Health inspection·July 15, 2022

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to identify and assess pressure ulcers for one of five residents (R44) reviewed for pressure ulcers in the sample of 33. Residents Affected - Few Findings Include: R44's Skin Integrity Care Plan date initiated is 12/25/20 documents I will have no skin issues/break down through next review period. The Care Plan also documents Do a weekly skin check and notify my family and Physician of any new areas. Peri care after each incontinence episode. R44's Physician Order Sheets (POS) dated 6/26/22 with an open-ended date, documents cleanse right buttocks with normal saline and apply Santyl and Calcium Alginate. Cover it with a dry dressing. R44's June POS dated 6/29/22 to 7/7/22 documents cleanse scrotal area with normal saline and apply collagen powder, cover with dry dressing daily until healed. R44's Local Wound consultant Form dated 7/6/22 also documents R44's Non pressure ulcer to scrotum with fat layer exposed is resolved. R44's Local Wound consultant Form documents R44's right buttock pressure ulcer is resolved and discontinue treatment. R44's POS dated 7/7/22 with an open-ended end date documents apply barrier cream to the scrotum twice daily and whenever necessary. (The previous treatment was discontinued when the scrotum was resolved on 7/6/22.) R44's Local Wound Consultant Form dated 7/12/22 documents that the Wound Consultant did not see R44's scrotum and right buttock for this visit. On 7/14/22 at 11:30 AM, V6 (Licensed Practical Nurse/LPN) entered the room to perform treatments on R44's left heel, right buttock. R44 has two dime size open areas to his scrotum. He also has a nickel size area open on his right buttock. There was no documentation in R44's medical record when these areas developed and if a new treatment was ordered for these pressure ulcers. R44's Treatment Administration Record for the month of July 2022 documents that skin checks are to be done daily with CROPS which stands for C-clear, R-redness, O-open, P-pressure, and S-skin tear. The daily skin check was completed but did not document the new open areas to the buttocks and scrotum. Page 1 of 9 145601 145601 07/15/2022 Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/15/22 at 12:09 PM, V3 (Assistant Director of Nursing/ADON) (The Local Wound Consultant) did not look at it because it was healed the week before, and no one told us that the pressure ulcer had reopened. The facility's Wound Care Program Policy dated 7/2014 documents in developing a comprehensive treatment plan for wounds, the clinician should assess not just the wound, but the whole person. The factors affecting the ability of the wound to close and ultimately heal need to be included in the overall treatment. Expect a clean ulcer with adequate interventions and blood supply to show evidence of healing within two weeks. Failure to do so should prompt a reevaluation of the plan of care, and evaluation of adherence to the plan and a possible modification of the plan. Assessment of the wound is necessary prior to developing a plan of care Parameters Include: etiology, pathogen confirmation, wound bed, location. 145601 Page 2 of 9 145601 07/15/2022 Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide supervision and implement effective interventions to prevent accidents/falls for 2 of 2 residents (R21, R257) reviewed for supervision to prevent accidents/falls in the sample of 33. Findings include: 1. R21's Care Plan dated 4/27/2022 (initiated 8/21/2021) documents At risk for skin breakdown. I have thin skin and am prone to skin tears. I wear derma-sleeves to my bilateral lower extremities R/T (related to) frequent reoccurrence of skin tears to my lower legs. Goal: My skin tear will be closed without infection by next review. Interventions/tasks: Administer treatment as ordered. See current physician order sheet or treatment book. Apply derma-sleeves to my lower extremities prior to getting out of bed and remove at bedtime. Encourage me to be out of bed as tolerated. Keep skin tear site clean and dry. Monitor dressing(s) if applicable and let the nurse know if it is saturated or falling off. Monitor fingernails weekly for length and jagged edges. Monitor for discoloration, bruises, swelling, new skin tears, and redness. If noted, report to nurse/MD (physician.) Notify physician if any s/sx (signs and symptoms) of infection occur. Please pay special attention when moving me. