Health inspection·June 9, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to add fall prevention interventions for a resident at high risk for falls for 1 of 2 (R8) residents reviewed for falls in the sample of 25. Findings include: R8's Face Sheet documented an admission date of 10/05/20, with diagnoses including old Myocardial Infarction, Gastro-esophageal Reflux Disease, and Unspecified Dementia without Behavior Disturbance. A Minimum Data Set, dated [DATE] documented that R8 requires extensive assistance from at least two staff members for transfers. A 2/20/21 Physicians Order documented an order for,(trade name weighted lap cushion) while up to wheelchair for proper posture and safety. A 1/14/23 Fall Risk Assessment documented a score of 12, indicating R8 is at high risk for falls. A January 2023 Incident Study Form documented that on 1/22/23, on the 7:00am to 3:00pm shift, R8 sustained a fall while in her room. A 1/22/23 Fall Investigation authored by V2, Director of Nurses, documented, Factors contributing to the fall: (R8) had slid down in chair and continued sliding until on the floor. Resident activity at the time of the fall: Preparing for transfer. Action Plan/Intervention if Warranted: (Left blank). A Nurses Note dated 1/22/23 at 12:45pm documented,Resident slid to floor during transfer after lunch. No injuries noted. Didn't hit head. Family aware. Doctor faxed. R8's Care Plan dated 1/21/23 documented a problem area, (R8) has a potential for falls related to confusion and weakness. Transfers per two assist. (Weighted lap cushion) while up to wheelchair to promote safety and a proper sitting position. No new fall interventions had been added to the Care Plan after R8's 1/22/23 fall. On 6/6/23 at 10:40am, R8 was observed in her room sitting in her recliner. R8 was alert only to self. On 6/8/23 at 1:48pm, V5, Registered Nurse/Care Plan Coordinator, acknowledged no new Care Plan interventions had been added following R8's 1/22/23 fall. V5 stated staff felt as though R8's existing fall interventions were effective. V5 stated R8 is not at high risk for falls. On 6/9/23 at 8:17am, V2 stated that on 1/22/23, she and another staff member were preparing to transfer R8 from the wheelchair to the recliner. V2 stated the other staff member went to retrieve the sitting to standing mechanical transfer lift, and V2 then removed R8's weighted lap cushion, which is used for positioning R8 in the wheelchair. V2 stated R8 began sliding out of the wheelchair, coming to a stop when with her buttocks made contact with the floor. V2 stated by herself, she was unable to stop R8 from sliding. V2 stated R8 sustained no injuries. V2 stated no new fall interventions Page 1 of 4 145380 145380 06/09/2023 Lutheran Care Center 702 West Cumberland Altamont, IL 62411

F 0689 were added to R8's plan of care, as staff felt the existing interventions were working. Level of Harm - Minimal harm or potential for actual harm An undated Fall Prevention Policy and Procedure documented,The interdisciplinary team will .develop interventions to address residents identified as at risk for falling and implement an interdisciplinary plan of care if necessary. Interventions should be based on the level of risk. Post Fall Management: The interdisciplinary team will .review fall prevention interventions and modify the plan of care as necessary. Residents Affected - Few 145380 Page 2 of 4 145380 06/09/2023 Lutheran Care Center 702 West Cumberland Altamont, IL 62411

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer prescribed medication per physicians orders and manufacturers directions for two residents of ten residents (R9, R8) reviewed for medication errors in the sample of 25. There were thirty medication opportunities observed with a total of three administration errors, making the error rate 10 percent. Residents Affected - Few Findings include: 1. R9's June 2023 Physicians Order Sheet(POS) and June 2023 Medication Administration Record (MAR) documented an order for Fluticasone 50 microgram spray, directions-two sprays in each nostril daily at 8:00am. On 6/7/23 at 7:16am,V3, Registered Nurse (RN) was observed administering medications to R9. V3 read aloud the directions on the MAR as referenced above. V3 did not shake the medication prior to administration. V3 administered one spray per each nostril, washed her hands, returned the medication to the medication cart, documented the administration, and began looking at the MAR for medication orders on the next resident for administration. When the surveyor pointed out the discrepancy between the order and the administration, V3 re-checked the MAR and acknowledged she should have given two sprays to each nostril. V3 then administered the remaining one spray to each nostril. On 6/8/23 at 11:55am, the Surveyor asked V3 if the Fluticasone should have been shaken before administration. V3 stated she was not sure. The Surveyor and V3 checked the directions on the Fluticasone manufacturers packaging which stated, Shake gently before administration. 2. R2's June 2023 POS and June 2023 MAR documented an order for, Humalog 100 units per milliliter Kwikpen, inject 8 units three times daily before meals. If premeal blood glucose is less than 120 mg/dl(Milligrams per Deciliter), inject 4(additional) units. If pre-meal blood glucose is less than 80 mg/dl, hold insulin. If premeal blood glucose is 250-300mg/dl, inject 2(additional) units. If premeal blood glucose is 301-350mg/dl, inject 3(additional) units. If premeal blood glucose is 351-400mg/dl, inject 4 (additional) units. If greater than 400 mg/dl, inject 5(additional) units. Diagnosis: Insulin Dependent Diabetes Mellitus. On 6/7/23 at 11:15am,V4, RN, was observed administering medications for R2. V4 checked R2's blood glucose level, which was 286. V4 retrieved R2's Humalog Kwikpen, and administered 8 units subcutaneously. V4 performed hand hygiene, left the room, and returned the Kwikpen to the medication cart. On 6/7/23 at 11:25am, the Surveyor approached V4 for clarification about the discrepancy between the order and the administration observation. V4 rechecked the order and acknowledged R2 should have had a total of 10 units of Humalog. V4 then administered the remaining 2 units to R2. A Medication Administration Policy dated 5/19/22 documented, Responsibility of the nursing professional is to be aware of the correct dosage prior to administration of medications .The nurse should always be knowledgeable of the medications they have prepared prior to administration .Read and follow any special instructions written on the labels. 145380 Page 3 of 4 145380 06/09/2023 Lutheran Care Center 702 West Cumberland Altamont, IL 62411

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record review the facility failed to provide at least 80 square feet of living space per resident bed for 2 of 2 residents (R18 and R196) reviewed for room size in a sample of 25. Findings include: On 6/9/23 at 12:20 PM, this surveyor accompanied V6 (Maintenance Supervisor) for the purpose of measuring the 2 resident rooms that V6 stated that are dually certified (Medicare and Medicaid) for 2 beds per room. The 2 rooms measured less than 80 square (sq.) feet (ft.) of living space per bed. The 2 room's measurements are as follows: room [ROOM NUMBER]: 154 sq. ft. (77 sq. ft. per bed) room [ROOM NUMBER]: 154 sq. ft. (77 sq. ft. per bed) A Daily Roster provided by the facility and dated 6/6/23 documents that R18 and R196 reside in the 2 rooms that provide less than the 80 square feet of living space per resident bed. During the survey from 6/6/23 to 6/9/23 rooms [ROOM NUMBERS] were equipped with one bed, one bedside table, one recliner and one chest of drawers. Observations of the undersized resident rooms found the rooms adequate to meet the medical and personal needs for the residents assigned to these rooms. Inquiries regarding the size of these rooms during the survey from 06/6/23 to 06/9/23, found no concerns or negative interviews from residents or families of residents who reside in the waivered rooms. On 6/9/23 all voiced no concerns with the size of their rooms during interviews. Review of Resident Council meeting minutes from the past 6 months indicated no concerns related to the size of the rooms. 145380 Page 4 of 4