Health inspection·July 27, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review, the facility failed to revise a care plan to include what size/type of gastrostomy tube (g-tube) a resident has and what to do if a gastrostomy tube comes out for two of three residents (R1, R2) reviewed for g-tubes in the sample of four. Findings include: 1. On 7/26/23 at 10:00 a.m., R1 was lying in bed on her back with her feet elevated and appeared to be sleeping. R1 had a g-tube feeding infusing at 55 ml (milliliters)/hr (hour). R1's Behavior note, dated 6/16/23 at 8:21 a.m., documents, R1 noted to have pulled out G-tube from abdomen. R1's Care plan, dated 6/16/23, documents, The resident has chosen to receive nutrition via tube feeding. (SPECIFY TUBE TYPE) in place; Size (SPECIFY); Tube length is (SPECIFY TUBE LENGTH VISIBLE). related to Dysphagia, Swallowing problem, R1 takes NPO (Nothing by mouth). She receives nutrition via G-Tube. Jevity 1.5 at 45 ml (milliliters)/hr (hour) continuous. Flushes as ordered. She has dysphagia. R1's care plan directs to include the tube type, size, and length; however, those areas are blank. Also, R1's care plan does not include what to do in the case of R1's gastrostomy tube coming out. 2. On 7/26/23 at 10:20 a.m., R2 was alert sitting in her wheelchair. R2 pulled her shirt up to show that she had a g-tube to her left abdomen. R2's Care plan, dated 5/15/23, documents, R2 receives Enteral nutrition support. Related diagnosis dysphagia. R2 has a g-tube and receives four times a day feedings. Patency checked prior to each feeding, flushes per MAR (Medication Administration Record) and change split sponge daily. Dietary services evaluate monthly and PRN (as needed). She receives her medications as ordered via g-tube. R2's care plan does not include what to do in the case of R2's gastrostomy tube coming out. On 7/27/23 at 11:30 a.m., V3 (Care Plan Coordinator) confirmed that R1 nor R2's care plans were revised to include what to do if the gastrostomy tube comes out and R1s care plan does not include what size/type of gastrostomy tube (g-tube) the resident has. Page 1 of 10 146020 146020 07/27/2023 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record, the facility failed to provide hygiene cares to residents dependent on staff assistance for two of four residents (R1, R4) reviewed for ADL (Activities of Daily Living) assistance in the sample of four. Residents Affected - Few Findings include: 1. R1's Care plan, dated 6/16/23, documents, (R1) has limited physical mobility related to Neurological deficits, weakness. R1 is dependent for cares. She requires full assist with ADL's, hygiene and transfers with two staff and mechanical lift to reclining wheelchair propelled per staff. She receives daily nutrition via gastrostomy tube. She does not make needs known. R1's Physician's orders, dated 7/26/23, documents that R1 is NPO (Nothing by Mouth) due to the diagnosis of Dysphagia following Cerebral Infarction, and that R1 is dependent of gastrostomy feedings. On 7/26/23 at 9:30 a.m., V11 (Registered Nurse) stated, When (R1) arrived at the hospital she had bad hygiene. Her hands and fingernails were dirty. On 7/26/23 at 10:00 a.m., R1 was sleeping. R1's bilateral hands had long fingernails extending past her fingertips. R1's right hand had dark brown matter under her fingernails. On 7/27/23 at 11:00 a.m., R1 was lying in bed. When spoken to R1 stares off with no tracking of her eyes. R1's lips and tongue had white/yellow stringy patches scattered throughout. R1's bilateral hands had long fingernails extending past her fingertips. R1's right hand had dark brown matter under her fingernails. V5 (Licensed Practical Nurse) confirmed R1's mouth debris, long fingernails, and brown matter under her fingernails, and stated, (R1) should have had mouth care done already today, and you can tell she did not have it done. On 7/27/23 at 1:05 p.m., V9 (CNA-Certified Nursing Assistant) stated, Mouth care should be done in the morning when we are getting residents up. I did not get (R1's) mouth care done today because we got busy. On 7/27/23 at 1:30 p.m., V10 (R1 family), I don't know if