Health inspection·November 3, 2022

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to notify the physician for one resident (R25) reviewed for physician notification out of a sample of 20. Residents Affected - Few Findings include: The Resident Care Policy and Procedure revised 5/2022, documents It is the policy of this facility to maintain current physician orders to provide treatment according to the attending physician for each resident of the facility. All medication and treatments shall be given only upon written order of thr physician. All such orders shall be written in the medical record and shall be given as prescribed by the physician at the designated times. If for any reason, a physician's medication or treatment cannot be followed, the physician shall be notified as soon as is reasonable, depending upon the situation, a notation of this will be made into the medical record. The Insulin Administration policy revised 10/2009, documents Proper administration of insulin to promote control of blood glucose levels. R25's Order Summary Report dated 11/2/22 at 10:00 AM, documents that R25 has a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. The Order written by V4 (R1's Primary Physician) is for Novolog Flex Pen Solution Pen-Injector 100 Unit/ML (milliliter), Inject 25 unit subcutaneously in the evening related to Type 2 Diabetes Mellitus with Hyperglycemia. R25's Computerized Medication Administration Note dated 10/29/22 at 4:22 PM, documents Note Text: NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML Inject 25 unit subcutaneously in the evening related to type 2 diabeties mellitus with hyperglycemia, res (resident) would only take 8 units. R25's Computerized Medication Administration Note dated 10/30/22 at 4:37 PM, documents Note Text: NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML Inject 25 unit subcutaneously in the evening related to type 2 diabeties mellitus with hyperglycemia, resident would only allow 15 units to be given. On 11/1/22 at 12:58 PM, V2 (Director of Nursing) stated The nurses should contact the doctor if a resident refuses to take their medication as ordered. I was not aware that (R25) was not taking the entire amount of insulin ordered. On 11/1/22 at 1:42 PM, V5 (Licensed Practical Nurse) stated (R25) did not want to take the whole 25 units of insulin because (R25) was afraid she would bottom out. There are several residents here that don't want to take the ordered amount. For a long time, we did notify (V4/R25's Primary Physician) to let her know when a resident refused their medication. Then we were told to document what the resident took, and we did not need to call each time. (V4) said the residents know themselves better Page 1 of 7 145616 145616 11/03/2022 Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664

F 0684 and it is their right to refuse the medication if they want. Level of Harm - Minimal harm or potential for actual harm On 11/1/22 at 2:03 PM, V4 (R25's Primary Physician) stated that she was not notified that R25 did not take her insulin as ordered on 10/29 and 10/30/22. A resident does have a right to refuse their medication, but we should be notified if it is on more than one occasion. Then we can encourage and educate the resident or see if the dosage needs changed. Residents Affected - Few 145616 Page 2 of 7 145616 11/03/2022 Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide necessary equipment or devices for pressure relief for residents at risk for developing pressure ulcers or who required extensive or total assistance from staff for positioning, placing those residents at increased risk for the development of pressure ulcers or the worsening of existing wounds which affected two of two residents (R37, R49) reviewed for pressure ulcers in a sample of 20. This failure resulted in R37 developing multiple pressure ulcers including a right buttocks stage two pressure ulcer which deteriorated to a stage 4 pressure ulcer; and R49 developing an abrasion to the right iliac crest which deteriorated to a stage 3 pressure ulcer. Residents Affected - Few Findings include: A Wound and Ulcer Policy and Procedure policy dated 1/10/18 states, It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management, This policy also states, Residents with existing pressure ulcers will be deemed as high risk for impaired skin integrity despite the Braden Risk Assessment score, and Specialty mattress (low air loss, alternating pressure, etc.) with enhanced pressure reducing/relieving properties may be placed on the resident's bed and chair as indicated. In addition, this policy states, Skin contact surfaces may be padded to protect bony prominences. This same policy documents, A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear, and states that a stage 2 pressure ulcer is defined as, Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed (without bruising or slough). This policy states that a stage 3 pressure ulcer is defined as, Full thickness tissue loss involving damage of necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia (a thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber and muscle in place). Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. This policy documents that a stage 4 pressure ulcer is described as, Full thickness loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. In addition, this policy describes an unstageable pressure ulcer as, Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/ or eschar (dead or devitalized tissue that is tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, cannot be determined. This policy describes a Deep Tissue Injury as, Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. This policy documents that equipment to be included in pressure ulcer prevention and treatment should include, Positioning aids; special mattress and/or chair cushion (low air loss, alternating pressure, etc.) with pressure reducing/relieving properties. A Facility mattress manufacturers information sheet, marked by the facility to indicate the model used by R37 and R49, states this mattress is recommended, For the prevention and treatment of pressure ulcers up to stage II (2). 1. R37's Minimum Data Set (MDS) assessment dated [DATE] documents R37 required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. R37's 3/17/22 MDS documents during that assessment R37 required extensive assistance of two people for bed 145616 Page 3 of 7 145616 11/03/2022 Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664

F 0686 Level of Harm - Actual harm Residents Affected - Few mobility, and extensive assistance of one person for transfers, dressing, toilet use, and personal hygiene. R37's MDS dated [DATE] documents during that assessment R37 required extensive assistance of two people for bed mobility, transfers and toilet use. R37's MDS dated [DATE] documents R37 requires extensive assistance of two people for bed mobility, transfers, toilet use and is totally dependent on staff for personal hygiene. R37's Braden Scale for Predicting Pressure Ulcer Risk dated 12/9/21 documents R37 was at risk for developing pressure ulcers. At the bottom of this same assessment is a list with boxes to be checked as clinical suggestions to prevent R37 from developing pressure ulcers, however, none of the boxes are checked. R37's medical record indicates R37 had 13 more Braden Scales for Predicting Pressure Ulcer Risk between 1/9/22 and 10/9/22, all document R37 is at risk or high risk of developing pressure ulcers, none of which have the clinical suggestion boxes marked. R37's Ulcer/ Wound documentation dated 12/27/21 as an initial assessment document that R37 had developed a facility acquired stage 2 pressure ulcer to R37's right buttock measuring 5.5 cm (centimeters) long x 2 cm wide. R37's Ulcer/ Wound documentation dated 1/18/22 documents that on that date R37 still had a stage 2 pressure ulcer to the right buttock and, additionally had developed a stage 2 pressure ulcer to R37's coccyx measuring 0.8 cm long x 0.4 cm wide x 0.1 cm deep in which the wound bed contained yellow or white slough tissue that was adhering to the ulcer bed in strings or in thick clumps or was mucinous. R37's Ulcer/ Wound documentation dated 2/8/22 documents R37's right buttock wound had deteriorated to an unstageable pressure ulcer measuring 2.2 cm long x 2.5 cm wide x 0.1 cm deep in which the wound bed contained black necrotic tissue. R37's Ulcer/ Wound documentation dated 2/22/22 documents R37's right buttock wound was still an unstageable wound but had deteriorated in size and was now measuring 3.7cm long x 3.2 cm wide x 0.3cm deep. This note also documents R37's wound was draining a serosanguineous (bloody) drainage during this assessment. R37's Ulcer/ Wound documentation dated 3/1/22 documents R37's right buttock wound was still unstageable and measured 3.7 cm long x 3 cm wide x 0.4 cm deep and was draining copious amounts of serosanguineous drainage. R37's Ulcer/ Wound documentation dated 3/22/22 documents R37's wound had deteriorated to a stage 3 pressure ulcer measuring 5 cm long x 3.5 cm wide x 2 cm deep. R37's Ulcer/ Wound documentation dated 4/18/22 documents R37's pressure ulcer to the right buttock had deteriorated to a stage 4 pressure ulcer measuring 6.5 cm long x 3.8 cm wide x 2 cm deep. R37's Ulcer/ Wound documentation dated 10/5/22 documents R37 still had a stage 4 pressure ulcer to the right buttocks but had also developed a new facility acquired Deep Tissue Injury to R37's left heel which measured 2.0 cm long x 2.8 cm wide. R37's Ulcer/ Wound documentation dated 10/25/22 documents that R37 had also developed a Deep Tissue Injury to R37's left elbow as of 10/5/22, although there is no ulcer/wound assessment for this wound on 10/5/22. R37's current care plan documents that since 12/10/20 R37 has had a plan of care for R37's risk for impaired skin and pressure injury (related to) age, sedentary behavior, decreased bed mobility, cognitive impairment, frequent incontinence of (bowel and bladder), and edema in (bilateral lower extremities.) This same care plan does not document any pressure relieving measures were implemented once R37's right buttocks stage 2 pressure ulcer developed on 12/27/22, or when R37 continued