Health inspection·July 8, 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 observation, interview and record review, the facility failed to identify causes of resident weight loss; failed to identify that a resident had AIDS (acquired immunodeficiency syndrome); failed to monitor R3's HIV diagnosis according to professional standards; failed to develop a plan of care to address known weight loss and refusals of care; failed to notify providers of abnormal lab results; failed to notify providers of severe weight loss; failed to follow physician orders for lab work; failed to notify the provider/implement dietician recommendations timely. These failures affect 1 resident (R3) reviewed for quality of care. These failures caused harm to R3 as evidenced by a 5.5% weight loss in 6 days, an 8.2% weight loss within a month and a 16% weight loss within 3 months.Findings include:R3's face sheet documents in part a diagnosis of HIV (Human Immunodeficiency Virus) hemiplegia and hemiparesis of the right side, memory deficit following unspecified cerebrovascular disease, and schizoaffective disorder. R3's significant change MDS (minimum data set) (6/6/2025) documents R3 has a brief interview of mental status (BIMS) summary score of 10, indicating that R3 has moderate cognitive impairment and R3 has had weight loss that was not prescribed by the physician. On 6/30/2025, an additional BIMS assessment was completed for R3 with a summary score of 6, indicating new cognitive decline and severe cognitive impairment. R3's laboratory testing indicates on 5/17/25, R3 had abnormally low CD4 (Cluster of Differentiation 4) levels of 151 uL (microliter.) No laboratory values for R3's HIV viral load were noted within the medical record and were not provided by the facility prior to the end of the survey. R3's medication administration record (MAR) dated June 2025 documents R3 refused medications for HIV treatment 14 times in 1 month. R3's documentation of R3's weights is as follows:-12/5/2024 106 lbs (pounds) -1/3/2025 105 lbs-3/3/2025 105.6 lbs-4/4/2025 106.4 lbs-5/7/2025 101.8 lbs (-4.3% weight change from comparison weight 4/4/2025) -5/26/25 97.6 lbs (-4.1% change from 5/7/2025; -7.6% change from 3/3/2025) -6/5/2025 97.8 lbs (-8.1% change from 4/4/2025) -6/11/2025 95.2 lbs (-10.6% change from 4/4/2025, -10.4% change from 12/5/2024)-6/17/2025 90 lbs (-5.5% change 6/11/2025, -8.2% from 5/26/2025, -15.4% from 4/4/2025)-6/24/2025 89.4 lbs ( -16% from 4/4/2025, -9.2% from 5/26/2025, -15.2% from 1/3/2025)R3's progress notes document V9 (Infectious Disease (ID) Nurse Practitioner (NP)) visited R3 on 5/13/2025 for R3's diagnosis of HIV and gave the following orders: .-Order CD4 and viral load, -Monitor CBC (Complete Blood Count), CD4 and viral load, -Staff to continue to monitor, -Inform PCP (Primary Care Physician)/PCNP (Primary Care Nurse Practitioner) or ID if acute change in condition or fever . There is no evidence the viral load order was carried out by the nursing staff. On 5/16/2025, V14 (Registered Nurse) reached out to V7 (Physician) and notified V7 of a change in condition described as functional decline including refusals of medications, decreased appetite, refusing food/drink. V7 responded to V14 and stated that V7 would come visit the R3 and to follow up with Infectious Disease MD (medical doctor). On 5/20/2025, V7 was notified by V14 of R3's change in condition described as decrease in appetite, refusing meds, not wanting to get out of bed and a Residents Affected - Few Page 1 of 5 145781 145781 07/08/2025 Generations at Applewood 21020 Kostner Avenue Matteson, IL 60443

F 0684 Level of Harm - Actual harm Residents Affected - Few general change in mental status. V7 reviewed the abnormal CD4 lab values and assessed the resident and ordered the resident to be sent to the hospital for further assessment for altered mental status. The abnormal CD4 laboratory results or diagnosis of acquired immune deficiency syndrome (AIDS) was not identified by V7. R3 was hospitalized from [DATE] until 5/23/2025 for a urinary tract infection. On 5/27/2025, V9 (Infectious Disease Nurse Practitioner) visited R3 and did not review the abnormal CD4 lab. On 6/6/2025, a significant change was identified by the facility and a significant change MDS was completed by the facility's interdisciplinary team. On 6/6/2025, V8 (Physician) assumed care from V7 and completed a visit with R3. During this visit, V8 did not identify the abnormal CD4 values resulted on 5/17/2025 and did not identify that R3 had AIDS. On 6/10/2025, V6 (Registered Dietician) identified that R3 had weight decline, was concerned with adequate by mouth intake and recommended an appetite stimulant if not contraindicated. There is no documentation that this recommendation was communicated to a provider. On 6/20/2025 (documented on 6/25/25), V8 examined R3 and identified significant weight loss, failure to thrive, HIV and ordered in response: (unknown medication) Consider starting dose: 7.5 mg at bedtime Can be titrated based on response and tolerability, usually in 7.5?15 mg/day range for appetite. There is no documentation in