Health inspection·February 23, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the Facility failed to develop a Resident centered Care Plan for three Residents (R6, R9, R17) of 33 reviewed for Care Plans in a sample of 33. Residents Affected - Few Findings include: Facility Comprehensive Care Plan Policy and Procedure, revised 6/25/20, documents: an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the Resident's medical, nursing, mental and psychological needs is developed for each Resident; the Facility's Care Planning/Interdisciplinary Team (IDT), in coordination with the Resident/Family/Representative, develops and maintains a Comprehensive Care Plan for each Resident that identified the highest level of functioning for the Resident to be expected to attain; the IDT documents in the clinical record the Resident's status in triggered areas; each Resident's Comprehensive Care Plan has been designed to incorporate identified problem areas, risk factors, treatment goals, objectives, aid in preventing/reducing declines in functional status/levels and enhance optimal functioning; and Care Plans are revised as changes in Resident's condition dictate. The Facility's Psychotropic Medication Management policy dated 12/4/19, states 12. A plan of care will be developed to include precipitating factors, non-pharmacologic interventions and potential side effects. 1. R6's Physician Order's document R6 takes Risperdal (Antipsychotic medication) 0.25 mg (milligrams) by mouth two times a day and Abilify (Antipsychotic medication) 5 mg one time a day for a diagnosis of Bipolar Disorder. R6's Care Plan dated 11/29/22, documents R6 is on an Antipsychotic therapy (Ability and Risperdal) for Bipolar Disorder. This same Care Plan does not document R6's precipitating factors and target behaviors/symptoms to justify the use of antipsychotic medications or non-pharmacological interventions. 2. R17's Physician Order Sheet document R17 takes Risperdal (antipsychotic medication) 1 mg daily for the diagnosis of Major Depression without Psychotic Features. R17's Care Plan last updated on 2/16/24, does not document R17's use of an antipsychotic medication, precipitating factor and target behaviors for the use of antipsychotic medication or the target behaviors/symptoms to justify the use of antipsychotic medication or non-pharmacological interventions. Page 1 of 12 145021 145021 02/23/2024 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/22/24 at 11:50 a.m., V2 (Director of Nursing) stated the care plan content for psychotropic medications should follow the facility policy. 3. R9's Physician Order Sheet/POS, dated 2/21/24, documents a Physician Order for Compression Stockings (TED Hose) on in the morning and off in the evening (on in AM and off in PM) every day and night shift for Prophylaxis. R9's current Care Plan does not document R9's order for Compression Stockings (TED Hose). On 2/22/24 at 11:05 am, V2 (DON) stated, I do the Care Plans and I do not remember why these (antipsychotics and Compression Stockings) are not on their (R6, R9, R17) Care Plans. I have got too much going on and too much on my plate. 145021 Page 2 of 12 145021 02/23/2024 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

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 Based on observation, interview and record review the Facility failed to follow physician orders for compression stockings for one of 33 Residents (R9) reviewed for quality of care in a sample of 33. Residents Affected - Few Findings include: Facility Physician Orders Policy and Procedure, revised 2/14/23, documents: to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards; physician orders must be documented clearly in the medical record including the components of a complete order; clear and complete orders will be transcribed to the appropriate administration record; monthly review of physician orders will be completed to assure appropriateness, accuracy and completeness; adherence to Physician Orders will be reviewed quarterly by the Quality Assurance Committee for recommendations for sustaining professional standards; and the licensed nurse is required to record the order on the Physician Order Sheet and on the appropriate administration record and also do a progress noted. R9's Physician Order Sheet/POS, dated 2/21/24, documents R9's diagnoses including Hypertension, Atherosclerotic Heart Disease, Need for Assistance with Personal Care, Lack of