Health inspection·October 18, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of records the facility failed to provide planning of care related to oral/dental care for 1 (R1) of 3 residents reviewed for improper nursing care. Findings include: R1 is [AGE] years old, initially admitted on [DATE], with diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R1 is cognitively intact as assessed on 8/27/2024 with a BIMS (Brief Interview of Mental Status) of 15. On 10/15/2024 at 1:07 PM, R1 was seen laying on bed in her room. R1 was alert and verbally able to express her thoughts within topic during conversation. R1 stated that her tooth does not bother her as much as before. R1 stated that her tooth problem is located at the top left area in her mouth and now she does not chew on the left side where she used to chew and she knew that there was a problem on her tooth when she felt a sharp end on her tooth. R1 said, At first it was terrible, and it was swollen. It started around the second week of September. R1 had a food tray in front of her and was barely eating her food. R1 was seen focusing on eating the dark green vegetable without touching the rest of her food. Per review of R1's progress notes, R1's tooth problem was first noted on 9/11/2024 by V18 (Medical Doctor) that R1 has a tooth pain and V18 ordered for R1 to be seen by a dentist. Per V3 (Registered Nurse) notes dated 9/12/2024, R1 was seen by the dentist and documented that Social Worker team to follow up for rescheduling. Progress notes dated 9/17/2024 by V4 (Registered Nurse) documented that R1 verbalized pain 8 out of 10, with 10 being the highest rate of pain. Pain went down to 3 after giving Tylenol medicine. Progress notes dated 8/19/2024 by V5 documents R1 enjoys eating as she finds this her only pleasure being in the facility. Progress notes dated 9/19/2024 by V5 (Licensed Clinical Social Worker) documents that R1 verbalized concern about tooth infection and how to cope with the situation. Progress notes dated 10/15/2024 by V5 (Licensed Clinical Social Worker) documents R1 anxiety persist due to tooth infection. R1 talked about how she needs to alter the way she chews her food. R1 also talks about more aches and pain she has been having and this contributes to her depression. On 10/15/2024 R1's care plan were reviewed and does not include identified problem of her tooth. On 10/16/2024 after request of full care plan, oral/dental health problems related to tooth pain was included and dated 10/16/2024. Page 1 of 2 145336 145336 10/18/2024 Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/16/2024 at 12:05 PM with V2 (Director of Nursing) stated that R1 has a tooth problem. V2 said, I think her tooth was broken and she complained of pain. Per V2, R1 was seen by the dentist on 9/12/2024 and recommended tooth extraction. R1 was scheduled to go out to an outside dental clinic but was cancelled due to transfer problem. R1 uses Hoyer lift for transfer and the dental clinic does not have equipment to transfer R1 from the wheelchair or stretcher to dental chair. Dental clinic was concerned about the safe transfer of R1. V2 said, that R1 has an appointment on 10/18/2024 for in-house tooth extraction and that R1's diet was changed from regular to mechanical soft. R1's Tylenol medication schedule was changed from as needed to every 8 hours. V2 was handed R1's full care plan to review. After full review, V2 pointed and acknowledged the care plan for oral/dental health problems related to tooth pain dated 10/16/2024. V2 stated that it was just done today and R1 did not have a care plan for oral/dental health problem until today. V2 stated that R1's care plan needs to be comprehensive enough to address all issues included in the interventions including pain, diet, and other areas that may be affected by R1's tooth problem. On 10/17/2024 at 11:24 AM, V1 (Administrator) explained that R1 was scheduled for an appointment going to outside dental clinic but was unable to go due to transfer issue. Dental clinic cannot accommodate because it is hard to transfer R1 from wheelchair or stretcher to the dental chair because R1 needs Hoyer lift. V1 was made aware that care plan was not started until today (10/16/2024) to address these concerns and contingencies such as the issue she (V1) just mentioned in case interventions by facility failed related to R1's dental/oral care. V1 stated that she was aware and will address the issue. Care Plan policy dated 7/26/2024, reads: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with federal regulations. Under procedures, after the comprehensive assessment is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days. These will be periodically reviewed and revised by a team of qualified persons after each assessment. Per policy of the facility, care plans are in conjunction with federal regulation. Under Code of Federal Regulation Title 42 dated 10/16/2024 on Care Plan, it reads: §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by the regulation. The services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality. 145336 Page 2 of 2