she's been checked on as much as she should be. Her mouth will be all filled with yellow crusty film stuff that we have to ask staff to clean her mouth out. Her nails are always long and have brown stuff that looks like poop under them. 2. R4's Care plan, dated 5/1/23, documents, Self care deficit-needs supervision and/or assist to complete quality care. R4 is alert with confusion noted. He is able to make needs known at times. R4 is dependent of staff to complete ADLs, but he is able to participate when set up and verbal cues are given by staff. R4 is incontinent of bowel and bladder at times and is on a continence program. R4 was admitted with right hand contracture. Interventions: Provide bathing, hygiene, dressing, and grooming. Fingernail care on shower day and as needed. On 7/26/23 at 10:05 a.m., R4 was alert, but confused, sitting in the activity area in a recliner. R4's right hand was in a contracted position and only able to partially open it. R4's fingers were in a straight locked position. R4's fingernails were of a long length extended past his fingertips. R4's right hand had a brown wet substance in the palm and between the fingers that had a sour smell to it. Multiple fingers on R4's bilateral hands had a dark brown substance underneath of them. 146020 Page 2 of 10 146020 07/27/2023 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0677 Level of Harm - Minimal harm or potential for actual harm On 7/26/23 at 10:15, V5 confirmed that R4's fingernails needed trimmed and cleaned out, and his right hand needed cleaned. On 7/27/23 at 1:45 p.m., V2 (Director of Nursing) stated, Oral care, skin care, fingernails, and hair care should be done on residents at a minimum of one time a day. Residents Affected - Few 146020 Page 3 of 10 146020 07/27/2023 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor weights upon admission, complete physician ordered daily weights, and document intakes for a resident dependent of gastrostomy tube feedings for three of three residents (R1) reviewed for g-tubes (gastrostomy tube) in the sample of four. These failures resulted in R1 being admitted to the hospital with the diagnosis of dehydration. Residents Affected - Few Findings include: The facility's Enteral Feedings policy, dated 2/08, documents, It is the policy of the facility to provide commercially prepared products for enteral feedings via a nasogastric, g-tube, jejunostomy tube, or PEG tube when it is has been determined that oral feedings are not sufficient to meet physical requirements. Purpose: To ensure a safe, nutritionally appropriate product which provides a source of complete nutrition in a form that will pass through a tube into the digestive system, and which will maintain nutritional status as designated. The fluid intake for the resident receiving a tube feeding should be equivalent to the fluid needs as assessed by the Dietician. Fluid needs may not be met by product alone in which case water flush ordered may be recommended to meet the needs of the tube fed resident. A record of daily intake of the tube feeding and the flushes for the resident will be kept by the nursing department. The facility's Weight Monitoring policy, dated 3/19, documents, New admission weight is obtained within 24 hours of admit and on the following two consecutive days after admission by CNA as directed by nurse. If there is an actual significant weight change (i.e., +\- 5% in one month, +\- 7.5% in three months, +\- 10% in six months), the resident, POAHC (Power of Attorney Healthcare)/family/guardian, physician and dietician are notified. All new admissions and re-admissions will be weighed weekly for at least four weeks. If weight is stable, weight will be monitored monthly. 