Health inspection·March 17, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to notify the physician and POA (Power of Attorney) for change in residents' condition. This applies to 1 of 5 residents (R1) reviewed for delay in notification in resident's condition. The findings include: The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE]. R1, a [AGE] year-old with multiple diagnoses included epileptic seizure, vascular dementia, aphasia due to cerebral infarction, post traumatic head injury, major depressive disorder, anxiety, bipolar disorder and SAD (schizoaffective disorder). The nurse's progress note dated 3/6/2024 showed R1 had a seizure on 3/6/2024 before breakfast had lasted 1.5 to 2 minutes. The notes showed R1 was monitored, and POA and physician were notified. The notes showed POA insisted R1 be sent to the hospital. R1 left the facility via 911 at 12:30 P.M. R1 was stable and had returned to the facility at 4:30 P.M. On 3/15/2024 at 1:45 P.M., V3 (RN) said on 3/6/2024 around 7:10 A.M., V3 was informed by other staff R1 was having seizure activity in his room. V3 said together with V4 (LPN/License Practical Nurse), both immediately went to R1's room. V3 said, (R1's) seizure was a 'petit mal' seizure had lasted 1.5 to 2 minutes, R1 was having mild involuntary shaking of upper and lower extremities, no rolling of eyes, and (R1) was coherent and able to carry conversation during the seizure. V3 said she had notified R1's POA at around 12:20 P.M. V3 said V6 (R1's Attending Physician) had called the facility around 12:25 P.M. and ordered to send R1 to the hospital. V3 said R1 was sent out via 911 at 12:30 P.M. V3 added there was a delay of notification since she was busy with multiple tasks such as administering morning medications to residents. On 3/15/2024 at 3:10 P.M., V6 said it was only when R1's POA had called her clinic on 3/6/2024 around noon she was first made aware of R1 seizure in the morning of 3/6/2024. V6 said R1's POA asked R1 be sent out to the hospital. V6 said facility should have informed her timely so I can go proceed any further follow up and treatment . On 3/5/2024 at 11:00 A.M., V1 (Administrator) said she was aware of R1's POA's concern regarding delayed notification of R1's seizure activity to V6 and R1's POA. On 3/15/2024 at 1:00 P.M., R1 was in his room walking with a rolling walker. R1's gait was steady. R1 was coherent, able to verbalize needs, was alert and oriented times 3. R1 said he has a daughter (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145433 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)