Health inspection·August 24, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review the facility failed to treat a resident with respect and dignity, affecting one of twenty residents (R40) reviewed for dignity in the sample of twenty. Residents Affected - Few The finding include: R40's Minimum Data Set, dated , July 1, 2022, shows, Brief Interview for Mental Status 15/15-Cognitively Intact. On 08/22/22 at 10:06 AM, R40 said, I asked V8 CNA-Certified Nursing Assistant to help me get out of bed. She became very irritated. She took my clothing out of the closet and threw them on my bed. She told me I was a racist; She said I was entitled. On 08/24/22 at 10:28 AM, R40 said, V8 CNA called me a racist. I asked her to help me get up. I reported it to the nurse on duty when it happened. I do not remember the date or the nurse that was working that day. I told the nurse when it happened. R40 said, when V8 CNA called me a racist and was speaking to me rudely I was bewildered. I had never treated her poorly. It was like she was having a bad day and decided to take it out on me. The way V8 CNA acted when calling me a racist made me feel bad. On 08/24/22 at 11:51 AM, V3 ADON-Assistant Director of Nursing said, V19 CEO-Chief Executive Officer was the abuse coordinator at the time, he did the investigation. V3 said, V8 CNA was R40's Primary Care Giver at the time of the incident. I attempted to contact V8 CNA today for an interview. I have not been able to reach her. On 08/24/22 at 12:00 PM, V19 CEO-Chief Executive Officer said, I spoke with R40. I also spoke with other residents in the area. I have to look at my notes to see if I interviewed any staff. No staff or resident interviews or other information was provided by V19 prior to exiting the facility. R40's Incident Report initiated 03/11/22 shows, a staff member came into her room, was very quick with her, didn't like answering questions, and seemed like she was in a rush to leave. The 3/11/22 Incident Report shows, no Certified Nursing Assistants were interviewed regarding the incident. Page 1 of 11 145840 145840 08/24/2022 Tabor Hills Health Care Fac 1347 Crystal Court Naperville, IL 60563

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review the facility failed to verify a resident's code status upon admission to ensure residents wishes were followed for 1 of 20 (R331) reviewed for advance directives in the sample of 12. The findings include: R331's admission Record dated 8/23/2022 shows an admission date of 8/15/2022. R331's admission Record dated 8/23/2022 does not have a code status listed under advance directives. R331's Order Summery Report as of 8/23/2022 does not have a code status order in place. On 8/24/2022 at 9:49, V3 Assistant Director of Nursing said the resident's code status should be addressed upon admission and their wishes should be entered in the computer charting system. V3 said the residents code status should match in all places. V3 said the resident's code status is found in the physician orders. 145840 Page 2 of 11 145840 08/24/2022 Tabor Hills Health Care Fac 1347 Crystal Court Naperville, IL 60563

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 ensure staff provided perineal cleansing in a manner to prevent infections for a resident with a history of urinary tract infections. This applies to 1 of 4 residents (R60) reviewed for bladder services in the sample of 20. The findings include: R60's Physician Order Sheets dated through August 2022 shows she is an [AGE] year old female with diagnoses including history of urinary tract infections, dementia and acute cystitis. R60's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, requires extensive assist for toileting and frequently incontinent. On 8/22/22 at 1:19 PM, V8 (CNA) transferred R60 from the wheelchair to the toilet using the mechanical stand lift and removed her soiled incontinent brief. V8 cleansed R60's perineal area from front to back and continued to use the same contaminated area of the wipe to cleanse her. V8 did not use a clean area of the wipe with each swipe. On 8/22/22 at 12:15 PM, V9 (Agency CNA) said perineal cleansing should be from front to back and use a clean area of the wipe with each swipe to prevent infections. The facility's Perineal Skin Care Policy undated policy states, Proper perineal care is essential to protect the perineal skin from damage caused by contact with urine and stool .females: separate the labia, clean front to back using downward strokes. Use a clean area of the cloth with each downward motion . 145840 Page 3 of 11 145840 08/24/2022 Tabor Hills Health Care Fac 1347 Crystal Court Naperville, IL 60563