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Turn and reposition every 2 hours and PRN (as needed). R21's Skin/Wound Note, dated 5/8/2022 at 6:27 AM documents CNA (Certified Nurse's Assistant) was getting resident out of bed and into wheelchair and hit resident's right leg on the wheelchair causing a 3 cm (centimeter) long skin tear. Skin well approximated. Area cleansed with NS (normal saline.) 3 steri strips and dry dressing applied. Resident denies pain. MD (physician) updated. R21's Physician's Order Sheet, dated 5/8/2022 documents right shin: monitor steri-strips to skin tear and change dressing daily and PRN until healed. On 7/14/2022 at 12:45 PM V7 (Certified Nursing Assistant/ CNA) and V8 (Certified Nursing Assistant/ CNA) transferred R21 from wheelchair to bed using a full body lift. V7 stated R21 used to be a 1 or 2 staff assist stand and pivot transfer but she is weaker now, so they use the lift. While R21 lay in bed, no derma sleeves were on her bilateral lower extremities. On 7/14/2022 at 1:40 PM, V7 stated R21 used to wear derma sleeves on her arms and legs, but she doesn't wear them anymore. On 7/14/2022 at 12:55 PM, V3 (Assistant Director of Nurses/ADON) stated when the incident is witnessed the facility does not document an investigation because they know how it occurred. V3 didn't know who transferred R21 to bed that day. She stated R21 was a 1 or 2 staff stand and pivot transfer in May 2022, it depended on how R21 was feeling that day to see how many staff needed to assist the transfer. On 7/14/2022 at 1:30 PM, V2 (Director of Nursing/DON) stated she expects staff to follow physician's orders and if the resident had a physician's order for derma sleeves to her bilateral lower extremities she should have them on. 145601 Page 3 of 9 145601 07/15/2022 Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216

F 0689 2. R257's undated Face Sheet documents he was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm R257's Fall Risk Assessment, dated 7/8/2022 documents he was a high fall risk. Residents Affected - Few R257's Progress Note dated 7/8/2022 at 9:00 PM documents resident arrived to facility via ambulance with two attendants and multiple family members accompanying. Resident transferred to bed with assistance of ambulance attendants. Resident admitted with hx (history): CVA (stroke), COPD (lung disorder) prostate CA (cancer), syncope and anemia. Resident incontinent of bowel and bladder. Alert and oriented x 0. Blind in both eyes r/t recent CVA. Allergic to morphine. Max (maximum) assist. Resident on 2L (liters) oxygen per NC (nasal cannula.) Respirations even and non-labored. Bowel sounds active and present x 4. R257's Progress Note dated 7/09/2022 at 5:27 PM documents At 4:24 writer observed res (resident) slide out of bed and onto his knees. Torso/head remaining on bed. Incontinent of bladder and linens soiled. Res unable to explain what he was doing. Appears he was attempting to gather soiled linens as he was balling them in his hands. No injuries noted to bil (bilateral) knees. Gripper socks on and bed in lowest position at time of fall. MD (doctor) notified of fall. Family, informed of fall with no injury. No questions voiced at this time. R257's Progress Note dated 7/10/2022 at 12:22 AM documents CNA found resident on floor of room. CNA notified nurse. No apparent injuries upon assessment. POA (Power of Attorney) and physician to be notified. R257's Progress Note dated 7/10/2022 at 11:09 AM documents At approximately 7:00 AM resident attempting to climb out of chair and has previously fallen twice. R257's Progress Note dated 7/10/2022 at 7:40 PM documents CNA called nurse to room at this time and resident was lying on floor. Family had recently been here and he was sleeping in (brand name) chair. Once family left resident tried transferring self out of chair and was found on the floor by his bed. No injuries noted. Combative with staff as we were trying to get resident assessed and back in chair. Appears to be baseline. Vitals obtained at this time. MD faxed. POA called and aware of fall. R257's Progress Note dated 7/10/2022 at 10:45 PM documents CNA called nurse to room and resident was lying on floor in urine. No injuries noted. Vitals assessed and neuros. WNL (within normal limits). R257's Progress Note dated 7/10/2022 at 11:46 PM documents due to combativeness and reoccurring falls discussed with POA sending resident to hospital for evaluation and treatment. R257's Electronic Medical Record (EMR) no documentation of when he was readmitted to the facility from the hospital. R257's Progress Note dated 7/11/2022 at 6:10 PM documents resident had witnessed fall. This nurse witnessed resident attempting to get of w/c (wheelchair) and slid and fell to the floor. Resident did not hit his head. Resident assessed, [NAME]. Vital signs WNL. Resident's family called to inform of event. R257's Undated Baseline Care Plan documents he was a high fall risk, no progressive interventions after the falls were documented. 