to have a stage 2 pressure ulcer during R37's Ulcer/Wound documentation on 1/18/22 when R37 was also assessed to have a new stage 2 pressure ulcer with slough on R37's coccyx; or when R37's right buttock wound deteriorated to an unstageable on 2/8/22, or when R37 had worsening depth to his right buttocks wound on 3/1/22. This care plan documented a pressure relieving cushion was provided for R37's wheelchair on 3/9/22 after R37's right buttock wound had deteriorated to an unstageable pressure ulcer, but no changes were made to R37's bed mattress. R37's care plan does not indicate R37's mattress was changed to a specialty mattress as per the facility's policy or any additional pressure 145616 Page 4 of 7 145616 11/03/2022 Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664

F 0686 Level of Harm - Actual harm Residents Affected - Few relieving measures were implemented when R37's right buttocks wound deteriorated to a stage 3 pressure ulcer on 3/22/22 or when R37's wound deteriorated to a stage 4 pressure ulcer on 4/18/22. R37's care plan documents that R37 was provided with pressure relieving boots after R37 developed an unstageable pressure ulcer to the left heel on 10/5/22. R37's care plan does not document that R37 is on a turning and repositioning program. On 11/1/22 at 11:15a.m. R37 was lying on a regular facility mattress turned slightly to the right with a blanket under R37's left hip. V6 (Wound Nurse) and V7 (Restorative Nurse) entered R37's room and were preparing to change R37's right buttocks wound dressing. V6 and V7 removed the blanket from under R37 then using total assistance, turned R37 to his right side. V6 removed R37's dressing then measured R37's wound. R37's right buttock wound was a large round open area measuring 5 cm long x 4 cm wide x 1.5 cm deep with tunneling at the 9:00 o'clock position measuring 2 cm deep. R37's wound bed was a pale pink with some white/yellow areas visible deep within the wound. On 11/2/22 at 9:38a.m. V6 stated she is also the care plan/MDS coordinator but assesses wounds every Tuesday. V6 stated that R37 had been noncompliant with lying down to take pressure off R37's buttocks prior to developing his right buttock wound 12/27/21. V6 stated that R37 prefers to sit up in his wheelchair during the day but that R37 will sleep in his bed at night. V6 stated that despite R37's preference to sit up in his wheelchair all day, the facility did not provide R37 with a pressure relieving cushion for his wheelchair until 3/9/22 after R37 had developed an unstageable pressure ulcer to his right buttock. V6 stated that R37 has a regular facility mattress on his bed. V6 stated the facility thought if R37 had a specialized pressure relieving mattress it would interfere with how R37 transfers from the bed using a standing mechanical lift. V6 verified that no new pressure relieving measures were implemented after R37 developed a stage 2 pressure ulcer to the right buttocks on 12/27/22, after R37 developed a stage 2 pressure ulcer to the coccyx on 1/18/22, after R37's right buttocks wound deteriorated to an unstageable wound on 2/18/22, or when it deteriorated in depth on 2/22/22 and 3/1/22. V6 stated the facility implemented R37's pressure relieving cushion for his wheelchair on 3/9/22 after R37's right buttock wound was already an unstageable pressure ulcer. V6 stated that even after R37's right buttock pressure ulcer deteriorated to a stage 3 on 3/22/22, and then deteriorated again to a stage 4 on 4/18/22, the facility did not provide R37 with a specialized air mattress as indicated in the facility's pressure ulcer policy. V6 stated the facility did not implement a defined every two hour turn and reposition schedule for R37 until 7/22/22 after R37's pressure ulcer had deteriorated to a stage 4. V6 verified that R37 did not have any pressure relieving boots to protect his feet until R37 developed an unstageable pressure ulcer to his left heel on 10/5/22. V6 stated that when R37's stage 4 pressure ulcer to the right buttock did not appear to be healing, R37's family transitioned R37 to hospice services on 6/14/22. 2. R49's Ulcer/Wound documentation dated 8/10/2022, documents Right Iliac crest (rear) Length 0.5 x 0.5 x 0 depth. Stage N/A (non-applicable). Granulation tissue pink, no drainage, round/oval crater like with regular firm edges, no tunneling, no necrosis. Date ulcer/wound was initially identified 8/10/2022. R49's Ulcer/Wound documentation dated 8/16/2022, documents Right Iliac crest (rear) Length 1.8 x 1.8 x 0 depth. Stage N/A. Peri wound intact. No warmth, swelling or redness noted. Granulation tissue pink. No drainage, round/oval crater like with regular firm edges, no tunneling, no necrosis. R49's Ulcer/Wound documentation dated 8/23/2022, documents Right Iliac crest (rear) Length 2.3 x 1.8 x 0 depth. Stage N/A. Peri wound intact. No warmth, no swelling, or redness noted. Granulation pink. No drainage, round/oval crater like with regular firm edges, no tunneling. Necrosis tissue 145616 Page 5 of 7 145616 11/03/2022 Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664

