Health inspection·October 19, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify the family/emergency contact of resident's change in condition. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for change of condition notification in a sample of 4. Findings include: On 10/17/23 at 11:00 AM, R1 said she does not remember what happened to her on 9/22/23. R1 said the last thing she remembers is eating breakfast that morning and then waking up in the hospital emergency room. R1 said she has family listed as an emergency contact that she wants notified when necessary and her emergency contact was not notified on 9/22/23. On 10/18/23 at 3:51 PM, V12 (R1's emergency contact) said she was never notified by the facility on 9/22/23 that R1 was transferred to the hospital or had any change of condition. V12 said she wants to be notified about any changes with R1. On 10/18/23 at 2:43 PM, V10 (LPN/Licensed Practical Nurse) said the reason R1 was sent out to the hospital on 9/22/23 was because her oxygen dropped below, and she was sleepy and had altered mental status which was not her baseline. V10 said she completed the Change of Condition and Interact forms when R1 was sent out to the hospital and documented notifying R1's emergency contact. V10 (LPN) documented R1's Change of Condition SBAR (Situation Background Assessment Recommendation) on 9/22/23 at 16:46 stating R1 was observed with shortness of breath and low oxygen saturation for which she was placed on 10 Liters of oxygen per nonrebreather mask. V10's Change of Condition documentation states that R1 had increased confusion or disorientation and R1 was unable to make her needs known as per her baseline. Under the review and notification section of the Change of Condition form next to name of family, V10 (LPN) documented R1's name, not the name of R1's family/emergency contact. The Interact Transfer Form dated 9/22/23 at 16:45 shows V10 documented notifying R1 of her own hospital transfer. V10 did not document on Interact Form that she notified R1's emergency contact. On 10/17/23 at 1:45 PM, V1 (Administrator) said he was in R1's room on 9/22/23 during her Change in Condition and he remembers R1 having a change in mentation. V1 said family should be notified of a change in condition or a send out to the hospital. V1 said if R1 has an emergency contact listed, they should have been notified of a hospital transfer. The facility's policy titled Notification for Change of Condition last revised 7/28/22 states, Policy Statement: The facility will provide care to residents and provide notification of resident change in status. Procedures: 1. The facility must immediately . notify the resident's legal Page 1 of 4 145339 145339 10/19/2023 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0580 Level of Harm - Minimal harm or potential for actual harm representative or an interested family member when there is: .b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) .d. A decision to transfer or discharge the resident from the facility . Residents Affected - Few 145339 Page 2 of 4 145339 10/19/2023 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents were free from mental abuse. Residents Affected - Few This applies to 2 of 4 residents (R1 and R4) reviewed for abuse in a sample of 4. The findings include: 1. R1's Face Sheet shows the following medical diagnoses: Peripheral Neuropathy, Cellulitis of Left Lower Limb, Edema, Carcinoma of Left Breast, Panic Disorder, Anxiety, and Morbid Obesity. R1's MDS (Minimum Data Set) dated 10/6/23 shows her cognition is intact and she requires moderate assistance with dressing her lower body and putting on and taking off socks and footwear. On 10/17/23 at 11:00 AM, R1 said V10 (LPN/Licensed Practical Nurse) acts apathetic towards her and when V10 is her nurse, R1 feels anxious wondering what kind of mood V10 is going to be in that day. R1 said one day when V10 was applying steroid cream to R1's legs, V10 said to R1 can't you do this yourself? On another occasion R1 asked V10 to put her socks on and V10 said, can't you do it yourself? and R1 told V10 that she was unable to bend her right knee high enough to put her sock on her right foot, so then V10 put R1's right foot sock on and left the room without offering assistance with the other sock. R1 said this made her feel like she was shamed like a child. R1 said in beginning of October after she returned to the facility from a hospitalization, V10 LPN brought in 40meq (milliequivalent) potassium and R1 told her she was no longer taking that dose and V10 told R1 that's what they ordered and still tried to administer the potassium to R1. R1 told V10 she was not going to take that dose and V10 replied, what else are you not taking? with an attitude and R1 replied just the potassium. R1 said the next time she saw V5 (Nurse Practitioner), she lowered R1's potassium dose to 10meq. R1's October 2023 eMAR (electronic Medical Administration Record) shows that on Monday 10/9/23 at 0900, R1 refused the 40meq potassium dose from V10. The eMAR shows that later that day at 1700, 10meq potassium dose was ordered and given to R1 by V8 (RN/Registered Nurse) on the evening shift. On 10/18/23 at 12:39 PM, V5 (Nurse Practitioner/NP) said she changed R1's potassium dose from 40meq to 10meq because she thought the higher dose was inappropriate and she told R1 that she was glad V10 and herself (V5) did a medication reconciliation. On 10/17/23 at 3:12 PM, V11 (LPN) said she knows R1 very well and has witnessed interactions between R1 and V10 (LPN) that have bothered her. V11 said on one occasion, R1 asked V11 to let the nurse practitioner know that R1 had a skin concern. V11 said she was not R1's nurse, V10 was R1's nurse that day, but V11 let the nurse practitioner know about R1's concern. V11 said R1 asked V11 to not tell V10 that she spoke to the nurse practitioner on her behalf because R1 was afraid if V10 found out, V10 would yell at R1. V11 said V10 somehow found out that V11 notified the nurse practitioner of R1's skin concern, and V10 said to V11 [R1] blows things out of proportion, implying that it was not necessary to notify the nurse practitioner. V11 said she personally and professionally has found V10 to be very mean to R1. V11 said she has witnessed R1 cry because she feels humiliated by V10 and R1 has told V11 that she is afraid to say anything about how V10 treats her because she is afraid of retaliation. V11 said the way V10 treats R1 is mental abuse. 145339 Page 3 of 4 145339 10/19/2023 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. R4's Face Sheet shows the following medical diagnoses: Chronic Heart Failure, Syncope and Collapse, Morbid Obesity, Repeated Falls, and Major Depressive Disorder. R4's MDS dated [DATE] shows her cognition is intact and she is totally dependent on staff for toileting. R4 is roommates with R1. On 10/18/23 at 3:22 PM, R4 said she has witnessed friction between R1 and V10 and she thinks the way V10 acts towards R1 is mental abuse. R4 said V10 is rude towards R1 in the tone she uses and in the actual things she has said to R1. R4 said she has also had problems with the way V10 treats her. R4 said one example was a few months ago when V10 came into R4's room to give her medication, a shot in her abdomen. R4 said V10 lifted up R4's gown and saw that her diaper had leaked and V10 said, Why are you always wet? R4 said V10 is passive aggressive towards her and talks down to her. R4 said sometimes it is not pleasant talking to [V10] if she is in a mood. The facility's policy titled, Abuse and Neglect last reviewed 7/14/23 states, Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse .Types of Abuse and Examples: 3. Mental: Mental abuse includes but is not limited to humiliation, harassment, threat of bodily harm, punishment, isolation (involuntary, imposed seclusion) or deprivation to provoke fear of shame. 145339 Page 4 of 4