145601 Page 4 of 9 145601 07/15/2022 Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/15/2022 at 8:45 AM, V2 (Director of Nursing/DON) stated she expects staff to document a progressive intervention after every fall. There were progressive interventions in place after the resident fell but they weren't documented on his care plan. The facility's Fall Management Policy, revised July 2017 documents residents identified as high fall risk will have fall prevention addressed on the plan of care. 145601 Page 5 of 9 145601 07/15/2022 Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation the facility failed to provide catheter care without breaches in infection control, and or reassess catheter after self-removal for two of three residents (R44, R30) reviewed for catheter care in the sample of 33. Findings Include: 1. R44's Minimum Data Set (MDS) dated [DATE] documents R44 has a catheter and is always incontinent of bowel. R44's Catheter Care Plan initiated on 9/24/2020 documents R44 has a suprapubic catheter and will show no signs and symptoms of a urinary tract infection. The Catheter Care Plan also documents cleanse the suprapubic catheter every day, and apply triad paste. Cover the catheter with a dry dressing. On 7/14/22 at 11:00 AM, V7 (Certified Nursing Assistant/CNA) removed the old dressing off of R44's left buttock, because he was incontinent of bowel. but she did not wash her hands or change her gloves. She wiped feces off of the resident with a washcloth that she wet in a basin of water and no rinse peri wash. V7 then went into the wash basin with the same gloves two more times to wet wash cloths, to cleanse the rectal area of feces. She then went in with same gloves, in the wash basin and performed catheter care. She removed the old dressing off of the catheter area with the same gloves and cleansed around the catheter insertion site and down the catheter with the same gloves. V7 did not cleanse her hands when going from soiled to clean while performing catheter care. On 7/14/22 at 11:30 AM, V6 (Licensed Practical Nurse/LPN) went in and applied Triad Cream and placed a dry dressing on R44's suprapubic catheter site. The Catheter bag was on the floor, and she was standing on it. On 7/15/22 at 9:15 AM, V3 (Assistant Director of Nursing/ADON) stated during catheter care. I would expect the (CNA) to introduce herself to the resident wash her hands, gather the water and wash cloths. Use more than one wash cloth, and wash hand and change gloves, when going from dirty to clean. The facility Care Plan dated 7/2017 documents use standard precautions when handling and manipulating the drainage system. Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. 2. R30's admission MDS, dated [DATE] documents he is moderately cognitively impaired, requires extensive assistance of one-person physical assist for toilet use and personal hygiene and an indwelling catheter. R30's Care Plan, dated 2/11/2022, had no documentation regarding R30's indwelling catheter. R30's Physician Order Sheet, dated 3/2022 documents an order dated 2/10/2022: Eliquis (anticoagulant) 2.5 mg (milligrams) take one tablet by mouth twice daily. R30's Nursing Note, dated 3/30/2022 at 4:34 PM documents CNA (certified nurse assistant) reported res sitting in w/c (wheelchair) in room bleeding from unknown source. Entered room to observe res 145601 Page 6 of 9 145601 07/15/2022 Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sitting in w/c near bed 2. Wearing t-shirt, gait belt and non-skid socks. Pants sitting on floor under front wheel of w/c. Nasal cannula in place, but not connected to concentrator. Foley drainage (catheter) bag hanging on side of bed closest to door and catheter lying across bed. Balloon intact. Large amount of blood smeared on floor and both beds. Large clots noted on floor under seat of w/c and blood dripping from urethral meatus (tip of penis). Res unable to report what happened. Writer and CNA assisted res from w/c to bed with use of gait belt and w/w (wheeled walker.) Physical assessment