Health inspection·February 16, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to provide perineal and catheter care in a manner that would prevent urinary tract infection (UTI). This applies to 2 of 3 residents (R45 and R203) reviewed for perineal and indwelling urinary catheter care in the sample of 21. The findings include: 1. R45 had indwelling urinary catheter. On February 14, 2024 at 1:22 PM, V20 and V21 (Both Certified Nursing Assistants/CNA) rendered incontinence care to R45 who had a bowel movement. V20 used wet wipes to clean R45 from front to back of the perineum. However, V20 did not separate the labia to clean the inner corners of the labia, the urethra, and the catheter tubing from the urethra down. 2. On February 14, 2024 at 2:16 PM, V21 (CNA) assisted R203 to use the bedside commode. R203 urinated and had a bowel movement. After R203 used the commode, V21 wiped R203 by reaching the resident's mid perineal area towards the back area. V21 then applied barrier cream and pulled the disposable brief without wiping/cleaning R203's frontal perineum. On February 15, 2024 at 5:06 PM, (Director of Nursing) stated she expects when staff provides peri-care, that staff should clean every part of the perineum. For a resident with urinary catheter, they should clean the urethra going outward towards the catheter. This process must be done to prevent UTI. The facility's policy and procedure regarding perineal care dated February 2018 showed, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. The same policy under procedure showed in-part, For female resident: . b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area). Page 1 of 9 145804 145804 02/16/2024 Oak Trace 250 Village Drive Downers Grove, IL 60516

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that the PICC (Peripherally Inserted Central Catheter) line insertion site was visible, so that it could be monitored for signs and symptoms of infection. This applies to 1 of 3 residents (R303) reviewed for intravenous therapy in the total sample of 21. Residents Affected - Few The findings include: On February 13, 2024 at 11:13am, R303 was in bed with PICC in left arm antecubital area. A two-inch square gauze pad covered where the catheter was inserted and the site could not be visualized. The dressing was labeled with the date 2/9/24 and was not signed. The facility record shows R303 was receiving intravenous antibiotic therapy. On February 14, 2024 at 1:05pm, R303 continued to have the PICC, and the dressing remained with the gauze pad folded under the clear occlusive dressing and dated 2/9/24. On February 15, 2024 at 10:56am, V3 (Director of Nurses) viewed the dressing on the PICC on the left arm of R303. V3 stated, I see, that is incorrect. V3 stated there should not be a gauze pad under the clear occlusive dressing. V3 also stated the dressing should be signed and said she believes she knew who did the dressing. On February 15, 2024 at 11:05am, V3 provided the facility policy titled, Midline Catheter Dressing Change, dated February 2018. V3 stated the Midline policy is applied to PICC dressings. The facility policy titled, Midline Catheter Dressing Change, dated February 2018, shows, Guidance: 2. When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed: 2.1 Upon admission 2.2 Every two days 2.3 If the integrity of the dressing has been compromised (wet, loose, or soiled). 3. Sterile gauze dressings must be occlusive and are changed: 3.1 Upon admission 3.2 Every two days 3.3 If the integrity of the dressing has been compromised (wet, loose, or soiled). 6. Assessment of the vascular access site is performed: 145804 Page 2 of 9 145804 02/16/2024 Oak Trace 250 Village Drive Downers Grove, IL 60516

F 0694 6.1 Upon admission and during dressing changes Level of Harm - Minimal harm or potential for actual harm 6.2 At least every 2 hours during continuous therapy 6.3 Before and after administration of the intermittent infusions Residents Affected - Few 6.4 At least once every shift when not in use 6.5 Routinely for signs and symptom of infusion related complications at a frequency based on patient condition, age, type of medication and rate of flow. 145804 Page 3 of 9 145804 02/16/2024 Oak Trace 250 Village Drive Downers Grove, IL 60516

