Health inspection·October 18, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an indwelling catheter and provide catheter care for residents in a manner to prevent cross contamination for 2 of 3 residents (R1, R2) reviewed for catheters in the sample of 5. The findings include: 1. R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, hypertensive urgency, unsteadiness on feet, neuromuscular dysfunction of bladder, iron deficiency anemia, generalized anxiety disorder, hypertension, chronic congestive heart failure, and generalized osteoarthritis. R1's facility assessment dated [DATE] showed she has no cognitive impairment and has an indwelling catheter in place. R1's October 2024 Physician Order sheet showed, . suprapubic catheter: Change dressing around stoma daily . Suprapubic catheter: Record Urine output every shift . R1's care plan initiated 4/3/24 showed, [R1] is at risk for alteration of bowel and bladder functioning related to: indwelling catheter use . Interventions: . Catheter care every shift and as needed . Monitor urine/catheter output every shift . R1's September and October 2024 eMAR (electronic Medication Administration Record) and eTAR (electronic Treatment Administration Record) showed no documentation for catheter care being completed, no outputs recorded, no dressing changes around the suprapubic catheter stoma site, and no evidence of drainage bag changes. On 10/18/24 at 2:10 PM, R1 was transferred from her chair into her bed for incontinence care by V5 CNA (Certified Nursing Assistant) and V9 CNA. R1's catheter bag had very little urine collected in the bottom of the bag and a minimal amount of urine visualized in the catheter tubing. When R1 was positioned in bed to start incontinence care V5 removed R1's pants and noticed R1's catheter tubing was kinked just below the insertion site. V5 unkinked R1's tubing and urine began to flow into the catheter tubing and drainage bag. V5 said, Now we have lots of urine. When care was completed for R1, V9 checked R1's catheter drainage bag and reported there was 400 cc of urine in the bag (10 minutes after the kink in the tube was straightened). During incontinence care R1's bed linens had been pushed into a pile at the bottom of her bed. R1's urinary catheter bag was placed on top of the pile of linen during cares putting it above the level of R1's bladder and R1's catheter tubing was noted to Page 1 of 5 145816 145816 10/18/2024 Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047

F 0690 be filled solidly with urine from the drainage bag back up to the insertion site of the suprapubic catheter. Level of Harm - Minimal harm or potential for actual harm On 10/18/24 at 2:44 PM, V5 CNA said R1's tubing had been kinked before they started incontinence care. V5 said, There was barely any urine in the bottom of drainage bag but when we got the kink out the urine started draining really well. Residents Affected - Few R1's 10/14/24 General Progress Note entered at 8:32 AM showed, Patient alert and oriented x 3. Early this morning at 6AM during medication pass, patient appeared lethargic, though verbal. Refused morning medication . R1's 10/14/24 General Progress Note entered at 8:45 AM showed, Received in report that resident is confused (not usual mentation) this AM (morning) and c/o (complains of) generalized pain; went in to assess; alert to self (praying out loud) . supra pubic catheter draining cloudy yellow urine; resident is grabbing lower right abdomen/groin and complains of pain at this time . R1's 10/14/24 General Progress Note entered at 10:50 AM showed, . ambulance here to transport resident to hospital . R1's Acute Care Hospital documents showed R1 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. The same document showed, . Hospital Course: . admitted through the emergency room and was found to have a urinary tract infection and AKI (acute kidney injury) . On 10/18/24 at 9:35 AM, V7 (R1's Power of Attorney) said R1 and R2 share a room and both have catheters. V7 said over a period of time she often saw multiple catheter bags in their bathroom all unlabeled as to whose catheter bag it was and no way to know. V7 said she recently went into the bathroom and there was a catheter drainage bag that was full of urine hanging over the toilet. V7 said she has been relaying her concerns regarding the catheter bags to V8 (Guest Services) and he has said he was taking her concerns to V2 DON (Director of Nursing). V7 said she had not heard back from V2 regarding her concerns until this week. V7 said R2 (R1's roommate) put labels up in the bathroom to try and help the staff know they are placing the right catheter bag on the right resident. V7 said they started labeling the catheter bags recently because R1's catheter drainage bag was put onto R2's and R2's catheter drainage bag was put on R1. V7 said R1 just got back from the hospital 10/17/24 and that was the first time the DON spoke with her regarding her concerns with the catheters. V7 said both R1 and R2 have recently been hospitalized with urinary tract infections. On 10/18/24 at 1:42 PM, V8 (Guest Services Director) said he meets with residents and relays concerns to the appropriate department. V8 said V8 (R1's Power of Attorney) has brought photos to him of the catheter bags hanging in the bathroom and wanted to discuss with nursing. V8 said from his understanding this issue was resolved a couple of months ago. On 10/18/24 at 10:36 AM, R2 said she had concerns regarding how their catheters are handled. R2 said she put post it notes up in the bathroom trying to label which bag was hers and which bag would be her roommates. R2 said a few weeks ago she was in her bed and looked over at R1's catheter bag that was hanging from her bed frame and she saw her (R2's) name on the bag. R2 said she could very clearly see her own name. R2 said there is a specific CNA who has mixed the catheter bags up frequently over the last couple of months but also agency staff have mixed the bags up. R2 said the staff do not do catheter care unless she is incontinent of stool and it gets up around the insertion site. R2 said the only time her catheter is cleaned is during her showers. R2 said she has been bringing her 145816 Page 2 of 5 145816 10/18/2024 Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concerns regarding the catheter bags to many staff members for months. R2 said she did not know staff were supposed to cleaning her catheter until she was in the hospital and they told her. On 10/18/24 at 3:39 PM, V11 RN (Registered Nurse) said, staff should be monitoring residents with catheters to ensure there are no kinks in their tubing preventing the urine from draining properly. If the CNAs (Certified Nursing Assistant) notice the resident is not having their usual amount of urine draining they would check themselves and see if their tubing is kinked. When catheter tubing is kinked the urine would back up into the bladder and could cause an infection. The resident's absolutely cannot share catheter drainage bags because of cross contamination. The drainage bag needs to be maintained below the level of the bladder to drain properly. I would say they should hook the drainage back on the bed frame while they are providing care to make sure it is below their bladder. On 10/18/24 at 3:10 PM, V2 DON (Director of Nursing) said she was not made of aware of concerns regarding R1 and R2's catheter bags until 10/17/24. V2 said she spoke with V8 (R1's Power of Attorney) and R2 regarding the concerns and said R2 told her it was one time that they almost put on her roommates catheter bag but she stopped the CNA before she did it. V2 said catheter care should be documented on the resident's eTAR along with outputs. V2 said catheter care should be done with all incontinence care and at least per shift. V2 said dressing changes for suprapubic catheters should be done as ordered and documented on the eTAR. V2 said the facility's protocol for changing catheter drainage bags would be as needed but usually every week or month. V2 said there should be an area on the resident's eTAR to document catheter drainage bag changes. V2 said applying another resident's catheter drainage bag to a resident would be an issue for cross contamination. V2 said if a resident had a physician order for catheter changes it would appear on the resident's eTAR. The facility's policy and procedure revised 8/19/24 showed, Urinary Catheter Care . Purpose: The purpose of this procedure is to prevent catheter associated urinary tract infections . General Guidelines: . Observe the resident's urine level for noticeable increased or decreases . Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks . the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. 2. R2's face sheet showed she was admitted to the facility 3/13/24 with diagnoses to include bilateral primary osteoarthritis of hip, anxiety disorder, obstructive reflux uropathy, hypertension, permanent atrial fibrillation, and congestive heart failure. R2's facility assessment dated [DATE] showed she has no cognitive impairment and has an indwelling catheter in place. R2's care plan initiated 9/2/24 showed, [R2] is at risk for alteration of bowel and bladder functioning related to . catheter use Foley catheter in place . Interventions: Catheter care every shift and as needed . R2's October 2024 Physician Order Sheet showed, . Change Foley catheter every 30 days or PRN (as needed) . R2's September and October 2024 eMAR and eTAR showed no evidence of catheter care and showed no upcoming catheter changes scheduled to reflect the order for catheter changes every 30 days. R2's 10/6/24 note entered at 6:12 PM showed, Writer called to follow up resident status at [acute 145816 Page 3 of 5 145816 10/18/2024 Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care hospital]. The resident has been admitted for fever/altered mental status/UTI (Urinary Tract Infection) as per ED (emergency department) nurse. R2's acute care hospital documents showed she was admitted to the hospital on [DATE] and returned to the facility on [DATE]. The same documents showed, . Hospital Course: . admitted through the emergency room for urinary tract infection and electrolyte imbalance . Her Foley catheter was changed and urine became clear as compared to when it was very dark and cloudy when she came in . 145816 Page 4 of 5 145816 10/18/2024 Avantara Lake Zurich 900 South Rand Road Lake Zurich, IL 60047

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure supervision of a resident while taking medications for 1 of 1 resident (R1) reviewed for medication administration. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, hypertensive urgency, unsteadiness on feet, neuromuscular dysfunction of bladder, iron deficiency anemia, generalized anxiety disorder, hypertension, chronic congestive heart failure, and generalized osteoarthritis. R1's facility assessment dated [DATE] showed she has no cognitive impairment. On 10/18/24 at 10:15 AM, R1 was sitting in her recliner in her room visiting with her niece and a friend. There were several pills scattered on the floor in front of R1's chair and under her bed. R1's breakfast tray was on the bedside table in front of her. R1 said when the nurse brought her medications in earlier she did not have any water to take them so she waited until her breakfast tray was delivered to take them. R1 said her hands are not working very well because she just got back the day before (10/17/24) and has been very shaky. R1 said when she tried to take her medications she accidentally knocked the cup of medications over and they fell on the floor. On 10/18/24 at 10:20 AM, V4 RN (Registered Nurse) said R1 usually does okay with taking her pills but today she was shaky so she should have stayed with her. On 10/18/24 at 3:39 PM, V11 RN said it is not acceptable to leave medications at a resident's bedside for safety reasons. V11 said she stays while the resident takes their medications to ensure they take them. On 10/18/24 at 3:10 PM, V2 DON (Director of Nursing) said R1 is not a resident who can take her medications independently. V2 said if a resident is able to take their medications independently they are assessed specifically for that and R1 would not be able to. V2 said nursing stays with the residents as they take their medications to ensure they are taking them. The facility's policy and procedure revised 8/16/24 showed, Medication Pass . It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures . 145816 Page 5 of 5