Grove Of Northbrook,the

Penalty

Inspection fine: $18,990

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide a safe environment and adequate supervision for a resident with a known history of Pica and command auditory hallucinations instructing her to ingest batteries. The resident was admitted with multiple psychiatric diagnoses, including severe bipolar disorder with psychotic features, schizoaffective disorder, borderline personality disorder, and an eating disorder characterized by ingestion of non-food items such as batteries. Her comprehensive care plan identified an eating disorder and risk from ingesting non-food items but did not include her specific behavioral history of auditory hallucinations commanding her to swallow batteries, prior involuntary psychiatric admissions related to this behavior, or the two recent in-facility battery ingestions. Despite multiple documented episodes of battery ingestion and psychiatric decompensation, the care plan was not revised or individualized to address her current behaviors, triggers, or specific interventions such as removal of access to TV remotes and structured monitoring. The facility also failed to ensure ongoing psychotherapy services and appropriate behavioral management. The last psychotherapy note in the record was dated several months before the recent incidents, and there was no documentation of psychotherapy sessions or of the resident’s refusals after a new psychotherapist began seeing residents. The psychotherapist reported being unaware of the resident’s behavioral issues and had no documentation of refusals, while social services staff acknowledged responsibility for behavioral care planning but did not update the resident’s plan despite repeated behavioral incidents and petitions for involuntary psychiatric admission. The facility’s own behavioral management policy required determining causes of behavior, ensuring safety when behavior placed the resident at risk of self-harm, and involving the IDT and social services in monitoring and intervention, but there was no documented implementation of these processes for this resident. In addition, the facility failed to report two separate in-facility battery ingestion incidents to the state agency and did not complete or retain incident reports for those events. Nursing and administrative staff, including the DON, nursing consultant, and RNs, acknowledged that the resident twice ingested batteries from TV remote controls while in the facility and required hospital transfer and endoscopic removal. Staff interviews revealed that the resident remained ambulatory with access to TV remotes, including remotes in other residents’ rooms, and that monitoring was done informally without documentation. The DON and nursing consultant stated that no incident reports were completed and no reports were made to the Illinois Department of Public Health because they considered the events to be behavioral issues. The facility also lacked a resident safety policy beyond general resident rights and did not have documentation of close monitoring or 1:1 supervision, despite multiple staff and the primary care physician indicating that such supervision and removal of access to remotes were necessary to prevent recurrence. The resident’s roommate reported seeing the resident with a TV remote and hearing her state that she had eaten the batteries again, confirming that the resident had physical access to remotes in her room. Multiple staff, including RNs, CNAs, social services, the psychiatrist, and the PCP, acknowledged awareness of the resident’s history of ingesting batteries and recent episodes but described generic, non-individualized care plan interventions and undocumented monitoring. The care plan coordinator and SSD confirmed that the behavioral care plan had not been updated since admission, despite significant changes in condition, repeated hospitalizations for battery ingestion, and multiple petitions for involuntary psychiatric admission due to command hallucinations to swallow batteries. These documented inactions and omissions in care planning, supervision, psychotherapy provision, and incident reporting led to repeated episodes of battery ingestion requiring emergency hospital treatment. Facility policies on incident reporting, care planning, and behavioral management required reporting serious incidents to IDPH, periodically reviewing and revising care plans after assessments and changes in condition, and ensuring safety when behaviors placed residents at risk of self-harm. However, the facility did not follow these policies for this resident. There was no evidence of incident reports for the two battery ingestion events, no notification to IDPH within required timeframes, and no narrative summaries submitted. The behavioral care plan remained generic and unchanged, and there was no documented interdisciplinary coordination or individualized interventions to address the resident’s specific risk of battery ingestion driven by command hallucinations. These failures collectively constitute the cited deficiency in providing appropriate treatment and care according to orders, resident preferences and goals, and in maintaining a safe environment and adequate supervision for a resident at high risk of self-harm through foreign-body ingestion.

