Health inspection·March 15, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow bed hold policy requirement in giving proper written notice for 1 out of 3 residents (R2) for the total sample of 3 residents reviewed for bed hold, admissions, transfers, and discharges rights. This failure affected 1 resident (R2) rights to be informed of the right to and exercise the right to bed hold under the regulation. Findings include: R2 was [AGE] years old, initially admitted on [DATE] for cerebral infarction, and aphasia following cerebral infraction. Per R2's progress notes dated 3/2/2024 by V25 (Registered Nurse/Agency) documents that R2 was transferred and was admitted in the hospital for Cerebrovascular Accident and aggressive behavior. On 3/12/2024 at 11:10 AM, V22 (Spouse of R2) stated that initially facility did not accept his husband (R2) because of his behavior due to brain damage. V22 said that facility did not inform her, instead hospital needed to inform her that the facility does not want to accept her husband (R2). V22 said, You see my husband is left with help from other people and I just want them to treat my husband with kindness. On 3/12/2024 at 2:54 PM, V2 (Assistant Administrator) provided a Bed Hold Policy notification dated 3/1/2024 that documents to comply with 10 days duration of bed hold per Federal regulation. Under Resident/Family Initial of the same notice, the initial of R2 was written. Per Minimum Data Set (MDS) dated [DATE], R2 was not cognitively intact because he never or rarely understands and as a result, Brief Interview for Mental Status was not done. On 3/13/2024 at 11:54 AM, V2 stated that he was informed by V18 (Director of Nursing) that Bed Hold notification form is being explained by whoever is the nurse on the floor. And it should be to the resident if the resident cognition is intact. Otherwise, to family or representative if resident is not cognitively intact. R2 cannot be notified of the bed hold because his cognition is not intact. The person who wrote the initial of R2 has no authority to put the initial of R2. Facility policy on Bed Hold and readmission dated 7/27/2023, reads: It is the facility's policy to adhere to the federal regulation on bed hold and on readmission of resident transferred out of the facility. The facility must inform the resident or family members being transferred of the duration of bed hold in writing. Page 1 of 4 145670 145670 03/15/2024 Chalet Living & Rehab 7350 North Sheridan Road Chicago, IL 60626

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interviews the facility failed to provide a person-centered care plan addressing necessary care for nutrition for 1 (R1) out of 3 residents reviewed for care plan. These failures have the potential to affect 1 resident (R1) nutritional services. Finding includes: R1 was [AGE] years old male resident, initially admitted on [DATE]. R1 medical diagnosis includes the following Pancytopenia and acute kidney failure. Per R1's record he was discharged on 2/23/2024. Weight Summary record of R1 documents multiple significant weight loss: R1's recorded weight documents significant weight loss on the following dates: R1's weight dated 5/16/2023 - 114.8 LBS compared to 5/24/2023 there was a decrease of -20.2 LBS or -17.6% weight loss for a period of 8 days. Weights on 7/7/2023 to 8/7/2023 comparison there was a decrease of -8.0 LBS or 7.2% weight loss for a period of 30 days. And weights on 2/9/2024 to 2/16/2024 comparison there was a decrease of -11.6 LBS or -10.92% weight for a period of 7 days or 1 week. R1's nutritional care plan was initiated on 4/25/2023 after R1 was admitted in the facility. Although R1 weights recorded documents significant weight loss, care plan was not reviewed. On 12/26/2023 V12 (Registered Dietitian) initiated a separate care plan related to R1's weights. V12's care plan for R1, R1 sustained significant weight loss and continues to meet criteria for severe protein calorie malnutrition. As compared to V27 (Medical Doctor) initial assessment dated [DATE] in the progress notes that documents R1 as moderate protein malnutrition, R1's status declined to severe protein malnutrition. V12's care plan intervention for significant weight loss is to provide dietary supplements as order: (Nutritional supplement) 1 carton three times a day. Care plan was not updated after the initial date of 12/26/2023. On 3/14/2024 at 10:21 AM, V21 (Minimum Data Set Coordinator) stated that significant weight loss should be addressed in the care plan. The importance of care plan is knowing the plan of care of the resident what is going on with the resident. Care plan is person-centered and to know what is going on with the resident. Intervention in the care plan is to ensure that you are taking care of the resident properly. We know that care plan is needed so that everybody knows what is going on with the resident. Care plan policy dated 7/27/2023, reads: After the comprehensive assessment is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days. Title 42 of Code of Federal Regulation (CFR) under §483.21(b), reads: The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights. 145670 Page 2 of 4 145670 03/15/2024 Chalet Living & Rehab 7350 North Sheridan Road Chicago, IL 60626