completed with only one source of blood identified. Perineal care provided. Small amount of bleeding continues from site. R30's Communication with Physician Situation Note, dated 3/30/2022 at 4:45 PM the Nurse Practitioner (NP) informed of displacement of foley catheter with bleeding from urethral meatus r/t (related to) trauma. Background: Currently on Eliquis therapy. Assessment (RN)/Appearance (LPN): Recommendations: Instructed to monitor bleeding. When it ceases, attempt to re-insert catheter. If met with resistance, unable to place catheter, it doesn't drain or he doesn't stop bleeding in 5-10 min (minutes) send res (resident) to ER (emergency room) for eval (evaluation)/tx (treatment.) If catheter re-inserted, monitor output and send to ER if bleeding continues. R30's Electronic Medical Record, dated 3/30/2022 between 4:45 PM and 6:59 PM documents no assessment of the resident. R30's Nursing Note, dated 3/30/2022 7:00 PM writer called to resident's room by aide and noted bright red blood dripping on bathroom floor and large amount noted to front of gown. resident up with walker and gait belt with stand by assist. Denies any dizziness, lightheadedness or pain. small amount of bright red blood/urine noted in cath (catheter) bag. vs (vital signs) 141/66-84-18-93% on O2 (oxygen) at 2L (liters.) R30's Communication with Physician Situation Note, dated 3/30/2022 7:05 PM large amount of bright blood noted around urethral meatus and in cath bag. Background: no information documented. Assessment (RN)/Appearance (LPN): no information documented. Recommendations: NP updated by ADON of impending transfer per previous order. R30's Communication with Family NOK (next of kin)/POA (power of attorney) Note, dated 3/30/2022 7:20 PM documents POA updated on continued bleeding and impending transfer for further eval. POA upset at resident's current condition and feels staff should have been monitoring more closely. this writer voiced understanding and stated ADON would be made aware of concerns. R30's Nursing Note, dated 3/30/2022 10:55 PM notified of need for pick up at 7:40 PM. Arrived with 2 EMTs (Emergency Medical Technicians) at 8:00 PM. Report called to hospital ER at 8:02 PM. On 7/14/2022 at 9:15 AM, the Director of Nursing (DON) stated the resident is alert and could say what happened so no investigation was completed. 7/14/2022 at 10:11 AM, V4 (Licensed Practical Nurse/ LPN) stated she was assigned to the resident on 3/30/2022 and recalled the incident. Staff notified her the resident was bleeding. She walked in the resident's room and there was a bloody mess. The resident was sitting in his wheelchair and there was blood dripping from his penis. The catheter bag was laying across the bed, the catheter balloon was intact. The resident was not able to state what occurred. There was a large puddle of blood with clots under the resident's wheelchair. V4 didn't put the catheter back in and could not recall if she monitored him after she left his room at that time. 145601 Page 7 of 9 145601 07/15/2022 Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/14/2022 at 10:30 AM, V3 (ADON) stated V4 (LPN) notified her that R30 pulled out his catheter. When she entered R30's room she observed blood on the floor, his bed sheet and on his curtain. R30's catheter was hanging on the side of the bed and it was pulled out. Blood was dripping from his penis and his penis was split open. She called the Nurse Practitioner (NP) and she instructed staff to monitor the resident for bleeding and if he's still bleeding to send him to the emergency room (ER.) She didn't know if the nurse put the catheter back in or not. On 7/14/2022 at 11:14 AM, V2 (Director of Nursing/DON) stated she expected staff to document if they reinserted the resident's catheter after it was pulled out but if nothing was occurring during that time, she didn't expect staff to document if they were monitoring the resident for bleeding or not. The facility's Catheter Care, Urinary policy, revised 7/2017 documents the purpose of this procedure is to prevent catheter-associated urinary tract infections. Complications: observe the resident for complications associated with urinary catheters check the urine for unusual appearance (color, blood etc.) Notify physician or supervisor in the event of bleeding, or if the catheter is accidently removed. Documentation: the following information should be recorded in the resident's medical record: any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting or pain. Any