the progress notes that indicates that the significant weight loss warnings from 5/7/2025, 5/26/2025, 6/5/2025, 6/11/2025, 6/17/2025, and 6/24/2025 were communicated to a provider. On 6/25/2025 at 1:15 PM, R3 was observed lying in bed and appeared cachexic. R3 had unintelligible speech at this time while trying to conversate.On 6/25/2025 at 1:49 PM, V5 (Restorative Nurse, Licensed Practical Nurse) affirmed that V5 is responsible for monitoring weights within the facility and addressing weight loss. V5 explained that R3 has had significant weight loss since May of 2025 and that the dietician was aware. R3 has been refusing meals and the facility does not know the cause of R3's decreased appetite. V5 stated, nothing seems to be working. We don't really know why. V5 affirmed that R3 has had significant decline. On 6/26/2025 at 10:15 AM, V2 (Director of Nursing) stated that V2 was aware that R3 had weight loss but was unsure of the cause of the weight loss. Surveyor reviewed the abnormal CD4 result (5/17/2025) with V2 (Director of Nursing) and V2 affirmed that V7 (Physician) reviewed the laboratory result. V2 denied knowledge of the result, affirmed that the resident could have AIDS, and was unsure if V7 had identified the abnormal CD4 level. V2 denied any knowledge that R3 was ever diagnosed with AIDS or if AIDS had ever been identified for R3. V2 affirmed that AIDS is life-threatening, can cause weight loss, and patients with AIDS have unique care needs in comparison with a resident with HIV. V2 stated that notifications of changes in a resident's health status made to the provider and family should be noted within a resident's progress notes. V2 was unsure of how often the facility was monitoring R3's CD4/HIV viral load. V2 affirmed that the last time R3 had lab work related to R3's HIV diagnosis was 1/28/2024. The facility was unable to provide additional documentation for lab monitoring prior to the exit. R3's physician orders do not document any active standing orders for regular monitoring of R3's CD4 and HIV viral load. On 6/26/2025 at 11:38 AM, V10 (Infection Preventionist, Licensed Practical Nurse) affirmed that V10 was aware of R3's HIV diagnosis. V10 reviewed R3's medical record and affirmed there was no active orders to monitor CD4 counts or Viral Load and that the 5/17/25 lab was abnormal for CD4. V10 reviewed R3's progress notes and providers documentation including but not limited to, V7 (Physician), V8 (Physician), V9 (Infectious Disease Nurse Practitioner) and V17 (Nurse Practitioner) and affirmed that the lab value was not addressed and that AIDS was not identified by any of R3's practitioners. V10 stated that AIDS can cause weight loss, increases their risk of opportunistic infections and places them at risk for death. On 6/26/2025 at 11:25 AM, R3 was observed lying in bed and V11 (MDS Nurse, Registered Nurse) affirmed that R3 had sunken in cheek bones, visible 145781 Page 2 of 5 145781 07/08/2025 Generations at Applewood 21020 Kostner Avenue Matteson, IL 60443

F 0684 Level of Harm - Actual harm Residents Affected - Few ribs, and sunken in areas around R3's collarbones (symptoms of cachexia, muscle wasting). When R3 was asked if R3 had lost any weight, R3 shook R3's head indicating yes. V11 affirmed that the facility is aware of R3's significant weight loss but was not sure the cause of the weight loss. On 6/26/2025 at 12:01 PM, V6 (Registered Dietician) affirmed that V6 is the dietician contracted to the facility. V6 stated that V6 was familiar with R3 and has a history of weight loss. V6 explained that R3 continues to lose weight despite having as many supplements as we (the facility) can provide. V6 had been told from staff that R3's appetite was poor so V6 recommended an appetite stimulant on 6/10/2025 to address the weight loss if the medication was not contraindicated. V6 stated that the facility needed to review that recommendation with a medical provider and that V6 expects when recommendations are made that they are communicated timely. V6 believed that R3 could have greatly benefited from an appetite stimulant to address R3's weight loss. Surveyor reviewed R3's lab work with V6 and V6 stated I (V6) had no idea that R3 had AIDS. I don't look at labs like that (CD4), I only look at labs like electrolytes. I rely on nursing or the providers to communicate information to me like that. AIDS can cause significant weight loss and cause decreased appetite. (R3) having AIDS would make perfect sense as the cause of his weight loss and lack of appetite! Now that I know (R3) has AIDS, I would say the root cause of (R3's) weight loss is the AIDS. R3's weights were reviewed with V6 and V6 affirmed that R3 has had severe, unintended weight loss.On 6/26/2025 at 12:54 PM, V8 (Physician) affirmed that V8 is the primary care provider for R3 and assumed care after V7 (Physician) on 6/1/2025. V8 stated that a CD4 <200 units/liter indicates that a patient has AIDS. V8 affirmed that treatment for AIDS vs. HIV differs, that AIDS can cause weight loss, and that AIDS is a life-threatening condition. V8 affirmed that V8 was aware that R3 had a diagnosis