Health inspection·November 18, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the advance directive information from the previous care facility was verified and incorporated into the treatment plan of R1. This applies to 1 of 3 residents (R1) reviewed for Advance Directives. Findings include: The Electronic Medical Record (EMR) showed that R1 was admitted to the facility from hospital on [DATE]. R1 was an [AGE] year-old with diagnoses that included but not limited to atrial fibrillation, hypertension, hyperlipidemia, asthma, chronic obstructive pulmonary disease, and stool infection (positive clostridium difficile), failure to thrive, diarrhea, UTI (urinary tract infection), BPH (benign prostate hypertrophy), wight loss, severe malnutrition. Multiple hospital documentations prior to R1 being admitted to the facility were as follows: -Face sheet dated [DATE] showed: R1 code status was a DNAR (Do Not Attempt Resuscitation)-Hospital demographics of R1 dated [DATE]; Code Status Information: DNAR.- Physician Progress Notes dated [DATE]; ;.(R1) over the last several weeks , (R1) has been progressively weaker due to diarrhea, poor sleep, was able to ambulate independently, but not able to get out of bed for the past 2 days; discussed with the family for PT/OT evaluation . although family prefer for (R1) to be at home, they are open to subacute rehab especially given the marked increased in strength globally over the last several weeks. Disposition: Patient (R1) is DNAR select, confirmed with multiple families at bedside.(R1) is alert and oriented x self only, able to answer basic questions. The hospital H&P (History and Physical) of R1 dated [DATE] showed Disposition: Patient (R1) is DNAR select, confirmed with multiple members at bedside. Patient (R1) and family given opportunity to ask questions and note understanding and agreeing with plan. The hospital's Discharge Summary dated [DATE] showed the following morbid conditions of R1: hypertension, congestive heart failure, history of pulmonary embolism, chronic hypoxemic respiratory failure, severe hypercapnic respiratory failure, COPD, gout. R1's GOC (Goal of Care) is DNR (Do Not Resuscitate). Review of the facility's admission packet/contract documentation dated [DATE] showed multiple pages of information/resident's rights and include questionaries for advance care planning that included Advance Directives. The questionnaire if R1 has or no Advance Directive was left blank. This admission packet includes other residents' rights, but they lack documentation of R1's answers/wishes. Furthermore, the signature for R1 showed refused to sign and the facility representative that had supposedly provided and informed R1 of his rights was also left blank. The Speech Pathologist Report dated February 5,2025 documents that R1 was seen and evaluated by SLP (Speech Language Pathologist) for treatment of cognitive communication deficit and dysphagia. The SLP evaluation showed that (R1) had initially passed the BIMS (Brief Interview Mental Status), however full cognitive communication evaluation was warranted due to R1's increasing concerns for cognition. The evaluation also showed that R1's cognition was oriented to place and person only; with issues of problem solving and moderate memory impairment. The SLP evaluation showed that SLUMS Cognitive Page 1 of 2 146192 146192 11/18/2025 Thrive of Lisle 2850 Ogden Avenue Lisle, IL 60532

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assessment (St. Louis University Mental Status; a screening tool for early signs of dementia and mild cognitive impairment). The assessment result showed that R1 scored 11/30, indicating a moderate score within the dementia range (1-20). The overall impression of assessment summary showed that R1 presents moderate cognitive deficits with deficits in in orientation, attention, recall, executive functioning, and problem solving. The Minimum Data Set (MDS) dated [DATE] showed that R1's cognition was moderately impaired. The nurse progress notes dated [DATE] showed that R1 was a Full Code since there was no available record that R1 had an advanced directive. On [DATE] at 11:00 A.M., V3 (Social Service Designee) said that on [DATE], a Social Services Evaluation Form was done. V3 showed that evaluation form. Review of the form showed that a question Does the resident have Advanced Directive; the answer was No; if No, would the resident like assistance with Advance Directive Planning, the answer was NO. V3 was asked if the answers for both questions were NO', if there were any follow made with R1's family regarding Advance Directive to ensure wishes be honored whether a Full Code of DNAR since there were documented wishes of R1 for a DNAR while at the recent hospitalization prior to admission at the facility. V3 said that there were care plans with R1's family but code status was not discussed or followed through for verification. The progress notes dated February 22,2025 showed that early morning, R1 was found unresponsive, with no vital signs and CPR (Cardiopulmonary Resuscitation) was initiated, 911 was called and chest compression (CPR) continued by paramedics until R1 got to the hospital. The hospital record dated February 22,2025 showed that R1 arrived at the hospital with paramedics at 8:49 A.M., medical staff continued with CPR and code ends at 8:53 A.M. R1's time of death was 8:53 A.M. The death certificate dated February 22,205 showed that R1's cause of death was cardiac arrest, and the primary cause was due to heart failure and atrial fibrillation. On [DATE] at 10:53 A.M., V7 (R1's daughter, and the #1 Emergency Contact for R1 as listed on R1's EMR) have expressed concern that R1's wishes were not honored since R1 was a DNAR. There was no documentation found in the EMR indicating that the facility contacted the family to verify or discuss the R1's prior DNAR status or wishes related to resuscitation. The facility's policy for Advance Directives dated [DATE] with most revision date on [DATE] showed: When a resident is admitted to the facility, a discussion of advance directives will take place between the resident or family, if the resident is incompetent, and the facility staff. This enables the staff to readily and clearly ascertain how to treat the resident in an event of an emergency. 146192 Page 2 of 2