Health inspection·December 21, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ongoing monitoring of a resident for 1 of 3 residents (R1) reviewed for quality of care in the sample of 5. Residents Affected - Few The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include acute on chronic systolic and diastolic heart failure, cardiomegaly, chronic obstructive pulmonary disease, dependence on supplemental oxygen, hypertensive heart and chronic kidney disease with heart failure and with Stage 5 Chronic Kidney Disease, paroxysmal atrial fibrillation, pressure ulcer of sacral region, pulmonary hypertension, atherosclerosis of coronary artery bypass grafts, chronic respiratory failure with hypoxia, dependence on renal dialysis, dysphagia, occlusion and stenosis of carotid artery, pericardial effusion, peripheral vascular disease, and pressure induced deep tissue damage of left heel. R1's facility assessment dated [DATE] showed she had moderate cognitive impairment and required substantial to maximum assistance with bed mobility, transfers, and toileting. This same assessment showed R1 to be at risk for and to have a pressure injury. R1's care plan initiated [DATE] showed, [R1] has pressure injuries to the left heel and coccyx related to recent hospitalization, impaired mobility . Remind patient to change positions frequently . R1's care plan initiated [DATE] showed, The resident is (high risk) for falls related to deconditioning, gait/balance problems, psychotropic medications, shortness of breath Staff will check residents' location and activity to ensure if resident is properly and safety positioned in bed or chair . R1's care plan initiated [DATE] showed, The resident has had an actual fall with no injury . Staff will assess and anticipate residents personal and ADL (activities of daily living) needs such as toileting, incontinence care, grooming, eating . during rounds. Staff will attend to needs as they are identified . R1's complete medical record was reviewed and showed she was assisted to the toilet at 9:41 PM on [DATE]. R1's record showed she had a Loop Recorder (device that monitors heartbeats) implanted [DATE]. The company who receives the information downloaded from R1's loop recorder provided a document that showed R1 had a cardiac event which led to R1's death on [DATE] at 1:04 AM. R1's [DATE] 6:30 AM nursing note showed, Entered room to give medications, noted unresponsive, no respirations or pulse. Yelled for help and initiated CPR (cardiopulmonary resuscitation) immediately Page 1 of 2 145612 145612 12/21/2023 Pearl of Crystal Lake, The 1000 East Brighton Lane Crystal Lake, IL 60012

F 0684 Level of Harm - Minimal harm or potential for actual harm Called 911 at 5:07 AM . There was no evidence R1 had been checked on, provided care, or assessed since 9:41 PM (over 7 hours). On [DATE] at 8:47 AM, V9 CNA (Certified Nursing Assistant) said they do rounds on their unit every 2 hours for normal patients and more frequently if the patient is a high risk for falls or is confused. Residents Affected - Few On [DATE] at 11:37 AM, V4 RN (Registered Nurse) said she usually stayed on the hall and would do rounds at least hourly. On [DATE] at 10:35 AM, V2 DON (Director of Nursing) said she expects staff to be rounding every 2 hours at a minimum to make sure residents are clean and dry. The facility's policy and procedure with review date of [DATE] showed, Routine Resident Checks/Rounding . Our facility will ensure that staff will conduct routine resident checks or rounding to help maintain resident safety and well-being . To ensure the safety and well-being of our residents, nursing staff will make a routine resident check/monitoring on each unit at least every 2 hours and/or based on the needs of the resident . Routine resident checks/rounding involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting the routine check/rounding will report promptly to the nurse, nurse supervisor/DON (Director of Nursing) any changes in the resident's condition and medical needs . The facility's policy and procedure with review date of [DATE] showed, Incontinence Care . General: Incontinence care is provided to keep residents as dry, comfortable, and odor free as possible. It also helps in preventing skin breakdown . The facility's policy and procedure with review date of [DATE] showed, Fall Prevention and Management . Universal Fall Precautions/Facility fall protocol will be implemented in addition to High-Risk Fall Precaution Interventions . Meaningful and or scheduled rounds . 145612 Page 2 of 2