Health inspection·January 26, 2023

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide incontinence care to a resident (R6). This applies to 1 of 1 resident reviewed for activities of daily living in the sample of 13. Residents Affected - Few The findings include: R6's electronic face sheet printed on 1/26/23 showed R6 has diagnoses including but not limited to dementia with behaviors, generalized anxiety disorder, major depressive disorder, hypertension, and type 2 diabetes, constipation, and glaucoma. R6's facility assessment dated [DATE] showed R6 has severe cognitive impairment and is always incontinent of bowel and bladder. R6's nursing care plan dated 4/27/19 showed, (R6) has always been incontinent. History of urinary tract infections. Clean perineal area with each incontinent episode. On 1/24/23 at 1:36PM, V6 & V7 (Certified Nursing Assistants) transferred R6 to her bed with a mechanical lift. V6 pulled R6's shirt down and started to cover her up. Surveyor asked V6 the last time R6 had received incontinence care and V6 replied Earlier this morning when I got her up. It was around 7:30AM. (6 hours had passed since R6 received incontinence care). V6 then removed R6's incontinence brief that was saturated with urine and had a strong odor. V6 stated Incontinence care is provided at least 3 times per shift, residents with lifts are a little different because we have to have 2 people, it's hard to get 2 people when we need it done so they usually have to go a little longer without receiving incontinence care. I would say yes R6 waited too long to receive incontinence care. It could lead to skin breakdown and possibly urinary tract infections if not cleaned & given a clean brief. On 1/25/23 at 12:53PM, V2 (Director of Nursing) stated, We don't have a specific policy regarding how often incontinence care is given. The standard of care is every 2-3 hours whether they are incontinent or not. They should at least be checked and cleaned. 6 hours is way too long for a resident who is completely incontinent and cannot tell you when she needs to go or is wet. It is important to keep resident's skin dry to promote skin integrity and those kinds of things. On 1/26/23 at 11:40AM, V2 stated, (V6) said he did check (R6) every 2 hours, but she was dry. I can't confirm that he did or didn't check her but she is hospice and doesn't have a lot of fluid intake so that might be why he didn't change her. Page 1 of 7 146166 146166 01/26/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 provide pressure ulcer prevention measures for a resident (R8) and failed to initiate treatment for a resident (R8) with a pressure ulcer. These failures apply to 1 of 4 residents reviewed for pressure ulcers in the sample of 13. Residents Affected - Few The findings include: R8's electronic face sheet printed on 1/26/23 showed R8 has diagnoses including but not limited to osteomyelitis, Parkinson's Disease, pneumonitis, dysphagia, peripheral vascular disease, and chronic kidney disease stage 3. R8's facility assessment dated [DATE] showed R8 has no cognitive impairment. R8's nursing care plan dated 1/16/23 showed, (R8) is at risk for the development of pressure related injury due to advanced age, multiple disease processes, polypharmacy, impaired mobility, generalized weakness, bladder incontinence, bowel incontinence. If (R8) refuses the treatment, confer with the resident, interdisciplinary team and family to determine why and try alternative methods to gain compliance. Document alternative methods. R8's skin/wound note dated 1/16/23 showed, Wound type: FULL THICKNESS WOUND Acquired date: CHRONIC; PRESENT ON admission Location: RIGHT LATERAL TOE/FOOT Drainage: NONE Size: 5.3 cm X 4.2 cm Wound bed: Dry stable eschar .Recommendations: Cleanse with gentle soap/water or wound cleanser, apply (brand name antiseptic) to (brand name gauze dressing) and secure with roll gauze; daily dressing change. R8's physician's orders showed, 1/16/23 heel suspension boots every shift; utilize at all times while in bed R8's physician's orders dated 1/25/23 showed, Dressing change right lateral foot every day shift; full thickness eschar wound; cleanse, pat dry, apply (brand name antiseptic) to gauze dressing, apply on eschar wound, secure with roll gauze. No previous wound care orders were present in R8's medical record from 1/16/23 thru 1/24/23. On 1/24/23 at 1:20PM, R8 stated, I don't wear the heel boots because they hurt my heel. They haven't put my feet up on pillows or anything yet today. (R8's feet were resting flat on the air mattress during this observation). On 1/25/23 at 9:57AM, V8 (Registered Nurse) stated, (R8) has a sore on his right foot, he wears heel suspension boots most of the time. Not sure when his treatment was started. Treatment should begin as soon as a wound is identified to prevent wound from worsening. On 1/25/23 at 12:34PM, R8 stated, They usually have 1 or 2 pillows under my legs to keep my feet up, but they haven't been doing it for some reason. I won't wear the boots they want me to wear because it rubs on the back of my foot where I have a sore, but I let them put the pillows underneath because then my heels don't rub on the bed. On 1/26/23 at 9:32AM, V5 (wound care nurse) stated, (R8) came in with a wound that was eschar on the right lateral aspect of his foot. He's getting (brand name gauze dressing) done daily and that 146166 Page 2 of 7 146166 01/26/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0686 Level of Harm - Minimal harm or potential for actual harm started on admission. We were doing