Health inspection·February 29, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 2. On 2/28/24 at 12:07 PM, V9 CNA (Certified Nursing Assistant) was sitting at a table feeding R71 while R56 sat at the same table without a food tray in front of her. R96 was brought over to the same table as R71 and R56 and did not have a food tray in front of her. V9 stated they have early trays for the residents that need to be fed and they feed those residents before other residents are given their food trays. At 12:18 PM, R56 was given her food tray and was able to feed herself. The food trays were removed from the food cart and were delivered to residents at different tables. Some residents were eating at the same table while others waited for their food trays. R96 was sitting at the table with R71 who had finished eating and R56 who had just received her tray. R96 stated she wanted her food and that she was hungry. R96 stated she needed to be fed. V13 (Activity Aide) told R96 he would look for her tray of food but he could not feed her because he was an activity aide. R96 yelled, Help me, Help me! On 2/28/24 at 1:26 PM, V10 (Social Services/Unit Director) stated the kitchen sends early trays first. We have a list of early trays, those people need assistance and supervision for feeding. The other trays come after that. We are trying to group them in groups so people can eat together, its a dignity issue for sure. On 2/29/24 at 1:20 PM, V1 (Administrator) stated the facility doesn't have a resident rights or dignity policy. V1 stated they follow the Illinois Long-Term Care Ombudsman Program Resident Rights for people in Long Term Care Facilities booklet. The booklet showed, your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. The Face Sheet dated 2/29/24 for R56 showed medical diagnoses including cerebral aneurysm, depression, hyperlipidemia, bipolar disorder, osteoporosis, chronic obstructive pulmonary disease, lack of coordination, acute cystitis, and dementia. The Care Plan dated 1/25/24 for R56 showed she is at risk for alteration in nutritional status, has mood distress present with signs and symptoms of depression, and has anxiety. R56's care plan showed she has been declining in health and requires the support of a long-term care setting and presents with some risk for failure to thrive secondary to poor insight/awareness and making questionable decisions. The Face Sheet dated 2/29/24 for R96 showed medical diagnoses including respiratory syncytial virus, dementia, dysphagia, pneumonia, anorexia, anemia, hyperlipidemia, major depressive disorder, obstructive sleep apnea, hypertension, macular degeneration, chronic obstructive pulmonary disease, gastritis, stage 4 pressure ulcer of the sacral region, chronic kidney disease, paroxysmal atrial fibrillation, and anxiety disorder. Page 1 of 15 145819 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Physician Progress Note dated 2/26/24 for R96 showed she is alert and oriented to person, time, and place; she is forgetful. The physician's assessment and plan showed R96 has chronic kidney disease with worsening creatinine; she is legally blind, has rheumatoid arthritis and a stage 4 pressure ulcer. The Care Plan dated 12/29/23 for R96 showed she is at risk for alteration in nutritional status. R96's nutritional status is compromised due to megestrol acetate; give 40 mg by mouth one time a day for anorexia. R96 has an activity of daily living self care performance deficit related to reduce mobility, muscle weakness and loss of vision from macular degeneration. Requires assistance to eat. R96 has a history of depression and presents with symptoms of depression during the interview for depression assessment. 3. R260's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Multiple Sclerosis, Respiratory Syncytial Virus Pneumonia, disorder of thyroid, degenerative disease of the nervous system, adult failure to thrive, ileostomy status, and pressure ulcer of sacral region. R260's facility assessment dated [DATE] showed she is dependent on staff for all cares. On 2/27/24 at 1:59 PM, V19 CNA (Certified Nursing Assistant) and V20 RN (Registered Nurse) were providing care for R260. The privacy curtain was not drawn between R260 and her roommate. R260's body was completely exposed except an incontinence brief was tucked in her perineal area. R260's roommate was sitting up in her bed using her tablet. While R260 was exposed, V20 was cleaning up feces that had leaked from R260's colostomy bag and had ran down her side. On 2/29/24 at 12:10 PM, V2 DON (Director of Nursing) said she would certainly expect them to pull the privacy curtain to provide the resident privacy and make them feel more comfortable. It is important to provide privacy for the resident's dignity. The undated State of Illinois Residents' Rights for People