Health inspection·August 30, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interview and record review the facility failed to answer call lights in a timely manner for five of 21 residents (R23, R85, R28, R19, R79) reviewed for call lights in the sample list of 49. Findings include: The facility's Call Light Policy with a revised date of 11/17/19 documents, Objective: To respond to the residents' request and needs in a timely manner. Procedure: Answer the resident's call light as soon as possible. The Resident Council Meeting Minutes dated May 3, 2023, documents concerns that residents have (call) lights on and the CNA (Certified Nursing Assistant) come in and turn off the call light and tell the residents they will be right back and never show up again on all of the shifts, (call) lights are not answered in a decent time on all shifts. The Resident Council Meeting Minutes dated July 7, 2023, documents concerns that the CNAs don't answer the call lights on time, and they sit at the nurse's station and chat and don't answer the call lights. 1.) R23's Minimum Data Set (MDS) dated [DATE] documents R23 has a BIMS (Brief Interview for Mental Status) score of 12/15. 2.) R85's MDS dated [DATE] documents R85 has a BIMS score of 15/15. 3.) R28's MDS dated [DATE] documents R28 has a BIMS score of 15/15. 4.) R19's MDS dated [DATE] documents R19 has a BIMS score of 15/15. 5.) R79's MDS dated [DATE] documents R79 has a BIMS score of 13/15. On 8/29/23 at 8:47 AM, R23, R85, R28, R19 and R79 all stated that there are still issues with staff not answering call lights timely. R79 stated a lot of the time they will turn on the call light and have to wait a long time for it to get answered. R79 stated R79 does not think they have enough CNAs (Certified Nursing Assistants) here to answer the call lights. R85 stated they don't get the help that they need without waiting a long time. R85 stated that R85 has waited an hour to have the call light answered. R79 stated that R79 has waited at least 30 minutes to have the call light answered. Page 1 of 22 145494 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0550 Level of Harm - Minimal harm or potential for actual harm On 8/30/23 at 10:05 AM, V2 Director of Nursing stated anyone can answer the call lights and ideally within five minutes. V2 stated that V2 has completed in servicing and audits regarding call lights but was not aware that the residents were having issues getting call lights answered timely again. Residents Affected - Some 145494 Page 2 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 8/28/23 at 9:38 AM, R61 was not in R61's room, there was a tube of topical analgesic on the counter in in R61's room. On 8/29/23 at 3:12 PM, the tube of topical analgesic is still sitting on the counter in R61's room. Residents Affected - Few R61's Physician Order Report dated 8/29/23 documents diagnoses including Muscle Wasting and Atrophy, Bilateral Primary Osteoarthritis of Hip, Pain in Right Hip, Pain in Left Hip and Pain Unspecified. This Physician Order Report does not document an order for the topical analgesic or an order to self-administer the topical analgesic. R61's Minimum Data Sheet (MDS) dated [DATE] documents R61 is cognitively intact and documents no impairment in range of motion in the upper and lower extremities. R61's Medical Record does not contain an assessment to self-administer the topical analgesic. On 8/29/23 at 3:03 PM, V2 Director of Nursing stated that residents can have medicine in their room if they have an assessment completed, V2 stated there should be a Physician's Order to self-administer the medication and an order for the medication. V2 confirmed there is no order for R61 to self-administer the topical analgesic and there is no current order for the topical analgesic. Based on observation, interview, and record review the facility failed to assess and obtain physician's order for self-administration of medication for two of two (R90, R61) residents reviewed for self-administration of medication in a sample list of 49. Finding Include: The facility's Medication Administration policy with a reviewed date of February 2023 documents, Self-Administration: Residents with appropriate cognitive status will be able to self-administer medication. The facility will complete a self-medication administration assessment to determine if resident is able to give their own medications appropriately. 1. R90's Physician's Order Summary includes a physician's order which was initiated 5/9/23 for albuterol sulfate HFA aerosol inhaler; 90 mcg/actuation; amt: 2 puffs; inhalation Special Instructions: rinse mouth after each use every 6 hours. There is no self-medication assessment documented and no physician's order to self-administer albuterol. On 08/28/23 at 12:34 PM, R90 stated he's Miserable from a respiratory infection. R90 was experiencing frequent wet sounding coughs. R90 was not covering his cough. R90 stated I've got a puffer, but it fell on the floor. A red inhaler was laying under R90's bed. R90 stated I just take it whenever I need it. On 08/28/23 at 12:40 AM V20, CNA entered the room. The lid was off the inhaler. V20 picked up the inhaler and handed it to R90. V20 nor R90 cleaned the inhaler. R90 took two puffs on the inhaler without waiting between puffs. V20 verified the inhaler was labeled Albuterol. On 8/29/23 at 10:00 AM V2, Director of Nurses (DON) verified that an assessment/physician's order for R90 to have the Albuterol inhaler at bedside for self-administration was not completed until 8/28/23 at 5:18PM. 145494 Page 3 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0641 Ensure each resident receives an accurate assessment. 