Health inspection·February 10, 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 Based on interview and record review the facility failed to follow physician orders to complete a comprehensive metabolic panel for one of three resident (R1) reviewed for physician orders. Residents Affected - Few Findings include: R1 face sheet shows R1 has diagnosis of Ogilvie syndrome, other specified myopathies, muscle wasting and atrophy, dysphagia, severe protein malnutrition, epilepsy syndrome, abdominal pain, cerebral palsy, hypertension, ileus, abdominal distension, constipation, severe intellectual disabilities, megacolon, mood disorder, ileostomy status, acquired absence of digestive tract, pressure ulcer stage 2 buttock, other seizures. R1 physician order sheet with order date of 10/15/24, start date of 10/21/24 denotes CBC W/DIFF (complete blood count and differentials) and platelets, comprehensive metabolic, magnesium, sent uncollected, one time only related to other seizures, Ogilvie's syndrome, cerebral palsy. Order dated 10/16/24 with start date of 10/21/24 denotes CBC W/DIFF and platelets, comprehensive metabolic, sent uncollected, one time only related to one time only related to cerebral palsy, hypertension, other myopathies. Order dated 10/25/24 with start date 10/28/24 denotes CBC W/DIFF and platelets, comprehensive metabolic, sent uncollected one time only related to other seizures, Ogilvie's syndrome, cerebral palsy, sent uncollected, one time only related to other mega colon. Order dated 10/30/24 with start date 10/31/24 denotes CBC W/DIFF and platelets, comprehensive metabolic, sent uncollected one time only related to severe intellectual disabilities, mega colon, severe protein malnutrition. R1 physician progress note dated 10/29/24 denotes in part the patient needs to be assessed and monitored for DVT, change in mental status, infection, electrolytes imbalances, bowel and bladder issues, and pain issues. R1 current plan of care prior to transfer denotes R1 was admitted to the facility for a skilled stay requiring physician ordered, medically necessary services including direct therapy services, skilled nursing care, management and evaluation of the patient care plan, observation, and assessment of the patient's condition and/or teaching and training activities related to the reason for stay or in preparation to transition to a lesser care environment. R1 requires skilled services related to impaired mobility, weakness, assist with ADL's (activities of daily living) medication administration, lab monitoring, pain management, and wound care. R1 has an alteration in gastrointestinal status r/t (related to) previous medical history of Ogilvie syndrome, abdominal distention, and ileus. She is s/p (status post) colectomy with end ileostomy. Interventions are Monitor vital signs as ordered/per protocol and record. Notify MD (Medical Doctor) of significant abnormalities, (rapid pulse, shallow, rapid, or labored respirations, low blood pressure), obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow up as indicated. Page 1 of 2 146053 146053 02/10/2025 Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/8/25 at 2:30pm V2 (Director of Nursing) said initially she was not aware that the lab draws for R1 was not being done. V2 said the NP (Nurse Practitioner) informed her that the labs she ordered for R1 were not done. V2 said on 10/31/24 she ordered R1 labs herself. Review of R1 lab report with V2. R1 report denotes CMP (complete metabolic panel) was not complete. V2 said she don't know why the CMP was not done. V2 was asked if there is an issue/concerns with their contracted laboratory. V2 denied that the laboratory is the issue. During follow up interview V2 said the specimen collected was not sufficient to run the test. Facility failed to present lab results for a comprehensive metabolic panel results for R1 for 10/21/24, 10/28/24, and 10/31/24. Facility physician orders policy dated 2/2023 denotes in part, drugs will be administered only upon a clean, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders will be received only by licensed nurse or pharmacist. And confirmed in writing by physician. Electronic order transmitted will be accepted. On 2/9/25 at 12:12pm V3 (Administrator) said the physician order policy speaks to verbal orders and verbal orders cover diagnostic orders. 146053 Page 2 of 2