Health inspection·August 10, 2023

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide activities per resident preferences for a resident in isolation for 1 of 1 residents (R117) reviewed for activities in the sample of 27. Residents Affected - Few The findings include: R117's electronic face sheet printed on 8/10/23 showed R117 has diagnoses including but not limited to major depressive disorder, secondary malignant neoplasm or retroperitoneum and peritoneum, history of bladder cancer, pressure ulcer sacral region stage 4, and muscle weakness. R117's facility assessment dated [DATE] showed R117 has no cognitive impairment and states it is very important to have books, newspapers, magazines to read, listen to music he likes, do things with groups of people, do his favorite activities, and go outside to get fresh air when the weather is good. R117's physician's orders dated 5/22/23 showed, activities as tolerated unless contraindicated. R117's care plan dated 5/30/23 showed, (R117) is dependent on staff for emotional, intellectual, physical and social stimulation. He has physical limitations, he will need assist to and from as well as during group activities of interest. Activities provide resident with in room social visits. Activity staff will introduce themselves and extend a warm welcome. Will engage resident in conversation discussing likes/dislikes current/past interests. On 8/8/23 at 1:30PM, R117 was lying in his bed and was under contact isolation. R117 stated, I have been on isolation for several days now and I think I have almost a week left. Activities staff come and sit with me but we just talk, if anything. They don't do anything else with me. I guess they can't because I'm on isolation. On 8/9/23 at 1:10PM, R117 stated, My family came in today and we played trivia. It was so much fun and I can't wait to get out of this room and be able to do activities again. I understand it's probably hard for the staff to do anything with me while I'm on isolation but I love playing games. On 8/10/23 at 12:24PM, R117s stated, If someone came in my room right now and said let's get up and go outside I would say Yes, absolutely. Let's do it. I love being outside and around other people so it's been difficult being in this room for so long. Activities comes in to check on me but they don't do anything other than talk with me. I would like to play a game or something to pass the time. On 8/10/23 at 12:35PM, V9 (Activities Director) stated, Upon admission, we go through a Page 1 of 10 146130 146130 08/10/2023 Hillcrest Retirement Village 1740 North Circuit Drive Round Lake Beach, IL 60073

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few questionnaire from the state regarding resident's activity preferences, likes/dislikes and then I enter it into the resident chart. When I went through (R117's) records and looked at what our department has been doing with him I only see 30 minute 1:1 visits. I thought the activity staff were doing more than that but it looks like I need to be monitoring them better. I'm shocked that this is all my staff have been doing with him because before he was in isolation he was out for activities all the time. I should have been checking on my staff more to make sure they were meeting his needs. Clearly we haven't been and I feel bad about that. On 8/10/23 at 1:33PM, V2 (Director of Nursing) stated, (R117) is on isolation for an infection in his wound. Technically he could probably come out of his room and go outside with a staff member if the wound doctor gives us clearance for that. His mental and psychosocial well-being means just as much as his physical well-being so if there is any way we can take him outside safely then we should be doing that. I feel awful that I didn't realize he likes being outside so much or I would have tried to facilitate this earlier. Whatever is the safest and best thing for (R117) and the other residents is what we should be doing. R117's activities participation record from 7/31/23-8/9/23 showed R117 received 30 minutes of 1:1 visits from activity staff on a daily basis. No documentation was present for any further activity involvement for R117 for these dates. The facility's policy titled, Activities Policy dated 2023 showed, It is the policy of this facility to provide an ongoing program to support residents in their choices of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community .8. Activities will include individual, small and large group activities as well as .g. In-Room activities. 146130 Page 2 of 10 146130 08/10/2023 Hillcrest Retirement Village 1740 North Circuit Drive Round Lake Beach, IL 60073

