Health inspection·May 23, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify a resident's significant change in condition; failed to assess a resident with a significant change in condition; and failed to notify a resident's provider of a change in condition; resulting in delay of potential lifesaving care to 1 of 3 (R2) residents reviewed for death in the sample of 12. Residents Affected - Few The Immediate Jeopardy began on 2/17/23 at 3:00 PM when R2 was unresponsive. V1, Administrator, was notified of the Immediate Jeopardy on 5/23/23 at 10:50 AM. They surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 5/23/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R2's admission Record (Face Sheet) showed an admission date of 2/14/23. R2's Face Sheet showed diagnoses to include but not limited to: achalasia (Achalasia is a rare disease in which food passage from the mouth to the stomach is disturbed.), gastric reflux disease, protein-calorie malnutrition, and diabetes. On 5/17/23 at 10:45 AM, V13, R2's Daughter and facility employee, stated R2 was admitted to the facility following a hospital stay. V13 stated R2 was vomiting and not eating at home, which lead to her subsequent hospital admission and having a feeding tube placed. V13 stated her mother was a Full Code (If R2's breathing or heart stopped, lifesaving interventions should be initiated.) R2's History and Physical (H&P), dated 2/15/23, (dictated 2/15/23 at 9:29 AM by V16, Medical Director/R2's physician) showed R2 .for 5 weeks prior to her admission was experiencing bouts of vomiting, which was worsening. She was experiencing frequent bouts of emesis (vomiting) despite taking [nausea medication]. The H&P showed She is feeling poorly and that she is nauseated .She is breathing well. The H&P showed, this is a middle-aged elderly female, currently in no acute distress. R2's Skilled Note from 2/15/23 at 7:25 AM showed, Resident has been nauseous and vomiting through shift. Resident on continuous feeding .resident also refused the TB (Tuberculosis) test, stating 'She got the shot .' R2's Social Service Note from 2/15/23 at 2:34 PM showed, .patient was alert and oriented . R2's Social Service Note from 2/16/23 at 2:06 PM showed, .patient cooperated in the evaluation even though she was feeling nauseated . Page 1 of 9 145593 145593 05/23/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few R2's 2/17/23 Physician Note (time of visit not indicated. Note was dictated 2/17/23 at 11:40 AM.) The patient is awake and alert, but continues to have emesis. We changed her feeding to now 18 hours a day to see if that will help better tolerate the feedings. The note stated the emesis was foul smelling. R2's Skilled Noted from 2/17/23 at 3:03 PM, showed, pt (patient) extremely lethargic and not responding to external stimuli. [V16,Medical Director/Doctor of Osteopathy/R2's physician] notified. Ordered to hold morphine [for] 6 hours and changed the morphine order to q6h prn (every 6 hours as needed). Orders carried out. Patient stable at this time. (Note authored by V23, Registered Nurse.) R2's Order Summary Report (Physician Order Sheet, POS) showed an order for Morphine (narcotic pain medication) 10 milligrams per 0.5 milliliters solution and to administer 0.75 milliliters via her feeding tube every 4 hours for pain for 7 days. This order was started on 2/15/23. The POS showed the order was changed to as needed on 2/17/23. R2's Diagnostic Note from 2/17/23 at 6:59 PM showed, cxr & kub (chest X-ray and kidney, ureter, bladder X-ray) results relayed to [V16.] R2's Skilled note from 2/18/23 at 8:24 AM (this note followed R2's 2/17/23 6:59 PM note; no other notes between), showed, The writer took a report from the night shift nurse saying that pt (patient) wasn't responding, and pt is gurgling. RN (Registered Nurse) check on the pt O2 71 (oxygen saturation 71 percent), put on non-rebreather (mask used to supply high concentrations of oxygen) went up to 76, BP (Blood-pressure) 73/57, T (temperature) 97.5, R 30 (Respiratory Rate 30 breaths per minute) Pt is non-responsive, not reactive to chest rub. Spoke to pt's daughter, explained the situation, pt's condition, okay to send her out. It was explained they take the pt to the closest ED (Emergency Department) at [local area hospital.] (Note authored by V22, Registered Nurse/RN) R2's Skilled Note from 2/18/23 at 8:34 AM showed, Per staff the last time they saw pt responding was last night. (Authored by V22, Registered Nurse/RN) R2's Skilled note from 2/18/23 at 1:58 PM showed, Call to [local area hospital] to get updates on pt, pt coded (heart and breathing stopped) at the hospital. R2's local area hospital records showed, [R2] is a [AGE] year old