Health inspection·November 8, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to a.) implement/revise the care plan interventions addressing the resident's required nutritional support for one (R4) resident b.) the facility's intermittent failure to provide required assistance/monitoring with eating resulted in poor intake for one (R4) resident out of three residents reviewed, in a total sample of three residents. This failure resulted in R4's significant, not severe, unplanned weight loss. Residents Affected - Few Findings include: R4's current face sheet documents R4 is a [AGE] year-old individual admitted to the facility on [DATE] with diagnoses not limited to: chronic obstructive pulmonary disease, unspecified, unspecified dementia, muscle weakness (generalized), hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, repeated falls, other seizures. On 11/06/2024. 12:17 PM, R4 sitting on a mobile reclining geriatric chair with a bedside table in front of him, food tray in front of R4, R4 grabbed food with hands and fed self. On 11/06/2024, 12:20 PM, Staff preparing meal trays, cook serving the meal plates, CNAs (certified nursing assistants) heading to pass out trays in rooms. On 11/06/2024, 12:20PM, R4's pillow slid towards upper back, and no longer supporting R4's back of head. R4 not eating, R4 appears laying back, chin tilted towards ceiling, mouth chewing movements. No staff helped R4. On 11/06/2024, 12:23 PM, R4 using his fork attempting to grab some food in a bowl and fed self. R4's chin slightly facing towards the ceiling, R4's head slightly tilted towards the ceiling while R4 is chewing the food. No staff helped R4. On 11/06/2024, 12:24 PM, R4 having difficulty reaching a bowl with a fork. R4 able to grab a piece of food with the fork and ate some food while food particles fell on R4's clothing. R4 grabbed a big piece of the quesadilla with fork but the quesadilla fell off, and R4 proceeded to grab the whole piece of the quesadilla with his left hand. No staff helped R4. On 11/06/2024, 12:26 PM, R4 struggling to drink with straw, appears forcing his neck up. Appears in an uncomfortable sitting position, chin facing up. No staff helped R4. On 11/06/2024, 12:32 PM, R4 sitting on a Geri-chair, R4's face slightly facing the ceiling as R4 is seen biting his sandwich. No staff helped R4. Page 1 of 7 145429 145429 11/08/2024 Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621

F 0692 Level of Harm - Actual harm On 11/06/2024, 12:35 PM, R4 using right hand, using fork to grab food from small bowl. Requesting juice, while food is in his mouth. R4 saying out loud that he wants some cake. Observed grabbing food with his left hand but then R4 observed placing the piece of food down on the plate. No staff helped R4. Residents Affected - Few On 11/06/2024, 12:50 PM, R4's ate half a sandwich, half of the quesadilla. On 11/07/2024, 12:39 PM, R4 lying in bed, right hand limited range of motion. No meal tray yet passed out to R4. V14 states I'm going to assist him. On 11/06/2024, 2:59 PM, via telephone V13 (Clinical Nutrition Manager) stated that she tries to come to the facility every week and the last time that she was in the building was last Wednesday. Surveyor questioned V13 who is involved in evaluating and addressing any underlying causes of nutritional risks or impairment. V13 stated that the dietary manager is part of the team, and V13 stated I am the one that pulls the weight changes and address weight changes. When I come in, V2 (Director of Nursing) and V14 (Assistant Director of Nursing), let me know the people that they want me to see. V13 stated that R4 weighed 138lbs (pounds) on August 7th, 2024, and then at the end of August 30th, 2024, R4 weighed 123lbs. V13 stated it was a significant weight loss, he wasn't in the hospital. That is a lot of weight to lose in a month. V13 was questioned on how often is the resident's food/supplement intake, weight, eating ability monitored? Where is it documented? V13 stated that R4's weight is monitored monthly unless there is a change to weekly, which could happen, V13 states eating is in the tasks, and med pass is in the MAR (medication administration record). V13 stated that it is important to monitor in the dining room, and if staff notice that he is not eating his meal or having difficulty than it would be the day that R4 needs help. V13 stated that R4 needs set up assist and encouragement. V13 stated as she is reviewing R4's record, task under eating, some days it looks like he needs assistance or total assistance. V13 stated that if a resident is a feeder, then it would be documented as dependent. 11/08/2024, 1:09 PM, via telephone V27 (Nurse Practitioner) stated he (R4) needs to eat more, and the goal is for weight increase. V27 stated that part of it is for staff giving V27 the weights for R4. V27 stated food intake is one part of the equation of weight loss, it's not always an indicator. V27 stated that nursing is responsible to make sure they are eating well and tell why they are not eating well. V27 reported he (R4) needs 1:1 eating, but if he does not want to be fed, they need to supervise him. V27 stated positioning matters, you cannot lie flat and eat comfortable. V27 stated that he has taken care of R4 for several years and R4 has had a significant weight loss. V27 stated it's a collection of effort, and multidisciplinary approach, meals are very important. V27 stated that the nurse and CNA are supposed to monitor. 