F 0692 Provide enough food/fluids to maintain a resident's health. 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 meal intakes were monitored and ordered interventions were followed through for a resident with significant weight loss, failed to initiate dietary recommendations for a resident with significant weight loss and failed to provide dietary supplements for residents with weight loss. This applies to 4 of 15 residents (R20, R21, R12, R26) reviewed for weight loss in the sample of 20. Residents Affected - Some The findings include: 1. R20's Physician Order Sheets (P.O.S.) dated through August 2022 shows she is a [AGE] year old female with diagnoses including esophgeal stricture, irritable bowel syndrome, cerebral infarct, dysphagia following cerebral infarct, encounter for attention for gastrostomy, hemiplegia and hemiparesis following cerebral infarct, and anxiety. The P.O.S. shows orders to give enteral feeding Jevity 1.5 if 50 % or less of meal consumed and hold if 50 % or more of meal consumed. R20's meal intake report from August 1, 2022 to August 23, 2022 shows 27 out of 69 meals she consumed less than 50%. R20's Medication Administration Record for August 2022 shows she did not receive her enteral feeding of Jevity 1.5 23 of 27 times based on her meal consumption less than 50 %. The M.A.R. shows 15 of 22 entries of (2) indicating refusals. R20's dietary note dated 7/7/22 documents her weight continues to decline despite fair intake and supplemental enteral nutrition and recommends to add a 240 ml bolus at night. R20's weight report dated 8/23/22 5/17/22- 167 lb (pounds) 6/13/22- 156.6 lb 7/12/22- 153 lb 8/9/22- 150.8 lb (10 % weight loss in three months). On 8/23/22 at 12:13 PM, R20 was in her room during the noon meal feeding her self. She said she had some nausea in the morning, but was feeling better. On 8/23/22 at 12:20 PM, V7 (CNA) said R20 is alert but forgetful and her appetite is good someday's and other days bad. V7 said R20 complains of nausea at times. On 8/23/22 at 1:11 PM, V5 (Dietitian) said R20 should be receiving enteral feedings of Jevity 1.5 if she consumes less than 50 % of her meals and she added an additional bolus feeding at night due to weight loss. V5 said she does not know why she is losing weight if she is eating and receiving the enternal feedings as ordered. It could be an administration issue (staff not providing the feeding). V5 said R20 is cooperative and not aware of her refusing any feedings. 145840 Page 4 of 11 145840 08/24/2022 Tabor Hills Health Care Fac 1347 Crystal Court Naperville, IL 60563

F 0692 Level of Harm - Minimal harm or potential for actual harm On 8/24/22 at 9:24 AM, V6 (LPN) said R20 is alert, forgetful and can answer questions. V6 said staff should administer her enternal feeding (Jevity) if she consumes less than 50 % of her meal. V6 said R20 is cooperative with cares and has no refusals of her feedings. On 08/24/22 at 9:27 AM, R20 said she does not refuse her enteral feedings. Residents Affected - Some 2. R21's Weights and Vitals Summary printed on 8/23/22 shows R21's weight on 7/5/22 was 150.4 pounds and R21's weight on 6/7/22 was 162.6 pounds (7.5% loss in 1 month). R21's weight on 8/23/22 was 146.4 pounds. R21's Dietitian Notes dated 7/7/22 shows that she recommended super cereal and yogurt with breakfast, pudding with lunch and a magic cup daily due to her significant weight loss. R21's Physician's Order Sheet (POS) printed on 8/25/22 does not show the above recommendations were ordered. On 8/23/22 at 1:11 PM, V5 (Registered Dietitian) said that she saw R21 on 7/7/22 due to a significant weight loss. V5 said that she recommended super cereal and yogurt with breakfast, pudding with lunch and a magic cup daily. V5 said that she emails the recommendations to the Director of Nursing and the Assistant Director of Nursing so they can get an order from the physician. V5 said that she emailed the recommendations on 7/7/22. V5 said that it must have gotten missed. 3. R12's POS printed on 8/24/22 shows that she is on nectar thick liquids and has an order for, Med Pass 2.0-Give 80 cc (cubic centimeter) after meals and at bedtime for weight loss supplement. R12's Weights and Vitals Summary printed on 8/24/22 shows that her weight was 126.4 pounds on 8/9/22 and 136.8 pounds on 5/1/22 (7.6% weight loss in 3 months). On 8/23/22 at 9:04 AM during morning medication pass, R12 did not receive Med Pass 2.0 (nutritional supplement) as ordered. On 8/23/22 at 9:04 AM, V14, Registered Nurse (RN) said that Med Pass was recalled about a week ago and they do not have anything to replace it with. On 8/23/22 at 1:11 PM, V5 (Registered Dietitian) said that the facility contacted her regarding Med Pass not being available. V5 said that she worked with them to find an alternative. V5 said that she recommended Resource (nutritional supplement) for residents on non-thickened liquids and to use a Magic Cup (frozen nutritional supplement) in place of Med Pass for residents on thickened liquids. On 8/23/22 at 1:50 PM, V2 (Director of Nursing) said that they have been out of Med Pass 2.0 since the recall on 8/10/22. V2 said that they reached out to V5 for recommendations and she said that Resource would be an alternative to order but while waiting to get it, residents on a non-thickened liquid diet should get an Ensure (nutritional drink) daily. V2 said that she did not give any recommendations for residents on a thickened liquid diet. On 8/24/22 at 10:35 AM, V11 (RN) said that she was told that Med Pass has been recalled and not to use it. V11 said that she was not directed to give anything else to replace the supplements that the residents were not receiving. 145840 Page 5 of 11 145840 08/24/2022 Tabor Hills Health Care Fac 1347 Crystal Court Naperville, IL 60563

