Health inspection·March 6, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prevent misappropriation of property for 1 resident (R1) of 3 residents reviewed for misappropriation of property in the sample of 7. Residents Affected - Few The Findings include: The Abuse policy, dated 11/28/19, documents, The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown sources, exploitation and use of any physical or chemical restraint not required to treat residents' symptoms. To protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms. The Final Investigation Report sent to the (State Agency), dated 2/13/24, documents a Drug Diversion Investigation. On 2/8/24, V2 (Regional Nurse Coordinator) notified V1 (Administrator) of a possible drug diversion for a bottle labeled Morphine Sulfate. During a routine medication cart audit by V4 (Pharmacy Nurse Consultant), V4 noted a bottle labeled morphine sulfate for R1. The bottle was stored in a zip lock bag along with the dosing syringe. The content of the bottle was gray in color. The morphine that is provided by the facility pharmacy is blue in color. V4 removed the bottle of morphine and the sign out sheet and took it to V5 (Previous Director of Nursing) due to her concerns. V4 left the bottle labeled Morphine for R1 containing the gray liquid, sign out sheet, and dosing syringe in V5's office. V5 and V3 (Assistant Director of Nursing) immediately initiated an investigation. After completion of interviews with all nursing staff, the time frame for this occurrence has been determined to be after 1/22/24. R1's Physician Order, dated 12/6/22, documents, Morphine Concentrate - Schedule II solution; 100 mg (Milligram)/5 ml (Milliliter) (20 mg/ml); Amount to Administer: 0.25 ml; oral. R1's Controlled Substance Record documents 30 ml of Morphine was delivered on 12/6/23. There was 27.5 ml remaining out of 30 ml. At the top of the sheet written in marker is Dark color - reported. R1's Medication Administration Record documents the last time R1 received Morphine was on 1/21/24 at 1:54 PM given by V16. On 3/5/24 at 10:56 AM, V3 had two bottles of Morphine. The bottles were white plastic with a clear area on the side where the medication could be seen and measured. The contents of R1's bottle was gray in color. The bottle had 27.5 ml of liquid in it out of the original 30 ml's. The unopened bottle of morphine was blue in color. R1's Morphine bottle had an expiration date of 7/25. Page 1 of 3 145597 145597 03/06/2024 Pekin Manor 1520 El Camino Drive Pekin, IL 61554

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/5/24 at 11:21 AM, V1 (Administrator) stated V4 found a bottle of morphine for R1 that V4 thought had been tampered with during V4's medication audit. The bottle should have had a blue medication in it, but what was in the bottle was gray. An investigation was done, and the facility was unable to identify what happened to (R1's) medication. On 3/4/24 at 2:32 PM, V3 (Assistant Director of Nursing) stated when V4 was doing her medication audit, V4 found a bottle of Morphine that V4 questioned if it was really Morphine. V4 brought the bottle to V3 and V5 and said she thought the color was different than it should be. V3 and V5 agreed the medication did not look like the correct medication. The bottle was a white bottle with a strip on the side that the color can be seen through. The medication should have been blue but was gray. V3 also stated V16 (Licensed Practical Nurse) was the last person to give the medication to R1 on 1/21/24. V16 said the medication she removed from the bottle for R1 was blue. On 3/4/24 at 1:36 PM, V4 (Pharmacy Nurse Consultant) stated when she was doing the narcotic counts at the facility, V4 noticed a bottle of Morphine for R1 that was gray in color instead of blue. The Morphine looked as though it had been tampered with. V4 also stated she could not say what was in the bottle, but knew it was not Morphine. 145597 Page 2 of 3 145597 03/06/2024 Pekin Manor 1520 El Camino Drive Pekin, IL 61554

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide nail care to 1 resident (R1) of 3 residents reviewed for nail care in the sample of 7. Residents Affected - Few The Findings include: The Nail Care policy, dated 3/2004, documents to provide cleanliness and prevent infection the nails should be trimmed. The Personal Care of Residents policy, dated 12/2002, documents, It is the policy of the facility to provide a plan of personal care for residents. To provide that residents of the facility receive adequate care. Each resident shall have proper daily personal attention and/or care, including skin, nails, hair, and oral hygiene, in addition to treatments ordered by the physician. R2's Nursing Note, dated 2/6/24 at 12:50 PM, documents R2 was seen today by V6 (Advanced Practical Nurse) and received an order to provide nail care. R2's Nursing Note, dated 2/7/24 at 10:48 AM, documents R2 has received a shower today and no new skin concerns. Areas on the bilateral lower extremity/BLE shows self-inflicted scratches. R2's nails have been trimmed and triamcinolone cream applied to the BLE. On 3/4/24 at 2:55 PM, R2's fingernails were observed. The fingernails were jagged with some sharp edges. V1 (Administrator) was asked to look at R2's fingernails. V1 observed R2's nails and stated she would have the nails cut. On 3/5/24 at 10:00 AM, V3 (Assistant Director of Nursing) stated she looked at R2's fingernails on 3/4/24, and although they were short, they were jagged and sharp. V3 told V20 (Certified Nursing Assistant) to cut R2's fingernails, and V20 said he had recently cut them. V3 told V20 the fingernails were sharp, and to do it again. On 3/5/24 at 10:25 AM, V6 (Advanced Practice Nurse) state she had ordered R2's nails be cut because R2's left hand is contracted, R2's nails were long, and V6 was concerned the nails would dig into R2's hand. V6 also stated R2's nails did need to be addressed. On 3/6/24 at 12:29 PM, V19 (Assistant Occupational Therapist) stated she worked with R2 four times from February 8th to 3/6/24. (R2's) fingernails were not super long, but longer than they should have been. 145597 Page 3 of 3