Health inspection·March 15, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to treat a resident in a dignified manner for 1 of 27 residents (R96) reviewed for dignity in the sample of 27. The findings include: R96's facility assessment dated [DATE] show R96 has no cognitive impairment. On 03/13/23 at 9:50 AM R96 said last Saturday 3/11/23 she was worried that she did not get her diabetic medication. I was asking the nurse about my diabetic medication. The nurse got upset at me with my simple question. The nurse screamed at me and said I should have asked the previous nurse not her. R96 said the nurse was rude and she felt so embarrassed about it. R96 said no one should be treated that way. On 3/14/23 at 11:30 AM, V8 (Registered Nurse-RN) said R96 asked her about her diabetic medication. V8 (RN) said she told R96 she should have asked the night nurse and not her. On 3/15/23 at 11:35 AM, V11 (Asst Adm in trainee) said he went to R96 again and asked her about V8. R96 said the nurse (V8) was rude and mean to her. V11 said it was R96's perception. Residents should be treated with dignity and respect. According to Illinois Department of Aging Resident Rights for People in Long Term Care revised in November 2018 showed Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Page 1 of 6 145816 145816 03/15/2023 Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047

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 observation, interview, and record review the facility failed to ensure staff changed their gloves and performed hand hygiene after performing incontinence care for 1 of 27 residents (R9) in the sample of 27 residents reviewed for infection control. Residents Affected - Few The findings include: On 3/14/23 at 10:27 AM, while changing R9's brief, V7, CNA (certified nursing assistant), wiped stool from R9's frontal peri area, then proceeded to wipe stool from R9's backside. R7 then applied white cream to R9's backside. R9 was then placed on her back and had more stool in the frontal peri area and upper thighs. V7 wiped the stool from R9's upper thighs and frontal peri area and applied the white cream remaining on her gloved hand to R9's upper thighs and frontal peri area. V7 then applied a clean brief and adjusted R9's blankets without changing her gloves or performing hand hygiene. R9's Minimum Data Set (MDS) dated [DATE] shows she is not cognitively intact and requires extensive assistance with toilet use. On 3/14/23 at 11:27 AM, V2, Director of Nursing (DON), said staff should change their gloves after cleaning up stool to prevent cross contamination. The facility's Incontinent and Perineal Care Policy (revised 7/28/22) shows, Policy Statement It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection . 8. Remove gloves and dispose .Wash hands. 9. Put on new set of clean gloves to put on clean briefs/incontinent pads, to make resident comfortable, groom and change clothing. 145816 Page 2 of 6 145816 03/15/2023 Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to ensure medications were safely secured on a dementia unit. This applies to 13 of 27 residents (R8, R21, R22, R47, R49, R87, R95, R109, R110, R120, R121, R337, R387) reviewed for safety in the sample 27. The findings include: The facility provided list of the wanderers on the unit on 3/14/23 showed R8, R21, R22, R47, R49, R87, R95, R109, R111, R120, R121, R337, R387 resided on the unit. The (Physician Order Sheet) POS for R79 shows an order for Ferrous Gluconate 2 tabs, Furosemide, Lexapro, Amlodipine, and Lisinopril all to be given daily. The (Medication Administration Record) MAR for March 2023 shows these medications are to be administered at 9:00 AM. On 3/13/23 at 10:16 AM, medications were in a medication cup in R79's room sitting on the breakfast tray on R79's bed side table. There were two green pills, one large white pill, two small white pills and one small peach color pill. There were six pills total. 03/13/23 at 10:49 AM, V7 (Registered Nurse) RN said no the medications should not bed left at the bedside. 03/13/23 at 12:30 PM, V13 (License Practical Nurse) LPN said if it is in the care plan it is ok for the medications left at the bedside. The CNA should not be giving the medications. There are no residents on this unit that have it in there care plan to leave the medications at the bed side. Most of them on this unit has Dementia or Alzheimer's. V13 said (R79) gets from me in the morning amlodipine 10mg (big white one), Lexapro 5mg little white one), ferrous gluconate green one 325mg 2 tab., furosemide 10mg (little white one) and Lisinopril 5mg which is a (little peach colored one). She gets six pills from me in the morning for me. 03/15/23 at 09:32 AM, V2 (Director of Nursing) DON said it is not ok to leave the medications at the bedside, unless there is a doctor's order for medication to be administered by (R1). V2 said if they have dementia it is not ok to leave the medication at the bedside. The facility policy for medication pass shows with a revision date 7/28/22 e. After medication is administered to each resident, sign the MAR that it was give. The facility policy for nursing supervisor job description M. Administer medications ., CC. Assure that established safety precautions are followed. 