Inspection·August 13, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a urinary tract infection (UTI) was addressed and monitored in a timely manner for 1 of 3 residents (R2) reviewed for urinary tract infections in the sample of 6. Findings include: R2's Physician Order Sheet for August 2024 documents diagnoses of Nontraumatic intracerebral hemorrhage, anxiety disorder, Chronic pain, depression, type 2 diabetic, diabetes mellitus without complications, chronic pain, UTI (urinary tract infection), hypertension, and repeated falls. R2's Minimum Data Set, MDS, dated [DATE] document she is moderately impaired for cognition for activities of daily living. She uses a walker, needs moderate assistance with toilet transfers, and she is frequently incontinent of urine and bowel. R2's Care Plan documents, Resident has impaired skin integrity, approach: Keep skin clean and dry as possible. Monitor labs as available. Provide treatment as ordered. Report changes to MD (Medical Director) and obtain treatments as ordered as indicated. Pressure Ulcer: Approach: Toilet (or check if resident is incontinent) after meals, naps, activities and prior to HS (at bedtime). Check every 2 hours and PRN (as needed) at HS. On 8/8/2024 at 2:33 PM, V11, R2's family, stated, My mom has had UTIs off and on and they told me they will not test her for another UTI unless she starts running a fever. This worries me because I think she still has the UTI, and they tell me they it is normal because my mom is at the end stage of life. I know when my mom started acting strange, I know she had a UTI and when I asked about it a couple of weeks ago, they kept blowing me off. I think they lost or did not order some of the lab work that she needed. When I checked at the hospital, they told me they did not get the order for the C & S (urine culture and sensitivity). My mom had a delay and she ended up having a serious infection (ESBL) and I know if they are not careful my mom could get sepsis and that could kill her. We talked with the staff here and at the hospital and were trying to coordinate everything and then sure enough my mom ended up with a nasty infection of ESBL. R2 was on the infection control surveillance log for a urinary tract infection for July 2024. R2's Progress Notes dated 7/10/2024 at 2:45 PM, Obtained urine specimen by straight catheter, per daughter request. Specimen taken over to (Hospital) lab. Will await results. Daughter is here and aware. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145465 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)