Health inspection·April 9, 2025

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to assess the need for a pommel cushion in a resident's reclining wheelchair prior to use, failed to obtain a physician's order for the use of the cushion and failed to document the intervention in R21's care plan. This applies to 1 of 12 residents (R21) reviewed for restraints in the sample of 12. Residents Affected - Few The findings include: On 4/8/25 at 8:24 AM R21 was sitting in her reclining wheelchair in the activity room. R21's chair was tilted back and R21 was seated on a pommel cushion. R21 was making sounds but was not forming words. R21 then fell asleep in the chair. On 4/8/25 at 9:08 AM V3 (Certified Nursing Assistant-CNA) was assisting R21 to lay down in the bed. As R21 was lifted with the mechanical lift there was also a non-slip fabric noted on her pommel cushion. V3 was asked why R21 has the pommel cushion in the wheelchair. V3 stated, She tends to scoot forward in her chair so this keeps her from falling out. On 4/8/25 at 11:47 AM, V2 (Director of Nursing) stated, I was not aware of that (pommel cushion). I don't know if that was hospice or it came from us. I do the care plans so it wouldn't be in there because I was not aware of it. On 4/8/25 at 2:45 PM V2 stated, I talked to the restorative aid and she said they added the cushion because (R21) has a seizure disorder and she tends to scoot down in her chair. She also has this behavior of throwing her arms up in the air. This is the 4th chair we have tried with her and so we trialed this cushion. It is not a restraint because it doesn't restrict her movement. The hospice nurse is aware it is there and she offered to get us one. R21's Physician's Order Sheet dated 4/1/25 shows no orders for the pommel cushion. R21's Care Plan dated 3/5/25 states, (R21) is at risk for falls r/t her fall assessment score of 7. She is no longer ambulatory, there are times when she slides/scoots forward in her wheelchair and will call out I'm falling. Her Dx (diagnoses) include; Epilepsy, Pseudobulbar affect, Delusional disorder, Abnormal breathing, Sleep apnea, Hypothyroidism, Down syndrome, Pain disorder, and Depression. There are no interventions related to the use of the pommel cushion listed on the care plan. The undated facility policy titled Physical Restraints states, Definition of a Physical Restraint: Any manual method physical or mechanical device, material or equipment attached or adjacent to the resident's body that he/she cannot easily remove, that restricts freedom of movement or normal access Page 1 of 6 145495 145495 04/09/2025 Medina Nursing Center 402 South Center Street Durand, IL 61024

F 0604 Level of Harm - Minimal harm or potential for actual harm to one's body. Restraints will only be used after all other alternatives less restrictive measures have been attempted unsuccessfully, and after informed consent from the resident and/or representative (Sponsor) and orders from the physician have been obtained and Inquiries concerning the use of a restraint should be referred to the care plan team. Residents Affected - Few 145495 Page 2 of 6 145495 04/09/2025 Medina Nursing Center 402 South Center Street Durand, IL 61024

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. 2. R43's current order summary report printed on April 8, 2025 shows, lorazepam oral tablet 0.5 mg (milligrams), give 1 tablets by mouth every 4 hours as needed for anxiety, agitation, restlessness . The medication was ordered on March 13, 2025 and has no stop/end date. 3. R28's current order summary report printed on April 8, 2025 shows, lorazepam PLO (Pluronic Lecithin Organogel) 1 mg/ml (milligram/mililiter) administer topically as needed if not accepting Ativan tablet every 6 hours as needed for anxiety, agitation. The medication was ordered April 12, 2025 and has no stop/end date. R28's current order summary report printed on April 8, 2025 shows, lorazepam tablet 1 mg, give 1 mg by mouth every 8 hours as needed for anxiety . The medication was ordered on March 31, 2025 and has no stop/end date. On April 9, 2025 at 8:56 AM, V2 Director of Nursing stated, PRN (as needed) psychotropic medications should have a stop date since it's the regulation. The facility's psychotropic medication policy did not show any information about stop/end dates for psychotropic medications. Based on interview and record review the facility failed to ensure stop dates were in place for psychotropic/antianxiety medications prescribed for 3 of 6 residents (R9, R43, R28) reviewed for unnecessary medications in the sample of 12. The finding include: 1. R9's Physician's Order Sheet dated 4/1/25 shows that R9 has an order for Ativan (antianxiety) Tablet 0.5mg (milligrams) every 4 hours as needed for agitation, repetitive chanting. This order is dated 6/29/24. R9's Pharmacy Consultant Medication Regimen Reviews dated 1/7/25, 2/6/25, 3/6/25 and 4/2/25 all show a request sent to R9's physician requesting a stop date for the as needed Ativan. On 4/8/25 at 2:00 PM V2 (Director of Nursing) stated, We have talked to the physician about her medications and he will not touch her meds. Now we have the new psychiatric Nurse Practitioner (NP) and she is addressing her medications. She is actually trying to decrease the psychotropic medications. The facility policy entitled Psychotropic Medication Policy dated 3/20/25 does not address the need for stop dates on PRN (as needed) psychotropic medications. 145495 Page 3 of 6 145495 04/09/2025 Medina Nursing Center 402 South Center Street Durand, IL 61024

