Health inspection·March 13, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. 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 supervise and assist with meals for 1 of 1 (R45) residents reviewed for nutrition in a sample of 38. Residents Affected - Few Findings include: R45's Face sheet, print date of 03/12/24, documents R45 has diagnoses of other specified eating disorder and dysphagia (difficulty swallowing), oropharyngeal phase. R45's Minimum Data set (MDS), dated [DATE], documents, R45 is severely cognitively impaired and requires partial/moderate assistance with eating. R45's Care Plan, last care conference date of 10/26/23, documents, Goal: R45 will consume 75% of all meals and will remain free from significant weight loss. Approach list but is not limited to protein supplement three times a day with med pass, fortified ice cream with lunch and dinner, routine weights, record, notify doctor (MD)/registered dietitian (RD) of any significant changes in weight, and selective menu choices. Substitutions available for food dislikes. R45's Weights for the past six months are as follows: 10/09/2023- Weight: 119.5 pounds (lbs.) 11/06/2023- Weight: 115.5 lbs. 12/04/2023- Weight: 116.0 lbs. 01/08/2024- Weight: 100.0 lbs. 01/23/2024- Weight: 100.5 lbs. 01/29/2024- Weight: 102.5 lbs. 02/05/2024- Weight: 104.5 lbs. 02/12/2024- Weight: 105.0 lbs. 02/19/2024- Weight: 105.0 lbs. Page 1 of 5 145483 145483 03/13/2024 Montgomery Nursing & Rehab Ctr State Route 127 Hillsboro, IL 62049

F 0692 02/26/2024- Weight: 105.5 lbs. Level of Harm - Minimal harm or potential for actual harm 03/04/2024- Weight: 102.0 lbs. 03/12/2024- Weight: 104.4 lbs. Residents Affected - Few R45's Dietary Note, dated 01/11/2024 at 6:19 PM, documents R45 has lost a significant amount of weight over the past month. On 12/04/23 R45 weighed 116 pounds and on 01/08/24 R45 weighed 100 pounds. Her previous weights had been fairly stable. R45 had some significant health changes. She had a fall, COVID, some increased confusion, difficulty eating and swallowing, refusing to eat at times and a poor appetite. Speech Therapy was ordered for swallowing issues, she was started on Remeron on 1/3/24 and protein supplements three times a day with medication passes (12/29/23). R45 is needed assistance with meals, weights are being monitored weekly, and fortified ice cream at lunch and supper. R45's Physician's Orders, dated 01/23/2024, documents protein supplement with medication pass three times a day 7:00-10:00 AM, 11:00-1:00 PM, 3:00-6:00 PM. R45's Physician's Orders, dated 01/03/2024, documents Remeron (mirtazapine) tablet; 15 milligrams (mg); amount: 1 tablet; oral Special Instructions: administer one tablet by mouth (po) every bedtime (hs) for depression and appetite stimulant. Once A Day 7:00 PM-10:00 PM (19:00 - 22:00). On 03/10/24 at AM, R45 is sitting up in her recliner beside her bed resting with her eyes closed, her call light is observed to be within easy reach, she is dressed appropriately in clean clothes her shirt seems a bit large and baggy on her, and she appears to be thin and frail. On 03/11/24 at 10:30 AM, R45 was observed in her room. She appeared to be very thin and frail in appearance and her sweatshirt appeared to be big and baggy on her. On 03/11/24 at 11:05 AM, R45's meal was brought to her. Meal tray was uncovered, and she had baked chicken, scalloped potatoes, broccoli, cookie, ice cream, milk, water. 03/11/24 11:15 AM, R45 was given a nutritional supplement by V16, Registered Nurse (RN) at this time. On 03/11/24 at 11:30 AM, R45 ate a couple bites from her lunch tray then pushed it away from her. On 03/11/24 at 11:40 AM, R45's lunch tray was still in her room pushed away from her and she hadn't taken any further bites. Staff did not encourage her to eat, offer to assist her with her meal, or offer to go and get her something else to eat. On 03/11/24 at 11:51 AM, V15, Certified Nursing Assistant (CNA) went into R45's room and asked R45 if she was done with her tray. V15 did not encourage her to eat, did not offer to assist her with her meal, or did not offer to get her a substitution from the kitchen. V15 then removed R45's lunch tray from her room. It was observed to have the nutritional supplement still on it, and the fortified ice cream was observed to still have the lid on it. The nutritional supplement was still full when this surveyor picked it up to check and see how much had been drank by R45. 145483 Page 2 of 5 145483 03/13/2024 Montgomery Nursing & Rehab Ctr State Route 127 Hillsboro, IL 62049

