Health inspection·August 28, 2024

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 assess a new pressure injury area, failed to implement pressure injury treatment orders, and failed to ensure pressure reducing interventions were in place for four of six residents (R16, R31, R6, R46) reviewed for pressure injuries in the sample of 15. Residents Affected - Some The findings include: 1. R16's Order Summary Report shows she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, bipolar disorder, dementia with agitation, and pressure injury of sacral region stage II. R16's Wound Care Physician Notes dated August 7, 2024 shows, Plan of Care: Continue with skin ulcer prevention protocol of the facility including daily skin check, provide stage appropriate mattress, offload heels with heel protectors or pillow. On August 26, 2024 at 10:35 AM, V5 and V6 CNAs (Certified Nursing Assistants) provided incontinence care for R16. R16's heels were directly on the bed and were not offloaded. R16 was laying on her back. V5 wiped R16's buttocks. There was an open area a little bigger that pea size noted to R16's coccyx. V5 applied A and D ointment to R16's buttocks, but did not place any ointment on the open area. R16 was transferred into her high back wheeled recliner via mechanical lift and brought out to the TV area. There was no cushion on R16's high back wheeled recliner chair. On August 27, 2024 at 11:00 AM, this surveyor requested V2 DON (Director of Nursing) to assess R16's buttocks. At 1:59 PM, V2 said that R16 has an open area on her coccyx. V2 said R16 had a pressure injury there in the past. V2 said the area is opened again and is a stage II pressure injury. V2 said she did not know R16 had an open area to her buttocks. R16's Treatment Administration Record shows a foam dressing was ordered from July 19, 2024-August 5, 2024. Zinc oxide cream was ordered on August 5, 2024. R16's Order Summary Report dated August 27, 2024 shows a new order was entered on August 27, 2024 for medihoney wound/burn dressing paste to coccyx every night shift and cover with foam bordered dressing. R16's Wound Care Physician Note dated August 28, 2024 shows R16 has a stage III pressure area to her coccyx that measure 1 cm X 0.8 cm X 0.1 CM. R16's Shower Day Worksheet shows she did not have any open areas on August 21, 2024 or August 24, Page 1 of 10 146182 146182 08/28/2024 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

F 0686 2024. It showed an open area noted on August 28, 2024. Level of Harm - Minimal harm or potential for actual harm On August 27, 2024 at 1:59 PM, V2 said that R16 should have heel protectors in her room for when she is in bed. V2 said the heel protectors are provided by the hospice company. V2 said if the wound care doctor recommends interventions, then staff should follow them. Residents Affected - Some 2. R31's admission Record dated August 27, 2024 shows she was admitted to the facility on [DATE] with diagnoses including right femur fracture, osteoporosis, difficulty walking, muscle weakness, pressure injury of right and left heel, history of falling and dementia. R31's Braden Scale dated August 17, 2024, shows she has a mild risk of developing a pressure injury. R31's Wound Physician Progress Notes dated August 21, 2024 shows Assessment and Plan: Low air loss mattress, reposition every two hours and as needed, pressure relieving seat cushion, offload heels, and heel protectors to both feet. R31's Wound Physician Progress Notes dated August 28, 2024 shows R31 has an unstageable pressure injury to her coccyx. On August 27, 2024 at 9:33 AM, V8 took R31 to the bathroom to toilet her. There was a foam dressing to R31's coccyx that was partially intact. V8 removed the foam dressing as it was coming off. V8 finished toileting R31 and transferred her back into her wheel chair to put her in the TV room. V8 notified V15 LPN (Licensed Practical Nurse) about R31's dressing at 10:04 AM. At 10:41 AM, V2 DON (Director of Nursing) and V15 went into R31's room to apply a new dressing. There was a nickel sized open area noted to R31's coccyx. The wound bed was covered with yellow tissue. R31 did not have a low air low mattress in place. On August 27, 2024 at 1:59 PM, V2 said she does not believe R31 has ever had a low air loss mattress. V2 said if the wound doctor recommends interventions, then staff should follow them. V2 said she usually enters the order when the wound care doctor emails her their notes. On August 28, 2024 at 10:16 AM, V3 CNA said if an open area is found on a resident, she tells her nurse right away, because she wants to make sure the nurse can assess the wound and get a dressing placed. 3.) R6's face sheet shows she has diagnoses including dementia and a pressure injury to her right heel. R6's active care plan shows she requires staff assistance to turn and reposition and is at risk to develop pressure a injury. A Braden Scale (pressure ulcer risk assessment) completed on 8/26/24 shows she is at risk to develop pressure. A wound assessment completed on 7/31/24 by V13 (wound care physician) shows R6 has a Deep Tissue Pressure Injury (DTI) to her right heel measuring 2 centimeters (cm.) long x 3 cm. wide x 0 cm. deep. The assessment identifies treatment orders to include off load heels and heel protectors to both feet, and for Betadine solution skin prep and an Optifoam dressing to be applied every 2 days and PRN (as needed). A wound assessment completed on 8/14/24 by V13 shows R6's right heel pressure injury remained the 146182 Page 2 of 10 146182 08/28/2024 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