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to follow physician's order for the administration of oxygen, and failed to ensure the oxygen nasal cannula tubing and humidifier bottle were labeled per policy and procedure. This applies to 1 of 1 resident (R153) reviewed for oxygen use in the sample of 21. Residents Affected - Few The findings include: R153 had multiple diagnoses including pulmonary fibrosis, acute respiratory failure with hypoxia and dependence on supplemental oxygen, based on the face sheet. On February 13, 2024 at 12:42 PM, R153 was in bed, alert and verbally responsive. R153 had ongoing oxygen at 5 (five) liters per minute via nasal cannula using an oxygen concentrator. R153 had no shortness of breath. The humidifier bottle attached to the oxygen concentration and the nasal cannula had no label to indicate when it was changed. On February 14, 2024 at 1:51 PM, R153 was in bed, alert and verbally responsive. R153 stated she was going to sleep. R153 had a breathing mask on while the BiPAP (Bi-level positive airway pressure) machine was connected to the oxygen concentrator at 3 (three) liters per minute was on going. The humidifier bottle and the oxygen tubing were attached to the oxygen concentrator had no label to indicate when it was changed. V6 (Registered Nurse) was inside R153's room and stated since the resident was taking a nap, V6 applied the BiPAP machine. V6 was asked at what level R153's oxygen should be set at, while the resident was on the BiPAP machine. V6 responded, 2 (two) liters per minute and then V6 proceeded to change R153's oxygen level to 2 (two) liters per minute. V6 was asked if the humidifier bottle and the oxygen tubing should be labeled and V6 responded, yes. R153's active medication report showed an active order dated February 6, 2024 for oxygen 2 (two) liters per minute via nasal cannula every shift. The same active medication report showed an order dated February 7, 2024 to use BiPAP machine at night with oxygen connector at 5 (five) liters for sleep apnea. On February 14, 2024 at 3:26 PM, V3 (Director of Nursing) stated the nurses should administer the oxygen via nasal cannula and/or via BiPAP machine as ordered by the physician because oxygen is like medication. V3 stated humidifier bottles and oxygen cannula/tubing's should be dated/labeled when changed, because the facility expects the nurses to change the oxygen cannula/tubing weekly every Wednesday. On February 14, 2024 at 3:30 PM, V3 and V6 confirmed R153 had an order for oxygen at 2 liters/minute when using a nasal cannula and oxygen at 5 liters/minute when using the BiPAP machine. R153's active care plan initiated on February 14, 2024 showed the resident uses oxygen and BiPAP machine due to chronic respiratory failure. The same care plan showed multiple interventions including administration of oxygen and BiPAP as ordered by the physician. The facility's policy and procedure regarding oxygen administration dated October 2010 showed, The purpose of this procedure is to provide guidelines for safe oxygen administration. The same policy showed, 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 145804 Page 4 of 9 145804 02/16/2024 Oak Trace 250 Village Drive Downers Grove, IL 60516

F 0695 Level of Harm - Minimal harm or potential for actual harm The facility's policy regarding respiratory care-oxygen use showed in-part, 1. Oxygen is administered under orders of the attending physician, except in the case of an emergency. 2. The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc. (et cetera)). The same policy under nursing responsibilities showed in-part, 1. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Date the tubing. Residents Affected - Few 145804 Page 5 of 9 145804 02/16/2024 Oak Trace 250 Village Drive Downers Grove, IL 60516