1. On 7/26/23 at 10:00 a.m., R1 was lying in bed and appeared to be sleeping. R1 had a g-tube feeding infusing at 55 ml (milliliters)/hr (hour). R1's Physician's orders, dated 7/26/23, document that R1 was admitted to the facility on [DATE], and has orders to be NPO (Nothing by Mouth) due to dysphagia following Cerebral Infarction. R1 also has orders to receive Glucerna 1.2 continuous at 55 ml (milliliters)/hour and 100 ml flush of water every four hours. R1's Nutrition care plan, dated 6/16/23, documents, The resident has chosen to receive nutrition via tube feeding related to Dysphagia, Swallowing problem. R1 takes NPO (nothing by mouth). She receives nutrition via G-Tube. R1's Dietician Review, dated 6/7/23, documents that the most current weight (on that date) for R1 was 158 lbs (pounds) from 5/1/23. R1's Weight Summary, dated 7/26/23, has no documentation of a weight upon admission 5/26/23. The summary documents R1's first weight was obtained on 6/15/23 of 133 lbs (25 lbs/15.8% weight loss in less than a month). The summary also documents that as of 7/26/23 R1 had only been weighed two other times once on 7/12/23 of 133 lbs and 7/26/23 of 132 lbs. There is also no documentation of weights on 6/21/23 or 7/21/23 upon readmission from the hospital. 146020 Page 4 of 10 146020 07/27/2023 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0692 Level of Harm - Actual harm Residents Affected - Few R1's Nurses notes, dated 5/29/23 at 9:00 p.m., document, Vital signs: 97.7 degrees Fahrenheit, 75/45 (Blood pressure), 78 (Pulse), 22 (Respirations), 83% oxygen (saturation) on room air. R1 not responding to touch or verbal stimuli. R1's Nurses' notes, dated 5/29/23 at 9:25 p.m., document, Oxygen applied at four liters per nasal cannula. 93% oxygen (saturation). Blood pressure 63/37. Oxygen saturations continue to decrease at this time. Crash cart obtained. R1's Nurses' notes, dated 5/29/23 at 9:35 p.m., document, R1 out of facility. Transported by ambulance service. R1's Hospital Encounter, dated 5/29/23, documents, Principal problem: Hypotension due to hypovolemia. Summary of History and Hospital Course: She was admitted due to profound hypotension likely volume depletion. Hydrated well and improving. R1's Hospital Discharge summary, dated [DATE], documents that R1 was admitted to the hospital from 6/1-6/7/23. Hospital course: R1 was admitted [DATE] with dysphagia. Initially R1 was admitted to an outside hospital for hypotension and dehydration secondary to hypovolemia. She had acute kidney injury at the time, both of which resolved after fluid resuscitation. R1's Intake/Output, dated 7/27/23, documents that from 5/26-7/27/23 while R1 was in the facility there was documentation of R1's intakes from g-tube feedings or water flushes. On 7/26/23 at 9:30 a.m., V11 (Registered Nurse) stated, When (R1) arrived at the hospital she had bad hygiene. Her hands and fingernails were dirty. A month prior to this she was here (hospital) with dehydration, and she has a g-tube. This shouldn't be happening. There's no reason for her to be dehydrated if she gets everything from her g-tube. On 7/27/23 at 1:30 p.m., V10 (R1 family), stated, I asked the nursing home why my mom was hospitalized with dehydration because anything she takes in is from them. I was confused. It just didn't make sense. The only response I got was that they were trying to figure out her feeding and flush orders. On 7/27/23 at 12:29 p.m., V4 (Medical Director) stated, Getting accurate intakes/outputs and weights are the way to monitor how a resident is doing both nutritionally and hydration wise. With the constant fluid and feeding going in you wouldn't have that problem. I wouldn't think a resident who is receiving only g-tube feeding and hydration would be dehydrated. A resident should be weighed when they are admitted . You need to know what their weight is to know how they are doing. (R1) should have been weighed when she was admitted . I'd be curious to hear why she wasn't weighed until 6/15/23. On 7/27/23 at 1:45 p.m., V2 (Director of Nursing) stated, Upon admission, a resident should be weighed on the day of admission, daily for three days, then weekly for four weeks. V2 confirmed that R1 was not weighed upon admission nor readmission as well as weekly. V2 stated, The intakes documented for (R1) don't have the actual amount that she took in feeding wise or water wise. If intake/outputs aren't being done and weights aren't being done, we don't have any way to know how the residents are doing nutritionally. These things weren't done before (R1) was hospitalized with dehydration. So, we have no way of knowing what went on to cause her to become dehydrated. 