of HIV but was unsure of who was following/treating R3's HIV. V8 explained that V8 defers to an infectious disease consult to manage HIV. R3's CD4 laboratory testing was reviewed with V8 and V8 affirmed that the CD4 level indicated that R3 had AIDS. V8 denied any knowledge of R3's CD4 levels prior to the interview and was never told that R3 had AIDS. V8 stated R3's weight loss certainly could be caused by AIDS and that AIDS would cause the lack of appetite and changes in condition that R3 had been experiencing. V8 stated that V8 was not notified of the dietician recommendation of an appetite stimulant until V8's visit with R3 on 6/20/2025 (the medication was not administered until 6/30/2025). V8 stated that the facility should be notifying V8 with weight loss and dietician recommendations. V8 explained that R3 frequently refuses medications/care and that this can place R3 at risk for AIDS and HIV-resistant infections. V8 affirmed that a plan of care should have been developed in response to R3's weight loss and refusals of HIV medication. V8 explained that the standard of care for monitoring a patient with HIV is a CD4/HIV viral load no longer than every 6 months. When the surveyor notified the physician that the last time the facility had documentation the CD4 was tested was 1/2024, V8 replied (R3) is lucky to be alive if (R3) had had AIDS this whole time. V8 explained that V8 has reviewed hospice care with R3 and stated, I (V8) think (R3) is even more appropriate for hospice care now that I know (R3's) failure to thrive is caused by AIDS. Review of R3's care plan does not document any identification, goals or interventions related to R3's identified weight loss and does not document any interventions of weight monitoring in R3's HIV care plan. A refusal of care and weight loss care plan was added on 6/27/2025 (after the start of the survey). On 6/26/2025 at 1:08 PM, V12 (MDS Nurse, Registered Nurse) reviewed R3's medical record, affirmed that there was not a weight loss care plan in place for R3, no monitoring of weight related to R3's HIV diagnosis, and that R3's care plan should have addressed R3's significant weight loss. V12 stated that the purpose of the care plan and the resident assessment process is to identify resident needs and have a plan in place to address their problems. V12 145781 Page 3 of 5 145781 07/08/2025 Generations at Applewood 21020 Kostner Avenue Matteson, IL 60443

F 0684 Level of Harm - Actual harm Residents Affected - Few reviewed R3's weights and affirmed that R3 has had significant weight loss. V12 stated when weight loss is identified, the provider should be immediately notified to address the weight loss and a plan should be put in place. On 6/26/2025 at 3:01 PM, V1 (Administrator) stated that V7 no longer has a relationship at the facility due to care concerns. V7 was attempted to be reached via phone on 6/25/2025 and 6/26/2025 and was unable to be reached. On 6/30/2025, R3's MAR documents an appetite stimulant (Mirtazapine 7.5 mg (milligrams)) was started (20 days after V6 gave the recommendation). On 6/30/2025 at 9:31 AM, V9 (Infectious Disease Nurse Practitioner) affirmed that V9 is the rounding infectious disease provider at the facility and that V9 sometimes rounds on HIV positive patients or they go to the specialized center. V9 recalled seeing R3 during rounds in May and asked V10 (Infection Preventionist, Licensed Practical Nurse) which provider was managing R3's HIV diagnosis. V10 told V9 that V10 was unsure and that V9 could follow so V10 put in labs. V10 stated that the standard of care for HIV positive patient lab work is a CD4 and viral load is drawn every 3 months but may need more lab work if they are unstable, maybe monthly. V9 denied that any staff member of the facility has communicated any concerns with R3's HIV diagnosis or results of the ordered lab work V9 had ordered. V9 stated, If the labs were abnormal or not collected, I would have expected the facility to call me. V9 explained that when a patient has a CD4 of less than 200 units/liter, the patient is considered to have AIDS. V9 stated that AIDS can cause weight loss, loss of appetite, opportunistic infections and is life threatening. Surveyor reviewed the lab work provided with V9 and V9 affirmed that R3 had AIDS. V9 stated, I had no idea of these lab results. The facility never told me that (R3's) CD4 was that low. I did not review the CD4 lab results when I visited (R3) on (5/27/25), I am not sure if the results were even available for me to view. I haven't had any calls or concerns about (R3's) HIV diagnosis or refusal of medications from the facility. They (the facility) should have told me, I could have changed his orders, like I would have also made sure psych was on board to manage the refusals of care. Refusing HIV meds can also put the resident at risk of developing AIDS. I wasn't made aware and didn't know the facility didn't follow my order for a viral load either. (V7) did not make me aware of the results either.On 6/30/2025 at 10:00 AM, V14 (Registered Nurse) stated that V14 is regularly assigned to care for R3 and was assigned