Health inspection·May 26, 2023

F 0692 Provide enough food/fluids to maintain a resident's health. 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 follow up on Registered Dietitian's (RD) recommendations for residents with significant weight loss and ensure RD recommendations are implemented in a timely fashion in 2 of 5 residents (R14, R48) reviewed for nutrition in the sample of 34. Residents Affected - Few Findings include: 1. R14's Face Sheet documents R14 has diagnoses including chronic atrial fibrillation, obstructive sleep apnea, vitamin D deficiency, Barrett's Esophagus without dysplasia, essential (primary) hypertension, and age-related cognitive decline. R14's Minimum Data Set (MDS) dated [DATE] documents R14 was severely cognitively impaired, walked independently, and had no significant weight loss. R14's Care Plan dated 4/18/23 documents, I may be at risk for nutritional problems r/t (related to) age related cognitive decline. The Facility's Weight Losses list documents R14 as a resident who has lost weight. R14's Weight and Vitals Summary dated 5/25/23 documents R14 weighed 155.9 pounds on 4/11/23 and 146.2 pounds on 5/7/23. It documents this is a 9.7 pound or 6.2% weight loss in less than a month. R14's Progress Note dated 5/12/23 at 9:28 AM by V13, Registered Dietitian, documents, RD (Registered Dietitian) WT (Weight) OBS (Observation) note for (R14) who is triggering for significant (-9.7#; -6.2%) wt loss x 1mo (month). CBW (Current Body Weight) 146#; BMI (Body Mass Index) 22.2 underweight for age. Generally eats well on a regular diet. Meds (Medications) reviewed noting Seroquel was recently D/C'ed (discontinued), CPAP (Continuous Positive Airway Pressure) orders, No edema (fluid retention) or skin breakdown. Accuchecks (blood sugar checks) wnl (within normal limits) and rarely >110mg/dL (milligrams per deciliter). Suspect wt loss r/t new environment/routines, activity level; recommend adding house supplement at 60cc (cubic centimeters) TID (three times daily) until healthy BMI is achieved and maintained. Refer PRN (as needed). The Facility's Dietitian Referral - Recommendation Report dated and completed 5/12/23 documents R14's Nutritional Information is, Sig (significant) loss x 1mo (month), eats well, 93yo (year old), no edema, from (Assisted Living), skin intact. Recommendation: Add house supp (supplement) @ (at) 60cc (cubic centimeters) TID (three times daily). R14's Physician Orders dated 5/25/23 document Med Pass Supplement was not ordered until 5/25/23. Page 1 of 5 145367 145367 05/26/2023 Gillespie Health & Rehab Ctr 7588 Staunton Road Gillespie, IL 62033