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to assess and address multiple significant weight loss and provide supplements for 1 (R1) out of 3 residents reviewed for nutrition and dietary services. These failures resulted to 1 resident (R1) significant weight loss, decline from moderate to severe protein malnutrition and recommendation for gastrostomy tube insertion. Residents Affected - Few Findings include: R1 was [AGE] years old male resident, initially admitted on [DATE]. R1's medical diagnosis includes the following Pancytopenia and acute kidney failure. Per R1's record, he was discharged on 2/23/2024. Weight Summary record of R1 documents multiple significant weight loss: R1's recorded weight documents significant weight loss on the following dates: R1's weight dated 5/16/2023 - 114.8 LBS (pounds) compared to 5/24/2023 94.6 LBS there was a decrease of -20.2 LBS or -17.6% weight loss for a period of 8 days. Weights on 7/7/2023 110.7 LBS to 8/7/2023 103.1 LBS comparison there was a decrease of -8.0 LBS or 7.2% weight loss for a period of 30 days. And weights on 2/9/2024 106.2 LBS to 2/16/2024 94.6 LBS comparison there was a decrease of -11.6 LBS or -10.92% weight for a period of 7 days or 1 week. R1's nutritional supplement under physician's order are as follows: House supplement was ordered to start on 8/7/2023 with instruction to give two times a day. From 5/24/2023 to 8/7/2023 R1 has no order for supplement despite -20.2 LBS or -17.6% weight loss for a period of 8 days. House supplement order was changed to (nutritional supplement) 1 carton two times a day on 11/17/2023 until 12/26/2023. On 12/26/2023 (nutritional supplement) 1 carton supplement was increased to three times a day until 2/24/2024 due to R1's discharge to hospital. On R1's MAR (medication administration record) that documents (nutritional supplement) 1 carton food supplement was not received by R1 and was coded as DR (drug refused) from 12/26/2023 to 2/23/2024 for a period of 59 days. No alternative supplement was documented due to R1 refusal. R1's nutritional care plan was initiated on 4/25/2023 after R1 was admitted in the facility. Although R1 weights that were recorded that document significant weight loss, care plan was not reviewed. On 12/26/2023, when V12 (Registered Dietitian) initiated a separate care plan related to R1's weight loss. V12 documents that R1 sustained significant weight loss and continues to meet criteria for severe protein calorie malnutrition. As compared to V27 (Medical Doctor) initial assessment dated [DATE] in the progress notes that documents R1 has moderate protein malnutrition. R1's status declined to severe protein malnutrition. V12's care plan intervention for significant weight loss is to provide dietary supplements as order: (Nutritional supplement) 1 carton three times a day. Care plan was not reviewed after the initial date of 12/26/2023. And R1 continued to refuse (nutritional supplement) almost every day from 12/26/2023 to 2/23/2024. R1's progress notes dated 2/23/2024 by V24 (Licensed Practical Nurse) document that R1 has had a 145670 Page 3 of 4 145670 03/15/2024 Chalet Living & Rehab 7350 North Sheridan Road Chicago, IL 60626

F 0692 Level of Harm - Actual harm Residents Affected - Few change in condition with poor appetite and weakness. Per care plan meeting with R1's family, the placement of a gastric tube was suggested. V28 (Medical Doctor) was informed and ordered to send R1 to hospital emergency room for possible gastrostomy feeding tube insertion. On 3/13/2024 at 9:35 AM, V12 (Registered Dietitian) stated when he took over R1's case he had a poor appetite. (Nutritional supplement) 1 carton was ordered to be given as his supplement. (Nutritional supplement) is very important because R1 eats food very slow that sometimes it takes a long time. V12 said, R1's mealtime last forever to eat. (Nutritional supplement) is very important because of the way R1 eats food. It takes forever and can last for 2 hours. We change the supplement to (nutritional supplement) because it has more calories than other supplements. V12 said after seeing R1's (nutritional supplement) documentation that almost every day R1 was not receiving (nutritional supplement) from 12/26/2023 to 2/23/2024, V12 said, Oh, that's a lot of days. V12 was asked due to R1's not receiving supplement does it contribute to R1's significant weight loss? V12 said there are other ways to give supplement. Like we did calorie count and other interventions. Review of R1's full physician order does not document calorie count. On 3/14/2024 at 9:46 AM, V18 (Director of Nursing) stated I don't know if he was assisted to eat during meals, I don't remember if we did a calorie count. I can't remember if he was receiving any supplement. Every time I see him, he is on the wheelchair. I cannot remember if he refuses medications or supplements. V18 stated that DR initial on the MAR (Medication Administration Record) means Drug Refuse. V18 said, That means it was offered and resident refused. 145670 Page 4 of 4