Health inspection·January 19, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise residents to prevent them from drinking alcohol, becoming drunk and falling. This applies to 3 of 3 residents (R3, R4 and R5) reviewed for supervision in the sample of 7. The findings include: R3's MDS (Minimum Data Set Assessment), dated 12/26/23, shows she has no cognitive impairment. R3's Care Plan, last reviewed on 1/16/24, states, Alcohol addiction/dependency have negatively impacted my health and cognitive functioning. I acknowledge mixing a concoction of alcoholic beverages in my room while at (facility). Due to my addiction history and husband's reports of her begging to go to the bar while out on pass and general expectation that I will pursue alcohol, I am not appropriate for independent out on pass. The interventions include: Implement increasingly restrictive interventions in a effort to help the resident break the addictive cycle. Interventions may include: supervision while in the community, restricted independent pass privileges, implementation of money guidance and budget controls to reduce/prevent access to substances. R3's Fall report, dated 12/1723, states, At 11:30 PM (V11, Certified Nursing Assistant/CNA) calling NOD (Nurse on Duty) to check resident on the dining room floor. NOD checked resident immediately resident seen sitting down on the dining floor and claiming she lost her balance and slid to the floor. Assessed resident both upper and lower extremities able to move without any pain. Both legs are equal. No bones protruding on both sides. Able to stand up with assist. Resident assisted back to bed. Vital signs taken. Neuro check initiated. Denies hitting the head. MD informed and with order to send to the hospital for X-ray. R3's Hospital Documents, dated 12/18/23, state, Brief Synopsis: (R3) is a [AGE] year old female with a PMHx (Past Medical History) of alcoholic liver cirrhosis complicated by Hepatic Encephalopathy, Non-insulin Dependent diabetes Mellitus, essential hypertension, seizure disorder, major depression with psychosis who presented from the skilled nursing facility with unwitnessed fall. Patient reported consuming 3-4 drinks of vodka the night prior and she had a fall and was unable to get up. Her alcohol level was .233. She had mild abdominal pain and lipase was notable elevated to 565. CT (Computed Tomography) showed mild pancreatic ductal dilation, no inflammation or lesions seen. R3's Progress Notes, dated 12/18/23, states, At 1:55 AM resident was being sent to Hospital due to fall and per Hospital resident found out that she intoxicated with alcohol. Per Hospital x-ray of Page 1 of 3 145809 145809 01/19/2024 Grove of Northbrook,the 263 Skokie Boulevard Northbrook, IL 60062

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pelvis and chest x-ray done with negative of fractures. Resident still in ER on IV fluids due to intoxication then they will run labs again. If result will be normal resident will come back to facility. Endorsed to A.M. nurse. R3's Progress Notes, dated 12/19/23, state, At 1:45 PM, resident returned from (local) Hospital ambulating with unsteady gait. Paramedic was walking with resident, stand by assist. Instructed and encourage resident to use walker during ambulation. Resident was evaluated post unwitnessed fall on 12/17/2023 with no fractures and negative CT scan per result records, and resident was treated for alcohol intoxication and mild acute alcoholic pancreatitis and lactic acidosis. R3's Progress Notes, dated 12/20/23, and written by V6 (Nurse Practitioner) state, Patient seen via video call regarding her recent ER encounter status post unwitnessed fall. Alcohol level was .233, she admits drinking vodka the night before the fall. She also complained of abdominal pain with lipase level of 565, CT abdomen with mild pancreatic ductal dilation. Patient was hydrated at the hospital with improvement symptoms wise and was sent back to (Facility). Currently patient reports having unsteady gait. She usually ambulates with walker independently. She denies pain or discomfort and is not in any acute distress. Promises not to drink alcohol ever again . On 1/19/24 at 9:30 AM R3 stated, The floors had just been waxed a few days before and I had my slippers on. I just slipped and fell. Me and (R5) had a little Christmas party in the dining room. We weren't supposed to but we had our own party. We had a bottle of Vodka-(R4) brought it in and (R5) paid for it. After I fell, I got up and I went to bed. Then they came in and and got me out of bed and put me in the ambulance. They were more concerned about my heart and my EKG than my fall. I know the rules are no alcohol. I went to the cafeteria to get a snack before bed and I slipped. I kind of caught myself with my hands. I wasn't hurt and I got myself up. I have a walker because therapy thinks I fell because my legs are weak, but I can walk without it. I didn't fall because I didn't have a walker. I fell because the floors were waxed and I had been drinking. On 1/19/24 at 1:30 PM, V11 (CNA) stated, I saw her on the floor as I was walking to my unit. She was saying help me, help me. I asked her what happened, and she told me the floor was slippery and she just wanted me to help her get up. I told her I had to get the nurse first, so I called for the nurse. (R3's) speech was slurred and she was walking funny. I kind of thought, did you drink? I just kept asking her if she was okay because she was walking sideways. She kept saying she was fine. We walked her to her room and got her in bed. She was very heavily perfumed, and that is all I could smell. She usually doesn't wear that much perfume. I went back to the dining room but I didn't see any alcohol. That is the only time I have heard of her doing that. The residents are not allowed to have alcohol in the facility. On 1/19/24 at 12:45 PM, V9 (Registered Nurse/RN) stated, It was right at the change of shift, and I was moving from one unit to the other. The CNA called to me and told me that (R3) fell. (R3) kept denying that she actually fell. We helped her up and she was very wobbly. She had been with a couple other residents (R4, R5) in the dining room for a while. She was just so wobbly. I called the doctor and I called my supervisor. (R3) smelled like alcohol and the doctor said to send her out. I had not ever seen her like this before. She seemed impaired. No one else was in the dining room with her when she fell, but (R4) and (R5) had been in there with her. They were having fun in there. We found out from the hospital that (R3's) blood alcohol level was really high. Residents are not allowed to have alcohol in the facility. On 1/19/24 at 9:50AM, R4 stated, I did not witness (R3) fall, I didn't see anything. She told me 145809 Page 2 of 3 145809 01/19/2024 Grove of Northbrook,the 263 Skokie Boulevard Northbrook, IL 60062

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was in bed and they came and got her out and took her by ambulance to the hospital. There was a bottle of alcohol brought in- ok, I brought it in. It was me, (R5) and (R3). It was a 750ml bottle and there wasn't any left when we were done, so I guess we drank it all. I had a pass to go out and (after that) they restricted it for like 3 weeks. I have it back now. When I was with (R3), she seemed fine. She was not stumbling or slurring her words or anything. No one wants to be treated like they are 12. They say this is not a jail, but there is really no freedom. It was never my intention to have anything happen to her. She seemed fine, and then she went to the hospital, and of course they drew blood and found the alcohol. I had gone back to my room and went to bed. R4's MDS, dated [DATE], shows she has no cognitive impairment. On 1/19/24 at 12:20 PM, R5 stated, The alcohol came from (Local Grocery Store). R5 did not want to say who brought it in, but when Surveyor asked if it was (R4) who got the alcohol, R5 agreed that it was. R5 continued, We sat in the dining room for a couple of hours. R5 was asked if R3 seemed impaired when they were done, and R5 smiled and stated, We all were. I went back to my room and went to bed. I did not see (R3) fall. I was diagnosed with Dementia a while back, and they took my pass away. I can't go out without someone going with me. I have never brought alcohol in before. We just wanted to have a little party. R5's MDS, dated [DATE], shows he has not cognitive impairment. 145809 Page 3 of 3