Health inspection·June 9, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and update resident's fall care plan with new interventions to prevent one resident (R6) who was a risk for falls, from falling and hitting her head on 1/23/23. This failure effects 1 resident of 3 residents reviewed for falls in a sample of 12. Findings include: R6 post fall occurrence forms document three falls 11/21/22, 12/8/22, and 1/23/23. R6's fall-initial occurrence report for 11/21/2022 documents R6 tried to get up but slid off the bed. R6 was found sitting on the floor with legs outstretched on the side of her bed. R6's fall-initial occurrence report for 12/8/2022 documents R6 was found face down on the floor, resident stated she lost her balance and fell, and precipitating factors: resident needed to void and forgets to use the call light and is on an anticoagulant. R6's Fall initial occurrence report for 1/23/23 documents R6 was found on the floor in her room lying on her back and head on the floor. R6 stated she was trying to go to the restroom. R6's Progress note dated 12/8/2022 documented a bruise to the forehead and was sent to the hospital. R6's hospital records dated 12/8/2022 document diagnosis as fall and traumatic hemorrhage of cerebrum. Resident was readmitted to the facility on [DATE]. There are no new interventions documented on the fall risk care plan after 7/13/22 until 1/23/23. Therefore, no new interventions after the 11/21/22 fall or the 12/8/22 fall with injury. 6/07/23 01:22 PM V2 (DON) stated after resident's fall, the facility came up with interventions and updated the resident's care plan with new interventions. The facility's Comprehensive Care Plan policy dated 11/17/17 documents the following: to develop a comprehensive care plan that directs the care team and incorporates the resident's highest practicable physical, mental, and psychosocial well-being. The facilities fall prevention program policy documents the care plan interventions are changed Page 1 of 3 145839 145839 06/09/2023 Park Ridge Healthcare Center 665 Busse Highway Park Ridge, IL 60068

F 0657 with each fall, as appropriate. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145839 Page 2 of 3 145839 06/09/2023 Park Ridge Healthcare Center 665 Busse Highway Park Ridge, IL 60068

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 Based on observation, interview and record review, the facility failed to provide treatment and care for a resident with seizures for one (R14) of four residents reviewed for seizures in a sample of 12. Residents Affected - Few Findings include: On 06/06/23 at 10:06 AM during observation, R14 was observed sitting on a Geri-chair in the dining room when she started presenting with jerking body movements, eyelids fluttering, and eyes rolling back. V6 (Certified Nursing Assistant) noticed R14, checked her, and informed V3 (Licensed Practical Nurse). V3 checked R14 and stayed with her. R14's jerking movements stopped after approximately 15 seconds, but eyelids and eyes remained the same. After approximately another 10 seconds, R14's eyelids and eyes started to relax. V3 was observed taking R14 to her room. On 06/07/23 at 10:48 AM, V3 said she brought R14 to room to decrease stimuli and make her comfortable. V3 stated she didn't think that when R14 had the jerking movements and eyes rolling backwards she was having a seizure. V3 said she did not check R14's vital signs or call the doctor. On 06/07/23 at 10:52 AM, V2 (Director of Nursing) stated that R14 has diagnosis of seizure disorder and she might've been having seizures at that time. V2 added that R14 is on seizure medication but cannot locate any laboratory results for R14 to check therapeutic levels. On 06/08/2023 at 1:12PM, V2 said if a resident had a seizure, she expects the nurses to assess the resident including the vital signs, provide care as needed, and then notify the doctor and/or family. On 06/07/23 at 11:00 AM, V6 said he saw R14 having jerking body movements, so he checked on R14 and informed V3. R14's order summary report dated 6/7/23 indicated admission date of 10/23/2019, diagnoses including other seizures and other sequelae of cerebral infarction, and order for Levetiracetam 250 milligrams (mg) by mouth in the morning and 500mg by mouth in the evening with start date of 7/12/2022. Care plan revised 7/22/2022 indicated R14 is at risk for seizures, Levetiracetam with interventions including monitor lab values for therapeutic levels of anticonvulsant medications and report to MD (Doctor of Medicine). Review of physician orders from 7/12/2022 to 06/06/2023 did not show any current or previous laboratory order to check therapeutic levels of Levetiracetam. Facility unable to provide policy on change in condition. 145839 Page 3 of 3