Health inspection·November 8, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to ensure resident rooms and environment were clean and home like for 6 of 23 residents (R69, R54, R84, R16, R59 and R17) reviewed for homelike environment in the sample of 23. The findings include: On 11/6/23 at 9:32 AM, R84's room was noted to have a strong foul smelling odor. On the floor and in his bed were multiple Styrofoam cups, straws, and wrappers. His bedside table base had a thick substance caked onto it with hair stuck to it. The floor was very dirty with pieces of dried food and wrappers on it. On 11/7/23 at 8:59 AM, R84's room was in the same condition a foul odor, dirty floor and sticky bedside table and his bottom sheet was also noted to be stained with what appeared to be spilled liquid. On 11/6/23 at 10:00AM and 11/7/23 at 9:05AM, the floor of R16's and R59's room was covered with trash, used tissues, used food containers, food wrappers, a clean brief, plastic wrappers and an empty box of gloves. On 11/7/23 at 9:05AM, R16 stated she thought housekeeping had been in already. On 11/6/23 the floor around the bed in R17's room was covered with used, dirty tissues. Again on 11/7/23, the R17's floor was covered with used, dirty tissues. On 11/6/23 at 10:14 AM, R54's room had lots of spots on the floor where dried food was caked on it, and areas on the floor that were very sticky with what appeared to be spilled liquids. On 11/6/23 at 10:28 AM, the garbage can inside R69's room was completely full with garbage spilling out onto the floor. In reference to the garbage can R69 said, I don't know what they do around here. On 11/7/23, the carpet in the third floor hallway was covered with small pieces of white debris and on the tile floor around the nurse's station and in front of the elevator there were several spots of orange, stickylooking fluid. On 11/7/23 at 8:45 AM, V4 (Registered Nurse/RN) stated, Housekeeping is here every day but when they leave at 3:00-4:00 PM it is hard for them to catch up in the morning. Nursing tries to help but we Page 1 of 6 145593 145593 11/08/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0584 can only do so much. Level of Harm - Minimal harm or potential for actual harm On 11/7/23 at 8:35 AM, V5 (Housekeeping) said the facility is short of housekeeping staff, and as a result, they cannot keep up with all the duties. She said the housekeepers are supposed to mop and empty garbage in resident rooms daily, but that is not always done. V5 said she tries to at minimum spot mop resident rooms. Residents Affected - Some The facility provided General Housekeeping policy, revised on 9/29/23, said the facility will ensure the resident rooms will be kept clean, orderly, sanitized and mopped. 145593 Page 2 of 6 145593 11/08/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 R79 with a PASRR (Preadmission Screening and Resident Review) thirty days after admission for one of seven residents (R79) reviewed for Preadmission Screening for individuals with a mental disorder in the sample of twenty. Residents Affected - Few The findings include: R79's admission Record on 11/08/23 at 1:01PM, shows R79 was admitted to the facility on [DATE]. R79's Physician's Orders on 11/08/23 at 1:02PM, shows, Diagnoses: schizoaffective disorder, bipolar type. Sertraline hydrochloride for depression related to schizoaffective disorder. R79's PASRR level One performed 07/07/2023 shows, Exempted Hospital Discharge, physician documented that he requires 30 days or less of nursing facility care. Mental Health Medications: olanzapine 15 milligrams daily, Diagnosis: schizoaffective disorder. Exempt Hospital Discharge 30-day approval- A 30 day or less stay in the nursing facility is authorized. Re-screening must occur by or before the 30th day if the individual is expected to remain in the nursing facility beyond the authorization timeframe. On 11/08/23 at 12:03PM, R79 was lying in bed watching television. On 11/08/23 at 11:00AM, V13, admission Director, said, (R79) was admitted for shortness of breath, there was no mention from the hospital that he needed psychiatric care. (R79) did not trigger for psychiatric care. On 11/08/23 at 12:03PM, R79 said, I was diagnosed with schizoaffective disorder a couple of years ago. I was seeing things that were not there. I have not seen a psychiatrist while I have been in the facility. I see the Nurse Practitioner for my leg pain. On 11/08/23, R79's Medical Record did not show R79 received specialized psychiatric care between 07/07/23 to 11/08/23. There was no level one PASRR re-screen with-in 30 days after admission, or a referral for a level two PASRR screen between 30-40 days after admission. The facility did not provide documentation for a PASRR Level One re-screen or a PASRR Level Two for R79 upon request. The facility's PASRR policy, revised 07/24/23, shows, .residents with mental disorder .will receive PASRR Screening within the timeframe allowed. 