resident and transport to dialysis. However, the doctor's office called 911 and resident was transferred to Hospital. This writer took the residents personal belongings, wheelchair and oxygen to facility and stored appropriately. MD and Family made aware. R5 progress notes dated 8.25.23 resident hospitalized DX (diagnosis) ESRD (end stage renal disease). On 9.14.23 at 12:28 pm, V3 (Administrator) said she was made aware by the receptionist that R5 was dropped off at the wrong facility (clinic) on 8.24.23. V3 said V2 (DON) and the social worker went to pick R5 up from that facility. V3 said when the DON got there the medics was there also to take R5 to the hospital. V3 said what happened was the transportation company arrived to the nursing home, stood near the door and said is he ready . V3 said the receptionist figured the transporter was talking about R5 because he said he . V3 said the receptionist call the unit to let them know that the transportation has arrived to take the resident to their appointment. V3 said when the residents go to dialysis, they do not have an escort, V3 said when the resident goes to appointments they will be escorted. V3 said R5's daughter did voice concerns regarding R5 going to wrong appointment. V3 (Administrator) said she did not complete an investigation; she did not complete an incident report regarding R5 being transported and left at the incorrect facility (clinic) on 8.24.23. V3 said this has never happened before. V3 said she did not have practices/policy in place on 8.24.23 for the staff to Page 1 of 5 145208 145208 09/20/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clarify/ask the transportation company driver who was the resident that is identified as he. V3 said the receptionist has been in-serviced. Review of the in-service presented by V3 dated 8.24.23, denotes topic: transportation pickup protocol, receptionist must verify with driver who they are picking up, write the name of company and phone number on appointment sheet. There is 3 receptionist names noted on the in-service. V3 said the CNA (Certified Nursing Assistant) that brought R4 down to the vehicle has not been in-serviced on the facility practice. V3 then said she doesn't know if that person was a Nurse or CNA. V2 (DON-Director of Nursing) said V21 (Nurse) brought R5 downstairs to the transportation vehicle. On 9.15.23 at 12:10 PM, V20 (Receptionist) said she was sitting at the receptionist desk when a gentle man from the transportation company came inside the facility, stood near the door, and said, is he ready and turned and left the facility. V20 said she pressed the button to let him out the facility. V20 said she then called up to the nursing unit, informed V21 (Nurse) to bring R5 down, because his transportation had arrived. V20 said she figured the guy was talking about R5 because it was only 2 appointments one male and one female. V20 said she figured the guy was talking about R5 also because he picked R5 up before for dialysis. V20 said the nurse brought R5 down and took him outside to the transportation van/car. V20 said she later got a call saying R5 was dropped off at the wrong clinic appointment. V20 said she doesn't know what time she got the call. V20 said she doesn't know the name of the person that called her. V20 said the transportation guy did not show his phone with R5 name on it for verification, V20 said she would not have been able to see his phone because he was too far for her to see. V20 said the resident should not be handed off to the transportation company before the transportation company identify the resident they are picking up. V20 said a different transportation company/person picks R5 up often for his dialysis appointment. On 9.14.23 at 2:33 pm, V21 (Nurse) said on 8.24.23 she received a call from V20 stating to bring R5 down because his transportation had arrived for dialysis. V21 said when she brought R5 down to the front desk, she did not see the guy from the transportation company. V21 said she asked V20 (Receptionist) where the guy was, V20 replied you know they don't like to wait and to take R5 outside. V21 said she thought that was unusual because she has never had to take the resident out the building, the company is usually waiting in the lobby/corridor. V21 said she took R5 out the door as she went up to the van she said R5's first and last name. V21 said the driver responded with a sigh, as though he was irritated. V21 said the guy did not respond if the resident name was correct or not that he was there to pick up. V21 said she doesn't remember if the window was down for the guy to hear. V21 said she doesn't know if the guy heard her or not. V21 said the guy got out the driver