in Long-term Care Facilities booklet provided by the facility showed, . You have the right to . safety and good care. Your facility must provide services to keep your physical and mental health, and a sense of satisfaction Privacy, Your medical and person care are private . Based on observation, interview, and record review the facility failed to provide dignity during dining and personal cares for 5 of 5 residents (R56, R96, R105, R260, R402 ) reviewed for dignity in the sample of 18. The findings include: 1. On 2/28/24 at 11:37 AM, R402 was sitting at the lunch table with R51 while R51 was being fed his meal. R402 stated he does not have his food yet but that R51's food sure looks good. At another table, R80 was being fed her meal while R105 watched her being fed and did not have her meal served yet. On 2/28/24 at 11:42 AM, V11 (Rehab Aide) stated, The residents that get fed first need assistance with meals so we give them more time to eat. It's kind of odd because other residents are waiting for their food but we need to make sure the ones that need assistance have enough time to eat. It's only about a 15 minute difference. On 2/28/24 at 12:04 PM, (27 minutes after the assisted residents began eating), the independent 145819 Page 2 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0550 Level of Harm - Minimal harm or potential for actual harm residents were beginning to be served on a random rotation, not by table. Residents were overheard complaining about not getting food when everyone else at their table had food. Staff continued the same meal service with no regard to resident complaints about the meal service. Residents Affected - Some 145819 Page 3 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide oral care and failed to ensure a resident received a shower for 2 of 3 residents (R301, R1) reviewed for Activities of Daily Living (ADLs) in the sample of 18. Residents Affected - Few The findings include: 1. On 2/27/24 at 10:55 AM, R301 was lying on her back, in bed. R301's lips were dry and cracked. There was a line of brown debris to the corners of her both, just below the lips. R301's tongue was dry and coated in white material. R301's teeth were coated in a white film. During the interview, R301's voice was rasping and her lips kept sticking to her teeth. R301 stated, Just a minute. It's so hard for me to talk. My mouth is so dry. R301 closed her mouth and swallow. R301's speech was difficult to understand at times, due to the dryness of her mouth, tongue, and lips. R301 said she had not received any oral care today. R301 said they are supposed to help me brush my teeth in the morning, but no one has been in here yet. R301 did not have any water at the bedside. On 2/29/24 at 10:19 AM, R301 was sitting in a dialysis chair, outside the door to dialysis. V3 (Certified Nursing Assistant - CNA) pushed R301 back to her room. V3 and V4 (CNAs) used a total lift machine to transfer R301 from the dialysis chair to her bed. R301 had no water on her overbed table or her nightstand. R301 had a surgical mask on. R301's voice was raspy and she asked V3 and V4 (CNAs) for coffee. R301 stated, I'm terribly thirsty. Please get me some coffee. R301 removed her surgical mask from her face. R301's lips and tongue were dry. The surveyor asked R301 if she had oral care today and she said, Nope, not yet. But boy am I dry. R301's Face Sheet dated 2/29/24 showed diagnoses to include, but not limited to: iron deficiency anemia, diabetes, obesity, hypercalcemia, bipolar disorder, depression, seizures, polyneuropathy, hypertension, osteoarthritis, low back pain, endstage renal disease, dependence on renal dialysis, difficulty walking, lack of coordination, and schizoaffective disorder. R301's Physician Order Sheet showed an order initiated 2/16/24, Per Family CNA to help (resident) brush teeth every shift. R301's Care Plan initiated 2/15/24 showed, [R301] had an ADL self-care performance deficit and impaired mobility . Interventions: .Personal Hygiene/Oral Care: I require weightbearing assistance with personal hygiene and oral care. R301's Nursing admission dated 2/15/24 showed she was alert to person and place; had the ability to express ideas and wants; and had pink and moist lips, tongue, and mouth. This document showed R301 required set-up or clean-up assistance from staff for oral care. R301's CNA Task Screen showed Oral Care should be completed Days/Evening and PRN (as needed) at night. R301's Oral Care CNA Task for the last 14 days showed on 2/27/24 oral care was not provided until 1:39 PM. R301 did not have any oral care documented on 2/21/24, 2/24/24, and 2/26/24. On 2/29/24 at 10:16 AM, V3 (CNA) said oral care should be completed after breakfast and lunch. 