145593 Page 3 of 6 145593 11/08/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure pressure reducing interventions were in place for a resident which applies to 1 of 8 residents (R78) reviewed for pressure wounds in a sample of 23. Residents Affected - Few The findings include: R78's Facility Assessment, dated 10/18/23, showed R78 is a [AGE] year old female, whom is dependent on staff for mobility care concerns, and at risk for developing pressure injuries. R78's Braden Assessment, dated 10/24/23, showed R78 to be at high risk for developing pressure injuries. On 11/6/23 at 9:55 AM, R78 was in bed watching television. R78's heels were resting on the mattress with her feet pressed against the footboard. R78 had no offloading devices in place (pillows or boots), and the pump to R78's air mattress was in standby mode. On 11/7/23 at 9:30 AM, V8, Certified Nursing Assistant, stated, When you push the standby button turns the pump on/off without turning the power off. When the yellow light is on the air pump is not on. The pump should be on when the residents are in bed. On 11/8/23 at 11:00 AM, V7, Wound Nurse, stated, (R78) had skin issues when she was admitted . (R78) has a non-open area on her leg and dry skin on her heels we need to keep an eye on. R78's Careplan, dated 10/25/23, showed an intervention for skin integrity included: off-loading bilateral heels when in bed as tolerated every shift and PRN (as needed). 145593 Page 4 of 6 145593 11/08/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure medications were administered according to standards of practice for 1 of 23 residents (R84) reviewed for pharmacy services in the sample of 23. The findings include: On 11/6/23 at 9:32 AM, R84's over bed table was next to his bedside. On the over bed table was a white container that was open with a white pill inside of it. There was also an inhaler sitting on the bedside table. R84 said he wasn't sure what the pill was, but someone left the medications in his room for him to take, and he dropped the white pill, so he left it. On 11/7/23 at 8:59 AM, the medication and inhaler were still present on R84's over bed table. V4 (Registered Nurse/RN) went into the room with the surveyor and asked R84 about the medications. R84 said the medications were in the room for about 2 weeks. On 11/7/23 at 9:00 AM, V4 said someone should have supervised R84 take the medications, as he is not able to self-administer them without an assessment and a physician order. V4 looked up the white pill inside R84's container and identified it as Metoprolol Tartrate; a blood pressure medication. R84's active physician order summary shows he has an order for Metoprolol Tartrate 25 milligrams (mg.) by mouth 2 times a day, with parameters to hold the medication if his blood pressure is less than 100/60. The order summary also shows R84 has an order to receive Fluticasone-Umeclidin-Vilant inhaler 1 puff 1 time a day for shortness of breath. R84's order summary shows an order was added on 11/7/23, after the medications were left at the bedside for him to self-administer the Fluticasone-Umeclidin-Vilant. The facility provided Medication Pass policy, revised on 7/28/23, shows medications should be passed according to federal and state regulations and standards of practice. 145593 Page 5 of 6 145593 11/08/2023 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food safety. This has the potential to affect all 100 residents residing in the facility. The findings include: The Facility Data Sheet dated 11/6/23 shows an in-house census of 100. On 11/6/23 at 12:02PM, V11, Cook, was observed moving his glasses around on the countertop, cleaning up scraps of paper on the counter, and putting them in the trash while plating residents' food for lunch. V11 did not change his gloves or wash his hands between touching his glasses and scraps of paper, before returning to plating food. On 11/6/23 at 12:02PM, V12, Dietary Aide, was observed putting silverware on trays for residents. V12 dropped a fork on the ground. V12 picked up the fork and placed it back on top of the silverware cart near the clean silverware and creamer packets. V12 did not wash his hands after picking up the fork off of the ground before returning to placing silverware on residents trays. On 11/6/23 at 12:57PM, V10, Food Service Director, said items that touch the floor should be discarded or sanitized, and are considered contaminated. V10 said contaminated items should not be placed near clean items. V10 said after touching contaminated items, gloves must be changed, and hands must be washed before returning to food prep. The facility's Kitchen policy, revised on 7/23/23, states, The facility will comply with state and federal regulations in operating facility's kitchen. 145593 Page 6 of 6