Health inspection·July 13, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide prompt assistance with ADLs(Activities of Daily Living) by not responding to residents' call light in a timely manner. Residents Affected - Few This applies to 2 of 3 residents (R9, R11) reviewed for improper nursing in the area of call light response in the sample of 10. The findings include: On July 5, 2023 at 11:34 AM, three resident call lights were illuminated above the residents' doorways, including above R9's doorway and R11's doorway. A continuous high-pitched noise could be heard at the nurse's station. No lights were illuminated on the resident room panel behind the nurse's station. V7 (RN-Registered Nurse) was sitting behind the nurse's station looking at a cell phone. V7 could not identify the source of the continuous high-pitched sound. V7 said, I have no idea what that alarm noise is. V7 did not attempt to answer the illuminated resident call lights and no other staff was visible in the hallway. On July 5, 2023 at 11:37 AM, R9 was sitting in a chair in her room. R9 said, My call light has been going off for two hours. R9 said she pressed her call light because she wanted to receive a shower. At 11:52 AM, R9's call light continued to be illuminated over R9's doorway. R9 was yelling out, Help me! After 16 minutes of observing R9's call light being illuminated, V11 (CNA-Certified Nursing Assistant) entered R9's room. V11 said, Hold on, I am helping someone else. V11 left R9's room with the call light still illuminated and without providing assistance to R9. R9's call light was answered by facility staff after being observed continuously illuminated for 23 minutes and 11 seconds. On July 5, 2023 at 11:58 AM, R11's call light was answered by V8 (LPN-Licensed Practical Nurse) and V9 (LPN) after observing the call light to be illuminated continuously for 24 minutes and 42 seconds. V9 said R11 was requesting to have his resident room door propped open because his room felt stuffy. The EMR (Electronic Medical Record) shows R9 was admitted to the facility on [DATE]. R9 has multiple diagnoses including, osteoarthritis, cognitive communication deficit, left humerus fracture, hypertensin, COPD (Chronic Obstructive Pulmonary Disease), chronic kidney disease, macular degeneration, presence of cardiac pacemaker, history of bowel, and bladder disorder. R9's MDS (Minimum Data Set) dated April 10, 2023 shows R9 has moderate cognitive impairment, is totally dependent on facility staff for transfers between surfaces, locomotion, dressing, toilet use, and personal hygiene, requires extensive assistance with bathing and bed mobility, and is able to eat Page 1 of 8 145339 145339 07/13/2023 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0677 with supervision. R9 is always incontinent of bowel and bladder. Level of Harm - Minimal harm or potential for actual harm The EMR shows R11 was admitted to the facility on [DATE]. R11 has multiple diagnoses including, multiple sclerosis, multiple pressure ulcers, weakness, osteoarthritis, COPD, chronic pain syndrome, quadriplegia, neuromuscular bladder dysfunction, major depressive disorder, atrial fibrillation, and chronic respiratory failure. Residents Affected - Few R11's MDS dated [DATE] shows R11 has severe cognitive impairment and is totally dependent on facility staff for all ADLs (Activities of Daily Living). R11 has an indwelling urinary catheter and is always incontinent of stool. On July 5, 2023 at 11:49 AM, V10 (CNA) said, The call lights do not alarm, so we cannot hear if they are going off. The only way for us to know if the call light is going off is we just have to see the light lit up over the door to know if the resident needs assistance. On July 10, 2023 at 2:05 PM, V15 (Maintenance Director) said, The call light system has the capability to make an audible sound when the call light has been triggered by the resident. The call light system volume is turned down, so no sound is heard if the call light is turned on. The call light system behind the nurse's station has little tiles with small lights to show which room is calling for assistance. The system is old, and the lights need to be inserted in the call light panel. It is difficult to have lights in place to illuminate the board. The facility's policy entitled Call Light Policy, revised on July 27, 2022 shows: Policy Statement: It is the policy of this facility to ensure that there is prompt response to the resident's call for assistance. The facility also ensures that the call system is in proper working order. Procedures: 1. Facility shall answer call lights in a timely manner.6. Be sure that when the call light is triggered, it will either alert the staff visually or audibly or both. 145339 Page 2 of 8 145339 07/13/2023 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document vital sign monitoring as ordered by the Physician. Residents Affected - Few This applies to 1 of 3 residents (R12) reviewed for vital sign monitoring in the sample of 10. The findings include: R12's EMR (Electronic Medical Record) showed R12 was admitted to the facility on [DATE]. R12's diagnoses include quadriplegia, traumatic brain injury, tracheostomy, gastrostomy, chronic respiratory failure, contracture of muscle multiple sites, neuromuscular dysfunction of the bladder, and asthma. R12's MDS (Minimum Data Set) dated July 3, 2023, showed severe cognitive impairment, total