Health inspection·April 10, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review the facility failed to ensure resident rooms were clean and repairs were performed in a timely manner for 11 of 13 residents (R1, R4, R5, R7-R14) reviewed for clean, comfortable and homelike in the sample of 14. The findings include: 1. On 4/10/23 at 10:25 AM, R4 was sitting in bed. R4's right siderail was broken. If pushed on, the siderail frame would pull away from the inner electrical component of the siderail. R4 had crushed up pretzels on the floor near her bed. R4's nightstand did not have a handle on the top drawer. R4's window valance had a layer of white dust on it. R4's walls had cobwebs on them. R4's window did not have a screen in it and there was a blanket on the windowsill that had brown/dirt debris and leaves on it. R4's white blinds had multiple colored splatters on them. R4's air conditioning/heating unit had brown/green spots on the vents of the unit. On 4/10/23 at 10:25 AM, R4 said that she has been in her room for about 9 years. R4 said that she notified staff about 3 weeks ago about her bed being broken. R4 said that the pretzels have been on her floor for about 3-4 days and the staff just step all over them when providing care. R4 said that her nightstand has not had a handle since her admission. R4 said that she does not think that the curtains have ever been taken down and cleaned. R4 said that the air conditioning unit was cleaned once that she can remember. R4 said, I feel disgusting in here. I don't like having visitors because it is embarrassing. A Compliment and Concern/Response Form dated 1/28/23 shows that R4 was asking for her room to be deep cleaned. 2. On 4/10/23 at 8:45 AM, R1 was sitting on the side of the bed. R1's floor was not clean. R1 had multiple pieces of tissue (including under the bed), a spoon, a cup, two pills, a white powdery substance and a black/brown dried debris spot on the floor. R1's wall had multiple large nicks along the lower portion of the wall. 3. On 4/10/23 at 10:32 AM, R5 was lying in bed. R5's garbage cans were full. R5's floor was sticky under her bedside table. R5 had a fork on the floor. R5's wall had multiple large nicks along the lower portion of the wall. On 4/10/23 at 10:32 AM, R5 said that they have not cleaned her room in about 3 days. R5 said that she would like it cleaned more often. Page 1 of 3 145868 145868 04/10/2023 Avantara Long Grove 1666 Checker Road Long Grove, IL 60047

F 0584 Level of Harm - Minimal harm or potential for actual harm A Compliment and Concern/Response Form dated 3/27/23 shows that R5 would like her room cleaned more often. 4. On 4/10/23 at 10:20 AM, R7-R14's rooms had multiple large nicks along the lower portion of the walls that extended more than ten feet. Residents Affected - Some On 4/10/23 at 9:35 AM, V5 (Housekeeping Supervisor) said that they are short staffed currently and all rooms are cleaned every other day or as needed. On 4/10/23 at 9:43 AM, V4 (Maintenance) said that if something needs to be fixed, the staff or resident lets them know and they will fix it right away. V4 said that if he knows about a wall that needs to be repaired, he will patch it and touch up the paint. V4 said that he does not currently have any walls that he is working on. At 12:19 AM, V4 said that he does not have any pending repair request for R4's room. Resident Council Minutes from 1/18/23 show, Residents have expressed that they would like to see housekeeping more frequently Resident Council Minutes from 2/15/23 show, Bathrooms need more attention. The facility's General Housekeeping Policy revised on 7/28/22 shows, The housekeeping staff will clean the resident rooms and bathrooms daily using approved sanitizing agents. The facility's Maintenance Policy revised on 7/28/22 shows, Any staff who is made aware of a malfunctioning equipment or any part of the building that is in disrepair will report the issue to the maintenance department. 145868 Page 2 of 3 145868 04/10/2023 Avantara Long Grove 1666 Checker Road Long Grove, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure prescription medications were administered according to standards of practice for 1 of 3 residents (R1) reviewed for medication administration in the sample of 14. The findings include: R1's admission Record printed April 10, 2023, showed R1 was admitted to the facility on [DATE], with diagnoses including dementia, psychosis, and Alzheimer's disease. R1's current care plan showed R1 was cognitively impaired. On April 10, 2023, at 8:40 AM, R1 was seated on the side of his bed. R1 was noted to be in a private room. V7 Certified Nursing Assistant (CNA) was assisting R1 with eating his breakfast. Two white circular pills were noted on the floor, directly next to R1's feet, under R1's bedside table. The two pills were unidentifiable as no writing was noted on the pills. V7 CNA picked up the two pills and stated, I will take these to his nurse. I have no idea what pills these are. V7 CNA placed the pills in plastic cup and exited the room. On April 10, 2023, at 9:20 AM, V10 Licensed Practical Nurse stated, I am the nurse for (R1) today. Yes, (V7 CNA) showed me the two pills that were found on the floor in (R1's) room. I have not passed any medications to (R1) yet today, so I have no idea if those pills were from last night or over the weekend. Nurses should watch residents take their medications to make sure they receive all of their medications. It's for patient safety. If a resident refuses to take their medications at that time, the nurse should document the refusal. Take the medications out of the resident room and dispose of them. V10 LPN stated she could not identify the two pills found on R1's floor. The facility's Medication Pass policy stated, It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures . 145868 Page 3 of 3