female who presents to the ED from [the facility] for being unresponsive when staff went to wake her up from sleep at 8 am. Last known well 11 pm when she went to bed. Per EMS (Emergency Medical Services) she was GCS 3 (Glasgow Coma Scale - A test to indicate consciousness. A score of 3 indicates she did not open her eyes to pain of verbal stimuli; she was non-verbal; and her motor function did not respond to painful stimulus.) They attempted intubation (oral airway) but she vomited and aspirated (went into her lungs.) The hospital records showed, Patient had CT (CAT scan) brain no bleed. After return she became bradycardic (slow heart rate) and pulseless. CPR (Cardio Pulmonary Resuscitation, chest compressions and breathing assistance) .CPR continued for [greater than] 30 minutes. No ROSC (return of spontaneous circulation) .Patient expired at 10:43 AM. R2's vital signs were documented as follows: * 2/14/23 (Admission) Blood pressure 167/94; O2 saturation 96 percent (only documentation of O2 saturation) 145593 Page 2 of 9 145593 05/23/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0684 *2/15/23 at 3:50 PM Blood pressure 210/101 Level of Harm - Immediate jeopardy to resident health or safety *2/16/23 at 6:42 PM Blood pressure 146/75 *R2's physician note on 2/17/23 show vital signs that reflect blood pressure, pulse, and respiratory rate that was taken by the facility staff and documented on 2/16/23 at 6:43 PM Residents Affected - Few *2/17/23 at 1:39 PM Blood pressure 99/61 (a change of more than 45 points from her previous systolic pressure and the lowest documented blood pressure during her admission at that time.) *2/18/23 at 8:24 AM (per progress note) Blood-pressure 73/57; Temperature 97.5 Fahrenheit; Respiratory rate 30; O2 saturation 71 percent; after non-rebreather mask applied (mask used to supply high concentrations of oxygen) O2 saturation went up to 76 percent On 5/17/23 at 10:45 AM, V13, R2's daughter and facility employee, stated she saw her mother every day of R2's stay, except 2/18/23. V13 stated her mother started to decline on 2/16/23. V13 said R2 started to become lethargic and out of it on 2/16/23. V13 said on 2/17/23 sometime shortly after 10:30 AM, she went to see her mother. V13 stated her mother had a bowel movement so she, herself, changed R2. V13 said when she provided the care, She couldn't move, she couldn't talk, she couldn't do anything, and it was like there was nothing there .When I cleaned her up there was no response from her at all, no acknowledgement at all from her that I was doing anything to her. I asked the nurses what was her vitals and no one could tell me that, and I believe they couldn't tell me that because no one was doing them. The nursing staff didn't seem concerned about her declining state. [V23] thought it was maybe the morphine, but other than that they had no idea why (she was declining). I thought my mom needed to be sent out and maybe I should have made them send her out, but they were nurses so I thought they would do that if they thought it was necessary. There was no change in my Mom's condition through the day of the 17th. The last time I saw her was around 7:30 PM. I saw the CNA (Certified Nursing Assistant) once or twice the first day, and the second day to do vitals but that was all. V13 said, I think the nurses should have recognized she was declining and sent her out. I assumed that the nurses were tracking her decline and they would make the appropriate decisions. V13 said, Every single day it was a different nurse, there was no continuity between the nursing staff. On 5/17/23 at 11:35 AM, V14, R2's Daughter, stated the first time she saw her mother at the facility was on 2/17/23, between the hours of 3:00 PM to 6:00 PM. V14 said, I went to see her and I was wondering what the foul smell in the room was. Then the nurse came in and I was also asking her what was that funny sound in her room, and the nurse said she is okay. I kept saying what is that noise? It sounded like there was mucous in her throat and the nurse was in her room and the nurse kept acting like everything was normal. My mom was slumped over in bed and we had to pick her up. I opened my mom's eyelid and there was nothing there, she didn't wake up at all; she didn't respond. She was okay when she went in there (2/14/23), and then on Friday (2/17/23) she couldn't respond, then the next day (2/18/23) she was gone. I was like what happened through the night and why did they not check on her? They kept saying she was sleeping. The noise was when she was breathing. It sounded like there was something in her throat. The nurse said the noise when she was breathing was normal because she has a feeding tube. I said