Health inspection·May 20, 2025

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 interview and record review, the facility failed to treat a residents (R1) urinary tract infection (UTI) for nearly 48 hours. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 5. Residents Affected - Few The findings include: R1's admission Record (Face Sheet) showed an admission date of 8/23/23 with diagnoses to include partial paralysis following a stroke, ESBL (bacteria in the urinary tract that are resistant to many antibiotics), history of urinary tract infections, morbid obesity, and congestive heart failure. R1's 3/26/25 Nurse's Note from 5:05 PM showed, Final report received for urine C&S (culture and sensitivity, a urine test showing which bacteria are present in the urine) . The note showed which bacteria and fungi were present and that R1's doctor, nurse practitioner, and the director of nursing were notified. R1's 3/27/25 Nurse's Note from 11:04 AM showed, (no other progress notes were documented between this note and the previous note listed) Resident in bed sleeping, easily awakened to take scheduled medications. c/o (complains of) urinary frequency, burning, and level 10 generalized pain with fatigue. Temp 97.8. PM [narcotic pain medication] given. Urine noted to be dark and concentrated. U/A (urine analysis) with C&S completed with results to [R1's doctor, nurse practitioner, and director of nursing] notified of results. R1's 3/27/25 Nurse's Note from 1:14 PM showed, (this is the next consecutive progress note) This nurse called [local area hospital] for [V10 Infectious Disease Doctor] switchboard took message regarding patient needing antibiotic for UTI. Awaiting return call from [infectious disease doctor]. R1's 3/27/25 Nurse's Note from 1:40 PM showed, (this is the next consecutive progress note) [V10] returned phone call to this nurse. [V10] states he has not seen resident recently enough and will not prescribe antibiotics for UTI at this time. R1's 3/28/25 Nurse's Note from 7:53 PM showed, (This is the next note with information pertaining to R1's UTI and more than 24 hours after the previous note) Res (Resident) requesting to be evaluated in ER (Emergency Room) for urinary symptoms. VS (vital signs) wnl (within normal limits) .Res left facility at [7:50 PM] (over 48 hours after positive UTI test results) . R1's 3/29/25 Nurse's Note from 1:54 PM showed, .res admitted with UTI . R1's March 2025 Medication Administration Record (MAR) showed she was taking Doxycycline 20 Page 1 of 2 145556 145556 05/20/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few milligrams twice daily due to personal history of urinary tract infections. This order was started on 8/23/23; R1's admission date. The MAR showed no other antibiotics were started on 3/26/25, 3/27/25, or 3/28/25. The facility's electronic provider communication system showed a message from V3 R1's Nurse Practitioner on 3/26/25 at 5:52 PM, Unfortunately, if she is symptomatic and we cannot treat in house at this time, she likely needs sent out for treatment. Her UTIs are getting more complicated to treat in house. On 5/20/25 at 12:33 PM, V3 stated that signs and symptoms of a urinary tract infection are lower abdominal pain, urinary frequency, urinary urgency, burning with urination, and urine odor. V3 stated, based on R1's culture and sensitivity from 3/26/25, she did have a urinary tract infection. V3 stated that prompt treatment of urinary tract infection is important to prevent blood infections and hospitalizations. On 5/20/25 at 2:11 PM, V3's electronic note from 3/26/25 at 5:52 PM was read back to her. V3 replied, If she was symptomatic and not able to be treated at the facility, they should have sent her out at that time. V3 continued, if the facility did not send her out on 3/26/25, they then should have sent her out following the infectious disease doctor's refusal to treat On 5/20/25 at 2:36 PM, V2 Director of Nursing (DON), stated that UTI treatment should not be delayed. V2 said a delay in treatment could lead to blood infections and/or hospitalizations. V2 said if the facility is unable to treat a resident's urinary tract infection, they should be sent out for evaluation. 145556 Page 2 of 2