Health inspection·September 3, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to assist a resident (R1) needing assistance with eating during meal services. This applies to 1 of 3 residents (R1) reviewed for feeding assistance. Residents Affected - Few The findings include: R1's EMR (Electronic Medical Record) showed R1 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, cognitive communication deficit, esophagitis, gastrointestinal hemorrhage, diabetes type 2, chronic kidney disease stage 4, and hypertension. R1's MDS (Minimum Data Set) dated 6/5/2024 showed R1 had moderate cognition impairment. R1's Order Summary Report dated 8/31/2024 showed R1 had an active order for 1:1 feed due to increased weakness initiated on 8/27/2024. On 8/31/2024 at 12:55 PM, R1 was in bed with her bedside table positioned in front of her with her lunch. R1 was not being assisted or supervised during her meal. R1 had her eyes closed and appeared very fatigued. R1 had food debris on her left lower lip area. R1 also had food in her mouth and was chewing very slowly. Then V8 (Certified Nurse Assistant/CNA) and V4 (Nursing Supervisor) came to R1's room and said they were going to boost R1 in bed for her meal. V8 (CNA) said R1 was able to feed herself before. They left after they boosted R1 in bed. V8 and V4 did not assist R1 with her meal and continued to leave R1 unsupervised with her lunch tray in front of her. R1 was observed with the same food in her mouth as prior. R1 was observed falling asleep and then starting to cough intermittently. On 9/1/2024 at 4:00 PM, V2 (Director of Nursing/DON) said R1 was a 1:1 feeder. V2 said R1 had an order to be assisted with feeding during meals. V2 said she expected staff to follow R1's feeding order to ensure her safety with eating and to prevent R1 from choking or aspiration. V2 continued to say R1 had to be assisted with feeding to assist her in maintaining her nutritional needs because recently she had been declining overall. R1's Progress Note dated 8/27/2024 from V15 (Nurse Practitioner/NP) said R1 was evaluated because of noted fatigue and anorexia. V15's progress note said Per staff, she has not been eating much. She needs frequent encouragement and assistance with meals and drinks. The progress noted continued to show that R1's son was updated, and he expressed concern about R1's coughing and being at risk for choking. V15's progress note said R1's assessment plan included 1:1 feed at this time and educate on frequent encouragement of meals/snacks and drinks. Page 1 of 7 145246 145246 09/03/2024 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0677 Level of Harm - Minimal harm or potential for actual harm The facility's policy titled Activities of Daily Living Support with Showers dated 5/22/2024 showed Policy Statement Residents will provide with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition . Residents Affected - Few 145246 Page 2 of 7 145246 09/03/2024 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure pressure ulcer recommendations and pressure ulcer treatments were completed as ordered. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for pressure ulcers. The findings include: R1's EMR (Electronic Medical Record) showed R1's diagnoses include diabetes type 2, neuropathy, unstageable pressure ulcer to the sacrum, left heel diabetic ulcer, hemiplegia, and hemiparesis following cerebral infarction affecting the left non-dominant side. R1's 8/16/2024 MDS (Minimum Data Set) showed R1 had moderate cognition impairment. R1's MDS showed R1 was dependent on staff with toileting and required substantial to maximal staff assistance with bed mobility. R1's MDS also showed that R1 was at risk for pressure ulcers and had a stage 3 pressure ulcer present on admission. On 8/31/2024 at 11:52 AM, R1 was lying on her backside in bed, underneath her was a mechanical lift sling. At 2:20 PM, V10 (Wound Care Nurse/WCN) said R1 had an unstageable pressure ulcer to her coccyx that was progressively worsening. R1 did not have a urinary catheter in place. V10 was asked to assess R1's coccyx wound. When V10 removed R1's dressing, there was a foul odor. The center of R1's wound bed had an open area, which V10 said was new. V10 said R1's wound measured 7.5 cm (centimeters) x 8 cm x unknown depth (L x W x D), and it had new undermining (dead space under the skin surrounding the wound) in one area which measured 3 cm underneath. V10 continued to say the wound had 75% necrotic slough tissue and 25% pink granular tissue with serosanguinous drainage with some odor. V10 said she last assessed and changed R1's coccyx dressing on 8/29/2024 when she obtained a wound culture. V10 said R1's physician ordered a wound culture to try to identify the source of R1's elevated white blood count. V10 said the floor nurses were expected to change wound care dressings as ordered when she did not change the dressings. V10 cleansed the wound with normal saline and then applied Medi honey gel on a calcium alginate dressing and placed it on top of R1's wound bed, without packing anything into the undermining dead space, and then covered it with a foam dressing. V10 said R1's coccyx wound had been deteriorating and she was being managed by the facility's in-house Wound Nurse Practitioner/NP (V15). On 9/03/2024 at 11:50 AM, V15 (Wound NP) said she was managing R1's wounds, including her coccyx pressure ulcer. V15 said R1 was at risk for wound complications due to her complex medical conditions. V15 said she last assessed R1's wound on 8/21/2024 (13 days earlier) and