Coordination, Unspecified Abnormalities of Gait and Mobility, Unsteadiness on Feet, Difficulty Walking and Acute Kidney Failure. R9's POS also documents a Physician Order for Compression Stockings (TED Hose) on in the morning and off in the evening (on in AM and off in PM) every day and night shift for Prophylaxis. On 2/20/24 at 10:10 am, 2/20/24 at 1:49 pm, 2/21/24 at 10:40 am and on 2/22/24 at 8:45 am, R9's was sitting in a wheelchair and R9's compression stockings were not on R9's lower extremities. R9's bilateral lower extremities were swollen/edematous and purple. On 2/20/24 at 10:10 am, R9 stated, I do not have any stockings on my legs and I do not know why, I do not know why they do not put them on. On 2/20/24, V2 (Director of Nursing/DON) stated, I am not sure why (R9) does not have on his compression stockings. I will check in to it. On 2/22/24 at 11:05 am, V2 (DON) stated, (R9) does not have TED Hose (Compression Stockings) on. (R9's) legs are swollen and discolored. I checked why (R9) does not have them on and they (Staff) told me that (R9) does not like to wear them, but nothing is documented anywhere and they have not notified (R9's) Doctor. 145021 Page 3 of 12 145021 02/23/2024 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

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 pressure ulcer on re-admission, to administer a physician ordered treatment for a pressure ulcer and provide timely incontinent care and pain management for a resident with a pressure ulcer for one of two residents (R6) reviewed for pressure ulcers in the sample of 33. Residents Affected - Few Findings include: The Facility's Skin Prevention, Assessment and Treatment policy dated 5/2/22, states Purpose: To promote healing of existing pressure ulcers. Procedure: Interventions for prevention or active skin alterations may include but are not limited to: i. Keep skin clean and dry; j. Incontinence care after each incontinent episode. 3. Upon identification of the development of a wound, the wound assessments/treatment will be documented in the medical record and start the weekly Wound Log. 4. Wounds are treated based on the etiology of the wound. Factors relevant to the selection of treatments include: a. Ulcer location, size, and depth; b. Presence of undermining or tunneling; c. Presence of necrotic tissue; d. Type and amount of drainage; e. Presence of granulation or epithelialization; f. Presence of surrounding skin erythema, edema, or induration; and g. Presence and severity of ulcer-related pain. 8. Residents should be assessed for pain, related to skin alteration or its treatment. 10. Nursing staff should keep the attending physician aware of the progress of all ulcers, especially those in higher risk residents, those that do not heal as anticipated, and those that develop complications. On 2/21/24 at 1:00 p.m., R6 stated he has a sore bottom. R6 stated he has been really sick and was in the hospital for four or five days with COVID-19, Influenza, and Pneumonia. R6 stated the pressure ulcer on his coccyx developed at the hospital. R6 stated he is in a lot of pain right now because he was incontinent of urine and the urine is burning the sore on his coccyx area. R6 was grimacing and trying to get pressure off of his buttocks. R6 stated he was waiting to be changed. R6 stated this is a horrible feeling; it burns like crazy. R6's sweatpants were visibly saturated in urine. R6's Nursing admission Assessment form dated 2/18/24 and completed by V10 (Registered Nurse), documents R6 was re-admitted from the hospital with a pressure ulcer on the coccyx. This same form does not document the assessment of R6's pressure ulcer such as size, shape, color, odor, or drainage. R6's Nurses Note dated 2/18/24 at 6:38 p.m., and completed by V10 (Registered Nurse), documents R6 was re-admitted from the hospital with a pressure ulcer on the coccyx. This same nurse's note does not document an assessment of R6's pressure ulcer such as size, shape, color, odor, or drainage. R6's Hospital Discharge Orders dated 2/18/24, document to apply a pressure ulcer dressing (Mepilex) to R6's coccyx daily. R6's Treatment Administration Record (TAR) dated 2/2024, documents R6 did not receive the pressure ulcer dressing (Mepilex) as ordered by the physician. R6's TAR dated 2/19/24 documents R14 (Licensed Practical Nurse) completed R6's pressure ulcer dressing (Mepilex). R6's Progress Notes dated 2/18/24 through 2/22/24, do not document that R6's physician was notified that treatment (Mepilex) was not available. 