Health inspection·November 19, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to assess one resident (R1) for safety to self-medicate of three residents reviewed for self-medication in a sample list of eight residents. Findings Include:R1's Care Plan updated 10/2/25 includes the following diagnoses: Open Wound to the Abdominal Wall, Polyneuropathy, Spondylosis, Severe Obesity, Reduced Mobility, Repeated Falls, Chronic Clostridium Difficile, History of MRSA (Methicillin Resistant Staphylococcus Aureus), and History of Total Knee Replacement.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and totally dependent on staff for mobility and incontinence care.There is no documentation of a self-medication assessment documented in R1's electronic medical record. R1's Care Plan does not address self-medication. On 11/19/25 at 12:50PM, R1 had a brown capsule on the over the bed table in a medication cup. R1 was not able to verbalize what pill it was but stated, They just leave my medicine and I take it. R1 swallowed the capsule and disposed of the cup. On 11/19/25 at 1:00PM, V5 Registered Nurse (RN) was at the medication cart in the hall outside R1's room. V5 verified V5 is the nurse caring for R1. V5 stated, (R1) is totally with it mentally. I thought she would take it, it's her Gabapentin. R1's Medication Administration Record (MAR) documents R1 has a current order for Gabapentin 300 milligrams four times daily. V5 verified V5 is aware she should watch residents swallow medication and not leave medication at bedside without a specific physician's order to do so.On 11/19/25 at 1:15PM, V2 Director of Nursing verified R1 is not to receive medication without the nurse on duty watching R1 take them. V2 verified R1 is not on a self-medication program and R1 has no physician's order to self-administer any medication.The facility's policy Administration of Medication revised 5/2025 states Self-Administration of medication is permitted when approved by the Intradisciplinary Team (IDT) with a written order by the primary attending physician. Residents Affected - Few Page 1 of 2 145243 145243 11/19/2025 Accolade Healthcare Danville 801 North Logan Avenue Danville, IL 61832

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 provide incontinence care/catheter care in a timely manner and failed to maintain a urinary catheter bag below the level of the bladder for one resident (R1) and failed to use appropriate hand hygiene for another resident during incontinence care (R5) of three residents reviewed for incontinence care in a sample list of eight residents.Findings Include:R1's Care Plan updated 10/2/25 includes the following diagnoses: Open Wound to the Abdominal Wall, Polyneuropathy, Spondylosis, Severe Obesity, Reduced Mobility, Repeated Falls, Chronic Clostridium Difficile, History of MRSA (Methicillin Resistant Staphylococcus Aureus), and History of Total Knee Replacement.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and totally dependent on staff for mobility and incontinence care.On 11/19/25 at 11:30AM, R1 was observed returning from a doctor's appointment. R1 was brought to R1s room. R1 told V7, Certified Nursing Assistant (CNA) she needs to go to bed to be cleaned as she has diarrhea. There was an odor of feces around R1. At 12:50PM, R1 was in bed with the sling type mechanical lift sling under her and her catheter bag was lying on her abdomen. V7 was in the room alone with R1. R1 stated, They haven't cleaned me since I got back at 11:30AM. V7 stated, We were busy with lunch and I had to get some help. V7 left the room to get help after verifying R1 had not been cleaned since returning from the doctor's appointment.On 11/19/25 at 1:30PM, V2 Director of Nursing verified R1 should have been cleaned up sooner especially given R1 has an open wound to her abdomen.On 11/19/25 at 12:00PM, V6 Certified Nursing Assistant (CNA) was completing incontinence care for R5 following R5 being incontinent of bladder and bowel. V6 first cleaned the urine from R5 and cleansed R5's perineal area. With the assistance of V3 ADON (Assistant Director of Nursing), V6 turned R5 on her left side and cleansed the feces off R5's anal area. V6 failed to complete hand hygiene or change gloves before to applying barrier cream to R5's abdominal fold. When asked, V6 verified she should have completed hand hygiene and donned clean gloves prior to applying the cream to R5's abdominal fold. V3 verified V6 should have performed hand hygiene and changed gloves prior to applying the cream.The facility's policy Toileting and incontinence care Revised 6/25/25 states, All will receive assistance with toileting needs according to their Plan of Care Guidelines. Incontinence care will be provided to keep skin clean, dry, free of irritation and odor. Incontinence care will be provided after each incontinence episode. 145243 Page 2 of 2