Health inspection·July 11, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure call lights were answered in a timely manner for two (R44 and R87) of two residents in a sample of 44 reviewed for accommodation of needs. Residents Affected - Few Findings include: R44 is a [AGE] year old, female, initially admitted in the facility on 08/21/2017 with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side; and Cerebral Infarction, Unspecified. On 07/08/24 at 12:40 PM, R44 pushed the call light. At 12:50 PM, her call light was observed still on. R44 stated, I want my CNA (Certified Nursing Assistant). I want to get up now. At 12:55 PM, observed V14 (CNA) go to R44's room and respond to her call light. It took 15 minutes for V14 to respond to R44's call light. R87 is a [AGE] year old, female, initially admitted in the facility on 11/21/2023 with diagnosis of Nontraumatic Chronic Subdural Hemorrhage; Dementia in other Diseases Classified Elsewhere, Unspecified Severity, with Other Behavioral Disturbance; and Multiple Fracture Ribs, Left Side, Subsequent Encounter for Fracture with Routine Healing. On 07/08/24 at 12:25 PM, R87's call light was observed on. It was observed that there were no staff present in the hallway and by the nurses' station. At 12:40 PM, her call light was still on. Surveyor went to R87's room, observed lunch tray at bedside table. Bedside table was situated at the foot of the bed. R87 stated I tried to call to turn that table around so I can eat but I still have no assistance. V11 (Licensed Practical Nurse, LPN) was observed sitting at the nurses' station. At 12:59 PM, V15 (CNA) was collecting food trays in the hallway where R87's room can be found. Surveyor observed that V15 left and went to other unit. V15 did not go to R87's room. At 1:00 PM, R87's call light was still on. V13 (Housekeeping) was observed in R87's room. V13 was observed going to the nurses' station and talked to V11. V13 was asked if she told V11 about R87's call light. V13 stated, I told her (V11) and she said that one CNA is attending other residents. At 1:06 PM, R87's call light was still on, V11 was observed going to R87's room to provide assistance. It took 41 minutes for a staff to respond to R87's call light. R87's care plan documented: ADL (Activities of Daily Living) self-care performance deficit - Interventions - eating: one-person assist; encourage to use call light to call for assistance. On 07/09/24 at 1:19 PM, V2 (Director of Nursing, DON) was interviewed regarding call lights. V2 stated, We received complaints from residents regarding call lights. We do staff in-services regarding responding to call lights; department heads do rounds on a daily basis during morning shift ensuring Page 1 of 4 145994 145994 07/11/2024 Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few call lights are responded. Staff on the floor do rounds at least every two hours and as frequent as needed. Reasonable time to respond to call light is not more than 5 minutes. Any staff in the facility should respond to call lights. I have talked to housekeeping and kitchen staff to not respond related to care but at least respond to call lights. If they responded to call lights and its related to care, they have to notify the nurse. On 07/8/24 at 11:00 AM to 11:30AM during observation in unit one of the facilities, observed several call lights going off in resident's rooms that were not answered promptly, some resident's beds were noted with no linens and stripped naked. On 07/9/24, between 9:46AM and 10:30AM, surveyor observed several call lights turned on in the 200 section of unit one with no staff observed answering responding to them. Surveyor responded to one of the lights and notified staff that resident needs to go to the bathroom. Several residents screened had concern with the call light not being answered in a timely manner, some residents said that it takes 30 mins to one hour for the call light to be answered. On 07/9/24 at 11:20 AM, V8 (Registered Nurse, RN) was presented with this observation, and she said that there are two CNA's that are assigned to the unit, one just went on break and the other one is probably in another room. Surveyor asked V8 why the call lights are not being answered in a timely manner and she said, The CNA's are usually pulled to help with lunch, right now one of them is on break and the other one is probably assisting another resident. On 07/9/24 at 1:15PM, V2 (DON), said call light response has been a concern and the expectation is that it should be answered in a timely manner, they provide in-service to staff and the department heads also do angel rounds during the day, the facility does not have managers in the evening so the floor nurses and CNA's will be responsible