145021 Page 4 of 12 145021 02/23/2024 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R6's Medical Record does not document R6's wound again until a Progress Note dated 2/20/24 at 8:47 a.m. R6's Progress Note dated 2/20/2024 at 8:47 a.m., states (R6) has a 10 cm (centimeter) by 6 cm pressure sore on his coccyx. It presented with greenish mucus like discharge today. Orange cream applied and a bordered gauze applied. Faxed doctor. R6's Medication Administration Record dated 2/18/24 through 2/21/24, documents no pain assessment or medications were given to R6. On 2/21/24 at 1:35 p.m., R6's pressure ulcer on the coccyx was 10 cm by 6 cm in size and irregular in shape. R6's coccyx wound had some bleeding around the edge of the wound. R6 stated It feels like raw meat when (urine) is on it. On 2/21/24 at 10:30 a.m., V9 (Licensed Practical Nurse) stated on 2/20/24 she was R6's nurses on day shift. V9 stated a Certified Nurse Aide came to V9 and reported R6 had an open wound on his coccyx. V9 stated V9 immediately went to assess R6's wound. V9 stated There was no dressing or treatment in place when I measured the wound on (R6's coccyx wound) and it was 10 centimeters by 6 centimeters. V9 stated R6's medical record documented R6 was re-admitted from the hospital on 2/18/24 with this wound to the coccyx. V9 stated there was an order for a pressure ulcer dressing (Mepilex) dressing but there are no Mepilex in the building to put on (R6's coccyx) wound. I put some triple antibiotic ointment and a border gauze dressing on it to help heal it. (R6) is incontinent and the urine burns his skin. On 2/23/24 at 9:35 a.m., V14 (Licensed Practical Nurse) stated she signed off the treatment for R19's wound on 2/19/24 but another (unknown) nurse was to complete the treatment for V14. V14 stated I can't wear an N95 mask and on 2/19/24, (R6) was in COVID-19 isolation and the nurses in the back had to do his cares for me but I signed them off. I have not seen (R6's) wound and I cannot say for sure if (R6's) treatment was actually completed on 2/19/24. On 2/22/24 at 10:15 a.m., V10 (Registered Nurse) stated on 2/18/24 when R6 was re-admitted from the hospital V10 was very busy and did not get a chance to observe or treat R6's pressure ulcer on the coccyx. V10 stated I can't give you any details about (R6's) wound because I haven't seen it yet. On 2/23/24 at 10:40 a.m., V1 (Administrator) stated she was not in the facility on 2/18/24 to assess R6's pressure ulcer. V1 stated I assessed his wound on 2/19/24. V1 verified there are no dressings (Mepilex) in the facility to use for R6's pressure ulcer as originally ordered by the physician on 2/18/24. V1 stated V10 should have assessed R6's pressure ulcer on re-admission. V1 stated the dressing (Mepilex) should have been ordered and the physician should have been notified that another treatment order was needed until the dressing (Mepilex) arrived. V1 stated R6 is frequently incontinent of urine and should be kept dry at all times to prevent pain and promote the healing of the pressure ulcer. On 2/22/24 at 9:50 a.m., V2 (Director of Nursing) stated she has not observed R6's pressure ulcer to the coccyx. V2 stated R6's treatment should have been completed per physician orders and the wound should have been assessed on re-admission on [DATE]. V2 stated R6's should be getting pain medications as needed to keep him comfortable. V2 stated staff should ensure R6 is kept clean and dry to keep urine off of his open area on the coccyx. 145021 Page 5 of 12 145021 02/23/2024 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the Facility failed to implement designated post-fall interventions for one of two Residents (R23) reviewed for Falls in a sample of 33. Residents Affected - Few Findings include: Facility Fall /Accident/Incident Protocol Policy and Procedure, revised 8/1/22, documents: it is the policy of this Facility to provide guidelines for the appropriate handling of a Resident's fall; we recognize that each situation is unique and must be handled in the manner that is most appropriate at the time and for the nature of the change of condition; a nursing evaluation on all Resident falls; and complete Risk Management. Facility Comprehensive Care Plan Policy and Procedure, revised 6/25/20, documents: an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the Resident's medical and nursing needs is developed for each