Health inspection·March 21, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess side effects and adjust medication for one resident (R2) out of three residents reviewed for medication adjustment based on blood level result. This failure resulted to R2 being hospitalized on [DATE] with diagnosis of altered mental status and lithium toxicity. Residents Affected - Few Findings include: On 3/19/2025 at 1:34, V12 (Registered Nurse-RN) said V12 was the nurse for R2 on 2/28/2025. V12 said that she received the lithium blood test result of 1.53 mEq/L (milliequivalent/Liter). V12 said that the normal range of lithium blood level is between 0.6 - 1.20 mEq/L. V12 said lithium level of 1.53 is high. V12 said that V12 notified the V15 (Medical Nurse Practitioner/NP) that was making rounds on the residents. V12 said that no new order was received from V15. V12 also said that V12 charted that V15 reviewed the lab results. V12 said that R2 was alert and oriented x 3 -4 and able to make her needs known. V12 said that R2 is ambulatory and goes downstairs for lunch with her friends. V12 said that V12 administered R2's medications to her as ordered. On 03/20/2025 at 11:06 AM, V12 said that the normal range for lithium level is 0.6 - 1.20. V12 said that high lithium level can result in patients having tremors, altered mental status, weakness, confusion, coma, and death. On 3/19/2025 at 12:55 PM, V11 (RN) said that V11 has taken care of R2 when R2 was a patient of the facility. V11 said that R2 is alert, and oriented x3. V11 said that R2 was cooperative, continent, and ambulatory. V11 said that R2 is able to express her needs. V11 said that normal lithium level is between 0.6 - 1.20 mEq/L. V11 said that V11 notifies the doctor of lithium level result regardless of whether it is normal or abnormal. V11 said that she was not the nurse that took care of R2 on February 28, 2025. On 3/20/2022 at 9:49 AM, V11 said that the reason why the lithium blood level is checked every month is to determine if the level is high or low. V11 said that lithium blood of 1.53 is high. V11 said that signs and symptoms of high lithium level are diarrhea, vomiting, abdominal pain, altered mental status such as disorientation, not able to speak clearly, confusion, and unsteady gait. V11 said that she was the day shift RN on 3/7/2025. V11 said that V11 was aware of R2's lithium level result of 2.81 mEq/L. V11 said that V10 (Assistant Director of Nursing) notified V16 (Psych Nurse Practitioner) of R2's lithium level result. V11 said that V10 received an order for R2's lithium carbonate to be discontinued. On 3/19/2025 at 2:56 PM, V13 (RN) said that V13 had R2 as one of V13 residents for about one year. V13 said that V13 always works the PM shift. V13 said that R2 was oriented x 4 and very cooperative. V13 said that R2 walks with normal gait and with no assistive device. V13 said that R2 only needs Page 1 of 4 145696 145696 03/21/2025 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0684 Level of Harm - Actual harm Residents Affected - Few supervision with ADL's (Activities of Daily Living). V13 said that around March 4th, V13 received report from the previous shift nurse that R2 was having a minor cough, and general weakness. V13 said that V15 (Medical Nurse Practitioner) gave an order for respiratory panel and ordered cough syrup. V13 said that all the respiratory panel came back negative. V13 said that in a couple of days, R2's condition changed from general weakness to confused state and V13 reached out to V15 for detailed labs. V13 said that V13 received an order on 3/6 evening shift for CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Chest X-ray, and urine culture to rule out UTI (Urinary Tract Infection) and sepsis to be drawn on the morning of 3/7. V13 said that every medication is prefilled by pharmacy, and V13 only dispenses it. V13 said V13 never dispenses more than what is ordered. On 03/20/2025 at 10:20 AM, V14 (RN) said that V14 is familiar with R2 because V14 provided care to R2 before. V14 said that R2 was oriented x 3-4, able to make her needs known, and ambulatory. V14 said that V14 was the nurse that sent R2 to (Local Emergency Room/ER). V14 said that V14 makes a quick assessment before getting shift report and observed that R2 was weak, and not like herself. During shift report, V14 said that V11 (off going RN) reported to V14 that R2's lithium level was elevated, and the lithium carbonate was discontinued. V14 said that V11 reported that R2 is weak and V14 should monitor R2 closely. V14 said that made V14 put R2 on V14's priority list. V14 said that V14 continued to monitor R2. V14 said that V14 checked R2's blood sugar, and it was normal. V14 said that V14 proceeded to assess other residents. V14 said after about 5 minutes, V14 went back to check on R2 and observed that R2 was getting weaker, and V14 said that V14 felt R2 needs to be transferred to the hospital. V14 said that V14 called the shift supervisor. V14 said the shift supervisor called V15 (Medical Nurse Practitioner) who was in the facility at the moment but on a different floor. V14 said that V15 came to assess R2 and V15 gave the order to transfer R2 to (Local ER). V14 said that monthly lithium levels are ordered so that medication can be adjusted depending on the test result. V14 said that the normal lithium level is between 0.6 - 1.20 mEq/L. V14 said that a Lithium level of 2.81 is high. V14 said that some of the side effects of high lithium levels are weakness, seizure, confusion, dizziness, and altered mental status. On 03/20/2025 at 11:20 AM, V10 (Assistant Director of Nursing), said that lithium levels are drawn in order to adjust the medication, and to find out if any toxicity is happening. V10 said that toxicity happens when levels go above normal range, and it can affect the mental status. V10 said that when mental status is altered symptoms include confusion, unable to walk, severe headache, vomiting, abdominal pain, seizure, coma, and death. V10 said that