Health inspection·August 9, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify resident's family and physician of changes in condition for two (R25, R31) of 16 residents reviewed for change in condition in the sample list of 20. Findings include: The facility's Notification for Change in Resident Condition or Status dated 7/1/23 documents the nurse will notify the resident's representative/family and physician when there has been a change in the resident's physical/emotional/mental condition, a need to alter medical treatment, symptoms of infection, abnormal lab results, and weight loss of 5% in 30 days and 7.5% in 90 days. 1.) R25's Minimum Data Set, dated [DATE] documents R25 has severe cognitive impairment. R25's May 2023 POS documents an order dated 5/25/23 for a urinalysis with culture and sensitivity and an order dated 5/30/23 for Nitrofurantoin (antibiotic) 100 milligrams (mg) by mouth every 12 hours for 5 days. R25's Urine Culture with reported date of 5/30/23 documents R25's urine contained Proteus Mirabilis (bacteria) of greater than 100,000 Colony Forming Units, indicating infection. R25's Nursing Notes document on 5/25/23 at 12:55 PM new orders were received and refers to the POS. R25's Nursing Note dated 5/30/23 at 12:10 AM documents R25's antibiotic was initiated. There is no documentation in R25's medical record that R25's family was notified of the orders for urine culture and sensitivity, the results of the culture, or the order for Nitrofurantoin. On 8/08/23 01:40 PM V2 DON confirmed residents' families should be notified of new orders, and family notification should be documented in a nursing note. V2 reviewed R25's nursing notes and confirmed there is no documentation that R25's family was notified of the urine culture order and results or the order for antibiotic treatment. 2.) R31's August 2023 POS documents R31 has diagnoses of Parkinson's Disease and Dementia. R31's 2023 Weight Logs document R31 weighed 162.6 lbs. in January, 150.5 lbs. in February (7.44% loss), 142.6 lbs on 3/29/23 (5.25% loss since February), 140.6 on 4/12 and 4/19 (13.53% loss since January), and 138.8 lbs on 4/26/23. There is no documentation that R31's family was notified of R31's weight loss until 4/26/23 when a nutritional supplement was ordered. Page 1 of 24 145631 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0580 Level of Harm - Minimal harm or potential for actual harm On 8/09/23 at 2:15 PM V2 DON confirmed R31's family was notified of R31's weight loss on 4/26/23. V2 stated V2 was unable to locate documentation that R31's family was notified of R31's weight loss prior to 4/26/23. Residents Affected - Few 145631 Page 2 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0641 Ensure each resident receives an accurate assessment. 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 accurately encode three falls, on three different minimum data set assessments for a resident. The facility also failed to make corrections on the minimum data sets regarding residents falls, as directed by the facility policy. This failure affects one resident (R16) out of four residents reviewed for accident hazard/falls on the sample list of 20. Residents Affected - Few Findings include: On 08/07/23 at 10:30 am, R16 was seated in a recliner next to her bed. R16 had deep purple, full facial bruising, below and above both eyes, chin, right side of her nose and her left cheek from a fall on 8/3/23. R16 stated R16 has had four falls from bed, which resulted in fractured left collarbone, and stitches in her head from those falls. 1. On 8/7/23 at 10:40 am V1, Administrator provided an Illinois Department of Public Health (IDPH) reportable fall on 2/5/23. This report documents R16 sustained a Left Clavicle fracture (major injury) from attempting to get out of bed. 2. R16's Interdisciplinary Team (IDT) progress note documents R16 had a second fall next to her bed when she lost her balance (2/13/23). R16's Minimum Data Set (MDS) dated [DATE] section J1800 documents: R16 has had no fall, (noted above, 2/5/23 and 2/13/23 falls) since admission/ entry or reentry or since prior assessment. A corrected adjustment was not made to R16's MDS until 8/8/23 during survey. 3. R16's IDT progress note dated 4/10/23 document R16 had a third fall when R16 got up on her own to get dressed and slid off the bed. R16's MDS dated [DATE] and 6/23/23 section J1800 documents: R16 has had no fall, (noted above, 4/10/23 fall) since admission/ entry or reentry or since prior assessment. No corrected MDS was provided to R16's MDS during this survey. The facility policy Resident Assessment/MDS) dated revised November 01, 2017, documents the following: It is the policy of (the corporation) Health Care to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining Resident strengths, needs, goals, life history and preferences to develop a comprehensive plan of care for each Resident with the goal of attaining or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. The same policy documents the following: The facility shall make every effort to ensure the MDS is accurate to the ARD and correct as of the completion and transmission date. Should an inaccuracy in coding be found, the facility shall follow the instruction for amending the assessment found in the RAI (Resident Assessment Instrument) manual. 145631 Page 3 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to update comprehensive care plans for three residents (R2, R26, R31) of 12 residents reviewed for care plans in a sample list of 20. The facility failed to update care plans in four care areas (accidents, nutrition, anticoagulant, urinary catheter). Findings include: 1.) R2's Final report of incident dated 4/29/23 documents (R2) is independent with ambulation was found on the floor in her bedroom and sent to the emergency room for evaluation and treatment. (The facility was) notifies today of closed compression fracture of L3 and L5 Lumbar Vertebrae. R2's Care Plan includes an entry dated 6/8/22 documenting Falls: Risk factors Include: Hip Replacement, Hypertension, Chronic Obstructive Pulmonary Disease, Psychotropic Medication Use. The only updated intervention for falls since 6/8/22 is dated 4/14/23 and document Nonskid Strips in front of the toilet. The facility's policy Fall Prevention revised 11/10/18 states Immediately after any resident fall the unit nurse will assess the resident and provide any care and treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of the fall in the nurse's notes or on an AIMS for wellness form along with any new interventions deemed to be appropriate at the time. R2's Physician's notification of weight loss dated 7/10/23 documents R2 has experienced a 7.42% weight loss in 30 days, a 5.19% weight loss in 90 days, and a 9.32% weight loss in 180 days. Dietitian recommends fortified pudding twice daily and Magic Cup three times daily. As of 7/13/23 the Advanced Practice Nurse signed an order for these recommendations. R2's care plan updated 4/13/23 does not address weight loss or nutritional concerns. The facility's policy Resident Weight Monitoring revised September 2021 states, Significant changes in weight are documented in the Care Plan with goals and approaches/interventions listed. R2's Physician's Order Sheet (POS) for 8/1/23 to 8/31/23 includes an order for Xarelto (anticoagulant) 10 milligrams daily originally dated 6/18/22. R2's Care Plan revised 4/13/23 does not include interventions to address R2's risk for side effects such as bleeding for this anticoagulant medication. On 8/9/23 at 2:00PM V2, Director of Nursing (DON) verified R2's Care Plan does not and should address specific interventions for R2's fall with injury, significant weight loss, and risk of bleeding from Xarelto. 