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 ensure opened insulin pens were labeled and expired insulin was discarded. This applies to 2 of 2 residents (R1 & R10) reviewed for medication labeling/storage in the sample of 12. The findings include: On [DATE] at 8:46 AM, R1's lispro insulin (fast acting) vial in the medication storage cart was opened and labeled, [DATE] (over a 30 days ago). R10's novolog insulin (fast acting) vial was labeled [DATE] (over 30 days ago). R10 also had an opened tresiba insulin (long acting) pen that was not dated with an open date. V15 Registered Nurse stated, insulin is only good for 27 days and they should be labeled with an open date. R1's current order summary report printed on [DATE] shows, a physician order for admelog solution (insulin lispro). R10's current order summary report printed on [DATE] shows, a physician order for novolog solution (insulin aspart) and tresiba flex touch subcutaneous solution pen-injector. The facility's insulin administration policy and procedure (no date) shows, Objectives: It is the policy of the facility to use insulin as ordered to control the blood sugar of our residents. Pre-Procedure considerations: .Once insulin is open it must be clearly labeled with date opened. Insulin is too be disposed of after 28 days or according to manufacturer's recommendations. 145495 Page 4 of 6 145495 04/09/2025 Medina Nursing Center 402 South Center Street Durand, IL 61024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure foods were discarded on or before their use by date, failed to ensure employee food was not stored with food to be used for residents, and failed to label and date foods in the refrigerator. These failures have the potential to affect all 46 residents residing in the facility. The findings include: The facility's CMS-671 dated 4/7/25 shows there are 46 residents in the facility. During the kitchen tour on 4/7/25 at 8:55 AM, the front fridge contained an open bag of turkey breast and an open bag of ham neither of which were labeled with an open date or a use by date. There was a reusable container of a white substance labeled with V14's (Dietary Manager) first name and 3-25, a metal container labeled potato salad with a use by date of 4/6, and a whipped topping container with no labels or dates which was full of black olives. V14 said the container with her name on it is her personal container, she had no idea now long the olives had been there and said the deli meats and potato salad need to be discarded since there was no date on the meats and it was past the use by date on the potato salad. V14 said all foods should have an open date and a use by date, which is seven days after opening/preparing the item. V14 said she goes through the refrigerators every other day to remove outdated items. V14 said the cooks should be looking every morning and afternoon for outdated items in the refrigerator or items that need to be used prior to being past the use by date. The facility's Storing & Handling of Perishable Foods Policy (undated) shows all items within the cooler will be properly labeled with the item, initials, date and use by date. Any food items not properly stored will be disposed of immediately. 145495 Page 5 of 6 145495 04/09/2025 Medina Nursing Center 402 South Center Street Durand, IL 61024

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 1 of 5 residents (R9) reviewed for immunizations in the sample of 12 was offered and/or received the recommended pneumococcal immunizations. Residents Affected - Few The findings include: On 4/8/25 at 9:18 AM, V4, Assistant Director of Nursing/Infection Prevention Nurse, said vaccines are offered to residents upon admission and yearly. V4 said they offer all types of the Pneumococcal vaccines. R9's admission Record dated 4/9/25 shows she is a [AGE] year-old female who was most recently admitted to the facility on [DATE]. R9's Immunization Report dated 4/9/25 shows R1 received pneumococcal vaccines on 1/20/16 (PCV-13) and 11/20/17 (PPV23). Per current U.S. Centers for Disease Control and Prevention (CDC), R9 was eligible and recommended shared clinical decision making to decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. No consent or refusal for the PCV20 for R9 was provided by the facility. The facility's Influenza & Pneumonia vaccinations Policy and Procedures (updated 12/20) shows Pneumonia vaccines will be offered upon admission and annually to all residents. Residents or their representatives will be asked to indicate whether or not they wish to receive the pneumonia vaccine along with information about the vaccine. 145495 Page 6 of 6