F 0692 Level of Harm - Minimal harm or potential for actual harm On 03/12/24 at 11:32 AM, V18, CNA asked R45 if she was done eating. R45 told her she was eating a little at a time. V18 reminded R45 she had ice cream on her tray. No offer to assist R45 with her meal was made. On 03/12/24 at 11:45 AM, R45 sitting in her chair with her meal tray still in front of her. Resting her head on the back of her chair, her eyes closed, and only a few bites of food has been eaten. Residents Affected - Few On 03/12/24 at 11:56 AM, V18 was observed picking up R45's tray. V18 asked R45 if she was done eating and if she was still hungry. No encouragement for her to eat or offer to assist her with her meal was made at this time. V18 left R45's supplement and water on her over the bed table for her to drink. On 03/12/24 at 12:03 PM, V18, CNA stated if she noticed someone wasn't eating, she would offer to go and get them something else to eat, she would ask someone else to go in and try to see if they could get them to eat, and let the nurse know. On 03/13/24 at 08:50 AM, V2, Director of Nursing (DON) stated she would expect the staff to find out if they liked what was on their plate, offer the alternative, have someone reproach, because sometimes if they won't eat for one person they will for someone else, supervise, give verbal cues, assist if needed, notify the nurse, and bring the resident to the dining room if they will come. On 03/13/24 at 10:52 AM, V31, Registered Dietitian stated if the resident wasn't eating she would expect the staff to give them their supplement, ice cream, and if they weren't eating and drinking those to let her know so they could change it because it would be pointless for them to continue to be given them. She said she would also expect for the staff to assist them with their meal and encourage them to eat. She said she would also have them move the resident to the dining room to eat for better supervision. The facility's policy and procedure, Weight Management Program, revision date February 2024, documents Policy: It is the policy of the facility to manage resident weight through prevention, assessment, and implementation and evaluation of interventions. 145483 Page 3 of 5 145483 03/13/2024 Montgomery Nursing & Rehab Ctr State Route 127 Hillsboro, IL 62049

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation, interview and record review, the facility failed to discard insulin pens after being in use for longer than 28 days, remove and dispose of expired medications, and not store food items in the medication refrigerator. This failure has the potential to affect all 75 residents residing in the Facility. Findings include: On 03/10/24 at 8:40 AM, The front medication room was inspected. The unlocked refrigerator, in the medication room contained the following: 1. There was a container of personal food and a 2% milk. 2. An unopened box of Tylenol suppository's 650mg (milligrams) with an expiration date of 12/2023. 3. R68's opened Lansprazole suspension 3mg/ml (milligrams/milliliter) with no open date or discard noted to the bottle. On 03/10/24 at 8:43 AM, 12, Registered Nurse (RN) stated the Lansprazole suspension should have an open date on it and there shouldn't be any food in the medication storage refrigerator. On 03/10/24 at 8:45 AM, The stock medication cabinet was inspected and contained the following: 1. Oyster Shell calcium Vitamin 250mg expiration date 06/2023. 2. Vitamin B-6 25mg expiration date 09/2023. On 03/10/24 at 8:55 AM, The front medication cart was inspected and contained the following: 1. R14's Lantus insulin multi dose vial 100/ml open date of 02/05/2024. 2. R14's Lispro insulin injection pen u100 with an open dated of 02/04/2024. 145483 Page 4 of 5 145483 03/13/2024 Montgomery Nursing & Rehab Ctr State Route 127 Hillsboro, IL 62049

F 0761 3. Level of Harm - Minimal harm or potential for actual harm R39's Tresiba insulin pen with an open date of 02/07/24. Residents Affected - Many On 03/10/24 at 9:05 AM, V4, Licensed Practical Nurse (LPN) stated the insulin should be discarded 28 days after opening. On 03/13/24 at 8:54 AM, V2, Director of Nursing (DON) stated she would expect the nurses to review the dates on the medications and check the dates on the insulin pens prior to administering them, and not have food in the medication fridge. The facility's policy and procedure, Storage of Medications, revision date of 05/01/2018, documents Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal if a current order exists. It further documents K. Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator. It also documents Expiration Dating E. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best sticker to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be [30] days unless the manufacturer recommends another dated or regulations/guidelines require different dating (See Forms: Medications with shortened expiration dates). F. The nurse will check the expiration date of each medication before administering. G. No expired medication will be administered to a resident. H. All expired medications will be removed from the active supply and destroyed in the facility regardless of amount remaining. The Resident Census and Condition of Residents Form 672 dated 3/10/2024 documents there are 75 residents residing in the Facility. 145483 Page 5 of 5