Health inspection·March 27, 2025

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, record review and interview, the facility failed to provide dignity for two of six (R3 and R19) residents reviewed for dining in a sample of 40. Findings include: On 3/24/2025 at 11:00 AM, V4, Certified Nursing Assistant (CNA), was at a half round table, in the assistive dining room, where there were 3 residents that needed feeding assistance. She was standing up feeding R3 from behind the half round table. V1, Administrator, asked V4 to sit down when she was feeding the resident. V4 stated that she was too short to reach R3. V1 walked away. She continued to feed R3 standing up instead of sitting down next to her. Another CNA asked V4 to switch her tables and feed R19. V4 did so, sat down and could not reach R19 across the table so she stood up instead of sitting next to R19 and gave her bites of food. R3's Minimum Data Set (MDS), dated [DATE] documented that she was rarely or never understood and that she was dependent upon staff for eating. R3's Care Plan, dated 11/24/2020, documented, Set up tray and hand her utensil with food and encourage her to place into mouth using hand over hand and verbal cue as needed. R3's Physicians order sheet, dated 3/26/2025 documented diagnoses of Alzheimer's, Delusional disorders and Dysphagia. R19's MDS, dated [DATE] documented that she was rarely or never understood and that she required substantial to maximal assistance from staff to eat. R19's Care Plan, dated 11/13/2017, documented, (Encourage)/ Assist her to perform all (activities of daily living) to (maximum) potential. R19's Physicians order sheet, dated 3/26/2025, documented diagnoses of Dementia and Hemiplegia affecting left non-dominant side. On 03/26/2025 at 11:08 AM, V15, CNA, stated that when she is feeding someone, she will sit down and make eye contact with them. On 03/26/2025 at 11:10 AM, V16, CNA, stated that she sits down to feed residents but may have to stand up to give bites. Page 1 of 8 145483 145483 03/27/2025 Montgomery Nursing & Rehab Ctr State Route 127 Hillsboro, IL 62049

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/26/2025 at 11:10 AM, V17, CNA, stated that she sometimes will have to stand up to reach a resident to feed them. When CNA was asked if she could sit next to the resident to assist with the meal, she stated that they were told they had to sit behind the table, across from the resident. On 03/26/2025 at 11:15 AM, V1, Administrator, stated that they were never instructed that they had to sit behind the table to assist a resident with a meal and that they could sit next to the resident. The facility's policy, Assisting Residents with meal, dated 6/2016, documented, 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting them with meals. 145483 Page 2 of 8 145483 03/27/2025 Montgomery Nursing & Rehab Ctr State Route 127 Hillsboro, IL 62049