145819 Page 4 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0677 Level of Harm - Minimal harm or potential for actual harm On 2/29/24 at 10:34 AM, V4 (CNA) said oral care should be done every day. V4 said R301 is able to make her needs known, but had been needing more assistance lately. On 2/29/24 at 10:39 AM, V5 (RN - Registered Nurse) said the CNAs assist the resident's with oral care. V5 said oral care is important for hygiene and freshness. Residents Affected - Few On 2/29/24 at 11:04 AM, V2 (DON - Director of Nursing) said oral care should be done when the residents get up and ready for the day and after meals. V2 said oral care is done to keep the mouth clean and healthy. The facility's Mouth Care Policy revised 1/14/22 showed, The facility shall administer proper oral care to its residents in order to keep the lips and oral tissues moist, to cleanse and freshen the resident's mouth and to prevent mouth infection . 2. On 2/27/24 at 11:15 AM, R1 was lying in bed, resting with her eyes closed. R1's hair was greasy and unkempt. R1 had long fingernails with brown debris noted under the nailbeds. The skin on R1's arms and upper chest was dry and flaky. R1 awoke to name, but said she was tired and requested an interview later. On 2/28/24 at 9:27 AM, R1 said it had been 4 weeks since she had taken a shower or washed her hair. R1 stated, I'm pissed about it! I'm supposed to get a shower twice a week. I've been asking for one (a shower) and keep getting told, I'm not on their list. My skin is getting itchy and it's super dry. R1's shoulder length, gray hair was greasy and unkempt. R1 stated, I'm just mad about the shower. I'm starting to stink. R1 had a knee immobilizer to her left stump. R1's Face Sheet printed 2/29/24 showed diagnoses to include, but not limited to: left femur fracture, dementia with severe behavioral disturbance, end-stage renal disease, dependence on dialysis, malaise, fibromyalgia, morbid obesity, congestive heart failure, idiopathic peripheral neuropathy, adjustment disorder, anxiety, diabetes, chronic pain, and generalized osteoarthritis. R1's facility assessment dated [DATE] showed had moderate cognitive impairment; and was dependent on staff assistance for shower/bathing. The shower schedule for R1's floor showed R1 was scheduled for showers on Monday and Thursday, during the day shift (7-3). R1's Progress Notes showed on 2/28/24 R1 received scheduled bed bath. R1's progress notes did not contain refusals of showers on other dates. R1's Shower/Bathing & Skin Monitoring Task showed a bed bath was documented on 1/18, 2/1, and 2/16/24. (There was no shower documented on 1/22, 1/25, 1/29, 2/5, 2/8, 2/12, 2/15, 2/19, 2/22, or 2/26/24 - These are R1's scheduled shower days). There was no resident refusals documented in the past 30 days. R1's Care Plan initiated 6/7/23 showed, [R1] has an ADL self-care performance deficit related to diabetes mellitus due to underlying condition with diabetic neuropathy, end stage renal disease, neuromuscular dysfunction of the bladder . Interventions: .Personal hygiene/oral care: I require weight-bearing assistance with personal hygiene and oral care. 145819 Page 5 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/29/24 at 10:16 AM, V3 (CNA) said the resident showers are scheduled by the room number. V3 said most residents get showers or baths 2 times a week, but some may have a different preference. On 2/29/24 at 10:34 AM, V4 (CNA) said the showers are scheduled by the resident's room number. V4 said the shower schedule is in the binder at the nurses' station and the CNAs use that to know who gets a shower that day. V4 said after the shower, we chart in the computer. V4 said most residents get a shower at lease once a week. V4 stated, I think she (R1) wants a bed bath. She doesn't go to the shower because she can't get up in the chair. I'm not sure when she had a shower last. On 2/29/24 at 10:39 AM, V5 (RN) said the frequency of showers depends on the residents, but most get 2-3 showers a week. V5 said the shower schedule is in the CNA's binder. V5 said she thinks R1 gets a shower because she can get up with assistance, she just can't put any weight on her left stump. V5 said R1 is alert and oriented at this time and able to make her needs known. On 2/28/24 at 11:04 AM, V2 (DON) said each floor has a shower schedule and most residents receive showers twice a week. V2 said sometimes a resident will get a bed bath instead of a shower. V2 stated, It depends on their preference. The showers should be charted in the computer. We don't use shower sheets any more. Everything should be charted in the computer. The purpose of regular showers is to keep the skin clean and it makes the resident feel good. The facility's Shower and Hygiene Policy revised showed, It is the policy of this facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident, and observe the condition of the resident's skin. Procedures: 1. Administer resident shower once weekly and/or as often as necessary. Any resident who needs hygienic care will be provided care to promote hygiene (facial, body, perineal care, etc.) . 