Health inspection·May 10, 2023

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** 2. R49's Care Plan, dated 4/28/23, documents ADLs, (activities of daily living), Functional Status/Rehabilitation Potential PROBLEM: (R49) admitted to facility from outlying hospital after suffering from a Cerebral infarct. (R49) has dx of, but not limited to: Huntington's disease, HTN, (Hypertension), atherosclerotic heart disease, autoimmune thyroiditis, type II diabetes, hyperlipidemia, hemiplegia, and hemiparesis to right side following CVA, (Cerebral Vascular Accident), dysphagia, abnormalities in gait and mobility, urinary retention, and convulsions. (R49) has an upper and lower partial. 6/15/22 June is able to ambulate short distances with two staff and a gait belt. Her primary mode of locomotion is a w\c, (wheelchair), that she requires assistance to propel. (R49) is alert and able to voice needs. It continues, APPROACH: Provide toileting assistance at least every 2 hours, PRN, (as needed), and upon any request. Document bowel and bladder tracking daily every shift. Notify nurse if (R49) has no BM, (bowel movement), in at least 3 days. If (R49) has an incontinent episode provide peri care and apply moisture barrier to skin. (R49) prefers to wear disposable briefs to bed. APPROACH: (R49) is to be ambulated, transferred, and toileted using two staff and a gait belt due to spastic movements r\t, (related to), Huntington's Disease. R49's Minimum Data Set, (MDS), dated [DATE], documents that R49 is always continent of bowel and bladder and requires extensive assist of 2 staff for toileting. On 5/8/2023 at 12:30 PM V14, CNA, assisted R49 to the toilet. V14 washed hands and applied gloves. V14 pulled down R49's soiled incontinent brief and assisted R49 onto the toilet. R49 using same gloves closed the bathroom door. R49 voided while using the toilet and voiced she was finished. V14 then grabbed toilet paper and wiped R49 from behind with 2 wipes. V14 then placed the toilet paper in the toilet and pulled R49's incontinent brief and pants up. 3. R207's admission Profile, undated, documents that R207 was admitted on [DATE] and has diagnoses of Hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side Muscle weakness, (generalized). R207's Minimum Data Set, dated [DATE], documents that R207 requires extensive assistance of 2 staff members for bed mobility, extensive assistance of 1 staff member for transfer, toileting, personal hygiene and is frequently incontinent of bowel and bladder. R207's care Plan, dated 4/26/23, documents, (R207) has bowel and bladder incontinence R/T, (related to), generalized weakness, use of diuretics, h/o, (history of), CVA, (cerebrovascular accident), with L, (left), hemiparesis. Goal: R207 will not have impaired skin integrity r\t incontinence through next review. Approach: Provide assistance for toileting at least every 2 hours, PRN, and upon any Page 1 of 7 145294 145294 05/10/2023 Prairie Village Healthcare Ctr 1024 West Walnut Jacksonville, IL 62650

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few request. Provide incontinence care after each incontinent episode. Report any signs of skin breakdown, (sore, tender, red, or broken areas). Apply moisture barrier to skin after each incontinent episode. May keep at bedside and be applied per CNA. On 5/7/23 at 8:25 AM, R207 had his call light on. R207 was questioned as to what he needed, R207 stated, I have had a bowel movement and I need to be cleaned up. R207 was questioned as to how long he has had his light on, R207 stated, It's been a while. On 5/7/23 at 8:30 AM, V6, Certified Nurse Aide, (CNA), entered R207's room. V6 stated, What do you need (R207)? R207 stated, I need to get cleaned up. I had an accident. V6 stated, I will be right back let me finish what I am doing across the hall. On 5/7/2023 at 9:00 AM R207 stated that his only concern is that it takes a long time for the staff to come and help him. R207 stated, that he was waiting for help for 45 minutes to an hour. R207 stated, that he told the staff, and no one has come to help and that he has had a bowel movement. On 5/7/2023 at 9:15 AM V6, CNA, stated, that she was going to give R207 a bed bath. V6 stated, that she was not going to give him a complete bed bath, but just clean him. V6 then left out of the room to get assistance. At 9:30 AM V6 and V8, CNA, entered the room. V6 then pulled back R207's bed covers revealing R207 lying in bed on top of fitted sheet, incontinent pad, and incontinent brief on. R207 was heavily soiled with stool. R207's incontinent brief, sheet and incontinent pad were saturated with dried urine and stool. R207's sheet and incontinent pad had a large dried brown circular stain from R207's lower back down to back of R207's knees. V6 stated Oh. You got a mess down there. R207 then stated, I have been patiently waiting. Then using a basin of water, peri wash and washcloths V6 and V8 provided incontinent care. The facility's Perineal Care policy, dated August 2008, documents, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident skin condition. It continues, Steps in Procedure 3. Wash and dry your hands thoroughly and apply gloves. 9 For a female resident: b. Wash perineal area, wiping from front to back. 10. For a male resident: b. Wash perineal area starting with urethra and working outward. 12. Remove gloves and discard into designated container. 13. Reposition the bed covers. Make the resident comfortable. Based on observation, interview and record review, the facility failed to provide complete urinary/bowel incontinence care in a timely manner to prevent the spread of infections for 3 of 5 residents (R8, R49, R207) reviewed for incontinent care in the sample of 28. Findings include: 1.) On 5/9/23 at 10:00AM, V8 and V9 both Certified Nurse Aides, (CNA), entered R8's room to provide incontinent care. R8 was lying on her left side in bed with a pillow place behind her back, to allow propping to left side and placed over the pillow was a visible 4 x (by) 4-foot incontinent protector pad. This incontinent protector pad was clearly visible of a large circular area of a discoloration of light yellow, with a boarder of dark brown coloration. The protector pad was in contact with R8's lower back and extended to her buttock. During R8's perineum care, V8 and V9 failed to cleanse R8's lower portion of the back. 145294 Page 2 of 7 145294 05/10/2023 Prairie Village Healthcare Ctr 1024 West Walnut Jacksonville, IL 62650