2.) On 08/07/23 at 2:48 PM V8 (R26's Family) stated R26 gets frequent Urinary Tract Infections (UTIs). R26's Minimum Data Set (MDS) dated [DATE] documents R26 has severe cognitive impairment, requires dependence on two staff for toileting, and is frequently incontinent of urine. R26's Urine Culture collected on 5/24/23 and reported on 5/27/23 documents Proteus Mirabilis 145631 Page 4 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (bacteria) greater than 100,000 Colony Forming Units (CFU). This lab result includes a handwritten order dated 5/29/23 for Levaquin (antibiotic) 500 milligrams (mg) by mouth twice daily for 10 days. R26's Urine Culture collected on 6/14/23 and reported on 6/17/23 documents Providencia Stuartii (bacteria) greater than 100,000 CFU. R26's June 2023 Physician's Order Summary (POS) documents an order dated 6/18/23 for Cefepime (antibiotic) 0.5 grams intravenous every 12 hours for 7 days. R26's Urine Culture collected on 7/24/23 and reported on 7/28/23 documents Escherichia Coli (bacteria) 100,000 CFU. R26's July POS documents an order dated 7/28/23 for Macrobid (antibiotic) 100 mg twice daily for 5 days, and R26 admitted to the facility on [DATE]. R26's Nursing Note dated 7/29/23 at 4:00 PM documents Macrobid therapy was initiated for UTI. R26's Physician order dated 7/27/23 documents Methanamine (antibiotic) 1 gram take twice daily by mouth. R26's Care Plan dated 3/15/23 documents R26 has bladder incontinence and includes interventions to notify the physician of symptoms of UTI. This care plan does not mention R26's history of frequent UTIs or any new interventions after 3/15/23. On 8/09/23 at 9:34 AM V12 MDS/Care Plan Coordinator stated V12 has not been updating care plans to reflect history of urinary tract infections. V12 confirmed R26's care plan does not identify new interventions for R26's UTIs after March 2023, and R26 has had three UTIs since admitting to the facility in February 2023. 3.) R31's MDS dated [DATE] and 4/28/23 document R31 has severe cognitive impairment, requires extensive assistance of one staff person for eating, and has not had a significant weight loss in one month or six months. R31's 2023 Weight Logs document R31 weighed 162.6 lbs. in January, 150.5 lbs. in February (7.44% loss), 153.4 on 3/8/23, 142.6 lbs on 3/29/23 (5.25% loss since February), 140.6 on 4/12 and 4/19 (13.53% loss since January), 138.8 lbs on 4/26/23, 141.8 lbs. on 5/17/23, 141 lbs. on 6/23/23, and 141.6 lbs on 7/19/23, and 147.5 on 8/2/23. R31's August 2023 Physician's Order Summary (POS) documents R31 has diagnoses of Parkinson's Disease and Dementia. R31's diet orders include 1 can nutritional supplement twice daily between meals and honey thickened liquids. R31's February, March, April, May, and August 2023 POS lists a frozen nutritional supplement three times daily, whole milk twice daily, chocolate milk twice daily as part of R31's diet order. R31's Physician Notification of Weight Change dated 2/20/23 documents V16 Physician approved the recommendation to add nutritional supplement 60 ml twice daily and notes R31's weight loss of 7.44 % in 30 days. R31's Nutrition Care Plan with a start date of 6/25/22 documents R31 has difficulty chewing and swallowing related to Parkinson's Disease and R31's diet is pureed with nectar thick liquids. This care plan does not document R31's significant weight losses, intervention of nutritional supplement 60 ml twice daily ordered 2/20/23, honey thickened liquids, and one can of nutritional supplement twice daily. On 8/9/23 at 9:34 AM V12 stated care plans are not always updated to reflect significant weight loss and new interventions. V12 stated, That is something I (V12) can start doing. 145631 Page 5 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

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 assistance with shaving/grooming for two (R19, R25) of three residents reviewed for Activities of Daily Living (ADLs) in the sample list of 20. Residents Affected - Few Findings include: 1.) On 8/07/23 at 9:30 AM R19 was sitting in a wheelchair in R19's room. R19 had long, dark, facial hair to R19's upper lip, chin, and cheeks. At 12:11 PM R19 was sitting in the dining room and had long, dark, facial hair. On 8/8/23 at 9:48 AM R19 was sitting in R19's room and had long dark facial hair to R19's upper lip, chin, and cheek. R19 made a shaving motion to R19's face and nodded yes when asked if R19 preferred to be shaved. At 3:34 PM R19 still had long, dark facial hair. R19's August 2023 Physician's Order Summary documents R19's has diagnoses of Self Care - Total Deficit, and history of intercranial injury and traumatic birth injury. R19's Minimum Data Set (MDS) dated [DATE] documents R19 requires extensive assistance of one staff for personal hygiene. 2.) On 8/07/23 at 9:57 AM and 12:25 PM R25 was sitting in a wheelchair in the dining room and had dark facial hair on upper lip and chin. On 8/8/23 at 9:26 AM R25 was sitting in the dining room. R25's hair was wet and R25 had dark facial hair to R25's upper lip and chin. R25's May 2023 Physician's Order Summary documents R25's has diagnoses of Dementia and Cerebrovascular Accident. R25's MDS dated [DATE] documents R25 has severe cognitive impairment and requires extensive assistance of one staff person for personal hygiene. On 8/08/23 at 3:30 PM V20 Certified Nursing Assistant stated residents are to be shaved every day. V20 stated R25 and R19 are cooperative with shaving and should be shaved. On 8/9/25 at 9:50 AM V2 Director of Nursing stated residents should be shaved during showers twice weekly. V2 confirmed women should have facial hair removed. The facility's Shaving- Male or Female policy with reviewed date of 3/20/23 documents Resident will be free of facial hair- male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the care plan. 145631 Page 6 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