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/25/23 at 8:15 AM, V1, Administrator, stated, (V13), Registered Dietitian, wrote her recommendations for (R14) on the communication form, but did not send us the actual recommendation form which is what we send to the doctor. 2. R48's Face Sheet Documents R48 has diagnoses including urinary tract infection, chronic obstructive pulmonary disease, major depressive disorder, gastro-esophageal reflux disease without esophagitis, repeated falls, essential (primary) hypertension, and difficulty in walking. R48's MDS dated [DATE] documents R48 was moderately cognitively impaired, required extensive on person assistance with bed mobility and transfer, did not walk over the previous 7 day period, and had lost weight without being on a prescribed weight-loss regimen. R48's Care Plan dated 4/27/23 documents, I may be at risk for nutritional problems d/t (due to) receiving a 2gm (gram) NA (sodium) regular diet r/t Dx (diagnosis) of HTN (hypertension) and having an unplanned weight loss on readmission. The Facility's Weight Losses form documents R48 is a resident who has lost weight. R48's Weight and Vitals Summary dated 5/25/23 documents weight of 153.9 pounds on 4/5/23 and 139.4 pounds on 4/21/23. It documents this is a 14.5 pound or 9.4% weight loss in less than a month. R48's Progress Note written 4/27/23 at 11:11 AM by V11, Dietary Manager, documents, Resident had a 11.3% weight loss on readmission compared to discharge weight of 154#'s on 4/5/23. Current weight as of 4/27/2023 is 139#'s with a BMI of 21.1. R48's Progress Note written 5/12/23 at 11:02 AM by V13, Registered Dietitian (RD), documents, RD WT OBS note: Significant wt loss b/t (between) 4/5 @ 153# and 4/21 @ 139#; noting (R48) was D/C'ed (discharged ) on 4/17, returning 4/21. CBW 5/8 138#; Sodium restricted diet ordered. Meds reviewed. Therapies ongoing, surgical incision noted. Continue to recommend liberalizing diet to regular and adding house supplement @ 60cc BID (twice daily). Rd will follow. Refer PRN. The Facility's Dietitian Referral - Recommendation Report dated and completed 5/12/23 documents R48's Recommendation as, Liberalize diet to regular. Add house sup (supplement) 60cc BID. Date Sent: 5/23/23. Refaxed 5/24/23. The form does not document a physician response. R48's Physician Orders printed 5/25/23 document, 2 GM NA diet. There was no supplement order or change in diet documented. On 5/25/23 at 8:15 AM, V1, Administrator, stated the reason they couldn't find R48's Recommendation Report before is because it was never signed off by the doctor and they had to fax it again it today. On 5/26/23 at 9:25 AM, V1, Administrator, stated she expects staff to follow up on dietary recommendations in a timely manner and follow the Facility's Dietitian Recommendation Process Policy. The Facility's Diet and Nutrition Care Manual 10th Edition, 2022, documents in the Preparing for Consultant Dietitian section, Review Dietitian's report, including sanitation from the prior month and develop plan of action to correct the identified problems. Follow up on Dietitian's recommendations and make sure that they are implemented in a timely manner. Inform Dietitian of any recommendations 145367 Page 2 of 5 145367 05/26/2023 Gillespie Health & Rehab Ctr 7588 Staunton Road Gillespie, IL 62033

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not completed or that the MD (Medical Doctor) has disagreed with. Documented in the Dietitian Recommendation Process section is, Policy: Dietitian recommendations will be completed in an organized and timely manner. If a recommendation is needed, the Dietitian will document in the medical record and complete a recommendation form. The Dietitian may make recommendations regarding resident care, which does not require a change in physician's orders. These recommendations will be documented. The Director of Nursing and the Food and Nutrition Services Manager are responsible for implementing these recommendations in their respective departments. The Dietitian will communicate with the Food and Nutrition Services Manager and Director of Nursing or other designate regarding documentation and recommendation. The Director of Nursing or designee will seek the physician's order changes in a timely manner. Responses should be obtained in 2-3 business days. 145367 Page 3 of 5 145367 05/26/2023 Gillespie Health & Rehab Ctr 7588 Staunton Road Gillespie, IL 62033