side of the vehicle. V21 said as the guy got out the vehicle and came around to where she was with R5, he asked if she could put R5 on the lift, V21 said she responded to him that she did not know how to work the lift on his vehicle. V21 said she handed R5 off to the guy from the transportation company. V21 said she came back inside the facility. V21 said she has not had an in-service on the transportation pick-up protocol. V21 said she told the facility the same thing she told surveyor. V21 said the resident should not be handed off to the transportation driver/company if they have not been identified to be the correct resident that they are picking up. On 9.15.23 at 10:18 am, V22 (personnel at clinic) said she is one of the managers at the non-dialysis clinic, V22 said based on the information that was gathered for this incident, R5 was observed sitting in the clinic waiting area by himself. The clinic staff inquired about R5 wellbeing and if R5 had an appointment. V22 said the clinic staff checked the appointment list, and their patient list, R5 name was not noted. V22 said the clinic staff checked other office suites for R5 to see if R5 had 145208 Page 2 of 5 145208 09/20/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few an appointment in one of the other suites. V22 said R5 did not have an appointment in the other clinics. V22 said R5 complained of difficulty breathing, and short of breath. V22 said R5 was noted using oxygen via nasal canula, and the oxygen tank was low. V22 said because R5 was on oxygen and was complaining of difficulty breathing the clinic called 911 and R5 was agreeable to them calling 911. V22 said R5 said the driver just dropped him off and left. V22 said R5 said he was thinking he was in the wrong clinic. V22 said the driver did not inform the clinic of anything related to R5. V22 said R5 had paperwork with him, and the nursing home name was listed and the nursing home was notified that R5 had been dropped off. V22 said the clinic was in communication with V2 (Director of Nursing). V22 said V2 informed the clinic that it will be a while before the transportation company could come and get R5. V22 said V2 was informed that 911 will be summoned and V2 then replied that she will come and get R5. V22 said V2 and the medics arrived just at the same time. On 9.19.23 at 12:03 pm, V2 (Director of Nursing) said the driver took R5 to the wrong appointment, investigation findings reviewed with V2 of V21 (Nurse) taking R5 outside to the driver and did not verify that R5 was the correct resident to be picked up at that time. V2 said the driver came in the building and said the words he, V2 was informed that the receptionist did not clarify who the driver was referring to as he, nor did the receptionist inquire about the name of the resident to be picked up. V2 said she did not do the investigation and she would have to ask the administrator about details. R5 physician order sheet dated 8.11.23 denotes orders for dialysis 3x week on Tuesday, Thursdays, and Saturday (address noted). R5 was dropped off on 8.24.23 to address (address number). R5 was not dropped off to address listed on physician orders. Oxygen per Nasal canula at 3 liters per minute continuous, every shift monitors and record that 02 (oxygen) sats remain above 92%. 145208 Page 3 of 5 145208 09/20/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed the facility failed to implement fall prevention interventions for two residents at high risk for falls. This failure affected two of three residents (R2 and R9) reviewed for fall prevention interventions The findings include: 1. R2's diagnosis include but are not limited to Amyotrophic Lateral Sclerosis, Weakness, and Osteoarthritis. On 9/14/23 at 11:29 AM, V9, Certified Nursing Assistant (CNA), said R2 was at risk for falls. On 9/14/23 at 3:15 PM, V10, Registered Nurse, said on 9/5/23 I observed R2 sitting on the floor. V10 said R2 had been sitting in a chair in his room and I believe he was trying to get his walker. V10 said I didn't know if R2 had fallen before. V10 said R2 had been walking independently with a walker and he was working with physical therapy. On 9/15/23 at 9:26 AM, V2, Director of Nursing, said R2 was admitted with a history of falls. V2 said R2 had a fall on 8/12/23. V2 said R2 had lost his balance on 8/12/23 and he was not using a walker. V2 said R2 was independent with walking and physical therapy only recommend he use a walker. V2 said on 9/5/23 R2 slid from a chair trying to self transfer. V2 said R2 was able to ambulate freely with a walker and R2 had a steady gait. V2 said Amyotrophic Lateral Sclerosis (ALS) is definitely a fall risk factor for R2. V2 said on 5/31/23 R2 had