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 accurately code the Resident Assessment Instrument (Minimum Data Set) for two of 32 residents (R61, R89) reviewed for Minimum Data Set assessments in the sample list of 49. Residents Affected - Few Findings include: The facility's Minimum Data Set (MDS) policy with a reviewed date of February 2023 documents, A Minimum Data Set will be completed for facility resident as outlined in the Resident Assessment Instrument (RAI) Manual. The facility will conduct admission and scheduled assessments for all facility residents. The assessment process includes direct observation, as well as communication with the resident and direct care staff. The MDS should reflect the resident's status and identify resident need and enhance resident-focused care planning. 1.) R61's Physician Order Report dated 8/29/23 documents diagnoses including Coronary Artery Disease and Hypertension. On 8/28/23 at 9:38 AM, R61 was not in R61's room, there was a CPAP (Continues Positive Airway Pressure) machine with tubing and mask attached and were laying on the cluttered bedside stand. On 8/29/23 at 3:12 PM, R61 was in R61's room with staff getting R61 ready to lay down in bed. R61 had the CPAP machine on the bedside stand with the mask and tubing attached. V29 Licensed Practical Nurse confirmed R61 wears the CPAP at night. R61's MDS dated [DATE] does not document the use of the CPAP machine. On 8/29/23 at 3:18 PM, V26 MDS Coordinator confirmed R61's MDS is not coded for the use of a CPAP machine. V26 stated the CPAP is not on the orders so V26 was not aware of the CPAP machine. 2. R89's August 2023 POS (Physician Order Sheet) documents an order dated 5/10/23 for Eliquis {Anticoagulant} 2.5 mg (milligrams) - one tablet BID (twice a day). R89's MDS dated [DATE] does not document that R89 received the ordered Anticoagulant during the look back time. R89's June 2023 MAR (Medication Administration Record) documents R89 received the ordered Eliquis during the look back time for the MDS. On 8/28/23 at 3:24 PM, V26 MDS Coordinator stated Anticoagulants are to be coded on the MDS. V26 reviewed R89's POS and (Treatment Administration Record) TAR and confirmed R89 did indeed receive the ordered anticoagulant. V26 confirmed the anticoagulant is not coded on the MDS. The facility Minimum Data Set Policy dated February 2023 documents the MDS should reflect the resident's status and identify resident need and enhance resident-focused care planning. 145494 Page 4 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I screening and a PASARR level II screening was completed for two (R55, R97) of seven residents reviewed for PASARR screenings from a total sample list of 49 residents reviewed. Residents Affected - Few Findings Include: The facility's admission procedure dated 6/13/19 documents that the facility will obtain an Omnibus Budget Reconciliation Act (OBRA), otherwise known as PASARR, level screening upon admission. 1. R55's level I PASARR dated 12/10/21, obtained by the facility on 8/30/23, documents a level II PASARR is not required due to R55 not having an SMI (Severe Mental Illness) Diagnosis upon admission to the facility on [DATE]. R55's diagnosis sheet dated 3/2/22 documents new diagnoses of Psychotic disorder with delusions and Unspecified Dementia with Behavioral Disturbances. R55's August 2023 physician order sheet documents Seroquel 25 milligrams to be given in the morning and Seroquel 50 milligrams to be given in the evening. On 8/29/23 at 1:53 PM, V6 Admissions Coordinator said that she did not know when to obtain a level II PASARR screening. On 8/29/23 at 1:0 0PM, V1 Administrator stated, I didn't realize that a level II was required. 2. R97's nursing notes dated 6/22/2023 at 3:55 PM, documents R97 was admitted to the facility. On 8/28/23 at 12:00 PM, R97's medical record did not contain a PASARR screen. On 8/29/23 at 9:39 AM, V1 Administrator stated, I'm sorry to tell you that we weren't printing off the PASARR screens off and scanning them in. V1 stated they printed them off today. R97's PASARR screen provided by V1 Administrator documents R97's PASRR was completed on 8/10/23. This PASARR documents that a PASRR was note completed on 6/22/23 when R97 was admitted to the facility. On 8/29/23 at 10:18 AM, V1 Administrator confirmed that a PASARR for R97 was not completed upon admission and was completed on 8/10/23. 145494 Page 5 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to timely complete a treatment as ordered by the physician for one of one (R4) resident reviewed quality of care on the sample list of 49. Residents Affected - Few Findings Include: R4's August 2023 Physician Orders document an order to apply elastic bandage wraps to bilateral lower extremities between 4:00 am - 7:00 am daily for localized edema and then remove between 8:00 pm 11:00 pm. R4's Care Plan dated 6/26/23 documents R4 has limited ability with ADLs (Activities of Daily Living) and requires assistance with ADLs due to chronic pain, easily fatigued and impaired mobility related to Osteoarthritis, Heart Failure and Muscle Weakness with an intervention for staff to apply the elastic bandage wraps every morning to R4's bilateral lower extremities and remove them at bedtime. On 8/28/23 at 9:20 AM, R4 was sitting up in a wheelchair with slippers on, feet not elevated. R4's legs were extremely edematous, with a scabbed area to left shin. R4 did not have the elastic bandage wraps on. On 8/29/23 at 8:15 AM, R4 was sitting up in Dining Room with feet resting on the wheelchair foot pedals. R4 did not have the ordered elastic bandage wraps in place. On 8/29/23 at 11:08 AM, V16 RN (Registered Nurse) stated V16 wrapped R4's legs today around 10:30 AM because V16 noticed they weren't done. V16 explained, V16 had to wrap them yesterday {8/28/23} mid-morning as well because they weren't done. V16 stated third shift is supposed to be wrapping them. 145494 Page 6 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

