Health inspection·September 8, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review the facility failed to notify a Physician for a resident change in condition. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for change in condition in a sample of 3. The findings include: On 9/8/24 at 9:50 AM, R1 stated that on last Friday, 8/30/24, from around 6pm - 630 pm, he began vomiting and having diarrhea until 8:00 AM the next morning. On 9/7/24 at 10:20 AM, V9 CNA (Certified Nurse's Assistant) stated that last Friday, 8/30/2024 she was R1's CNA for 1st and 2nd shift. V9 stated that during 2nd shift, R1 had 2 episodes of vomiting where she and V3 (Nurse) each emptied a wash basin of emesis. V9 stated that she also changed R1's linen 5 to 6 times because R1 had 4-5 episodes of diarrhea during 2nd shift and the last episode was around 10 pm 10:30 PM. V9 stated that she notified V3 of R1's episodes of vomiting and diarrhea and she recorded his bowel movements but the electronic charting only allows to chart bowel movement once per shift, so she recorded his bowel movements as large. On 9/7/24 at 3:17 PM, V3 (Nurse) stated that he did not recall calling R1's doctor about R1 having emesis and diarrhea on 8/30/24. R1 stated that if a resident has 2 episodes of vomiting and 4-5 episodes of diarrhea the nurse should assess the resident and call the doctor. On 9/7/24 at 3:45 PM, V4 (R1's Nurse Practitioner/NP) stated she was not informed on 8/30/24 nor any other time that R1 had vomiting and diarrhea. V4 stated that if a resident had 2 episodes of vomiting and 4-5 episodes of diarrhea, she would order labs, including C-diff and order Imodium (anti-diarrhea medication) for the resident. On 9/8/24 at 1:40 PM, V6 (R1's Physician) stated that he had no knowledge of R1 having diarrhea or vomiting on Friday 8/30/2024. On 9/7/24 at 4:12 PM, V2 DON (Director of Nursing) stated that she has no knowledge that R1 had diarrhea and vomiting on 8/30/24. V2 stated that if a resident has episodes of vomiting and four to five episodes of diarrhea her expectations are for the nurse to check the resident's vitals and call the doctor and if it is not resolved the resident should be transferred to the emergency room for evaluation. On 9/7/24 at 4:30 PM, V1 (Administrator) stated that he has no knowledge that R1 had episodes of Page 1 of 2 145611 145611 09/08/2024 St James Wellness Rehab Villas 1251 East Richton Road Crete, IL 60417

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few vomiting and diarrhea on 8/30/24. V1 stated that his expectations are that if a resident is vomiting and has diarrhea that the nurse assesses the resident and notifies the physician. On 9/7/24, R1's progress notes were reviewed and there was no documentation showing that R1 had any episodes of vomiting and diarrhea or that the doctor or NP was notified of the vomiting and diarrhea. R1's EHR (Electronic Health Record) did show that on 8/30/24 at 5:46 pm (2nd shift) R1 had a large bowel movement and on 8/31/24 at 12:06 PM (1st shift) that R1 had a small bowel movement. The facility's Notification of Change Guidelines (10/01/2021) showed, it is the practice of the facility that changes in a resident's condition or treatment are immediately shared with the resident and or the resident representative, according to their authority, and are reported to and consulted with the attending physician. Objective of Notification of Change Guideline - the objective of notification guideline is to ensure facility staff make appropriate notification to the physician or delegated non-physician practitioner and immediate notification to the resident and or the resident representative when there is a change in condition. Requirements for notification of resident, the resident representative, and their physician: A significant change in the resident's physical, mental, or psychosocial status. A significant change includes deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications. A need to alter treatment significantly. A significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. Notification and Consultation - notification is provided to the physician to facilitate continuity of care and obtain guidance from the physician about changes, addition to discontinuation of treatment. Procedures: The facility shall promptly notify the resident and or resident representative and consult with the physician with changes in the resident's condition or status. Obtain orders for appropriate treatment and monitor and promote the resident's rights to make choices about treatment and care preferences. Document the notification and record any new orders in the resident's medical record. Educate the resident and representative about the proposed plan to treat, manage, or monitor the resident's change in condition. Educate the resident and or resident representative about the risks and benefits of the proposed treatment change and provide an opportunity for the resident to make an informed choice of treatment. Update the resident's care plan, transcribe, and implement the providers orders. Communicate the changes to the care team and pharmacy. 145611 Page 2 of 2