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/9/23 at 1:05PM, V8, stated, she was assigned to R8, she noticed that R8's bed pad was soiled and that is why she requested help from another CNA to assist with incontinent care. V8 stated, she had not provided incontinent care for R8 during her work shift prior and stated, unless it was performed by another CNA. R8's, entitled, Face Sheet, undated, documented, diagnoses: Urinary tract infection, (UTI), calculus of kidney bilateral staghorn calculi and Pressure ulcer of sacral region, stage 2. R8's, Care Plan, with a problem start date, of 3/31/23, documented, experiences of bladder incontinence, due to dementia and impaired mobility with interventions to utilize incontinence briefs to prevent trapping moisture against the skin, R8 unable to utilize toilet, commode or bed pan. R8's, hospital records, dated 3/13/23 through 3/20/23, documented an admission diagnosis of, severe sepsis, acute complicated UTI, acute kidney injury. R8's, hospital records, dated 10/18/22, documented at diagnosis of UTI and acute kidney infection, both documented an onset of 10/18/22. On 5/9/23 at 3:35PM, V1, Administrator stated, she would expect nursing staff to cleanse all areas, of a residents body that came in contact to bowel/bladder incontinence. 145294 Page 3 of 7 145294 05/10/2023 Prairie Village Healthcare Ctr 1024 West Walnut Jacksonville, IL 62650

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide 8 hours of consecutive Registered Nurse coverage. This failure has the potential to affect all 55 residents living in the facility. Residents Affected - Many Findings include: On 05/09/23 at 11:02 AM, V1, Administrator, stated, that some weekends she is short a few hours for Registered Nurse, (RN), coverage. The facility Nurse Schedule, dated 03/01/23 - 05/07/23, was reviewed. These schedules failed to document eight hours of consecutive RN coverage on 05/06/23, 04/22/23, 04/23/23, 04/08/23, 04/09/23, 03/25/23 and 03/26/23. The Resident Census and Conditions of Residents, CMS 672, dated 05/08/23, documents that the facility has 55 residents living in the facility. 145294 Page 4 of 7 145294 05/10/2023 Prairie Village Healthcare Ctr 1024 West Walnut Jacksonville, IL 62650