Penalty

Inspection fine: $53,804

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its Code Yellow (elopement) Policy, which resulted in a resident eloping from the facility. The resident, who had a history of mild cognitive impairment and other medical conditions, was able to leave the facility without being noticed. The facility is located near an outdoor mall and bordered by retail outlets and a major expressway, with exit doors equipped with alarm monitors. However, the alarm system was not effectively monitored, as the door alarm was canceled by staff without initiating the Code Yellow protocol. On the day of the incident, several staff members were unable to hear the door alarm due to various reasons, including being occupied with other duties or being in areas where the alarm was not audible. The receptionist, who was responsible for monitoring the security cameras, did not see the resident leave and assumed the situation was resolved when the alarm was silenced. Additionally, a CNA admitted to turning off the alarm without checking the outside area or notifying anyone, as he was in a rush to assist another resident. Interviews with staff revealed a lack of immediate response to the door alarm and a failure to conduct a head count promptly. The resident was eventually discovered missing when her lunch tray was found untouched. The facility's Code Yellow protocol, which includes conducting a head count and notifying the administrator or DON, was not followed, leading to a delay in initiating a search for the missing resident.

Removal Plan

• Facility staff immediately called a Code Yellow when facility determined that resident was missing. Staff conducted a search inside the facility including outside of facility premises.
• A Police Report was immediately filed for a missing resident, R1, to Officer (name, badge#) of the (city) Police Department.
• The CNA who responded to the alarm door was immediately educated not to turn off the alarm until a visual check/search is completed. This training was conducted by the Asst. Administrator.
• The Receptionist assigned was educated to make sure to look at the monitor to make sure no resident had exited, and not to turn off the alarm until a visual check/search is completed. Training was conducted by Assistant Administrator. The in-service included proper Alarm Response and utilization of the zone panel & camera system. Discussed appropriate times to call Code Yellow and to not cancel the alarm until given the 'all clear' following a head count. Emphasized the scope of receptionist responsibilities as the 'security station' of the facility.
• All employees were in serviced to ensure an immediate response to an exit door alarm is done, educated not to turn off the alarm until a visual check/search is completed. A head count is also to be completed to ensure that all residents are accounted for. If a resident is noted missing, staff to follow the facility protocol on missing residents. This in service will also be provided for every newly hired staff moving forward. The training was initially conducted by Social Services and Assistant Administrator for those present. The training continued both in person and over the phone for the remaining employees and was conducted by Food Services Director, CNA Supervisor, Social Services, Assistant Administrator, and Administrator. HR Manager printed out a complete facility roster which was cross-referenced to ensure all employees were educated.
• The Maintenance Director conducted an immediate check of the facility exit alarmed doors. All exit doors are alarmed and functioning. This check will continue checking daily.
• A facility wide audit to identify residents at risk for elopement, those at-risk for elopement must have photos in the elopement list posted on the bulletin board on each unit and at the reception desk for quick reference. Currently, there are 15 residents identified at risk for elopement. Audit was completed by Assistant Administrator/Social Services Director. Resident photos are taken upon admission to the facility and Elopement List is posted at each nursing station (both in a binder and on bulletin board for quick reference) and at the reception desk. Staff were in-serviced that bulletin boards will be used as the central location point in which to reference the elopement list at each nurse's station.
• The Social Service Department reassessed residents identified for elopement and elopement care plan was reviewed and updated. This was completed by Social Services.
• A facility door alarm drill was conducted to ensure staff are appropriately responding to an exit alarmed door and not to turn off the alarm until a visual check/search is completed. A facility protocol was put in place to ensure a head count is conducted after the visual check/search is done to ensure all residents are accounted for. This in-service was initiated by Social Services.
• The facility has identified approximately 25 (city) & surrounding area hospitals which facility staff continue to call daily in search of R1. This is ongoing.
• (Electric company) was called in to provide extra sound devices to project a more amplified sound to ensure staff can hear & respond to an alarm. (Electric company) will complete the work order to install necessary devices to address the concern.
• (Electric company) arrived and installed 7 new sound devices throughout the facility which project a more amplified sound to ensure staff better hear the door alarms. (Electric company) has also placed an order for dome lights to be installed at each exit door.