F 0686 present 90% (percent). Level of Harm - Actual harm R49's Ulcer/Wound documentation, dated 8/30/2022, documents Right Iliac crest (rear) Length 3.4 x 2.9 x 0 depth. Stage: is unstageable. Wound Bed Tissue Type, Necrotic tissue (Eschar) - Black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin. Peri wound skin, 90% necrotic tissue with 10% yellow/slough tissue. Peri wound intact. No warmth or swelling. Redness noted to peri wound. Residents Affected - Few R49's Ulcer/Wound documentation, dated 9/6/2022, documents Right Iliac crest (rear) Length 4.7 x 4.2 x 0 depth. Stage: is unstageable. Wound Bed Tissue Type : Necrotic tissue (Eschar). Peri wound is 50% necrotic tissue with 50% yellow/slough tissue. redness around peri wound. R49's Nurses Notes dated 9/9/2022, documents (R49) is being transferred and admitted to the local hospital for wound infection. R49's Nurses Notes dated 9/20/2022, documents R49 returned from the hospital on that dated and was assessed to have, Right posterior thigh, pressure ulcer Length (CM) Centimeters 8.1 x 5.6 x 0. Wound bed necrotic, stage 3, wound exudate: serosanguinous-thin, watery, pale/pink drainage. Moderate drainage 26-75%. Obscured full thickness skin and tissue loss. R49's Ulcer/Wound documentation dated 9/27/2022, documents Right Iliac crest (rear) Type: Pressure. Length 8 x 5 x 0.5 depth Stage 3. Slough- yellow white tissue that adheres to the ulcer bed. Noted to the center off the wound. Moderate drainage with firm edge. R49's Ulcer/Wound documentation dated 10/4/2022 documents, Right Iliac crest (rear) Type: Pressure. Length 7.5 x 5.8 x depth 0.5, Stage 3. Slough- yellow- white tissue that adheres to the ulcer bed. Noted to the center of the center of wound bed. moderate drainage. R49's Ulcer/Wound documentation dated 10/11/2022, documents, Right Iliac crest (rear) Type; Pressure, Length 7.5 x 5.3 x 0.5 depth, Stage 3. Yellow slough and necrotic tissue noted in the center of wound. Edges are sloped. R49's Nurses Notes dated 10/18/2022, documents (R49) Stage 3 pressure ulcer to right posterior iliac crest, 7.5 CM (Centimeters) x 4.8 CM x 0.5 CM. Yellow slough and 50% necrotic tissue noted to center of wound. Pink granulation tissue noted to outer wound bed. Edges noted to be sloped. No warmth, swelling or redness noted to peri wound. Moderate serosanguineous drainage noted. R49's Nurse notes dated 10/25/2022, documents (R49) Stage 3 pressure ulcer to right iliac crest, 6CM x 5.5CM x 0.5 CM depth. Yellow slough noted to the center of the wound. Cleansed area and applied an antiseptic solution with gauze and covered wound with Silicon foam dressing. R49's Ulcer/Wound documentation dated 11/1/2022, documents Right Iliac crest (rear), Type: Pressure. Slough 7.2 x 4.6 x 0.5 Stage 3. Yellow slough noted in the middle of the wound. R49's Care plan, dated 10/31/2022, documents Unstageable Pressure Ulcer to Posterior Right Iliac crest, Pressure relief mattress (also concave properties) to maintain skin integrity. The facilities mattress manufacturer guideline sheet documents that, It is recommended for prevention and treatment of pressure ulcers up to stage 2. 145616 Page 6 of 7 145616 11/03/2022 Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664

F 0686 Level of Harm - Actual harm Residents Affected - Few R49's Braden Scale for Predicting Pressure Ulcer Risk, dated 9/27/2022, documents, Sensory Perception: Completely Limited. Moisture: Occasionally moist, Activity: Chair fast, Mobility: Slightly limited, Nutrition: Probably inadequate. Result: Moderate risk for skin breakdown. On 11/1/2022 at 2:55PM, R49's wound care treatment was observed to right iliac crest. Wound measured 7.2 x 4.7 x 0.5 with yellow slough in the center of wound. Edges were sloped. Moderate drainage noted on old dressing. Wound bed was odorous. R49 did not have a specialized mattress on the bed, and had two mattresses on floor. On 11/1/2022 at 3:00PM, V6/Wound Nurse stated The mattress (R49) has on the bed right now is the mattress that is used by all residents in the facility. This one has concave edges to help (R49) from rolling out of bed. I suppose (R49) should have a special pressure relieving mattress for (R49) wound. (R49) was admitted to hospice services on 9/20/2022, and they should provide (R49) with one. On 11/2/2022 at 9:00 AM, V2/DON (Director of Nurses) stated On 11/1/2022, I requested a special relieving mattress for (R49) to help with (R49's) pressure ulcer. Hospice should provide this mattress. On 11/2/2022 at 10:00AM, V6/Wound Nurse stated We did not order a special pressure relieving mattress until now. (R49) has that mattress that prevents (R49) from falling out of bed. We felt (R49) needed that one more. On 11/2/2022 at 9:30AM, V9/LPN (Licensed Practical Nurse) stated I requested a special air loss mattress for (R49) today. Hopefully it will show up, today. On 11/2/2022 at 1:30PM, V8/Physician stated (R49's) mental capacity isn't good. I would of like to see this type of (air) mattress on (R49's) bed. I don't know why they didn't provide (R49) one, but can you take an order over the phone for a special mattress for (R49's) bed? 145616 Page 7 of 7