Health inspection·March 18, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, monitor, document, and care plan a resident with a cholecystostomy drain and failed to provide care and services for a resident needing staff assistance for 2 of 4 residents (R2, R4) reviewed for quality of care in the sample of 4. Residents Affected - Few The findings include: 1. On 3/18/25 at 11:06 AM, R4 was sitting up in a wheelchair in her room. R4 had a cholecystostomy drainage bag sitting next to her in the wheelchair. R4 stated she had a gallbladder attack in hospital and the bag is from that. R4 stated there is some drainage into the bag and the nurses drain it. R4 lifted her shirt and showed this surveyor the cholecystostomy incision site on the right side of her abdominal area. R4's incision site had gauze covering the insertion area with the drainage tube coming out. The gauze was covered with a transparent dressing. The gauze had a nickel size dried brownish red area of drainage around the drainage tube. There was no date on either dressing. R4 stated this dressing is from the hospital, no one here has changed it or looked underneath the dressing. V12 (R4's) son was sitting bedside and confirmed that the dressing around the insertion site of the cholecystostomy was the one the hospital put on. On 3/18/25 at 10:07 AM, V6 Licensed Practical Nurse stated R4 has a drain that needs to be emptied and documented once a shift. V6 stated R4's drain has a small amount of golden colored drainage usually. V6 stated she was not aware of dressing change orders or monitoring for the insertion site. On 3/18/25 at 11:31 AM, V2 Director of Nursing stated nurses should be looking and assessing R4's cholecystostomy insertion site to monitor for signs and symptoms of infection. V2 stated there should be orders for dressing changes to the site and if the hospital discharge orders did not contain orders the nurse should reach out to the doctor for orders. R4's face sheet shows R4 was admitted on [DATE] with a diagnosis of calculus of gallbladder with acute cholecystitis with obstruction. R4's admission assessment dated [DATE] shows Does the Resident have surgical drain? NO is marked. R4's Progress Note dated 3/9/25 shows the resident does not have a surgical drain. R4's Care Plan shows R4 is at risk for alteration in skin integrity related to fall, hematoma center forehead, acute displaced fractures of left and right nasal boned, calculus of gallbladder with acute cholecystitis, chole tube, acute kidney injury, respiratory failure. There are no interventions listed for monitoring or care of R4's cholecystostomy drain. Page 1 of 3 146194 146194 03/18/2025 Thrive of Fox Valley 4020 E New York Street Aurora, IL 60504

F 0684 Level of Harm - Minimal harm or potential for actual harm R4's Physician Orders (POS) shows orders dated 3/9/25 to cleanse area with normal saline, apply clean dry split sponge to site and secure with tape, as needed (order does not address what area being cleansed). The same POS contains an order to empty drain, measure and record amount of drainage. Notify doctor of any abnormal drainage and color change. There are no orders to monitor the cholecystostomy site. Residents Affected - Few On 3/18/25 at 1:25 PM, V13 Nurse Consultant stated she was not sure what the order to cleanse are with normal saline was for and would get the order clarified. R4's Infectious disease Nurse Practitioner note dated 3/10/25 shows routine cholecystostomy tube care per facility protocol and Needs follow up with Gastrointestinal/Surgery for drain management. The facility's Wound Policy and Procedure dated 5/23 shows Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing and preventing infection.2. R1's medical record indicated resident admitted to facility on 03/07/2025 with a past medical history not limited to: acute kidney failure, urinary tract infection, morbid obesity, gout, and bilateral primary osteoarthritis of the knee. R1's Brief Interview for Mental Status Evaluation dated 03/07/2025 documented score of 15 which indicated no cognitive impairment. R1's care plan report with date initiated of 03/07/2025 reads in part: activities of daily training (ADL's) self-care performance deficits and limitations in physical mobility, resident is incontinent with interventions to check every 2-3 hours and as needed for incontinence and is at risk for skin integrity and falls. R1's order summary report as of 03/18/2025 showed order for occupational therapy 3-4 times per week for 4 weeks to include but not limited to ADL's and bed mobility; and skilled physical therapy services 3-4 times per week for 4 weeks to include but not limited to therapeutic exercises and activities. On 03/18/2025 at 11:04 AM, R1 stated a few days after she came to the facility (couldn't recall date), she had spilled ice water on her bed at around 6:30 AM. R1 stated she pressed her call light for staff assistance and when someone finally came, she asked for her wet sheets to be changed but was told someone would be back to help her. R1's call light was turned off and the staff member left the room. R1 stated when her breakfast tray was brought in around 9:00 AM, she again asked the staff member to change her bed linens and was told it would be done after all trays were passed but no one came back. R1 then stated her son came in around lunch time and her cold and wet bed linens still had not been changed so her son went to the desk and informed staff that R1's bed linens needed to be changed. R1 added that she had pressed her call light multiple times for several hours to have the bed linens changed, but a staff member didn't come into the room to provide assistance until after 1:00 PM. R1 added that when staff did come, she asked them to assist her roommate (R2) first because she had an incontinence episode in her wheelchair. On 03/18/2025 at 11:46 AM, V2 (Director of Nursing) stated she expects for staff to answer all call lights within a timely manner, normally within 10-15 minutes. V2 added that staff should not turn off a call light without providing assistance, and the call light should remain on until all of the resident's needs are met. 146194 Page 2 of 3 146194 03/18/2025 Thrive of Fox Valley 4020 E New York Street Aurora, IL 60504

F 0684 Level of Harm - Minimal harm or potential for actual harm Call light policy last reviewed 01/2024 reads in part, the call light system is provided as a tool for residents to communicate with staff .Staff members will acknowledge and respond to the call light by entering the resident's room and determining and assisting with the resident's needs. Residents Affected - Few 146194 Page 3 of 3