F 0692 Level of Harm - Minimal harm or potential for actual harm 4. On 8/22/22 at 12:10 PM, R26 was in the dining room eating lunch. R26 ate 25% of her meal. On 8/23/22 at 12:12 PM, R26 was in the dining room eating lunch. R26 ate 25% of her meal. R26's POS printed on 8/24/22 shows an order dated 1/27/20 for magic cup twice a day for supplement post breakfast and dinner. Residents Affected - Some R26's August Medication Administration Record does not have an order for magic cup listed. On 8/23/22 at 1:55 PM, V14 (Registered Nurse) said that when a magic cup is ordered, it will show on the EMAR (Electronic Medication Administration Record) to be given. V14 viewed R26's EMAR and said that a magic cup was not on the EMAR so it would not be given. On 8/23/22 at 1:50 PM, V3 (Assistant Director of Nursing) said that R26's magic cup was ordered wrong in the system so it will not show up on the EMAR to be given. The facility's Weights: Establishing, Monitoring, and Maintaining Policy dated 1/2019 shows, All significant weight loss and gain (5% in 1 month, 7.5% in 3 months, or 10% in 6 months) are: Reported to the attending physician/nurse practitioner for appropriate orders and interventions. The nurse will document the significant weight change, the notification and interventions in the resident's clinical record. Registered Dietitian will complete a nutritional assessment. The resident's Care Plan will be reviewed and/or updated. The facility's Dietary Supplements Policy dated 4/5/2006 shows, Dietary Supplements are ordered by physician. Residents are regularly assessed by clinical dietitian, dietary manager or physician if and when supplements are needed .Need for supplements is based on weight loss (5%-one month, 7%-3 months, 10%-6 months) Pharmacy lists supplements on Medication Administration Record (MAR). 145840 Page 6 of 11 145840 08/24/2022 Tabor Hills Health Care Fac 1347 Crystal Court Naperville, IL 60563

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 ensure oxygen was applied by a licensed professional as ordered and failed to ensure oxygen tubing was changed as ordered for 5 of 8 residents (R12, R21, R26, R50 and R78) reviewed for respiratory care in the sample of 20. Residents Affected - Some The findings include: 1. R21's Care Plan for oxygen shows, I am currently on O2 at 3L/NC Administer my O2 as MD ordered. The position for the intervention says registered nurse or licensed practical nurse. On 8/22/22 at 12:45 PM, V13, Certified Nursing Assistant (CNA) turned off R21's portable oxygen tank to transfer her to bed for care. R21 was provided care and transferred back to her chair. V13 turned the portable oxygen dial to 2 liters and applied the oxygen to R21. On 8/23/22 at 12:14 PM, V14, Registered Nurse (RN) said that CNA's can adjust the oxygen tubing but they should not be turning on the portable tanks and adjusting the liters of oxygen administered. V14 said that the orders should be checked and followed any time oxygen is administered. The facility's Oxygen Therapy Policy revised 8/2015 does not indicated what staff members are allowed to administer oxygen. 2. R26's POS printed on 8/24/22 shows an order dated 8/28/20 for, Change nasal cannula/mask/tubing/humidifier weekly on Sat. (Saturday) on 11-7 shift-date tubing. On 8/23/22 at 9:10 AM, R26 was wearing oxygen administered by a portable oxygen tank. R26's oxygen tubing for her portable oxygen tank was dated 8/7/22. R26's Oxygen Care Plan shows, Change my nasal cannula, tubing, and humidifier bottle q (every) weekly and PRN (As Needed). 3. On 8/23/22 at 9:10 AM, R12 was wearing oxygen provided by an oxygen concentrator in her room. R12's oxygen tubing was dated 8/14/22. 4. R50's POS printed on 8/24/22 shows an order dated 7/13/21 for, Change mask/cannula/tubing every week on 11-7 shift. On 8/23/22 at 12:47 PM, R50 was wearing oxygen administered by a portable oxygen tank. R50's oxygen tubing for her portable oxygen tank was dated 8/14/22. On 8/23/22 at 12:14 PM, V14 (RN) said that oxygen tubing is changed weekly by the night shift nurses. The facility's Oxygen Therapy Policy revised 8/2015 shows, Oxygen cannula or mask, tubing and humidifier is changed weekly by 11-7 shift staff Regulate flow meter as ordered 5. On 8/22/2022 at 10:20AM, R78 was observed with a nasal cannula in place in her room. On 8/23/2022 at 10:14AM, R78's oxygen tubing was dated 8/6/2022. 145840 Page 7 of 11 145840 08/24/2022 Tabor Hills Health Care Fac 1347 Crystal Court Naperville, IL 60563