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 observation, interview, and record review the facility failed to perform hand hygiene and prevent cross contamination during catheter care, ensure an indwelling catheter was secured to prevent it being pulled, ensure a dignity cover was covering the catheter drainage bag, ensure the catheter drainage bag was kept off of the floor, and obtain an urological consult for two of three residents (R89, R94) reviewed for indwelling catheters on the sample list of 49. Findings Include: The facility's Catheter Care Policy last reviewed in February 2023 documents do not tug or pull onto the catheter and secure indwelling catheter as needed. 1. On 8/28/23 at 9:25 AM, R89 was in a wheelchair being pushed down the hall by an unidentified staff member. R89's catheter drainage bag did not have a dignity cover on it, and the drainage bag was dragging on the floor under the wheelchair. R89's Care Plan dated 6/21/2023 documents R89 requires an indwelling urinary catheter Related to diagnosis of Neurogenic Bladder with interventions to manipulate tubing as little as possible during care to avoid obstructions in the drainage, position drainage bag below the level of the bladder, avoid allowing tubing or any part of the drainage system to touch the floor, and store collection bag inside a protective dignity pouch. R89's August 2023 Physician Order Sheet documents orders for Catheter Care to be completed every shift and on 8/10/23, an order for Gentamicin {Antibiotic} ointment 0.1 % to the left side of the penis BID (twice a day), after cleansing the area with soap and water, was implemented for a diagnosis of Unspecified Injury of the External Genitals. On 8/29/23 at 10:36 AM, V12 CNA (Certified Nursing Assistant) and V13 CNA entered R89's room to complete the ordered catheter care. R89's indwelling catheter was not secured and the head of R89's genital was slit down the head to the shaft. On 8/29/23 at 1:05 PM, V2 DON (Director of Nursing) stated catheter drainage bags should be up off the floor, and the drainage bag should be in a dignity bag if the resident is out of the room. V2 also stated that the facility has securement devices for indwelling catheters that should be used to prevent movement and pulling on the indwelling catheter during cares. 2.) R94's Minimum Data Set, dated [DATE] documents that R94 requires an indwelling catheter, is a two assist for toileting and is cognitively intact. R94's physician order sheet dated 4/4/23 documents catheter care to be performed every shift. R94's progress notes dated from admission [DATE]) to present (8/30/23) document that R94's catheter has been changed twelve times. Additionally, no consultation to urological services was found in R94's medical record. Urinary tract infections are documented in R94's medical record on three occasions, in four months, 145494 Page 7 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the following treatment orders including: Cephalexin 500 milligrams (mg) twice a day for seven days beginning on 4/24/23, Macrobid 100 mg twice a day for five days beginning on 6/5/23 and Macrobid 100 mg beginning twice a day for five days on 8/25/23. The facility Catheter Care policy dated 2/2023 documents that the objective is to cleanse the urinary meatus and adjacent catheter and to make sure that after providing peri-care and before starting catheter care, to wash hands. Additionally, if at any time the resident was incontinent of bowels, perineal care should be provided with new supplies and hands washed. The catheter should be secured. The facility Incontinent Care policy dated 2/2023 documents instructions to separate the labia and start from the top to the bottom and wash one side of the meatus. Repeating on the other side using a new washcloth or different area of the same washcloth, using proper hand hygiene in-between clean and dirty cares. On 8/29/23 at 10:49 AM, V18 and V19 Certified Nursing Assistants (CNA) provided catheter and perineal care for R94. V19 CNA began with catheter care, without separating the labia, and wiped the unsecured catheter with a wet washcloth. Feces was visualized at the posterior of the catheter. V19 CNA then wiped R94's vaginal area and anus of feces without washing her hands between clean and dirty care. Neither V18 nor V19 secured the catheter, once completing cares. On 8/29/23 at 11:30AM, V2 Director of Nursing confirmed that hand hygiene and catheter care needed to be completed per policy, not as it was done for R94 at 10:49 AM on 8/29/23., On 8/30/23 at 10:45AM, V2 Director of Nursing confirmed that R94 had many issues with her catheter clogging with mucous, leaking, multiple catheterizations and infection and that a urological consultation had not been obtained. 145494 Page 8 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

