Health inspection·February 9, 2022

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to complete a restraint assessment including the risk versus benefits of a seat belt with alarm for 1 of 2 residents (R24) reviewed for physical restraints in the sample of 41. Residents Affected - Few Findings include: R24's admission Record, admission date of 9/16/19, documented a medical diagnosis of Alzheimer's disease, Dementia, history of falling, muscle weakness, unsteadiness on feet, urgency of urination. R24's Physician Order Sheet, dated 2/8/22, documented an order for seat belt chair alarm in wheelchair, release every two hours and as needed, order dated 12/9/21. R24's Physical device/Psychoactive Medication initial Quarterly Evaluation, dated for the following; R24's admission quarterly evaluations dated from 2/19/20 through 12/2/20 documented, device recommendations of a lap buddy when up in wheelchair for a medical diagnosis of; symptom interference of with judgement, gait, unable to transfer without assistance, physical limitation, history of falls and balance issues and a medical diagnosis of Alzheimer's dementia. On 1/11/21, documented a physical restraint of a seat-belt with alarm. On 5/17/21, documented a physical restraint of a lap buddy placed over the seat-belt, due to resident had physically destroyed the seat-belt beyond repair. On 8/16/21 and for the last physical restraint evaluation, dated 11/15/21, documented the use of a lap buddy. The facility failed to do an initial evaluation for a physical restraint provided on 12/9/21. R24's Fall Occurrence Report, dated 12/8/21 at 9:00PM, V2, Director of Nursing (DON), documented, R24 was observed in front of nurses station, in a wheelchair, placing self under the lap buddy and sliding out onto the floor. New intervention to be put into place is to discontinue the lap buddy and sensor alarm in chair and add seat belt alarm when in wheelchair. On 2/2/22 at 2:00PM, V2 stated she could not provide an initial evaluation of R24's seat belt restraint that was initiated on 12/9/21. V2 stated she was not aware that a new physical restraint assessments needed to be completed, since R24 was previous placed with a lap buddy physical restraint. V2 continued to state, R24 had literally positioned her body under the lap buddy and to the ground, in which the incident happened so quick, V2 could not prevent the fall. R24's Care Plan, dated 1/11/21, documented, Focus area; entitled, I am at risk for falls r/t (related to) Alzheimer's dementia with poor safety awareness, weakness from CVA, (Cerebrovascular attack), medications that may cause hypotension or dizziness vision and communication impairments and incontinence, initiated, 10/27/19. Intervention, dated 12/9/21, documented, Seat belt alarm while in Page 1 of 9 145267 145267 02/09/2022 Pana Health and Rehab Center 1000 East Sixth Street Road Pana, IL 62557

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchair. Release q (every) 2 hours and PRN (as needed) when in direct supervision of staff, and check seat belt alarm for fitting, placement, and working condition every shift and report any damage to the supervisor. The Facility's policy and procedure, entitled, Restraint Program Policy and Procedure, revision date of 11/10/15, documented, Prior to the use of any restraint, each resident is assessed for potential alternatives. During this investigation ,on 1/31/22 through 2/9/22, R24 was observed in a wheelchair, stationed either a the nurses station or propelling herself down halls. R24, had visual and hand helded sensory objects at all times, seat belt alarm attached and sent to room for toileting assistance every one-two hours. On 2/2/22 at 9:30AM, V7, Certified Nurse Aide (CNA), stated she has cared for R24 for a long while and she is one to get up out of her wheelchair unassisted, has had many falls and the seat belt alarm is for her safety. V7 revealed that R24, is capable of removing and attached her seat belt. 145267 Page 2 of 9 145267 02/09/2022 Pana Health and Rehab Center 1000 East Sixth Street Road Pana, IL 62557

