Health inspection·July 14, 2023

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident's representative in writing of the facility's Bed Hold Policy when a resident was transferred to the hospital. This failure affected one of two residents (R16) reviewed for hospitalizations on the sample list of 23. Findings Include: On 7/13/23 at 4:00 PM V1 Administrator and V2 Director of Nurses both confirmed the facility attaches the Bed Hold Paperwork to the Resident Transfer paperwork and sends them with a resident when they are sent to the emergency room however, when applicable they do not provide a written copy of either document upon transfer to the resident's representative. The Nurses Note dated 6/16/2023 documents R16 was transported to the emergency room for altered mental status via ambulance. The facility could not provide documentation that R16's representative (V8) was provided a written copy of the Bed Hold Policy when R16 was transferred to the emergency room on 6/16/23. R16's Medical Diagnoses dated July 2023 document R16 is diagnosed with Autistic Disorder. R16's Minimum Data Set, dated [DATE] documents R16 is severely cognitively impaired. R16's Clinical Resident Profile dated July 2023 documents V8 is R16's Sister, Responsible Party, and Emergency Contact. Page 1 of 7 145347 145347 07/14/2023 Gilman Healthcare Center 1390 South Crescent Street, Box 307 Gilman, IL 60938

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review the facility staff failed to provide safety for one resident (R21) when using the mechanical lift for transfer for one (R21) of four residents reviewed for accidents in a sample of 23. This failure resulted in R21 falling onto the floor out of of a mechanical lift sling during a transfer requiring a emergency department evaluation and sustaining a facial laceration. Findings include: The Physician's Orders dated July 2023 list the following diagnosis for R21: Obstructive Hydrocephalus, Unspecified Dementia with Behavior Disturbance, Bipolar and Seizures. Facility incident report dated 6/19/2023 documents R21 was being transferred with a mechanical lift by V7, CNA (Certified Nursing Assistant). R21 was up in the air above the bed in the mechanical sling and the strap broke which caused R21 to fall out of the sling and was assisted to the floor by V7. R21 hit his head, left temple area on the leg of the mechanical lift and received a laceration to left eyebrow and skin tear to left hand along with a large area of bruising the the left hand and arm. R21's progress notes dated 6/19/23 documents the ambulance was called and transferred R21 to the Emergency Department and R1 returned to the facility at 6:30 AM on 6/20/23. R21's Emergency Department provider notes dated 6/19/23 documents presenting to ED for evaluation of fall, head trauma. Staff was assisting patient with a (Mechanical lift transfer) and patient fell off (mechanical lift) and hit his head. Physical exam: Skin- 2 centimeter jagged laceration noted lateral to the left eyebrow, skin tear to dorsum left hand. Laceration repair: Repair method- Tissue adhesive. V7, CNA stated in interview at 2:48 PM One of the straps that was on the the mechanical lift hooks broke which caused (R21) to fall out of the sling and V7 assisted (R21) to the floor and (R21) hit his head on the leg of the mechanical lift. V7 stated (R21) was still in the sling above the bed in the air and this is when the sling's strap broke causing ( R21) to fall and hit his head. V2, DON (Director of Nurses) stated in interview on 7/14/23 at 10:05 AM. The CNA V7 hooked the sling up wrong when transferring (R21). We have two slings one is complete full body sling for transfers and the other sling is one that covers the body under the buttocks area. V2 stated this sling you have to criss cross the sling straps in order to use it correctly. V7 did not have the sling applied appropriately and V7 was educated on the proper placement of sling usage, also always have 2 staff when using mechanical lift for transferring residents. The care plan for R 21 dated 5/21/23 states R21 must be transferred with 2 staff and a mechanical lift. The facility policy titled Safe Lifting and Movement of Residents revision date October 2009, documents The Policy Statement is In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 145347 Page 2 of 7 145347 07/14/2023 Gilman Healthcare Center 1390 South Crescent Street, Box 307 Gilman, IL 60938

