Health inspection·August 1, 2024

F 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a staff member was skilled to change an indwelling pleural catheter dressing appropriately for a resident with respiratory conditions. This applies to 1 out of 4 residents (R2) reviewed for nursing care services. Residents Affected - Few The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE] with multiple diagnoses including toxic encephalopathy, acute respiratory failure, pleural effusions, pneumothorax, chronic obstructive pulmonary disease, atrial fibrillation, bradycardia, anemia, pulmonary hypertension, ascites, and congestive heart failure. R2's EMR showed R2 was to be receiving indwelling pleural catheter for the management of his pleural effusions (excess fluid accumulation) in his lungs and shortness of breath related to his chronic respiratory conditions. On 8/01/2024 at 8:35 AM, V6 (Wound Care Registered Nurse/WC RN) said on 7/25/2024 at 10:30 AM during R2's wound care he was observed agitated and having difficulty breathing. V6 said V8 (Wound Care Nurse Practitioner/WC NP) alerted her to assess R2's indwelling pleural catheter dressing. V6 said underneath R2's indwelling pleural catheter transparent dressing the catheter was visible, and the tip was not capped. V6 said there was fluid observed at the end of the open catheter tip. V6 said she alerted V5 (RN) to assess R2 and of his noted uncapped indwelling pleural catheter. On 8/01/2024 at 8:45 AM, V8 (WC NP) said on 7/25/2024 during R2's wound care he noticed R2's Indwelling pleural catheter was not capped. V8 said R2 was then observed with difficulty breathing. On 7/31/2024 at 4 PM, V5 (RN) said on 7/25/2024 V6 (WC RN) alerted her that R2's indwelling pleural catheter drainage catheter was observed not capped. V5 said she last changed R2's Indwelling pleural catheter dressing on 7/23/2024. On 8/01/2024 at 10:10 AM, V2 (Director of Nursing) said nurses were expected to change indwelling pleural catheter dressings in a sterile manner and cap the tip of the catheter to prevent infections. V2 said nurses not trained or not competent in the use of indwelling pleural catheter drains should not perform the task. BD manufacture document titled Drainage Instructions for (Indwelling pleural catheter) Systems showed Final steps and disposal .12. Clean around the valve opening with second alcohol pad. 13. Place new cap on catheter valve and twist it until it clicks into its locked position .15. Place foam catheter pad around catheter and wind catheter on top of pad. Cover catheter with gauze pads . Page 1 of 3 145473 145473 08/01/2024 Pearl of Orchard Valley 2330 West Galena Boulevard Aurora, IL 60506

F 0659 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's policy titled (Indwelling pleural catheter) Drainage and Dressing Procedure dated 6/26/2024 showed Purpose: To ease discomfort and minimize signs and symptoms related to malignant ascites and pleural effusion .3.k. Place the cap over the catheter valve and twist clockwise until snaps into locked position .Reportable conditions: .Potential complications of abdominal drainage include infection. The facility's document titled Nurse Supervisor RN/LPN Job Description undated showed Essential Job Functions .Wears and/or uses safety equipment and supplies when indicated and properly trained to use 145473 Page 2 of 3 145473 08/01/2024 Pearl of Orchard Valley 2330 West Galena Boulevard Aurora, IL 60506

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document the assessment of a resident (R2) who had a change in condition and required a transfer to the hospital for abnormal vital signs. This applies to 1 out of 4 residents (R2) reviewed for nursing care services. Residents Affected - Few The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE] with multiple diagnoses including toxic encephalopathy, acute respiratory failure, pleural effusions, pneumothorax, chronic obstructive pulmonary disease, atrial fibrillation, bradycardia, anemia, pulmonary hypertension, ascites, and congestive heart failure. R2's EMR continued to show R2 was transferred to the hospital on 7/25/2024 for abnormal vital signs. On 8/01/2024 at 8:35 AM, V6 (Wound Care Registered Nurse/WC RN) said on 7/25/2024 at 10:30 AM during wound care R2 was observed agitated and having difficulty breathing. V6 said she alerted V5 (RN) to assess R2. V6 said R2's vital signs were unstable, his blood pressure was 56/46 mmHg (millimeters of mercury), his heart rate was 33 bpm (beats per minute), and his oxygen saturation was 77% (percent). V6 said R2 was placed on 4 L (liters) of oxygen via nasal cannula and his oxygen saturation improved to 99%. V6 said R2 was transported to the hospital by the emergency paramedics. V6 said she assumed V5 documented R2's change in condition assessment in R2's EMR. On 7/31/2024 at 4:00 PM, V5 (RN) said she was assigned to R2 on 7/25/2024. V5 said V6 alerted her to R2's change in condition and then subsequently the emergency paramedics arrived to transfer R2 to the hospital. V5 said R2 had chronic bradycardia (low heart rate) and was unsure why the emergency paramedics were called. V5 said she assumed V6 documented R2's change in condition assessment in R2's EMR. On 8/01/2024 at 10:10 AM, V2 (Director of Nursing) said V2 nurses were expected to document residents' assessment findings when there was a change in condition in the residents' EMR. R2's comprehensive care plan was reviewed on 8/01/2024 showed Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities (pulse rapid, respirations shallow, rapid or labored, blood pressure low. R2's SNF/NF to Hospital Transfer form dated 7/25/2024 at 10:45 AM showed R2's reason for transfer was bradycardia. The form did not show R2's change in condition of abnormal vital signs, the last vital signs recorded were R2's blood pressure of 113/41 mmHg, heart rate of 84 bpm, and oxygen saturation of 94% on 3 L of oxygen from 7/25/2024 at 8 AM. The facility's policy titled Resident Change in Condition dated 9/01/2023 showed Policy Statement: Our facility will ensure and provide appropriate services and treatment to the extent possible when a change in condition occurs. Guidelines .3. When there is a change in condition, or any accident/incident identified and observed, the nurse will perform an assessment, provide immediate nursing interventions, continue to monitor .6. The nurse will record in the resident's medical record information relative to change in the resident's medical/mental condition or status. 145473 Page 3 of 3