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 obtain a Physician's Order for the use of a CPAP (Continuous Positive Airway Pressure) machine, failed to obtain an order to clean the CPAP equipment and failed to protect the CPAP mask and tubing from contamination for one of three residents (R61) reviewed for respiratory in the sample list of 49. Residents Affected - Few Findings include: The facility's Oxygen Administration policy with a reviewed date of February 2022 documents, Administration of oxygen under positive pressure may be ordered. Positive pressure is achieved by using a special face mask with a valve which permits expiration against a controlled, calibrated resistance, ranging up to 6 cm (centimeters) of water. The optimum pressure is the maximum tolerated by the resident. Keep a plastic bag available to store the oxygen delivery (cannula or mask) when not in use. Date the bag when placed and change weekly. Guidelines for changing/cleaning respiratory equipment will be as follows: CPAP masks and reservoir - weekly. On 8/28/23 at 9:38 AM, R61 was not in R61's room, there was a CPAP machine with tubing and mask attached and were laying on the cluttered bedside stand open to air, not covered. On 8/29/23 at 3:12 PM, R61 was in R61's room with staff getting R61 ready to lay down in bed. R61 had the CPAP machine on the bedside stand with the mask and tubing attached and laying open to air. V29 Licensed Practical Nurse confirmed R61 wears the CPAP at night. R61's Physician Order Report dated 8/29/23 does not document an order for the CPAP and does not document an order to clean the CPAP mask, tubing or reservoir. On 8/29/23 at 3:13 PM V2 Director of Nursing confirmed there is no Physician's order for the CPAP or for the cleaning of the CPAP but there should be order for that. V2 stated V2 does not know where the CPAP machine came from, V2 stated V2 was not aware that R61 had a CPAP in R61's room. 145494 Page 9 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to have ongoing communication and collaboration with the dialysis facility regarding care for one of one resident (R36) reviewed for dialysis on the sample list of 49. Residents Affected - Few Findings Include: On 8/28/23 at 10:00 am, R36 stated R36 goes out to dialysis three times a week. R36's Care Plan dated 6/10/23 documents R36 receives hemodialysis related to ESRD (End Stage Renal Disease) and will at times refuse dialysis with interventions of assessing for fluid excess, monitoring/recording food/fluid intake and output, monitor weights daily and notify the physician and family of significant weight changes, report abnormal labs indicative of fluid volume excess, and educate on the risks of refusing dialysis. R36's medical record did not contain any dialysis communication forms. On 8/29/23 at 9:45 AM, V7 RN (Registered Nurse) stated there is no communication between dialysis and the nursing home on a routine basis. V7 stated, V7 can only recall R36 returning to the facility once with any papers and that was because they were wanting an updated medication list. At this time, V10 RN/Unit Manager confirmed there is no communication or communication forms between dialysis and the facility for each dialysis session. On 8/29/23 at 10:13 AM, V11 Dialysis RN stated the nursing home has not been sending us any communication forms. That form should document R36's pre-dialysis weight and vitals, then the dialysis facility would document R36's post dialysis weight and vitals, any medications that was needed to be administer during R36's treatment and how R36 tolerated the treatment. V11 stated the nursing home would benefit from the communication sheets, and that most nursing homes send one with their residents. 145494 Page 10 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to administer medications according to Physician's Orders and Manufacture's Recommendations for two of four residents (R4, R89) reviewed for medication administration on the sample list of 49. The facility had three errors out of 32 opportunities for a medication error rate of 9.38%. Residents Affected - Few Findings Include: 1.) R89's August 2023 Physician Orders document orders for Levothyroxine {Thyroid Hormone} 200 mcg (Microgram) one tablet every morning, and Levothyroxine 25 mcg one tablet every morning to be taken with the 200 mcg for a total of 225 mcg every day, both to be given between 5:00 am - 10:00 am. On 8/29/23 at 8:25 AM, V7 RN (Registered Nurse) prepared all of R89's morning medications, including R89's ordered Levothyroxine, while R89 sat at the dining room table eating breakfast. There was no warning label on the Levothyroxine Card indicating that the medication needed to be given on an empty stomach. By the time, V7 had prepared R89's medications, R89 had completed breakfast and returned to the unit. V7 left the dining room and returned to the unit, then administered R89's medications. At 8:30 AM, V7 explained 89's morning medications are normally given in the dining room except when he is already finished and leaves like today. On 8/29/23 at 3:52 PM, V28 Pharmacist stated Thyroid medication should be given before meals, on an empty stomach due to absorption, that is the manufacturer's recommendation. V28 explained the pharmacy does not place warning labels on medication cards alerting staff of when to give the medication but staff can find that information through their computer system. Staff just needs to click on the medication being administered and it will pull up the package insert that tells them that information. The undated Levothyroxine computerized Clinical Drug Information Sheet documents to take on an empty stomach, at least 30 to 60 minutes before breakfast. On 8/30/23 at 1:54 PM, V2 DON (Director of Nursing) stated, the facility started doing a liberalized medication administration time of 5:00 am - 10:00 am earlier this year. 2.) R4's August 2023 Physician Orders document an order for Novolog {Fast Acting Insulin}100 units per ml (milliliter) subcutaneously to be administered before meals per sliding scale based on R4's blood glucose level with the following instructions: If Blood Sugar is 0 to 150, give 0 Units. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, give 6 Units. If Blood Sugar is 301 to 350, give 8 Units. If Blood Sugar is 351 to 400, give 10 Units. 145494 Page 11 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0759 If Blood Sugar is 401 to 450, give 12 Units. Level of Harm - Minimal harm or potential for actual harm If Blood Sugar is greater than 450, call the physician. Special Instructions: CALL Provider if less than 70 or above 400 Residents Affected - Few On 8/29/23 at 11:12 AM, V16 RN (Registered Nurse) checked R4's blood glucose level, which was 276. On 8/29/23 at 11:16 AM, V16 prepared and administered 6 units of Novolog to R4. On 8/29/23 at 11:58 AM, 42 minutes after receiving the Novolog, R4 was served lunch. At this time, R4 stated R4 had not eaten since breakfast, around 9:00 am. The Novolog Package Insert dated 2/28/23 documents Novolog is to be given 5-10 minutes before a meal. 145494 Page 12 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0760 Ensure that residents are free from significant medication errors. 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 prevent significant medication errors by failing to administer hormone medication to ensure for proper absorption contributing to abnormal lab results for a resident and failing to administer medication for a resident on dialysis. This failure affects two of five residents (R89, R36) reviewed for significant medication errors on the sample list of 49. Residents Affected - Some Findings Include: 1.) R89's ongoing Census documents R89 was admitted to the facility on [DATE]. R89's ongoing TSH laboratory results document, historically from 2017 - 2019, R89's TSH levels ranged between 0.872 - 2.289 (Normal Value is 0.3 - 5.0). This ongoing TSH results do not document any other results until 8/10/23, in which R89's TSH level is 25.271. R89's Progress Notes dated 8/14/23 documents new orders received to increase R89's Levothyroxine dose based on R89's TSH (Thyroid Stimulating Hormone) level. R89's August 2023 Physician Order Sheets document a diagnosis of Hypothyroidism (underactive thyroid) with orders for Levothyroxine {Thyroid Hormone} 200 mcg (Microgram) one tablet every morning, and Levothyroxine 25 mcg one tablet every morning to be taken with the 200 mcg for a total of 225 mcg every day, both to be given between 5:00 am - 10:00 am. On 8/29/23 at 8:25 AM, V7 RN (Registered Nurse) prepared all of R89's morning medications, including R89's ordered Levothyroxine, while R89 sat at the dining room table eating breakfast. There was no warning label on the Levothyroxine Card indicating that the medication needed to be given on an empty stomach. By the time, V7 had prepared R89's medications, R89 had completed breakfast and returned to the unit. V7 left the dining room and returned to the unit, then administered R89's medications. At 8:30 AM, V7 explained 89's morning medications are normally given in the dining room except when he is already finished and leaves like today. On 8/29/23 at 3:52 PM, V28 Pharmacist stated Thyroid medication should be given before meals, on an empty stomach due to absorption, that is the manufacturer's recommendation. V28 explained the pharmacy does not place warning labels on medication cards alerting staff of when to give the medication but staff can find that information through their computer system. Staff just needs to click on the medication being administered and it will pull up the package insert that tells them that information. The undated Levothyroxine computerized Clinical Drug Information Sheet documents to take on an empty stomach, at least 30 to 60 minutes before breakfast. On 8/30/23 at 1:54 PM, V2 DON (Director of Nursing) stated, the facility started doing a liberalized medication administration time of 5:00 am - 10:00 am earlier this year (for the last five months). On 8/30/23 at 3:00 PM, V27 Nurse Practitioner stated V27 is aware that the facility has liberalized medication pass times but Levothyroxine still should be given on an empty stomach. It is absorbed best on an empty stomach. 145494 Page 13 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0760 Level of Harm - Minimal harm or potential for actual harm 2.) On 8/28/23 at 10:00 AM, R36 was in R36's wheelchair and stated, on Sunday, 8/27/23, R36 did not get R36's morning or noon medications, including R36's dialysis medications. R36 explained, R36 goes out for church every Sunday and staff always send medications with R36 for when R36 is out of the facility however on 8/27/23, there was a substitute nurse at the facility and when R36 returned to the facility, the nurse stated it was too late to give them. Residents Affected - Some R36's MDS (Minimum Data Set) dated 6/8/23 documents R36 is alert and oriented. R36's Progress Notes dated 8/28/23 by V10 RN (Registered Nurse)/Unit Manager documents when speaking to R36's POA (Power of Attorney) this morning, the POA mentioned that R36 had reported that R36 did not receive R36's medications yesterday. Reviewed medication administration & medications were signed out by V9 Agency RN that was here yesterday. Spoke with V9 who was here yesterday and V9 stated that R36 did receive morning medications after R36 returned from church yesterday. V9 stated that R36 did not tell V9 that R36 was leaving the facility to go to church. V9 stated that if R36 would have told V9, V9 would have given R36's the ordered medications before R36 left. V9 also stated that R36 received R36's afternoon medications around 1:30. On 8/28/23 at 3:37 PM, V9 Agency RN confirmed V9 was R36's nurse on 8/27/23. V9 stated R36 was