Health inspection·July 30, 2024

F 0563 Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. 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 follow their policy by not ensuring restricted visitor information was posted for 2 of 3 residents (R1, R3) reviewed for safety in the sample of 3. Residents Affected - Few The findings include: 1. R1's face sheet printed on 7/30/24 showed diagnoses including but not limited to dementia with mood disturbance, psychosis, dysphagia, and adult failure to thrive. The same face sheet showed the names of five family members allowed to visit R1. The face sheet showed instructions to call R1's state guardian if anyone else attempts to visit. R1's facility assessment dated [DATE] showed severe cognitive impairment and total staff assistance required for all ADLs (activities of daily living). R1's July 2024 physician order summary showed hospice care and receiving comfort medications. On 7/30/24 at 10:00 AM, V3 (Social Service Director/SSD) stated R1 was admitted to the facility in November of 2022 and at that time, only five family members were allowed in to see her (R1). V3 said in October of 2023 the state guardian office removed all visitor restrictions after a pending adult protective services case against R1 was resolved (not guilty). V3 said the family dynamics are dysfunctional and the staff had no knowledge of a father even existing until he came to the facility in March of 2024. The father was verbally aggressive, rude, and demanding. The state guardian was notified and instructions to deny R1's father access to the facility was given. V3 said approximately one week later, the father was at the front desk with an aunt and pastor. V3 was notified and made the father leave immediately. V3 said staff are all aware that the father is not allowed in the building, and he has not tried to return. V3 said there is a binder at the front desk showing the receptionists all visitors that are not allowed in the facility. The restricted visitors' names are also posted on a sign behind the front desk. The electronic medical records also show under the special instructions banner who is not allowed to visit. On 7/30/24 at 10:23 AM, V4 (Receptionist) stated she works the day shift, another person covers the afternoon shift, and a third person covers the night shift. V4 said she just knows who is and who is not allowed to visit. V4 said she has it memorized for the current residents and asks a nurse or V3 (SSD) if it is a newer resident. V4 said at one time there was a binder of who is not allowed in the facility, but it was missing. V4 said she could not recall the last time she saw it at the front desk. V4 said signs or notes are also posted at the front desk with names of people that cannot visit. This surveyor observed the front desk area and there was no signage related to restricted visitors. V4 did provide a front desk green binder that showed the names of people that could take Page 1 of 2 146159 146159 07/30/2024 The Terrace 1615 Sunset Avenue Waukegan, IL 60087

F 0563 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents out for appointments. The binder did not show any information related to visitors denied access. (V4 was able to voice knowledge in R1's father being restricted and R3's son being restricted.) On 7/30/24 at 10:36 AM, V5 (Licensed Practical Nurse/LPN) stated she looks at the special instructions banner in the electronic chart for any visitor restrictions. V5 said she was aware that R1's father was banned and opened the electronic record. There was no information in the banner to indicate the father was restricted. On 7/30/24 at 10:45 AM, V6 (Hospice Nurse) stated she was aware R1's father is denied access to visiting. V6 stated the special instruction banner area does not document his restriction. On 7/30/24 at 11:39 AM, V2 (Director of Nurses) said all residents should have visitor restrictions clearly posted at the front desk on a note and in a binder. The same information should be in the electronic charts for the floor nurses and aides to see. V2 confirmed R1 was missing the documentation under the special instructions area. V2 said it must have gotten erased when R1's feeding tube was discontinued. A lot of nurses go in and out of that charting area. It 100% should be documented there. It must have somehow gotten taken down. On 7/30/24 at 11:59 AM, V7 (LPN) stated R1's father is denied access to the facility. V7 said she was told verbally by V3 (SSD) after he was loud and rude. V7 said she looks under the profile area (special instructions) and R1's father should be listed there as no visitation allowed. On 7/30/24 at 12:36 PM, V3 confirmed the green binder did not include restricted visitors and only contained information for outside appointment transportation. 2. On 7/30/24 at 12:43 PM, R3 stated he has one son that is no longer allowed to visit him. His son had a marijuana pipe and some other things with him at a visit so he can't come in to see him anymore. On 7/30/24 at 1:09 PM, V1 (Administrator) and V2 (Director of Nurses) confirmed R3's son is not allowed inside the facility. R3 did not have any signage or binder information at the front desk. The facility's Visitation policy dated 10/24/22 states: 6. The facility will impose reasonable restrictions on visiting which include but are not limited to: denying access to visitors who are inebriated or disruptive. Restricted or supervised visitation, if the resident's visitor(s) are deemed to be . bringing in illegal substances to the facility. 146159 Page 2 of 2