3. Shower refusal by the resident shall be relayed by the assigned CNA to the charge nurse . Documentation (Shower Log/CNA Assignment Sheet): a. Date and shift the shower/bath was performed. b. The name/title of the nursing staff who assisted the resident with the shower/bath. c. Assessment data as to reddened areas and skin breakdown and to whom it was reported to. d. If the resident refused the shower and/or if the shower was not administered and interventions taken (e.g. bed bath/rescheduling the shower schedule consistent to facility protocol.) 145819 Page 6 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 heels were off-loaded for a resident with contractures and history of pressure injury to her heels for 1 of 10 residents (R67) reviewed for pressure in the sample of 18. Residents Affected - Few The findings include: On 2/28/24 at 10:15 AM, R67 was in bed on her left side with splints in place to her hands. R67 had braces on her legs. The left side of R67's foot and heel was on the mattress of her bed not offloaded. R67 had a scarred area to her left heel with some red discoloration in the middle of the scarred area. On 2/28/24 at 1:15 PM, V7 (Wound Care Certified Nursing Assistant) and V8 LPN (Licensed Practical Nurse/Wound Nurse) went into R67's room to change the dressing to her stage 4 pressure ulcer on her sacrum. R67 was laying on her right side in bed with a thin pillow between her legs. The right side of R67's foot and heel were resting on the mattress. V8 stated R67's left heel looked red where she had a previous heel wound. V8 stated they are supposed to off-load R67's heels because of what she had before. V8 stated it is difficult to off-load R67 because she has contractures. Her daughter even bought her a specialty pillow for it. The pillow is the one over there in the chair. The Restorative Note dated 2/28/24 for R67 showed, Dressing to coccyx area changed this afternoon. Left heel noted to have intact dark pink scar tissue. Skin remains intact. Able to palpate a clear thin scab. Wound care specialist updated of findings with new order noted and carried out. Will continue to off-load and monitor closely for any changes. The Face Sheet dated 2/29/24 for R67 showed diagnoses including left sided hemiplegia and hemiparesis, neuromuscular dysfunction of the bladder, peripheral vascular disease, dementia, contracture of left knee, alzheimer's disease, contracture of left wrist, hypothyroidisam, hyperlipidemia, hypertension, heart failure, cerebral infarction, asthma, dysphagia, and stage 4 pressure ulcer of sacral region. The Physician Orders dated 2/29/24 for R67 showed, skin: heel offloading at all times while on bed. The Skin/Wound note dated 2/19/24 at 9:11 AM showed, Preventative measures: Patient has limited mobility. Please ensure that patient is turned and/or repositioned when in or out of bed as per facility protocol. The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. The Care Plan dated 1/8/24 for R67 showed, R67 is a [AGE] year old female at risk for additional breakdown related to need of total assistance with bed mobility, incontinent of bowel, age, left sided hemiplegia, and the left side of her body contracted. Coccyx stage 4 pressure injury; Left lateral plantar foot deep tissue injury (resolved); Left heel stage 2 pressure injury (resolved). Off load heels. The Minimum Data Set, dated [DATE] for R67 showed she is dependent for all activities of daily 145819 Page 7 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0686 living. Level of Harm - Minimal harm or potential for actual harm The facility's Skin Care Treatment Regimen policy (7/28/23) did not show off-loading as a preventative measure for pressure injuries. The policy stated residents who are not able to turn and reposition themselves will be turned and repositioned every two hours unless specified on the physician order sheet. Residents Affected - Few 145819 Page 8 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