F 0686 Level of Harm - Minimal harm or potential for actual harm same size and the same treatments and interventions were ordered. (There is no documented wound assessment in the Electronic Medical Record in between 7/31/24 and 8/14/24). R6's active Physician Order Summary shows the order for Betadine was not entered until 8/14/24, and the Optifoam dressing order was not entered until 8/15/24. Residents Affected - Some R6's Treatment Administration Record (TAR) shows no treatment for the DTI to her right heel were administered until 8/14/24 (Betadine solution) and Optifoam (8/15/24). (15 and 16 days later) On 8/28/24 at 7:17 AM, V13 said R6's DTI was identified on 7/31/24 and he saw her that same day. V13 said he gave treatment orders that day to include offloading off heels with heel protectors or pillows and Betadine with a Optifoam dressing. V13 said DTI's can develop very quickly and off loading is one piece that is important to prevent pressure injuries from developing or worsening. On 8/28/24 at 7:32 AM, V2 (Director of Nursing) V13 and this surveyor entered R6's room. Her bed was in the low position and she was still asleep. V2 raised R6's bed and when the covered were pulled back to assess the pressure injury, R6's heels were flat against the mattress with no offloading of her heels. V13 completed the assessment and said it measured 2 cm x 2 cm and was improving. R6's right heel had a purplish discoloration to it. After the assessment was completed V2 verified that R6's heels should have been offloaded. On 8/28/24 at 10:20 AM, V2 said she was not aware of the treatment orders for R6's pressure injury until 8/14/24. V2 looked for any prior orders on the TAR and was unable to find that it was being administered prior to 8/14/24. V2 said the wound care doctor had not sent his 7/31/24 assessment to her and she was not sure who V13 rounded with on 7/31/24 when he gave the treatment orders. V2 verified V13's 7/31/24 assessment showed treatment orders to begin that day and every continue every 2 days and as needed. The facility policy provided Prevention and Treatment of Pressure Injury and Other Skin Alteration policy dated 03/02/21 shows treatment modalities and interventions should be identified and implemented. Pressure injury skin assessments should be documented weekly. 4.) R46's active alteration in skin care plan initiated on 7/18/24 shows she has a pressure injury to her right coccyx. Interventions include turning and repositioning and off loading heels. R46's Braden Scale completed 8/20/24 shows she is at risk to develop pressure injuries. A wound assessment completed on 8/21/24 by V13 shows R46 has a 0.4 x 0.4 x 0.1 stage 3 pressure injury to her coccyx. Treatment recommendations include offloading heels with pillows or heel protectors. On 8/26/24 at 9:50 AM, this surveyor entered R46's room with V9 (CNA) to observe care being provided. When V9 pulled back the covers from R46, her heels were flat against the bed and not off loaded. On 8/27/24 at 8:51 AM, V5 CNA said when residents are at risk for pressure and in bed they should have their heels off loaded with pillows or heel protectors. On 8/27/24 at 1:59 PM, V2 said interventions for residents with pressure injuries include off loading heels with either a pillow or heel protectors and the staff should follow the physician 146182 Page 3 of 10 146182 08/28/2024 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

F 0686 recommendations. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 146182 Page 4 of 10 146182 08/28/2024 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

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 a resident urinary drainage bag below the level of her bladder in order to prevent urinary tract infections for one of five residents (R16) reviewed for urinary catheter or urinary tract infections in the sample of 15. The findings include: R16's Order Summary report dated August 27, 2024 shows she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, encounter for fitting and adjustment of urinary device, mental disorder, bipolar disorder, and dementia. On August 26, 2024 at 10:35 AM, V5 and V6 CNAs (Certified Nursing Assistants) transferred R16 from her bed to her high back wheeled recliner via mechanical lift. While R16 was on her sling, in the air, V6 lifted R16 urinary drainage bag above the level of her bladder and set the bag on top of R16's lap. V5 and V6 transferred R16 into her recliner. V6 then lifted R16's urinary drainage bag above the level of her bladder again, in order to hang it on the side of her recliner. There was amber urine in the tubing and in the urinary drainage bag. On August 28, 2024 at 10:16 AM, V3 CNA said urinary drainage bag should be kept below the level of the bladder because if it's not, then the urine could go back and create infection. The facility's Catheter Care Policy dated September 2020 shows daily and as needed catheter care will be done to promote comfort and cleanliness. It does not include information regarding where to keep the urinary drainage bag. 146182 Page 5 of 10 146182 08/28/2024 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