2. R2's Physician's orders, dated 7/26/23, document that R2 has the diagnosis of complication of 146020 Page 5 of 10 146020 07/27/2023 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0692 Ventricular Intracranial shunt, and an order to be weighed daily that was ordered on 4/26/23. Level of Harm - Actual harm R2's TAR (Treatment Administration Records), dated 5/23, 6/23 & 7/23, have no documentation of R2 receiving daily weights. Residents Affected - Few On 7/27/23 at 1:45 p.m., V2 (Director of Nursing) confirmed that R2 has not had daily weights completed since 5/23. V2 stated, (R2) has been on daily weights since 10/22, but I'm not sure why she is on daily weights. It could have been from when she had a VP (Ventriculoperitoneal) shunt. It has since been removed. 146020 Page 6 of 10 146020 07/27/2023 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a gastrostomy tube feeding as ordered by the physician, failed to ensure staff are educated on what to do if a g-tube (gastrostomy tube) comes out, failed to check for placement prior to administering medications, failed to ensure a g-tube was flushed prior to and after administering medications, and failed to ensure a resident was wearing an abdominal binder for three of three residents (R1, R2, R3) reviewed for g-tubes in the sample of four. Findings include: The facility's Enteral Feedings policy, dated 2/08, documents, Commercially prepared tube feedings are ordered by the attending physician and dispensed from the nursing department. Physician order will be obtained for all infusion orders prior to initiation of feeding. Placement of tube will be confirmed via aspiration of residual. If unable to confirm placement via aspiration, air installation method may be used. Placement will be confirmed: Prior to initiating a flush; Prior to instillation of flush/medication administration; Prior to initiating new feeding and/or adding product to an already infusing produce; Minimally every six hours if product infuses continuous; PRN (as needed) when clinical indication of tube placement is suspect. The facility's Replacement of Gastrostomy Tube policy, dated 4/07, documents, It is the policy of the facility, with physician order and unless contraindicated, that a licensed nurse may replace a gastrostomy tube when necessary. Equipment: Replacement gastrostomy tube (if replacement tube not available, may use Foley catheter on a temporary basis). The facility's Administration of Medication via a Feeding Tube policy, dated 3/17/23, documents, Check for tube placement by checking for residual. If no residual is aspirated, verify placement by placing stethoscope over stomach and instilling approximately 30 ml (milliliters) of air. Auscultate for air instillation, proceed if heard. Using a 30 ml or larger syringe, rinse the tube with 30 ml of warm water before administration of prepared medications. Pulverize crushed medications and disperse well in water as indicated above before administration via the tube. Flush tube with 5 ml water between crushed and liquid medications. Flush/rinse tube with 30 ml of water after administration of prepared medications. 1. R1's Physician's orders, dated 7/26/23, document that R1 has orders to be NPO (Nothing by Mouth) due to dysphagia following Cerebral Infarction. R1 also has orders to receive Glucerna 1.2 continuous at 55 ml/hour, 100 ml flush of water every four hours, and medication orders to receive Gabapentin 100 mg via g-tube three times a day and Norco 5/325 mg four times a day. R1's physician's orders have no orders for what to do if R1's g-tube came out, what size/type of g-tube R1 has, nor orders to check for placement of R1's g-tube. R1's Nutrition care plan, dated 6/16/23, documents, The resident has chosen to receive nutrition via tube feeding related to Dysphagia, Swallowing problem. R1 takes NPO (nothing by mouth). She receives nutrition via G-Tube. Jevity 1.5 at 45 ml (milliliters)/hour continuous. Flushes as ordered. She has dysphagia. Interventions Check for tube placement and gastric contents/residual volume per facility protocol and record. 