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** 2. On 2/27/24 at 11:12 AM, R70 was sitting on the toilet in the bathroom in her room with her call light on. At 11:16 AM, V6 CNA (Certified Nursing Assistant) was wearing a gait belt around her waist and went into R70's bathroom to assist the resident and provide pericare. V6 assisted R70 to stand while holding onto the resident's shirt and under R70's right arm. It took three attempts for the resident to stand. V6 instructed R70 to hold onto the grab bar and turn so V6 could clean R70 off with disposable wipes. R70 had urinated and had small amount of a bowel movement. V6 cleaned R70 off with the disposable wipes while she was standing at the grab bar. V6 put an incontinence brief on the resident and pulled her pants up. V6 instructed R70 to reach back and grab onto the arms of her wheelchair to sit down. No gait belt was used during the transfer. On 2/28/24 at 3:03 PM, V11 (Rehab Aide) stated a gait belt is used when assisting residents with walking and for all one person transfers. V11 stated they use the gait belt for anyone that needs 1 person assistance. V11 stated they use the gait belt for safety purposes. On 2/29/24 at 11:17 AM, V9 CNA stated a gait belt is used when they transfer a resident with 1 person. V9 stated it is for the security of the resident and the security of herself. On 2/29/24 at 11:18 AM, V12 CNA stated R70 is one on one for transfers. V12 stated they use a gait belt for transfers for R70. V12 stated R70 is pretty steady but does lean. V12 stated R70 wobbles back and forth at times so it is for her safety. The Face Sheet dated 2/29/24 for R70 showed diagnoses including dementia, heart failure, sarcopenia, mitral valve insufficiency, hyperlipidemia, paroxysmal atrial fibrillation, hypertension, osteoarthritis, and history of falling. The Care Plan dated 2/14/24 for R70 showed, self- care deficit related to muscle weakness, difficulty walking and reduced mobility. R70 requires extensive assistance of 1 staff with toileting. R70 requires extensive assistance of 1 staff with transfers. R70 is at high risk for falls related to dementia, a history of falling, and heart failure. The Falls without report dated 12/13/23 for R70 showed she had a fall in the bathroom after bending down while in her wheelchair. R70 slid out of her chair to the floor. The Minimum Data Set, dated [DATE] for R70 showed she needs partial/moderate assistance for transfers. The Fall Risk Evaluation dated 11/9/23 for R70 showed she is at high risk for falls. The Facility's Gait Belt policy (7/28/23) showed, the facility will use gait or transfer belts to assist residents needing limited to total assistance during transfers and walking. Based on observation, interview, and record review, the facility failed to supervise a resident with dysphagia during meal time for 1 resident (R8) and failed to transfer a resident with a gait belt for 1 resident (R70). These failures apply to 2 of 10 residents reviewed for accidents in the sample of 18. 145819 Page 9 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0689 The findings include: Level of Harm - Minimal harm or potential for actual harm 1. R8's electronic face sheet printed on 2/29/24 showed R8 has diagnoses including but not limited to chronic obstructive pulmonary disease, dysphagia, chronic fatigue, dementia with behaviors, pseudobulbar affect, delusional disorder, bipolar disorder, type 2 diabetes, and major depressive disorder. Residents Affected - Few R8's facility assessment dated [DATE] showed R8 has severe cognitive impairment and receives a mechanically altered diet. R8's physician's orders dated 10/9/23 showed, General diet, pureed texture, nectar thick liquids. R8's nursing care plan dated 10/10/23 showed, Swallowing problems: some risk to potentially choke or aspirate food or liquids. This problem is related to diagnosis of dysphagia. R8's local hospital records dated 10/5/23 showed R8 had been sent to the hospital following a choking episode and diagnosed with aspiration pneumonia. On 2/27/24 at 11:51 AM, R8 was sitting up in her room in her reclining wheelchair by herself. R8 was feeding herself her lunch meal that was a pureed diet with thickened liquids. R8 had consumed approximately 50% of her meal at this time. No staff were present in R8's room during this observation. On 2/29/24 at 11:55 AM, V17 (Therapy Director) stated, The last time speech therapy worked with (R8) was in October 2023 and we recommended a pureed diet and nectar thick liquids. I would assume staff are assisting her but I'm not sure if she eats in the dining room in a supervised area or not. I would just have to refer to the speech therapy notes from that time to tell you if she needs to be supervised or not because the speech therapist that evaluated her is not available. R8's speech therapy Discharge summary dated [DATE] showed, Intake Protocol: To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: guided bolus/utensil placement, lingual sweep/reswallow, alternation of liquids/solids, effortful swallow and general swallow techniques/precautions upright posture during meals, and upright posture for >30 mins after meals. Supervision for oral intake=Close supervision. As of 2/29/24, the facility stated they do not have a policy for resident receiving mechanically altered diets. 145819 Page 10 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