not around during morning medication pass so R36 did not receive medications at that time. V9 explained, when asking staff where R36 was, the other staff informed V9 that R36 was at church and that was R36's weekly routine. V9 stated R36 did not report to V9 that R36 was leaving the facility, if R36 had, V9 would have given R36 the ordered medications before R36 left. V9 explained around 1:30 pm, (R36) approached (V9) wanting (R36's) medications. I (V9) explained that I (V9) could only give (R36) some of the medications because if (R36) was due for them again at 5:00 pm, it was too close, and I (V9) wasn't able to administer them. V9 explained R36 was really concerned about the binder but (R36) had already eaten. V9 also explained that V30 (R36's family) reported that R36 had been back to the facility for about an hour but that V9 didn't know that because R36 didn't tell V9. V9 explained, V9 don't normally work there so I (V9) don't know (R36's) routine. V9 stated V9 did give the binder late around 1:30 - 2:00 pm per (R36) and (V30's) request but (V9) explained to (R36) it should be taken with food so it would not have the same effects and work the way it should. V9 also stated, V9 does not recall which morning and noon medicines V9 administered after R36 returned to the facility but all I (V9) know is I (V9) didn't give (R36) anything that (R36) was going to be given at 5:00 pm, except the binder. On 8/29/23 at 9:02 AM, V2 DON (Director of Nursing) confirmed that R36 is alert and oriented. The medications that were not given on 8/27/23, per V9's statement of medication not given if ordered again at 5:00 pm, are the following, according to R36's August 2023 Physician Order Sheets. Acidophilus {Probiotic for digestive and abdominal health}, schedule between 5:00 am - 10:00 am. Calcium Acetate 667 mg (milligrams) {Phosphate Binder for End Stage Renal Disease} schedule with breakfast and again at lunch {which was given late, after R36 had already eaten}Carvedilol 6.25 mg {Beta-Adrenergic Blocking Agent for Hypertension}, Fish Oil 1,000 mg for Hyperlipidemia, Minoxidil 2.5 mg {Antihypertensive for Hypertension}, Renvela 800 mg {Phosphate Binder for End Stage Renal Disease} with breakfast and again at lunch {which was given late, after R36 had already eaten}, and 145494 Page 14 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0760 Saline Mist {Sodium Chloride} 0.65% for Allergic Rhinitis. Level of Harm - Minimal harm or potential for actual harm On 8/29/23 at 10:13 AM, V11 Dialysis RN stated Phosphate Binders should be taken at the start of the meal so it can absorb the phosphates in the food so the patient can excrete them. If (R36) was going out that day, the nurse should have sent the medications with (R36) so they could be taken with food. Residents Affected - Some On 8/29/23 at 3:46 PM, V28 Pharmacist stated both Calcium Acetate and Renvela are Phosphate Binders and should be given with food. By not giving it or giving it after the resident is finished eating, it will not work as it should and residents' phosphate levels could increase causing muscle spasms, itchy skin, weakened bones due to the depletion of calcium levels. V28 stated, not giving these medications as ordered is a significant medication error. 145494 Page 15 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure Scheduled II medications were locked in a permanently affixed compartment, date insulin and liquid protein when opened, resident medications were properly labeled with a pharmacy label and dispose of discontinued medication for residents. This failure affects 10 of 49 (R89, R16, R23, R13, R40, R12, R81, R28, R14, and R26) residents reviewed for medication storage and labeling on the sample list of 49. Findings Include: The facility's Drug Labeling Policy dated December 2021 documents the label of each individual container shall clearly indicate the resident's full name, physician's name, prescription number, name and strength of drug, directions for administration, date of issue, the initials of the pharmacist filling the prescription, and the amount of medications contained in each individual prescription. In addition, the pharmacy's name, address, and telephone number shall be on all prescription labels. Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels shall be returned to the issuing pharmacy for disposal. Medications having no labels should be destroyed in accordance with Federal and State Laws. The facility's Medication Destruction Policy dated February 2023 documents medication will be disposed of in accordance with Federal, State and Local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. The facility's Medication Room Policy dated February 2023 documents all medications for residents will be properly labeled and stored near the nurses' station in a locked medication room, locked mobile medication cart or may be kept in resident room per provider order. All Schedule II controlled substances should be stored with two separate locks, utilizing two different keys, to access these substances. This should include the medication refrigerators. 1.) On 8/29/23 at 8:25 AM, V7 RN (Registered Nurse) was in the dining room passing medications while the medication cart was in the hall/dining room entrance. Upon returning to the cart, V7 unlocked the cart and started preparing R89's ordered medications, which included Norco (Scheduled II Narcotic) 7.5/325 mg (milligrams) and liquid protein. V7 lifted the lid to the narcotic compartment with V7's fingernail. V7 confirmed the lid was not locked and should have been. Within the unlocked narcotic compartment, there were cards of controlled substances for the following residents: Norco 5/325 mg for R1, Norco 5/325 mg for R16, Fentanyl Patches (Scheduled II Narcotic) 12 mcg (microgram)/hour for R13, and Fentanyl Patches 75 mcg/hour for R23. The bottle of liquid protein was open, half full and did not have a date on it documenting when it was opened. The label documents the liquid protein only has a shelf life of 3 months once opened. 