Health inspection·July 8, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide supervision and safe eating interventions for residents with swallowing and eating disorders. This applies to 2 of 4 residents (R1, R2) reviewed for weight loss and nutrition. Findings include: 1. R1 is an [AGE] year-old male readmitted to the facility on [DATE], with the following diagnosis: anorexia, repeated falls, hernia, dysphagia, hypertension, and anxiety. R1's POS (physician order sheet) documents mechanical soft diet with thin liquids with upright position during and 30 minutes after meals with supervision. Small/single bites, single sips, alternating food, and liquids with double swallow. R1's speech therapy evaluation and plan of treatment dated July 2, 2024, documents as part of R1's treatment plan, upright position during and 30min (30 minutes) after meals, small/single bites, single sips, alt food/liquids double swallow. R1's assessment showed prolonged mastication and pocketing of food. R1 was observed on July 5, 2024, at 12:12PM in the second-floor dining room. R1 was observed with his plate of food and 1 cup of fruit drink. R1 was feeding himself spoonsful of food without staff supervision. V5 (Certified Nursing Assistant/CNA) and V7 (CNA) were not prompting or supervising R1. V7 was cleaning up the spilled fruit drink from R1 and V5 was on the other side of the room. V3 (Registered Nurse/RN) was not in the dining room at that time. R1 did not have his communication board at this time and none of the staff on duty were able to communicate with R1 regarding his eating. V5, V7 and V3 were interviewed and were not aware of the interventions for R1. V5 was unable to locate R1's communication board. On July 5, 2024 at 1:15PM V2 (Director of Nursing/DON) stated that she confirmed the orders for R1 and he required supervision and the special eating plan. 2. R2 is a [AGE] year-old female with the following diagnosis: protein calorie malnutrition, anxiety, hypertension, and psychotic disorder with delusions. R2 has an order for general puree diet, (nutritional supplement drink) and (nutritional supplement dessert) with lunch and dinner. R2 is underweight at 104 pounds. R2 has a care plan focus dated October 16, 2023, that documents R2 has a chewing problem related to dysphagia and malnutrition. R2 also has listed as a care plan intervention to, eat in an upright position, to eat slowly and chew each bite thoroughly. R2 was observed in the second-floor dining room on July 5, 2024 at 12:23PM. R2 was scooping her food with her fingers and consuming food rapidly until all food items were consumed. V5 and V7 (CNAs) did not prompt R2 to slow down with her eating nor did they prompt R2 to swallow between meals. V7 stated that, she always eats Page 1 of 3 145473 145473 07/08/2024 Pearl of Orchard Valley 2330 West Galena Boulevard Aurora, IL 60506

F 0689 this way. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145473 Page 2 of 3 145473 07/08/2024 Pearl of Orchard Valley 2330 West Galena Boulevard Aurora, IL 60506

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide nutritional supplements as ordered for residents with weight loss and nutritional needs. This applies to 2 of 4 residents (R2, R8) reviewed for nutrition and weight loss. Findings include: 1. R2 is a [AGE] year-old female with the following diagnosis: protein calorie malnutrition, anxiety, hypertension, and psychotic disorder with delusions. R2 has an order for general puree diet, (nutritional supplement drink) and (nutritional supplement dessert) with lunch and dinner. R2 is underweight at 104 pounds. R2 has a care plan focus dated October 16, 2023, that documents R2 has a chewing problem related to dysphagia and malnutrition. R2 also has listed as a care plan intervention to, eat in an upright position, to eat slowly and chew each bite thoroughly. R2 was observed in the second-floor dining room on July 5, 2024 at 12:23PM. R2 was scooping her food with her fingers and consuming food rapidly. V5 and V7 (Certified Nursing Assistant/CNA) did not prompt R2 to slow down with her eating nor did they prompt R2 to swallow between meals. V7 stated that, she always eats this way. R2's meal tray did not contain the (nutritional supplement dessert) as ordered. 2. R8 was observed on July 5, 2024 at 12:30PM being fed by V6 (CNA). R8's tray did not contain the (nutritional supplement dessert). R8's diet order per the POS (Physician Order Sheet) is puree, nectar thick liquids and (nutritional supplement dessert) at lunch and dinner. R8's diagnosis include protein calorie malnutrition, dysphagia, and hypertension. V6 was not aware of the order for the (nutritional supplement dessert). V9 (Dietary Director) stated during interview of July 5, 2024 that the (nutritional supplement dessert) is kept on the unit refrigerators and added to the tray by nursing staff. The (nutritional supplement dessert) provided by the facility provides 9 grams of protein and 250 calories. 145473 Page 3 of 3