Inspection·October 31, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor a resident who was having a decline in health condition. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for change in health condition. The findings include: R1 face sheet documents that R1 is a [AGE] year old admitted to the facility July 13, 2024 with multiple diagnoses including: unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, heart failure, sepsis, end stage renal disease, dependence on renal dialysis, colostomy status, cutaneous abscess of abdominal wall, psoas muscle abscess, methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere, elevated prostate specific antigens, cognitive communication deficit, chronic kidney disease, unspecified, pressure ulcer of sacral region and muscle wasting. R1's history of present illness shows that R1 was sent from the nursing home on September 25, 2024 with progressive lethargy and loss of consciousness and found to have seizures, in status, and was intubated. R1's EEG report dated September 27th shows that R1 has multiple episodes of generalized electrographic abnormality consistent with electrographic seizures. The findings were consistent with electrographic status epilepticus. Marked diffused slowing into delta range was noted. This constellation of findings can be seen in encephalopathy due to metabolic/toxic etiology, medication effects or diffuse cerebral injury. The physical therapy treatment notes dated October 10, 2024, shows R1 was diagnosed with UTI, acute respiratory failure, encephalopathy, and seizures. R1 was intubated on September 26, 2024, for airway protection and was extubated on October 3rd. Progress Note dated 9/25/24 shows that R1 was sent to the hospital for change in condition status. R1's hospital medical records shows: R1 was seen in the emergency department from the nursing home, and was admitted in the hospital on September 25, 2024, due to altered mental status, less oral intake, and sleeping all day. On October 29, 2024, at 11:26 AM, V4 (Nurse) stated R1's normal baseline condition was that he was alert and oriented, he was able to talk to the staff, was able to eat on his own, and he usually likes to sit on his wheelchair. V4 added that on the morning of September 23, R1 was sleeping, had no energy and could not feed himself. According to V4, the staff fed him for breakfast and lunch but R1 had a poor appetite. R1 went out for dialysis in the afternoon and continued to be lethargic. V4 stated that R1 remained lethargic the next day and reported the change to V2 (RN-Director of Nursing). V2 instructed V4 to contact the physician, V3. V4 could not confirm if the physician was called September 24 about R1's status. V4 stated that R1 continued to be sleepy and needed assistance with (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 2 Event ID: 145761 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 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 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)