noted her wound was deteriorating, but it did not have undermining. V15 said V10 (WCN) notified her on 8/31/2024 of R1's worsening coccyx wound. V15 said she reviewed R1's EMR on 9/03/2024 (during the survey) and based on R1's coccyx wound assessment, she would recommend the wound's undermining be packed with Medi honey and calcium alginate. V15 continued to say she expected R1's wound care to be completed as ordered and monitored per facility protocol. R1's Wound Assessment Details Report from 5/20/2024 showed R1 had an unstageable pressure ulcer to her coccyx, measuring 1 x 0.9 cm x unknown depth with 50% intact skin and 50% slough tissue. The report showed R1's Braden Score was 15- at risk for pressure injuries. R1's 8/7/2024 Wound Nurse Practitioner note showed pressure ulcer of coccygeal region, stage 3 frequently soiled with urine Measurements showed 5.5 x 2.5 x 0.2 cm with 25% intact skin, 40% slough 145246 Page 3 of 7 145246 09/03/2024 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tissue, and 35% bright beefy red tissue. Under Plan the note showed consider indwelling [urinary catheter]; continue bony prominence offloading . R1's 8/7/2024 Wound Assessment Details Report includes an 8/9/2024 narrative by V10 (Wound Nurse) under Current Plan & Comments that showed .frequent incontinence care provided. Family aware of current wound state. There is no mention in the note regarding any discussion with R1's family that references urinary catheter placement as a potential intervention to protect R1's wound and skin. R1's 8/14/2024 Wound Nurse Practitioner note showed pressure ulcer of coccygeal region, stage 3 frequently soiled with urine. Under the Problems list, the note showed [bowel/bladder (BB)] incontinencefrequent urinary incontinence, may need to consider [urinary catheter] to protect skin. The wound measurements showed 5.5 x 4.2 x 0.2 cm. Under Plan the note showed Consider indwelling [urinary] catheter; continue bony prominence offloading . R1's 8/14/2024 Wound Assessment Details Report includes a 8/17/2024 narrative by V10 under Current Plan & Comments that showed Family aware of current wound state. There is no mention in the note regarding any discussion with R1's family referencing urinary catheter placement. R1's 8/21/2024 Wound Nurse Practitioner note showed coccyx- measurements 5.8 x 5 x 0.2 8/21: decline in wound status with increased purple skin changes . The Problems list showed BB incontinence- frequent urinary incontinence, may need to consider [urinary catheter] to protect skin . Under Plan the note showed Consider indwelling [urinary] catheter .continue bony prominence offloading . In R1's 8/21/2024 Wound Assessment Details Report includes a narrative by V10 (Wound Nurse) dated 8/24/2024 under Current Plan & Comments, the note ends .Son [name] updated. There is no mention in the note regarding any discussion with R1's family referencing urinary catheter placement. On 9/3/2024 at 12:15 PM, V16 (R1's Son) stated he was not notified of recommendations for an indwelling urinary catheter or an arterial doppler test until the previous Saturday (8/31/2024). R1's Treatment Plan Recommendations (Historical) from 1:21 PM on 9/3/2024 (last day of the survey) showed a late entry by V10 (Wound Care Nurse) for 8/14/2024 (20 days earlier). The note showed On 8/14/24 after completing wound assessment and rounds with Wound NP, spoke with son [name] regarding NP recommendations. Recommendations included possible [urinary] catheter insertion to help reduce moisture to wound site. [Son] stated that he had to speak with his wife, but wasn't interested in pursuing that option at this time. A second late entry was written by V10 from 1:23 PM on 9/3/2024 (for 8/21/2024, 13 days earlier), which showed spoke with [Son] regarding new recommendation from Wound NP regarding arterial doppler for [left lower extremity] as well as the [urinary] catheter. [Son] stated at this time he was not interested but would speak with his wife. R1's 8/28/2024 Wound Assessment Details Report showed R1's now unstageable coccyx pressure ulcer measurements continued to decline, measuring 6.5 x 7 x unknown depth with 20% slough tissue and 50% bright beefy red tissue. The wound assessment did not show R1's wound had undermining or odor. R1's Order Summary Report dated 8/31/2024 showed orders to Cleanse coccyx wound with [normal saline solution], apply medical grade honey and calcium alginate cut to fit wound, apply house stock zinc to peri-wound skin, and cover with bordered foam dressing daily and PRN as needed, initiated on 8/15/2024. The report showed other orders for Order to culture sacral wound 8/29, initiated on 8/28/2024 and Daily skin check if moderate risk to high risk, based on Braden scale-perform daily skin check 145246 Page 4 of 7 145246 09/03/2024 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few if any skin issues are identified; please complete the SKIN ASSESSMENT FORM every night shift for Prevention, initiated on 5/18/2024. R1's TAR dated 8/31/2024 showed R1's scheduled coccyx treatment dressing changes were not signed off as completed on 8/10/2024, 8/16/2024, 8/19/2024, and 8/30/2024. On 9/1/2024 at 4 PM, V2 (Director of Nursing/DON) said she expected the nurses to perform wound care dressing changes as ordered and to document in the TAR (Treatment Administration Record). V2 said she expects wounds to be assessed during wound care and as needed to monitor for any change, including undermining. V2 said she expected nurses to notify the physician of wound changes to ensure proper wound care was ordered. The facility's 8/31/2024 Wound Prevention and Healing policy showed Policy Statement: To Provide wound care treatments/services (using a multidisciplinary approach) based on evidence-based standards of care under the direction of a physician. 