11/07/24, 10:54 AM, via telephone V23 (Certified Nursing Assistant) stated that R4 eats and is an assistive feeder as well. V23 stated he (R4) has a hard time keeping the food on the spoon. Since I work nights, I don't know currently. V23 stated that R4 can feed himself, V23 stated although his food will fall because his hand will be unsteady. R4's nutrition note dated 10/26/2024, 5:27 PM, documents in part, current diet general/mech soft diet with thin liquids, supplements noted. Wt. (weight) -119.0# sig wt (weight) loss -14.1% -19.6 x2mo (months), -13.5% -18.6 x4mo. Diet does support 100% resident est (estimate) needs. Total assist, PO (by mouth) intake 51-100%. Will rec (recommend) appetite stimulant. R4's Nutrition Quarterly/Reassessment assessment dated [DATE] documents in part comments: Total 145429 Page 2 of 7 145429 11/08/2024 Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621

F 0692 assist. Level of Harm - Actual harm R4's Minimum Data Set (MDS), section GG dated 9/03/2024, documents in part that R4 requires supervision or touching assistance for eating. Residents Affected - Few R4's weight log documents the following: June 2024 is 138.2 lbs (pounds), July shows no weight documented, August 2024 is 138.6 lbs, September 2024 is 123.4 lbs, and October 2024 is 119.0 lbs. R4's 30-day look back for CNA documentation for task: Amount Eaten shows no documentation for the following dates: 10/13/2024, 10/17/2024, 10/18/2024, 10/20/2024, 10/26/2024, 10/27/2024, 10/28/2024, 10/29/2024, 10/31/2024, 11/01/2024, 11/02/2024, 11/03/2024. Several other dates noted with discrepancies (missing documentation for different meals, only one meal documented for the date). No lunch meal amount eaten documented in R3's medical record for 11/06/2024. R4's 30-day look back for CNA documentation for Eating: the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident shows no documentation for the following dates: 10/13/2024, 10/17/2024, 10/18/2024, 10/20/2024, 10/26/2024, 10/27/2024, 10/28/2024, 10/29/2024, 10/31/2024, 11/01/2024, 11/02/2024, 11/03/2024. Several other dates noted with discrepancies (missing documentation for different meals, only one meal documented for some dates). R4's current care plan documents in part, R4 requires nutritional support. R4 will maintain current nutritional status with current nutritional interventions. Will maintain weight. Interventions/Tasks meal monitoring and recording as indicated. Set up resident's tray and provide assist or cueing for meals as needed. R4's care plan does not document that he has been assessed for the use of finger foods to make eating easier. The facility's Policy, titled Comprehensive Care Plans dated 11/2017, documents in part, The comprehensive person-centered care plan will: Describe the services that are to be provided to attain or maintain the highest practical physical, mental and psychosocial well-being. 145429 Page 3 of 7 145429 11/08/2024 Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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 special eating equipment and appropriate assistance for one (R3) resident out of three residents reviewed, in a total sample of three residents. This failure has the potential to affect the resident's ability to maintain or improve their ability to eat or drink independently. Residents Affected - Few Findings include: R3's current face sheet documents R3 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dementia in other diseases classified elsewhere, muscle weakness (generalized). On 11/06/2024, 12:16 PM, R3 in dining room using her left-hand appears having difficulty grabbing food off the plate with a spoon. Observed dropping food off the spoon as she lifted to feed herself slowly. On 11/06/2024, 12:20 PM, R3 sitting in dining room not eating. Staff preparing meal trays, cook serving the meal plates, CNAs (certified nursing assistants) heading to pass out trays in rooms. On 11/06/2024, 12:21 PM, R3 in dining room attempting to reach her food with utensil, but unsuccessful, opened mouth, grabbed the whole piece of quesadilla with her left hand. R3 bit a piece of the quesadilla off and placed the rest on the plate. On 11/06/2024, 12:28 PM, R3 in dining room using her left hand to grab food. Did not observe staff clean residents' hands/apply hand sanitizer. On 11/06/2024, 12:30 PM, R3 sitting in dining room eating slowly, no staff sitting next to her. On 11/6/24, 12:32 PM, R3sitting in dining room not eating, sitting in front of her meal tray. On 11/06/24, 12:38 PM, R3 grabbing/touching her food with her left hand to feed herself, right hand/arm bent against her chest. R3 eating slowly. 11/06/2024, 12:43 PM, R3 sitting in dining room grabbing food with her left hand and placed it back on the plate. On 11/06/2024, 12:50 PM, R3's sitting in dining tray ticket for 11/6/2024, documents in part Adap. (adaptive) Equip (Equipment): Plate Guard. No plate guard noted. 11/07/2024, 12:45 PM, R3 lying in bed, head of the bed elevated, observed V21 (Licensed Practical Nurse) feeding R3. R3's tray ticket for 11/7/2024, documents in part Adap. (adaptive) Equip (Equipment): Plate Guard. No plate guard noted. V21 states I just came in, she (R3) was feeding herself. She was using the spoon to pick up the meat, I gave her the fork to use. 11/7/24, 12:53 PM, V25 (Dietary Supervisor) stated the nurses fill out the dietary slips and V25 145429 Page 4 of 7 145429 11/08/2024 Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621