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 observation, interview, and record review the facility failed to clean a wound during a wound treatment and label a dressing with a date for one resident (R31) reviewed for wounds in the sample list of 20. Residents Affected - Few Findings include: R31's Physician Progress Notes dated 8/7/23 and recorded by V21 Podiatrist, documents R31's full thickness burn wound of the lower leg daily treatment order as collagen moistened with saline, cut to fit the wound, apply petroleum jelly dressing, cover with dry gauze, wrap with rolled gauze, and apply an elastic dressing to secure. This note documents to cleanse the wound with saline and the wound measured 10.5 centimeters (cm) by 2 cm by 0.1 cm. On 8/9/23 at 10:39 AM V22 Licensed Practical Nurse administered R31's wound treatment. V22 removed the undated dressing from R31's right outer calf wound. The wound was linear and had red/pink tissue. V22 did not cleanse the wound prior to applying the wound treatment of saline moistened collagen, petroleum jelly dressing, gauze dressing, and rolled gauze. V22 labeled the dressing with a date. At 11:02 AM V22 stated there is no order to clean the wound, but saline should be used to clean the right calf wound. V22 stated, I think I forgot to do that. On 8/9/23 at 11:19 AM V2 Director of Nursing confirmed wound dressings should be labeled with a date. V2 stated wounds should be cleaned with normal saline unless otherwise ordered. 145631 Page 7 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

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 observation, interview, and record review the facility failed to label a pressure ulcer dressing with a date, implement pressure relieving interventions, and implement a treatment order for one resident (R31) reviewed for pressure ulcers in the sample list of 20. Residents Affected - Few Findings include: R31's Minimum Data Set, dated [DATE] documents R31 has severe cognitive impairment, 4 unstageable pressure ulcers present on admission, requires extensive assistance of one staff for bed mobility, and requires dependence on two staff for transfers. R31's Care Plan initiated on 6/25/23 documents R31 is at high risk for pressure ulcers and includes an intervention to notify the physician of any open or bruised areas. There is an intervention dated 2/24/23 to refer to the Physician's Order Summary for current wound treatment orders and interventions dated 3/6/23 to check right heel every 2 hours, air mattress, and heel protector boots. There is no documentation of any new pressure relieving interventions for R31's heels after 2/24/23 until 3/6/23. R31's February 2023 Physician's Order Summary (POS) documents R31 readmitted to the facility on [DATE]. On 2/27/23 orders were received to apply a skin protectant to bilateral heels and to wear pressure relieving boots when in bed. There are no treatment orders for R31's right heel pressure ulcer prior to 2/27/23. R31's February 2023 Treatment Administration Record (TAR) documents skin protectant was administered once on 2/27/23 and heel protectors were implemented on 2/27/23, there is no documentation that a treatment was administered for R31's right heel pressure ulcer prior to 2/27/23. R31's 2023 Wound Logs document: On 2/25/23 R31's unstageable right heel pressure ulcer measured 1.3 centimeters (cm) long by 1.2 cm wide. On 5/9/23 the right heel wound was unstageable and on 5/16/23 the right heel wound was classified as a stage IV pressure ulcer that measured 1.1 cm by 0.1 cm, and no depth. On 8/7/23 R31's right heel stage IV pressure ulcer measured 0.5 cm by 0.5 cm by 0.5 cm deep. The Assesses Intervene Monitor (AIM) for Wellness form dated 5/13/23 documents R31 had two open areas to R31's right and left heels, and new orders were received for calcium alginate dressing and foam. There is no documentation of the size of these wounds and description of the wounds such as color, odor, and drainage until 5/16/23. R31's Physician Progress Notes dated 8/7/23 recorded by V22 Podiatrist documents the right heel wound daily treatment as collagen moistened with saline, apply dry gauze, apply foam adhesive apply foam heel pad, and secure with rolled gauze. On 8/9/23 at 10:39 AM V22 Licensed Practical Nurse administered R31's right heel ulcer treatment. V22 removed the undated dressing from R31's right heel pressure ulcer. The ulcer was circular, with dark tissue and some depth. On 8/9/23 at 11:19 AM V2 Director of Nursing confirmed wound dressings should be labeled with a 145631 Page 8 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few date. V2 stated R31 admitted to the facility with the right heel unstageable pressure ulcer. V2 stated skin protectant was the treatment ordered upon admission and confirmed R31's TAR and POS do not document treatment orders/administration for R31's right heel ulcer prior to 2/27/23. V2 stated pressure relieving interventions are documented on the care plan and the pressure relieving boots should be documented on the Treatment Administration Record. V2 stated the wound size and assessment should have been documented on the AIM form when the ulcer opened on 5/13/23. The facility's Decubitus Care/Pressure Areas policy revised January 2018 documents pressure areas will be assessed including size, stage, site, depth, drainage, color, odor, treatment, and documented on the Treatment Administration Record or Wound Documentation Record. This policy documents to notify the physician of skin breakdown to obtain treatment orders, and additional interventions will be implemented and recorded on the care plan when a pressure ulcer is identified. The facility's Preventative Skin Care policy dated as reviewed 3/16/23 documents pressure relieving interventions may include special mattresses, chair cushions, turning/repositioning every 2 hours, use of pillows/blankets to relieve pressure off bony prominences, and use of pressure relieving devices to relieve pressure from heels and elbows. 145631 Page 9 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

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 a safe environment for residents at risk for falls, failed to care plan a targeted intervention post fall, failed to investigate an improper transfer of a resident and implement interventions to prevent improper transfers. This failure affects three of four residents (R4, R16, R239) reviewed for accidents/falls on the sample list of 20. Findings include: 1. R4's Physician Order Sheet (POS) dated 8/1/23- 8/31/23 documents the following diagnoses Chronic Back Pain, Kyphosis, Spinal Stenosis, History of Stroke, and Restless Leg Syndrome. R4's Minimum Data Set (MDS) dated [DATE] documents the following: R4's Brief Interview of Mental Status score of nine, out of possible 15, indicating severe cognitive impairment. The same MDS documents R4 requires extensive physical staff assist of one person with bed mobility, is totally dependent of two staff for transfers, and has bilateral lower extremity impairment in range of motions. R4 Fall Risk Assessment date 7/11/23 documents a score of 19 points. The same fall risk assessment documents 10 or more points equals high risk for falls. On 08/07/23 at 11:15 AM, R4 was lying in bed. R4 had a full mechanical lift slide on a bedside chair. R4's bed was elevated four feet off the floor. R4 stated I feel really uncomfortable with my bed up so high today. I don't want to fall. On 8/7/23 at 11:20 AM V4, Licensed Practical Nurse (LPN) confirmed R4's bed height was approximately four feet off the floor. V4, LPN lowered R4's bed to the lowest position and stated the following: (R4) requires a full (mechanical lift) to transfer. She was up this morning. The CNA's (unidentified, Certified Nursing Assistants) must have transferred her (R4) back to bed and forgot to lower her bed. It is obviously way too high. On 8/9/23 at 10:10 V2, DON confirmed R4 is at risk for falls, and her bed should be kept in the lowest position. 