Resident; and each Resident's Comprehensive Care Plan has been designed to incorporate identified problem areas, risk factors, treatment goals, objectives, aid in preventing/reducing declines in functional status/levels and enhance optimal functioning. R23's current Care Plan documents R23's diagnoses including: Parkinson, Epilepsy, Unspecified Convulsions, Hemiplegia affecting Right Dominant side; Intellectual Disabilities, Abnormal Gait and Mobility, Lack of Coordination, Cognitive Communication Deficit, Glaucoma and Need for Assistance with Personal Care. R23's Care Plan also documents a non-slip adhesive pad to wheelchair and anti-roll backs to wheelchair. Facility Fall Tracking Form, dated 12/1/23 through 2/21/24, documents R23's falls on 12/6/23, 1/28/24, 1/29/24, 2/6/23 and 2/17/23. The Fall Tracking Form documents a fall intervention on 2/13/24 for anti-rollbacks to R23's wheelchair. Facility Interdisciplinary Team/IDT Review Form, dated 1/20/24, documents R23's fall out of R23's wheelchair and an intervention of an non-slip adhesive pad to R23's wheelchair seat. Facility Interdisciplinary Team/IDT Review Form, dated 2/13/24, documents R23's fall out of R23's wheelchair and an intervention of anti-roll back (stoppers) to R23's wheelchair. On 2/20/24 at 10:45 am, 2/20/24 at 12:40 pm and 2/21/24 at 1:20 pm, R23 was sitting in R23's wheelchair and anti-roll backs (stoppers) and non-slip adhesive pad were not placed on R23's wheelchair. On 2/22/24 at 8:45 am, R23 did not have a non-slip adhesive pad on R23's wheelchair seat. On 2/21/24 at 1:20 pm, R23 was sitting in R23's wheelchair, in room, and R23 stood up and a non-slip adhesive pad (Dysem) or anti-rollbacks (Stoppers) were on R23's wheelchair and R23 stated, I do not see any blue pad on my wheelchair cushion or any stoppers on the back of my wheelchair. I do get up a lot and have fallen quite a bit lately and I know I should not be doing that. On 2/21/24 at 1:05 pm, V2 (Director of Nursing/DON) stated, (R23) should have fall interventions of Dysem in (R23's) chair from R23's 1/20/24 fall, and anti-roll backs on R23's wheelchair from R23's 2/13/24 fall. I do not see them on (R23's) wheelchair, maybe his wheelchair got switched when he 145021 Page 6 of 12 145021 02/23/2024 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0689 came out of COVID isolation last week. I will check on those. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145021 Page 7 of 12 145021 02/23/2024 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to document the justification for duplicate antipsychotic medication therapy, ensure resident behaviors/symptoms to justify the use of antipsychotic medications, attempt a gradual dose reduction on antipsychotic medications, accurately complete psychotropic medication consents, complete psychotropic assessments prior to the use of antipsychotic medications and document the residents response to non-pharmacological interventions to manage behaviors/symptoms for two of five residents (R6, R17) reviewed for unnecessary medications in the sample of 33. Findings include: The Facility's Psychotropic Medication Management policy dated 12/4/19, states 1. An assessment must be conducted to identify specific behaviors/symptoms, potential causative factors, and recommendations for managing behaviors. 2. The medical record documentation must reflect the specific behaviors/symptoms and the resident's response to non-pharmacological interventions to manage the behaviors/symptoms. 4. The physician should evaluate use of antipsychotic medication use if one or more of the following is/are the only indication: a. Wandering; b. Poor self-care; c. Restlessness; d. Impaired memory; e. Anxiety; f. Depression (without psychotic features); g. Insomnia; h. Unsociability; i. Indifference to surroundings; j. Fidgeting; k. Nervousness; l. Uncooperativeness; or m. Agitated behaviors which do not represent danger to the resident or others. 5. The resident or Durable Power of Attorney/Responsible Party will be advised on the non-pharmacological interventions attempted and the resident's response. The need for psychotropic medication, indication for use, and any potential side effects will be presented to assist them with making an informed decision. 8. After implementation of psychotropic medication, behavior/symptom and medication side-effects will be monitored and documented. 10. Residents will receive ongoing evaluation to identify possible causes that may be reduced or eliminated through care plan modification. 