the normal range for lithium blood level is between 0.6 - 1.20. V10 said that a lithium of 1.53 is mildly abnormal because it is above the normal level. V10 said that staff follow the doctor's order. V10 said that on 3/7/2025, V10 reviewed the lithium lab result of 2.81 at 1:23 PM. V10 said V10 called V16 (Psych NP) and notified V16 of the 2.81 lithium level result. V10 said that V16 discontinued the lithium carbonate 450 mg (milligrams). V10 said that moderate toxicity is between 2.5 - 3.5, and severe toxicity is greater than 3.5. On 03/20/2025 at 12:08 PM, V2 (Director of Nursing), said that the lithium blood draws are ordered to monitor the levels. V2 said that the purpose is to make sure that the medication is actually treating the patient. V2 said that V2 does not memorize the range for normal lab results. V2 said that when V2 looks at the lab results, V2 looks at the range. V2 said that toxicity is when the result is above the normal range. V2 said that signs of lithium toxicity are nausea, vomiting, abdominal pain, restlessness, weakness. coma, and maybe death. V2 said that V2 was aware of R2's lithium level result of 2.81 on 3/7/2025. V2 said that when V10 called V16 (Psych NP), V16 discontinued R2's lithium Carbonate. V2 said that when V15 (Medical NP) came later and saw R2, V15 ordered for R2 to be sent out to the hospital. 145696 Page 2 of 4 145696 03/21/2025 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0684 Level of Harm - Actual harm Residents Affected - Few On 3/20/2025 at 12:50 PM, V15 (Medical NP) said that lithium carbonate was ordered for R2 because R2 has schizoaffective disorder. Levels are drawn to make sure that she is being treated with a dose that is appropriate for her to prevent toxicity. V15 said that toxicity is too high of the lithium level. V15 said that altered mental status is a sign of lithium toxicity such as nausea, vomiting, confusion, and kidney failure. V15 said that you want the level to be less than 1.5 and also assess the patient condition. V15 said that she will say that a lithium level of 1.53 is on the high side, but she will also assess the patient symptoms. V15 said that she was aware of R2's lithium level on 2/28/2025. V15 said that V15 collaborates with the psych NP and V15 told the nurse to inform the psych NP R2's lithium level result. V15 said that it is the decision of the psych NP to adjust the lithium carbonate dose for R2. V15 said that she was not managing R2's psychotropic medication. On 3/20/2025 at 1:19 PM, V16 (psych NP) said that R2 was V16's patient. V16 said that R2 is alert, oriented and usually pleasant. V16 said that V16 was not aware of R2's lithium level of 1.53 mEq/L on 2/28/2025. V16 said that if he was notified of the 1.53 mEq/L lab result on 2/28/2025, V16 would have discontinued R2's lithium carbonate. V16 said that staff was to notify psych NP about results of psych medications and notify medical NP of medical medications. V16 said that V16 saw R2 last in January. V16 said that V16 is required to see residents every 60 days. V16 said that V16 was notified of the lithium level of 2.81 on 3/7/2025. V16 said that V16 ordered for the lithium carbonate to be discontinued. V16 said that lithium toxicity is above 2.5 mEq/L. V16 said that lithium toxicity signs include nausea, vomiting, diarrhea, and confusion. V16 said that he ordered for the patient to be monitored. V16 said that V15 (Medical NP) is responsible for sending residents out to hospital for medical reasons, and V16 sends patients to the hospital for behavioral reasons. V16 said that V16 did not contact V15 regarding R2's high lithium level. V15 said that she was notified of the level on 3/7/2025 of 2.81 in the morning. V15 said that V15 told the staff to make sure that the psych NP is notified. V15 said that when V15 came to facility, V15 assessed R2. V15 said that R2 was confused. V15 said that R2 could not answer her questions appropriately like R2 normally does, so V15 sent R2 out to the hospital. R2 is a [AGE] year-old female admitted to the facility on [DATE]. R2's order indicates that R2 was on Lithium Carbonate tablet 450 mg twice a day. Review of the medical administration record from 10/24/2025 to 3/7/2025 indicated that R2 received Lithium Carbonate 450 mg twice daily as ordered. R2's blood lithium level from 10/24/2025 to 3/7/2025 indicated that R2's blood lithium level for 2/28/2025 = 1.53 mEq/L and for 3/7/2025 = 2.81 mEq/L were above the normal range of 0.6 - 1.20 mEq/L. R2's electronic medication administration record indicated that R2 continued to be medicated with Lithium carbonate 450 mg twice daily after a lithium level of 1.53 mEq/L. Review of R2's progress note indicated that R2's weakness started on 3/4/2025. V13 (RN) indicated that R2 was weak on 3/4/2025; V11 (RN) indicated that R2 was weak both on 3/5 & 3/6; V15 (Medical NP) indicated that R2 had general weakness on 3/6 and indicated in V15's note that R2 should continue lithium 450 mg twice daily; On 3/7/2025, V15 indicated that R2 was not able to follow commands and was only speaking minimally. V14 (RN) indicated that R2 had increased confusion and general weakness on 3/7. Lab result from (Local ER) indicated that R2's lithium level on 3/7/2025, was 2.8. It was indicated on R2's ER record that R2 was admitted with 1) Altered Mental Status (AMS) and 2) Lithium Toxicity. The facilities Policy and Procedure for Psychotropic Drugs Usage indicates: Policy: 145696 Page 3 of 4 145696 03/21/2025 Niles Nsg & Rehab Ctr 9777 Greenwood Niles, IL 60714

F 0684 Level of Harm - Actual harm Factors that may contribute to or are responsible for changes in a resident's behavior will be identified by the facility. Such factors may include but are not limited to psychosocial and/or environmental stressors, medical conditions, etc. Residents Affected - Few Procedure: 1. Each resident receiving an antipsychotic medication for organic brain disorders is observed for. Adverse reactions and side effects. 145696 Page 4 of 4