it didn't sound normal. It sounded like there was something in her throat. She didn't wake up at all that day when I saw her. When I brought up the sound to the nurse, she did not do any vital signs. The nurse would talk to her and give her insulin. She (the nurse) was talking to her like everything was normal, but she (R2) was not waking up at all or responding to her when she talked to my mom. The last time I saw her was on [DATE] on her birthday . V14 continued, The nurse said the noise was normal and it was the feeding tube, but I was like how is that the 145593 Page 3 of 9 145593 05/23/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few feeding tube, it's when she is breathing, it didn't sound right it sounded like she had so much mucous in her throat. V14 said, Mom did not respond the entire time I was there. I kept trying to talk to her and I touched her and there was no response. My sister and I lifted her up to reposition her and she was just dead weight; there was no response. I was wondering if she needed to be sent out, but I was going off of what the nurse said, which was she was okay and that my mom was sleeping, but that did not make sense. The next morning, they said they were rushing my mom to the hospital and they were doing CPR (Cardio Pulmonary Resussitation) at the hospital, and they said she was gone. All I kept thinking about was the night before and what happened in that short amount of time. I kept thinking something didn't feel right; that she was not waking up and that she was just sleeping didn't make sense. I knew something wasn't right and why didn't they check on her all night until the next morning. They just kept saying she was sleeping, but she wasn't. On 5/17/23 at 12:10 PM, V19, R2's Sister and Power of Attorney (POA), stated, I didn't get to go and see her I was going to go and see her (R2) on Saturday. That is usually when I do my traveling. I talked to her on the phone on Wednesday (2/15/23); it would have been around 1:00 PM. She was concerned about some bills that needed to be paid, and I told her I was going to take care of her personal business. She sounded her normal self; she was cracking jokes and she was doing well at that time. She said she was feeling fine at that time. She didn't say anything about nausea at that time. I tried to call her Thursday (2/16/23) and she didn't answer, so I called [V13] and asked her why [R2] wasn't answering the phone. [V13] said she wasn't doing well. [V13] said it was like she was going backwards and not doing well. Then the following day she [V13] called me and said her levels had dropped and they were trying to get her levels back up. (Levels) I think she was talking about her blood pressure and stuff like that; like her vital signs. I talked to [V13] on Thursday and Friday. She said on Friday her color did not look good; she looked sick. She said she wasn't alert; she was sleeping. She said she was going to ask the nursing staff to lower that drug she was on for the pain, the morphine, and that they were giving her too much and only give it to her when she asked for that. The facility's staffing schedule for R2's floor on 2/17/23 showed V23, RN, was scheduled to work from 7:00 AM to 7:00 PM, then V18, Agency RN, was scheduled for from 7:00 PM to 7:00 AM the following morning. The schedule for R2's floor on 2/18/23 showed V22 was scheduled to be R2's day nurse. On 5/17/23 at 9:54 AM, V23 stated she believed 2/17/23 was the only time she had provided care for R2. V23 stated she had received report that R2 was lethargic. V23 stated when she began her shift on 2/17/23, R2 was drowsy, not opening her eyes, and she was not responding to questions. V23 stated she documents all physician communication regarding resident status changes. V23 stated if there was an order to hold morphine for lethargy she would notify the doctor if the lethargy did not improve. V23 stated she would expect a person's lethargy to improve in a couple of hours if morphine was the cause. (R2's record showed no assessment or vital signs following V23's progress note on 2/17/23 at 3:03 PM until the following morning.) On 5/17/23 at 2:23 PM, V18, Agency Registered Nurse, stated she does recall R2, and, to the best of her knowledge, 2/17/23 was her only shift providing care for R2. V18 stated, She was not responsive to anything around her. As far as I knew, she was not responsive. I was told by the previous nurse that when she came to the facility she had her eyes open .I was not told that she was ever alert and oriented .The nurse prior did not tell me she had called the doctor regarding this patient. I don't recall any indication that I should be doing any sort of assessment on this resident. As