Health inspection·April 3, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 follow its policy of implementing care plan interventions to prevent the further decline of pressure ulcers, for one of three residents R100 reviewed for pressure ulcers, in a sample of 31. Residents Affected - Few FINDINGS INCLUDE: The facility policy, Skin Prevention, Assessment and Treatment, dated (revised) May 2, 2022 directs staff, Purpose: To identify factors that place the residents at risk for the development of pressure ulcers; To implement appropriate interventions to prevent the development of clinically avoidable wounds; To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown; To promote healing of existing pressure ulcers. Residents identified as high risk should be addressed in the resident's care plan to assure appropriate interventions to manage the risk are implemented. Care Plan interventions include: Wound Consultant review; Registered Dietician review; Nutritional supplement; Encourage or turn and reposition on a resident centered time frame (approximately every 2 hours); Use pillows, pads, etc. to aide in positioning, cushion bony prominence's and elevate heels off surface; Encourage activities such as range of motion, ambulation and exercises as tolerated; Practice good transfer techniques to avoid friction and shearing; Keep linens clean and wrinkle free; Keep skin clean and dry; Incontinent care after each incontinent episode; Provide pressure relieving device or cushion on surfaces as indicated; Inspect skin daily for reddened areas or breakdown; Monitor cast, braces, splints and compression bandages for skin irritation; Encourage to maintain adequate nutrition and hydration; Showers at least two times weekly; Nails maintained to promote cleanliness, prevent infection and enhance sense of wellbeing; Arm sleeves, leg protectors; Pad frequently bumped areas. Wounds are treated and based on the etiology of the wound. R100's March 2024 Physician Order Sheet documents that R100 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease, Urinary Tract Infection, Malignant Neoplasm of the Rectum and Diarrhea. R100's Nursing admission Assessment, dated 3/23/24 and signed by V5/Licensed Practical Nurse includes the following Skin Issues, Left ear, Pressure, 1.3 CM (Centimeters) X 0.3 CM, Stage 1; Right Buttock, Pressure, 5.0 CM X 2.0 CM, Stage 1 and Right Buttock, Pressure, 5.0 CM X 2.0 CM, Stage 1. No admission Care Plan to address R100's admission skin conditions and interventions to prevent further deterioration of R100's skin, is present in R100's medical record. R100's Care Plan, dated 3/25/24 includes no focus area to address R100's newly acquired pressure ulcer, or interventions to prevent further deterioration of R100's skin. Page 1 of 6 145604 145604 04/03/2024 Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537

F 0686 Level of Harm - Minimal harm or potential for actual harm The facility Weekly Wound Tracking Log, dated 3/25/24 documents, (R100) Pressure wound, Right Buttock, Stage 2, 2.5 CM X 1.5 CM X 0.1 CM, Open (area). On 4/2/2024 at 1:00 P.M., V4/Care Plan Coordinator verified R100's current Care Plan did not address (R100's) pressure ulcer or include interventions to prevent further deterioration of R100's skin. Residents Affected - Few On 4/2/24 at 2:40 P.M., V5/Licensed Practical Nurse verified no admission care plan to address (R100's) skin condition on admission was developed. 145604 Page 2 of 6 145604 04/03/2024 Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, it was determined the facility failed to ensure weights were obtained as ordered for 1 of 1 (R10) resident reviewed for Heart Failure in a sample of 31 residents. Residents Affected - Few Findings include: The Minimum Data Set (MDS) section I documents R10 has an active diagnosis of Heart Failure. The current care plan documents R10 has an alteration to my cardiac system and to monitor vital signs as ordered and PRN (as needed); expect weight fluctuations due to edema and diuretics (medication that helps reduce fluid in the body). On 3/11/24, the Physician ordered weights to be conducted daily. Daily weights were not conducted in March 2024, 6 of 20 days. On 4/2/24 at 2:00 PM, V2 (Director of Nurses) stated R10's weights were not recorded daily and should have been. 145604 Page 3 of 6 145604 04/03/2024 Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview and record review the facility failed to document target behaviors to warrant the use of Seroquel (antipsychotic medication) for one of two residents (R14) reviewed for antipsychotic medications in the sample of 31. Findings include: The facility's Psychotropic Medication Management policy, dated 12/4/19, documents Purpose to provide guidance for the psychopharmacologic drug treatment for a resident with specific conditions, including but not limited to dementia and other cognitive disorders, and/or behaviors as documented in the resident's clinical record. An assessment must be conducted to identify specific behaviors/ symptoms, potential causative factors and recommendations for managing