problems or complaints made by the resident related to procedure. Reporting: report other information in accordance with facility policy and professional standards and practice. The facility's Change in Condition policy, revised 2/2021 documents policy: it is the policy of the facility that resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely manner. Definition: change in condition is defined as an improvement or decline in the resident's physical, mental or psychosocial status that effects less than two areas of activities of daily living. Significant change is defined as an improvement or decline in the resident's physical, mental or psychosocial status that effects two or more areas of activities of daily living. Procedure: the staff person who first notices the change reports resident change in condition immediately to the licensed nurse. The licensed nurse assesses the resident including vital signs and notes signs and symptoms, regarding physical and mental changes in condition. The results of the assessment, including vital signs, symptoms and any physical and/or mental changes in condition are documented in the resident's medical report. The resident's primary physician or designated alternate will be notified immediately of any change in resident's physical or medical, this includes: accident involving the resident, deterioration in health, mental or psychosocial status. Need to alter (need to discontinue an existing form of treatment due to adverse consequences or to commence new form of treatment.) Notification of physician and/or responsible parties shall be documented in the clinical record as well as on the 24-hour report form. Status changes, which are not significant enough to be reported, must also be documented in the medical record. Significant change in condition requires a comprehensive resident reassessment (MDS) with associated documentation in the clinical record and care plan. The assessment must address all aspects of the resident's condition affected by the change. Acute conditions or clinical complications can trigger a reassessment. All changes in condition must be completely and objectively documented in the clinical record. Appropriate follow through from shift to shift is imperative for all resident with any change in condition. The nursing staff must utilize the tools provided for formal communication from shift to shift. 145601 Page 8 of 9 145601 07/15/2022 Aviston Countryside Manor 450 West 1st Street Aviston, IL 62216

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 and label food in a manner that keeps it free from contaminants. This has the potential to affect all 57 residents living in the facility. Residents Affected - Many Findings include: On 07/12/22 at 8:08 AM on the initial tour and follow-up tour on 07/13/22 at 7:45 AM of kitchen, the following dry foods were found opened, not dated and no expiration date: - 50-pound bag of rolled oats was opened and left open with no date of opening. - 60-ounce bag of croutons open, with no date of opening. Bag was closed with a rubber band - 60-ounce bag of baking coconut, open, with no date of opening and taped closed. - 100-ounce bag of spaghetti, open, with no date of opening and closed with a rubber band. - 160-ounce bag of macaroni, open with no opening date and closed with a rubber band. On 07/13/22 at 7:45 AM, the following refrigerated items were found to be unlabeled and undated: Two 1- gallon pitchers with liquid (1 red and 1 brown) were not labeled and without a date. On 7/13/22 at 7:45 AM, V18 (Dietary Manager) states This must have occurred because my worker was out sick. I have trained staff to make sure they follow the policy and procedures, and my directions are followed. I normally double check to make sure things are labeled and sealed. On 7/13/22 at 8:00 AM, V1 (Administrator) states, I rely on my staff to make sure we are following our policy and procedures. V18 is pretty thorough so I am sure it was something that was overlooked. On 7/13/22 at 12:30 PM, both V12 (Cook) and V13 (Dietary Aide) both state they have been trained on when and how to label, date and close bulk dry goods. The policy on Food and Storage dated 2019 and revised March 2022 documents: Plastic containers with tight-fitting covers must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. The Facility's Resident Census and Census and Conditions of Residents form, CMS 672, dated 07/12/22 documents the facility had a census of 57 residents. 145601 Page 9 of 9