2.) On 8/30/23 from 9:15-9:30 AM the 300 Hall Medication Room and Team 1 Medication Cart was checked with V7 RN (Registered Nurse) present. The Medication Cart contained a Humalog KwikPen (Insulin) for R16 that had a faded pharmacy label on it and was not dated when it was opened. V7 confirmed the Humalog was an active order and stated, it's an older pen, it's almost all gone. V7 stated insulin pens are to be dated when they are opened. The medication cart also contained the same undated open bottle of liquid protein from 8/29/23. There was also a biohazard bag with R40's name handwritten on it that contained four individual doses of Ipratropium Bromide with Albuterol Inhaler Solution 145494 Page 16 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0761 Level of Harm - Minimal harm or potential for actual harm {Anticholinergic with Bronchodilator}. There was no pharmacy label on the bag or medication. At this time, V7 stated R40 doesn't even have an order for the solution anymore; normally medications are either sent back to the pharmacy when the order is discontinued. The Medication Room refrigerator drawer had seven loose/unlabeled Compro Suppositories {Antipsychotic and Antiemetic} in it. Residents Affected - Some The undated Insulin Storage Graph documents Humalog expires 28 days after being opened. 3.) On 8/30/23 between 10:15-10:30 AM, the 400 Hall Medication Room and Medication Cart was checked with V21 LPN (Licensed Practical Nurse) present. There was an open/undated bottle of Liquid Protein. V21 stated R12, R81 and R28 all have orders for Liquid Protein and use out of this unopened bottle. The Medication Room refrigerator contained a bottle of Lorazepam {Benzodiaepine} 2 mg (milligrams)/ ml (Milliliter) without a pharmacy label or resident name on it. At this time, V21 stated, that is for R14. There were also two cups of loose/unlabeled Bisacodyl {Laxative}suppositories in the refrigerator. 4.) On 8/30/23 at 10:35 AM, Team 2 Medication Cart contained an open, undated bottle of liquid protein that was halfway full. V22 LPN (Licensed Practical Nurse) stated R26 is the only resident that uses the liquid protein and confirmed the bottle should have been dated when opened. 145494 Page 17 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to have a certified dietary manager on staff. This failure has the potential to affect all 103 residents in the facility. Residents Affected - Many Findings include: The facility resident census and condition report dated 8/29/23 documents 103 residents in the facility. On 8/28/23 at 9:20 AM, V5 Dietary Manager attempted to test the low temperature dishwasher with high temperature heat strip. When this did not change for heat, V5 Dietary Manager stated that he did not realize that he needed to test the machine with a chlorine strip, but that his staff know how to test the machine. On 8/29/23 at 11:40 AM, residents were observed being served lunch at the same tables, at different times, leaving some to wait and watch others eat for long periods of time. At 1:01 PM, V2 Director of Nursing said that serving times were all over the place, and that she would prefer for the residents to be served at the same time but sometimes, it's all over the place. On 8/29/23 at 11:55 AM, R97 was sitting in the dining room eating lunch and was given a lunch tray with the wrong ticket on the tray. R97's tray belonged to a different resident and did not have correct meat consistency on the tray. On 8/29/23 at 11:59 AM, V5 Dietary Manager said that residents should receive the correct ticket and diet as ordered. On 8/30/23 at 9:30AM, V5 Dietary Manager stated that serving is done as it is because it has always been done that way, but that it is chaotic. On 8/28/23 at 9:45AM, V5 Dietary Manager stated, I have been here for two years, and I don't have my certification as a dietary manager yet. 145494 Page 18 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records contained preadmission screenings for three of four residents (R97, R51, R80, R55) reviewed for preadmission screenings on the sample list of 49. Findings include: 1. R51's Electronic Medical Record documents R51 was admitted to the facility on [DATE] at 7:26 AM. On 8/28/23 at 12:00 PM, R51's medical record did not contain a PASSAR screen. On 8/29/23 at 9:39 AM, V1 Administrator stated R51's PASSAR screen was not printed when it was obtained and was not put into R51's medical record. 2. R80's Electronic Medical Record documents R80 was admitted on [DATE] at 9:59 AM. On 8/28/23 at 12:00 PM, R80's medical record did not contain a PASSAR screen. On 8/29/23 at 9:39 AM, V1 Administrator stated R80's PASSR screen was not printed when obtained and put into R80's medical record. 3. R55's face sheet documents admission to the facility on [DATE]. On 8/28/23 at 2:25PM, V6 Admissions Coordinator stated, I can't find R55's PASARR. On 8/29/23 at 9:39AM V1 said that the facility had not been scanning the PASARR's into the medical record and that R55's PASARR had to be requested. On 8/30/23 at 11:00AM, V1 Administrator provided R55's PASARR screening with a fax date received of 8/30/23. 