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 perform proper hand hygiene to prevent the spread of infection for 3 of 5 (R5, R39, R47) residents reviewed for and infection control in the sample of 41. Residents Affected - Few Findings include: 1. On 02/08/22 at 9:40 AM, V22, Certified Nurse Aide (CNA), provided incontinent care for R5. V22 put gloves on without hand hygiene prior to glove placement, pulled R5's incontinent brief down which was soiled front and back with a large amount of loose smeared brown stool. V22 took a wet cloth and put cleanser on the cloth, cleansed her front perineal area, rolled R5 on her right side, removed the soiled depends, with the same gloves V22 picked up a wet wash cloth and took the bottle of cleanser and put some cleanser on the cloth, cleansed the rectal area. V22 then removed her gloves washed her hands, placed a new incontinent brief down on the bed. On 2/9/22 at 8:45 AM, V2, Director of Nursing (DON), stated, she would expect staff to use appropriate hand hygiene and use hand hygiene prior to applying gloves. The facility Policy and Procedure for Resident Care dated 12/05, revised 11/2016 documents, Policy: Following evidence based practice, glove changes and the performance of hand hygiene during perineal care may be limited to before initiating perineal care, any time gloves are visably soiled, and at the completion of perineal care. 2. On 02/01/22 at 10:30 AM, V8, Licensed Practical Nurse (LPN), placed surgical mask over N95, donned gown. V8 then donned gloves, V8 did not sanitize her hands prior to donning gloves. V8 entered R39's room. 3. On 02/08/22 at 1:15PM ,V15, CNA, had gloves on and used cleansing cloths to perform catheter care for R47. V15 Cleansed penis, pulled foreskin back, cleansed head, then cleansed the catheter tubing. V15 then cleansed R47's groin. V15 removed her gloves. V15 donned new gloves and cleansed R47's scrotum.V15 did not sanitize her hands prior to donning gloves. On 2/08/22 at10:47 AM V2 Director of Nursing (DON) stated that she would expect staff to sanitize hands prior to donning glove. The Facility Donning and Doffing PPE (Personal Protective Equipment) and Isolation Competency, undated, documents performs hand hygiene. 145267 Page 3 of 9 145267 02/09/2022 Pana Health and Rehab Center 1000 East Sixth Street Road Pana, IL 62557

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 4. R27's current physician orders dated 2/1/2022 documents that R27 is currently receiving Seroquel 37.5mg in the AM and 25mg at hs and Buspar 5mg Three times a day. R27's face sheet dated 11/30/2018 documents that R27 has a diagnosis to include unspecified Dementia with behavioral disturbances. R27's In Home Medical Group (IHMG) sheet dated 8/11/2021 documents increase am dose of Seroquel to 37.5mg. R27's IMHG dated 12/22/2021 documents increase buspar 5mg am and pm Start buspar 2.5mg in afternoon. R27's sheet dated 1/5/2022 documents increase Buspar. R27's physician order dated 2/2/2022 documents Seroquel 25mg at hs and Seroquel 37.5 mg by mouth in the morning. Physician orders dated 2/1/2022 documents Buspirone 5mg three times a day. R27's medication review dated 1/21/2021 documents see report for any noted irregularities and/or recommendations. Report dated 2/13/2021 documents no irregularities. Report dated 3/16/2021 documents no irregularities/or recommendations. Report dated 4/21/2021 documents see report for any noted irrregularities and/or recommendations. The pharmacy note to attending physician dated 4/29/2021 documents pharmacist recommended dose reduction to - trial reduction of seroquel 25mg BID to Seroquel to 12.5mg am and Seroquel 25mg pm. The physician did not mark agree or disagree with any type of rational, The physcian marked further dose reduction clinically contraindicated but to behavioral interventions continue to be attempted. R27's physician orders do not document an attempted dose reduction, but an increase. The Facility Policy Psychotropic Medication dated 11/28/17, documents the requirements for Gradual Dose Reduction must be followed. Based on interview and record review, the facility failed to attempt Gradual Dose Reductions (GDR's) and put resident centered behavior tracking in place for 4 of 5 residents (R18, R27, R33, R53) reviewed for psychotropic medications in the sample of 41. Findings include: 1. R18's Face Sheet, print date of 2/1/22, documents R18 was admitted on [DATE] with diagnoses of Major Depression Disorder and Anxiety. R18's Pharmacy Recommendation, dated 6/29/21, documents, Resident receives the following medication used for depression: Cymbalta 60 mg (milligram) Q (every) AM for Depression since 3/22/2020 145267 Page 4 of 9 145267 02/09/2022 Pana Health and Rehab Center 1000 East Sixth Street Road Pana, IL 62557