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to administer enteral tube feeding in a safe manner to resident. The facility failed to label an enteral tube feeding with resident name, product name, date and time prepared, in accordance with facility policy. This failure affects one resident (R209) out of one reviewed for gastrostomy tube feedings on the sample list of 23. Findings include: On 7/11/23 at 9:34 am, R209 was in bed in R209's own private room. R209 was receiving a gastrostomy tube feeding through a delivery pump. The feeding product being administered to R209 had no identification, nor was there a label on the product bag to indicate which resident this product was to be administered to, the type of product being administered, nor was the product bag labeled with the date and time the product was prepared to be administered. On 7/12/23 at 8:57 am, R209 was in bed in R209's own private room. R209 was receiving a gastrostomy tube feeding through a delivery pump. There was no identification on the product bag, and there was no label on the product bag to indicate which resident the product was to be administered to, the type of product being administered, nor the date and time the product was prepared to be administered. On 7/12/23 at 10:08 am, V2 Director of Nursing, exhibited the gastrostomy feeding product in a 1,500 milliliter plastic bag which had the manufacturer identification Fibersource HN. V2 stated, Our nursing staff are pouring the product from the original bag (approximately 1 foot by 1 foot square shape bag) into the smaller bags (approximately 4 inches wide by 16 inches long) so we can use the pump. V2 further stated, We are going to be switching to Jevity 1.5 (gastrostomy feeding) product this Friday (7/14/23) and we do have the Jevity here at the facility right now. V2 continued to state, When we buy the feeding product, we buy it in cases so there are no labels with any resident's name like there would be from a pharmacy. The facility policy Enteral Tube Feeding via Continuous Pump dated December 2011 documents, General Guidelines: Check the enteral nutrition label against the order before administration. Check the following information: resident name, type of formula, date and time formula was prepared, route of delivery, access site, method (pump, gravity, syringe), rate of administration. Steps in the Procedure: Check the label on the enteral formula against the physician order. On the formula label document initials, date and time the formula was hung/ administered, and initial that the label was checked against the order. On 7/12/23 at 10:46 am, V2, Director of Nursing, stated, According to the policy we should be labeling the tube feeding bags. V2 acknowledged there was no way to know what type of feeding product was in the bag except for what is on the physician orders. V2 could not confirm the product in the tube feeding bag was the currently ordered Fibersource HN. R209's Progress Note dated 7/10/23, documented by V6, Registered Dietician, documents, Per DON (Director of Nursing) the Fibersource HN is not expected to be available, however, Jevity 1.5 is available. Rec (recommend) when Fibersource is not available, switch to Jevity. 145347 Page 3 of 7 145347 07/14/2023 Gilman Healthcare Center 1390 South Crescent Street, Box 307 Gilman, IL 60938

F 0693 On 7/12/23 at 12:19 pm, V2, Director of Nursing, stated, We can't keep any product, it has to be discarded after 24 hours once it is opened. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145347 Page 4 of 7 145347 07/14/2023 Gilman Healthcare Center 1390 South Crescent Street, Box 307 Gilman, IL 60938

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 obtain a physician's order for a CPAP (Continuous Positive Airway Pressure) treatment for one (R50) of one resident reviewed for CPAP/BIPAP treatments in the sample list of 23. Residents Affected - Few Findings include: The Facility's CPAP (Continuous Positive Airway Pressure) /Bi-Level (Bi-PAP) (Bilevel Positive Airway Pressure), Support Policy dated 3/2020 documents.: Obtain a physician order for the use of BIPAP/CPAP, information should include the level of IPAP (inspiratory positive airway pressure) in cmH20, and the level of EPAP (expiratory positive airway pressure) in smH20, FI02, and humidification, if needed. On 7/12/23 at 8:22am R50 was in R50's room sitting in R50's wheelchair, next to a bed side table with a CPAP (Continuous Positive Airway Pressure) device on it. On 7/12/23 at 8:22am R50 said, R50 was admitted to the facility on [DATE]. R50 said, R50 has asthma and breathing issues, and uses a CPAP machine at bedtime. R50 said, R50 has been using a CPAP machine since admission into the facility. R50 said, R50 can apply the CPAP mask at bedtime and remove it in the morning without staff assistance. On 7/13/23 at 1:56pm V2 Director of Nursing (DON) said, V50 was admitted from an assisted care facility with R50's CPAP machine. V2 said, V50 has been using it since admission, and doesn't need help from staff to put it on or remove it. V2 said, on 6/2/23 the facility received a fax from the CPAP provider with V50's CPAP settings. V2 said, the facility never notified V5 R1's Physician to obtain an order for R50 to receive CPAP treatments. V2 said, the facility should have obtained an order prior to administering R50 CPAP treatments and should have had a care plan with interventions for the use of R50's CPAP machine. R50's Order Summary Report dated 7/14/23 documents diagnoses Asthma with (Acute) Exacerbation, Obstructive Sleep Apnea (Adult), Chronic Obstructive Pulmonary Disease, Sleep Apnea, Shortness of Breath, Acute Bronchiolitis Due to Respiratory Syncytial Virus and Bronchiectasis. R50's Care Plan updated on 6/6/23 does not document R50's use of a positive airway pressure device. R50's Facility Medical Record has no documentation regarding R50's CPAP (Continuous Positive Airway Pressure Device) mask, tubing, or humidifier. 145347 Page 5 of 7 145347 07/14/2023 Gilman Healthcare Center 1390 South Crescent Street, Box 307 Gilman, IL 60938

