Health inspection·October 4, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide ADL (activity of daily living) care to a dependent resident and provide incontinence care at least every two hours, and failed to ensure residents are provided a bath per facility policy. This affected four of four residents (R1, R3, R4, and R6) reviewed for activity of daily living. Residents Affected - Some Findings include: 1. On 10/1/24 at 11:50am R6 was observed alert and orientated to person, place, time, and situation. R6 said she had not been changed for hours. R6 said she was changed at 11:00am, and prior to that she was changed at 5:30am. R6, with assist from V1 (CNA/Certified Nurses Aide) showed surveyor her gown, shirt, and mattress, R6's shirt, gown and mattress was observed soiled in urine and smelled of urine. 10/3/24 at 2:26pm V9 (ADON-Assistant Director of Nursing) said staff should be checking and changing residents every two hours, they should apply skin barrier cream as appropriate to prevent moisture from breaking down the skin. R6's care plan dated 4/13/24 denotes resident has ADL care performance deficit related to DX (diagnosis) of adult failure to thrive, weakness, abnormalities of gait and mobility and lack of coordination and abnormal posture. Check resident for incontinence every two hours. Provide one person assistance for ADL cares. Provide incontinence care as needed. Provide verbal cues, supervision, set and assistance as needed for bed mobility, transfers, eating and toileting. Facility activities of daily living with effective date of 2/2023 denotes in part purpose the base on a comprehensive assessment of the resident and with the resident needs and choices, our facility provides necessary care and services to ensure that a residence's abilities and activities of daily living do not diminish unless the circumstances of the individual's clinical condition demonstrates that such guidelines were unavoidable. In accordance with the comprehensive assessment together with respect for individual residents needs and choices our facility provides care and services for the following activities, hygiene mobility, elimination, dining, and communication. 2. On 10/1/24 at 11:54AM V5, CNA, said showers are given based on shower day on the list. V5 said we get the resident into the shower room or some people want a bed bath. V5 said we let the nurse know who wants a bed bath or if they are shower refusals. On 10/2/24 at 9:17AM V7, LPN (Licensed Practical Nurse), said for refusals of care the staff should report to the nurse. V7 said I would then try to explain to the resident the reason for it to be done. V7 said if the resident still refuses, then we document the patient refusals. V7 said we Page 1 of 6 145608 145608 10/04/2024 Thryve of South Holland 2145 East 170th Street South Holland, IL 60473

F 0677 document so that staff is aware of her condition. Level of Harm - Minimal harm or potential for actual harm On 10/1/24 at 12:32PM V4, (Infection Preventionist), said if a resident refuses their shower, then we should document and call the family. V4 said I looked for documentation on R4's shower and I didn't see anything. Residents Affected - Some On 10/2/24 at 9:42AM V9 (ADON), said the shower policy is that each resident gets at least one shower a week, but our culture is to give them two a week. V9 said showers are documented on shower sheets and nurses are to double check that they are completed. V9 said refusals are supposed to be documented in the nurses notes. V9 said the main tracking tool for showers are the sheets to track completion. V9 said shower refusals are to be documented on the shower sheet and the notes. V9 said the CNA is to report to the nurses any refusals. V9 said the residents are expected to get a shower on the shower day. V9 said if we are made aware the showers have not been done, we will give the resident a shower. V9 said a resident should go no more than 1-2 days without a shower, past the assigned shower day, water needs to touch them in some way. V9 said sometimes the person refuses showers and wants a bed bath instead. V9 said a bed bath is acceptable. V9 said bed baths will be documented on the same shower sheet. V9 said if it is a continued problem with a particular resident, the shower sheet comes to the Director of Nursing (DON) or myself. V9 said the purpose is so we can track if the showering is getting done or not. V9 said at the moment everyone has been getting their showers. V9 said a bathing preference is not documented, no one has said they prefer bed bath or showers, but it would be in the care plan if they said. V9 said all the supplies are available for showers. The surveyor asked V9 about the showers documented and V9 said the CNAs forget to fill out shower sheets. V9 said we would know if a shower was missed if we get a complaint from the family or the resident. V9 said some residents can't tell us. The surveyor requested documentation of shower refusals that her or the DON followed up on. At 10:10AM V9 said I have no documentation for us looking at showers that were refused. V9 said yes to the surveyor when asked if the residents should be getting a minimum of 8 showers a month. R1's diagnosis include, but are not limited to Hypertensive Heart and Chronic Kidney Disease, Chronic Kidney Disease, Osteoarthritis, Benign Neoplasm of meninges, Dementia, Depression, Alzheimer's Disease, and Heart Failure. According to census, R1 has been on the same unit and room since 8/27/24. R1's Cognitive Patterns dated 8/14/24 BIMS (Brief Interview for Mental Status) score is 4. R1 has no behavior of rejection of care on 8/14/24. Functional Abilities and Goals, Shower/bathe: the ability to bathe self Dependent - helper does all of the effort. On 9/27/24 the surveyor attempted to interview R1, she makes eye contact, but does not answer verbally or nod her head to questions. R1's Bath and Skin Report Sheet September 2024 indicates bed baths performed 3 days in September. 9/3 and 9/6 documentation address R1's wound dressing. Room and Shower list notes R1 scheduled for a shower on Wednesday and Saturday. The dates provided do not correlate with the schedule dates. R1's charting for bathing does not indicate the bathing was complete. Progress note reviewed for September does not include record of bathing refusals. R1's care plan does not have intervention for bathing refusals. 145608 Page 2 of 6 145608 10/04/2024 Thryve of South Holland 2145 East 170th Street South Holland, IL 60473

