Health inspection·September 18, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's representative was notified of a resident's increase in behaviors, a new skin tear, and bruising for 1 of 3 residents (R1) reviewed for notification in the sample of 9. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Urinary Tract Infection, hypothyroidism, hypertension, major depressive disorder, and asthma. R1's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires assistance from staff for all cares. On 9/17/23 at 9:31 AM, V11 (R1's Power of Attorney) said the biggest problem that she has with the facility is that they don't notify her when R1 is having behaviors. V11 said R1 had an episode that resulted in a skin tear and bruises. V11 said she had come into the facility for a visit on Sunday (7/23/23) and noticed R1 had a bandage on her arm and bruises. V11 said she asked the CNAs on duty at that time about it and no one knew what happened. V11 said she went in and spoke with (V2 Interim Director of Nursing) on Monday and spoke to her about not being notified that something had happened with R1 and V2 assured her she would take care of the problem. V11 said another incident happened over this past weekend and no one notified her until V2 called her on Monday (9/11/23). R1's 7/21/23 nursing progress note showed, 1930 (7:30 PM) Patient began going in and out of other patients' rooms, screaming at them to get out of bed. Staff tried to redirect her, and she started hitting and pinching them. She continued to go up and down hallway yelling and entering rooms. Behavioral Health NP (Nurse Practitioner) notified with a message, waiting for a reply. R1's 7/21/23 nursing progress note entered at 10:58 PM showed, Continuing to wait for a response from Behavioral Health to call back. Patient keeps entering rooms stating that she is supposed to go in and check on the people and that she doesn't have to listen to anyone but her boss . Patient then went to the end doors and was banging on them and screaming. R1's 7/22/23 nursing progress note entered at 3:42 AM showed, No response from behavioral health at this time. CNA notified this nurse that patient was continuing to go into rooms and yell that they were in her house. Staff was unable to get patient out of other residents' rooms and patient was yelling and screaming very loudly. Staff had to remove patient because she wouldn't cooperate and leave other residents' rooms. Patient was brought off the unit to the desk. She was attempting to bite, kick, hit, and pull hair of staff. Patient received a skin tear to right forearm during this. Patient Page 1 of 4 145440 145440 09/18/2023 Neighbors Health Center 811 West 2nd Byron, IL 61010

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few continued to scream and state she was telling the Sheriff so we couldn't bandage it. Call placed to telehealth. During waiting period patient continued to be delusional and verbally and physically aggressive with staff. A call was then made to telehealth by phone. After 20 minutes waiting for return call, another call was made to telehealth. After 10 minutes a call was received from the on-call MD. A condition update was given, and new orders received. Patient finally started to calm down and talk to staff about her family. A snack was given and eventually after several more minutes she agreed to go back to her room and get her shoes. Patient went to bed with no problem. Patient has a history of these occasional outbursts but very infrequent. R1's 7/23/23 10:00 AM nursing note recorded as Late Entry on 7/24/23 at 10:55 AM showed, Niece, POA here for a visit and she is aware that resident had some behavior issues on Friday night. Niece said in the future she would like to be called and she would come and sit with her if necessary. R1's 8/15/23 nursing progress note entered at 8:05 PM showed, Patient was agitated this shift. She was going into other people's rooms and not wanting to leave them. She was very hard to redirect. (No notification to the Power of Attorney was documented.) R1's 9/9/23 nursing progress note entered at 11:33 PM showed, Patient shoving her bed in front of her bedroom door and refusing to let staff in the room. She appears very agitated and is hard to redirect. She will keep bothering her roommate and making hard for her to sleep. Patient refuses to come to the dayroom to watch TV so that her roommate can rest. (No notification to the Power of Attorney was documented.) R1's 9/11/23 nursing progress note showed, Call placed to resident POA (Power of Attorney) to update regarding recent behaviors. After speaking with [R1's POA] a request was made for a urinalysis. On 9/17/23 at 2:30 PM, V8 (Licensed Practical Nurse/LPN) said, . If there are extensive behaviors, we contact the behavioral health nurse practitioner and POA (Power of Attorney). If they are redirectable then we don't always make notifications . On 9/17/23 at 2:54 PM, V10 (LPN) said R1 gets anxious and territorial. V10 said R1 gets worked up and delusional and becomes hard to redirect. V10 said R1 does not have any PRN (as needed) medications to be given during these times because these behaviors are usually the result of a UTI (Urinary Tract Infection). V10 said R1 sustained a skin tear during one of her more recent behavioral outbursts because she was swinging her arms and punching at the CNAs (Certified Nursing Assistant). V10 said this last time she did not notify the POA of the behaviors because they happened in the middle of the night. On 9/18/23 at 12:40 PM, V2 (Interim Director of Nursing) said, I would encourage them to call (to update) POA because I would air on the side of caution. I can't say if notification needed to be made because I don't know the situation. R1's POA did express a desire to be notified which is why I touch base with her. The facility's policy and procedure reviewed 3/2003 showed, Change in Resident's Condition or Status, Objective: Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. Procedures: . 2. Unless otherwise instructed by the resident, the nurse will notify the resident's representative when: a: The resident is involved in any accident or incident including injuries of an unknown source. b. There is a significant change in the resident's physical, mental or psychosocial status . 145440 Page 2 of 4 145440 09/18/2023 Neighbors Health Center 811 West 2nd Byron, IL 61010

