Health inspection·May 28, 2024

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure ostomy care was provided in a manner to prevent skin irritation. This applies to 1 of 2 residents (R1) reviewed for ostomies in the sample of 7. The findings include: R1's face sheet shows he is a [AGE] year-old male admitted to the facility on [DATE]. R1's diagnoses include end stage renal failure, dependence of renal dialysis, acute respiratory failure with hypoxia, orthostatic hypotension, ileostomy status, gout, pain in right foot and primary osteoarthritis in right foot and ankle. On 5/22/24 at 12:02 PM, V5 (RN) stated R1's ostomy would leak often, his appliance would have to be changed two to three times a shift. Sometimes we would use tape to reinforce it to the skin. There was skin irritation around R1's stoma site. R1 would report burning around the site. On 5/22/24 at 1:04 PM, V16 (Licensed Practical Nurse-LPN) stated R1's ostomy was leaking a lot, sometimes we would have to change it two to three times a shift. R1 report burning around the stoma area. We would use wipes around the stoma and sometimes apply the skin prep. On 5/22/24 at 1:27 PM, V17 (Certified Nursing Assistant-CNA) stated R1's ostomy would leak all the time, from the bottom of the appliance. Stool was leaking on his skin. R1's skin was raw he would say it was burning from the fecal matter. The nurse knew about the skin irritation. On 5/23/24 at 9:27 AM, V21 (RN-Registered Nurse) said R1's ostomy leaked quite often. R1 reported burning when it leaked. There was some irritation around the stoma site. I did not report to the wound nurse. On 5/23/24 at 9:41 AM, V20 (RN) stated R1's ostomy would leak, the appliance would have to be changed two to three times a shift because it was not adhering to the skin. There was skin irritation around the stoma. On 5/22/24 at 11:23 AM, V9 (Wound Nurse) stated nursing should notify me if there is any skin issues for residents who have ostomies. Ostomies should be changed as needed. You don't want to keep ripping them off because it could cause irritation to the skin. Most of the skin issues are from the ostomy leaking, because there is not a good seal to the skin. She saw R1's ostomy and at the time it was not leaking. I would expect nursing to notify me if the appliance continued to not adhere to skin so I could take a look at it and recommend treatment. Page 1 of 2 146194 146194 05/28/2024 Thrive of Fox Valley 4020 E New York Street Aurora, IL 60504

F 0691 Level of Harm - Minimal harm or potential for actual harm On 5/22/24 at 2:46 PM, V2 (DON) stated she knew there was some issues with R1's ileostomy leaking at the time V9 was notified, but it was not leaking. Standard of care includes documentation of the skin around the stoma site and report any skin irritation. There should be ostomy orders and care for each resident with an ostomy. Nursing should notify the wound nurse if there is skin breakdown around the stoma site. V2 confirmed R1 did not have ostomy care orders. Residents Affected - Few R1's nurses note dated 4/20/24 documents R1's ileostomy bag was leaking. R1's nurses note dated 4/25/24 documents excoriation skin around the bottom of the stoma site. R1's nurses note dated 4/25/24 documents ostomy leaking. R1's Physician Progress note dated 5/1/24 documents R1 has been having problems with leaking from the ileostomy as well as skin issues around his site .he should have his ostomy cut so that minimal skin is exposed. R1's Physician Orders, Medication/Treatment Orders dated May 2025 does not include ostomy care orders. R1's current care plan shows R1 has an ostomy with interventions include to monitor stoma color for any changes, provide ostomy care per protocol. The facility's Colostomy-Ileostomy Care revised 2023 states, wash around the colostomy site with appropriate skin cleansing preparation, evaluate resident skin noting, apply barrier cream, apply paste if needed, replace clean or new drainage bag, ensure bag is adhered to the skin .document in nursing noted any skin issued and condition of stoma, report these issues to physician, ostomy appliances are changed weekly and PRN as standard of care . 146194 Page 2 of 2