2. R16's MDS dated [DATE] documents that R16 has moderate cognitive impairment. On 08/07/23 at 10:30 am, R16 was seated in a recliner next to her bed. R16 had deep purple, full facial bruising, below and above both eyes, chin, right side of her nose and on her left cheek from a fall on 8/3/23. R16 stated R16 has had four falls from her bed, which resulted in fractured left collarbone, and stitches in her head from those falls. The facility fall log confirmed R16 had four falls on the following dates: 2/5/23, 2/13/23, 4/8/23 and 8/3/23. R16's Fall Risk Assessments dated 12/23/22, 2/5/23, 2/13/23, 3/24/23, 4/8/23, 6/7/23, and 8/3/23 all document R16 has greater than 10 points score on each assessment indicating R16 is at high risk for falls. 145631 Page 10 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0689 The following documents confirm R16's four falls were all at the side of R16's bed: Level of Harm - Minimal harm or potential for actual harm On 8/7/23 at 10:40 am V1, Administrator provided an Illinois Department of Public Health (IDPH) reportable (unwitnessed) fall on 2/5/23. This report documents R16 sustained a Left Clavicle fracture (major injury) from attempting to get out of bed. R16's Care plan intervention for this fall was non-skid strips placed in front of the bed to prevent sliding. Residents Affected - Few R16's Interdisciplinary Team (IDT) progress note documents R16 had a second (unwitnessed) fall, next to her bed, when she lost her balance (2/13/23). R16's Care plan intervention for this fall was to screen for therapy. R16's IDT progress note written and signed by V2, Director of Nursing, dated 4/10/23 document R16 had a third (unwitnessed) fall on 4/8/23. Res (resident R16) is I (independent), (c abbreviation for with), RW (roller walker). Res got up to get dressed per self. She (R16) states she sat on the side of the bed to put jeans on et (abbreviation) she slid off the bed. Asked res (R16) if (the) bed had rolled away, r/t (related to) bed rolls, occasionally. Resident did not believe so, but it could be possible. Maintenance placed blocks under bed wheels to prevent bed rolling and res (resident) will cont (continue) therapy. There was no intervention documented on R16's Care Plan for this fall, until 8/9/23 late entry for 4/8/23, added by V2, DON that documents: Res slid off bed attempting to put jeans on. (V11, R16's Family Member) states the bed rolls. Placed blocks under wheels to prevent possible rolling of bed. R16's IDT note dated 8/4/23 documents R16 had a fourth (unwitnessed) fall on 8/3/23 and was found on floor between the nightstand and recliner. R16's Care plan intervention late entry during this survey 8/9/23, for this fall 8/3/23, is documented as floor mat per (alarming) per (V11, family member)'s request. On 8/8/23 at 12:25 pm, There were wood blocks under all four of R16's bed wheels, and an alarmed floor mat over non-skid strips, fall interventions, were present in R16's room. V11, R16's family member stated The bed was sticking out from the wall, until after this last fall a week ago (8/3/23). I reported to the facility in February, after the first fall (2/5/23) that (R16's) bed wheels were not locking right. I repeated that after the next two falls (2/13/23 and 4/8/23). Her (R16's) bed is now up against the wall for that reason. The wood blocks do work (to prevent R16's bed from rolling). They (wood blocks under the wheels) should have been on there. On 8/8/23 at 1:05 pm, V12, Care Plan Coordinator/ MDS Coordinator stated the wood blocks under the (R16's) wheels should have been documented after 4/8/23 fall. V12 also stated R16's fall 4/8/23 was determined to be a caused by, or definitely contributed to the brakes on R16's bed not working properly. 3. On 8/8/23 at 11:00 AM R239 was on front patio with V19, R239's family member smoking. V19 inquired if R239 was going to tell (surveyor) about when they almost dropped (R239) off the (sling type mechanical lift). R239 stated The other day (V10, Certified Nurse's Aide CNA) was using the (sling type mechanical lift) to transfer me from the bed to my wheelchair, the lift got caught on my wheelchair pedal. When they pulled me in my wheelchair back out of the lift, the lift jerked, and my wheelchair jerked me backward and then forward. I didn't fall out of the chair, but I was scared to death, and it made me cry. V19 stated was there I thought (R239) was going to get knocked out of the chair. On 8/8/23 at 11:10AM V2, Director of Nursing (DON) stated I was aware that (R239)'s wheelchair got caught under the (sling type Mechanical Lift) a few days ago. (R239) didn't fall from the wheelchair 145631 Page 11 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0689 and wasn't hurt, so we didn't do an investigation or identify a root cause. Level of Harm - Minimal harm or potential for actual harm A note dated 8/3/23 at 8:45AM documents My coworker and I went into (R239's) room to get (R239) up with the (sling type mechanical lift). When we got (R239) into the wheelchair, the chair jolted down from the pedal being caught on the (lift) leg. (R239) was startled. Residents Affected - Few On 8/8/23 at 2:00PM V10, Certified Nurse's Aide (CNA) stated I was one of the CNAs who transferred (R239) with the (Sling type mechanical lift) on 8/3/23. The wheelchair pedal got caught under the leg of the lift. When we went to pull the wheelchair with (R239) in it, out from the lift legs, the lift leg popped off the wheelchair pedal causing (R239) to be jolted in the wheelchair. It made a loud noise and jolted (R239). It did startle (R239) but she wasn't hurt. 145631 Page 12 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