the dressing changes, but they weren't documented. The only place it would be documented would be in a note or on the treatment administration record. If it's not documented, then it wasn't done. I think it just got missed. Pressure ulcer prevention for (R8) includes low air loss mattress, heel suspension boots or pillows under his feet. These are prevention measures in place for him because his skin is so fragile, and he is a higher risk for further skin breakdown. Residents Affected - Few On 1/26/23 at 11:40AM, V2 (Director of Nursing) stated, When a pressure sore or any other skin condition is identified an assessment should be completed, initiate repositioning & heel boots or pillows. Treatment should be initiated right away and documented on the treatment administration record. If the orders are not in the system, then the nurse will not know what the orders would be and if it's not documented then we can't always assume it's not done. I'm sure this wound care was done they just didn't document it. The facility's policy titled, Skin Maintenance-Pressure Injury-Prevention and Maintenance dated 01/20/2022 showed, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. To eastablish guidelines to prevent development of avoidable pressure injury for residents in our community .2. Interventions .c. Interventions will be documented in the resident care plan and revised based upon ongoing assessment and evaluation. 146166 Page 3 of 7 146166 01/26/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide range of motion (ROM) exercises for a resident with a muscle wasting disease. This applies to 1 of 1 resident (R18) reviewed for restorative services in the sample of 13. The findings include: R18's Face Sheet showed he was admitted to the facility on [DATE] with diagnoses to include Inclusion Body Myositis (progressive muscle weakness that can cause muscle damage); left fibula and tibia fracture (lower leg bones), and spinal stenosis. R18's 11/25/22 Minimum Data Set (MDS) showed he was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. The MDS showed he was totally dependent on two staff for bed mobility and transfers as well as requiring extensive assistance of two people for dressing. On 1/24/23 at 11:18 AM, R18 was in his bed and laying on his back. R18 was wearing a hospital gown and he was covered with a sheet. R18's hands were contracted into a claw type grip. R18 stated, I used to have range of motion exercises at the facility I was at prior to here. I really think that would help with my legs. Someone told me that someone from OT (Occupational Therapy) would come to me and see if I needed PT (Physical Therapy) or ROM therapy, but that was a week or so ago. When the CNA's take care of me throughout the day they don't do any extra ROM exercises with my legs. I have a rare muscle wasting disease, so I do have some contractures to both hands . The range of motion exercises would help to keep them (legs) more mobile, if they stay in this position 24/7 (24 hours a day, 7 days a week) and they are going to stiffen up .I think I should get ROM exercises at least once a day. On 1/25/23 at 2:22 PM, V10 (Certified Nurse Assistant/CNA) was R18's CNA and she was not aware of any residents requiring ROM exercises; however, V10 stated she provided ROM exercises for all of her residents while she got them dressed. (R18 wore a hospital gown on 1/24/23 through 1/26/23.) On 1/25/23 at 2:32 PM, V9 (Restorative Nurse) stated ROM is a part of restorative responsibilities. V9 stated passive ROM is ROM that is performed by the staff for the resident. V9 said active ROM is when the resident does the ROM them self. V9 stated she is responsible for entering ROM orders and she is responsible for updating the electronic charting which. V9 said ROM is more deliberate than assisting a resident with dressing. V9 said, [R18] is not on a ROM program. I don't know why he is not on a ROM of program. He would benefit from the ROM program. He would benefit from ROM program because he is going to atrophy (muscle wasting) and his muscles will suffer. It (ROM) can help prevent or minimize contracture. V9 said she does not need a physician order to provide ROM services and she was not certain why R18 was not placed on ROM exercises from admission. On 1/26/23 at 10:26 AM, R18 said he was evaluated for ROM on 1/25/23 and he was given an exercise band for the upper body, and he will be receiving passive ROM for his legs. R18 said 1/25/23 was the first day either of those interventions occurred. R18 said, I have very little movement with my legs. I can bend my right knee a little, but I can't lift it off the bed, my left leg I broke some bones so all I can do is wiggle the foot. I cannot do ROM with my lower body at all; I need help with 146166 Page 4 of 7 146166 01/26/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that. R18 said, Applying the hospital gown is very little ROM. I have to lift my arms a little but that's really all I have to do; it's very minimal. I don't recall anyone assessing my ROM from this facility but maybe they did it at the other facility. I am not able to manually stretch my hands apart (his contracted fingers.) No one ever stretches my hands apart, but that sounds like a good idea I would really like that. The facilities Restorative Census (dated 2023) showed R18 is not in any restorative program to include active ROM, passive ROM, bed mobility, or transfers. R18's care plan showed Provide gentle range of motion as tolerated with daily care. (Initiated 11/18/22, the type of range motion, extremities included, repetitions, and frequency was not specified.) The facility's Rehabilitative/Restorative- Mobility and Range of Motion policy (revision 12/29/21) showed, Mobility training can improve the range of motion (ROM) of a resident joints and muscles by increasing flexibility and stamina. [The facility] works with our residents to improve their mobility reducing the risk of injuries .as part of the resident's comprehensive assessment, the nurse will identify the resident's: current range of motion of his or her joints .opportunities for improvement . The policy showed, The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion . 146166 Page 5 of 7 146166 01/26/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to transfer a resident (R13) with a gait belt. This applies to 1 of 2 residents reviewed for safety and supervision in the sample of 13. The findings include: R13's electronic face sheet printed on 1/26/23 showed R13 has diagnoses including but not limited to history of falls, dementia with behaviors, delirium, major depressive disorder, and peripheral autonomic neuropathy. R13's facility assessment dated [DATE] showed R13 has severe cognitive impairment and requires 2 staff member assistance for transfers. R13's fall risk assessment dated [DATE] showed R13 is a high fall risk. R13's care plan dated 1/2/22 showed, (R13) is high risk for falls related to gait/balance problems, history of falls secondary to fall with right femur distal end distal fracture. R13's care plan dated 1/2/22 showed, (R13) has an activities of daily living (ADL) self-care performance deficit related to dementia, limited mobility, and musculoskeletal impairment secondary to fall with right femur distal end fracture. Transfer program: (R13) will transfer with 1 staff assist, gait belt and walker, stand pivot transfer. On 1/24/23 at 9:33AM, V7 (Certified Nursing Assistant) was transferring R13 from the toilet to her wheelchair. V7 had R13 hold onto the metal bar next to her toilet, lifted her up by the back of her pants. R13 did not have a gait belt around her waist during the transfer. V7 stated, It's my fault for not using a gait belt, I should know better, but I didn't have one. If (R13) began to fall I would have to try and catch her because I don't have a gait belt on her to try and keep her steady. On 1/26/23 at 9:46AM, R13's ADL care guide in her room showed R13 requires 1 staff member assistance with a gait belt for all transfers. On 1/25/23 at 9:57AM, V8 (Registered Nurse) stated, Gait belts should be used for any resident that requires assistance with transfers or walking in case they become weak and need to be lowered to the floor or chair. If these are not used a resident could become injured if staff, try to catch them. On 1/26/23 at 11:40AM, V2 (Director of Nursing) stated, (R13's) transfer status depends on her level of cooperation. If she's having a difficult time following direction, we would use 2 assist for transfers. A gait belt should definitely be used for her because she's not always cooperative with transfers. The facility's policy titled, Positioning/Moving-Safe Resident Handling revised on 12/29/2021 showed, It is the policy of (facility) and its affiliates to ensure the safe physical transfer of residents using the identified transfer method that promotes the appropriate level of independence and safety for the resident and associate care givers .2. Gait belt usage: a. Gait belt usage is recommended for all 1 person transfers with the exception of bed mobility and/or medical contraindications. 146166 Page 6 of 7 146166 01/26/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 wear hair nets while working in the kitchen, thaw foods in a manner to prevent a food borne illness and failed to cover bulk foods. This applies to all residents in the facility. The finding include: The Centers for Medicare and Medicaid Services Resident Census and Resident Conditions 672 form dated 1/25/23 shows there are 40 residents residing in the facility. On 1/24/2023 at 9:20 AM the dietary staff were observed entering the kitchen without wearing a hair net. When this surveyor entered the kitchen and applied a hair net, several dietary staff were observed putting on a hair net. In the dry storage room, the bulk containers containing the sugar and the panko breadcrumbs were observed to be uncovered. At 1:00 PM the same day the storage containers were still uncovered. On 1/24/2023 at 9:30 AM, a dietary worker was observed placing a tray of frozen ground sausage on top of the convection oven. This surveyor at 9:45 AM asked V4 (Executive Chef), why that pan of frozen meat had been placed on top of the oven. V4 said that should not have been put there to thaw. There is a better way. V4 took the pan and placed it into the refrigerator. 01/25/23 10:00 AM V4 and V3 (Director of Dining) said they expect staff to thaw all meats in the refrigerator, wear hair nets while in the kitchen and close the lids to all storage bins when not in use. The facility policy with a revision date of 1/2022 for Uniform Dress Code shows: wear the approved hair restraint when on duty regardless of length or presence of hair. The policy provided to this surveyor for food storage dated 10/1/22 for storage facilities shows food storage containers with tight-fitting covers should be used for storing bulk foods such as flour, sugar ., the undated food handling guidelines for thaw frozen meats shows meat to be thawed under refrigeration, under running water, as part of the cooking process or in the microwave. 146166 Page 7 of 7