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to designate a qualified director of food and nutrition services. This failure has the potential to affect 59 out of 60 residents residing in the facility. Findings include: On 7/11/23 at 9:35 am, 11:49 am, and 3:36 pm, V3, Dietary Manager was observed actively supervising the routines and services of the facility's kitchen. On 7/11/23 at 9:35 am, V3 stated, I do not yet have my CDM (Certified Dietary Manager) certificate. I qualified for a 3 month extension. I have completed 3 out of 7 modules in the course, so I am basically at the mid-term. V3 further stated, I do have the CFPM (Certified Food Protection Manager) certificate (not Certified Food Protection Professional). On 7/11/23 at 4:10 pm, V1, Administrator, stated, I have a CDM certificate and I am serving as (V3's) proctor (preceptor) for (V3's) course. V1, Administrator, further stated, I do not work 40 hours supervising the kitchen. On 7/13/23 at 3:18 pm, V3, Dietary Manager, stated, I do not yet have the CDM, but I am scheduled to be completed September of 2023, I have to have it completed by September or the course expires. I do have the Certified Food Protection Manager (CFPM, food sanitation manager, not certified food service manager). I do not have an associates degree in anything for food service. I do have more than the 2 years experience, I started in the kitchen 3 or 4 years ago in 2017 or 2018. I worked directly under the supervisor and I filled in when she was on vacation, and I do have the food safety (sanitation) certificate. V3 further acknowledged not meeting the state requirements and definitions for a Dietetic Service Supervisor (admin code 300.330 Dietetic Service Supervisor definitions, and 300.2010 Director of Food Services) by stating, I am not a registered Dietician. I have not graduated from any school course or program. I was born in 1989 so I didn't graduate from a 90 hour course prior to 1990. I am currently in the CDM (Certified Dietary Manager) course which is also gives me the CFPP (Certified Food Protection Professional) certificate. I do not have any military experience. The facility's Resident Census and Conditions of Residents dated 7/11/23 documents 60 residents reside in the facility, all of whom with one exception (R209 receives nothing by mouth) consume food prepared by the facility kitchen. 145347 Page 6 of 7 145347 07/14/2023 Gilman Healthcare Center 1390 South Crescent Street, Box 307 Gilman, IL 60938

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to implement procedures to protect food products from cross contamination by leaving utensils inside bulk food storage tubs. This failure has the potential to affect 59 out of 60 residents residing in the facility. Findings include: On 7/11/23 at 8:57 am, in the facility's dry storage room were two 3-gallon tubs of a dry powder thickening agent (used to thicken liquid drinks), and one 3-gallon tub of rice. Inside one of the tubs of thickening agent were 2 small plastic cups (approximately 6 ounces capacity), both cups in direct contact with the thickening agent. Inside the second tub of thickening agent was one small plastic cup in direct contact with the thickening agent. Inside the tub of rice was one small plastic cup in direct contact with the rice. On 7/11/23 at 9:40 am, V3, Dietary Manager, acknowledged the small plastic cups should not be left inside the food containers and stated, We will get those out of there. The facility's policy Storage of Dry Goods/ Foods dated revised 2017 documents, Food stored in bins (e.g. flour or sugar) are removed from their original packaging. Bins are labeled and dated. Scoops are stored in scoop holders or in a clean designated place. The facility's Resident Census and Conditions of Residents dated 7/11/23 documents 60 residents reside in the facility, all of whom with one exception (R209 receives nothing by mouth) consume food prepared by the facility kitchen. 145347 Page 7 of 7