146020 Page 7 of 10 146020 07/27/2023 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0693 Level of Harm - Minimal harm or potential for actual harm R1's Psychotropic care plan, dated 6/16/23, documents that R1 has a history of pulling out her tracheostomy and G-tube several times. R1's Behavior note, dated 6/16/23 at 8:21 a.m., documents, R1 noted to have pulled out G-tube from abdomen. Residents Affected - Few R1's Hospital Discharge summary, dated [DATE], documents that R1 was hospitalized from 6/17-6/23/23 with the principal problem of percutaneous endoscopic tube placement. The summary also documents, Hospital Course: R1 was admitted [DATE] with status post percutaneous endoscopic gastrostomy (PEG) tube placement. R1 presented in the setting of recurrent displacement of PEG tube. Underwent replacement by surgery. Surgery team noted that if she has displacement in the next 6-8 weeks, surgery service should be contacted for admission urgently as felt to be a surgical emergency and they noted that will need 14-18 French tube to be inserted and gastrostomy tract to maintain patency and prevent trachea closure and advised to continue abdominal binder at all times. Case summary: PEG placement on 4/18 who was admitted to the hospital for prerenal hypovolemia leading to hypotension and AKI on 5/30. Recent admission with g-tube dislodgement requiring operative replacement as g-tube had been out three days and tract had sealed. PEG placement on 6/5/23. R1 transferred from ED for g-tube dislodgement, out since 6/16/23 morning. Assessment and Plan: PEG tube dislodgement: PEG tube was placed on 6/18/23. If PEG tube is inadvertently removed in the first 6-8 weeks after placement, THIS IS A SURGICAL EMERGENCY. Please contact surgery team as soon as possible if R1 is inpatient or go to the emergency department to be evaluated. Please place a Foley or other 14-18 French tube into the gastrostomy tract to maintain patency and prevent tract closure. Must wear abdominal binder at all times. On 7/26/23 at 10:00 a.m., R1 was lying in bed sleeping. R1 had a g-tube feeding infusing at 55 ml (milliliters)/hr. It was in a bag labeled with the date only of 7/26/23. A carton of Jevity 1.5 was on the bedside table. R1 was not wearing an abdominal binder. On 7/26/23 at 11:50 a.m., V6 (Licensed Practical Nurse-LPN) stated that R1 was getting Norco and Gabapentin for her noon medications. V6 had a small cup with a white colored liquid and confirmed that both of those medications (Norco & Gabapentin) were in the cup. V6 stopped the g-tube feeding that was infusing at 55 ml/hr. V6 stated that R1's feeding was Jevity 1.5. R1 was not wearing an abdominal binder. Without checking placement, V6 flushed R1's g-tube with 30 ml of water by gravity. Then, she administered the medications mixed together, and finished with a flush of 30 ml of water. Placement was not checked at any time. V6 stated, I didn't check for placement. I only check it if it's necessary, if we think there is a problem. V6 also confirmed that R1 did not have an abdominal binder on. On 7/27/23 at 11:00 a.m., V5 (LPN) applied gloves and opened a Neurontin 100 mg capsule into a medicine cup. Then, V5 crushed a Norco 5/325 mg tablet into another medicine cup. V5 applied PPE and entered R1's room. V5 disconnected R1's feeding and added 60 ml of water to the piston syringe to flush the g-tube by gravity. Before the water was cleared of the syringe, V5 added the medicine cup containing the Neurontin mixed with 30 ml of water. Prior to the medication clearing the syringe, V5 added 30 ml of water. Prior to the water clearing the syringe, V5 added the Norco mixed with 30 ml of water. Prior to the Norco clearing the syringe, V5 added the 60 ml of water ending flush. On 7/27/23 at 1:10 p.m., V5 confirmed that when she was administering R1's medications, she did not ensure that the g-tube tubing was cleared before each step of the process including flushes. R1's MAR (Medication Administration Record)/TAR (Treatment Administration Record), dated 7/1/23, 146020 Page 8 of 10 146020 07/27/2023 