to care for R3 today. V14 described that R3 has had a change in condition in June and explained that R3 has had very poor appetite, non-compliant with medications at times, and doesn't like to get up out of bed. V14 recalled reporting these symptoms to R3's physician (V7) and recalled that R3 was admitted for a UTI at the end of May (2025). V14 stated, (R3) is really declining. I have noticed that R3 has lost a little weight but restorative handles that. (R3) seems appropriate for hospice now due to the decline, (R3's) providers have been discussing it with (R3) lately. V14 stated that when a resident refuses care the provider needs to be notified immediately, especially if education doesn't work. V14 affirmed that restorative notifies the provider of weight changes but the nurses are responsible for communicating lab results to the providers immediately if they are abnormal. V14 stated that V14 was unaware of R3 having AIDS until the end of last week. V14 stated that AIDS can cause weight loss and is life threatening. V14 affirmed that if the facility was addressing the refusals of care or weight loss a plan would be developed in the care plan.On 6/30/2025 at 10:32 AM, V3 (Assistant Director of Nursing) affirmed that V2 (Director of Nursing) was not in the facility and that V3 is the acting director of nursing in V2's absence. V3 stated that the standard of care is that if weight loss identifies or triggers that the physician and dietician are notified, and that the documentation of this notification is made in the resident's progress notes. V3 reviewed R3's progress notes and affirmed that there is no documentation that any provider was notified about R3's weight loss. V3 stated that the facility should be 145781 Page 4 of 5 145781 07/08/2025 Generations at Applewood 21020 Kostner Avenue Matteson, IL 60443

F 0684 Level of Harm - Actual harm Residents Affected - Few notifying and documenting to the provider about R3's weight loss. V3 stated that the standard of care is that when weight loss is identified that a care plan is put into place to prevent further weight loss. V3 reviewed R3's care plan and affirmed that a care plan was created on 6/27/25 to address R3's weight loss and should have been created earlier when the weight loss was first identified. V3 stated that the standard of care for lab work is that the provider should be reviewing their lab work and abnormal lab values should be communicated to the provider for follow up. After, the notification should be documented within the resident's progress notes. V3 reviewed R3's progress notes and affirmed that V9 (Infectious Disease Nurse Practitioner) did not review R3's CD4 and the expectation is that V9 should be monitoring and following up on labs that V9 orders. V3 reviewed R3's records and V3 affirmed that there was no documentation that a provider was notified about R3's abnormal CD4 level that indicated AIDS and that the provider, should have been notified right away. V3 reviewed R3's progress notes and orders and affirmed that the dietician's recommendations for an appetite stimulant were not carried out until 6/30/2025. V3 stated that the recommendation should have been communicated to the provider right away and affirmed that R3 experienced a delay in care. V3 reviewed R3's orders and affirmed that V9's viral load lab order for R3 was not completed and that when providers give orders, they should be carried out. V3 stated, we should have known (related to the AIDS). R3's lab work documents on 7/1/2025 that R3's CD4 count was 75 uL (further decline from 5/17/2025). Facility policy titled, Weight Management (3/2022) documents in part, . It is the policy of this facility to monitor the nutritional status of all residents including all significant trending patterns of weight change to maintain acceptable standards of nutritional status . All significant, unplanned or trending weight changes must be investigated by the facility . In the case of significant or trending weight change, the following steps will be taken: A. Determine Possible Cause B. Determine Plan of Action C. Notify the Physician and responsible party . The Registered Dietician will assess each resident with a significant weight change and make appropriate recommendations to the physician . The Director of Nursing will refer all concerns and recommendations to the appropriate department for action. The Director of Nursing or designee will ensure physicians and resident representatives are informed of significant or trending weight fluctuations or concerns regarding a change in resident's nutritional status . Facility policy titled, Change in a Resident's Condition or Status (2/2025) documents in part, The Nurse will notify the resident's attending physician or physician extender when: .b. There is a significant change in the resident's physical, mental or psychosocial status c. There is a need to alter treatment significantly d. The resident repeatedly refuses treatment or medications .On 7/8/2025 at 12:00 PM, V2 (Director of Nursing) affirmed there is no facility policy for following physician orders. 145781 Page 5 of 5