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure medications are labeled and stored appropriately until they are administered for 4 of 4 residents (R4, R21, R23, R32) reviewed for medication storage in the sample of 34. Findings include: On 5/24/23 at 7:50 AM, V7, Licensed Practical Nurse (LPN), was observed doing the AM medication pass on the 100 and 200 Halls. When V7 opened the top drawer of the medication cart, there were three medication cups containing multiple pills and capsules. These cups were labeled with R4's, R21's, and R23's names, but no other identifying information or dates were written on the cups. There were two cups of clear fluid on top of the medication cart. 1. R4's Physician Order Summary dated 5/24/23 documents he takes the following medications in the morning: Fluoxetine 10 milligram (mg), Ergocalciferol 2000 units (u), Carbidopa-Levodopa 25-100 mg 2 tabs, Vitamin B12 1000 micrograms (mcg), Miralax 17 Grams (Gm), Aspirin 81 mg, Acetaminophen 325 mg 2 tablets, Odansatron 4 mg, and Trihexyphenidyl 1 mg. On 5/24/23 at 8:25 AM, V7 reviewed the medications labeled with R4's name. There were 10 pills in the cup. V7 identified the pills as Carbidopa-Levadopa 25/100 (2), Aspirin 81 mg (1), Odansatron 4 mg (1), Trihexyphenidyl 1 mg 1/2 tab, Vitamin B12 1000 mcg (1), Ergocalciferol 2000 u (1), and Tylenol 325 mg (2). V7 stated this was R4's morning meds. When pills were counted in the cup, there were 10 pills in the cup and V7 only identified 9 medications. When pills were compared to pills on R4's med cards and in stock medication bottles, the 10th medication was identified as Fluoxetine 10 mg and orders were all reconciled. V7 stated she thought she would recognize all of the pills and be able to identify what they were, but she was unable to identify the Fluoxetine until it was compared to his card of Fluoxetine. V7 also took a cup of fluid that looked like water off the top of the medication cart to give to R4. V7 identified this cup of fluid as R4's Miralax 17Gm. She stated the second cup of fluid was also Miralax in water for another resident to whom she still had to administer medications. These two cups of clear fluid had been sitting on the top of the medication cart since the start of the medication administration observation. 2. R21's Physician Order Summary dated 5/24/23 documents she takes the following medications in the morning: Sertraline 50 mg (1), Senna 8.6 mg (1), Miralax 17 Gm, Acetaminophen 325 mg (2), Apixaban 2.5 mg (1), Carvedilol 6.25 mg (1), and Isosorbide 20 mg (1). 3. R23's Physician Order Summary dated 5/24/23 documents she takes the following medications in the morning: Buspirone 5 mg (1), Sertraline 25 mg (1), Aspirin 81 mg (1), Seroquel 12.5 mg (1), Vitamin B12 500 mcg (1), Allopurinol 100 mg (1), Metoprolol Succinate 100 mg (1), and Ferrous Sulfate 325 mg (1). 4. R32's Physician Order Summary dated 5/24/23 documents she takes the following medications in the morning: Midodrine 2.5 mg (1), Allegra 180 mg (1), Carbidopa-Levadopa 25-100 mg (2), Senna 8.6 mg (1), Baclofen 10 mg (1), Entacapone 100 mg (1), Miralax 17 Gm, Vitamin D3 1000 u (1), Dulcolax 5 mg (3), Tylenol Extra Strength 500 mg (2), Lasix 20 mg (1), and B-Complex Tablet (1). 145367 Page 4 of 5 145367 05/26/2023 Gillespie Health & Rehab Ctr 7588 Staunton Road Gillespie, IL 62033

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/24/23 at 8:20 AM, V7 stated, I'm not going to lie. I set the medications up for these residents when I first started my medication pass. I already signed them out on the MAR (Medication Administration Record) when I set them up. I will go back in and document any additional information, like a pain level or blood pressure, as soon as I get them. They are in the top drawer of the medication cart. I know we are not supposed to pre-set up medications, but if I didn't, I would be here forever doing my med pass. I do this every morning. If I had to leave and another nurse had to take over, and I had set a resident's medications up ahead of time, most of the other nurses know the residents and know their medication by sight. On 5/24/23 at 1:00 PM, V7 confirmed the second unlabeled cup of water containing Miralax that was sitting on the top of the medication cart this morning was for R32. V7 stated she had pre-mixed the Miralax when she set up the other medications to remind her to go down and administer R32's medications. V7 stated she did not need to label the cups containing Miralax with R4's or R32's names because Miralax is always the same dose so it doesn't matter which cup she gives them. On 5/24/23 at 9:10 AM, V1, Administrator stated, The nurses know they are not supposed to pre-set up any residents' medications. They should be checking the medication card against the order in the e-MAR (electronic medication administration record) and then give the medication at that time, not setting it up to give later. The facility's policy, Medication Administration, dated 1/11/10 documents, Objective: To provide accuracy during medication pass to assure quality care for residents. Policy: It is the policy of this facility to accurately administer medication following physician's orders. Procedure: 6. Compare label with MAR. Medications should be charted during the med pass in a consistent manner before moving on to the next resident. 145367 Page 5 of 5