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative therapy services to 1 of 3 residents (R117) reviewed for range of motion in the sample of 27. The findings include: R117's electronic face sheet printed on 8/10/23 showed R117 has diagnoses including but not limited to severe protein-calorie malnutrition, major depressive disorder, secondary malignant neoplasm or retroperitoneum and peritoneum, history of bladder cancer, pressure ulcer sacral region stage 4, and muscle weakness. R117's facility assessment dated [DATE] showed R117 has no cognitive impairment and participates in a restorative therapy program. R117's physician's orders dated 5/22/23 showed, rehab/restorative therapy program R117's physician's orders dated 7/11/23 showed, Physical therapy to evaluate and treat. (Order was discontinued on 7/24/23 due to R117 meeting his maximum potential). R117's care plan dated 5/22/23 showed, The resident has an activities of daily living self-care performance deficit related to limited mobility. Transfer program #1, Bed mobility program. R117's care plan dated 8/10/23 showed, The resident has limited physical mobility related to contractures .Provide gentle range of motion as tolerated with daily care. (This care plan was developed following surveyor's interview with V3-Restorative Nurse) R117's certified nursing assistant task list showed no restorative therapy exercises to be completed. On 8/10/23 at 12:24PM, R117 stated, I used to get therapy but now that I'm on isolation they don't do it anymore. I think they stopped doing it because I got put on isolation and they don't want to come in here. I try to do my own exercises but it would be nice to have a structured set of exercises so I can try to keep some mobility. On 8/10/23 at 1:22PM, V3 (Restorative Nurse) stated, (R117) came off physical therapy at the end of July and I don't have a restorative assessment or anything in the chart for him so he does not have a program right now. He should have been assessed when he got discharged from physical therapy and should have a program to try and prevent his contractures from getting worse. He is a resident who would be very active with his own program and do the exercises independently if needed. On 8/10/23 at 1:33PM, V2 (Director of Nursing) stated, When a resident gets admitted they should have an order for restorative as part of our standing orders and should be assessed for a program. When residents are discharged from physical therapy we should be assessing them for a restorative program to try and at least maintain what abilities they have. The facility's undated policy titled, Restorative Nursing Programs showed, It is the policy of this 146130 Page 3 of 10 146130 08/10/2023 Hillcrest Retirement Village 1740 North Circuit Drive Round Lake Beach, IL 60073

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level .4. All residents will received maintenance nursing services, as needed, by certified nursing assistants (CNA's). 5. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides/CNA when they are assessed to have a need for restorative nursing services. These services may include: a. passive or active range of motion .c. bed mobility training and skill practice .6. Residents may receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitation therapy, or upon discharge from therapy. 146130 Page 4 of 10 146130 08/10/2023 Hillcrest Retirement Village 1740 North Circuit Drive Round Lake Beach, IL 60073

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer a resident for psychological services for a resident with depression. This failure applies to 1 of 3 residents (R117) reviewed for mood & behavior in the sample of 27. The findings include: R117's electronic face sheet printed on 8/10/23 showed R117 has diagnoses including but not limited to severe protein-calorie malnutrition, major depressive disorder, secondary malignant neoplasm or retroperitoneum and peritoneum, history of bladder cancer, pressure ulcer sacral region stage 4, and muscle weakness. R117's facility assessment dated [DATE] showed R117 has no cognitive impairment, has little interest or pleasure in doing things, feels down, depressed, or hopeless, feels bad about himself-or that he is a failure or has let himself or his family down, and has trouble concentrating. R117's nursing care plan dated 5/30/23 showed, The resident uses antidepressant medication related to depression and poor nutrition. Administer meds as ordered, monitor/documented/report as needed any adverse reactions to antidepressants. R117's nursing care plan dated 5/24/23 showed, Resident participated in mood interview and expressed feelings of depression most of the time (staff observe him to be withdrawn) and states he has very little interest in doing anything (dx: depression). He states he is sleeping well but still gets tired sometimes. Resident states his appetite is good at this time. He states he feels bad about himself every day and wishes things were different. Resident states he gets restless and also has difficulty concentrating sometimes. Overall, he seems pleasant when approached and interacts well with others .arrange for psych consult, follow up as indicated, discuss with the resident/family any concerns, fears, issues regarding health or other subjects as needed, monitor/document/report as needed any signs/symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, tearfulness. On 8/8/23 at 1:52PM, during interview with R117 he became tearful when talking about how he just retired and then ended up in a nursing home and has neuropathy, contractures, and a pressure wound. Asked R117 if he has been speaking with any type of therapist and R117 stated, No, but that would probably be helpful. My life is just a mess and I'm having trouble coping with all of these changes. This all happened so fast. It feels like one day I was fine and the next day I was in a nursing home. R117's social services initial progress note dated 5/31/23 showed, Resident was admitted to facility on 5/22/23 from his home where he lived with his brother. He was referred to psych on 5/24/23 for evaluation and treatment for depression. No psychological visit notes were present in R117's electronic medical record. On 8/10/23 at 12:27PM, V6 (Social Services Director) stated, I did not have (R117) evaluated by psych services. He was going to be hospice so we thought they would be able to help with the emotional side of things. After they decided not to go with hospice I forgot about the referral to psych 146130 Page 5 of 10 146130 08/10/2023 Hillcrest Retirement Village 1740 North Circuit Drive Round Lake Beach, IL 60073