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide mechanical soft chili and pureed carrot cake for residents with modified diet consistencies. This applies to 8 of 8 residents (R13, R19, R30, R40, R42, R51, R66, R72) observed during dining in the sample of 21. The findings include: 1. On February 13, 2024 at 11:59 PM, during tray line service on the 4th floor, it was noted residents on Regular and Mechanical Soft diets received the same Chili. The Chili was noted to have whole red kidney beans and varying textures of ground meat. The Fall/Winter menu spreadsheet extension for Tuesday, Week 3 showed to serve ground chunky beef chili for mechanical soft diets. On February 13, 2024 at 12:20 PM, R66 was in the dining room with a diet card showed mechanical soft, nectar thick liquid. V10 (Dietary Assistant) who was in the area stated R66 should receive mechanical soft chili. R66 received regular consistency chili with sour cream along with mashed potatoes, creamed corn and nectar thick liquids. On February 13, 2024 at 12:28 PM, R30 was in the dining room with a diet card showed mechanical soft and R30 also received regular consistency chili with sour cream along with mashed potatoes, creamed corn. On February 13, 2024 at 12:34 PM, R13 received a room tray which included a bowl of regular consistency chili with sour cream. R13's diet card showed mechanical soft. V11 (R13's daughter) who was present in the room stated R13's food should be ground up as its hard for her to eat due to missing teeth. On February 13, 2024 at 12:36 PM, V9 (Cook) who was serving at the tray line in the unit pantry, stated she prepared the chili. V9 stated since the chili was prepared with ground beef was already ground, she was of the understanding it is already mechanical soft consistency. Facility recipe for Ground Chunky Beef Chili included as follows: Prepare per separate recipe. Set aside portions for ground texture. Place product inside robot coupe [blender] and pulse until desired consistency achieved (product resembles cooked Taco meat). Remove product from robot coupe and moisten with Broth . 2. On February 13, 2024 at 12:29 PM, R42 was in the dining room spoon fed by V12 (R42's Spouse). R42 was noted coughing profusely with his face turning red while he was fed pureed consistency dessert appeared to be a chocolate-colored pudding like mixture with uneven consistency. V12 stated, It's the consistency of the dessert triggered R42's coughing spell. V8 (Certified Dietary Manager) who was in the vicinity stated the dessert item was pureed carrot cake. V8 stated the same carrot cake was served to the regular consistency diet was pureed. When taste tested, the item had granular consistency with small pieces of unknown substance in it with a [NAME] flavor. V8 who also taste tested the same agreed to gritty texture and stated it must be the carrots was used to prepare the cake. R19, R40, R51 and R72 who were in the same dining room had diet cards showed pureed diet and was observed to receive the above granular consistency pureed carrot cake. 145804 Page 6 of 9 145804 02/16/2024 Oak Trace 250 Village Drive Downers Grove, IL 60516

F 0805 Level of Harm - Minimal harm or potential for actual harm Facility recipe for Cake Carrot no Icing from Mix (Plain Carrot Cake) included to mix cake mix and water as directed on the package; pour into prepared pans; and bake as directed. Facility recipe for Pureed Carrot Cake included blending ingredients of above prepared carrot cake, apple juice and thickener in a food processor until it develops a smooth mashed potato consistency. Residents Affected - Some Facility recipe for regular consistency Carrot Cake included yellow cake mix, carrots julienne shredded fresh, water, eggs, oil, raisins (dry), crushed pineapple, ground cinnamon and whole cloves. On February 14, 2024 at 11:02 AM, V13 (Cook) stated she pureed the carrot cake. V13 stated she had originally prepared a separate carrot cake for mechanical soft and pureed diets and placed it on a counter to be pureed and stepped away. V13 stated she is not sure if the carrot cake prepared by another cook for the regular diets had walnuts added to it, was also mixed in with the cake she had earlier set on the counter to be pureed. V13 then showed a sample of leftover cake stored in the freezer she had prepared for mechanical soft and pureed diets. When taste tested, the cake had raisins added to it. On February 14, 2024 at 11:40 AM, V7 (Dietitian) stated the recipe should be followed to attain the diet texture for mechanically altered consistencies for residents with chewing and swallowing difficulties as larger pieces of food can cause choking, aspiration, hospitalization and even death. V7 added raisins and nuts should be avoided for preparation for pureed consistency diets. Facility policy titled Modified Texture Foods (revised January 2024) included as follows: Policy: Provide a standardized process for modified texture foods to meet community approved diet guidelines and to assure palatability, flavor, texture and nutritional value. Procedure: Foods requiring modification to a puree texture will have a smooth texture. Facility Dietary Manual (Tenth Edition) showed desserts must be smooth, like custard or yogurt. No course or textured desserts. Facility Diet Type Report printed on February 13, 2024 showed R13, R30 and R66 were on mechanical soft diets and R19, R40, R42, R51 and R72 were on pureed diets. 145804 Page 7 of 9 145804 02/16/2024 Oak Trace 250 Village Drive Downers Grove, IL 60516