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 and record review the facility failed to timely report urine culture results to the physician and timely implement antibiotic orders for one resident (R26) reviewed for Urinary Tract Infections (UTIs) in the sample list of 20. Findings include: On 08/07/23 at 2:48 PM V8 (R26's Family) stated R26 gets frequent UTIs and one time R26's urine sample was collected on a Friday and the results were not available until Thursday. V8 stated that day an unidentified nurse told V8 that a prescription was ordered, and the medication would be delivered that night. R26's Minimum Data Set, dated [DATE] documents R26 has severe cognitive impairment. R26's Care Plan dated 3/15/23 documents R26 has bladder incontinence and includes interventions to notify the physician of symptoms of UTIs. R26's Urine Culture collected on 5/24/23 and reported on 5/27/23 documents Proteus Mirabilis (bacteria) greater than 100,000 Colony Forming Units (CFU). This lab result includes a handwritten order dated 5/29/23 for Levaquin (antibiotic) 500 milligrams (mg) by mouth twice daily for 10 days. R26's Nursing Note dated 5/29/23 at 7:00 PM documents new orders were received and refers to the Physician's Order Summary (POS) and there is no documentation that attempts were made to notify the physician on 5/27 and 5/28/23. R26's May 2023 POS documents the order for Levaquin dated 5/29/23. R26's Urine Culture collected on 6/14/23 and reported on 6/17/23 documents Providencia Stuartii (bacteria) greater than 100,000 CFU and includes a handwritten notation that the physician was notified of the results on 6/18/23. R26's June 2023 POS documents an order dated 6/18/23 for Cefepime (antibiotic) 0.5 grams intravenous every 12 hours for 7 days. R26's Nursing Notes do not document attempts were made to report R26's urine culture results to the physician on 6/17/23. R26's Urine Culture collected on 7/24/23 and reported on 7/28/23 documents Escherichia Coli (bacteria) 100,000 CFU. R26's July POS documents an order dated 7/28/23 for Macrobid (antibiotic) 100 mg twice daily for 5 days. R26's Nursing Note dated 7/28/23 at 6:00 PM documents the new order for Macrobid. R26's Nursing Note dated 7/29/23 at 4:00 PM documents Macrobid therapy was initiated for UTI. R26's July MAR documents the 1st dose of Macrobid was not administered until the next day 7/29/23 at 8:00 AM. The facility's Emergency Medication Kit Contents List dated 8/7/23 documents the kit contains Nitrofurantoin (Macrobid) six 100 mg capsules and six 50 mg capsules. On 8/09/23 at 9:50 AM V2 Director of Nursing stated urine culture results should be reported to the physician right away and the antibiotic orders implemented right away. V2 stated the facility has a convenience medication box that includes Macrobid. V2 confirmed R26's urine culture results were not reported timely to the physician and Macrobid was not implemented timely. V2 stated we reported the urine results on 5/28/23 but did not hear back from the physician until 5/29/23. 145631 Page 13 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R2's Physician's notification of weight loss dated 7/10/23 documents R2 has experienced a 7.42% weight loss in 30 days, a 5.19% weight loss in 90 days, and a 9.32% weight loss in 180 days. Dietitian recommends fortified pudding twice daily, Yogurt at lunch and dinner, and Magic Cup three times daily. As of 7/13/23 the Advanced Practice Nurse signed an order for these recommendations. Residents Affected - Few On 08/07/23 at 12:25 PM R2 was observed feeding self pureed green beans, mashed potatoes, meat with gravy, pureed peaches. No fortified pudding or yogurt. Ate all of mashed potatoes, 75% peas, bite of meat. Drank all of tea. R2 left dining room to sit in recliner at 12:35 PM. Meal tray card does not document any supplements. On 8/8/23 at 12:10 R2 was observed feeding self pureed turkey and gravy, mashed potatoes and gravy, pureed vegetables, and pureed blueberry desert. R2 ate about 90% of her food and drank all of her tea. R2 left dining room to sit in recliner at 12:45 PM. Meal tray card does not document any supplements. On 8/8/23 at 2:00PM V2, Director of Nursing (DON) verified R2 should have fortified pudding and yogurt with lunch, and it should be on the tray card. Based on observation, interview, and record review the facility failed to administer nutritional supplements as ordered, failed to document nutritional supplement intakes, and failed to timely identify significant weight loss and report significant weight loss to the physician and dietitian for two (R31, R2) residents reviewed for nutrition in the sample list of 20. This failure resulted in R31 experiencing a significant weight loss of 13.53% in 90 days. Findings include: The facility's Resident Weight Monitoring policy dated as revised March 2019 documents the following: Monthly weights are to be obtained by the 5th of each month. The Dietary Manager and Director of Nursing are responsible for reviewing the monthly weights by the 8th of each month. The Food Service Manager and interdisciplinary team review weights, nutritional status, and make recommendations for nutritional interventions. The physician and dietitian will be notified of significant weight loss of 5% or more in one month, 7.5 % or more in three months, and 10 % or more in six months. The Dietitian will review significant weight changes and nutritional interventions monthly and document in the dietary progress notes. Nursing staff are responsible for notifying the physician of nutritional recommendations and obtaining new orders. Significant weight changes are reviewed weekly during the Weight Committee Meetings to identify any gradual weight trends. Residents with an increased risk for weight loss will be weighed weekly for at least 4 weeks. 1.) R31's August 2023 Physician's Order Summary (POS) documents R31 has diagnoses of Parkinson's Disease and Dementia. R31's diet orders include 1 can nutritional supplement twice daily between meals and honey thickened liquids. R31's MDS dated [DATE] and 4/28/23 document R31 has severe cognitive impairment, requires extensive assistance of one staff person for eating, and has not had a significant weight loss in one month or six months. R31's 2023 Weight Logs document R31 weighed 162.6 lbs. in January, 150.5 lbs. in February (7.44% loss), 153.4 on 3/8/23, 142.6 lbs on 3/29/23 (5.25% loss since February), 140.6 on 4/12 and 4/19 145631 Page 14 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (13.53% loss since January), 138.8 lbs on 4/26/23, 141.8 lbs. on 5/17/23, 141 lbs. on 6/23/23, and 141.6 lbs on 7/19/23, and 147.5 on 8/2/23. R31's Nutrition Care Plan with a start date of 6/25/22 documents R31 has difficulty chewing and swallowing related to Parkinson's Disease and R31's diet is pureed with nectar thick liquids. This care plan does not document R31's significant weight loss and has not been updated with any interventions after 4/26/26. This care plan does not include the intervention for the nutritional supplement 60 milliliters twice daily as ordered on 2/20/23. There is no documentation that R31's Physician (V16) was notified of R31's weight loss until 2/16/23, then not again until 3/6/23, and then not again until 4/12/23. There is no documentation that V7 Registered Dietitian was notified of R31's significant weight loss in February, or that V7 Registered Dietitian evaluated R31's nutritional status in April. R31's Physician Notification of Weight Changes document the following: On 2/20/23 V16 Physician approved the recommendation to add nutritional supplement 60 ml twice daily and notes R31's weight loss of 7.44 % in 30 days. On 4/12/23 V16 approved the recommendation to add a