for monitoring the call light and ensuring that it is answered timely. V2 was asked to be a little more specific on what is considered timely, and she said within 5 minutes. The facility does not have any system in place to show how long a call light has been on before it was answered. She added that when a call light is on, any staff can answer it, even if they cannot provide the type of assistance that the resident needed, at least they can get the right person to assist the resident. Facility's policy titled, Call light Policy, dated 1-28-23 stated in part but not limited to the following: Purpose: To respond to the resident's requests and needs in a timely manner. Performed by: All Staff Procedure: 1. Answer call light promptly and turn the light off after entering the room. Knock on the door before entering. 145994 Page 2 of 4 145994 07/11/2024 Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 follow its policy on conducting background checks for four (R52, R103, R105 and R106, ) of 10 residents reviewed for admission screening. This failure has the potential to affect 117 residents currently residing in the facility. Residents Affected - Many Findings include: Per census report, there are 117 residents currently residing in the facility. R52 is a [AGE] year old, female, admitted in the facility on 06/15/24 with diagnosis of Unspecified Fracture of Shaft of Humerus, left Arm, Subsequent Encounter for Fracture with Routine Healing. R52's Criminal History Information Response Process (CHIRP) was done on 06/17/2024, two days after admission. R103 is [AGE] year old, male, initially admitted in the facility on 01/05/24 with diagnosis of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R103's name was checked in the National Sex offender website on 03/30/2024, which was more than two months after admission. There was no documentation that R103's CHIRP was checked, nor his name checked under State Sex offender website and Department of Corrections. R105 is a [AGE] year old, female, admitted in the facility on 06/24/24 with diagnosis of Sepsis, Unspecified Organism. There was no record that her name was checked under Illinois Department of Corrections upon admission. R106 is a [AGE] year old, female, admitted in the facility on 03/01/24 with diagnoses of Anorexia; Adult Failure to Thrive and Major Depressive Disorder, Recurrent, Unspecified. Her CHIRP was done on 03/05/24, which was four days after admission. R106's name was checked in the Illinois Department of Corrections, State and National Sex offender websites on 07/09/24, which was four months after she was admitted . R106 is an identified offender for criminal offenses and had history of incarceration. On 07/09/24 at 3:05 PM, V1 (Administrator) was asked regarding background checks on residents. V1 stated, For new admissions regarding background checks, the team is notified that we have to check with National and State sex offender websites and the department of corrections. We have to do those prior to admission. CHIRP is done within 24 hours of admission. We want to make sure if there is a hit for sex offenders so we could provide a private room. V20 (Medical Director) was also asked on 07/10/24 at 4:27 PM regarding background checks. V20 verbalized, Regarding screening of new residents, they should be screened prior to admission to facility for background checks and at sex offender websites. We want to make sure they are not a danger to other residents and other staff. Facility's policy titled, Abuse Prevention Policy, dated 9/28/23 documented in part but not limited to the following: Procedures: 145994 Page 3 of 4 145994 07/11/2024 Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067

F 0607 II. Pre-admission Screening of Potential Residents Level of Harm - Minimal harm or potential for actual harm This facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. Residents Affected - Many This facility will: Request Criminal History Background Check within 24 hours after admission of a new resident Check for the resident's name on the Illinois Sex Offender Registration Website Check for the resident's name on the Illinois Department of Corrections sex registrant search page While the background or fingerprint checks, and/or Identified Offender Report and Recommendations are pending, the facility shall take all steps necessary to ensure the safety of residents. Facility's policy titled, admission of Identified Offender, dated 5/3/22, stated in part but not limited to the following: Guidelines: 1. Screened on Sex offender website. 2. Criminal History record information requested. 4. Facility must review screenings and all supporting documentation to determine if the placement is appropriate. 145994 Page 4 of 4