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few services for him. I did document that I referred him but I never did. I didn't know how much he was struggling with the adjustment to the changes in his life. I can definitely put him on the list to see psych services so that he can get the support he needs. The facility's policy titled, Social Services Policy dated 2023 showed, The facility, regardless of size, will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 4. The social worker, or social service designee, will pursue the provision of any identified need for medically-related social services of the resident. Attempts to meet the needs of the resident will be handled by the appropriate discipline. Services to meet the resident's needs may include: j. providing or arranging for needed mental and psychosocial counseling services. 5. The facility should provide social services or obtain needed services from outside entities during situations that include but not limited to the following: d. Difficulty coping with change or loss (ex: change in living arrangement, change in condition or functioning ability, loss of meaningful employment, or loss of a loved one). The facility's policy titled, Behavioral Health Services dated 2023 showed, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning .1. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders .3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety 6. Conditions that are frequently seen in nursing home residents and may require the facility to provide specialized services and supports based upon residents' individual needs, include but are not limited to: a. depression- it is not a natural part of aging, however, older adults in the nursing home setting are more at risk than older adults in the community 146130 Page 6 of 10 146130 08/10/2023 Hillcrest Retirement Village 1740 North Circuit Drive Round Lake Beach, IL 60073

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a resident's medication for her chronic obstructive pulmonary disorder. This applies to 1 of 1 residents reviewed for pharmacy services in the sample of 27. The findings include: R22's admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include: chronic obstructive pulmonary disorder (COPD); type 2 diabetes; heart failure; and dementia. R22's admission Minimum Data Set (MDS) from 6/12/23 showed she was cognitively intact with a brief interview for mental status score of 13 out of 15. On 8/08/23 at 11:43 AM, R22 stated she did not receive two inhalers for the treatment of her COPD. R22 stated the inhalers were Umeclidinium-Vilanterol (UV) inhaler (a medication which relaxes the airway making it easier to breath) and Fluticasone-Umeclidinium-Vilanterol (FUV) inhaler (a similar medication as the previous inhaler with the addition of a steroid to reduce inflammation) R22 stated she was told by her nurse on Monday 8/7/23 the facility could not find them and she would not be able to have them until Tuesday 8/8/23. R22 stated she was given them that morning (8/8/23). R22 stated a similar occurance happened in July 2023 and she did not receive the inhalers for one or two days. On 8/09/23 at 1:50 PM, R22 stated, she was not offered a nebulizer treatment or any other breathing treatment as a replacement for her unavailable inhalers. R22 said she felt as if the facility should have ordered the medication prior to running out especially if the pharmacy does not deliver every day. R22 stated, when she was home, she would order the inhalers a week ahead of time due to their importance for the maintenance of her COPD. R22 stated she did notice her breathing was more labored on the days the facility failed to provide her inhalers. On 8/10/23 at 10:18 AM, V7 R22's Daughter stated she was with R22 in July 2023 when R22 ran out of her inhalers. V7 stated she spoke with the nurse at the time. V7 said, I was there, it was a Saturday or Sunday, and she (the nurse) told me she (R22) didn't get her inhaler. It was last month but I don't remember exactly when. I asked the nurse about it and she either said they could find it or they ran out, it was one of those two, I don't remember which, and they said it wouldn't be in until Monday, so I know she went at least a day last month without them. R22's July 2023 Medication Administration Record (MAR) showed and order for UV and FUV to be given once a day for COPD. The MAR showed nursing staff documented the inhalers as being given for the entire month. R22's August 2023 MAR showed, on 8/7/23, UV and FUV were documented as other/See Progress Notes. R22's 8/7/23 Progress Notes for UV and FUV inhalers showed the medications were not available. R22's July and August 2023 MARs showed an order for Albuterol Nebulizer (short acting medication to improve shortness of breath) to be given every 6 hours as needed for shortness of breath or 146130 Page 7 of 10 146130 08/10/2023 Hillcrest Retirement Village 1740 North Circuit Drive Round Lake Beach, IL 60073

