Health inspection·June 23, 2023

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 ensure that a facility-acquired stage III pressure ulcer had a treatment in place as ordered by the physician. This applies to 1 out of 6 residents (R22) reviewed for pressure ulcer in a sample of 13. Residents Affected - Few The findings include: On June 20, 2023, at 10:13 AM, R22 stated she was not feeling well because she was sitting in poop. V4 and V5 (Certified Nursing Assistants/CNA) came in to provide incontinence care. When V4 removed R22's incontinence brief, R22 had been incontinent of stool, and R22's sacral wound was visualized. No pressure wound dressing was in place for R22's wound. R22's June 2023 Physician Order Sheet showed a June 9, 2023, order stage 3 pressure wound sacrum leptospermum honey apply 3x per week and cover with foam with border . On June 20, 2023, at 10:20 AM with V6 (Registered Nurse/RN) stated that she did not know R22's Stage III pressure ulcer on sacrum did not have a dressing. V6 stated she had changed the dressing the day before, and maybe the wound dressing came off. V6 said that if a wound dressing comes off, the nurse should apply new dressing. V7's (Wound Physician) December 28, 2022, Initial Wound Evaluation and Management Summary showed R22 acquired a stage II pressure ulcer on her sacrum while in the facility. V7's Wound Evaluation and Management Summary from March 29, 2023, showed R22's sacral wound had healed. V7's April 12, 2023, Wound Evaluation and Management Summary dated showed R22's sacral wound reopened and was at Stage III. On June 22, 2023, at 9:10 AM, V7 (Wound Doctor) stated she had seen R22 on and off and the wound on R22's sacrum had healed and re-opened a couple of times. V7 stated that a wound needs to always have a dressing to aide in healing and she expects nurses to follow treatment orders for wounds. Review of R22's June 21, 2023, Pressure Ulcer care plan (created during the survey) showed Provide treatment as ordered. Facility's Wound Care Program Policy dated July 2014 stated the following: . If the wound is on the buttocks and may become soiled by incontinence: 4. Cleanse and re-apply PRN, until healed . Page 1 of 5 145609 145609 06/23/2023 Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to store and dispose of medications in a secure manner. This applies to 2 of 2 residents (R8, R29) in a sample size of 13. Findings include: 1.) On June 21, 2023, at 10:20 AM, during the medication administration observation R8 brought his Incruse Ellipta inhaler out of his room and handed it to V2 (Director of Nursing/DON). R8 stated Someone left this in my room and now I don't know if I got it. When they leave it there, I'm not sure if I got it or not. On June 22, 2023, at 12:19 PM, V2 stated R8 does not have an assessment to keep medications at his bedside. V2 stated, The nurse should have taken it with them after it was administered. (R8) could have taken too much since he didn't remember if he had taken it or not. Another resident could have wandered into the room and taken it by mistake. Review of R8's physician orders include Incruse Ellipta one puff by mouth daily [DX (diagnosis): Chronic Obstructive Pulmonary Disease] 04:00 AM - 05:45 AM. 2.) On June 21, 2023, at 4:52 PM, during the medication cart review, V2 (DON) and V7 (Licensed Practical Nurse) were observed conducting the electronic narcotic count. Tramadol 50 MG (Milligrams) for R29's electronic count was 103 and the actual count was 104. The medication card showed the blister pack for one pill was opened. V2 (DON) stated R29 had refused the medication so he placed it back in the blister pack. V2 stated the proper procedure is to waste the medication with two nurses by dissolving it in water, adding kitty litter and placing it in a red biohazard bag for disposal. Review of R29's physician orders include Tramadol 50mg one tablet oral [DX: Alcohol- induced chronic pancreatitis] every 12 hours 08:00 AM, 08:00 PM. Facility Policy Controlled Substances dated July 2014 states, unless otherwise instructed by the Director of Nursing Services, when a resident refuses a non-unit dose medication or it is not given, or receives partial tablets or single dose ampules, or it is not given, the medication shall be destroyed, and may not be returned to the container. The facility undated policy General Medication Administration Procedures states, open the packaged medication only when administering medication directly to the resident. Removing the medication from its packaging in advanced lessens the ability to positively identify the medication and increases the chance of drug administration errors and contamination. 145609 Page 2 of 5 145609 06/23/2023 Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents receive their meals tasty, appetizing and at the required temperatures that affect palatability. This applies to 10 of 45 residents (R8, R10, R15, R16, R19, R23, R27, R28, R36 and R40) reviewed for food temperatures in the sample of 13. This deficiency has the potential to affect 45 out of 46 residents. Residents Affected - Many The findings include: Facility Resident Census and Conditions of Residents (Form CMS - Centers for Medicare and Medicaid Services - 672), dated 6/20/23, documents the total census was 46 residents. Form CMS 672 also showed, there was 1 resident with GT (gastrostomy tube) feeding. Facility policy on 'Safe food preparation and handling' dated January 2012 showed 'Foods will be held at proper temperatures - Hot food will be