Health inspection·January 20, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 3. The facility's document , All Falls for Facility dated 1/17/23 documents R32 had falls on 1/17/22, 5/26/22, and 8/4/22. R32's Face Sheet documents her diagnoses to include Cerebral Infarction, Polyosteoarthritis, Other Malaise, Unsteadiness on Feet, Wedge Compression Fracture of Third Lumbar Vertebra, and Generalized Anxiety Disorder. R32's MDS dated [DATE] and 5/5/22 both document R32 is severely impaired cognitively and requires extensive assist of staff for transfers, walking and toileting. R32's Care Plan dated 10/12/22 (revised 1/5/23) documents: Problem: I am at risk for falls with dementia progression. poor safety awareness. Poor insight to my own deficits. History of falls. Has history of suddenly getting up to go to bathroom when she needs to have a BM (bowel movement). Now on hospice s/t (secondary to) condition decline. R32's Care Plan intervention dated 10/12/22 documents: Approach: One assist with all transfers. Make sure she is wearing gripper socks at all times. Make sure she is covered with blankets when in bed. Keep bed in lowest position. Check on her frequently when she is in bed. Up in Broda chair as tolerated. R32's Fall Risk assessment dated [DATE] documented her score as 17, indicating she is at high risk of falls. R32's Fall Event dated 1/17/22 at 5:13 PM documents, Resident is alert with confusion. Her diagnoses include Alzheimer's Disease, Dementia, HTN (hypertension), Depressive Disorder, and Anxiety Disorder. She is ambulates ad lib (as desired), without device. Her gait is slowly declining. Staff walked with her to restroom, staff turned around to get depend out of closet and resident fell onto her knees. Staff was educated on sitting resident safely down on toilet before turning around. Staff should keep a handful of depends in bathroom so resident is not left unattended. R32's Fall Event dated 5/26/22 at 12:03 PM documents, Resident is A&O (alert and oriented) x 0-1 with confusion noted. Her diagnoses include Alzheimer's, Dementia, HTN (hypertension), Cerebral Infarction, Hyperlipidemia, Major Depressive Disorder, GERD (Gastroesophageal Reflux Disease), Unsteadiness on Feet, Low Back Pain, and Generalized Anxiety Disorder. Staff toileted resident and was walking resident to dining room for lunch. Resident was holding onto the handrail and staff let go and stepped away to throw something away and resident tripped over her own feet and landed on buttocks. ROM was WNL (within normal limits) and resident did not hit head. Resident has c/o (complaint of) pain Page 1 of 7 145384 145384 01/20/2023 Eden Village Care Center 400 South Station Road Glen Carbon, IL 62034

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some daily so resident was watched closely. Per Kardex resident is to be walking with staff and have a gait belt on. Staff walking with resident at the time was disciplined accordingly. Inservice was done with nursing staff that resident is to have gait belt on during any ambulation and not to be left unattended for any reason until resident is safely sitting or resting in bed. Resident was given her own gait belt, so she has one at all times. 4. The facility's document , All Falls for Facility dated 1/17/23 documents R34 had falls on 5/9/22, 10/2/22, and 11/24/22. R34's Face Sheet documents her diagnoses to include: Difficulty in Walking, Not Classified Elsewhere R34's MDS dated [DATE] documents R34 is severely cognitively impaired and she requires extensive assist from staff for transfers and toileting. R34's Care Plan dated 5/5/22 ( last reviewed 1/5/23) documents, Problem: I am at risk of additional falls due to a history of falling. No safety awareness due to dementia progression. No insight to my deficits. I have Alzheimer's with history of some behaviors. I might try to transfer myself and try to walk unassisted. I do not use the call light. I have wandered around on the secured unit before. I have deliberately sat myself on the floor at times. History of falls. R34's Fall Risk assessment dated [DATE] documents a score of 13. This document states a fall risk score of 10 or higher represents a high risk of falls. R34's Fall Event dated 11/24/22 at 6:07 PM documents, Resident is pleasantly confused with poor safety awareness and no insight to own deficits. Diagnoses include Alzheimer's, Schizoaffective Disorder, MDD (Major Depressive Disorder), and Generalized Anxiety. Resident takes psychotropic medications. At 1720 (5:20 PM) resident fell in restroom with CNA present. Resident was hesitant to ambulate, lost balance, shifted, and