nutritional shake three times daily, fortified pudding twice daily is listed as a current nutritional intervention and notes an 8.73 % weight loss in 90 days. There is no documentation that V7 was notified of R31's significant weight loss noted in February 2023 and April 2023. R31's Dietary Notes document on 3/17/23 V7 evaluated R31's nutritional status, R31's weight was stable for past month, R31's weight was down 5.89 % in the last three months, R31 had pressure ulcers and burn wounds, R31 is at risk for weight loss related to dementia and inflammatory process, and interventions include fortified pudding twice daily and nutritional supplement 60 milliliters twice daily. There is no documentation that V7 evaluated R31's nutritional status again until 5/2/23. V7's Dietary Note dated 5/2/23 documents R31's weight loss of 8.73 % in three months, R31's Body Mass Index was 22.5 (underweight), and fortified pudding is listed as part of R31's nutritional interventions. V7 did not recommend any additional nutritional interventions on 5/2/23. R31's February 2023 POS documents R31's diet included a frozen nutritional supplement three times daily, whole milk and chocolate milk twice daily, and an order dated 2/20/23 for a nutritional supplement 60 milliliters (ml) twice daily. R31's POS dated 2/24/23-2/28/23 does not document the nutritional supplement 60 ml twice daily was transcribed as an active order upon R31's readmission from the hospital on 2/24/23. R31 had wounds to R31's bilateral lower extremities. There is no documentation that the facility consulted with V7 or V16 regarding discontinuing R31's nutritional supplement. R31's March 2023 POS documents on 3/6/23 Prostat (protein supplement) 30 ml daily, fortified pudding twice daily at 10:00 AM and 2:00 PM, cottage cheese in the morning, and Vitamin C was added as recommended by V7 Registered Dietitian. This POS does not document the nutritional supplement 60 ml twice daily as ordered on 2/20/23. R31's April 2023 POS documents a nutritional shake three times daily and the nutritional supplement 90 ml three times daily were added as part of R31's diet orders in addition to the fortified pudding, and frozen nutritional supplement as previously ordered. R31's May 2023 POS lists frozen nutritional supplement three times daily, fortified pudding twice daily, nutritional shakes three times daily, and 90 ml nutritional supplement three times daily as part of R31's diet orders. R31's February 2023 Medication Administration Record (MAR) documents the nutritional supplement 60 ml twice daily was added on 2/20/23 and indicates R31 was hospitalized that day. There is no documentation that the nutritional supplement was administered as ordered or transcribed onto R31's MAR 145631 Page 15 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0692 Level of Harm - Minimal harm or potential for actual harm after R31 returned from the hospital on 2/24/23. R31's March 2023 and R31's April 2023 MAR do not document the nutritional supplement was administered until ordered on 4/26/23 for 90 ml three times daily. These MARs do not record fortified pudding intake. R31's Food & Fluid Intake Sheets dated February 2023-August 2023 do not document fortified pudding (ordered on 3/6/23) intake was monitored/recorded until 5/1/23. Residents Affected - Few On 8/9/23 at 11:19 AM V2 Director of Nursing stated the facility has weekly weight meetings and if a meeting is missed, V2 tries to review the weights. V2 stated if a significant weight loss is identified then the physician should be notified to request orders for supplements. V2 stated monthly weights are obtained within the first week of each month. R31 had COVID-19 (Human Coronavirus Infection) at the end of January which contributed to R31's weight loss. R31's additional weight loss was believed to be due to R31's lack of appetite related to pain medications and surgical wound treatments. V2 tries to involve V7 for each weight loss. V7 may not have evaluated R31's weight loss in February due to being after V7's scheduled visit. V2 stated on 2/20/23 we implemented nutritional supplement 60 ml twice daily and V7 confirmed the order was not transcribed onto R31's POS/MAR after R31 returned to the facility on 2/24/23. V7 stated the nurses should have followed up with the physician to evaluate continuing any previous orders, and document this in the progress notes. V2 stated fortified pudding was added on 3/6/23 and intake of this supplement is recorded by dietary staff. At 12:40 PM V2 confirmed R31's fortified pudding intake is not documented until 5/1/23. At 2:15 PM V2 confirmed V2 provided all of the documentation that V2 could locate for physician and dietitian notification of R31's weight loss and R31's dietary notes between February and August 2023. V2 stated V7 did not assess R31 in April due to V7 canceling V7's monthly visit for that month. On 8/09/23 at 1:07 PM V7 Registered Dietitian stated V7 rounds at the facility once per month and reviews the weight reports at that time to identify significant weight loss. V7 stated the facility only notifies V7 when there are skin issues, and the facility does not notify V7 of significant weight loss. V7 was unable to recall if V7 had evaluated R31's nutritional status in February 2023. V7 stated V7's evaluations and recommendations are recorded in V7's notes. V7 expects nutritional recommendations/interventions to be implemented/followed and V7's new recommendations should be implemented the day after V7's visit. V7 stated the facility is not very good about carrying over the nutritional recommendations/orders from month to month. V7 stated the facility should record the nutritional supplement intakes, but it isn't consistently documented. V7 confirmed R31's nutritional interventions were for weight loss and wound healing. 145631 Page 16 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

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 interview and record review the facility failed to assess at least quarterly, document nonpharmacological interventions, and obtain informed consent for one resident (R2) who receives psychotropic medication of five residents reviewed for psychotropic medications in a sample list of 20 residents. Findings Include: R2's Physician's Order Sheet (POS) for August 1st, 2023, through August 31st, 2023, includes the following current physician's orders for psychotropic medication: Citalopram (Antidepressant) 40 milligrams daily. 2. Risperdal (Antipsychotic) 2 milligrams twice daily. 3. Geodon (antipsychotic) 60 milligrams twice daily. 