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 dietary supplements were provided for 2 of 15 residents (R46, R14) reviewed for weight loss in the sample of 15. Residents Affected - Few The findings include: 1.) R46's face sheet shows she was admitted to the facility on [DATE] and has diagnosis including dementia and severe protein-calorie malnutrition. R46's active nutrition care plan initiated 7/29/24 and active Physician Order Summary (POS) both show she should receive the following supplements: Mighty Shakes with meals, fortified cereal at breakfast, Magic Cup with lunch and Pro T gold (nutritional supplement) 2 times a day. R46's July admission weight is documented at 90.8 pounds (lbs.) and on 8/8/24 her weight was 86.2 (lbs.) A comprehensive nutrition assessment completed by V10 (Dietician) on 8/21/24 shows R46 had a significant weight loss of 5.1% in one month. On 8/27/24 the breakfast service on the B wing was observed between 8:20 AM until 8:51 AM when R46 was finished with breakfast. R46 was not served a Mighty Shake. Next to R46's meal tray was her diet order card which clearly indicated she should receive a 4 ounce carton of Mighty Shake at Breakfast. No Mighty Shakes were seen being handed out with meals during the breakfast service to any residents on the B wing. On 8/27/24 at 8:40 AM, V12 (Registered Nurse/RN) said she doesn't believe anyone on the unit is on Mighty Shakes, but some residents receive Med Pass (another supplement) and those can sometimes be interchanged. V12 said there is no tracking of Mighty Shakes in the nursing documentation (Medication Administration Record) to show if someone received one. 2.) R14's face sheet shows she was admitted to the facility 9/30/2023 with diagnoses including dementia, and vitamin B12 deficiency anemia. R14's active care plan does not address weight loss. R14's last Comprehensive Nutritional Summary was completed 6/14/24 by V10 and shows she should be on Mighty Shakes and fortified cereal at breakfast. R14's active POS shows Mighty Shakes were changed on 8/7/24 to be given 2 times a day with lunch and dinner. R14's weight summary report shows a July weight (no specific day was specified on the monthly report) of 118.6 lbs. and an August weight of 110.8 lbs. a 6.58% (7.8 lbs.) weight loss in one month. On 8/27/24 at 10:10 AM, V10 said dietary supplements are given to residents with weight loss, or at 146182 Page 6 of 10 146182 08/28/2024 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

