Health inspection·July 27, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to provide hygiene care (showers) for four (R6, R18, R30 and R36) of 16 Residents reviewed for hygiene in a sample of 22. Residents Affected - Some Findings include: Facility Shower Care Policy and Procedure, revised 11/24/20, documents that it is the practice of this Facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. Facility Shower Schedule, effective 3/1/2012, documents that all Residents residing in the Facility are scheduled to receive a shower twice a week. Facility Certified Nursing Assistant Job Description, documents: this position is to assist the nurses in the providing of Resident care primarily in the area of daily living routine; must be physically and mentally capable of performing routine, repetitive job duties; knowledge of State and Federal Regulations; carry out assignments for resident care including bathing and grooming; and be responsible for the well-being and nursing care of all residents assigned to his/her unit while on duty. Facility Resident Council Minutes, dated 1/10/23, document: showers (100 Hall) still not being done, they are told by staff that they are short of help; feel nurses spend too much time at nurse's desk; showers (400 Hall) said their showers are better they at least get one shower a week. Facility Resident Council Minutes, dated 5/9/23, document issues with showers on Second Shift, Residents are told they are too short on staff to do them. Facility Resident Council Minutes, dated 6/13/23, document issues with showers on second shift are not being done on regular basis and that V2 (Director of Nursing) has talked to staff and shower audits are also in place and being tracked. Facility Resident Council Minutes, dated 7/11/23, document that showers again have not been done in a timely fashion and that Residents feel that more staff is needed. R30's Minimum Data Set/MDS, Section G, dated 5/21/23, documents that R30 requires staff assistance with bathing. R30's current Care Plan documents, requires extensive assistance of one to two staff to provide showers (two times a week) and as necessary. Page 1 of 5 145604 145604 07/27/2023 Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537

F 0677 Level of Harm - Minimal harm or potential for actual harm R36's Minimum Data Set/MDS, Section G, dated 7/20/23, documents that R36 requires staff assistance with bathing. R6's Current Comprehensive Assessment indicates R6 is cognitively intact and able to make all needs known. Residents Affected - Some R6's current Care Plan indicates R6 requires assistance with ADL's (Activities of Daily Living). On 7/27/23, at 1:30 pm, R6 stated, I do not always get my showers and that the CNA's will tell me that they do not have enough time to give them because there is not enough staff. R6's CNA (Certified Nursing Assistant) Task Documentation, dated 7/2023, indicates R6 was admitted on [DATE] and did not receive a shower on 7/25/23. R18's Current Comprehensive Assessment indicates R18 has moderate cognitive impairments. R18's current Care Plan indicates R18 requires assistance with ADL's (Activity of Daily Living) including showering/bathing. R18's CNA (Certified Nursing Assistant) Task Documentation, dated 7/2023, indicates R18 was admitted to the facility 2/23/23, and received one shower on 7/6/23. On 7/25/23, at 8:19 am, R36, with oily and unkempt hair, stated, I do not remember when my showers are, and I do not remember the last time I got one. I do not think I get them all the time when I am supposed to. On 7/26/23, at 9:50 am (during Resident Group Meeting), R24 (Resident Council [NAME] President) stated, There was a problem with the nurses not helping to cover the hallways when the CNA's were in giving showers, so the showers were not getting done all the time and there were not enough CNA's to give showers. On 7/26/23, at 8:15 am, R195 stated, I am the Resident Council President and there are many people, in the meetings, that complain about not getting their showers when they are scheduled. This has been going on for a few months, we keep complaining and nothing is ever done. I am supposed to get my showers on Monday and Thursday evening, but I do not get them. I like my showers right before I go to bed, and I definitely do not get my showers when they are scheduled. On 7/26/23, at 9:15 am, V4 (Ombudsman) stated, At this Facility, I get concerns over the Residents not receiving their showers and this has been ongoing for a few months. I think the Facility has trouble and issues with second shift staff. On 7/26/23, at 1:20 pm, V2 (Director of Nursing) stated, I know that we have had issues with showers, but we have less CNA's (Certified Nursing Assistants) on second shift, and we need more help, but it is hard finding second shift CNA's. I am looking specifically just for a shower aide. I do not have any documentation showing that (R30 and R36) got their twice a week showers. 