4. Trazadone (antidepressant) 50 milligrams twice daily. and 5. Melatonin (sleep aid) 3 milligrams at bedtime daily. The most recent assessment for R2's citalopram, Risperdal, and Geodon are dated 4/7/23. There are no documented assessments for R2's Trazadone or Melatonin. The dosage on R2's consent for Trazadone is documented as 25 milligrams. The current dosage being administered is 50 milligrams twice daily. There is no documentation to support the facility has attempted nonpharmacological interventions for R2. On 8/8/23 at 2:00PM V2 stated It is our policy to complete assessments quarterly for all psychotropic medications. I see that (R2's) assessments are either late or have not been done. The facility's Psychotropic Medication Policy revised 6/17/22 states Any resident receiving any psychotropic medication will have the psychotropic medication evaluation done at a minimum of every quarter. 145631 Page 17 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to administer the accurate dose of a liquid concentration, of the physician ordered, Oxycodone (narcotic analgesic) medication. Subsequently, R90 was administered an excessive dose of Oxycodone, twenty times greater than prescribed. The significant medication administration error resulted in R90 experiencing depressed respirations, prolonged apnea episodes, unresponsiveness, and lethargy. R90 is one of one resident reviewed for Hospice/Pain management on the sample list of 20. Residents Affected - Few Findings include: R90's Physician Order Sheet (POS) dated 7/17/23- 7/31/23 documents R90 was admitted on [DATE] on Hospice (care services for terminally ill). R90's same POS documents the following medication order dated 7/17/23: Oxycodone one milligram (mg) per one milliliter (ml), (concentration) oral solution, take five ml (equals five milligrams) by mouth every three hours as needed for pain (PRN). R90's same POS documents for the above medication, one mg per one ml, liquid solution Oxycodone order, was crossed through, and had a triangle shape, with an apostrophe d, to indicate the order had been changed. R90's same POS documents a new physician order was received on 7/24/23, with an increase concentration strength of Oxycodone liquid solution. The new order for R90's Oxycodone documents the more concentrate liquid medication of 20 mg per one (1) ml, give 0.25 (one quarter of a ml) ml (equals five mg), every three hours, PRN. The facility pharmacy receipt/narcotic count supply sheet documents R90's liquid solutions of Oxycodone 100 mg per five ml (equals 20 mg per one ml as noted above 7/24/23 physician order), 30 milliliter bottle was dispensed by pharmacy. The Oxycodone directions for administration documents: 0.25 ml (5 mg, same as the previous dose, at the lesser concentration) by mouth, every three hours as needed for pain. R90's same Oxycodone pharmacy receipt/ narcotic count supply sheet documents on 7/24/23 at 6:40 pm, V18, Licensed Practical Nurse (LPN) signed, and removed five ml (equals 100 mg) of the newly dispensed, 30 ml bottle of R90's higher concentrated liquid Oxycodone. R90's Medication Administration Record (MAR) PRN sheet, dated 7/17/23- 7/31/23 documents the following: Oxycodone 20 mg per ml, give 0.25 ml (equals 5 mg) by mouth every three hours (PRN). On the back of the same PRN, MAR documented by V18's initials to indicate R90 was administered Oxycodone five ml (equal to 100 mg, not 0.25 ml, that equals 5 mg in the higher concentration ordered) on 7/24/23 at 6:40 pm, the same time the Oxycodone concentrated dose was removed from R90's Oxycodone narcotic count supply, as noted above. R90's Oxycodone pharmacy bottle label documents the increased strength of 100 mg per 5 ml and directs nurses to administer 0.25 ml by mouth every 3 hours for pain. The facility Medication Discrepancy Report dated 7/24/23 at 7:57 pm, signed by V2, Director of Nursing, documents the following: V17, LPN and V18, LPN completed the narcotic count at shift change. 145631 Page 18 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0760 V17, LPN and V18, LPN discovered the discrepancy. V18, LPN had administered five ml (100 mg) of R90's new concentrated Oxycodone in error, instead of the 0.25 ml (5 mg) ordered. Level of Harm - Actual harm Residents Affected - Few The same Medication Discrepancy Report documents the previous order for the lower concentration Oxycodone liquid was five ml (equals five mg). The new higher concentration of Oxycodone liquid was 0.25 ml (equals five mg). Five ml (100 mg) of the concentrated Oxycodone was administered to R90 in error. The same Medication Discrepancy Report also documents: Possible effects to the resident (R90), shallow breathing, confusion, unresponsiveness, possible death. The same Medication Discrepancy Report also documents at the time of the report on 7/24/23: The actual effects to the resident (R90), shallow breathing, unresponsiveness, vitals (measurement of pulse, respirations, blood pressure and body temperature) stable, aroused at 5:15 am (7/25/23, by progress note). R90's Nurse's Notes dated 7/24/23 at 7:57 pm signed by V18, LPN documents V18, LPN had given R90 the wrong dose of Oxycodone. The same note documents R90's vital signs were measured and R90's blood oxygen was 86 percent on room air. Supplemental oxygen was administered via mask at four liters per minute. (R90) with periods of apnea (stopped breathing, duration was not documented). The same Nurses Note documents R90's blood oxygen level, after supplemental oxygen was provided, was at a saturation level of 95 percent. The same note documents R90's unidentified family members declined Narcan medication administration (Narcan is used for the treatment of an opioid overdose emergency, with signs of breathing problems and severe sleepiness, or not being able to respond). R90's Nurses Notes throughout the evening 7/24/23, overnight into the morning of 7/25/23 document R90 continued to be monitored approximately every 15 to 20 minutes, with Hospice (staff unidentified) and family members (unidentified) at bedside intermittently overnight. R90's nurses note dated 7/24/23 at 10:55 pm documents R90's respirations were measured at six per minute with two episodes of apnea, that lasted 10 seconds, and 23 seconds without breathing. The Nurses Notes on 7/25/23 at 12:20 am documents R90's respirations dropped to two breathes per one minute with apnea episodes that lasted 36 seconds and 23 seconds without breathing. The nurses note dated 7/25/23 at 1:20 am documents R90 was repositioned and unresponsive to care. The Nurses Notes continued to document respirations between 4 and 7 per minute overnight. The Nurses Note dated 7/25/23 at 5:15 am documents R90 spontaneously opened her eyes, responded to contact stimulation, but remained lethargic. Nurses note at 6:30 am documents R90 is lethargic and stated to the nurse she feels sleepy. Nurses note at 8:30 am documents stated her head felt weird, and R90 refused to continue with oxygen. Family member at bedside. On 8/9/23 at 1:30 V13, Regional Nurse, Clinical Director reviewed R90's medical records and confirmed a significant medication error occurred. R90 was given 100 mg (five ml), instead of five mg (0.25 ml) of Oxycodone. On 8/9/23 at 1:35 pm V2, Director of Nursing confirmed R90 received a dose of 100 mg Oxycodone liquid solution instead of the five mg ordered on 7/24/23. On 8/9/23 at 2:37 pm V15, Pharmacist who filled R90's second Oxycodone