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0693 have no documentation of R1's g-tube being checked for placement. Level of Harm - Minimal harm or potential for actual harm On 7/27/23 at 1:30 p.m., V10 (R1's family), stated, She's pulled her g-tube out multiple times now. The last time she was in the hospital and had the surgery to put her g-tube back in, the hospital told the facility that she had to wear the abdominal binder at all times so that she couldn't pull it out again. Residents Affected - Few 2. R2's Physician's orders, dated 7/26/23, document that R2 has orders for 2.0 Calorie Supplement 80 ml three times a day via g-tube, 100 ml flush of water three times a day, and Jevity 1.5 8 oz carton two times a day via g-tube. R2's physician's orders have no orders for what to do if R1's g-tube came out or what size/type of g-tube R2 has. On 7/26/23 at 10:20 a.m., R2 was sitting in her wheelchair, and pulled her shirt up to show that she had a g-tube to her left abdomen. 3. R3's Physician's orders, dated 7/27/23, document that R3 has the following orders: 60 ml water flush three times a day for g-tube, Jevity 1.5 Cal/Fiber 50 ml/hr (hour) via g-tube starting at 8:00 p.m. and stopping at 5:00 a.m. for malnutrition. R3's Physician's orders have no orders for type/size of g-tube, checking placement of R3's g-tube, or what to do if R3's g-tube comes out. On 7/26/23 at 10:30 a.m., R3 was alert lying in bed with a g-tube to his left abdomen. R3 was not hooked up to a g-tube feeding at the time. R3's Nurses' notes, dated 6/10/23 at 6:00 a.m., document, Resident pulled G-tube and port broke off. Unable to flush easily. New order to send out to replace and return. R3's Nurses' notes, dated 7/16/23 at 8:47 p.m., document, The resident had the g-tube tube on the floor by the bed when the CNA (Certified Nursing Assistant) walked in to check on the resident. This nurse went to assess the resident and the resident was continuing to yell out a bunch of words. The g-tube site was not bleeding or didn't look swollen or red either. This nurse then notified physician and got new orders to send resident to ER (Emergency Room) to evaluate and treat. R3's Plan of Care note, dated 7/17/23 at 9:59 a.m., documents, Resident pulled his g-tube twice over the weekend and sent to ER (Emergency Room). Resident also with nausea and vomiting and leaking around g-tube site. G-tube replaced by hospital. On 7/27/23 at 12:10 p.m., V8 (RN) stated, If a resident's g-tube is out. I'm immediately sending them out. We don't have capability to ensure proper placement of the g-tube if I tried to put it back in. I don't even feel comfortable attempting to. (R1) wears a binder because she pulls out her g-tube. On 7/27/23 at 12:29 p.m., V4 (Medical Director) stated, If a g-tube comes out the nurse should know to try to put it back in or replace it with a new one. The information regarding what kind of tube they have, and the size should be available to the nurses. If they can't get the tube back in, they should use a foley catheter to try and at least keep it open and send them to the ER. On 7/27/23 at 1:45 p.m., V2 (Director of Nursing) stated, If a g-tube comes out the nurses should replace it with an indwelling foley catheter if we don't have a 2nd g-tube available. It needs something in it, so it doesn't close. Every time the nurses access the g-tubes, they should be checking 146020 Page 9 of 10 146020 07/27/2023 Goldwater Care Roseville 145 S Chamberlain St, Box 770 Roseville, IL 61473

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few placement by aspiration. So, before medications are administered placement should have been check. V2 confirmed that (R1, R2, and R3's) physician's order did not include orders for what to do if their g-tubes were to come out or the type/size of their g-tubes. V2 also confirmed that (R1 and R3) also did not have orders for checking placement of their g-tubes. V2 stated, (R1's) abdominal binder should be on at all times. It was my understanding that we should be still using it because of her pulling her g-tube out several times. (R1's) current order is to receive Glucerna tube feeding. 146020 Page 10 of 10