dependence on staff for bed mobility, transfer, dressing, eating, toileting and personal hygiene, and is always incontinent of bowel and bladder. R12's EMR showed a Physician's order dated June 28, 2023, for vital signs every shift. R12's Monitoring Record for July 2023 showed the facility failed to document vital signs every shift. The Monitoring Record shows: July 1, 2023 -night shift - no vital sign documentation July 2, 2023 -night shift - no vital sign documentation July 3, 2023 -day shift - no vital sign documentation July 3, 2023-evening shift - no vital sign documentation July 4, 2023-evening shift - no vital sign documentation July 4, 2023-night shift - no vital sign documentation July 5, 2023- night shift - no vital sign documentation July 6, 2023-evening shift - no vital sign documentation July 7, 2023-day shift - no vital sign documentation July 7, 2023- night shift - no vital sign documentation July 9, 2023-day shift - no vital sign documentation July 9, 2023-evening shift - no vital sign documentation July 10, 2023-evening shift - no vital sign documentation On July 12, 2023, at 10:50 AM, V20 (RN, Registered Nurse) stated R12 has an order to monitor vital 145339 Page 3 of 8 145339 07/13/2023 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0684 signs every shift. Level of Harm - Minimal harm or potential for actual harm The facility's policy titled Physician Orders dated July 28, 2022, shows It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (Physician Order Sheet). Residents Affected - Few 145339 Page 4 of 8 145339 07/13/2023 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure residents received pressure ulcer treatments as ordered by the physician. Residents Affected - Few This applies to 2 (R5, R6) of 4 residents (R5, R6, R7, R8) reviewed for pressure ulcers in the sample of 10. The findings include: 1. On July 5, 2023 at 1:51 PM, R5 was lying in bed on his back. R5 had a tracheostomy in place and was not interviewable due to his cognitive status. V13 (CNA-Certified Nursing Assistant) turned R5 to his side in the bed. A pressure ulcer was visible on R5's sacral area. The pressure ulcer was open to air, and no dressing was present. The wound appeared approximately 2 inches long, by 2 inches wide, by 1 inch deep. A small amount pink-tinged drainage was present on the linens directly under R5's pressure ulcer, approximately 4 inches long by 2 inches wide. V12 (Wound Care NP-Nurse Practitioner) said R5's sacral pressure ulcer should be covered with a dressing. V12 continued to say if R5's pressure ulcer dressing comes off between daily dressing changes, facility staff should follow the physician's order for the PRN (As Needed) pressure ulcer dressing, or at the very least cover the pressure ulcer with a dressing. V5 (Wound Care Nurse) provided pressure ulcer treatment to R5's sacrum with V12 present. V5 packed the pressure ulcer with a calcium alginate material coated with medihoney and covered the pressure ulcer with a foam dressing. The EMR (Electronic Medical Record) shows R5 was admitted to the facility on [DATE]. R5 has multiple diagnoses including, cerebral infarction, sepsis, history of recurrent pneumonia, history of UTIs (Urinary Tract Infections), anemia, tachycardia, dysphagia, respiratory failure, encephalopathy, intracerebral hemorrhage, heart failure, sudden cardiac arrest, chronic atrial fibrillation, hypertension, tracheostomy, and gastrostomy. R5's MDS (Minimum Data Set) dated June 17, 2023 shows R5 is in a persistent vegetative state, with no discernible consciousness, and is totally dependent on facility staff for all ADLs (Activities of Daily Living). R5 has an indwelling urinary catheter and is always incontinent of stool. R5's MDS continues to show, at the time of the MDS assessment, R5 had one Stage 2 pressure ulcer, one Stage 4 pressure ulcer, and one unstageable pressure ulcer, all present on admission or reentry to the facility. R5's care plan, initiated June 13, 2023 shows R5 has impairment to skin integrity. Interventions dated June 13, 2023 include, Apply wound treatment as ordered by the physician. The facility's Wound Assessment Report dated July 5, 2023 shows R5 has a Stage 4 pressure ulcer to the sacrum measuring 6.40 cm. (Centimeters) long by 5.20 cm. wide, by 2.10 cm. deep (2.52 inches long by 2.04 inches wide by 0.82 inches deep). The report continues to show R5's pressure ulcer had a moderate amount of serosanguineous exudate present during the wound assessment. The EMR shows the following order dated June 12, 2023: Medihoney calcium alginate (wound dressings). Apply to sacrum topically every day shift for treatment. Cleanse area with normal saline and pat dry dressing. 145339 Page 5 of 8 145339 07/13/2023 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The EMR also shows the following order dated June 12, 2023: Medihoney Calcium Alginate 4 (Wound Dressings). Apply to sacrum topically as needed for treatment. 