• All receptionists were in-serviced on Alarm Response and Utilization of Camera System to ensure camera is checked thoroughly before canceling the alarm system. Training was conducted by Assistant Administrator. The in-service included proper Alarm Response and utilization of the zone panel & camera system. Also discussed were appropriate times to call Code Yellow and to not cancel the alarm until given the 'all clear' following a head count. Lastly, we emphasized the scope of their responsibilities as representing the 'security station' of the facility.
• An additional in-service was conducted to all employees of the new amplified alarm devices to ensure staff are familiar with the amplified sound and respond immediately to the alarm. All staff were also in serviced on the purpose and locations of the zone panels should an exit alarm be sounded to determine location of alarm if uncertain. Staff were also in serviced on the location of the elopement risk residents' list that is posted on the bulletin board in every nurse's station for quick reference. Training was initiated by our two Social Services Designees and our Social Services Director for those employees who were present. The training continued both in person and over the phone for the remaining employees and was conducted by the Food Services Director, CNA Supervisor, Social Services/Assistant Administrator, Administrator and Guest Relations. The HR Manager printed out a complete facility roster which was cross-referenced to ensure that all employees were educated.
• A QA (Quality Assurance) audit tool was initiated to ensure the main exit door alarm system and the (electronic monitoring) system are checked for functionality daily and documented by maintenance. This will be done daily x14 days and 3x/week x2 weeks and weekly x 8 weeks.
• A QA audit was initiated to ensure staff are following door alarm drill, and all residents are accounted for. This audit will be done daily x7 days and 3x/week x3 weeks and weekly x 8 weeks.
• The QA audit tool that was initiated was revised after the additional amplified alarms were installed by (electric company) to ensure the exit door alarm system remains amplified. This will be conducted daily x7days, 3x/weekly x 8 weeks.
• A QA Audit was initiated to ensure receptionists are responding to an alarm system by initiating a 'Code Yellow' and checking the camera thoroughly before canceling the alarm system. This QA will be completed daily x 7 days and 3x/week x8 weeks.
• The elopement policy was reviewed and revised, which included specifying types of door alarms and defining them, as well as creating a centralized location at each nurse's station for quick reference of the elopement list. Policy was also revised to reflect the facility's specific protocols on Routine Procedure for Wandering Residents and Prevention of Missing Residents/Elopement. Training on the revised Elopement Policy was initiated by Social Services for those employees who were present. The training continued both in person and over the phone for the remaining employees and was conducted by the Food Services Director, CNA Supervisor, Social Services/Assistant Administrator, Administrator and Guest Relations. The HR Manager printed out a complete facility roster which was cross-referenced to ensure that all employees were educated.
• The QA trends will be discussed in QAPI scheduled and then monthly.
• The facility Medical Director was notified of the basis of abatement plan, and has approved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately monitor a resident, R3, during a change in mental condition, leading to an incident where R3 injured another resident, R1. R3, a male resident with diagnoses including major depressive disorder and bipolar disorder, became agitated and aggressive, resulting in physical altercations with staff and residents. Despite being on a one-to-one supervision, R3 managed to head-butt a staff member and subsequently pushed R1's wheelchair aggressively, causing her to fall and injure her back. R1, a female resident with diagnoses including schizoaffective disorder and paranoid schizophrenia, was alert at the time of the incident. She attempted to intervene when R3 was yelling and causing disturbances, which led to R3 pushing her wheelchair into a bathroom door, tipping it over and causing her to fall. R1 sustained injuries to her back and arm, as noted in a subsequent assessment. The incident was not directly witnessed by staff, and the response to the situation was delayed, with staff taking approximately five minutes to assess the situation. The facility's failure to provide adequate supervision and timely intervention during R3's behavioral escalation resulted in harm to R1 and highlighted deficiencies in monitoring residents with known mental health conditions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its abuse prevention policy by not completing abuse assessments and updating abuse care plans after allegations of resident-to-resident physical altercations. This deficiency affected three residents. In one incident, a resident attempted to take another resident's remote control, leading to a physical altercation where the first resident fell. Despite the altercation, the abuse assessments and care plans for both residents were not updated as required by the facility's policy. Both residents had significant mental health diagnoses and histories that placed them at risk for abuse, yet their care plans were not revised to reflect the incident. In another case, a resident reported being hit on the shoulder by another resident while passing in the hallway. The resident was assessed and monitored, but no physical injuries were found. However, the abuse assessment and prevention care plan for this resident were not updated following the incident, contrary to the facility's policy. The resident had a history of serious trauma and was identified as at risk for abuse, making the lack of updated care plans a significant oversight. The facility's policy on abuse and neglect mandates the identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflicts or neglect. Despite this, the facility did not follow through with the necessary updates to the abuse assessments and care plans after the incidents, as confirmed by the Social Service Director. This failure to adhere to the policy was observed and documented during the survey, highlighting a significant lapse in the facility's abuse prevention measures.