Health inspection·October 3, 2024

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure daily weights were obtained for a resident with a diagnosis of heart failure, and failed to notify the resident's doctor when weight gain was outside of the set parameters for 1 of 1 resident (R19) reviewed for congestive heart failure (CHF) in the sample of 15. Residents Affected - Few The findings include: R1's admission Record, printed by the facility on 10/2/24 showed he had diagnoses including, but not limited to, heart failure, dementia, Parkinson's disease, anxiety, depression, and obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). R19's Order Summary Report, printed by the facility on 10/2/24, showed an order dated 5/14/24 for daily weights and to update V13 (R19's Cardiologist) if R19 had a gain of more than 2-3 pounds (lbs.) overnight or 5 pounds (lbs.) in a week. The report showed the order was still active on 10/2/24. R19's facility assessment dated [DATE] showed he had severe cognitive impairment, required partial/moderate assistance from staff for toileting, bathing, and transfers, and substantial to maximal assist for lower body dressing and putting on/taking off footwear. Section I of the assessment showed R19's primary medical condition was debility, cardiorespiratory conditions. R19's undated/untitled document, provided by the facility on 10/3/24 showed R19's weight on 6/30/24 was 201.6 lbs. R19's Weights and Vitals Summary, printed by the facility on 10/2/24, showed R19's weight on 7/1/24 was 204.9 lbs. (a 3.3 lb. gain in one day). R19's Weights and Vitals Summary, printed by the facility on 10/2/24, also showed the following: On 7/5/24 R19 weighed 200.6 lbs. On 7/6/24 R19 weighed 206.5 lbs. (a 5.9 lb. increase). On 7/24/24 R19 weighed 201.4 lbs. On 7/25/24 R19 weighed 208.3 lbs. (a 6.9 lb. increase). On 8/6/24 R19 weighed 199.9 lbs. No weight was entered for 8/7/24. On 8/8/24 R19 weighed 206.1 lb. (a 6.2 lb. increase). On 9/26/24 R19 weighed 198.5 lbs. On 9/27/24 R19 weighed 202.9 lbs. (an increase of 4.4 lbs.). On 9/29/24 R19 weighed 203.3 lbs. On 9/30/24 R19 weighed 206.6 lbs. (an increase of 3.3 lbs.). Page 1 of 3 145414 145414 10/03/2024 Prairie Crossing Lvg & Rehab 409 West Comanche Road Shabbona, IL 60550

F 0684 Level of Harm - Minimal harm or potential for actual harm R19's Progress Notes from 7/1/24-10/2/24 were reviewed. The only documentation during that time period of V13 being notified regarding R19's weights was on 9/30/24. R19's Weights and Vitals Summary, printed by the facility on 10/2/24, showed no weights entered for the following days: 7/20/24; 7/27/24; 7/28/24; 8/3/24; 8/7/24; 8/13/24; 8/17/24; 9/8/24; 9/14/24; and 9/22/24. Residents Affected - Few R19's July 2024-September 2024 Medication Administration Records showed no weights entered for the following days: 7/27/24; 7/28/24; 9/8/24; and 9/22/24. R19's care plan initiated on 7/3/24 showed he had a diagnosis of heart failure. The care plan showed Daily weight monitoring. The care plan also showed Monitor/document/report PRN (as needed) any (signs or symptoms) of Heart Failure .weight gain unrelated to intake . On 10/3/24 at 9:05 AM, V2 (Director of Nursing-DON) said R19's orders show to do daily wts and update (V13) if he has a 2-3 lb. weight gain. V2 looked through R19's electronic medical record for documentation that V13 had been notified on the dates in question while this surveyor waited. V2 said she did not see any documentation in R19's progress notes or in the electronic miscellaneous tab showing that V13 had been updated regarding R19's weights, other than on 9/30/24. V2 said R19 should have been reweighed and V13 should have been updated if there was that much of a difference in his weight. V2 said she did not see anything showing (V13) was updated until 9/30/24. It is important to notify the cardiologist. the resident could be having an exacerbation of CHF, that is what we are monitoring for when doing daily weights. V2 said she would continue to look and see if she could find any documentation showing that V13 was notified. At 10:51 AM, V2 said We looked for notification to the cardiologist and did not see anything. At 11:20 AM, V2 said R19 should have been weighed daily because there was an order for daily weights. The facility's policy and procedure titled Acute Condition Changes-Clinical Protocol, with a review date of 8/29/24, showed Notification: 1. The Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .h. Instructions to notify the physician of changes in the resident's condition. 145414 Page 2 of 3 145414 10/03/2024 Prairie Crossing Lvg & Rehab 409 West Comanche Road Shabbona, IL 60550

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 cool a pork roast before freezing and failed to use serving utensils while serving food. This applies to all residents in the facility. Residents Affected - Many The findings include: The CMS (Center for Medicare and Medicaid) 671 dated 1/10/24 shows there are 43 residents in the facility. On 10/1/2024 at 10:00 AM, a pork roast was observed in the refrigerator wrapped in aluminum foil with the date 9/18/2024 written on it. V3 Dietary Manager said the roast was cooked before for another meal and the leftovers were placed in the freezer. The roast was removed from the freezer on 9/18/2024 to thaw and will be used for a meal this week. V3 said they usually don't do this, that meals are prepared the day they are used, so a cooling log could not be provided. V3 said cooling logs should be used to reduce the risk of food borne illnesses. On 10/1/2024 at 1:26 PM, V4 [NAME] said when food is saved for leftovers the temperatures are checked but not logged anywhere, we just do it in our heads. On 10/2/2024 at 12:15 PM, V4 was observed serving the noon meal. V4 was wearing gloves and was observed placing garlic bread on the resident's plates with her gloved hands. V4 was also observed placing a slice of lasagna onto the plates using a spatula and using her hands to guide the lasagna onto the plates. V4 was observed while wearing the same gloves going to the storage room and into drawers for utensils. V4 did not change her gloves after leaving the work area. On 10/2/24023 at 1:16 PM, V3 said the cooks are supposed to be using utensils to plate the food and should not be using their hands. I expect the staff to use utensils to prevent cross contamination. The facility policy dated 2017 for Bare hand contact with food shows staff will use clean barriers such as single use gloves, tongs, deli paper and spatulas when handling food. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. The facility policy dated 2017 for general HACCP (Hazard Analysis Critical Control Points) shows to cool food 135 degrees Fahrenheit (F) to 70 degrees F in 2 hours and from 70 degrees F to 41 degrees F in 4 hours. 145414 Page 3 of 3