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident also continues on Buspar 5 mg bid (twice a day) and hydroxyzine 25 mg q 6 hours prn (as needed) itching. The Centers for Medicare and Medicaid Services (CMS) requires attempts at dosage reductions on antidepressant medications used for managing behavior, stabilizing mood, or treating psychiatric disorders twice a year, in two separate quarters (with at least one month between attempts), within the first year of admission or initiation, and annually thereafter unless clinically contraindicated. Resident is due for an evaluation. Please complete on of the following sections. 1. ( x) Further dose reduction is clinically contraindicated due to: ( ) The continued use in accordance with relevant current standards or practice. A dose reduction at this time would likely impair resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder as supported by the following CLINICAL RATIONALE AND EVIDENCE OF THE FOLLOWING SYMPTOMS: (no documentation available for review). R18's Pharmacy Recommendation, dated 8/31/21, documents, Resident receives the following medication used for anxiety: on Buspar 5 mg bid for anxiety since 7/31/2020. The Centers for Medicare and Medicaid Services (CMS) requires attempts at dosage reductions on antidepressant medications used for managing behavior, stabilizing mood, or treating psychiatric disorders twice a year, in two separate quarters (with at least one month between attempts), within the first year of admission or initiation, and annually thereafter unless clinically contraindicated. Resident is due for an evaluation. Please complete on of the following sections. 1. ( x) Further dose reduction is clinically contraindicated due to: ( ) The continued use in accordance with relevant current standards or practice. A dose reduction at this time would likely impair resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder as supported by the following CLINICAL RATIONALE AND EVIDENCE OF THE FOLLOWING SYMPTOMS: (no documentation available for review). R18's Order Summary Report, dated 2/1/22, documents, Buspirone HCL Tablet 5 mg. Give 1 tablet by mouth two times a day for anxiety. Start date of 7/31/2020. R18's Order Summary Report, dated 2/1/22, documents, Cymbalta Capsule Delayed Release Particles 60 mg. Give 60 mg by mouth in the morning for depression. On 2/8/22 at 4:00 PM, V2, Director of Nurses (DON), stated, I review the the pharmacy recommendations and then pass them on to the Doctor. He gives them back to me and I did not see that he had not addressed the reasons he does not want to her to have a dose reduction. 2. R33's Face Sheet, documents R33 was admitted on [DATE] with diagnoses of Alzheimer's Disease, Dementia and Major Depression Disorder. R33's 2/2022 Physician Orders document, Fluoxetine HCl Tablet 10 MG. Give 10 mg by mouth at bedtime for depression. Start date of 8/30/2019. R33's last Pharmacy Gradual Dose Reduction Recommendation for Fluoxetine was 12/08/2020. 145267 Page 5 of 9 145267 02/09/2022 Pana Health and Rehab Center 1000 East Sixth Street Road Pana, IL 62557

F 0758 Level of Harm - Minimal harm or potential for actual harm On 2/8/22 at 4:00 PM, V2 stated that R33 should have had an attempted dose reduction on 12/4/21 and it was missed. 3. R53's Face Sheet, print date of 2/1/22, documents R53 was admitted on [DATE] with diagnoses of Dementia with behaviors and Major Depressive Disorder. Residents Affected - Some R53's 2/2022 Physician Order Summary documents, Alprazolam Tablet 0.25 MG. Give 0.25 mg by mouth every 8 hours as needed for anxiety. Start date of 9/28/21 and Risperdal Tablet 0.5 mg. Give 0.5 mg by mouth two times a day related to unspecified Dementia with Behavioral Disturbance. Start date 10/12/21. R53's 12/2021 - 2/9/2022 Medication Administration Record (MAR) documents, R53 received Alprazolam 0.25 mg tablet 7 times as an as needed medication. R53's Nurses Note, dated 10/5/21 at 3:44 PM, documents, This nurse knocked on residents door. Door slightly ajar. Resident slammed the door and stated, 'this is my room!' This nurse knocked again stating I was the nurse. Resident opened the door and invited this nurse in. Resident is agitated and tearful with increased resp (respiration) rate. Resident went on to state that there were people trying to kill her and her children. Resident stated men and woman were shooting needles out of small guns into her neck. The resident stated there was a woman with a large knife trying to stab her from across the street. Resident then stated that when she was eating she looked at her arm and food began to leak out of her arm like it was blood and had to dive behind a car to keep the small man in the bed in the window from shooting her and her kids. Resident worried he will set her and her children on fire in the middle of the night. Resident also stated that if these people come on her property that they will be arrested, but the police won't do anything to stop them from trying to kill her and her kids. Resident then stated she was awaiting three surgeries to remove her liver, spleen and another part she can't remember. This nurse provided TLC (tender loving care) to resident somewhat successful. Resp even and unlabored, no longer tearful. Resident states she is still worried but not as much. Resident is currently sitting in chair in room. PRN (as needed) acetaminophen administered as ordered c/o (complaint of) pain. Call light within reach. Staff will continue to monitor. R53's Nurse Note, dated 10/5/21 at 10:04 PM, documents, Writer took HS (hour of sleep) meds (medication) into room and noted res (resident) was in the BR (bathroom). Res came out and stated, 'I was hiding in there from those people.' Writer reassured res that the room was safe and that writer had meds for her. Res sat down and proceeded to take meds without difficulty. Res resting quietly in recliner at this time. R53's Nurse Note, dated 10/6/21, documents, Primary care physician stated he wants to be notified on 10/7/21 about residents behaviors following the start of the Risperdal 0.5mg BID. R53's Behavior Tracking does not address the use of Risperdal for hallucinations. R53's Behavior Tracking address exit seeking only. On 1/31/22 at 2:30 PM, V25, Licensed Practical Nurse (LPN), stated that R53 does have hallucinations of her old neighbors trying to kill her and that she has 45 children. V25 stated she doesn't have them as often now but she does still have them. On 2/8/22 at 4:00 PM, V2 stated she thought the initial order for an as needed psychotropics needed to be for 14 days only and then after that is could be long standing. V2 also stated that R53 145267 Page 6 of 9 145267 02/09/2022 Pana Health and Rehab Center 1000 East Sixth Street Road Pana, IL 62557