fell onto buttocks and hit back of head on bathtub. Small abrasion to back of head with no bleeding. No other injuries noted and ROM WNL. Resident did not get sent to ER (emergency room) due to neuro checks WNL and no change in condition. Resident did not have a gait belt on while being transferred/assisted with ambulating. Education and in service given to staff that residents need gait belts while transferring and while being assisted with ambulation. R34's Care Plan documented a progressive care plan intervention following her fall on 11/24/22 as: Approach: Fall intervention 11/24/22; Education and in service given to staff that residents need gait belts while transferring and while being assisted with ambulation. On 1/20/23 10:00 AM, V1, Administrator, stated she would expect a gait belt to be used while transferring or walking any resident who is unsteady or needs assist. She stated she would expect staff to ensure a resident is safe before leaving that resident unattended to retrieve an adult diaper or any other needed items. The facility's policy, Gait Belt Policy and Procedure revised 5/21/19 documents, Policy: To protect the safety of residents requiring assist with transfer and to proactively participate in risk management initiative, it is the policy of the (facility) to require the use of gait belts by certified nursing personnel according to the following procedure: It continues, 4) Gait belts will be used during the transfer and/or ambulation of residents requiring assist unless contraindicated by the resident's diagnosis. 145384 Page 2 of 7 145384 01/20/2023 Eden Village Care Center 400 South Station Road Glen Carbon, IL 62034

F 0689 2. On 1/18/2023 at 2:03 PM, R163 was in her wheelchair with no anti roll back's on wheelchair. Level of Harm - Minimal harm or potential for actual harm R163's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses which include: Repeated falls, hypertension, dementia, bipolar disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (History of), foot drop right foot, polyneuropathy, major depressive disorder, and polyosteoarthritis. Residents Affected - Some R163's Fall Risk Assessment, dated 1/9/23 documents she was a high risk for fall. R163's MDS dated [DATE] documents she has severely impaired cognition and requires limited assistance for transfers, locomotion on unit, and toileting. According to this MDS, R163's balance during transitions and walking is not steady. The facility's document, All Falls for Facility dated 1/17/23 documents R163 had falls on 1/11/2023, 1/14/2023, and 1/16/2023. R163's Care Plan, dated 1/16/2023 documents the focus Falls : I am at risk for falls due to having repeated falls at home, weakness, spinal stenosis with lower back pain (LBP), neuropathy, right foot drop. Mild right lower extremity weakness from old stroke. Forgets safety precautions. Has made self transfer attempts with resulting falls. She has stated that there are other people here that need more help than she does, so she tries to do things on her own. Interventions dated 1/16/2023 include fall intervention encourage resident to eat meals in Main Dining Room (MDR) for safety and supervision, increased staff supervision with intensity based on resident need ankle foot orthosis (AFO) on right foot when out of bed. Intervention added after R163's fall on 1/14/23 is: anti - roll back device applied to resident's wheelchair and resident educated to use call light when needing assistance. R163's Progress Note, dated 01/14/2023 at 07:40 AM, documents therapy reported resident was sitting on floor next to bed. Elder is alert. Denies pain. ROM (range of motion) good to extremities. No injury reported. Up in wheelchair (w/c) dressed per therapy. Reminded to call for help. On 01/18/23 at 10:18 AM, V14, Certified Nurse Assistant (CNA), stated that R163 fell a couple times in this last week. V14 stated, (R163) gets up by herself and is supposed to have help. We tell her to use her call light but sometimes she doesn't. She uses a wheelchair and propel's herself. She's in therapy right now, sometimes she will use her call light and sometimes not. She uses her wheelchair. On 1/18/2023 at 10:18 AM, V15, CNA, stated, (R163) just fell a couple times this week. She uses her call light at times but she sometimes she does not. We make sure her call light is where she can reach it. On 1/18/2023 at 10:20 AM, R163 was observed in therapy using a bicycle. R163 stated she has fallen several times trying to go to the bathroom. She stated she tries to get to the wheelchair from her bed but will fall sometimes. R163 stated she will turn her light on but they don't answer the light in time and and she needs to use the bathroom so she tries to get to the bathroom on her own. On 1/18/2023 at 10:22 AM, V16, Physical Therapist Assistant (PTA), stated, (R163) is getting therapy but she hasn't had any falls that I know of in the facility. They didn't tell me if she fell 145384 Page 3 of 7 145384 01/20/2023 Eden Village Care Center 400 South Station Road Glen Carbon, IL 62034

