Grove of Northbrook,the

Inspectors wroteBased on interview and record review the facility failed to provide a safe environment and adequate supervision to a resident (R1) who was at risk of self-harming or foreign-body (batteries) ingestion; failed to develop and update an individualized care plan addressing the behavioral problem; failed to ensure to provide continues/ongoing psychotherapy program; and failed to report the two (2) incidents of R1 ingesting batteries in the facility to IDPH (Illinois Department of Public Health). These failures resulted in R1 having repeated access to batteries from TV remote controls, resulting in two (2) separate episodes of battery ingestion within one week that required transfer to hospital for emergency battery removal. This deficiency affects one (R1) of three residents reviewed for Quality of care.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow its Code Yellow (elopement) Policy regarding monitoring residents identified as at risk for elopement. This failure resulted in R1 eloping from the facility and being off grounds for an unknown amount of time before a search was started, and a Code Yellow was called. All 15 residents being monitored for risk of elopement can be affected by this failure. The Immediate Jeopardy began on 10/23/2024 when R1 eloped from the facility, and the door alarm was canceled by the staff without initiating the code yellow protocol. V1 (Administrator) and V2 (Director of Operations) were notified on 12/02/2024 at 3:45 PM of the Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident during a change in mental condition. This resident was able to injure a resident by pushing a wheelchair aggressively, causing this resident to slide out of the wheelchair hurting her back. The failure affects one of three residents (R1) reviewed for resident-to-resident physical assault.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its abuse prevention policy by failure to complete abuse assessment and update abuse care plan after allegation of resident-to-resident physical altercation. This deficiency affects three (R25, R78 and R87) of three residents reviewed for Abuse prevention policy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident received medications, treatments, and care as ordered by physician. This deficiency affects one (R25) of three residents in the sample of 24 reviewed for Quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up with pharmacy recommendation review and document physician response in resident medical record. This deficiency affects one (R28) of three residents in the sample of 24 review for Pharmacy medication review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the medication cart locked during medication administration when cart was out of site. The facility also failed to keep the medications refrigerated as manufacturer recommendation. This deficiency affects all three residents (R49, R55 and R97) in the sample of 24 reviewed for Medication Safety Storage.

Inspectors wroteBased on interview and record review, the facility failed to have effective interventions in place for the monitoring and supervision of residents assessed to be at risk for falls and requiring staff assistance with dressing and ambulation; and failed to follow the resident plan of care by not providing needed assistance with dressing and ambulation. This failure applied to two of two (R3, R4) residents reviewed for falls, and resulted in R3 sustaining a fall resulting in a left hip fracture requiring surgical intervention, and R4 sustaining a left wrist fracture after a fall while not being assisted during ambulation.

Inspectors wroteBased on interview and record review, the facility failed to supervise residents to prevent them from drinking alcohol, becoming drunk and falling. This applies to 3 of 3 residents (R3, R4 and R5) reviewed for supervision in the sample of 7.

Inspectors wroteBased on interviews and record reviews, the facility failed to use the proper equipment when providing incontinence care. This affected one of three residents (R11) reviewed for safety during care. This failure resulted in the use of a sit to stand device while providing incontinence care, contributing to R1 falling and sustaining a right shoulder fracture.

Inspectors wroteBased on interview and record review, the facility to follow their abuse policy and prevent incident of resident-to-resident physical assault, and resident to resident inappropriate touching. This affected three of four (R4, R5, and R10) residents reviewed for abuse prevention.

Inspectors wroteBased on interview and record review, the facility failed to follow hospital discharge instructions and neurosurgeon's recommendation for a repeat CT (Computed Tomography) scan of head prior to restarting anticoagulant therapy. This affected one of three residents (R1) reviewed for physician orders and discharge instructions. Findings Include: R1 was admitted in the facility on 10/12/23. R1 had right temporal parietal intraparenchymal hemorrhage and was taken emergently for right craniotomy for hematoma evacuation on 10/3/23. Hospital record on 10/17/23 hospitalization reads: Per Neurosurgery recommendation, R1 needs repeat CT in approximately one week with follow up prior to determining whether to restart formal AC (Anticoagulant). [...]

Inspectors wroteBased on observation and interview, the facility failed to repair leaking water from the air-conditioning unit in the resident's room. This deficiency affects 4 (R14, R20, R34 and R54) residents in the sample of 25 reviewed for Safe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a fall investigation to determine the cause of a fall, failed to update a resident's fall care plan after each fall incident, and failed to ensure a functional alarm was attached a resident who is at risk for falls. This deficiency affects 4 (R38, R72, R77 and R85) residents in the sample of 25 reviewed for Fall prevention management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Medication Storage Policy by not returning to the pharmacy expired medications belonging to R3, R4, R6, R19, and R112; the facility also failed to return, destroy or store seperately expired stock medications. This affects 5 residents (R3, R4, R6, R19, and R112) in the sample reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy for one resident (R84) of eight residents reviewed for privacy in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to shave facial hair and provide nail care to a dependent resident. This deficiency affects one (R54) of 6 residents in the sample of 25 reviewed for Personal hygiene and Grooming.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use hand splints to prevent/decrease further contractures for one of one residents (R4) reviewed for contractures in a sample of 25 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report pharmacist recommendations to the Physician. This deficiency affects one ( R113) of three residents in the sample of 25 reviewed for pharmacy medication review.