145816 Page 3 of 6 145816 03/15/2023 Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review the facility failed to administer medications through a gastrostomy tube (G-tube) according to the facility's policy for 1 of 3 (R125) residents reviewed for feeding tubes in the sample of 27. The findings include: R125's admission Record dated 3/15/23 shows his diagnoses include, but are not limited to, gastrostomy status. R125's Physician Order Sheet dated 3/15/23 shows R125 can take medications crushed or via PEG (Percutaneous Endoscopic Gastrostomy) tube. On 3/13/23 at 10:06 AM, V7, Registered Nurse (RN) crushed R125's medications, placed them in medication cups, added apple sauce and water to the medications, and proceeded to administer R125's medications through his G-tube. On 03/14/23 at 11:27 AM, V2, Director of Nursing (DON) said when administering medications through a G-tube, the nurse should add some water to the crushed medication, draw it up in the syringe and push it through the G-tube. V2 said they don't use apple sauce through the G-tube. On 3/15/23 at 10:13 AM, V2 said the facility's policy/procedure is to use water for medication administration through a G-tube. The facility's Medication Pass Policy (reviewed 7/28/22) shows the G-tube should be flushed with at least 30 ml (milliliters) of water before and after administering medications and water can be used to rinse the med cup as flushing in between meds. The policy does not show apple sauce should be used in the administration of G-tube medications. 145816 Page 4 of 6 145816 03/15/2023 Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to manage a resident's pain for 1 of 27 residents (R96) reviewed for pain in the sample of 27. Residents Affected - Few The findings include: R96's Physician Order Sheet (POS) show R96 has diagnoses that include chronic pain due to generalized osteoarthritis and right 6th rib fracture. R96's facility assessment dated [DATE] show R96 has no cognitive impairment. R96's electronic medication administration record (EMAR) show R96 has an order for-Lidocaine external patch 4% apply to right shoulder topically one time a day for pain 12 hours on (0600), 12 hours off. 6PM) Lidocaine external patch 4% apply to right shoulder topically one time a day for right 6th rib fracture apply at 0600 (6AM) removed at 1800 (6PM) On 3/13/23 at 9:37 am, R96 was in bed with a pained facial expression. There were two (2) Lidocaine patches with each patch dated 3/13/23 at R96's overbed table. R96 pointed to the Lidocaine patches and stated the patch pain was due at 6am, the nurse just left the patch here, she never came back to apply the patch to me. R96 said she had been waiting for the nurse to go back to her room R96 said she has severe shoulder pain, her pain level is 9 out of 10 (9- being a severe pain) due to arthritis. V9 (Registered Nurse-RN) who was with surveyor in R96's room said that those Lidocaine patches should have been applied to R96, the patches were due at 6AM. At 10:02 AM V10 (License Practical Nurse-LPN) said she was the night nurse. V10 confirmed that she did not apply R96's pain patches but already signed in R96's MAR that the patches have been applied V10 said she put the patches in R96's overbed table but forgot to apply R96 Lidocaine patches On 3/15/23 at 10 AM V9 (RN) said pain is what the residents says. Pain medications should be administered to the residents as ordered to manage or control resident's pain R96's careplan dated 11/12/22 show, at risk for pain related to Osteoarthritis right humerus fracture chronic pain syndrome with intervention to include provide analgesic as ordered. 145816 Page 5 of 6 145816 03/15/2023 Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure a medication labeled for a particular resident was not administered to another resident for 2 of 27 residents (R28 and R288) reviewed for pharmacy services in the sample of 27. The findings include: R28's Order Summary report showed an order for ceflriaxone (antibiotic) 2 grams (GM) to be given intravenously (IV). R288's Order Summary report showed an order for ceflriaxone 2 GM to be given intravenously. On 03/13/23 at 10:18 AM, R28 was in his room. R28 was connected to IV tubing and receiving an IV antibiotic of ceflriaxone 2 GM. The antibiotic bag that R28 was connected to was labeled with R288's name. On 03/13/23 at 10:18 AM, V3 (Registered Nurse-RN) said R28 and R288 have similar antibiotic orders. V3 confirmed the antibiotic bag that R28 was receiving was labeled with R288's name. V3 said, when connecting R28 to the antibiotic, she tripled checked the name of the antibiotic and dose but she, missed checking the resident's name on the antibiotic. V3 said pharmacy will need to be contacted regarding R288 being a dose short because it was given to R28. On 03/14/23 at 09:40 AM, V4 (RN) said medication that is intended for one resident should not be given to another resident even if the medication is the same. V4 said doing so would cause a resident to be short of their medication. The facility's Medication Pass policy with a revised date of 7/28/22 showed, It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. 145816 Page 6 of 6