Inspection·September 14, 2024

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor resident's advance directives for DNR (Do Not Resuscitate) for 1 resident (R1) of 3 residents reviewed for CPR (cardiopulmonary resuscitation)/Advanced Directives in the sample. Findings include: R1 is a [AGE] year-old with diagnoses including metabolic encephalopathy, left heel pressure ulcer, Dementia with psychotic disturbance, heart failure, and Alzheimer's Disease. R1 was shown to have a DNR (Do Not Resuscitate) order that was signed by his guardian on [DATE]. On [DATE] at 12:20 PM, V2 director of nursing (DON) stated, R1 was in his 80's or 90's, alert times one and up and about with 2-staff assist using mechanical lift. He (R1) hangs out in the dining room, is verbal but confused and needs assist with feeding. V2 stated I (V2) was in the building in the morning and when I left, I was called by (V4) about R1's change of condition when I (V2) came in the building around 4:00 PM, V4 licensed practical nurse (LPN) stated she called V3 assistant director of nursing (ADON) and gave a report and we had called a code blue and R1 went to the hospital. Paramedics came and continued CPR after staff-initiated CPR. Surveyor asked which staff performed CPR, V2 indicated that there were two people, one of which was V4 but did not know the other staff person but was possibly a CNA. On [DATE] at 12:25 PM V3 (ADON) stated, The staff will know the advanced directive of DNR or Full Code and it is shown in the electronic medical record. She (V4) told me she found (R1) unresponsive and she had already initiated CPR and she called 911 and had the paperwork and that paramedics were enroute. It's in PCC (electronic medical record system) if they are DNR or full code. If the resident was full code that would mean to initiate CPR and if DNR they know not to provide resuscitation and otherwise they would call a code. On [DATE], efforts to reach V4 could not be obtained for interview. However, on [DATE] at 4:58 PM, V4 wrote in part, Nurses Notes Note Text: resident sitting at dining room table, head facing table, no response noted when name called. Resident color appears dusk, no blood pressure, no carotid or brachial pulse noted. No vital signs noted. No spo2 noted. CPR started, Oxygen applied via nasal cannula 911 called, left voicemail with state guardian and family member, DON and ADON aware. 3 paramedics arrived, continued CPR and oxygen. Resident placed on stretcher, Paramedics transporting to nearest hospital. Records showed a DNR order dated 5/16 24 signed by R1's State Guardian which reads in part: Do Not (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146078 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahva Care of Stickney 3900 South Oak Park Avenue Stickney, IL 60402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)