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 perform safe medication administration for one residents (R7) of seven residents reviewed for medication administration on the total sample list of 18. The findings include: R7's February 2024 medication administration record showed R7 receives aspirin 81mg (milligrams), dutasteride 0.5mg, cranberry capsule 425mg, flomax 0.4mg, folic acid 800mg, isosorbide mononitrate ER (extended release) 30mg, nifedipine ER 60mg, methocarbamol 750mg, and sodium bicarbonate 650mg at 9:00AM. On 2/27/24 at 10:47 AM, V18 (Registered Nurse) took R7's medications into his room and set them on his overbed table. V18 assessed R7 and then told him to take his medications and left the room. V18 stated, I know he will take his medications, he's good about it. I have a few residents that I leave them in the room for them. I know it's not best practice but this is a busy unit so we have to keep moving. On 2/28/24 at 11:07 AM, V2 (Director of Nursing) stated, It is not our practice to leave medications at the bedside for residents to take whenever they want. Medications are scheduled at a certain time for a reason so we need to be sure they are taking them when they are supposed to. This is a poor practice and should not be occurring. The facility's policy titled, Medication Pass dated 7/28/23 showed, It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures e. after medication is administered to each resident, sign MAR (Medication Administration Record) that it was given . 145819 Page 11 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 31 opportunities with 5 errors resulting in a 16.13% medication error rate. This applies to 2 of 7 residents (R7 and R84) reviewed in the medication pass on tthe total sample list of 18. Residents Affected - Few The findings include: 1. R7's February 2024 medication administration record showed R7 receives ferrous sulfate 325mg (milligrams), methocarbamol 750mg, sodium bicarbonate 650mg, and adalat 60mg at 9:00 AM and 5:00 PM every day. On 2/27/24 at 10:47 AM, V18 (Registered Nurse) took R7's medications into his room and set them on his overbed table. V18 assessed R7 and then told him to take his medications and left the room. V18 stated, I know he will take his medications, he's good about it. I have a few residents that I leave them in the room for them. I know it's not best practice but this is a busy unit so we have to keep moving. (1 hour and 47 minutes past the ordered administration time). 2. R84's February 2024 medication administration record showed R84 receives Senna S 8.6/50mg at 9:00 AM and 5:00 PM every day. On 2/27/24 at 10:49 AM, V18 administered R84's Senna (1 hour and 49 minutes past the ordered administration time). V18 stated she knows these medications are late but she has a busy unit and she has a lot of residents to take care of. On 2/28/24 at 11:07 AM, V2 (Director of Nursing) stated, Medications are to be given one hour before and one hour after the ordered administration time or else that is considered a medication error. The facility's policy titled, Physician's Orders dated 7/28/23 showed, It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician order as it is written in the POS (Physician's Order Set). 145819 Page 12 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to refrigerate and label open insulin vials with open and use by dates. This applies to 1 of 1 resident (R14) reviewed for Medication Storage in a sample of 18. The findings include: 1. On 2/27/24 at 1:28 PM, the 300 hall medication cart had R14's open, multi dose vial of Novolog insulin with no open or use by date on it. The vial had 50 units left in it. R14's Levemir flexpen had no open or use by date and had 150 units left in it. R14's un-opened Tresiba pen was not refrigerated. The packaging for the Tresiba pen had a sticker on it that shows to Refrigerate. On 2/27/24 at 1:42 PM, V18 RN (Registered Nurse) said, We should have insulin dated so we know when it was opened and when to discard it, and to ensure it remains effective. V18 said, We should be discarding it after 28 days, but we wouldn't know the 28 days unless it was labeled with the opened date. On 2/28/24 at 11:07 AM, V2 DON (Director of Nursing) said, insulin vial dates should contain the open and use by dates, because without them you wouldn't know if the insulin was still good. V2 said, the purpose of the use by date is to ensure that the medication is thrown out after the 28 days because it isn't good after that. R14's admission Record shows her diagnoses to include type 2 diabetes mellitus with hyperglycemia. R14's POS (Physician Order Sheets) shows she takes Insulin Aspart 6 units SQ (subcutaneous) before meals, Novolog insulin SQ for sliding scale insulin, and Tresiba Flex/touch 100 units/ml (milliliter) inject 45 unit in the morning. The Medication Storage, Labeling, and Disposal Policy and Procedure (revised 8/24/23) shows, It is the facility's policy to comply with federal regulations in storage, labeling and disposal of medications. Procedures: 1. Medications from pharmacy will be labeled .to include the name of the resident, route of administration, instructions, medication name (generic/brand), strength and expiration date when applicable. 