F 0689 recently. Level of Harm - Minimal harm or potential for actual harm On 1/19/2023 at 12:55 PM, V21, Restorative Aide stated and confirmed there was no anti roll back device on R163's wheelchair. Residents Affected - Some On 1/19/2023 at 1:02 PM, V20, MDS/Care Plan Coordinator, stated and confirmed there was no anti roll back device on R163's wheelchair and stated she does not know why the anti-rollback is not on R163's w/c because they are included on her care plan. V20 stated a work order for maintenance should have been done to ensure the anti-rollback device was put on R163's w/c. V20 stated V2, Director of Nursing (DON), or V3, Assistant DON, usually do the work orders. On 1/19/2023 at 1:07 PM, V2 stated she thought the work order was turned in to the maintenance department for the anti roll back to be put on R163's wheelchair. On 1/19/2023 at 1:10 PM, V3 stated she or V2 usually put the work order in to maintenance after their morning meetings when they have investigated the falls and discussed them in the morning meeting, She stated sometimes even V20 will put the order in to maintenance. At times, the floor nurse will put in the work orders in to maintenance. V3 stated she is not sure why the anti roll back was not put on R163's wheelchair. On 1/19/2023 at 1:18 PM, V2 stated she is putting in another work order to maintenance for the anti roll back to be put on R163's wheelchair. V2 stated she does not know why they didn't get put on the wheelchair when first ordered. Based on observation, interview and record review, the Facility failed to implement and follow progressive fall interventions and utilize safety devices for 4 of 14 residents (R32, R34, R53, R163) reviewed for falls in the sample of 39. Findings include: 1. R53's January 2023 Physician Order Sheet (POS) documents R53 has diagnoses including unspecified severe protein-calorie malnutrition; unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified convulsions; restlessness and agitation; spondylosis without myelopathy or radiculopathy, cervical region; and spondylosis without myelopathy or radiculopathy, thoracic region. R53's Minimum Data Set (MDS) dated [DATE] documents R53 is moderately cognitively impaired, requires extensive one person assistance with bed mobility and transfer, and requires total dependence with one person assistance for toileting. R53's Fall Risk assessment dated [DATE] documents R53 is at high risk for falls. The Facility's All Falls for Facility Report dated 1/17/23 documents R53 had falls on 6/29/22, 7/31/22, and 8/1/22. R53's Care Plan with Problem Start Date of 4/1/22 documents, I am at risk for falls due to increased weakness from a recent UTI (Urinary Tract Infection). Care Plan approaches dated 4/1/22 include Call Don't Fall signs in room. 145384 Page 4 of 7 145384 01/20/2023 Eden Village Care Center 400 South Station Road Glen Carbon, IL 62034

F 0689 Level of Harm - Minimal harm or potential for actual harm R53's Event Report dated 6/29/22 documents resident had unwitnessed fall while attempting to self-transfer. The Evaluation Notes document, Resident trying to get out of bed to urinate however, resident does (have) a Foley cath (catheter) in place. Resident was reminded of Foley and call light use. Staff was educated to keep bed low when (R53) is laying down and mat was placed at bedside. Residents Affected - Some R53's Care Plan documents 6/30/22 Fall Intervention, Low bed with mats on floor at bedside. R53's Event Report dated 7/31/22 documents resident had unwitnessed fall. The Evaluation Notes document, Resident was trying to get up to empty Foley, per resident, 'so my wife didn't have to'. After investigation it was found resident's Foley was full. Intervention was presented to staff to empty Foley at a minimum twice a shift by nursing staff. R53's Care Plan documents 7/31/22 Fall Intervention, Keep Foley (catheter) bag emptied to avoid possible tugging/pulling on catheter from wt (weight) of urine in bag. R53's POS documents, Catheter care every shift. Every Shift; days, evenings, midnights with start date of 4/27/22. R53's Vitals Report does not document R53's catheter bag was emptied on 