F 0880 Provide and implement an infection prevention and control program. 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 provide incontinence care in a manner to prevent cross contamination for 2 of 4 residents (R2, R4) reviewed for incontinence care in the sample of 9. Residents Affected - Few The findings include: 1. R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include hypertensive heart disease, chronic kidney disease, vascular dementia, major depressive disorder, paroxysmal atrial fibrillation, and osteoarthritis. R2's facility assessment dated [DATE] showed she has severe cognitive impairment and requires extensive assistance of staff for all cares. R2's care plan initiated 4/22/23 showed, . Toilet Use: [R2] is incontinent of her B&B (bowel and bladder). Extensive assist for toileting, peri care, and dependent for changing her lower body clothing . On 9/17/23 at 12:58 PM, R2 was being assisted to use the bathroom by V4 and V5 (Certified Nurse Assistants/CNAs). V4 and V5 wheeled R2 into the restroom and donned gloves. V4 and V5 performed a stand pivot transfer from the wheelchair to the toilet. During the transfer they pulled R2's pants down to sit her on the toilet. V4 placed her entire gloved hand directly on R2's backside to assist with pivoting her around to sit onto the toilet. V4 then used those same gloved hands to touch R2's wheelchair handles and armrests, the drawer pulls to the cabinet in the restroom, a clean towel, the faucet handles, and picked up a new incontinence brief. V4 wet a part of the towel with water and cleanser. V4 wiped R2's perineal area a couple of times with the wet end of the towel. V4 then pulled up R2's pants and flushed the toilet. V4 and V5 performed another stand pivot transfer for R2 into the wheelchair. V4 removed the gait belt from around R2 with the gloved hands. V4 and V5 then removed their gloves and exited the restroom without performing hand hygiene. V4 touched R2's wheelchair handles again, arm rests again, and straightened her clothing before pushing her wheelchair back into the common area. There were no glove changes or hand hygiene completed at any time during R2's cares. 2. R4's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dementia with other behavioral disturbance, muscle wasting and atrophy, muscle weakness, hypertension, irritable bowel syndrome without diarrhea, and osteoarthritis. R4's facility assessment dated [DATE] showed she has severe cognitive impairment and requires extensive assistance from staff for all cares. R4's care plan initiated 1/19/23 showed, ADLs (Activities of Daily Living) Functional Status . Toilet Use: [R4] is frequently incontinent of bowel and bladder. She is extensive assist for toileting, peri care, and changing clothing as needed . On 9/17/23 at 12:36 PM, V5 (CNA) assisted R4 out of the recliner and ambulated her into the bathroom. V5 assisted R4 to pull her pants down and then seated her on the toilet. V5 donned gloves and removed R4's urine-soaked incontinence brief which also had stool in it. V5 folded up the incontinence brief with her gloved hands and placed it in the trash bin. V5 then picked up a new incontinence brief with the same gloves on and placed the brief around R4's legs. V5 touched the faucet handles with the same gloved hands, turned the water on, grabbed a clean towel and wet the towel under the faucet. V5 picked up the cleanser bottle and squirted some onto the wet end of the towel. V5 then used the wet end of the towel and wiped R4's perineal area several times before she folded the towel over 145440 Page 3 of 4 145440 09/18/2023 Neighbors Health Center 811 West 2nd Byron, IL 61010

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and used it to wipe R4's buttocks. V5 then took a clean dry towel with the same gloves and wiped R4's perineal area again and then wiped her buttocks. V5 opened the laundry bin and placed the dirty towels into the bin before she assisted R4 to stand and pull her wet pants back up. V5 then removed the gloves and immediately ambulated R4 back out of the bathroom into the common area. V5 did not perform hand hygiene of any kind after the gloves were removed. V5 assisted R4 into the recliner in the common area and covered her up with a blanket before moving on to assist another resident with repositioning in her reclining wheelchair. On 9/17/23 at 2:38 PM, V9 (CNA) said after her gloves get dirty, she should change them because that would be going from dirty to clean. V9 said hand hygiene should be performed after gloves are removed. On 9/18/23 at 12:40 PM, V2 (Interim Director of Nursing) said, Hand hygiene should be done before providing care, after removing gloves, and before putting on a clean brief because we don't want to contaminate their clean underwear or brief. The facility's policy and procedure with revision date of 05/17 showed, Gloves; Objective: 1. Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Procedure: . a. If it is likely that the employee's hands will come in contact with blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin while performing the procedure; 8. Hand hygiene is necessary when gloves are removed . The facility's policy and procedure with revision date of 05/17 showed, Hand Hygiene; Objective: 1. Hand hygiene (handwashing or the use of Alcohol Based Hand Rub) is regarded by this organization as the single most important means of preventing the spread of infections . 1. All personnel will follow our established hand hygiene procedures to prevent the spread of infection and disease to other personnel, residents, and visitors . 2. Hand hygiene must be performed under the following conditions: g. Before and after assisting a resident with personal care; . q. After contact with a resident's blood mucous membranes, body fluids, excretions, or non-intact skin; . t. After moving gloves . 3. The use of gloves does not replace hand washing/hand hygiene . The facility's policy and procedure with revision date of 5/17 showed, Perineal Care; Objective: . 2. To prevent infection and odors . Procedure: 3. Wash hands and put on disposable gloves 6. Remove gloves and wash your hands . 145440 Page 4 of 4