F 0810 Level of Harm - Minimal harm or potential for actual harm just prints them out. V25 stated I add to the slips if there are double portion orders and likes and dislikes. Surveyor requested to see a plate guard. V25 stated plate guards are on order; I don't think they have been ordered yet. Let me go find out. V25 provided surveyor with documents that the plate guard orders were placed on 11/7/24. Residents Affected - Few R3's Nutrition Quarterly/Reassessment assessment dated [DATE] documents in part Diet: Adaptive Equipment: Plate Guard. R3's Minimum Data Set (MDS), section GG dated 9/11/2024, documents in part R3 requires supervision or touching assistance for eating. R3's 30-day look back for CNA documentation for task: Plate Guard: promotes independence while minimizing messy spills at mealtime documents that on several days documents yes including for 11/06/2024, no refusals documented. R3's care plan does not document that she has been assessed for the use of finger foods to make eating easier. The facility's Policy, titled Restorative Nursing Program dated 3/10/2022, documents in part, it is the policy of this facility that a resident is given the appropriate treatment and services to enable residents to maintain or improve his or her abilities and to promote the resident's ability to adapt and adjust to living as independently and safely as possible. 145429 Page 5 of 7 145429 11/08/2024 Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records for one resident (R1) in accordance with its policy and accepted professional standards of practices that are complete and accurately documented. This failure affects one of three residents reviewed for records, in a total sample of three residents. Findings include: During record review of R1s' electronic health record on 11/06/2024, at approximately 1:30 PM, R1s' most recent community survival assessment dated [DATE], documents that R1 is not capable of unsupervised outside pass privileges at this time. R1s' community survival skills assessment dated [DATE] and signed by V29 (Behavioral Health Counselor/BHC), documents that R1 is not sufficiently oriented and coherent affording her the potential for independent pass privileges. R1s' assessment also documents that R1 is not capable of unsupervised outside pass privileges. Surveyor requests a copy of R1s' most recent community survival assessment from V7 (Director of Behavioral Health) on 11/06/2024, at approximately 2:45 PM. On 11/06/2024, at 3:22PM, V2 (Director of Nursing/DON) states the facility staff assesses the residents quarterly to update their needs to go out on community pass. On 11/06/2024, at approximately 4:15 PM, V7 brings surveyor a community survival skills assessment dated [DATE]. Surveyor makes V7 aware that the assessment was not documented in R1s' electronic health record prior to surveyor's request. V7 states the assessment was completed on 08/08/2024 but was not signed until today 11/06/2024. On 11/06/2024, at 5:22 PM, V1 (Administrator) provided surveyor with a community survival skills assessment with information handwritten in ink dated 07/11/2023. Surveyor observes that this handwritten assessment dated [DATE], provided by V1 does not match the information from the electronic assessment dated [DATE] inside of R1s' electronic health record. On 11/07/2024, at 2:30 PM, surveyor inquires to V1 about the handwritten assessment. V1 states V7 provided the assessment to V1 to give to surveyor. Surveyor makes V1 aware that the handwritten assessment dated [DATE], provided by V7, does not match the information from the assessment dated [DATE], inside of R1s' electronic health record. On 11/07/2024 at 3:02 PM, V7 (Director of Behavioral Health) stated the reason for the handwritten assessment is because she realized that R1s' electronic community survival skills assessment was completed inaccurately. V7 stated upon her noticing it, she gave V29 (BHC/Behavioral Health Counselor) another assessment form and informed V29 to complete a new form, which is why the form is now handwritten. V7 stated the electronic assessment that is dated 07/11/2023, in R1s' electronic health record documents that R1 cannot have unsupervised pass privileges which conflicts with R1s' physician orders. V7 stated R1s' physician orders document that R1 can have unrestricted independent passes. V7 stated the community survival skills assessment are completed annually or upon any significant 145429 Page 6 of 7 145429 11/08/2024 Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few change. V7 stated R1s' community survival skills assessment dated [DATE], would also be considered past due since it is dated 08/08/2024 and more than one year after 07/11/2023. R1s' care plan documents in part, R1 has independent pass privileges, R1 understands that she is pass level 2, 1 hour and reports that she will comply with the pass policy of the facility. R1 community survival skills will be assessed quarterly and annually. Facility policy dated 10/2023, titled [NAME] Behavioral Health Program Assessment/Reassessment and Care Planning Requirements documents in part, Policy- [NAME] staff will complete a thorough assessment on all residents for the purpose of proper care planning and treatment. 4. a. Comprehensive Assessment (Initial, annual or significant change): - Community Survival Skills Assessment. 145429 Page 7 of 7