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review, the facility failed to administer a Gastrostomy Tube (G-tube) feeding according to standards of care for 1 of 1 residents (R230) reviewed for tube feedings in the sample of 40. Findings include: R230's Face sheet dated 3/26/2025 documents R230 has a Gastrostomy Tube (G-tube). R230's Care Plan dated 3/18/2025 documents R230 currently has a feeding tube in place, placing him at risk for complications, including aspiration (inhaling fluid into the lungs). R230's Physician's Orders dated 3/19/2025 documents R230 gets a tube feeding at 237 milliliters over 60 minutes four times a day via G-tube. On 3/24/2025 at 4:00 PM, V6, Licensed Practical Nurse (LPN) entered R230's room to administer his tube feeding. V6 donned gloves, but no gown. V6 connected the tube feeding to R230's G-tube and began the feeding at 237 milliliters per hour. R230 was laying flat in bed. V6 did not elevate the head of R230's bed. On 3/25/2025 at 7:58 AM, V2 Director of Nursing (DON) stated she would expect the nurse administering a tube feeding to elevate the head of the bed. V2 stated she asked V6 if she did elevate the head of R230's bed and V6 confirmed she did not. R230's Progress Notes dated 3/26/2025 documents R230 currently has aspiration pneumonia, continues the tube feedings and the head of the bed is elevated 30 degrees while infusing. The Facility's Policy does not address elevating the head of the bed prior to initiating a tube feeding. 145483 Page 3 of 8 145483 03/27/2025 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 properly store medication and label multi dose insulin vials and pens. This has the potential to effect all residents residing in the facility. Findings include: On 3/24/2025 at 11:12 AM the facility's 500 Hall Medication Cart was inspected. The medication cart contained the following: 1. An opened and unlabeled multi dose Lispro insulin vial. The multi-dose vial did not have a resident identifier or open date. On 3/24/2025 at 11:13 AM V20, Licensed Practical Nurse (LPN), verified that the vial was open, partially used, undated and not labeled. V20 stated that the vial should be labeled with the resident's name and open date. V20 stated that the vial belonged to R31. On 3/26/2025 at 1:56 PM V7, LPN, stated that the multi-dose vials that are not labeled are stock. V7 stated that when using the multi-dose vial it is labeled with the resident's name and open date. V7 stated that R31's insulin was discontinued October 2024. A review of R31's medical record Physician Order Sheet (POS) document no current Lispro order for R31. On 3/24/2025 at 11:15 AM the 100 Hall Medication Cart was inspected. The medication cart contained the following: 2. R29's opened, partially used, and undated multi-dose Lantus vial. 3. 1 opened, partially used, unlabeled and undated multi dose Basaglar Pen. On 3/24/2025 at 11:17 AM V22, Registered Nurse (RN), stated that the medication was open, partially used and should have a date on it. 4. On 3/24/2025 at 12:48 PM observed a clear medicine cup with a large white pill and an oblong red, white, and blue pill on a food tray in the hallway on a cart. On 3/24/2025 at 12:50 PM V6, LPN, identified the pills as R8's Tylenol 500 MG (milligram) capsule and half tablet of potassium 20 meq (milliequivalent). V6 stated that R8 must have spit it out. On 3/26/2025 at 2:00 PM V23, LPN, stated that when opening a new multi dose vial or pen an open date is written on the vial, pen and box with the expiration date. V23 stated that if there isn't a name then one is written on at that time. On 3/27/2025 at 10:00 AM V3, Assistant Director of Nursing, stated that when the staff remove a stock multi-dose vial or pen the nurse is to place the resident name and the date open. V3 stated that 145483 Page 4 of 8 145483 03/27/2025 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 this date is important because it tells the nurse when the medication expires. V3 stated that once the insulin is out of the refrigerator it has a 30 day life and the written date alerts the nurse to the expiration date. V3 stated that when the nurse passes the medication they are to stay and make sure the medication is taken. V3 stated that the medication is not to be left at the bedside or on meal tray. The Resident's Census and Conditions of Resident, CMS 671, dated 3/24/2025, documents that the facility has 78 residents living in the facility. The facility's MAC Rx of Missouri Pharmacy Policies and Procedures Manual, ID1 Storage of Medications, dated 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: Expiration Dating D. Drugs re-packaged by the pharmacy staff will generally carry an expiration date as follows: (Note: the pharmacist determines the exact date based upon a number of factors as well as applicable law or regulation) 2) Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: In a multi-dose injectable vial, An ophthalmic medication, An item for which the manufacturer has specified a usable life after opening. 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 stickers 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 date 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. 145483 Page 5 of 8 145483 03/27/2025 Montgomery Nursing & Rehab Ctr State Route 127 Hillsboro, IL 62049

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 follow their Enhanced Barrier Precautions (EBP) policy by not posting signage or utilizing Personal Protective Equipment (PPE) when caring for residents with qualifying criteria for 4 of 4 residents (R33, R74, R75, and R230) reviewed for Transmission Based Precautions (TBP) in the sample of 40. Residents Affected - Some Findings include: 1. On 3/24/2025 at 10:10 AM, R75 was observed in a low bed with a catheter bag attached. The catheter bag was rested on the floor. There was no signage or Personal Protective Equipment outside R75's room or near the vicinity of R75's room. On 3/24/2025 at 3:18 PM, V20, Licensed Practical Nurse (LPN) stated R75 had a catheter but she removed it because he was pulling at it. V20 stated R75 still has a nephrostomy tube that gets flushed every day by the nurses. R75's Progress Notes dated 3/23/2025 at 10:27 AM documents R75's nephrostomy tube and catheter were in place. R75's Progress Notes dated 3/23/2025 at 1:58 PM documents R75's nephrostomy tube and catheter were draining urine and catheter care was provided by staff. R75's Care Plan dated 3/10/2025 documents R75 has a indwelling catheter and nephrostomy in place, putting him at risk for complications. R75's Care Plan further documents, as well as, ensure the bag and tubing are off the floor at all times. R75's Physician's Orders dated 3/11/2024 documents, Flush nephrostomy drainage tube with 10 CC (Milliliters) N/S (Normal Saline) every 12 hours. On 3/26/2025 at 10:00 AM, V7, LPN brought the treatment cart inside R75's room, performed hand hygiene and applied gloves. V7 did not don a gown. V7 then proceeded to flush R75's nephrostomy tube and empty the urine from the bag. V7 then attached the bag to the bed. The urinary bag was touching the floor. 2. The Facility Matrix provided on 3/25/2025 documents R74 has Intravenous Therapy (IV) R74's Face sheet undated, provided on 3/26/2025, documents R74 has a diagnosis of Bacteremia (infection in the blood). R74's Care Plan dated 2/20/2025 documents R74 currently has a PICC line to her left upper arm for antibiotic treatment related to bacteremia. It continues to document to administer medication per orders. On 3/24/2025 at approximately 10 AM, R74 was observed in her room. There was a bag of medicine observed connected to an IV pole. At this time R74 stated she was receiving antibiotic medications through her IV site but was not sure why. There was no signage on R74's door to indicated enhanced barrier precautions should be utilized nor or any PPE located nearby. 145483 Page 6 of 8 145483 03/27/2025 Montgomery Nursing & Rehab Ctr State Route 127 Hillsboro, IL 62049