identified behaviors. The physician should evaluate use of antipsychotic medication use if one or more of the following is/are the only indication: Wandering, Poor self-care, Restlessness, Impaired Memory, Anxiety, Depression (without psychotic features), Insomnia, Unsociability, Indifference to surroundings, Fidgeting, Nervousness, Uncooperativeness or Agitated behaviors which do not represent danger to the resident or others. On 4/1/24 at 10:30 AM R14 was sitting in a wheelchair in her room. R14 was pleasantly confused with conversation and unable to answer questions. R14 was not displaying any behaviors. On 4/1/24 at 12:00 PM R14 was sitting in dining room at a table being assisted by staff with her meal. R14 was not displaying any behaviors. On 4/3/24 at 9:45 AM R14 was sitting in her wheelchair in the activity room watching a movie. R14 was not observed displaying any behaviors. R14's current Physician Order Sheet, dated 4/3/24, documents R14 has an order for Quetiapine Fumarate (Seroquel, antipsychotic medication) 25 milligrams by mouth one times daily related to psychotic disorder with delusions due to known physiological condition. This same order sheets also documents an order for Quetiapine Fumarate 50 milligrams by mouth in the evening related to psychotic disorder with delusions due to known physiological condition. R14's current Care Plan, dated 3/9/23, documents I currently have acute confusion episodes or delirium due to Dementia and psychotic disorder. I currently have an alteration in my behavior status related to Dementia/Anxiety/Insomnia/Psychotic Disorder with Delusions. (R14) often wants to speak to her mother and believes staff/residents are her sisters/children. Has a history of being agitated/yelling out/grabbing/pushing staff during cares. It can be very difficult to redirect resident when she is agitated. R14's electronic behavior monitoring, dated 3/4/24-4/1/24, documents R14 is being monitored daily for behaviors of Agitation/ Restlessness/ Anxious, Confusion/disorganized thinking, Cursing, Depression/withdrawn, Delusion. On 4/03/24 at 9:35 AM, V7 (Certified Nursing Assistant) stated (R14) mostly has been sleepy lately. She is newly on palliative care. When (R14) does display behaviors, they are of being resistive 145604 Page 4 of 6 145604 04/03/2024 Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537

F 0758 with cares. She is not a harm to other residents at all. Level of Harm - Minimal harm or potential for actual harm On 4/03/24 at 9:40 AM, V8 (Licensed Practical Nurse) stated (R14) typically is just resistive to care at times. She can be sassy, her symptoms are that of Dementia. (R14) has no behaviors towards other residents. Residents Affected - Few On 4/03/24 at 11:54 AM, V2 (Director of Nursing) Confirmed R14's behaviors that are being tracked are those of agitation, restlessness, confusion/disorganized thinking, cursing, depression/withdrawn, and delusion. V2 stated R14's delusions are often thinking staff are family/parents and confirmed R14 is not at risk of harming herself or other residents. V2 confirmed R14's behaviors being tracked are not psychotic in nature and relate back to her diagnosis of dementia. 145604 Page 5 of 6 145604 04/03/2024 Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Personal Protective Equipment was utilized and hand hygiene was performed for 3 of 6 residents (R10, R22 and R27) reviewed for Infection Control Practices in a sample of 31. Residents Affected - Few Findings include: The Hand Washing policy dated 11/5/19, documented Hands should be washed before resident care, after resident care. The Enhanced Barrier Precautions policy dated 3/27/24, documented Are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or patient's environment. In addition to residents who have an infection or colonization with CDC (Center for Disease Control)-targeted or other epidemiologically important MDRO when contact precautions do not apply. Hand Washing. R10 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Atrial Fibrillation, history of Urinary Tract Infection (UTI) with Multi-Drug Resistant Organism and Acute Respiratory Failure. On 2/14/24, R10's Physician ordered Contact CDC Isolation Precautions d/t (due to) ESBL (Extended-Spectrum beta-lactamase/multi-drug resistant organism) Urine. On 4/2/24 at 12:00 PM, (R10) was observed to have a Contact Precautions and Enhanced Barrier Precautions signage posted on the door. On 4/2/24 at 12:00 PM, V6 (Certified Nurse Aide/CNA) was observed assisting R10 with meal setup. V6 was observed to not have any personnel protective equipment donned; exited R10's room without conducting hand hygiene; entered R22's room and assisted R22 and R27 with setting up their meals; exited the room without conducting hand hygiene; re-entered R10's room and exited without conducting hand hygiene and then entered the staff lounge. On 4/2/24 at 12:20 PM, V2 (Director of Nursing) stated V6 should have donned a gown and gloves while providing care for R10 and conducted hand hygiene before and after exiting room [ROOM NUMBER] and 411. 145604 Page 6 of 6