Health inspection·June 14, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to attempt Gradual Dose Reductions on psychotropic medications for 1 of 3 residents (R23) in a sample of 10. Findings include: R23's face sheet from EHR (electronic health record) dated on 6/14/024 noted that R23 was admitted on [DATE] with diagnoses of: Chronic obstructive pulmonary disease, unspecified, cerebral infarction, unspecified, encounter for palliative care, type 2 diabetes mellitus without complications; unspecified psychosis not due to a substance, insomnia, unspecified, Alzheimer's Disease, unspecified dementia, with psychotic disturbance, specified anxiety disorders, major depressive disorder, single episode, essential hypertension, chronic ischemic heart disease, gastroesophageal reflux disease without esophagitis, hypoxemia, chronic pain acute kidney failure, headache, diverticulosis of both small and large intestine without perforation or abscess without bleeding, benign prostatic hyperplasia without lower urinary tract symptoms. R23's Minimum data set (MDS) dated [DATE] scored the brief interview of mental status (BIMS) at a 13, cognitively intact. The E section noted to report R23's overall presence of behavioral symptoms is a 0. R23's care plan dated 6/2/2023 noted R23 has impaired cognitive function and impaired thought processes r/t Alzheimer's, Dementia with confusion; 1) Administer Alzheimer's medication as ordered. Monitor for side effects and effectiveness. R23 uses psychotropic medications r/t (related to) depression. 1) Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q-shift (every shift). 2) Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. R23's POS, (physician order sheet) dated 6/14/2024, noted Buspar 5 MG PO ( by mouth) twice a day; Donepezil HCL 10 MG PO at sleep, Duloxetine HCL 60 MG twice a day, Ativan 0.5 MG PO mornings, Ativan 1 MG PO twice a day, Risperidone 0.5 MG in morning, Zoloft 50 MG in morning, Trazadone 100 MG PO at sleep, Vicodin 10-325 MG PO six times a day, Morphine Sulfate 0.5/20 MG PO every 2 hours when necessary, melatonin 5 MG at sleep. On 6/14/2025 at 2:30 PM, R23 is a 76 Y/O alert and oriented to person, place, and time. R23 voiced no concerns at the time of interview. Stated that he takes his medications when the nurse gives them to him. Page 1 of 5 145497 145497 06/14/2024 Three Springs Sr Living & Rhab 161 Three Springs Road Chester, IL 62233

F 0758 Level of Harm - Minimal harm or potential for actual harm R23's EHR noted pharmacy consults on medications of Ativan 1/31/2024, Trazadone 2/28/2024, Duloxetine 3/28/2024, Risperidone 4/29/2024, Zoloft 5/28/2024, Ativan 6/6/2024 with no new orders. No behavior documentation noted on MAR (medication administration record) for each month of January, February, March, April, May and June. Residents Affected - Few R23's OBRA Screen dated 7/1/2022 identifies R23 as having no mental illness noted. On 6/14/2024 at 1:40 PM V2 (Director of Nurses/DON), stated that she and V1 (Administrator) will be starting a committee to train the nursing staff on behavior monitoring and documentation. She stated that she does expect to be collaborating with the pharmacy, nursing staff, and physician. She stated the pharmacy recommendations for the residents on psychotropic medication reduction will be discussed with the physician. The Facility's Policy titled MED-PASS, Inc. (Revised December 2016) documents: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period and are subject to gradual dose reduction and re-review. 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The Attending Physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. 3. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will: a. Complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate; or b. Re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether the medication can be reduced, tapered, or discontinued. 145497 Page 2 of 5 145497 06/14/2024 Three Springs Sr Living & Rhab 161 Three Springs Road Chester, IL 62233