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/25/2025 at 8:10 AM, V5, Registered Nurse (RN) entered R74's room, donned gloves, but no gown, and connected R74's IV antibiotic medication to R74's peripherally inserted central catheter (PICC) 3. The Facility Matrix provided on 3/25/2025 documents R230 receives dialysis. On 3/24/2024 at 9:50 AM, there was no signage on R230's door to indicate EBPs were to be utilized, nor was there any PPE readily available. R230's Face sheet dated 3/26/2025 documents R230 has a Gastostomy Tube (G-tube) and is dependent on renal dialysis. R230's Care Plan dated 3/18/2025 documents R230 currently has a feeding tube in place. It further documents R230 has a pressure area to his coccyx (backside) and receives dialysis. R230's Physician's Orders dated 3/18/2025 documents R230 receives dialysis three times a week. On 3/24/2025 at 4:00 PM, V6, Licensed Practical Nurse (LPN) entered R230's room to administer his tube feeding. V6 donned gloves, but no gown. V6 connected the tube feeding to R230's G-tube and began the feeding. On 3/26/2025 at 1:50 PM, V3, Assistant Director of Nursing (ADON) stated she is in charge of infection control. When asked if a resident who receives a feeding via G-tube should be on EBP, V3 stated, That's a really good question. We don't get a lot of G-tubes. I know chronic wounds should be, but I'm not sure what the time frame is to determine if it's a chronic wound. (R74) had the IV Monday and Tuesday and (R75's) catheter was 'pulled' on Monday (3/24/2024) afternoon. He should have been on EBP because I know (catheters) should. On 3/26/2025 at 2:38 PM, V3 stated, Yes, they should have been wearing gowns while providing direct care. I am going to put the sign and PPE cart out for (R75) now. 4. R33's undated face sheet documented she was admitted to the facility on [DATE] with diagnoses of pressure ulcer left heel, long term use of antibiotics, foot drop left foot, and sepsis. R33's MDS dated [DATE] documented she is moderately cognitively alert, requires assistance with all activities of daily living. R33's care plan last updated 3/13/25 documented she has an unstageable pressure ulcer to her left heel and that she will wear heel boots on to offload pressure, cleanse area with wound cleanser, apply betadine to wound bed, cover with dry dressing daily and a needed. R33's physician orders dated 3/13/25 documented to cleanse left heel with wound cleanser, apply betadine to wound bed and cover with dry dressing daily. On 03/26/25 12:40 PM V3, assistant director of nursing (ADON) provided wound care to wound left heel. R33 was lying in bed. Previous dressing had gotten caught in resident's sock and she requested that staff performed wound care. Wound measured .5 cm x .5cm (centimeters) which V3 stated is significantly smaller than last week. Appropriate hand hygiene was performed. Wound was cleansed with wound cleanser and betadine was applied. Wound covered with dated, bordered gauze. Foot is elevated off the bed on a foot pillow. There were no enhanced barrier precautions sign on R33's door. 145483 Page 7 of 8 145483 03/27/2025 Montgomery Nursing & Rehab Ctr State Route 127 Hillsboro, IL 62049

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Facility's Policy dated April 1, 2024 documents, It is the policy of (Facility) to make every effort to prevent the spread of infection in the Facility. Standard Precautions require the health care worker (HCW) to estimate the degree of risk associated with a given task and plan for appropriate personal protective equipment. Enhanced Barrier Precautions is used in combination with Standard Precautions and expect the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's (Multidrug-Resistant Organisms) to staff hands and clothing. It continues to document EBP will be used for any resident who meets the following criteria: Chronic wounds such as pressure ulcers, indwelling medical devices, such as central lines, urinary catheters, and feeding tubes. It continues to documents resident who meet the above criteria, EBP are recommended while performing high contact resident activities such as changing briefs/linens, indwelling medical device care and chronic wound care. It continues, Place EBP sign at entrance to the room for the resident who meet the criteria and Staff will wear gloves and a gown for high- contact resident care activities. 145483 Page 8 of 8