Health inspection·August 14, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on interview and record review the facility failed to ensure resident dignity was maintained during dining for 1 of 6 residents (R1) reviewed for dignity in the sample of 6. The findings include: R1's face sheet printed on 8/14/24 showed diagnoses including but not limited to atrial fibrillation, pulmonary embolism, malnutrition, Alzheimer's Disease, and dementia. R1's facility assessment dated [DATE] showed severe cognitive impairment and substantial/maximal staff assistance needed for eating. On 8/14/24 at 1:51 PM, V8 (R1's daughter) stated she was visiting R1 on the morning of 7/8/24 and found her seated in the group dining room wearing only a hospital type nightgown. V8 said R1 had a blanket draped over her shoulder's but nothing over the rest of her. V8 said she absolutely brought clothes to the facility including pajamas, the day prior. V8 said she immediately complained to staff. V8 was told that R1 was restless during the early morning hours and was taken to the nurse station in her nightgown. Staff reported R1 was sent to the dining room wearing the same gown when breakfast began. V8 said R1 looked ungroomed and her hair was a mess. On 8/14/24 at 12:49 PM, V3 (Social Service Director) stated she was at a staff morning meeting in July and was told R1's family member (V8) was unhappy with R1's care. V8 found R1 in the group dining room seated at the breakfast table wearing a hospital type gown and was poorly groomed. V3 said the entire morning team heard about it and knew V8 was unhappy about the situation. V3 said she met with V8 to further discuss the situation. V3 said it never should have happened. It is undignified and not the normal procedure. On 8/14/24 at 12:58 PM, V2 (Director of Nurses) stated all residents should receive morning cares, including face washed, hair combed, and appropriately dressed, before leaving their room. V2 said he was aware that R1 had been placed in the group dining room while still wearing her night gown. V2 said he knew V8 complained to staff when she saw R1 undressed and outside of her room. V2 said residents should be dressed before coming out of their rooms. It is the decent thing to do. The facility's Quality of Life policy last review dated 3/31/24 states under the dignity section: Nursing staff1. [NAME] resident as they wish to be groomed. Maintains personal privacy by keeping residents covered/clothed while being taken to areas outside their room. 2. Encourage/assists resident to dress in their own clothing rather than hospital-type gowns and to wear appropriate footwear according to their preferences. Page 1 of 2 145986 145986 08/14/2024 Lake Forest Place 1100 Pembridge Drive Lake Forest, IL 60045

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 a homelike environment by allowing a damaged nightstand to remain in a resident room for 1 of 6 residents (R4) reviewed for environment in the sample of 6. The findings include: On 8/14/24 at 1:51 PM, V8 stated her aunt was a resident at the facility for about one week in July 2024. V8 said the nightstand in the room was damaged during the entire time. The top handle was hanging off and the left upper corner was missing a section. V8 said staff were repeatedly in and out of the room but the nightstand was never repaired or replaced. On 8/14/24 at 10:44 AM, the facility nightstand in the same room V8's aunt had resided in was observed. The handle was still falling off and the left, upper corner was heavily damaged. R4 was the resident currently residing in the room. R4 said it had been that way since she arrived at the facility. On 8/14/24 at 1:32 PM, V5 (Maintenance Technician) stated he was unaware of any complaints or work repair orders for the nightstand. V5 said items like nightstands can typically be repaired the same day it is reported. On 8/14/24 at 1:55 PM, V1 (Administrator) stated damaged resident items should be reported right away. All staff are responsible for reporting it. Damaged room items just look bad and are not how things are kept around here. The facility's Personal Possessions and Safe Environment policy last revision dated 3/31/24 states under the purpose section: (Facility name), to the extent possible, provides a homelike environment. Provides housekeeping and maintenance services necessary to maintain a sanitary, orderly (uncluttered environment that is neat and well kept), and comfortable interior. 145986 Page 2 of 2