Health inspection·June 25, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to protect a resident's right to dignity for two of two residents (R1, R11) by another resident (R5) reviewed for dignity in the total resident sample list of 27. Findings Include: The State of Illinois Ombudsman Program, Resident Rights in Long Term Care Facilities dated 11/2018 documents that all residents have a right to dignity and respect and the facility must care for residents in a manner that promotes their quality of life. The facility must provide services to keep each resident's mental health at the highest practical level. On 6/24/24 at 1:20 PM R11 stated R5 is very loud and constantly talking and he makes derogatory and prejudice comments as well as false comments. R11 states this makes him uncomfortable, bothers him a lot and also bothers others in the room. R11 stated he will often forgo activities or community outings if R5 is going because he doesn't want to be subjected to the negativity. R11 stated he has not complained about this to anyone in particular but staff are around and have heard these comments. R11 states staff tell R5 to stop but he just keeps doing it. On 6/24/24 at 1:25 PM R1 stated R5 does talk all of the time, is disruptive, and does make derogatory and racist comments about Chinese people. R1 stated it does bother her and she wishes that he would stop. R1's Medical Diagnoses list dated June 2024 documents R1 is diagnosed with Depression, Insomnia, and Obsessive Compulsive Disorder. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R11's Medical Diagnoses list dated June 2024 documents R11 is diagnosed with Diabetes. R11's Minimum Data Set, dated [DATE] documents R11 is cognitively intact. R5's Medical Diagnoses list dated June 2024 documents R5 is diagnosed with Depression, Cerebral Palsy, and Mental Disorder. R5's Minimum Data Set, dated [DATE] documents R5 is moderately cognitively impaired. On 6/24/24 at 1:30 PM V1 Administrator stated she had not been told about any prejudice or derogatory remarks made by R5 but will begin an investigation into the allegation. Page 1 of 7 145466 145466 06/25/2024 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

F 0550 Level of Harm - Minimal harm or potential for actual harm On 6/25/24 at 11:30 AM V1 Administrator stated she is conducting the investigation from the complaints of R1 and R11 and feels it is a resident rights issue. Residents have the right to be comfortable in their home and R5 should not be making comments that create a bad or negative atmosphere for others. Staff need to be more vigilant and intervene when necessary. V1 confirmed when R5 makes negative and prejudice comments it can impede on other resident's right to dignity. Residents Affected - Few 145466 Page 2 of 7 145466 06/25/2024 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to implement interventions in response to signs and symptoms of shortness of breath for a resident and ensure respiratory tubing is maintained in a sanitary manner for a resident receiving oxygen therapy. These failures affect one (R183) of three resident's reviewed for respiratory care from a total sample list of 27 residents. Residents Affected - Few Findings include: The Facility provided Respiratory Assessment Policy dated 8/2003 documents that respiratory assessments and interventions are to be documented in the resident's medical record. R183's undated diagnoses sheet documents diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. R183's care plan dated 6/19/2024 documents to monitor R183 for signs and symptoms of respiratory distress and to report to the physician changes in respiratory condition including respirations, pulse oximetry, tachycardia, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage and skin color. R183's progress notes document on 6/24/24 an oxygen saturation level of 88 percent. On 6/23/24 at 9:33AM, R183 appeared short of breath. Her color was pale, and she was using abdominal muscles to breathe. R183 was sitting up in the bed with oxygen at one liter being administered via nasal canula. The oxygen tubing nor water was dated, and the tubing was laying on the floor. On 6/23/24 at 9:35AM, R183 stated, This is a bad breathing morning. On 6/23/24 at 1:30PM, R183 remained in bed, resting her eyes and pursed lip breathing (breathing technique). On 6/24/24 at 10:35AM, R183 appears very short of breath and gray in color. R183 is breathing with accessory muscles and cannot speak due to shortness of breath. R183's oxygen continues at one liter per nasal cannula and the tubing, nor the water is dated. On 6/24/24 at 10:36AM, V15 Certified Nursing Assistant was taking R183's vital signs. R183's oxygen saturation was 89 percent on one liter of oxygen and her pulse rate was 125 beats per minute. R183 was not able to speak and was gasping. R183 is opening and closing her eyes and appears very uncomfortable. On 6/24/24 at 10:38AM, V2 Director of Nursing (DON) said that she had a discussion with R183 and V16 (Family Member) about hospice and comfort care options but that they were not wanting that at this time. When asked about the plan for R183's comfort during periods of air hunger, V2 DON said that it was a difficult situation to manage. On 6/24/24 10:40AM V4 Licensed Practical Nurse (LPN) stated, I just turned her oxygen up to two liters because of her vital signs. I will notify the doctor. On 6/24/24 11:00AM, V1 Administrator stated, I went down, and her coloring isn't good, and she 145466 Page 3 of 7 145466 06/25/2024 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