3. Medications will be stored safely under appropriate environmental controls. 145819 Page 13 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0807 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Based on observation, interview, and record review the facility failed to provide water/other liquids for a resident for one of five residents (R301) reviewed for hydration in the sample of 18. Residents Affected - Few The findings include: On 2/27/24 at 10:55 AM, R301 was lying on her back, in bed. R301's lips were dry and cracked. There was a line of brown debris to the corners of her both, just below the lips. R301's tongue was dry and coated in white material. R301's teeth were coated in a white film. During the interview, R301's voice was rasping and her lips kept sticking to her teeth. R301 stated, Just a minute. It's so hard for me to talk. My mouth is so dry. R301 closed her mouth and swallow. R301's speech was difficult to understand at times, due to the dryness of her mouth, tongue, and lips. R301 said she had not received any oral care today. R301 did not have any water at the bedside. R301 said a drink of water would be nice. On 2/29/24 at 10:19 AM, R301 was sitting in a dialysis chair, outside the door to dialysis. V3 (Certified Nursing Assistant - CNA) pushed R301 back to her room. V3 and V4 (CNAs) used a total lift machine to transfer R301 from the dialysis chair to her bed. R301 had no water on her overbed table or her nightstand. R301 had a surgical mask on. R301's voice was raspy and she asked V3 and V4 (CNAs) for coffee. R301 stated, I'm terribly thirsty. Please get me some coffee. R301 removed her surgical mask from her face. R301's lips and tongue were dry. The surveyor asked R301 if she had oral care today and she said, Nope, not yet. But boy am I dry. R301 did not have water on her bedside table or night stand. R301's Face Sheet dated 2/29/24 showed diagnoses to include, but not limited to: iron deficiency anemia, diabetes, obesity, hypercalcemia, bipolar disorder, depression, seizures, polyneuropathy, hypertension, osteoarthritis, low back pain, endstage renal disease, dependence on renal dialysis, difficulty walking, lack of coordination, and schizoaffective disorder. R301's Physician Order Sheet did not show an order for a fluid restriction. R301's Care Plan initiated 2/15/24 showed, [R301] has an ADL self-care performance deficit and impaired mobility . R301's Nursing admission dated 2/15/24 showed she was alert to person and place; had the ability to express ideas and wants; and had pink and moist lips, tongue, and mouth. On 2/28/24 at 9:27 AM, R1 (R301's roommate) said there is no regular time that the facility passes water. R1 stated, They don't give my roommate water unless she asks for it and that's wrong. R1 had a pitcher of room temperature water on her bedside table. The pitcher was half full and there was no ice. During the Resident Council Meeting on 2/28/24, residents said that the facility does not pass water. They said you only get water if you ask for it. They said it would be nice to have fresh water with ice in it. They said you get some drinks with your meal trays, but the water pitchers do not get refreshed with ice and water regularly. 145819 Page 14 of 15 145819 02/29/2024 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0807 Level of Harm - Minimal harm or potential for actual harm On 2/29/24 at 10:16 AM, V3 (CNA - Certified Nursing Assistant) said water pitchers are delivered with the lunch trays and the residents can ask for ice water then. V3 said the residents have to ask for water refills. On 2/29/24 at 10:34 AM, V4 (CNA) said water is usually given to the residents during meal times. V4 said she is not aware of any scheduled water pass, just at meal times. Residents Affected - Few On 2/29/24 at 10:39 AM, V5 (RN - Registered Nurse) said the nurses keep a pitcher of water on the medication cart. V5 said the nurse provides water for the residents to take medications or the CNA can go to the room where the water and ice is kept to fill a resident's pitcher. V5 said the water is provided during meal times. V5 said R301 is able to make her needs known. V5 said proper hydration is an important aspect of the resident's overall health. The facility's Hydration Policy revised 7/28/23 showed, It is the facility's policy to ensure that residents are adequately hydrated. Procedures: Encourage fluid intake unless contraindicated . 145819 Page 15 of 15