1/5/23 or 1/11/23. Documentation from 1/1/23 and 1/3/23 through 1/18/23 document R53's catheter bag was emptied only one or two times per day. On 1/18/23 at 8:52 AM, R53 was sleeping in bed in his room. There were no floor mats on either side of R53's bed. Two floor mats were lying against the wall across the room from resident. R53's catheter bag was filled past the 2000 mL (milliliters) mark with amber colored liquid. There was a Call Don't Fall sign on a table several feet away from R53's bed that was out of R53's vision. On 1/18/23 at 10:19 AM, R53's catheter bag was filled to the top of the bag and appeared taut and heavy. V13, Certified Nursing Aid (CNA), stated, It should have been emptied already from the midnight shift, but if it's already that full I'm sure it wasn't emptied. V13 filled up a urinal from the catheter bag, then clamped bag and stated, This was 1000 (mL). V13 then disposed of the urine, filled another urinal, and stated, That was another 1000 (mL). V13 again disposed of the urine and emptied the catheter bag into a third urinal. V13 stated, This is another 300 (mL). Two floor mats remained against the wall, and the Call Don't Fall sign remained face up on the table out of R53's vision. On 1/20/23 at 9:02 AM, V1, Administrator, stated she would expect staff to be following progressive fall interventions and empty catheter bag at least once a shift. 145384 Page 5 of 7 145384 01/20/2023 Eden Village Care Center 400 South Station Road Glen Carbon, IL 62034

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 ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 59 residents living in the Facility. Findings include: On 1/17/23 at 7:33 AM, the walk in freezer had a small amount of ice on the bottom of the fan. There was a box on a shelf labeled stew vegetables. The plastic bag inside the box was open and not sealed with vegetables exposed to the air. There was no date on the package to denote when it was opened. On 1/17/23 at 7:35 AM, the fan in the walk in refrigerator had a significant amount of dust. There were 3 stainless steel containers of food that were dated, but none were labeled to identify the contents inside. There was one half of a circular shaped cake that was wrapped in plastic wrap and dated, but did not have a label. There was a cart containing approximately 48 individual servings of coleslaw that were not labeled or dated. The entire cart was covered with a plastic sheet, but the individual items inside were not labeled, dated, or wrapped. V7, Dietary Manager, stated, Those will be used for lunch. On 1/17/23 at 7:40 AM, there was dust and dirt behind the ice machine and along the edge of the flooring. The hood above the stove near the dietary office was greasy with black, flaky residue on the metal part of the light. On 1/17/23 at 7:42 AM, there was a fan near the beverage table that was not in use, but covered in dust. V7, Dietary Manager, stated, Maintenance must have put that there. On 1/17/23 at 7:44 AM, the hood above the cook top beside the tray line had grease and dust on the metal part of the lights. V7, Dietary Manager, stated, We are just about due for our 6 month cleaning. We have a specialist that comes in every 6 months to clean the hoods. On 1/17/23 at 7:52 AM, on the shelf below the steam table there were two tubs of cereal that were not labeled or dated. There was also a bag of toasted oats cereal that was sealed up, but not dated. On 1/17/23 at 7:54 AM, there were two 22 quart containers on the counter next to the beverage refrigerator. One container had yellow liquid filled to the 8 quart mark. The other container had red liquid filled to the 8 quart mark. Neither container was labeled or dated. On 1/17/23 at 7:55 AM, the standing beverage refrigerator had 6 trays with individual glasses of yellow liquid that were not labeled or dated. On 1/20/22 at 9:02 AM, V1, Administrator, stated she would expect food service staff to follow the Facility's policy for dating and labeling. The Facility's Safe Storage of Food Policy issued 9/1/21 documents, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. All packaged and canned food items will be kept clean, dry, and properly sealed. All foods will 145384 Page 6 of 7 145384 01/20/2023 Eden Village Care Center 400 South Station Road Glen Carbon, IL 62034

F 0812 Level of Harm - Minimal harm or potential for actual harm be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The Facility's Resident Census and Conditions of Residents Form (CMS 672) dated 1/17/23 documents there are 59 residents living in the Facility. Residents Affected - Many 145384 Page 7 of 7