Health inspection·April 5, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on record review and interview the facility failed to notify, in writing, and maintain a copy in the Medical Record for notification of Resident/Resident Representatives upon Transfer/Discharge that were reviewed for Bed Hold Transfers. This failure has the potential to affect all 75 Residents residing in the Facility. Findings include: Facility Census and Condition Report, dated 4/2/24, documents 75 Residents residing in the Facility. Facility Bed Hold readmission Policy, dated 11/2016, documents: it is the policy of this Facility to readmit Residents after hospitalization or temporary therapeutic leave when the Resident requires services which can be provided by the Facility; this may be accomplished by holding a specific bed or by making available the next semi-private accommodations in the event a Resident does not desire to hold the specific bed; Residents, or their Designated Representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours; the Facility provides written notification at the time of transfer as included in the designated state form; the notice to the Resident or their representative will specify the Facility's Policy, the duration of the state bed hold policy and the reserve bed payment policy; in the event of an emergency hospitalization the Resident or their Representative shall be notified by telephone or in person of this policy, within 24 hours, and asked to provide the Facility with their decision; the staff member making the call or explaining the policy may accept verbal determination as to whether the Resident desires bed hold or having their name placed on the reservations/waiting list, and shall document same in the medical record and in the progress notes; and follow up written confirmation may be required; in the event a private pay Resident, or Representative, do not advise Facility upon receipt of bed hold notice as to whether or not the bed is to be held, authorization must be given within 24 hours or the bed will be released. On 4/3/24 at 10:49 am, V2 (Director of Nursing/DON) stated, I cannot find any copies of any notification to the Resident Representatives for any Bed Hold's for any of our Residents that discharged to the hospital. On 4/3/24 at 12:00 pm, V3 (Social Service Director) stated, I have not completed or sent any Bed Hold forms to any Family or Family Representative, for any Resident that has discharged or been sent to the hospital. On 4/4/24 at 11:53 am, V2 (DON) stated, We have not been sending any Bed Hold forms to the Page 1 of 8 145404 145404 04/05/2024 Farmington Village Nrsg 701 South Main Street Farmington, IL 61531

F 0623 Resident's Representatives when the Resident's discharge to the hospital, and I do not have any copies. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 145404 Page 2 of 8 145404 04/05/2024 Farmington Village Nrsg 701 South Main Street Farmington, IL 61531

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on record review and interview the facility failed to notify, in writing, and maintain a copy in the Medical Record for notification of Resident/Resident Representatives upon Transfer/Discharge that were reviewed for Bed Hold Transfers. This failure has the potential to affect all 75 Residents residing in the Facility. Findings include: Facility Census and Condition Report, dated 4/2/24, documents 75 Residents residing in the Facility. Facility Bed Hold readmission Policy, dated 11/2016, documents: it is the policy of this Facility to readmit Residents after hospitalization or temporary therapeutic leave when the Resident requires services which can be provided by the Facility; this may be accomplished by holding a specific bed or by making available the next semi-private accommodations in the event a Resident does not desire to hold the specific bed; Residents, or their Designated Representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours; the Facility provides written notification at the time of transfer as included in the designated state form; the notice to the Resident or their representative will specify the Facility's Policy, the duration of the state bed hold policy and the reserve bed payment policy; in the event of an emergency hospitalization the Resident or their Representative shall be notified by telephone or in person of this policy, within 24 hours, and asked to provide the Facility with their decision; the staff member making the call or explaining the policy may accept verbal determination as to whether the Resident desires bed hold or having their name placed on the reservations/waiting list, and shall document same in the medical record and in the progress notes; and follow up written confirmation may be required; in the event a private pay Resident, or Representative, do not advise Facility upon receipt of bed hold notice as to whether or not the bed is to be held, authorization must be given within 24 hours or the bed will be released. On 4/3/24 at 10:49 am, V2 (Director of Nursing/DON) stated, I cannot find any copies of any notification to the Resident Representatives for any Bed Hold's for any of our Residents that discharged to the hospital. On 4/3/24 at 12:00 pm, V3 (Social Service Director) stated, I have not completed or sent any Bed Hold forms to any Family or Representative, for any Resident that has discharged or been sent to the hospital. On 4/4/24 at 11:53 am, V2 (DON) stated, We have not been sending any Bed Hold forms to the Resident's Representatives when the Resident's discharge to the hospital, and I do not have any copies. 145404 Page 3 of 8 145404 04/05/2024 Farmington Village Nrsg 701 South Main Street Farmington, IL 61531

F 0644 Level of Harm - Minimal harm or potential for actual harm Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review the facility failed have a valid PASRR (Pre-admission Screening and Resident Residents Affected - Few Review) for one resident (R49) of three reviewed for PASSR in a total sample of twenty-three. Findings Include: The Facility's undated PASRR (Pre-admission Screening and Resident Review) Guideline documents the objective of the PASSR guideline is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASRR will be evaluated annually and upon any significant change for those individuals identified, R49's Pre-admission Screening and Resident Review/ Level 1 Screen dated [DATE] documents Convalescence Category with no required services. R49's PASSR dated [DATE] also documented Approval Period: 60 days. On [DATE] at 9:00 AM V1 (Administrator) confirmed that R49's Pre-admission Screening and Resident Review validity expired on [DATE] and should have been redone. 145404 Page 4 of 8 145404 04/05/2024 Farmington Village Nrsg 701 South Main Street Farmington, IL 61531

