Health inspection·November 15, 2024

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. Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter bag included a privacy cover and the catheter tubing was off the floor for one (R22) of one resident reviewed for indwelling urinary catheters in a sample of 26. Findings include: The facility's undated Catheter Care policy documents, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. R22's current Physician Order Sheet/POS documents R22 has an indwelling urinary catheter due to urinary retention. On 11/12/24, at 10:23am, R22 sat in his room with no privacy cover on his indwelling urinary catheter bag. On 11/12/24, at 12:40pm, R22 sat at a dining room table with no privacy bag on his indwelling urinary catheter bag and the catheter tubing was touching the floor. On 11/12/24, at 1:07pm, V6 Certified Nursing Assistant/CNA confirmed that R22's indwelling catheter bag is not in a privacy bag and should be covered. V6 also confirmed that R22's catheter tubing was touching the floor and should not be. On 11/13/24, at 8:30am and 11:58am, R22 sat at a dining room table with an indwelling catheter bag hanging underneath his wheelchair. R22's catheter bag did not contain a privacy covering. On 11/14/24, at 1:21pm, V2 Director of Nursing/DON stated that catheter bags are to be covered with privacy covers and catheter tubing should not be touching the floor. Page 1 of 2 145151 145151 11/15/2024 Allure of Mendota 1201 First Avenue Mendota, IL 61342

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders and medication instructions for two (R6 and R56) of seven residents reviewed during Medication Administration. This failure resulted in two medication errors out of 26 opportunities resulting in a 7.69% (percent) medication error rate. Residents Affected - Few Findings include: The facility's undated Medication Administration policy documents, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and compliance Guidelines: 10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. 1. On 11/13/24, at 8:45am, R56 sat on her bed. V5 Registered Nurse/RN administered Vitamin D 25mcg (micrograms) one tablet to R56. R56's current Physician Order Sheet/POS documents an order for Vitamin D3 oral tablet give 125mcg by mouth in the morning. On 11/13/24, at 2:40pm, V5 RN confirmed that V5 gave the wrong medication to R56, that V5 pulled the wrong Vitamin D from the drawer of the medication cart. 2. On 11/13/24, at 9:04am, R6 was in bed. V4 RN gave R6 his Albuterol inhaler in which R6 inhaled two puffs orally. Next V4 gave R6 his Arnuity Ellipta 50mcg (micrograms) inhaler and R6 inhaled one puff orally. This inhaler was followed by his Stiolto 2.5mg (milligrams) inhaler in which R6 inhaled two puffs. V4 took the three inhalers and left R6's room. R6's current Physician Order Sheet/POS documents an order for Arnuity Ellipta Inhalation Aerosol Powder Breath Activated 50 mcg/act (micrograms/actuation) (Fluticasone Furoate (Inhalation) one puff inhale orally in the morning related to Chronic Obstructive Pulmonary Disease, Unspecified. The facility's undated Full Prescribing Information for Arnuity Ellipta documents Dosage and Administration: Administration: After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis. On 11/13/24, at 2:43pm, V4 RN confirmed that V4 should have had R6 rinse and spit after inhaling the Arnuity Ellipta as it is a steroid. 145151 Page 2 of 2