F 0695 On 8/24/2022 at 10:40AM, V11 Registered Nurse said oxygen tubing is changed once a week. Level of Harm - Minimal harm or potential for actual harm On 8/24/2022 at 10:40AM, V3 Assistant Director of Nursing said oxygen tubing is to be changed weekly on nights. Residents Affected - Some The facility's Oxygen Therapy policy, revised on 8/15, states .Oxygen cannula or mask, tubing and humidifier is changed weekly by 11-7 shift staff. 145840 Page 8 of 11 145840 08/24/2022 Tabor Hills Health Care Fac 1347 Crystal Court Naperville, IL 60563

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure the kitchen food storage was free of pests which applies to all 81 residents reviewed for sanitary food storage. Residents Affected - Many The findings include: The CMS-672 dated 8/22/22 showed a census of 81 residents. On 8/22/22 at 10:00 AM, upon entering the kitchen's dry storage area, a swarm of flying insects were concentrated on and around the bread and bread cart in the middle of the storage room. Across the storage room there was a smaller swarm of flying insects centralized around bananas stored on a shelf. On 8/22/22 at 10:15 AM, V17 Dietary Manager and V20 Maintenance/Housekeeping Manager (while on kitchen tour) stated the facility has had problems with drain flies for about 2 months. We have had pest control in, but I am not sure what they have done in the storage area. On 8/23/22 at 9:15 AM, flying insects were in and around the bread cart. The food storage room has no drains, bug zappers lights, or other types of insect pest controls (fly traps) devices in it. On 8/23/22 at 10:10 AM, V21 Pest Control Representative verified the treatments listed on the work invoice dated 7/25/22 were focused on floor drains, sinks, and equipment in the kitchen. V21 stated he was not asked to check or provide any treatments to the food storage area. 145840 Page 9 of 11 145840 08/24/2022 Tabor Hills Health Care Fac 1347 Crystal Court Naperville, IL 60563

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 8/22/22 at 9:58 AM, V7 (CNA) provided perineal care to R14. With the same gloves on, V7 pulled R14's pants up, assisted with the transfer back the wheelchair, took the sit to stand lift sling off from around R14, touched the lift and touched R14's wheelchair. Residents Affected - Few On 8/23/22 at 12:29 PM, V13 (CNA) said that gloves should be removed, and hands sanitized right after providing perineal care and before touching any clean surfaces to prevent the spread of germs. The facility's Hand Hygiene Policy dated 11/2018 shows, Proper hand hygiene techniques are used for the prevention of transmission or infectious diseases. [Facility] follows the World Health Organization's Five Moments of Hand Hygiene model After body fluid exposure risk Hand hygiene must be performed any time a staff member moves from a dirty site to a clean site . Based on observation, interview, and record review the facility failed to ensure a resident on contact/droplet isolation remained in the room, and failed to perform hand hygiene and glove exchange during peri care to prevent cross contamination. This applies to 3 of 20 residents (R331, R78, R14) reviewed for infection control in the sample of 20. The findings include: 1. R331's admission Record shows R331 being admitted to the facility on [DATE]. On 8/22/2022 at 12:15AM, R331 was observed in the communal dining room with her mask off sitting at a table waiting for lunch to be served. There were other residents sitting in the same communal dining room as R331. On 8/22/2022 at 1:29PM, V11 Registered Nurse said R331 was on contact/droplet isolation precautions because she didn't have her boosters and wasn't up to date. V11 said R331 has been eating meals in the dining room. On 8/22/2022 at 1:51PM, V4 Infection Control Preventionist said R331 was on contact/droplet isolation precautions for 10 days because she didn't have her COVID boosters and is not up to date. V4 said no residents on droplet isolation/quarantine should be eating in the common dining areas. V4 said residents on quarantine should be eating all meals in their rooms. V4 said residents on droplet isolation/quarantine who are outside of their rooms put other residents at risk for spreading infections such as COVID to other residents. The facility's CORONAVIRUS (COVID-19)-Staff and Resident Testing policy, revised August 2022, states .If the resident is asymptomatic and not up to date with COVID-19 vaccinations, quarantine for 10 days even if testing negative. 2. On 8/22/2022 at 10:20AM, V16 Certified Nursing Assistant was providing incontinence care to R78. V16 did not change her gloves or perform hand hygiene after wiping R78 and applying a clean brief. On 8/24/2022 at 10:14AM, V4 Infection Control Preventionist said gloves should be changed and hand hygiene should be performed after cleaning up a resident before applying a new brief to the resident. 145840 Page 10 of 11 145840 08/24/2022 Tabor Hills Health Care Fac 1347 Crystal Court Naperville, IL 60563

F 0880 The facility's Incontinent Care policy, not dated, states .Wash your hand before and after changing the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145840 Page 11 of 11