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 store foods in a manner that prevents foodborne illness. This has the potential to affect all 66 residents living in the Facility. Residents Affected - Many Findings include: On 6/11/24 at 9:17 AM, there were crumbs on the bottom shelf of the serving counter and the bottom shelf of the food preparation area. The oven handles were sticky to the touch. On 6/11/24 at 9:20 AM, the standing refrigerator had a plastic bag with julienned zucchini that was not labeled or dated. There was a container holding various colored cups of individual liquids that were not labeled or dated. There were two opened containers of whipped cream with frosting tips that were lying on the shelf and were not re-wrapped or dated upon opening. There was a container of unlabeled fruit that was dated 6/2/24. On 6/11/24 at 9:20 AM, the deep freezer in the dry storage room contained a package of chicken breasts that had been opened, but were not resealed upon opening, leaving the contents open to air. The package was not labeled or dated upon opening. On 6/11/24 at 9:23 AM, the standing refrigerator in the dry storage room contained two individual Styrofoam containers of salad with no label or date. On 6/7/24 at 9:25 AM, there was a large container of sanitizer for a low temperature dish machine that was placed directly on the floor of the dry storage room. It was touching the bottom rack of a shelf with a can of cherry pie filling and a can of baked beans directly next to it. On 6/11/24 at 9:34 AM, in the break room refrigerator there were three plastic bags labeled R64. One was labeled toffee, but the other two package contents were not documented. None of the bags were dated. The freezer had brown smears covering a majority of the bottom shelf. The refrigerator had red spills on the bottom shelf. On 6/14/24 at 9:05 AM, in the standing refrigerator there was a container of pasta salad that was not labeled or dated. V10 (Dietary Manager) stated she will get rid of it because she does not know how long it has been in there. She stated she expects all items to be labeled and dated. The Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy dated 2016 documents, Food shall be stored in a clean, dry area, free from contaminants. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. The Facility's Labeling and Dating Foods (Date Marking) Policy dated 2016 documents, All foods stored will be properly labeled according to the following guidelines. Date marking for freezer storage food items documents, Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. 145497 Page 3 of 5 145497 06/14/2024 Three Springs Sr Living & Rhab 161 Three Springs Road Chester, IL 62233

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Prepared food or opened food items should be discarded when: The food item does not have a specific manufacturer expiration date and has been refrigerated for 7 days; The food item is leftover for more than 72 hours; The food item is older than the expiration date. The Facility's Long-Term Care Facility Application For Medicare And Medicaid dated 6/11/24 documents there are 66 residents living in the Facility. 145497 Page 4 of 5 145497 06/14/2024 Three Springs Sr Living & Rhab 161 Three Springs Road Chester, IL 62233

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide 80 square feet of floor space per resident bed for 50 residents (R2, R3, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R21, R22, R23, R24, R26, R27, R28, R29, R32, R35, R37, R38, R41, R42, R45, R46, R47, R49, R51, R52, R53, R55, R58, R58, R59, R60, R61, R62, R63, R64, R167, R168, R169, R217, R267) reviewed for room size in the sample of 63. Findings include: A Hall Rooms 1 - 12 are all Medicaid certified and provide 75 square feet per bed. B Hall Rooms 1 - 6 and 8 are all Medicaid certified and provide 75 square feet per Bed. C Hall Rooms 1 -8, 10 and 12 are all Medicaid certified and provide 75 square feet per bed. D Hall rooms [ROOM NUMBERS] are Medicaid certified and provide 77 square feet per bed. On 06/14/24 at 11:00 AM, V17 (Maintenance Director) measured the rooms and verified that R2, R3, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R21, R22, R23, R24, R26, R27, R28, R29, R32, R35, R37, R38, R41, R42, R45, R46, R47, R49, R51, R52, R53, R55, R58, R58, R59, R60, R61, R62, R63, R64, R167, R168, R169, R217, R267 all reside in those rooms. Observations made throughout the survey from 06/11/24 through 06/14/24 demonstrate no concerns or complaints vocalized by residents in relation to waivered room size. On 06/14/24 at 1:30 PM, V4 (Vice President of Operations) stated there have been no changes to the historical measurements and accuracy of the facility's waivered resident room numbers and certifications. 145497 Page 5 of 5