Health inspection·February 6, 2025

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 interview and record review, the facility failed to obtain a resident's urine specimen in a timely manner to rule out a urinary tract infection. Residents Affected - Few This applies to 1 of 6 residents (R2) reviewed for quality of care. The findings include: R2's Face Sheet showed she was admitted to the facility on [DATE] and her diagnoses include history of UTIs (Urinary Tract Infections), ESBL (extended-spectrum beta lactamase) resistance, acute kidney failure, and anemia of chronic disease. R2's 1/21/25 nursing progress note from 5:08 PM showed .writer also spoke to resident's daughter [name] who said she talked to her mom and it was disturbing. She noted her mother seems paranoid and just wanted to let writer know. Writer informed daughter of my own interaction with her and daughter believes she could maybe have a UTI because 'this happens when she has a UTI ' Labs ordered to be drawn in the AM, urine to be collected per NP [Nurse Practitioner] . R2's 1/22/2025 Psychiatric Evaluation progress note from 12:16 PM (written by V7- Psychiatric NP), showed .Obtain a urine sample for urinalysis and culture to rule out a UTI. Will await results to identify reversible causes of confusion and psychosis R2's 1/23/2025 NP progress note from 7:39 AM showed .LABS: Awaiting UA/CS [urinalysis/culture & sensitivity] results . R2's 1/25/2025 nursing progress note from 4:47 PM (four days after initial order on 1/21/25) showed Family came in and asked writer if resident UA collection has been done, writer stated that it had been collected but due to the lid of the specimen cup not being tightly secured the urine fell into the bag and the collection was contaminated, writer stated to family that I could straight cath resident and collect another specimen, family stated that they wanted to take her to the ER Resident left facility with family to [local] Urgent Care. R2's 12/3/2024 MDS (Minimum Data Set) showed she only requires partial/moderate assistance for walking 50 feet, toileting transfers, and toileting hygiene. The same MDS showed she is always incontinent of bladder and bowel. On 2/4/25 at 3:18 PM, V7 (Psychiatric NP) stated he ordered R2's UA. V7 stated They need to collect it- the resident shouldn't wait for 4 days. R2's current and discontinued orders for January 2025 Page 1 of 2 145901 145901 02/06/2025 Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439

F 0684 showed an order for R2's UA/CS was not transcribed until 1/25/2025. Level of Harm - Minimal harm or potential for actual harm On 2/4/25 at 9:30 AM, V2 DON (Director of Nursing) stated that R2's family took her to urgent care and they did a urinalysis and R2 has a UTI. R2's 1/28/2025 nursing admission note from 5:14 PM showed she returned from the hospital via ambulance with an IV line. Residents Affected - Few The facility's February 2014 Medication and Treatment Order Policy showed .3. Telephone and/or verbal orders taken by licensed personnel must be promptly recorded on the Physician's Order Sheet in the resident's record 145901 Page 2 of 2