prescription on 7/24/23, stated he was aware the wrong dose of Oxycodone was administered to R90. V15 confirmed the wrong dose 145631 Page 19 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0760 Level of Harm - Actual harm Residents Affected - Few of Oxycodone was administered and stated R90 was supposed to be administered Oxycodone, (liquid concentration of 20 milligrams per milliliter), 0.25 ml which equals five milligrams. V15 stated R90 was administered five milliliters equal 100 milligrams, 20 times the dose prescribed. V15 also stated The most serious potential for harm is death. An excessive dose of Oxycodone can cause Hypoxia (loss of oxygen to the brain, coma, brain damage, and neurological issues. Normally, a resident is very sedated. If a patient remains alert, it would likely be because they had a tolerance for opioid (narcotic) use. V15 Pharmacist then stated (R90's) Oxycodone bottle was labeled correctly. The error should have never occurred. The facility policy ADVERSE DRUG REACTIONS AND MEDICATION DISCREPANCY dated October 2006, documents the following: Policy: Adverse drug reactions and drug errors are to be reported to the resident's physician, documented in the nursing notes, and documented on an Adverse Drug Reaction or Medication Discrepancy Report. These reports are to be completed in coordination with the Director of Nursing and filed with the Administrator and reviewed by the Medical Director and Consultant Pharmacist. Responsibility: All Licensed Nurses monitored by the Director of Nursing. Procedure: 1. A medication discrepancy/error has been made when one of the following occurs: *Wrong medication administered. * Wrong dose administered. *Medication administered by wrong route. *Medication administered to the wrong resident. *Medication administered at the wrong time. *Medication not administered. 145631 Page 20 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to designate a qualified director of food and nutrition services. This failure has the potential to affect 38 out of 39 residents residing in the facility. Findings include: On 8/8/23 at 9:41 am, V3, Director of Food and Nutrition Services (Dietary Manager) was actively managing and directing the services of the facility's kitchen and staff preparing residents food. On 8/8/23 at 9:50 am, V3 exhibited a Certified Food Protection Manager certificate, valid through 8/12/24. V3 stated this certificate was achieved from an 8 hour course in food sanitation. V3 stated she is a high school graduate, does not have a Certified Dietary Manager certificate, nor a Certified Food Protection Professional certificate. V3 stated she is not a Registered Dietician. V3 also stated she did not meet any of the state requirements for a Dietetic Service Supervisor by stating she is [AGE] years old so has had no courses prior to 1990 and does not have any military or hospitality experience. The facility's Resident Census and Conditions of Residents dated 8/7/23 documents 39 residents reside in the facility, all of whom, with one exception, consume food prepared in the facility kitchen. R18 receives nutrition solely through a gastrostomy tube and eats nothing by mouth. 145631 Page 21 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide alternate meals to residents that did not eat what was served/or requested a substitute menu item. This failure affected five R9, R11, R17, R32, and R89 reviewed during resident group on the sample list of 20. Findings include: On 08/08/23 at 1:30 PM during a group meeting, residents stated the following: R9, stated the facility does not offer a substitution menu. R11 stated there are no substitute food items every available. R11 also stated R11 has asked several times. R17, stated there are no alternate menu items available during meals. R32 stated there are no substitutes offered for meals. R32 stated R32 sees many residents (unidentified) that can't speak for themselves, that don't eat what is served. Staff (unidentified) just remove the residents plate and do not offer anything else. R89 stated there are no substitutes for meals. Everybody gets whatever the facility wants to serve. R89 also stated R89 has asked staff (unidentified) and was told there is not anything else available. On 8/9/23 at 10:20 am V1, Administrator stated The facility has had some problems. (V1) has been addressing the issue, of an available substitute menu. V1 also stated With the turn-over in kitchen staff, and a new dietary manager starting, substitute menus items will be offered and available. The facility policy Meal Alternatives dated April 2017 documents the following: It is the policy of [NAME] Health Care to provide appropriate alternates to those residents who dislike or do not eat the main entree and vegetable to help ensure adequate nutritional intake. Procedure: 1. The general menus are posted within the facility. 2. An appropriate entree and vegetable alternate is prepared and readily available at meals. The alternate may be provided to a resident who dislikes the main entree and vegetable and may also be offered to a resident who has not consumed at least fifty percent (50%) of their entree and vegetable at the meal. Other dining options may be available as well; such as, but not limited to, an Always Available menu, Buffet or Restaurant style menu. 145631 Page 22 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0806 3. Level of Harm - Minimal harm or potential for actual harm If a resident refuses the original entree and/or the alternate, the nurse shall be informed. Refusal to eat or poor intake should be documented in the resident's medical record. Residents Affected - Some 145631 Page 23 of 24 145631 08/09/2023 Newman Rehab & Health Care Ctr 418 South Memorial Park Drive Newman, IL 61942

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 food and food service utensils in a manner to prevent cross contamination of residents food. This failure has the potential to affect 38 of 39 residents residing in the facility. Findings include: On 8/7/23 at 9:15 am, there was a 10 pound package of ground beef thawing in the reach-in refrigerator. This thawing ground beef was stored above a package of hard boiled eggs. On 8/8/23 at 9:45 am, V3, Dietary Manager, stated, That meat shouldn't have been above the eggs. On 8/8/23 at 9:50 am, there was a bulk container of flour in the facility's dry food storage room. Inside this bulk container was a foam cup, approximately 12 ounces, laying in direct contact with the flour. On 8/8/23 at 9:50 am, V3 stated, That cup should is not supposed to be left inside the container. The facility's policy Storage dated 10/2020 documents, Do not leave any serving utensils or tools in food containers. The facility's Resident Census and Conditions of Residents dated 8/7/23 documents 39 residents reside in the facility, all of whom, with one exception, consume food prepared in the facility's kitchen. R18 receives nutrition solely through a gastrostomy tube and eats nothing by mouth. 145631 Page 24 of 24