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R4's diagnosis include but are not limited to Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Sequelae of Cerebral Infarction, Diabetes Mellitus, Chronic Kidney Disease, and Dementia. On 10/1/24 at 1:25PM R4 said I don't want to get up into the shower room. R4 said I wash up or they help me to wash up in the bed. R4 said I don't know when I last did that. The surveyor noted R4 has body odor during interview. The odor increased the longer in the room with R4. R4's charting for bathing does not indicate that bathing was completed for the month of September, bed bath or shower. Document presented is not completed. Room and Shower list notes R4's shower days are Wednesday and Saturdays. Cognitive Patterns dated 9/13/24 BIMS score is 11. R1 has no behavior of rejection of care on 9/13/24 assessment. 9/13/24 Functional Abilities and Goals, Shower/bathe: the ability to bathe self Dependent helper does all of the effort. No care plan for bathing refusals was provided and no progress notes related to bathing attempts or interventions. R3's diagnosis include but are not limited to Hemiplegia following Cerebral Infarction, Hypertensive Heart Disease, Convulsions, Diabetes, Major Depressive Disorder, Anxiety, Altered Mental Status, Weakness, and Bell's Palsy. R3's Cognitive Patterns dated 7/25/24 BIMS score is 15. R1 has no behavior of rejection of care on 7/25/24 assessment. 7/25/24 Functional Abilities and Goals, Shower/bathe: the ability to bathe self Dependent helper does all of the effort. R3's Bath and Skin Report Sheet for September 2024 indicates 3 showers or bed baths were provided. 9/9/24 documents a refusal, no nurse signature. 9/30 does not indicate what care was provided. R3's progress notes do not include record of shower/bed bath refusal or interventions offered. R3's charting for bathing does not indicate bathing was completed. Progress note reviewed for September does not include record of bathing refusals. R3's care plan does not have intervention for bathing refusals. Room and Shower list notes R3 is scheduled for a shower on Monday and Thursday. R3's showers were documented on Mondays, no documentation for Thursdays in September was found. The facility policy on Shower/Tub Bath dated August 2002 states the purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The following information should be recorded if the resident refused the shower/tub bath, the reason(s) why and the intervention taken. Reporting: Notify the supervisor if the resident refuses the shower/tub bath. The facility policy on Refusal of Medications and Treatments dated 11/2023 states it is the resident's right to refuse medication, treatments and care. Standards: Second and third efforts to administer medications, treatments, and care should be made. The resident should be given a full explanation 145608 Page 3 of 6 145608 10/04/2024 Thryve of South Holland 2145 East 170th Street South Holland, IL 60473

F 0677 Level of Harm - Minimal harm or potential for actual harm verbally and in writing of the consequences of the refusal. In the event of continued refusal despite education, will be documented in the residents care plan and/or progress notes. Each refusal shall be documented in the nurses progress notes and include, at a minimum, the following data: date and time of attempt, treatment attempted, resident response and reason for refusal, name of the person attempting to administer treatment. Residents Affected - Some 145608 Page 4 of 6 145608 10/04/2024 Thryve of South Holland 2145 East 170th Street South Holland, IL 60473