14. Within the first year in which a resident is admitted on or initiates antipsychotic medication therapy, a Gradual Dose Reduction (GDR) must be attempted in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. 1. On 2/21/24 and 2/22/24, during random observations, R6 did not exhibit any type of behaviors. On 2/21/24 at 1:35 p.m., R6 was alert, oriented and cooperative during incontinence care and wound treatment. R6's electronic medical record documents R6 was admitted to the facility on [DATE] with diagnoses which include Bipolar Disorder and Alzheimer's Disease. R6's Physician Order's document R6 takes Risperdal (Antipsychotic medication) 0.25 mg (milligrams) by mouth two times a day and Abilify (Antipsychotic medication) 5 mg one time a day for a diagnosis of Bipolar Disorder. R6's Minimum Data Set assessment dated [DATE], documents R6 is cognitively intact with a Brief Interview for Mental Status of 15 out of 15; and R6 has no behaviors. R6's Care Plan dated 11/29/22, documents R6 is on an Antipsychotic therapy (Abilify and Risperdal) for Bipolar Disorder. This same Care Plan documents R6 has an alteration in behavior status of 145021 Page 8 of 12 145021 02/23/2024 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0758 withdrawal, suicidal ideation, inappropriate comments towards staff, mood swings, anxiety, and depression. Level of Harm - Minimal harm or potential for actual harm R6's Behavior Tracking dated 11/1/24 through 1/31/24, does not document what R6's target behaviors are. This same tracking documents R6 has had no behaviors to justify the continued use of antipsychotic medications. Residents Affected - Few R6's electronic medical record does not document any attempts of a gradual dose reduction, failed gradual dose reductions or psychotropic assessments completed including R6's response to non-pharmacological interventions. A Facsimile dated 5/15/23, documents R6's physician declined a gradual dose reduction of R6's Risperdal and Ability due to exacerbation of previous symptoms likely. R6's Psychotropic Medication Informed Consent for Abilify 5 mg, documents no behaviors exhibited by R6 and incorrectly classifies Abilify as an anti-depressant medication. On 2/21/24 at 1:15 p.m , V9 (Licensed Practical Nurse) stated she has never seen R6 have any behaviors. V9 stated R6 is a character but very nice and no negative behaviors have been observed. On 2/21/24 at 1:35 p.m., V12 (Certified Nurse Aide) stated she is not aware of R6 having any behaviors. V12 stated she has no issues when caring for R6. On 2/22/24 at 11:10 a.m., V2 (Director of Nursing) stated she is responsible for psychotropic medications with the help of V1 (Administrator). V2 stated she is not aware of R6 having any behaviors to justify the continued use of antipsychotic medications. V2 stated she was not aware of any failed GDR on R6's antipsychotics that supports R6's physician decline of the GDR attempt. V2 stated R6 does not present a danger to himself or other residents. V2 stated she does not know of any type of psychotropic assessment that is being completed by the facility. V2 stated I'll have to check into that. V2 stated R6's Informed Consent form for Abilify was completed incorrectly by listing Abilify as an antidepressant and V2 will have a new consent completed with the correct classification. V2 stated a GDR should be attempted if there is no evidence of a prior failed attempt. V2 stated she is not aware of what R6's target behaviors are. 2. On 2/21/24 and 2/22/24, during random observations, R17 did not exhibit any type of behaviors. On 2/21/24 at 11:10 a.m., R17 was alert, oriented, and cooperative during the interview process. R17's electronic medical record documents R17 was admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder without Psychotic Features. R17's Physician Order Sheet document R17 takes Risperdal (antipsychotic medication) 1 mg daily for the diagnosis of Major Depression without Psychotic Features. R17's Minimum Data Set assessment dated [DATE], documents R17 is cognitively intact with a Brief Interview for Mental Status of 15 out of 15; R17 did not exhibit any behaviors and takes an antipsychotic medication, high risk medication, daily. R17's Behavior Tracking and Progress Notes dated 11/1/23 through 1/31/24, do not document R6 has any behaviors to justify the use of antipsychotic medication and does not specify