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation and record review, the facility failed to perform hand hygiene and change soiled gloves to prevent cross contamination for 3 of 24 residents (R12, R19, R49) reviewed for infection control in the sample of 28. Residents Affected - Few Findings include: 1. On 05/07/23 at 10:48 AM, V6, Certified Nurse Assistant, (CNA), entered R12's room to assist R12 to the restroom, using a gait belt and a walker. R12's incontinent brief was wet with urine. While on the toilet R12 placed her hand into the inside of the bottom of brief. R12 was assisted back to bed for incontinent care. V6 failed to offer to assistance with washing R12 hands. The incontinent care was provided in bed with assist from, V8 CNA. V6 cleansed the peri-vaginal area and then dried it with a towel. V6 draped the towel over R12's walker bars. 2. On 05/08/23 at 8:07 AM, V4, Licensed Practical Nurse, (LPN), prepared an insulin injection for R19. V4 pushed, R19 in her wheelchair to her room. V4 donned gloves and gave the insulin, subcutaneous injection in the right lower abdominal quadrant. V4 failed to perform hand hygiene before donning gloves. On 05/10/23 at 11:18 AM, V1, Administrator, stated, that hand hygiene should be performed, before putting on gloves and soiled gloves should be removed and then perform hand hygiene. V1 also stated, that soiled linens should not be placed on personal items. 3. On 05/08/2023 at 12:30 PM V14, CNA, assisted R49 to the toilet. V14 washed hands and applied gloves. V14 pulled down R49's soiled incontinent brief and assisted R49 onto the toilet. R49 using same gloves closed the bathroom door. R49 voided in the toilet and voiced she was finished. V14 then grabbed toilet paper and wiped R49 from behind with 2 wipes. V14 then placed the toilet paper in the toilet and pulled R49's incontinent brief and pants up. V14 then using the same soiled gloves, stood R49 up and assisted her to the wheelchair. Using the same soiled gloves, V14 then grabbed hold of, roommate R51's, overbed table and placed it next to R51. Using the same soiled gloves, V14 then grabbed hold of the privacy curtain, pulling it between the two beds, then grabbed hold of floor mattress and pulled back bed covers. The facility's Perineal Care policy, dated August 2008, documents Steps in Procedure 3. Wash and dry your hands thoroughly and apply gloves. 9 For a female resident: b. Wash perineal area, wiping from front to back. 10. For a male resident: b. Wash perineal area starting with urethra and working outward. 12. Remove gloves and discard into designated container. 13. Reposition the bed covers. Make the resident comfortable. The Hand - Washing / Hand Hygiene Policy, dated 03/2020, documents, When hands are not visibly soiled, employees may use an alcohol - based hand rub (foam, gel, liquid) containing at least 60% alcohol in all of the following situations: It continues, c. before donning gloves. 145294 Page 5 of 7 145294 05/10/2023 Prairie Village Healthcare Ctr 1024 West Walnut Jacksonville, IL 62650

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to employ a trained Infection Preventionist. This failure has the potential to affect all 55 residents living in the facility. Residents Affected - Many Findings include: On 05/09/23 at 11:15 AM, V3, Registered Nurse, stated, I stated on 02/28/23. I do not have the infection prevention certificate. I am being trained by, V7 Corporate Infection Preventionist. I talk with him via email and telephone. On 5/9/23 at 11:15 AM, V1, Administrator, stated, that V7 comes in once a month he does training and reviews the infection control logs. Part time is considered anything less than 32 hours a week. The policy Infection Prevention and Control Program (ICPCP), dated 2019, documents, The facility will designate one or more individual(s) as the infection preventionist (s) (IP) (s) who is responsible for the facility's IPCP. The infection preventionist will: a. Have primary professional training in nursing, medical technology, microbiology, epidemiology, or another related field: b. is qualified by education, training, experience or certification. c. Works at least part-time at the facility. d. Has completed specialized training in infection prevention and control. The Resident Census and Conditions of Residents, CMS 672, dated 5/8/23, documents that the facility has 55 residents living in the facility. 145294 Page 6 of 7 145294 05/10/2023 Prairie Village Healthcare Ctr 1024 West Walnut Jacksonville, IL 62650

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to educate residents and offer the Pneumococcal Immunizations yearly, to residents that had previously refused it, for 2 of 5 residents (R32, R46) reviewed for immunizations in the sample of 28. Residents Affected - Few Findings include: On 05/08/23 at 12:58 PM, V1, Administrator, stated, that she did not realize that once a resident refused the Pneumococcal Vaccine that it should be offered to them every year. 1. R32's Pneumococcal Vaccine Record, dated 03/16/20, documents that R32 refused the vaccine. In handwriting on this Record, it reads, Due for refusal/consent 03/2025. R32's Face Sheet, undated, documents that R32 was admitted on [DATE] and has diagnoses of Dementia and personal history of COVID 19. 2. R46's Pneumococcal Vaccine Record, dated 11/16/21, documents that R46 refused the vaccine. In handwriting on this Record, it reads, Due for refusal/consent 11/2026. R46's Face Sheet, undated, documents that R46 was admitted on [DATE] and has diagnoses of Dementia and Chronic Obstructive Pulmonary Disease. The policy Influenza and Pneumococcal Immunizations, dated 11/2016, documents, Policy: To assure that each resident receives educations regarding the benefits and potential side effects before being offered influenza and pneumococcal immunizations and securing their informed consent for administration of these immunizations. 1. Each resident, or when appropriated their resident representative, will be educated regarding the benefits and potential side effects of both influenza and pneumococcal immunizations and will be provided the opportunity to accept or refuse them. 145294 Page 7 of 7