Health inspection·October 29, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to respect end of life wishes for 1 of 3 residents (R2) reviewed for advanced directives in the sample of 4. Findings include: R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2, chronic kidney disease stage 3, liver cirrhosis, heart failure, and chronic venous hypertension. R2's Undated Care Plan documents R2 has chosen DNR (Do Not Resuscitate) as advanced directives for end-of-life plan. R2's Progress Note by V12 (Social Services Director/SSD) on [DATE] documented R2 wished to be a DNR with comfort focused care, and R2's IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form was completed with R2 and sent to physician for signature. R2's POLST Form signed by V13 (R2's Physician) on [DATE] documents, No CPR (Cardiopulmonary Resuscitation): Do Not Attempt Resuscitation (DNAR). R2's Physician Orders document [DATE] orders for both Full Code and DNR. R2's Progress Note by V10 (Licensed Practical Nurse/LPN) on [DATE] at 5:20 AM documents (R2) was found sitting in recliner without blood pressure or respirations. The Note documents (R2) was a full code and was assisted onto the floor where CPR was started, and an ambulance was called. R2's Progress Note by V10 (LPN) on [DATE] at 5:32 AM documents CPR was in progress with no improvement when the ambulance arrived, and paramedics called (R2's) time of death. On [DATE] at 9:25 AM, V10 stated she entered (R2's) room and found him unresponsive in the recliner. She stated she checked (R2's) Code Status which was listed as Full Code on his admission records and Face Sheet, then called out for other staff to help and initiated CPR which was done until the paramedics arrived and pronounced (R2) deceased . On [DATE] at 11:35 AM, during a confidential interview, V5 (Confidential Interview #2) stated she assisted with R2's CPR for about ten minutes until the ambulance arrived. She stated she felt R2's ribs crack on the first push down. Page 1 of 3 145497 145497 10/29/2024 Three Springs Sr Living & Rhab 161 Three Springs Road Chester, IL 62233

F 0578 Level of Harm - Minimal harm or potential for actual harm On [DATE] at 1:15 PM, V1 (Administrator) stated R2 was a Full Code initially on admission, then his Code Status was clarified, and R2 was changed to a DNR. She stated R2's brother attempted to take him home, but R2 returned to the Facility the same day and all his orders were reinstated, including the orders for both Full Code and DNR. V10 (LPN) looked in R2's orders and saw Full Code and performed CPR not knowing he had a POLST Form for DNR. Residents Affected - Few On [DATE] at 12:00 PM, V13 (R2's Physician) stated, Advances directives serve as guidelines so staff know what to do (in end of life situations). (R2)'s physical health was deteriorating, but his cognition was intact, and he was a DNR. He left the hospital as a DNR. He did not want to be in a nursing home. The Facility's Advanced Directives Policy revised 12/2016 documents advance directives will be respected in accordance with state law and facility policy. The Policy documents Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated. The Policy documents Do Not Resuscitate indicates that, in case of respiratory or cardiac failure, the resident legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. 145497 Page 2 of 3 145497 10/29/2024 Three Springs Sr Living & Rhab 161 Three Springs Road Chester, IL 62233

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days a week. This has the potential to affect all 70 residents living in the Facility. Findings include: The Facility's Nurse's Schedule does not document a RN was scheduled for at least eight hours on 10/12/24, 10/13/24, 10/19/24, or 10/20/24. On 10/25/24 at 3:18 PM, V1 (Administrator) stated the Facility did not have a RN for at least eight hours on 10/12/24, 10/13/24, 10/19/24 or 10/20/24. On 10/25/24 at 9:25 AM, V2 (Director of Nursing), stated there can be problems with staffing due to call offs and the Facility is actively recruiting staff. On 10/25/24 at 9:50 AM, V1 stated the Facility is trying its best to recruit nurses, but it is difficult in a rural setting when the Facility does not use agency staffing. On 10/29/24 at 8:50 AM stated the Facility does not have a policy on RN staffing and follows the federal regulations. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 10/29/24 documents there are 70 residents living in the Facility. 145497 Page 3 of 3