agency, I did have access to PCC (Point Click Care/ electronic documentation system) and that is where I would do all of my documentation for her. The day nurse was just saying she had her eyes open and if I recall that was just a few days prior. If I had been aware that she was alert and oriented 145593 Page 4 of 9 145593 05/23/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and the doctor was called regarding her condition that day, I would have been more concerned regarding her condition that night. I, personally, if had known that information, I would have been monitoring her . V18 said during the night I would check on her and talk to her but she did not respond. I tried talking with her, and she would not look at me, turn her head, open her eyes or respond in anyway what-so-ever. I didn't notice anything in particular about her breathing .If I or the CNA's did any vitals or assessments it would be in [R2's electronic health record] in the vitals tab, or the progress notes, or the MAR/TAR. (medication/treatment administration record. R2's electronic health record showed no documented vital signs or progress notes during V18's shift.) V18 stated, I was not told any of that information; that she was suspected lethargic due to morphine and that she was alert and oriented a couple of days prior. If I had been told that information, I would have definitely called the doctor; if I didn't get ahold of the doctor I would have called 911 and had her sent out. I don't need a doctor's order to call 911 for a full code resident. On 5/16/23 at 1:50 PM, V22 stated she cared for R2 when she was admitted (2/14/23), and she was the nurse that had her sent out (2/18/23.) V22 said R2 was alert and oriented on her admission. V22 said, I came at 7:00 AM and got report from the agency nurse and she said [R2] seemed to be sleeping and unresponsive, so I saw [R2] first. She was unresponsive so I sent her out. V22 said the previous nurse was not concerned because, the order was to stop her morphine and she was still coming down from the morphine. Morphine can affect your breathing; I don't remember if she was on oxygen. V22 stated when a resident is experiencing a change in condition the physician and family are notified and if the physician is not available she would send the resident to the ED. On 5/18/23 at 2:00 PM, V2, Director of Nursing (DON), stated all assessments and vital signs should be documented. V2 stated when a nurse recognizes a change in condition they should do a head-to-toe assessment, vital signs, and then contact the provider. V2 said if a nurse is monitoring a resident for lethargy related to morphine, the nurse should be doing on-going assessments as appropriate to include vital signs. V2 stated morphine affects the respiratory system, which is monitored through respiratory rate assessment and oxygen saturation measurements. V2 stated this monitoring would be passed to the next nurse and should continue. V2 stated nurse-to-nurse hand-off should include physician calls as well as changes in mental status over the previous days. V2 stated this information is important for the nurse to be able to determine if a change in condition has occurred. V2 said gurgling is not a normal sound for a resident on a feeding tube, and it can signify pneumonia or aspiration. On 5/18/23 at 1:15 PM, V16, Medical Director/Doctor of Osteopathy/R2's physician, stated he remembers R2 well. V16 stated he recalled seeing R2 2 or 3 times, but he could not recall the time of day he saw her on those visits. V16 stated he does not recall a phone call on 2/17/23 regarding R2's morphine. V16 said if he was called and told she was not responding, he would have ordered her to be sent out. (R2's Skilled Noted from 2/17/23 at 3:03 PM was recited to V16) V16 replied, Lethargy and not responding to external stimuli is a contradiction. V16 stated if he gave an order to hold morphine because the nurse believed the patient was narcotized (under the influence of a narcotic) I think frequent assessment would be appropriate during that time, and if the nurse told me several hours later they were not improving, they (nurses) are my eyes and ears; I depend on them to give me an accurate description of the patient, if they told me not responsive; I would ask them to send her out. V16 stated he is not always available, and the nurses should be capable to make the decision to send a resident with a significant change in condition to the ED (Emergency Department). V16 said a resident being unresponsive is a significant change in condition and they should be sent out in a timely manner. V16 said the purpose of sending a resident to the ED is the hospital has more medical services