Health inspection·March 27, 2025

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation of a resident's AD (Advance Directives) to the ALS (Advance Life Support) paramedics and the hospital during a hospital transfer. This applies to 1 of 3 residents (R1) reviewed for facility-initiated transfer to the hospital and AD. The findings include: The EMR (Electronic Medical Record) showed that R1, a [AGE] year-old with diagnoses that includes acute and chronic respiratory failure, fluid overload, congestive heart failure, dependence on oxygen supplement, asthma, diabetes mellitust type 2, chronic kidney diase, end stage renal disease and dependence on renal dialysis, anemia, cardiomyopathy, aortic valve stenosis, lack of coordination, osteoarthritis, and presence of vascular implants and grafts, R1 was originally admitted to the facility on [DATE]. R1 was sent out to the hospital via 911 on March 11,2025 and returned to facility on March 14, 2025. The Social Service Notes dated February 28,2025 showed that R1, an African American female who admitted to the facility .primary language is English. (R1's) speech is clear, and her hearing appears adequate. (R1) is alert x3. (R1) is able to understand, as well as be understood Discussed advanced directives. (R1) reported she did not have a POA (Power of Attorney); however, per nursing notes resident's daughters provided POA paperwork and POLST (Practitioner Order Life Sustaining Treatment). (R1) did confirm she would like to be DNR (Do Not Resuscitate). The MDS (Minimum Data Set) assessment dated [DATE], showed that R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. The POLST form signed by R1 marked with a date of March 19,2019 showed R1's AD wishes as follows: DNR (if patient with no pulse); When not in cardiopulmonary arrest and patient is breathingComfort-Focused Treatment: primary goal of maximizing comfort; Relieve pain and suffering through use of medication, by any route, as needed, use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments Listed in Full and Selective Treatment unless consistent with comfort goal. REQUEST TRANSPORT TO HOSPITAL ONLY IF COMFORT NEEDS CANNOT BE MET IN CURRENT LOCATION. The progress notes dated March 11,2025 showed that R1 was sent out to the hospital via 911 due to shortness of breathing. R1 was admitted to hospital's ICU (Intensive Care Unit) with diagnoses of cardiac overload. Page 1 of 3 145901 145901 03/27/2025 Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The hospital H&P (History and Physical) dated March 11,2025 showed that (R1) to ER (Emergency Room) for worsening SOB (shortness of breathing) over the last 2 hours . Upon arrival, (R1) was in significant amount of distress .admitted to ICU. The EMR's SS (Social Service) progress note dated March 14, 2025, which was documented by V4 (Social Serve Director) showed that V12 (R1's daughter/POA/Power of Attorney) had requested the facility for a care plan meeting due to multiple concerns. One of the concerns was regarding R1's hospital transfer on March 11,2025. On March 25,2025 at 11:36 A.M., V4 said that on March 13,2025, she had received an email from V12. V4 added that the email was about V12 asking that a copy of R1's Advance Directives/POLST (Practitioner Order Life Sustaining Treatment) Form be fax immediately to the hospital. The facility provided the email correspondence between V12 and V4 dated March 13,2025. The email showed that V12 asked V4 Please fax a copy of (R1's) DNR (Do Not Resuscitate form) to .(hospital) .Pursuant to Illinois state law protocols, a copy of the DNR should have been provided to the transporter (ambulance) as well as a copy to the receiving facility .Please confirm once completed. The facility's concern form dated March 18,2025 showed that V12 was concern that DNR Form/POLST was not sent with (R1) to the hospital. On March 26,2025 at 4:55 P.M., V9 (LPN/Licensed practical Nurse) said that she sent R1 out to the hospital on March 11,2025 sometime around 10:00 A.M. V9 said that R1 was sent out due to labored breathing, and pulse oxygen level showed an alarming result of 72 % (normal 95). V9 said that she only provided documentation to paramedics of R1's Face Sheet/ and Medication List. V9 added that she did not provide R1's POLST documentation to the paramedics. V9 further said that she was informed by the nurse for the next shift that a POLST copy should be provided to the paramedics who then will provide to the hospital during resident's transfer. V9 said that she was also informed by V2 (Director of Nursing) after V12 had complained that a copy of the POLST was not provided to the paramedics/and hospital. V9 said that she was told that an in-service regarding appropriate documentation forms to be provided during transfer will be given; however, had not receive the in-service up to the current time. V9 also said that she has been working in the facility since July of 2024 and this was not the first time, she had sent a resident to the hospital. V9 said she was not aware that a copy of documentation of AD/POLST was to be provided to paramedics/hospital during transfer. The EMS (Emergency Medical Services) transport report dated March 11, 2025, showed that 911 was summoned by the facility on March 11,2025 at 8:30 A.M., paramedics were dispatched at 8:31 A.M., en route at 8:33 A.M., with (R1) at 8:39 A.M., and at hospital at 9:08 A.M. The EMS transport report also showed that R1 was in minor distress, with hyperventilation and fluctuation of oxygen saturation level, remained alert and oriented times 4 spheres (name, time place, person). The report also showed NONE for R1's Advance Directives. On March 25,2025 at 1:30 P.M., V13 (EMS Director) had validated that according to the EMS transport report for R1, none was checked for Advance Directives. V13 also sent a correspondence email dated March 25,2025 that paramedics crew that transported R1 to the hospital were only provided documents that included medication list and a face sheet. On March 24,2025 at 3:45 P.M., V12 said that facility had not provided a copy of POLST/DNR/Advance Directives to the paramedics and the hospital. V12 said she had sent an email to V4 once she had 145901 Page 2 of 3 145901 03/27/2025 Lemont Nursing & Rehab Center 12450 Walker Road Lemont, IL 60439

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few found out POLST copy was not sent out with R1 at time of transfer. V12 also said that R1 did not coded en route of transfer nor at the hospital. V12 also added it's the ramification of not sending a copy and (R1's) wishes would not be implemented. She (R1) does want a DNR status. On March 25,2025 at 12:30 P.M., R1 was observed sitting in her wheelchair in her room. R1 was alert and oriented times 3. R1 said that she was sent out to the hospital a week or 2 weeks ago. R1 said her wish was to remain a DNR status. On March 26,2025, V1 (Administrator) explained the facility's policy and procedure regarding resident transfer to the hospital. V1 said that their policy was to give forms that included face sheet and medication list that was on the POS (Physician Order Sheet). 145901 Page 3 of 3