Health inspection·November 7, 2024

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 Based on interview and record review the facility failed to follow a physician's order for a resident (R1) in a timely manner. This failure affected one resident (R1) out of three residents reviewed for improper nursing care and resulted in R1 not receiving the medication from 10/22/24 to 10/31/24. Residents Affected - Few Findings include: R1's admission Record documents diagnoses including but not limited to Vitamin D deficiency, unspecified, unsteadiness on feet, unspecified protein-calorie malnutrition, slowness and poor responsiveness, rhabdomyolysis, other specified metabolic disorders, other lack of coordination, other abnormalities of gait and mobility, metabolic encephalopathy, iron deficiency anemia, unspecified, hyperosmolality and hypernatremia, hyperkalemia, homelessness unspecified, fatty (change of) liver, not elsewhere classified, delusional disorders, constipation, unspecified, cognitive communication deficit, altered mental status, unspecified, alcohol induced acute pancreatitis without necrosis or infection, and alcohol use, unspecified with other alcohol-induced disorder. R1's Brief Interview for Mental Status (BIMS) dated 10/14/2024 documents R1 has a BIMS score of 03, which indicates R1's cognition is severely impaired. On 11/06/2024, V1(Administrator) presented R1's Clinic Record dated 10/22/2024, which was reviewed. The clinic record documents in part, please re-start Lantus 12 units every 24 hours. R1's fasting sugars are still high so he will need insulin. On 11/06/2024, V1(Administrator) presented R1's order entry, with an order date of 11/1/2024 by V9 (Nurse Practitioner) which documents in part, Lantus Subcutaneous Solution 100 unit/ml-Inject 12 unit subcutaneously at bedtime. On 11/06/2024 reviewed R1's POS (Physician Order Statement) dated 11/06/2024, which documents in part, Lantus Subcutaneous Solution 100 unit/ml-Inject 12 unit subcutaneously at bedtime for dm (diabetes mellitus). Start Date: 11/1/2024 21:00. On 11/06/2024 at 3:06pm, V3 (ADON/Assistant Director of Nursing) stated the nurse who receives the resident from the hospital, or a clinic appointment is responsible for reviewing the paperwork for any new medication orders the resident may have gotten from the hospital or clinic appointment. V3 stated the nurse who receives the resident from the hospital, or a clinic visit should check for any new medication orders before the nurse's shift ends; the nurse should contact the resident's physician or NP (Nurse Practitioner) to verify if the Physician or NP wants to continue or discontinue the resident's medication order received from the hospital or clinic visit. V3 stated eight to nine days after a resident receives an order from the hospital or clinic visit is not an acceptable time frame (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145679 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)