available compared to the facility and the 145593 Page 5 of 9 145593 05/23/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0684 services can be provided more quickly. V16 said, It's possible [R2's] outcome would have been different, if she was sent out sooner; however, it is difficult to say in hind sight. Level of Harm - Immediate jeopardy to resident health or safety R2's Care Plan for her feeding tube showed report signs of aspiration or intolerance of feeding. Residents Affected - Few R2's Certificate of Death Worksheet showed she passed on 2/18/23. The death certificate showed the immediate cause (Final disease or condition resulting in death) was Myocardial Infarction (MI, Heart attack) with R2's achalasia condition leading the MI and the aspiration being the event which initiated the MI. The facility's Notification for Change in Condition policy (revised 7/28/22) showed, The facility must immediately inform the resident; consult with the resident's physician .a significant change in the resident's physical, mental, or psychosocial status . The Immediate Jeopardy that began on 2/17/23 was removed on 5/23/23, when the facility took the following actions to remove the immediacy: 1. One on one training was provided to nursing staff providing care for R2 on 2/17/23 and 2/18/23 by V2, regarding change in condition policies and procedures as well as assessments and documentation. 2. On 5/17/23 through 5/23/23, in person in-service was conducted by administration regarding physician notification for change in condition; assessment for change in condition; general change in condition policies and procedures; documentation; nurse-to-nurse handoff; and hospital transfer. 3. All agency and new hire staff who did not receive training described in #2 above will be in serviced prior to the start of their shift. 4. On 5/23/23, a facility wide assessment for residents experiencing change in condition was conducted by administration; MD or NP notified as appropriate. 5. Quality Assurance audit tool was initiated by V3 to ensure physician is notified for any resident with significant change in condition. Audit to be conducted three times per week for 12 weeks. 6. V16, Medical Director, was notified of the Immediate Jeopardy and approved the abatement plan. 145593 Page 6 of 9 145593 05/23/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise a resident who was on a mechanically altered diet related to swalling concerns. This applies to 1 of 3 (R1) residents reviewed for mechanically altered diet in the sample of 12. The findings include: R1's admission Record (Face Sheet) showed an original admission date 12/27/22, with diagnoses to include: dysphagia (difficulty swallowing), diabetes, schizoaffectifive disorder, and Alzheimer's disease. R1's 1/19/23 Speech Therapy Evaluation and Plan of Treatment showed she required supervision/assistance 50 to 75 percent of the time during meals for swallow safety. The evaluation showed she had moderate dysphagia and speech therapy was necessary to instruct family/staff in compensation techniques and reduce signs and symptoms of aspiration (breathing in food) in order to improve ability to consume intake with decreased supervision from caregivers .Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: aspiration and decreased ability to return to prior level of supervision/assistance. (Evaluation was conducted by V15 Speech Language Pathologist) R1's 1/22/23 Progress Note from 11:57 PM showed she was admitted to a local area hospital related to COVID-19 and low blood oxygen saturation. R1's 1/27/23 hospital Speech Therapy notes showed, Recommendations: .constant supervision, small bites/sips, allow extra time to swallow, sit fully upright for all PO (by mouth) intake . R1's 1/28/23 Progress note from 6:35 PM showed, Patient was admitted around 5:20 PM from [local area hospital] via ambulance. Patient was alert and oriented x3 (by person, place, and time). Patient ate dinner per orders and was ok yelling and talking as normal. CNA (Certified Nursing Assistant) stepped out of room to gather trays and notice resident wasn't talking or yelling. CNA went back to room and noticed patient pale and looking different. CNA notified writer immediatley, and 911 was called. Writer enter room, patient was lethargic, grunting, cyanotic (bluish colored skin) and taking deep breaths. Along with two other nurses at bedside Code blue was initiated as well as CPR (chest compressions and external breathing assistance.) Paramedicas arrived quickly and assumed patient care and transported back to [local area hospital]. Writer notified patient POA (Power of Attorney.) The facility's internal incident report, dated 1/28/23, showed R1's