2. On July 5, 2023 at 1:20 PM, R6 was lying on her back in her bed. R6 had a tracheostomy in place and was not interviewable due to her cognitive status. V13 (CNA) turned R6 to her side in the bed. A pressure ulcer was present on R6's sacral area. The pressure ulcer was open to air, and no dressing was covering the pressure ulcer. V5 (Wound Care Nurse) said R6's pressure ulcer should be covered with a dressing. R6's pressure ulcer appeared to be approximately 1 inch long, by 1 inch wide, by one-half inch deep. V5 provided wound care to R6 with V12 (Wound Care NP) present at the bedside. V5 packed the pressure ulcer with a collagen material and covered the pressure ulcer with a large dressing. The EMR shows R6 was admitted to the facility on [DATE], with multiple diagnoses including, Parkinson's disease, Stage 4 sacral pressure ulcer, chronic respiratory failure, heart failure, schizophrenia, anxiety disorder, tracheostomy, ventilator dependence and gastrostomy tube. R6's MDS dated [DATE], shows R6 has severe cognitive impairment, is totally dependent on facility staff for all ADLs, and is always incontinent of bowel and bladder. At the time of the MDS assessment, R6 had one Stage 4 pressure ulcer. R6's care plan, initiated February 21, 2023 shows R6 has an actual impairment to skin integrity. R6's care plan has multiple interventions initiated on February 21, 2023 including, Apply wound treatment as ordered by the physician. The facility's Wound Assessment Report dated July 5, 2023 shows R6 has a Stage 4 pressure ulcer of the sacrum measuring 2.00 cm. long by 2.30 cm. wide, by 0.40 cm. deep (0.78 inches long by 0.90 inches wide by 0.15 inches deep). The report continues to show R6's pressure ulcer had a moderate amount of serosanguineous exudate during the wound assessment. The EMR shows the following order dated June 30, 2023: Wound: Sacrum Cleanse with normal saline, pat dry, apply collagen and cover with a dressing every day shift and as needed. 145339 Page 6 of 8 145339 07/13/2023 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders for enteral feeding administration. This applies to 2 of 3 residents (R6 and R12) reviewed for enteral feeding in a sample of 10. The findings include: 1. On July 12, 2023, at 9:01 AM, R6 was receiving care from staff and the tube feeding was turned off. V14 (RN- Registered Nurse) entered the room at 9:05 AM and turned the feeding pump on. The feeding container was labeled as Jevity 1.2, infusing at a rate of 60 ml/hr. (milliliters per hour) and total volume infused showed 267 ml (milliliters). V14 showed the history of the volume administered on the feeding pump over the last 24 hours was 859 ml. R6's EMR (Electronic Medical Record) showed a Physician order dated June 30, 2023, Enteral Feed Order every shift Enteral feeding- Tube type: GT (Gastrostomy Tube), Jevity 1.2, Rate: 65 ml/hr. (22 hrs) on at PM; off at noon. Daily Total Volume = 1430 ml. Turn off during ADLs (Activities of Daily Living) and PRN (as needed). R6's July 2023 MAR (Medication Administration Record) showed the following documentation for R6's total volume of tube feeding infused (TVI) each day: July 1, 2023 - NA (no volume documented) July 2, 2023 - 390 ml. infused July 3, 2023 - 390 ml. infused July 4, 2023 - blank (no volume documented) July 5, 2023 - 390 ml. infused July 6, 2023 - NA (no volume documented) July 7, 2023 - 390 ml. infused July 8, 2023 - NA (no volume documented) July 9, 2023 - 390 ml. infused R6's EMR showed R6 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, Stage 4 sacral pressure ulcer, chronic respiratory failure, ventilator dependent with tracheostomy, heart failure, schizophrenia, anxiety disorder and gastrostomy tube. R6's MDS (Minimum Data Set) dated May 17, 2023, showed R6 has severe cognitive impairment, is totally dependent on facility staff for all ADLs, and is always incontinent of bowel and bladder. 145339 Page 7 of 8 145339 07/13/2023 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The dietician assessment dated [DATE], showed R6 needs to receive tube feeding formula at a rate of 65 ml. per hour for 22 hours with a total volume of 1430 ml. to be administered daily to provide 1715 calories to maintain weight. 2. On July 12, 2023, at 10:40 AM, R12 was lying in bed with his tracheostomy attached to humidity, was not interviewable due to his cognitive status. The tube feeding was infusing through the gastrostomy tube. The tube feeding was labeled as Jevity 1.5 at a rate of 60 ml. per hour. R12's physician order for tube feeding initiated June 30, 2023, shows every shift Enteral feeding- Tube type: GTube, Jevity 1.5, Rate: 65 ml/hr; On at PM, Off at 12 noon (22 hours) until Total Volume of 1430 ml is infused . R12's July MAR shows the following documentation for R12's TVI: July 9, 2023 - 1200 ml infused July 10, 2023 - 1200 ml infused July 11, 2023 - 1200 ml infused July 12, 2023 - 1200 ml infused The EMR showed R12 was admitted to the facility on [DATE]. Diagnoses include quadriplegia, traumatic brain injury, tracheostomy, gastrostomy, chronic respiratory failure, contracture of muscle, multiple sites, neuromuscular dysfunction of the bladder, asthma. R12's MDS dated [DATE], showed severe cognitive impairment, total dependence on staff for bed mobility, transfer, dressing, eating (gastrostomy tube), toileting and personal hygiene, always incontinent of bowel and bladder. No pressure ulcer identified, but at risk for skin breakdown. On July 12, 2023, at 11:10 AM, V6 (ADON-Assistant Director of Nursing) stated the feeding pump displays the total volume infused and the nurse is to document the TVI on the MAR. V6 further stated the nurses may have a different perception on how to read the order. The facility policy Physician Orders dated July 28, 2022, shows It is the policy of the facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (physician order sheet). 145339 Page 8 of 8