F 0692 Level of Harm - Minimal harm or potential for actual harm risk for weight loss, including hospice residents. V10 said the documentation for med pass and liquid protein is in the MAR and nurses document that, but Magic Cup and Mighty Shakes is identified on the residents diet cards and the Certified Nursing Assistants (CNA's) are responsible to obtain those from the nourishment/serving area refrigerators on the units. V10 said the CNA's then document them in the tasks charting of the Electronic Medical Record/EMR. Residents Affected - Few On 8/27/24 at 12:24 PM, R14 was observed in the dining area on the B wing there was no Mighty Shake or Magic Cup served with her noon meal. On 8/28/24 at 10:31 AM, V9 (CNA) said there is no list on the unit or any other way of identifying who should receive Magic Cups or Mighty Shakes and they do not know who gets them until they complete their task charting in the EMR at the end of the day. The facility provided Dietary Supplement policy revised 5/24 shows food and dietary supplements should be provided as ordered to enhance a resident's nutritional status. 146182 Page 7 of 10 146182 08/28/2024 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the facility failed to ensure PRN (as needed) psychotropic medications had a stop date for 2 of 5 residents (R16, R33) reviewed for psychotropic medications in the sample of 15. The findings inlcude: R16's Physician Orders (POS) dated 08/08/24 shows an order for lorazepam intensol oral concentrate 2 mg/ml Give 0.25 ml sublingually every 1 hour as needed for anxiety/agitation related to unspecified dementia, unspecified severity, with agitation, bipolar disorder. There are no stop dated included in this order. R33's POS dated 5/28/24 shows an order lorazepam intensol oral concentrate 2 mg/ml Give 0.25 ml by mouth every 2 hours as needed for anxiety, restlessness and another order for lorazepam intensol oral concentrate 2 mg/ml Give 0.5 ml by mouth every 2 hours as needed for anxiety, restlessness. There are no stop dates included in this order. On 08/28/24 at 11:14 AM, V2 Director of Nursing said PRN medications need to have a stop date of 14 days after the start of the order and be reordered by the doctor if still needed. The facility's As-needed Psychotropic and Antipsychotic Medication Orders dated 1/2022 shows PRN orders for psychotropic medications (excluding antipsychotics) are limited to 14 days. 146182 Page 8 of 10 146182 08/28/2024 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to secure controlled substances and the facility failed to label insulin pens with the date opened for 5 of 15 residents (R47, R33, R6, R24, R8) reviewed for medications in the sample of 15. The findings include: On 8/28/24 at 9:30 AM, V15 Licensed Practical Nurse unlocked the medication room door and entered the medication room with this surveyor. This surveyor saw the fridge was unlocked and V15 said oh that should be locked. The medication room contained house stock (over the counter) medications in cabinets, medical supplies and a fridge. Inside the fridge contained: an opened bottles of R47's hyrdromorphone (schedule II narcotic) a bottle of liquid lorazepam, and an unopened bottle of liquid lorazepam and opened bottles of liquid lorazepam for R6, R33, and R24. On 08/28/24 at 9:52 AM, V2 Director of Nursing said the fridge needs to be locked because it has controlled substances which need to be double locked. V2 said the nurses need to lock the fridge at all times. The facility's Storage/Labeling/Packaging of Medications dated 1/2022 shows Schedule II controlled medications are stored under a double-lock system accessible to only licensed staff. 2.) On 8/27/24 at 8:25 AM, during morning medication pass inside the medication on the B wing there were two open and not dated insulin pens inside of it belonging to R8. One insulin pen was identified as containing Lispro and the second was identified as Aspart. V12 (Registered Nurse) said all insulin pens should be labeled and dated with an open date and expiration date. R8's active order summary shows an order for Lispro insulin to be given on a sliding scale basis with a start date of 8/19/24, and an order for Lantus Solostar 17 units to be given one time a day, expires after 28 days. No active order was found for Aspart. On 8/28/24 at 11:14 AM, V2 (Director of Nursing) said insulin pens should be labeled when open and have an expiration date of 28 days after opening. The facility provided Prefilled Insulin Multi-Dose Pens, Use of policy dated 01/2022 shows Insulin pens should be initialed and noted with the open date and the expiration date and initials of the nurse at the time the pen is first used. 146182 Page 9 of 10 146182 08/28/2024 Alden Courts of Waterford 1991 Randi Drive Aurora, IL 60504

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** Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP) and failed to change their gloves and perform hand hygiene in a manner to prevent cross contamination for two of 15 residents (R16, R44) reviewed for infection control in the sample of 15. Residents Affected - Few The findings include: 1. R16's Order Summary report dated August 27, 2024 shows she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, encounter for fitting and adjustment of urinary device, encounter for attention to gastrostomy, mental disorder, bipolar disorder, and dementia. An order for EBP for device care or use of feeding tube and urinary catheter dated August 5, 2024. On August 26, 2024 at 10:33 AM, there was a sign on R16's door that showed Enhanced Barrier Precautions. V7 (RN) Registered Nurse and V6 CNA (Certified Nursing Assistant) were in R16's room to disconnect R16's percutaneous endoscopic gastrostomy tube. Neither V7 or V6 had gowns on. On August 26, 2024 at 10:35 AM, V5 and V6 CNAs provided incontinence care to R16. V6 wiped R16's front peri area, helped R16 turn onto her side. There was stool in R16's buttocks. V6 did not change her gloves or perform hand hygiene. 2. R44's admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, diabetes, palliative care, and chronic cough. On August 26, 2024 at 10:17 AM, V5 CNA took R44 to the bathroom. There was urine in R44's incontinence brief. V5 removed R44's incontinence brief, touched R44 handles of her wheel chair, retrieved wet wipes then proceeded to wipe R44 front peri area and buttocks. V5 applied cream, touched the transfer belt, placed a new brief onto R44, and then pulled up R44 pants. V5 did not change her gloves or perform hand hygiene before touching multiple clean items. R44's Care Plan initiated July 31, 2024 shows, R44 requires bowel and bladder support secondary to bladder incontinence and bowel incontinence. On August 28, 2024 at 10:16 AM, V3 CNA said gloves and gown should be worn when residents have a peg tub, urine catheter and wounds. V3 said gloves should be changed before placing a new incontinence brief because you could contaminate clean items. The facility's Enhanced Barrier Precautions policy dated December 14, 2023 shows, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. As well as to prevent multi drug resistant organism acquisition of those with an increased risk of acquiring MDROs including residents with a chronic wound or an indwelling medical device. Gown and gloves use prior tot he high contact care activity. The facility's Hand Washing and Hand Hygiene policy dated June 4, 2024 shows, Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items. 146182 Page 10 of 10