dinner tray provided as per orders of thickened liquids and pureed food. Resident provided dinner tray by CNA. Resident was sitting up in bed. CNA provided resident with tray and noted that resident was feeding herself. Resident was also on the phone with her sister. CNA stepped out of the room and came back and noted the resident looked different (cyanotic) and was gurgling . On 5/18/23 at 6:50 AM, V12, Certified Nursing Assistant, stated he delivered a pureed pasta meal and thickened liquids to R1 on 1/28/23. V12 stated R1 began to feed herself, the nurse was in the room, so he left the room. V12 stated he came back later to setup R1's wall phone, and R1 was still eating her meal. V12 said the nurse was not in the room at that time. V12 said after he setup R1's 145593 Page 7 of 9 145593 05/23/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few phone, he left the room and resumed picking up meal trays from other residents. V12 said approximatley 10 minutes later, R1 was off of the phone and he picked up her meal tray. V12 said at that time R1 was not in distress. V12 said less than 10 minutes later, as he walked by, he noted R1 to be pale and not looking well. V12 stated he notified the nurse. On 5/18/23 at 3:33 PM, V12 reiterated his previous statement and said he was not aware R1 required supervision during meal time. V12 stated if he was aware R1 required supervision, he would have stayed with her while she ate her meal. V12 stated he would expect supervsion to be in the [NAME]. (Electronic care plan available to CNAs) On 5/18/23 at 10:42 AM, V15 stated she would have relayed to the staff that R1 required supervision 50-75 percent of the time. V15 said, I cannot tell you what I would have told the CNA's 50-75 percent of the time means for her. I feel like the CNA's should use their best judgement and inofrmation that I provide to them to make that determination as to what supervision is required. V15 stated aspiration can happen with one bite and the recommendations she makes are to promote safe eating. V15 stated preventing aspiration is a component of safe eating. On 5/18/23 at 11:15 AM, V24, CNA, stated she has never heard a speech therapist give a percentage of time required for supervision during meals. V24 said the therapist would just tell her that the resident needed supervision. V24 said if she was told 50-75 percent supervision she would remain in the room the entire meal time. V24 said recommendations from therapists come from shift handoff and/or the [NAME]. On 5/18/23 at 12:02 PM, V25, CNA, said, Some resients can feed themself and need supervision. Usually we sit in the room and watch them. V25 stated she has never heard a speech therapist give a percentage of time required for supervision during meal times. V25 said, 50 to 75 percent of the time means they do need some supervision but that, to me, means I would have to spend the entire time in the room, because if I left the room and something happened, that would be horrible. I don't time the resident and know how long they take to eat. On 5/18/23 at 12:13 PM, V20, CNA, stated the speech therapist would tell her a resident needs supervision, and would not express that as a percentage of time. V20 said, I hear 'they need supervision' to me that means I need to be in the room the whole time. It would not be okay to leave the room and get trays because you are not supervising that resident. V20 said she would go to the [NAME] for supervision requirements. On 5/18/23, R1's [NAME] was requested regarding meal time supervision. On 5/17/23 at approximatley 1:00 PM, the facility provided page 17 of 20 of R1's care plan. V2 stated the care plan interventions are what the CNAs would have available to them on the [NAME]. R1's care plan showed no interventions stating supervision during meal times. On 5/18/23 at 2:00 PM, V2, Director of Nursing, stated V12, CNA, had told her he stayed in the room the entire time. V2 said, I think if the CNA assessed her it is okay for a CNA to leave the room. Assess is not the right word, the CNA can look at the resident and based on the resident's cognition and abilities, determine how much supervision a resident requires. V2 said there are no interventions in R1's care plan that specifically say supervision is required during meal times; however, the interviention report signs or symptoms of diet and/or testure intolerance could be interpreted as supervision. 145593 Page 8 of 9 145593 05/23/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0689 On 5/18/23 at 3:00 PM, CNA training on assessing resident suprvision requirements during meal time was requested and not provided. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145593 Page 9 of 9