145604 Page 2 of 5 145604 07/27/2023 Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to identify potential triggers for one resident (R35) of five residents reviewed for PTSD (Post Traumatic Stress Disorder) in a total sample of 22. Residents Affected - Few Findings Include: The Facility's Trauma-Centered Care Policy dated, 11/12015, documents It is the policy of this facility that we will create and maintain a safe, calm, and secure environment with supportive care, a system-wide understanding of trauma prevalence and impact, recovery and trauma specific service as needed, and recovery-focused services. As approach that appreciated healing is possible, trauma informed care engages people with histories of trauma, recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. This approach seeks to shift the paradigm from one that asks What's wrong with you? to one that asks, What has happened to you? Every part of a trauma-informed system's organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking service. The Facility's Trauma-Centered Care policy also documents the facility routinely assist residents to develop a plan that is designed to prevent and manage a crisis. All staff directly involved in the resident's treatment is informed about the resident plan and how they can support it. The facility has a system in place to identify and implement policies, procedures, environmental conditions, activities, social climate, documentation and treatment practices that promote a safe and secure environment in order to reduce the likelihood of re-dramatization or re-victimization. R35's undated care plan documents I experienced a traumatic event in my past. childhood trauma and physical abuse. R35's care plan does not include any triggers or approaches for R35. On 7/27/23 at 9:30 AM V2 (RN DON) stated That (Care Plan) should include approaches specific to (R35's) specific triggers which are also not on the care plan and should be. 145604 Page 3 of 5 145604 07/27/2023 Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on interview and record review the facility failed to offer bedtime snacks to six of nine residents (R7, R24, R37, R38, R41, R195) who attended the Resident group meeting in the sample of 22. Findings include: Facility Policy/Nutritional Snacks and Supplements, dated 11/5/2019, documents: Nutritional supplements are available, and will be provided for all appropriate residents by the nursing staff; bedtime snacks will be offered daily; and the nursing staff will deliver the supplements/snacks to residents. The Facility Week at a Glance Dietary Menu, dated Spring/Summer 2023, documents fruit drink, assorted snacks, cookies, and crackers as the Evening Snack. Facility Resident Council Minutes, dated 1/10/23, documents, snacks are available in kitchenette, behind nurses' station, you need to ask for them if not offered. Facility Resident Council Minutes, dated 3/14/23, documents, still not receiving their nighttime snacks (they need to ask for snack if they do not receive one) and still no nighttime snacks. On 7/26/23, at 9:45 am, R7, R24, R37, R38, R41 and R195 (Resident Council President) stated they were never offered snacks at bedtime and were not aware there were snacks available. All six residents stated they would like a snack to be offered and acknowledged it is a long time between dinner and breakfast and a snack would be helpful. On 7/25/23, at 8:19 am, R36 stated, I do not ever remember getting offered a snack at night. On 7/26/23, at 8:15 am, R195 stated, I am the Resident Council President and I have heard complaints that other Resident's do not get offered a snack at night. They do not offer me a snack at night either, and I would like them to ask me if I want one. On 7/26/23, at 9:50 am, V6 (Activity Director) stated they had been short staffed on evening shift and may not have had time to pass out snacks. On 7/27/23, at 2:05 pm, V7, CNA (Certified Nurse Assistant) stated she was just arriving for work as she works the evening shift. V7 stated, sometimes there are snacks available, but not always V7 stated, sometimes staff have to go to the Memory Care Unit to get snacks if a resident asks for them. V7 also stated the staff do not offer snacks, Residents have to ask for them. On 7/27/23, at 10:20 am, V3 (Dietary Manager) stated, The Dietary [NAME] is responsible for bringing out the nighttime snacks and delivering them to the nurses station. Then, at night, it is the CNA's responsibility to offer and pass them to the Residents. We always send out nutritional snacks for the Diabetics, but it is the responsibility of the Nursing Staff to deliver them and offer snacks to other Resident's, with food from the pantry by the Nurse's Station. On 7/27/23, at 10:10 am, V2 (Director of Nursing) stated, Dietary delivers a tub of snacks at the 145604 Page 4 of 5 145604 07/27/2023 Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Nurse's Station and the CNA's (Certified Nursing Assistant's) are responsible for delivering the snacks. We do not offer each individual resident a snack, there is a snack schedule, and each Resident has to be on the list to receive a snack, such as Diabetics. If they are not on the list, the Residents can always ask for a snack, but the CNA's do not offer each individual Resident a snack every night. I have been working on the snack delivery over the last months. I have trouble hiring CNAs on second shift and now I have hired a few more, so hopefully everything on second shift will get better. We have less CNAs on second shift, and we need more help, but it is hard finding second shift CNA's. 145604 Page 5 of 5