F 0695 doesn't look comfortable to me. We are going to send her to the ER. Level of Harm - Minimal harm or potential for actual harm On 6/24/24 3:50PM V3 LPN stated, I saw that she was struggling before she went to the hospital and I'm sure that it is the Lasix (diuretic) that made the difference. Residents Affected - Few On 6/25/24 at 9:30AM, R183's coloring is much improved to pale pink and R1 is able to speak while breathing more easily. On 6/25/24 at 9:31AM, R183 said that she was very scared yesterday and that she received an extra dose of Lasix (diuretic) in the hospital and that seems to have helped. On 6/25/24 at 10:44AM, R183's oxygen remains undated. On 6/25/24 at 10:45AM, V11 LPN stated, Oxygen tubing is supposed to be labeled weekly. They usually do it on nights. 145466 Page 4 of 7 145466 06/25/2024 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the facility failed to document psychotropic medication assessments, identify and track targeted behaviors, and attempt non-pharmacological behavioral interventions for two (R15, R20) of five residents reviewed for psychotropic medication in a sample list of 27 residents. Findings Include: The facility's policy Psychotropic Medication Policy revised 11/28/17 states Residents who receive antipsychotic drugs shall receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Any resident receiving psychotropic medications will be reviewed at minimum of every quarter by the interdisciplinary team. 1. R15's Care Plan revised 6/25/24 includes the following diagnoses: Major Depression and Mild Dementia with Anxiety. R15's Medication Administration Record (MAR) for June 2024 includes the following active physician's orders for Psychotropic Medication: Sertraline HCL (antidepressant) Give 75 milligrams by mouth one time a day. Aripiprazole (antipsychotic) 20 milligrams by mouth in the morning. There is no documentation of psychotropic assessments observed for R15. No targeted behaviors are identified or tracked for R15. No non-pharmacological interventions are documented as initiated for R15. 2. R20's Care Plan revised 6/5/24 includes the following diagnoses: Dementia with Agitation and Major Depressive Disorder. R20's Medication Administration Record (MAR) for June 2024 includes the following active physician's orders for Psychotropic Medication: Fluoxetine HCl (antidepressant) Oral Capsule 40 MG Give 80 mg by mouth one time a day. Quetiapine (antipsychotic) 25 MG Tab Give 12.5 mg by mouth two times a day. Divalproex Sodium DR (neuroleptic) 125 MG Give 1 tablet by mouth two times a day for dementia with behaviors. R20's most recent Psychotropic Medication Assessment is dated 9/29/23 and includes only the Fluoxetine. No targeted behaviors are identified or tracked for R20. No non-pharmacological interventions are documented as initiated for R20. On 6/25/24 at 10:01AM V16, Care Plan Coordinator stated I wasn't aware I needed to do quarterly assessments for residents with psychotropic medications. I will be doing the assessments and documenting specific behaviors and non-pharmacological interventions in the future. I do see this was not done for (R15 and R20). 145466 Page 5 of 7 145466 06/25/2024 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to dispose of expired schedule two narcotics for one (R6) of three residents reviewed for medications from a total sample list of 27 residents. Findings Include: The facility provided Procurement and Storage of Medications Policy dated [DATE] documents that all discontinued/expired non-controlled medications are to be removed from the active medication storage area, and the quantity should be noted on the medication sheet. All medications should then be returned to pharmacy or destroyed per facility policy as soon as practical. All controlled substances are to be destroyed according to the facility policy and procedure. R6 's undated physician order sheet documents an order for Morphine 20 milligrams per milliliter per 30 milliliter bottle, administer .25 milliliters, sublingually as needed, every four hours as needed for pain. On [DATE] at 9:30AM, two bottles of Morphine Sulphate were in cart two's narcotic box. One bottle had 13 cubic centimeters of medication left in it and one bottle was full with 30 cubic centimeters in it. Both bottles had expiration dates of [DATE]. On [DATE] at 9:35AM, V4 Licensed Practical Nurse stated, They are expired. It should have been destroyed. 145466 Page 6 of 7 145466 06/25/2024 Twin Lakes Extended Care 310 Eads Avenue Paris, IL 61944

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to provide at least 80 square feet of floor space per resident bed in 28 of 56 resident rooms at the facility, 28 of these rooms were occupied by residents. This failure affects all 31 residents residing in the facility. Findings include: Historical room documentation and actual onsite measurements on 6/25/24 at 12:00PM with V13 Maintenance Director, determined rooms 2, 4 through 11, and 14 through 32 are undersized; providing either 73.11 square feet per resident bed in rooms 9-11, 14-24; and 75.65 square feet in rooms 2, 4-8, 25-32. The most recent Centers for Medicare and Medicaid Services Certification and Transmittal undated, documents 56 of the facility's 62 beds are certified Title 18 (Medicare) and/or Title 19 (Medicaid). Rooms 2, and 4 through 11 are double occupancy and dually certified for Medicare and Medicaid, while rooms 14 through 32 are double occupancy and certified for Medicaid. The facility's Daily Roster dated 6/23/24, documents 31 of these 56 certified beds are occupied by residents residing in the facility. On 6/25/24 at 11:30AM, R18 said that his room was big enough for one person, but not two people. On 6/25/24 at 11:32AM, R19 said that his room is big enough for two people and that he wouldn't mind having a roommate. On 6/25/24 at 11:35AM, R6 said that his room is big enough for himself but that he could not have another person in it because it would be too small. On 6/25/24 at 12:42PM, R4 said that she and her roommate get along well and that there is enough room for the two of them. On 6/25/24 at 12:43PM, R1 said that her room isn't really very big and that she and her roommate don't have enough space, but the facility can't help it because her roommate has to have a bed. On 6/25/24 at 12:44PM, R14 said that she shares with a roommate and that the space is ok. On 6/25/24 at 12:45PM, R12 and R17 said that they have enough room in their room. On 6/25/24 at 3:00PM, V14 Regional Director of Operations said that she was aware that some of the facility rooms do not meet the size requirement per resident. 145466 Page 7 of 7