a fall risk evaluation score of 10, high risk. V2 said anything greater than 10 is a fall risk. V2 said on 8/12/23 R2's fall risk evaluation score was 22. V2 said R2 was able to continue to ambulate independently with a walker and he could transfer independently. On 9/15/23 at 10:42 AM, V11, Licensed Practical Nurse (LPN), said if a resident is at high risk for falls they should not walk independently because they are unsteady. On 9/15/23 at 11:52 AM, V16, Director of Rehab, said R2 was issued a walker for ambulation on 8/1/23. V16 said R2 used the walker independently. V16 said R2's ALS was progressing. V16 said we had to educate and encourage R2 to use the walker. V16 said R2's falls were in his room. V16 said R2 needed assistance. V16 said while a patient is on therapy case load, they are not independent with transfers or ambulation. V16 said R2 needed assistance getting up from the toilet seat. V16 said realistically R2 was not going to improve because of his ALS diagnosis. V16 said over the last couple weeks R2's diagnosis was advancing and we discussed it in morning meeting. V16 we (therapy) told the team R2 needs more assistance. V16 said R2 was not safe to be independent, we would not be providing therapy services if he was safe to be independent with ambulation and transfers. On 9/15/23 at 2:58 PM, V4, CNA, said R2 fell in his room on 9/5/23. V4 said R2 was very independent and went to the washroom independently. V4 said on 9/5/23 I checked R2 on my first round and he was okay. V4 said at about 5:00 PM, I was in the dining room for 30 minutes and then went to pass meal trays. V4 said the next time she saw R2 was when he was on the floor. V4 said if R2 was a fall risk he would not be walking independently. V4 said if he was at risk for falls, I would have stayed with R2, even if he shooed me away. V4 said on 9/5/23 R2 was becoming a fall risk and he had a 145208 Page 4 of 5 145208 09/20/2023 Pavilion of Bridgeview, The 8100 South Harlem Avenue Bridgeview, IL 60455

F 0689 wheelchair on 9/5/23. V4 said if you are a fall risk, you gotta be in a wheelchair all the time. Level of Harm - Minimal harm or potential for actual harm R2's Functional Status assessment dated [DATE] notes he requires limited assistance with bed mobility, transfers, toilet use, and personal hygiene. Residents Affected - Few R2's fall risk reviews dated 5/31/23 and 8/12/23 as reviewed with V2 are noted to not include a score. R2's 8/12/23 incident report notes he has a history of falls and weakness. R2's 9/5/23 incident report notes predisposing physiological factor of history of falls and gait imbalance. R2's physical therapy progress report notes impairments limitations in range of motion, safety awareness, strength impairments, postural alignment/control and balance deficits. Continued services are necessary in order to analyze gait pattern, improve balance, increase independence with gait, minimize falls and promote safety awareness. Ambulation walk 10 feet = supervision or touching assistance. For toilet use and transfer. R2's care plan indicates he has weakness and requires assistance from staff with moving in bed, has limited mobility. Intervention dated 5/31/23 states assist with ambulation and transfers. Requires extensive assistance by 1 staff 2. R9's diagnosis include but are not limited to Cerebral Infarction, Hemiplegia and Hemiparesis, Muscle Weakness, Difficulty in Walking, Osteoarthritis of Knee, Altered Mental Status On 9/14/23 at 12:37 PM, R9 observed sitting in the dining room in a black wheelchair. No roll back device or anti-tip bars observed on the wheelchair. On 9/14/23 at 12:37 PM, V24, Registered Nurse (RN), identified R9 to the surveyor. V24 reported that R9 is post stroke, is at risk for skin impairments and is on an altered diet. V24 said I think R9 is a 2 person assist with the gaitbelt and he is able to pivot for transfers. On 9/14/23 at 2:36 PM, V7, LPN, said R9 is confused and requires total care from staff. V7 said R9 requires the use of a mechanical lift for transfers. V7 said I was told R9 tries to get out of bed. On 9/15/23 at 9:26 AM, V2 said R9 has an anti rolling mechanism on his wheelchair. V2 presented a picture of R9 in a wheelchair with a silver box in the back and anti-tip bars. The surveyor asked when the picture was taken and V2 said on 9/14/23 after 1:00 PM. V2 said maybe restorative or maintenance had R9's wheelchair when the surveyor observed R9 on 9/14/23. V2 said I just added the anti-tip bars. R9's care plan initiated on 6/28/23 identifies R9 at risk for falls related to deconditioning and gait/balance problems. Intervention dated 9/4/23 notes Antiroll back mechanism applied to wheel chair. 145208 Page 5 of 5