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 observation, interview and record review the facility failed to provide supervision during smoking breaks for a resident (R8) identified to require supervision. This affected one of three residents (R8) reviewed for safety during smoking. Findings include: On 10/1/24 11: 20am R8, R9, R10 were observed smoking outside on the patio. Staff was observed inside the facility. V13 (Activity aide) said she was monitoring the resident but had to step away. R8 was observed with holes in his shirt and pants. There was no ash tray observed for R8, R9, R10 to use while smoking. Greater than 200 cigarettes butts were observed on the ground. There was a brown flowerpot observed melted (place on the ground), half of the flowerpot was missing. There was a circular burn area noted on the metal table with melted debris on the table and ground. V13 said the residents were putting their cigarettes out in that flowerpot. V13 said she did not report that to anyone. V13 said there was an ash tray just out here, V13 was asked where the ash tray was, V13 said that's a good question, there was one here. R8, R9, and R10 smoked their cigarette and did not have an ashtray to extinguish their cigarette. 10/1/24 R8 observed alert to person place and situation. R8 said the holes in his clothing was from his cigarettes. R8 was asked if he was able to get the cigarette ash off him when it fell on him. R8 said the cigarette ash did not burn his skin. R8's smoke assessment dated [DATE] denotes R8 has cognitive loss, no visual deficits, no dexterity problems, R8 smokes 2-5 cigarettes a day, supervised smoking times, safe to smoke with supervision. R8's MDS (Minimum Data Set) dated 8/16/24 denotes BIMS (Brief Interview for Mental Status) score of 15. R8's care plan dated 5/14/24 denotes R8 smokes tobacco, R8 will smoke safely as evidence by following the facility smoke policy. 10/1/24 at 1:25pm V11 (Activity Director) said she was not aware of the melted flowerpot, no one informed her that the residents were putting their cigarettes out in the flowerpot. V11 said she should have been made aware of the incident. V11 said the activity aide is responsible for monitoring the patio during the supervised smoke breaks. V11 said staff should be outside with the residents and not inside. V11 said staff is monitoring for safety. On 10/3/24 at 12:35pm V12 (Social Services Director) said upon admission residents are assessed for smoking safety, the facility policy is reviewed with the residents at that time. V12 said the smoking assessment is reviewed and updated upon admission, quarterly and as needed. V12 said the facility does not have residents' that are independent with smoking, V12 said the facility only have supervised smoking breaks for residents. V12 said the residents are supervised for safety reasons, residents are not allowed to have smoke material in their possession, residents can light their own cigarettes and staff must retrieve the lighter from the resident immediately after. V12 said the staff should be monitoring for residents that use devices when smoking, residents that are displaying weakness when holding the cigarette, residents that are not dumping the cigarette ash, residents that allow cigarette ash to fall on their clothing, and staff should be monitoring for residents that have burn holes in their clothing. V12 said when the resident is done smoking their cigarette, the resident should extinguish the cigarette in the ash tray, and then put the cigarette butt in the metal garbage 145608 Page 5 of 6 145608 10/04/2024 Thryve of South Holland 2145 East 170th Street South Holland, IL 60473

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few can. V12 said the ash tray is provide by the facility. V12 said if a resident has burn holes in their clothing the resident would be reassessed for safe smoking and provided a smoke apron. V12 said no one informed her of R8 having burn holes in his clothing, V12 said V13 did not inform her that residents were putting cigarettes in the flowerpot, V12 said she was not aware of the melted flowerpot on the patio. V12 said she was not aware of the large number of cigarette butts on the patio ground. V12 said cigarette butts should not be discarded on the ground. V12 was asked how the staff is monitoring residents sufficiently when they are inside the facility and the residents are outside, cigarette butts are discarded on the ground, there's no ash tray for extinguishing cigarettes, R8 observed with burn holes in his clothing, and it's not reported to her (V12) so that she can follow up. V12 said she will talk to the staff. V12 said if she was aware of the burn holes in R8 clothing, she would have followed up with R8, reassessed R8 for safe smoking, and implemented a smoke apron and she would have updated R8's plan of care for smoking. 145608 Page 6 of 6