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during medication administration and provisions of peri-care. This applies to 4 of 5 residents (R16, R45, R60, R203) reviewed for infection control in the sample of 21. Residents Affected - Some The findings include: 1. On February 14, 2024 at 9:20 AM, V22 (Nurse) administered medications to R16 via gastrostomy tube (g-tube). V22 performed multiple tasks from medication preparation, to getting water from the bathroom faucet, to checking placement of g-tube, and administration of medication via g-tube while wearing the same gloves. After administration of the medications to R16, V22 removed her gloves and left the room without hand hygiene and proceeded to approach another resident (R45) to administer medications. 2. On February 14, 2024 at 9:35 AM, V22 (Nurse) administered medications to R45 via g-tube. V22 put on her gloves without hand hygiene. V22 did multiple tasks from medication preparation, to getting water from the bathroom faucet, to checking placement of g-tube, and administration of medication via g-tube while wearing the same gloves. After administration of the medications to R45, V22 removed her gloves and left the room without hand hygiene. On February 14, 2024 at 1:22 PM, V20 and V21 (Certified Nursing Assistants/CNA) rendered incontinence care to R45 who had a bowel movement. V20 used her right gloved hand to clean R45's rectum and buttocks. While wearing the same gloves, V20 opened the bedside drawer to get a clean disposable brief, then V20 returned the same brief back inside the drawer when V21 told her that a clean disposable brief was already prepared and set up for R45. With the same soiled right gloved hand, V20 proceeded to apply barrier cream to R45's rectum and buttocks. After V20 completed the incontinence care to R45, V20 removed and disposed her gloves and left the room without performing hand hygiene to attend to another resident. 3. On February 14, 2024 at 1:38 PM, V20 and V21 (Both CNA) rendered peri-care to R60. V20 cleaned R60's frontal perineum, while V21 cleaned the back perineum. V20 and V21, applied new disposable brief, straightened the beddings, and repositioned R60 while wearing the same soiled gloves. 4. On February 14, 2024 at 2:40 PM, V20 provided peri-care to R203 after the resident urinated and had a bowel movement. V20 cleaned R203's perineum with her right gloved hand and using this same gloved hand applied barrier cream to R203. V20 changed her gloves without performing hand hygiene and assisted R203 back to bed. On February 15, 2024 at 9:41 AM, V5 (Infection Control Nurse) stated if the nurse is passing medication, and/or staff is providing direct care to a resident, the staff is expected to follow standard precaution by performing hand hygiene before and after care, changing gloves and performing hand hygiene in between task, and performing hand hygiene in between residents. This is to prevent spread of infection and cross contamination. The facility's hand hygiene policy and procedure dated December 1, 2021 showed, Hand hygiene is the most effective measure for preventing infections. Hand hygiene includes several actions intended to decrease colonization with transient flora. This objective can be achieved through handwashing 145804 Page 8 of 9 145804 02/16/2024 Oak Trace 250 Village Drive Downers Grove, IL 60516

F 0880 Level of Harm - Minimal harm or potential for actual harm (20-seconds) or hand disinfection with alcohol-based hand rub. The policy showed that the CDC (Centers for Disease Control and Prevention) had recommended multiple indications to perform hand hygiene including, contact with a resident's intact skin, between visits to different residents, anytime you remove protective gloves or PPE (personal protective equipment), between performing different procedures on the same resident. The same policy showed, Wearing gloves does not replace the need for hand hygiene. Residents Affected - Some 145804 Page 9 of 9