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to develop a care plan to include a biliary drain and a skin condition for two (R33, R42) of 18 residents reviewed for care plans in a sample of 23. Findings include: Facility Care Plans policy, updated October 2022, documents An individualized Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident. Facility Skin and Wound Management policy, revised 10/2019, documents The presence of skin impairment should be denoted on the person-centered plan of care. 1. R33's physician orders, dated 2/02/2024, documents Cleanse biliary drain site with wound cleanser, cover with split sponge. Change daily and as needed for soiling. Monitor Biliary Drain Site every shift for signs and symptoms of infection. R33's nurses notes, dated 2/2/24, documents (R33) returned on 2/02/2024 at 4:02 PM. Resident has right biliary drain site. On 4/02/24 at 11:00 AM and 4/3/24 at 9:33 AM, R33 was and alert sitting in a manual wheelchair with a biliary drain bag for her gall bladder located under her right leg pant leg. On 4/03/24 at 9:44 AM, V5 LPN/Licensed Practical Nurse stated (R33's) drain is emptied daily and it is a drain for her infected gall bladder. R33's current care plan has no documentation of R33 biliary drain. On 4/05/24 at 9:50 AM, V4 LPN CPC/Care plan Coordinator stated I just put (R33's) drain on her care plan on 4/3/24 after you asked for her care plan. I normally put it on right away after they come back with new orders from the hospital, but I didn't on her. 2. R42's physician orders, dated 3/15/24, documents Appointment with (local) Clinic Dermatology. Possible skin cancer under left eye. On 4/02/24 at 10:46 AM, R42 was sitting in his electric recliner and under his left eye the skin was red and appeared irritated. At that same time R42 stated the area gets better and then worse, and he is putting lotion on it. On 4/03/24 at 9:58 AM, R42 was sitting in his electric recliner and under his left eye the skin was red. At that same time R42 stated the area was getting better. R42's current care plan has no documentation of R42's left under eye skin redness. On 4/05/24 at 9:50 AM, V5 LPN CPC stated (R42's) skin concerns under his left eye should be on the care plan, but I see it isn't. 145404 Page 5 of 8 145404 04/05/2024 Farmington Village Nrsg 701 South Main Street Farmington, IL 61531

F 0656 On 4/05/24 at 10:11 AM, V5 LPN stated, I am the nurse taking care of (R42) and we are monitoring the area under his eye. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145404 Page 6 of 8 145404 04/05/2024 Farmington Village Nrsg 701 South Main Street Farmington, IL 61531

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, record review and interview, the facility failed to revise a plan of care for 1 of 4 (R26) residents reviewed for indwelling catheters in a total sample of 23. Residents Affected - Few Findings Include: Facility Care Plans policy, updated October 2022, documents An individualized Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident. On 4/2/2/24 at 9:38 AM R26 was in his room and did not have an indwelling catheter. R26's Physician Orders dated March 2024 did not have an order for an indwelling catheter. R26's current Care Plan dated 03/05/24 lists an indwelling catheter as an area of care. On 04/03/24 at 2:34 PM, V4, Care Plan Coordinator, confirmed R26 does not have an indwelling catheter but his Care Plan states he does. 145404 Page 7 of 8 145404 04/05/2024 Farmington Village Nrsg 701 South Main Street Farmington, IL 61531

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have orders and follow up on a dermatology order for one (R42) of one resident reviewed for skin conditions in a sample of 23. Residents Affected - Few Findings include: Facility Skin and Wound Management policy, revised 10/2019, documents To ensure appropriate assessment, treatment, monitoring and documentation of skin and skin alteration. The presence of skin impairment should be denoted on the person-centered plan of care. R42's Wound Evaluation and Management Summary, dated 3/5/24, documents Recommend referral to Dermatology. R42's physician orders, dated 3/15/24, documents Appointment with (local) Clinic Dermatology. Possible skin cancer under left eye. R42's physician orders for March and April 2024 have no orders regarding R42's left under eye skin concern. R42's TAR/Treatment administration record or MAR/Medication administration record for March and April 2024 do not have any orders/documentation for R42's left under eye skin concern. On 4/02/24 at 10:46 AM, R42 was sitting in his electric recliner and under his left eye the skin was red and appeared irritated. At that same time, R42 stated the area gets better and then worse, he is putting lotion on it, no one else has done anything with the area, and there is no treatment done by the facility. On 4/03/24 at 9:58 AM, R42 was sitting in his electric recliner and under his left eye the skin was red. At that same time, R42 stated the area was getting better. R42's nurses notes, dated 4/5/24 at 7:37 AM by V2 DON/Director of Nursing, documents I talked with transportation, and she talked with R42's POA/Power of Attorney, and does not want him to go to any appointments. On 4/05/24 at 9:59 AM, V2 DON verified there was no follow up to R42's 3/15/24 appointment with (local) Dermatology clinic until 4/5/24. On 4/05/24 at 10:11 AM, V5 LPN stated I am the nurse taking care of (R42) and we are just monitoring the area under (R42's) eye but not charting this anywhere. He has an order in his chart for an appointment entered on 3/15/24 to see dermatology but it doesn't say he has an appointment scheduled. He hasn't gone to any appointment at dermatology I can find. There is an order to monitor the lesion under his left eye put in on 4/5/24. 145404 Page 8 of 8