2. Wound Assessment and Document Tool b. Goal will focus on the clinical status of the wound, guide the appropriate intervention for the wound .re-assess and alter the plan, monitor and evaluate overall client outcomes (progression or regression), and determine the effectiveness of treatment 7. Elimination of Dead Space- treatment for dead space maybe filled, though not overfilled to promote healing and prevent premature closure of wound . 8. Absorption of Exudate b. Consider more frequent dressing changes as indicated .9. Continued/Ongoing Treatment a. Nurse/therapist will provide wound care per physician orders and continue to implement and evaluate the plan of care based on the effectiveness of treatment. b. At each dressing change the wound will be assessed and documentation will be included a description of the wound bed, drainage, and undermining and tunneling if present .10. Wound Care and Treatments a.) Wound care treatments are provided with an individualized plan of care under the direction of a physician. b.) Wound care treatments will be based on the principles of moist wound healing . The facility's 1/20/2024 Physician Orders policy showed Intent: Facility has a process to ensure that all Physician Orders are documented appropriately. Policy: 1. Licensed Professional Nurses/Registered nurses will follow orders from physicians and document in a timely manner. 145246 Page 5 of 7 145246 09/03/2024 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to properly label and date intravenous fluid bag/tubing and timely administer physician ordered intravenous antibiotics as ordered for a resident (R1) with an infection. This applies to 1 of 3 residents (R1) reviewed for intravenous medications. Residents Affected - Few The findings include: R1's EMR (Electronic Medical Record) showed R1 had multiple diagnoses including an unstageable pressure ulcer to the sacrum and a left foot diabetic ulcer. R1's Order Summary Report dated 8/31/2024 showed an order Vancomycin 1gm every 24 hours Pharmacy to dose at bedtime for Elevated WBC (white blood cell) To start after PICC (peripherally inserted central catheter) line insertion, with a start date of 8/30/2024. R1's document titled Professional Nursing Services, document showed R1 had a right brachial midline inserted at 3:40 PM on 8/30/24 for antibiotic treatment. R1's MAR (Medication Administration Record) report dated 8/31/2024 showed R1's initial scheduled dose for 8/30/2024 at 9 PM was not administered. R1's lab result dated 8/28/2024 showed a white blood cell count of 13.41 H (elevated). On 8/31/2024 at 11:52 AM, R1 was in bed receiving an IV infusion through her right upper arm midline. R1's infusion bag manufacturing label said it contained 250 mL (milliliters) of 0.9% Sodium Chloride Injection USP. R1's IV infusion bag did not indicate that Vancomycin was contained in the IV fluid bag, and the IV tubing was not labeled or dated. V5 (Agency Licensed Practical Nurse/LPN) said V4 (Nursing supervisor) started R1's vancomycin antibiotic infusion in the morning. V4 said R1 was started on the IV antibiotic for an elevated white blood count level. At 12:55 PM, R1 was still receiving her IV infusion. V4 (Nursing Supervisor) said she prepared and started R1's vancomycin infusion in the morning. V4 said she forgot to label the infusion bag and tubing because she pulled the first dose from the facility's convenience box. V4 continued to say R1 had a midline inserted on 8/30/2024 for her IV therapy. On 8/31/2024 at 4:10 PM, V3 (Unit Manager) said R1 was noted with increased weakness and a general decline. V3 said she reviewed R1's labs and updated R1's physician on 8/30/2024. V3 said R1's physician ordered R1 to start on IV vancomycin antibiotics because of an elevated white blood count level. V3 said R1 should have been started on her antibiotic after her midline was inserted on 8/30/2024 as ordered. V3 said R1's midline was inserted at the facility at 3:30 PM on 8/30/2024 and was not sure why R1 was not started on her infusion on 8/30/2024 as ordered. On 8/31/2024 at 4:30 PM, V2 (Director of Nursing/DON) said she expected nurses to start residents on their order intravenous antibiotics as ordered. V2 said she also expects nurses to label and date intravenous infusion when being administered for medication safety. V2 said vancomycin IV was readily available for use in the facility's convenient box. V2 said R1 should have not been started on her antibiotic late. The facility's policy titled Physician Orders dated 1/20/2024 showed Intent: Facility has a process to ensure that all Physician Orders are documented appropriately. Policy: 1. Licensed Professional Nurses/Registered nurses will follow orders from physicians and document in a timely manner. The 145246 Page 6 of 7 145246 09/03/2024 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0760 Level of Harm - Minimal harm or potential for actual harm facility's policy titled Medication Administration dated 4/18/2024 showed Intent: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. The facility's policy titled Administration Set/Tubing Changes dated 9/1/2016 showed Procedure .11. Label administration set and tubing with date, time, and initials. Residents Affected - Few 145246 Page 7 of 7