what R17's target 145021 Page 9 of 12 145021 02/23/2024 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0758 behaviors are. Level of Harm - Minimal harm or potential for actual harm R17's medical record does not document any assessment has been completed regarding R17's use of an antipsychotic medication or R17's response to non-pharmacological interventions. Residents Affected - Few On 2/22/24 at 1:10 p.m., V2, DON stated she is not aware of R17 having behaviors to justify the use of antipsychotic medications. V2 stated R17 was admitted on Risperdal, and it has not been changed to her knowledge. V2 stated R17 does not have behaviors that put him or others at risk for danger. V2 stated she is not aware of what R17's target behaviors are and that no psychotropic assessment was completed on R6's admission or since then. 145021 Page 10 of 12 145021 02/23/2024 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to explain the arbitration agreement to the resident, or their representative in a form or manner they could understand. This had the potential to affect all 49 residents residing in the facility. Residents Affected - Many Findings include: The Binding Arbitration Agreement documents This Arbitration Agreement is entered into by and between the Resident the Resident Representative in his/her individual and representative capacity and (the Facility) (the Resident, Resident Representative, and Facility are referred to herein collectively as the Parties) in connection with that certain admission agreement (the admission Agreement), executed by the Parties simultaneously herewith. The Parties believe that it is in their mutual interest to provide for a less burdensome and more efficient and cost-effective manner for handling their respective disputes. Accordingly, the Parties agree as follows: 8. The Arbitration Agreement was explained to the Resident, his/her Resident Representative, or Guardian with legal authority to enter into the Arbitration Agreement in the case of a Resident without capacity signing below, in a form and manner that he or she understands, including in a language the Resident and his/her Resident Representative signing below understand. 9. This Arbitration Agreement is made part of the admission Agreement and is not a condition of admission to the Facility or as a requirement to continue to receive care at the Facility. The Arbitration Agreement has been explained to the Resident and his/her Resident Representative signing below in a form and manner that he or she understands, including in a language the Resident and his/her Resident Representative understands. On 2/21/24 at 2:25 PM, V4 (Social Services) stated that she does not explain the arbitration agreement to the resident or their representative. V4 gives the paperwork to them to read and return to her. V4 also stated she did not realize the resident was giving up their right to take legal action against the facility. V4 thought the agreement was only about the resident paying the facility. On 2/22/24 at 10:05 AM, V6 (Admissions) stated that when she started doing the admissions job, she was assigned the job of getting the arbitration agreement signed. No one explained what the arbitration agreement meant. V6 said that she read the contract and saw that it said the resident or representative did not have to sign the agreement and that is what V6 told them. V6 trained V4 and did not explain to V4 what the arbitration agreement meant because V6 did not understand it. On 2/22/24 at 9:15 AM, R5 confirmed he signed all his own paperwork. R5 stated that he did not know if he signed the arbitration and does not understand what an arbitration agreement is. On 2/2/24 at 9:20 AM, V13 (R105's Power of Attorney) stated that he signed the arbitration agreement for R105 but did not understand what it meant. V13 also stated that he wants the arbitration agreement torn up. R5's Arbitration Agreement dated 1/18/24, documents that R5 signed the binding arbitration agreement. R105's Arbitration Agreement dated 2/19/24, documents that V13 (R105's Power of Attorney) signed the binding arbitration agreement for R105. 145021 Page 11 of 12 145021 02/23/2024 Macomb Post Acute Care Center 8 Doctors Lane Macomb, IL 61455

F 0847 Level of Harm - Potential for minimal harm Medicare and Medicaid signed by V1 (Administrator) and dated 2/20/24 documents 49 residents currently reside in the facility. Residents Affected - Many 145021 Page 12 of 12