F 0755 wheezing. The MARs showed the nebulizer was not given either month as of [DATE]. Level of Harm - Minimal harm or potential for actual harm On 8/08/23 at 11:43, R22's room did not have a nebulizer machine. Residents Affected - Few On 8/9/23 at 2:08 PM, R22's UV and FUV inhalers, in the nurses medication cart, showed they had a countdown timer indicating the number of remaining doses. On 8/09/23 3:15 PM, V2 Director of Nursing stated refills for inhalers need to be requested from the pharmacy because they are not an automatic refill. V2 stated staff should request the refill with ample enough time to allow time for any insurance issues or pharmacy closures. V2 said the pharmacy delivers every evening except Sunday. V2 said if a medication is exhausted and it is not available in their emergency supply nursing staff should contact the facility's contracted pharmacy who will in turn contact a local pharmacy. V2 stated the facility staff can then pick up the prescription from the local pharmacy. V2 stated all staff have been educated on this procedure. R22's Care Plan from 6/12/23 showed, The resident has altered respiratory status r/t (related to) diagnosis of COPD .Administer medication/puffers as ordered. Monitor for effectiveness and side effects . The facility's Medication Reordering Policy (copyright 2023) showed, .Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner .Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting . 146130 Page 8 of 10 146130 08/10/2023 Hillcrest Retirement Village 1740 North Circuit Drive Round Lake Beach, IL 60073

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure foods were kept out of the danger zone (below 41 degrees Fahrenheit for cold foods, and 135 degrees Fahrenheit or above for hot foods) prior to serving. The facility also failed to ensure trayline temperature logs and two-step cool-down logs were filled out. This has the potential to affect all of the residents in the facility. The findings include: The CMS 672 Resident Census and Conditions of Residents form dated 8/8/23, showed 121 residents resided in the facility. The 672 form showed 1 of the residents received tube feedings (enteral nutrition). On 8/10/23 at 9:48 AM, V1 (Administrator) said there are 2 residents with feeding tubes. Only one of the residents receive supplemental tube feedings. V1 said both of the residents with feeding tubes receive food by mouth. On 8/8/23 at 10:09 AM, V13 was already putting food on the plates for the lunch meal. After plating the food, V13 handed the plate to the dietary aides, who placed the trays into a heated cart. V8 (Dietary Manager) said the dietary staff plate that early because they go on break at 10:30 AM. V8 said the dietary staff plate the trays for all of the halls, except the dependent trays (the trays for the residents that need staff to feed them during meals). V8 said after all of the heated carts are delivered, the CNAs (Certified Nursing Assistants) come and get the dependent residents' trays and assist the residents with their meal. On 8/08/23 at 11:41 AM, in the South dining room staff were passing trays from the heated cart to the residents' rooms. V12 (Registered Nurse-RN) was asked if she could have someone from dietary bring a thermometer to the south dining room. V12 went to the kitchen and brought back a thermometer. At 11:48 AM, V12 obtained the temperature from a tray in one of the heated carts in the south dining room. The temperature of the chili mac was 132.8 degrees Fahrenheit. The green beans were 130.1 degrees Fahrenheit. At 11:50 AM, V12 tested a tray from the other heated cart in the south dining room. The temperature of the chili mac on the tray was 126.1 degrees Fahrenheit and the green beans were 122.7 degrees Fahrenheit. On 8/8/23 at 11:54 AM, in the North dining room, V11 CNA was starting to push the 400 hall cart down to the 400 hall, to pass the residents' lunch trays. This surveyor informed staff that I would like to check the temperatures for a couple of the trays before taking them out of the dining area. At 11:55 AM, V8 (Dietary Manager) obtained the temperatures on 2 of the trays from the 400 cart. On the first tray, the chili mac was 121.8 degrees Fahrenheit and the green beans were 117.5 degrees Fahrenheit. On the second tray the chili mac was 120.3 degrees Fahrenheit and the green beans were 117.5 degrees Fahrenheit. V8 went over and talked to V2 (Director of Nursing-DON), who was in the dining room. V2 took the 400 cart back to the kitchen. On 8/9/23 at 9:47 AM, V8 was asked where the cooling logs were located for monitoring the leftover food, cool-down process. V8 said they just put the leftover food in the cooler and serve it that day or the next day. V8 was asked if the dietary staff monitor and document the cooling process for the leftover meats and other foods. V8 again said they just put the food in the cooler and serve it later that day or the next day. V8 was asked if she had any logs to show that time-sensitive foods were 146130 Page 9 of 10 146130 08/10/2023 Hillcrest Retirement Village 1740 North Circuit Drive Round Lake Beach, IL 60073