a minimum of 135 F and cold food will be a maximum of 41 F. During initial tour, concerns regarding cold and unappetizing food was heard from the following residents: On 6/20/23 at 10:38 AM, R16 stated, Food does not taste good. It is always cold. On 6/20/23 at 10:44 AM, R27 stated, Food is cold mostly all the time. On 6/20/23 at 11:10 AM, R36 stated, Food is always cold. On 6/21/23 at 10:00 AM, resident council group meeting was held. Group included R8, R10, R15, R19, R23, R28 and R40. Facility Minimum Data Set assessment, section C, showed, R8, R10, R19, R23 and R28 were cognitively intact. R40 had moderate impairment and R15 had severe cognitive impairment. All the attendees of the group verbalized that food is always served cold. On 6/21/23 at 11:45 AM, lunch was served. Lunch included spaghetti and meatball, steamed vegetables, and garlic bread. The last tray on one of the carts was tested for food temperature by V6 (Dietary Manager): meatball 100 degrees F (Fahrenheit), vegetables 97 F and garlic bread 90 F. On 6/22/23 at 9:47 AM, V2 (Director of Nursing) stated, residents have complained about the food temperatures a lot. V2 stated, she had tried to help them distribute the trays so that food is not cold when it reaches the residents. V2 stated, facility is trying to get a portable steam table in the dining room & get residents to eat in there. V2 stated, that plan has not been in effect yet. Facility policy on 'Safe food preparation and handling' dated January 2012 showed 'Foods will be held at proper temperatures - Hot food will be a minimum of 135 F and cold food will be a maximum of 41 F. 145609 Page 3 of 5 145609 06/23/2023 Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 have thermometers and failed to monitor temperatures in residents' personal refrigerators. This applies to 3 out 5 residents (R3, R16, R27) reviewed for refrigerators in a sample of 13. Residents Affected - Few Findings include: 1.) On June 20, 2023, at 10:24 AM, R3's refrigerator had therapeutic nutrition shakes and several bottles of salad dressing. There was no thermometer inside. There was no temperature log outside of the refrigerator. R3 stated she does not recall staff ever checking the temperature in her fridge. R3's MDS (Minimum Data Set) dated 5/5/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which means she is cognitively intact. On June 21, 2023, at 10:56 AM, surveyor went with V3 to R3's room. R3's fridge still did not have a thermometer. R3 told V3, I never had a thermometer here. 2.) On June 20, 2023, at 10:38 AM, R16's refrigerator had several containers of yogurt, protein shakes, and a package of peaches. There was no thermometer inside. There was no temperature log outside of the refrigerator. R16 stated she does not recall staff ever checking the temperature in her fridge. R16's MDS dated [DATE] documents a BIMS score of 15, which means she is cognitively intact. On June 21, 2023, at 11:02 AM, surveyor went with V3 to R16's room. R16 still did not have a thermometer. 3.) On June 20, 2023, at 10:44 AM, R27's refrigerator was not turned on and there was no thermometer inside. R27 stated that she received the new fridge not too long ago. R27 was unable to remember when exactly she received the fridge. R27 stated, It's not set up. I told somebody here to set it up and they still haven't done it. I can't even put my food in here because it's not set up yet. R27's MDS dated [DATE] documents a BIMS score of 13, which means she is cognitively intact. On June 21, 2023, at 11:00 AM, surveyor went with V3 to R27's room. R27's fridge still was not turned on and did not have a thermometer. R27 stated, My fridge has not been turned on yet. I can't put any food in there. V3 stated she will have someone turn on her fridge. On June 21, 2023, at 10:48 AM, V3 (Housekeeping Supervisor) stated, Yes, the residents are supposed to have thermometers in their refrigerators. The temperature logs are kept here with me. I check the thermometer of some of the resident's refrigerators and log them here. Some of the other housekeepers do it as well. If I'm not here, someone else is supposed to do it. The nurses and CNAs (Certified Nursing Assistants) never told me to check R16 or R27's refrigerators. I don't have temperature log sheets for them. As for R3, I only have log sheets until March 2023. I don't have anything after March. V3 submitted R3's temperature monitoring system sheet for her refrigerator. The last time it was 145609 Page 4 of 5 145609 06/23/2023 Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560

F 0813 checked was on March 31st. V3 was unable to provide any temperature logs for R16 and R27. Level of Harm - Minimal harm or potential for actual harm On June 21, 2023, at 11:45 AM, V1 (Administrator) said, Yes, every resident who has a refrigerator needs a thermometer inside. And it should be monitored, and the temperature should be logged on a sheet. The housekeeping department is responsible for this. Residents Affected - Few Facility's policy Food and Supply Storage (January 2012) shows 8. Each nursing unit with a refrigerator/freezer unit will be supplied with thermometers and monitored for appropriate temperatures. Facility's policy Personal Refrigerators in Resident Rooms (April 2015) shows Family members who decide to bring in a refrigerator must daily check the temperature and record it on the log that is on the outside of the refrigerator. The refrigerator must be maintained at a temperature of 41 degrees or lower. 145609 Page 5 of 5