Health inspection·January 5, 2024

F 0881 Implement a program that monitors antibiotic use. 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 obtain laboratory results documenting the organisms being treated prior to initiating and/or continuing antibiotic therapy for 3 of 23 residents (R69, R91, R94) reviewed for antibiotic stewardship in a sample of 41. Residents Affected - Few Findings include: 1. R69's Face Sheet, undated, documented that she was admitted to the facility on [DATE] from an area hospital. R69's Nurse Progress notes, dated 11/28/23, documented that the hospice nurse placed R69 on an antibiotic, due to her urine had changed in character and resident had some pain related to having a catheter. No laboratory work was ordered. R69's Physician Order Summary, undated, documented an order Sulfamethoxazole-Trimethoprim 800-160 milligrams (mg) for 10 days with a Start Date 11/28/23. R69's Hospital Lab results, dated 12/8/23, documented, R69's urine specimen was setup for culture but there were no results documenting that the culture and sensitivity were received. R69's Physician Order Summary, undated, documented an order for Amoxicillin-Potassium Clavulanate 875-125 mg for 7 days with a Start Date 12/13/23 and End date of 12/20/23. 2. R91s Face Sheet, undated, documented that R91 was admitted to the facility 11/27/23 from an area hospital. R91's Hospital Lab results, dated 12/9/23, documented that a urine specimen was setup for culture but there were no results documenting that culture and sensitivity were received. R91's Physician Order Summary, undated, documented an order for Sulfamethoxazole-Trimethoprim 800-160 mg for 7 days with a Start Date 12/11/23 and End date of 12/18/23. 3. R94's Face Sheet, undated, documented R94 was admitted to the facility on [DATE] from an area hospital. R94's Lab results, dated 12/9/23, documented that a urine specimen was setup for culture but there were no results documenting culture and sensitivity were received. R94's Physician Order Summary, undated, documented an order for Amoxicillin-Potassium Clavulanate 875-125 mg for 5 days with a Start Date 12/16/23 and End date of 12/23/23. R94's Electronic Medication Administration (eMARS), dated 12/2023, documented that R94 received 1 out of 1 dose of Amoxicillin-Potassium Clavulanate 875-125 mg for 7 days with an Order Date 12/14/23. R94's Electronic Medication Administration (eMARS), dated 12/2023, documented that R94 received 16 out of 16 doses of Amoxicillin-Potassium Clavulanate 875-125 mg for 7 days with an Order Date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 12/15/23. Level of Harm - Minimal harm or potential for actual harm R94's Electronic Medication Administration (eMARS), dated 12/2023, documented that R94 received 5 out of 5 doses of Amoxicillin-Potassium Clavulanate 875-125 mg for 7 days with a Start Date 12/23/23. Residents Affected - Few On 1/5/24 at 8:21 AM, V19 (Registered Nurse) stated that when a new admit or re-admission from the hospital arrives with an order for an antibiotic, the medical provider is contacted to determine if the antibiotics will be continued. V19 was unaware of the policy regarding antibiotic stewardship. On 1/5/24 at 8:27 AM, V20 (Licensed Practical Nurse) stated that oftentimes the resident will not have any paperwork from the hospital upon arrival, other the medication list, at that point the medical provider is contacted, and he orders what medication is to be continued or stopped. She continued to state that oftentimes when the staff receives a report from the sending nurse, they will provide the name of the organism that is being treated. On 1/5/24 at 8:35 AM, V3 (Assistant Director of Nursing/ADON), stated that the process of receiving an admission or new admit on antibiotics start with identifying the organism and reviewing if the organism is sensitive to the antibiotic prescribed. She continued to state that the Infection Preventionist is responsible for obtaining the lab results from the hospital if the resident does not arrive with that paperwork and that more often than not the paperwork does not contain the lab work. On 1/5/24 at 1:45 PM, V4 (Infection Control Preventionist/ICP), stated that she was new in the job and has been going through the Infection Control Log to ensure that lab results are available for the medical provider before initiating any antibiotics. She continued to state that for the most part, the medical providers have been receptive but they are some that are old school and are unwilling to change their way of prescribing antibiotics and that education is ongoing for the medical providers and staff. The Facility policy /procedure, Antibiotic Stewardship, revised 3/9/23, documented, The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if: (1) The organism is not susceptible to antibiotic chosen; (2) The organism is susceptible to narrower spectrum antibiotic; (3) Therapy was ordered for prolonged surgical prophylaxis; or (4) Therapy was started awaiting culture, but culture results and clinical findings do indicate continued need for antibiotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145571 If continuation sheet Page 3 of 3