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received medications, treatments, and care as ordered by the physician. The resident, who has multiple diagnoses including Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease, and several psychiatric disorders, was observed sleeping throughout the day with meals left untouched at the bedside. The nursing staff, including an LPN and CNAs, reported that the resident has behavioral issues and a routine sleeping pattern of being awake at night and sleeping during the day. Despite this, no individualized care plan interventions were formulated to address the resident's needs, such as adjusting the timing of medications and treatments. The resident's Medication Administration Record (MAR) indicated that medications were marked as given even though the resident was observed sleeping. The LPN admitted to not administering the morning medications because the resident was asleep and did not notify the physician of the missed doses. Additionally, daily blood sugar tests were not conducted as ordered, and there were discrepancies in the documentation of restorative programs and treatments. The interdisciplinary team, including the physician, nurse practitioner, dietitian, and pharmacist, were not informed of the resident's missed medications, treatments, and meals. The facility's policies on missed medications and physician orders were not followed. The policies require that missed medications be documented and the physician be notified to determine any necessary changes. However, the resident's medical records lacked documentation of missed medications and treatments, and there was no evidence that the physician or nurse practitioner was informed of these omissions. The facility did not provide the necessary care, treatment, and services as per the physician's orders, leading to a deficiency in the quality of care provided to the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow up with a pharmacy recommendation review and document the physician's response in the resident's medical record. This deficiency affected one resident (R28) out of a sample of 24 reviewed for pharmacy medication review. R28 was admitted with multiple diagnoses, including Schizoaffective disorder, Bipolar disorder, Antisocial personality, Anxiety disorder, Pressure ulcer, and Spina bifida. The active physician order sheet indicated prescriptions for Depakote ER and Valporic Acid, but there was no clinical indication for the usage of these medications. The consultant pharmacist recommended clarifying with the prescriber if the resident should continue both medications due to potential duplicate therapy. However, this recommendation was not followed up, and there was no documentation in the resident's medical records to indicate that the physician had been notified or that any action had been taken. The Assistant Director of Nursing (ADON) and the Psychotropic Nurse were responsible for following up on pharmacy recommendations. The ADON stated that they typically follow up within three days, but in this case, the recommendation dated 5/30/24 was not addressed. The Psychotropic Nurse presented a copy of the pharmacy recommendation, noting that she had notified the physician and continued the orders as prescribed, but she did not document this in the physician order sheet or progress notes. The facility's policy on medication regimen review requires that the consultant pharmacist's recommendations result in a written response by either a physician or nurse, and any identified irregularities must be documented in the medical record. This policy was not adhered to in the case of R28, leading to the deficiency noted in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to keep the medication cart locked during medication administration when the cart was out of sight and did not store medications as per manufacturer recommendations. During an observation, it was noted that a nurse left the medication cart unlocked while administering medications to a resident, which was acknowledged as a mistake by the nurse. Additionally, controlled substances such as Lorazepam were found stored in the medication cart instead of the medication refrigerator, contrary to the manufacturer's storage recommendations. The Director of Nursing confirmed that the medication cart should always be locked when out of sight and that medications should be stored according to manufacturer recommendations. The facility's policies on Medication Storage, Labeling, and Disposal, as well as Medication Pass, were reviewed and indicated that medications should be stored safely under appropriate environmental controls and secured in locked storage areas. The failure to adhere to these policies affected three residents in the sample reviewed for Medication Safety Storage.