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many cooled appropriately and V8 said she did not have any logs. At 9:49 AM, V8 was shown the facility's HACCP (hazard analysis and critical control points) Temperature Monitoring Sheets for the month of August (8/1/23-8/9/23). The log sheets did not have any trayline temperature readings for the ground meats or the pureed foods on any of the sheets, for any of the meals that were served between 8/1/23-8/9/23. The temperature logs showed only 3 of the days (8/2/23, 8/5/23 and 8/7/23) had any temperature readings for cold food items (i.e. milk, cold tossed salads/greens, cold desserts etc.). V8 said the temperatures for all of the food items, for all of the food consistencies (i.e.regular, mechanic soft and pureed consistencies) should be obtained prior to serving the food to the residents. On 8/10/23 at 1:14 PM, V8 (Dietary Manager) said hot foods should be kept above 135 degrees Fahrenheit and cold foods should be 41 degrees Fahrenheit or lower prior to serving. V8 said it is important because the danger zone; the prime temperature for bacterial growth to occur is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. V8 said this is important to prevent food-borne illness. V8 said it is important to fill out the logs for the temperatures of all of the foods on the serving line to ensure foods are not in the danger zone. V8 said it is important to make sure food is cooled properly; Temperatures decreased to 70 degrees Fahrenheit within 2 hours and from 70 to below 41 degrees Fahrenheit within 4 hours. Taking no longer than 6 hours total to bring the temperature below 41 degrees Fahrenheit to prevent food-borne illness. V8 said the food temperatures should be obtained right before serving the food. The facility's policy and procedure titled Holding and Service, with a revision date of 2017, showed Hot foods are held at a minimum temperature of 135 degrees Fahrenheit. Time/Temperature Controlled for Safety (TCS) cold foods are held at 41 degrees Fahrenheit or below. The policy showed The temperature of the food is periodically monitored throughout the meal service to ensure proper hot or cold holding temperatures are maintained. The facility's policy and procedure titled Cooling Cooked PHF/TCS Foods (Potentially Hazardous Food/Time Temperature Control for Safety), with a revision date of 2017, showed Hot foods are cooled in the refrigerator from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours. Within four more hours the food is cooled to 41 degrees Fahrenheit. Cooling time from 135 degrees Fahrenheit to 41 degrees Fahrenheit does not exceed a total of six hours. The policy showed, The time and temperature are recorded at the beginning of the cooling process. The timing of the cooling process begins when the temperature of the food is at 135 degrees Fahrenheit. Two hours later, the temperature is taken and recorded. The food needs to be 70 degrees Fahrenheit or lower. The person in charge is notified if the temperature is greater than 70 degrees Fahrenheit. If the food is not 70 degrees Fahrenheit or lower it is discarded. The temperature is taken and recorded again four hours later. The food needs to be 41 degrees Fahrenheit or lower. The person in charge is notified if the temperature is greater than 41 degrees Fahrenheit. If the food is not 41 degrees Fahrenheit or lower, it is discarded. Food for which no temperatures have been taken is discarded. Time and temperature are recorded on labels affixed to the pan and/or on a Two-Step Cool-Down Temperature Monitoring Log. 146130 Page 10 of 10