145494 Page 19 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to utilize Personal Protective Equipment (PPE) and implement infection control interventions for one (R90) of four residents reviewed for infections in a sample list of 49. Residents Affected - Few Findings Include: R90's Face Sheet printed includes the following diagnoses: Chronic Systolic (Congestive) Heart failure, Cough, Essential (Primary) Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Generalized Anxiety Disorder, Venous Insufficiency (Chronic) (Peripheral), and Lymphedema R90's progress note dated 08/26/2023 at 9:36 AM documents (R90), has productive cough, audible wheezing noted. (R90) taking Norco prn (as needed) for rib pain due to coughing. Hospice called and will be out later to see (R90). 08/26/2023 at 11:45AM documents (R90), had COVID test and was negative. On 08/28/23 at 12:34 PM R90 stated he's, Miserable from a respiratory infection. R90 was experiencing frequent wet sounding coughs. R90 was not covering his cough. R90 stated, I am really congested. R90 had visible respiratory secretions around his oxygen cannula. R90 stated, I've got a puffer, but it fell on the floor. A red inhaler was laying under R90's bed. On 08/28/23 at 12:40AM, V20 Certified Nurse's Assistant entered the room. The lid was off the inhaler. V20 picked up the inhaler and handed it to R90. V20 was not wearing gloves and did not perform hand hygiene. V20 verified the inhaler was labeled Albuterol. V20 nor R90 cleaned the inhaler. R90 took two puffs on the inhaler. There was no sign on the door indicating transmission-based precautions and there was no PPE (Personal Protective Equipment) outside R90's door. On 8/29/23 at 10:16 AM, V14 County Public Health Registered Nurse stated I would expect a resident who is experiencing active respiratory signs and symptoms to be on contact droplet precautions until they are symptom free or at very least staff should wear a mask and eye protection. I would expect at least a second COVID test on day five to be negative before the precautions are removed. Even if it isn't COVID it could be RSV (Respiratory Syncytial Virus) or other communicable respiratory disease. This is especially true when a resident does not use good respiratory hygiene. On 8/29/23 at 2:00 PM V2, Director of Nursing (DON) stated, We did one COVID test and it was negative. Based on that and the fact that (R90) has CHF (Congestive Heart Failure) I made the decision not to use any transmission-based precautions. The facility policy Standard Precautions revised 2/23/23 states Standard Precautions will be used in the care of all residents to reduce the risk of transmission of microorganisms from both recognized and unrecognized infection sources. Standard Precautions include a group of infection prevention practices that apply to all residents, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include hand hygiene; use of gloves, gown, mask, eye protection or face shield (depending on anticipated exposure); and safe injection practices. Also, equipment or items in the resident's environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agent (e.g. wear gloves 145494 Page 20 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0880 Level of Harm - Minimal harm or potential for actual harm for direct contact; contain heavily soiled equipment; properly clean or disinfect or sterilize reusable equipment before use on another resident.) The application of standard precautions during resident care is determined by the nature of the healthcare worker-resident interaction and the extent of anticipated blood, body fluid, or pathogen exposure. Residents Affected - Few 145494 Page 21 of 22 145494 08/30/2023 McLean County Nursing Home 901 North Main Normal, IL 61761

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow antibiotic stewardship guidelines for one (R300) of four residents reviewed for infections in a sample list of 49. Residents Affected - Few Findings Include: R300's hospital history and Physical dated 8/7/23 documents (R300) was admitted with diagnoses of Sepsis due to Urinary tract Infection, Right Hip Fracture, and Left ankle Fracture. R300's Face Sheet dated 8/18/23 (date of admission) also documents R300 has Metastatic Cancer and was admitted to the facility on hospice care. R300's progress Note dated 08/27/2023 at 7:59 AM documents (R300's) output from (Urinary Catheter) this AM was pink and thick. Called hospice to notify. Also reported edema in AL hand/forearm. Hospice will be calling back with any new orders. R300's progress Note dated 08/27/2023 at 9:27 AM documents Hospice called back with orders to change catheter now and start Levaquin 250 mg for 5 days. Power of Attorney called and aware of orders. There is no documentation of a culture. On 8/29/23 at 2:00 PM V2, Director of Nursing (DON) stated, We didn't get a culture (R300) is on hospice and they don't order cultures. V2 verified R300 has an indwelling urinary catheter so a sample for culture could be obtain without an invasive procedure or any discomfort to (R300). On 8/30/23 at 2:30 PM, V31 Hospice physician stated, I wasn't on call when the antibiotic was ordered for (R300). As a rule, we don't order cultures on hospice patients. However, given (R300) was recently discharged from the hospital with Sepsis due to a Urinary Tract Infection it probably would have been a good idea in this case, but the facility would have had to report that when they called us for an order. The facility's policy Antibiotic Stewardship reviewed 2/2023 documents This facility will maintain an antibiotic stewardship program with the mission of promoting the appropriate use of antibiotics to treat infections while reducing the possible adverse events associated with antibiotic use. 145494 Page 22 of 22