Health inspection·March 9, 2023

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 interviews and record reviews, the facility failed to follow their policy and procedures for providing care and services in a timely manner by not ensuring nursing staff respond to call lights in a timely manner. This failure applied to four (R343, R443, R445, R446) of four residents reviewed for assistance with activities of daily living. Residents Affected - Some Findings include: On 03/06/23 at 10:44 AM R343 stated she has been at the facility with diarrhea for 3 days. R343 stated sometimes it takes 40 minutes for someone to respond to her call light when she uses it for incontinence care. On 03/06/23 at 12:50 PM R443 stated no one ever gets her out of bed other than for therapy and she stopped using her call light because no one ever responds. On 03/06/23 at 12:03 PM R445 stated he threw up on himself after eating lunch one day and pressed his call light for assistance. R445 stated it took 20-30 minutes for someone to respond to clean him up. R445 stated sometimes it takes this long for a response to his call light. On 03/06/23 at 11:00 AM R446 stated, this morning it took an hour for someone to respond to the call light. R446 stated during a shift change you can't get anyone to respond to the call light. R446 stated the night before her roommate rang the call light and she did as well, however the staff responded to her roommate but did not acknowledge that she pressed the call light for assistance as well. R446 stated she had to yell out and remind them that she needed to be changed. R446 stated she had already been waiting soiled for more than an hour but then had to wait another 30-45 minutes before being changed. On 03/07/23 at 11:17 AM R446 stated a lot of times she has to wait for assistance possibly because she's larger and needs two person assistance. On 03/08/23 at 01:44 PM V13 (Ombudsman) stated she has received multiple concerns from residents about staffing, including call light response time. Resident council meeting report dated 11/08/22 and 02/14/23 documents nursing concerns include: resident stated that sometimes their call lights at night are being answered late. Will inform night nurses and supervisor to take frequent rounds. Stand up meeting was held with staff. On 03/09/23 at 11:17 AM V3 (Director of Nursing) stated it is all nursing staff's responsibility to respond to the call lights and they should always be answered. V3 stated she is not sure what is a Page 1 of 3 145268 145268 03/09/2023 Glenview Terrace 1511 Greenwood Road Glenview, IL 60025

F 0677 reasonable amount of time the call light should be responded to, however as soon as staff become aware of them. Level of Harm - Minimal harm or potential for actual harm The facility's Call Light Policy reviewed 03/09/23 states: Residents Affected - Some It is the policy of this facility to ensure that there is prompt response to the resident's call for assistance. Facility shall answer call lights in timely manner. 145268 Page 2 of 3 145268 03/09/2023 Glenview Terrace 1511 Greenwood Road Glenview, IL 60025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide documentation of administering a narcotic medication that was in use. This failure applied to one resident (R121) whom was reviewed during medication storage and labeling. Findings include: R121 is an [AGE] year old male who was admitted to the facility 7/1/22 with diagnoses that include Alzheimer's, Dementia. According to R121's MDS (Minimum Data Set) he exhibits severe cognitive impairments scoring a BIMS (Brief Interview of Mental Status) of 2 out of 15. According to Physicians Order Sheet (POS) dated 2/17/23 R121 has been receiving hospice services while living in the facility. On 03/08/23 3:50 PM, during medication and storage review with V19 LPN, lorazepam 1mg/ml gel narcotic sheet for this resident was found in the narcotic control book and the medication was not on the cart. V19 said that they did not know where the medication was located at that time. Surveyor and V19 checked the medication cart and the refrigerator. At 4:10PM V17 Nursing Supervisor presented the missing medication with resident label and said that it was open and had been used. V17 said, the nurses should sign out the medication immediately after the medication has been administered and it should have been on the cart. 3/9/23 at 10:13AM V17 presented with V20 LPN with the lorazepam medication and a modified control sheet which indicated 2ml were wasted on 3/8/23. This was not signed by any nurse or practitioner. V17 said this medication was discontinued on 2/8/23 and should have been removed as well as the sheet. V17 said usually, we take it and give it to the DON to destroy, but V20 LPN forgot to tell me that it was wasted, and she forgot to record it on the sheet. It was in the refrigerator, but I didn't recognize it as the medication because it is a new form of medication that we are not accustomed to using. V20 said, I noticed that the medication was discontinued and was opened after I counted with the nurse in the morning, but I forgot to sign it out before I left the facility yesterday. On 3/9/23 at 10:40AM V3 Director of Nursing said, when a medication is wasted, two nurses have to sign out and verify that the medication was wasted. R121 Physician Order Sheet was reviewed which included an order for lorazepam gel dated 2/9/23 and discontinued 2/23/23. Facility Policy titled Controlled Medications Count revised 7/27/22 states; Statement: It is the policy of the facility to maintain an accurate count of Scheduled II controlled medications. Procedure: 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. 2. After administration of the controlled medication, the nurse will sign off the eMAR. 3. If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication. 145268 Page 3 of 3