F 0758 should be behavior tracked for her hallucinations. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 145267 Page 7 of 9 145267 02/09/2022 Pana Health and Rehab Center 1000 East Sixth Street Road Pana, IL 62557

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation interview and record review the facility failed to provide food at a palatable temperatures during meal service. This had the potential to affect all 72 residents in the facility. Residents Affected - Many Findings include: Resident Council minutes dated 11/2/21, 12/6/21 and 1/3/22, documented, the food continues to be served cold. The concerns addressed to the dietary manager, with dietary manager documentation of, hot food is always temped where it should be before going onto the steamtable. The Facility's Quality Assurance Performance Improvement, (QAPI) dated, 1/3/22, documented an action Plan titled, COLD food, that addresses issues of, monitor temperatures in the kitchen before serving, with the first tray and last to be served on each cart, monitor pass times, educate staff to keep door closed to cart during serving and random interviews with residents after meals. On 02/07/22 at 11:45 AM, entered kitchen food was placed in the steam table. The following meal service was temped for the following; Ham slices at 152 degrees (F), (Fahrenheit), Peas at 162 degrees( F), Sweet Potatoes at 160 degrees (F), gravy at 150 degrees (F), pureed Ham at 170 degrees (F), pureed Peas at 164 degrees (F) and pureed Sweet Potatoes at 142 degrees (F). On 2/7/22 at 11:50AM, 12 meal trays that contained the meal in Styrofoam closed container, were loaded onto an uninsulated roll hall cart. On 2/7/22 at 11:55AM, the cart was then transferred to the 300 hall, with the first tray delivered by two staff members at 11:55AM, to the residents rooms, with the last tray delivered at 12:05PM with 11 meal trays distributed. On 2/7/22 at 12:07 PM, the 12th meal tray was temperature checked with the following; Ham at 90 degrees (F), peas at 110 degrees (F) and cubed sweet potatoes at 100 degrees (F). On 02/7/22 at 1:04 PM through 1:15PM, the following were interviewed; R19, R6, R42 and R50, they all stated the lunch served today was warm and has been this way for quite a while. On 2/8/22 at 12:30 PM, V1, Administrator, stated he is aware of residents voicing concerns of the food low temperatures with monitoring by kitchen and administration staff. V1 continued to state the kitchen has been serving meals using Styrofoam since October not due to quarantine status, but kitchen staffing. On 2/8/22 at 12:40 PM, V10, Dietary Manager, stated the food is served in Styrofoam due to three kitchen staff out on quarantine status and due to staffing issues, washing meal plates is time consuming. The facility's procedure, entitled, Time and Temperature Standards, dated 6/2018, documented, Serving: Maintain internal temperature at more than 135 degrees (F). 145267 Page 8 of 9 145267 02/09/2022 Pana Health and Rehab Center 1000 East Sixth Street Road Pana, IL 62557

F 0804 The Facility's Resident Census band Conditions of Residents, CMS 672 dated 2/1/22, documented the facility had a census of 72 residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 145267 Page 9 of 9