Health inspection·June 13, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy when they did not provide a notice of discharge to the resident's representative, before the discharge, which included explanation and rights to appeal, when the facility did not allow a resident to return after the ten-day bed hold lapsed, which constituted a facility discharge. This applies to 1 of 3 residents (R1) reviewed for bed holds. The findings include: R1's Electronic Health Record (EHR) showed R1 was originally admitted on [DATE], and was recently sent to the hospital on [DATE], where she is. The EHR showed R1 had multiple diagnoses including cerebral infarction, Alzheimer's disease, hypertension, type 2 diabetes, dysphagia, hemiplegia left dominant side, dementia, and vascular dementia. R1's Minimum Data Set (MDS), discharge - return anticipated, dated [DATE] showed R1 could not complete the mental assessment, but was considered severely impaired for daily decision making. R1's Care Plan dated [DATE] showed: R1 will not be discharging from the facility, as determined by the inter-disciplinary team, physician, resident and/or legal representative. R1 has impaired cognitive functioning related to diagnosis of dementia. Assist with decision making including family or responsible party as needed. On [DATE], V2 (Director of Nursing/DON) stated, on [DATE], V2 informed V12 (R1's Guardian) that R1's 10-day bed hold lapsed, and another resident was going to be admitted to R1's room. V2 stated, she informed V12 that R1 is considered long term and there are no other beds available, and R1 would need to go on the waiting list if she wanted to return to the facility. V2 stated, R1 was discharged on the 11th day, [DATE]st, per policy. During interviews, V1 (Administrator) stated, R1's room was held for 10 days, from [DATE]-[DATE], and on [DATE], V1 made V12 aware that the bed hold period expired. V1 stated, she made V12 aware that R1 would not be able to return to the facility, because R1's room was going to a new admission, and since R1 is considered long term, and there were no more long-term beds available, she would have to go on the waiting list. V1 stated, there was no semi-private long-term beds available, and the last semi-private female bed was considered a short-term bed, but a new admit was taking that bed on [DATE]th. V1 stated, R1 had electronic monitoring and a resident in a semi-private room would have to Page 1 of 4 146182 146182 06/13/2023 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few consent to the use of the camera. V1 stated, she did not ask V12 if she would forgo the electronic monitoring to be put in a semi-private room, because the only bed available could not accommodate a long-term care resident. When asked if V1 was advised to or if there was any reason to give V12 a notice of discharge, she said no. R1's Electronic Health Records (EHR) showed no documentation of Involuntary Discharge Notice provided to V12. The facility policy titled Discharge or Transfer, Involuntary ([DATE]) reviewed showed: Policy: The facility will provide proper procedure and notification of an involuntary transfer or discharge pursuant to the regulations of long term care facilities .; and state rules and regulations . Notification and Documentation . 2) Residents and their representative(s) must be notified of the transfer and the reasons for the transfer. This notice must be provided in writing thirty (30) days prior to transfer or, as soon as practical . d) The state public health form Notice of Involuntary transfer or Discharge and Opportunity for a Hearing must be completed and given to the resident with a copy placed in the resident record. Additional copies must be sent by registered or certified mail to the resident's representative This information must be documented in the record with corresponding notation of the information having been provided to the resident and appropriate individuals 146182 Page 2 of 4 146182 06/13/2023 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy when they did not provide the Bed Hold and re-admission Policy Notice to a resident's representative within 24 hours of transfer. This applies to 1 of 3 residents (R1) reviewed for bed hold notification. The findings include: R1's Electronic Health Record (EHR) showed R1 was originally admitted on [DATE], and was recently sent to the hospital on May 20, 2023, where she remains. The EHR showed R1 had multiple diagnoses including cerebral infarction, Alzheimer's disease, hypertension, type 2 diabetes, dysphagia, hemiplegia left dominant side, dementia, and vascular dementia. R1's Multiple Data Set (MDS), discharge - return anticipated, dated May 20, 2023 showed R1 could not complete the mental assessment, but was considered severely impaired for daily decision making. R1's Care Plan dated April 18, 2023 showed: R1 will not be discharging from the facility, as determined by the inter-disciplinary team, physician, resident and/or legal representative. R1 has impaired cognitive functioning related to diagnosis of dementia. Assist with decision making including family or responsible party as needed. On June 7, 2023, V5 (Registered Nurse/RN) stated on May 20, 2023, she was alerted that R1 vomited, and after she assessed R1 and discussed with V3 (Assistant Director of Nursing/ADON), she called V4 (R1's Doctor) and he ordered R1 to be sent out. V5 stated, V13 (R1's daughter) and V4 was present when she called V4. V3 called V12 (R1's Guardian). V5 stated, R1 was stable, so 911 was not called, but ambulance service was requested. V5 stated, she prepared the paperwork to give to the paramedic, which included the bed hold notice. V5 stated, V12 arrived before the ambulance, but she did not give a copy of the bed hold notice to her. V5 stated, instruction she received from the facility for bed hold notice was to give a copy to the paramedic and complete the bed hold assessment in the electronic record but did not include giving a copy to the representative. On June 7, 2023, V3 (ADON) stated, V5 got all the paperwork ready for R1's transfer, and she saw a copy of the bed hold notification in the paramedic's paperwork. V5 stated, she did not personally give V12 a copy of the notice. On June 7, 2023, V6 (Receptionist) stated, when a resident is transferred to the hospital, the receptionist mails a copy of the bed hold notification to the resident's representative within 24 hours or hands it to the representative if they are present. V6 stated, if she hands the representative a copy, they have them complete the notice of receipt, otherwise, they do not send a letter with the mailed copy, to complete notice of receipt and return it to the facility. V6 provided a copy of R1's Bed Hold and re-admission Policy Notification and explained R1's date of transfer was May 21, 2023 and the date the form was mailed to the legal representative was May 22, 2023, which is past the 24 hour notification requirement. 146182 Page 3 of 4 146182 06/13/2023 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On June 8, 2023 V2 (Director of Nursing/DON) stated, instruction was given to the nurses, when a resident is transferred to the hospital, the bed hold notification should be handed to the representative when the resident's representative, or if the representative is not present at the time, mail the notice, and complete the bed hold assessment in the electronic record. V2 stated, the nurse should document in a progress note that the bed hold notice was given to the representative. V2 stated, a copy goes with the paramedics because the hospital keeps a copy and gives a copy to the resident's representative. V2 stated, the notice should be provided within 24 to 48 hours of transfer. On June 8, 2023 (V1) Administrator stated, the facility should provide notice of bed hold notice to the resident's representative within 24 hours of transfer to the hospital. V1 stated, if the representative is present at the time of transfer, the notice should be handed to them, signed, and scanned. If they are not present, a copy is given to the receptionist to mail. V1 stated, she was not aware if V12 (R1's Guardian) was handed the notice, but it was mailed. R1's progress notes reviewed for May 20, 2023 did not show documentation that the bed hold notification was provided to V12. The facility policy titled Bed Hold/Ombudsman Notification Documentation (December 2018) and attached Bed Hold and re-admission Policy Notice reviewed showed: Policy: The facility will be responsible for documenting that the bed hold policy was given to the resident at the time of transfer, and to the resident representative within 24 hours Procedure: 1) The nurse will be responsible for opening the bed hold and ombudsman notification assessment for any resident being transferred to the hospital or going out on therapeutic leave. 2) The nurse will document that the bed hold notification was provided to the resident, and to the resident representative if present. 3) The facility designee will provide the resident representative the bed hold notification within 24 hours, if not previously given, and document completion in the bed hold and ombudsman notifications assessment 146182 Page 4 of 4