Health inspection·January 26, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, report, and assess a new open wound and the facility failed to ensure medication wipes were not left at the bedside for one of 22 residents (R42) reviewed for wound care and services in the sample of 22. Residents Affected - Few The findings include: R42's Physician Order Report shows R42 was admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, morbid obesity, major depressive disorder, and urinary tract infections. An order for calmoseptine ointment to sacrum dated 7/25/21; Document findings of skin check on shower sheet. R42's Skin Risk Assessment with pressure ulcer risk dated 1/24/22 shows R42 is at risk of developing pressure injuries. R42's Tissue Tolerance Test Documentation dated 1/18/22 shows R42 had non blanchable redness to her coccyx after being off of the area for two hours. (No changes in skin treatment since 7/25/21). On 1/24/22 at 1:03 PM, R42 was transferred from her wheel chair to bed. V10 CNA (Certified Nursing Assistant) performed incontinence care to R42. V10 wiped a moderate amount of stool from R42's buttocks. There was an open area smaller than a dime size to R42's coccyx area. V10 and V12 CNA said that R42 has been in the wheel chair since about 9:30 AM. R42 said, I have pain there when I sit in my chair. On 1/25/22 at 1:10 PM, V9 Wound care nurse said, residents' skin is assessed on shower days and is documented on the residents shower sheets. If a new wound is found then the nurse notifies V9 with the new wound and V9 assesses the wound. At 1:53 PM, V9 assessed R42's new open area to R42's coccyx area. V9 said she was not aware of the open area to R42's coccyx area. R42's shower sheet dated 1/11/21 (possible error to year) shows R42's skin was intact. On 1/25/21, R42 had redness on her buttocks. Neither shower sheet was signed by the charge nurse. R42's Wound Evaluation done by V9 dated 1/25/22 shows, R42 has an abrasion to her sacrum that measures 1/3 cm (Centimeters) X 1.2 cm. The wound has 80% granulation tissue and 20% slough. A referral was made to the wound care doctor. R42's Care Plan last edited 12/02/21 shows, [R42] continues to be at risk for pressure ulcer formation related to diabetes, incontinence and decreased ability to relieve pressure independently. Skin Page 1 of 11 145652 145652 01/26/2022 Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098

F 0684 is intact. Level of Harm - Minimal harm or potential for actual harm On 1/26/22 at 11:24 AM, V3 DON (Director of Nursing) said residents' skin should be assessed every time residents are washed up or showered. V3 said skin abnormalities should be listed on shower sheets and the CNAs should report open areas to the nurse and then that gets reported to the wound care nurse so she can assess it. Residents Affected - Few The facility's undated Tissue Tolerance Testing Policy shows, If the area has persistent non-blanchable redness, warmth to the touch or induration, initiate a wound assessment form, notify the physician and power of attorney of a stage one pressure injury. 2. R42's Physician Order Report dated 12/24/21-01/24/22 shows an order for medicated hemorrhoid pads. Special instructions: As needed every brief change, leave in place in brief, diagnosis: hemorrhoids as needed. On 1/24/22 at 1:03 PM, there was a container of medicated hemorrhoidal wipes at V10's bedside. R42 has external hemorrhoids noted to her rectum. V10 CNA (Certified Nursing Assistant) took a wipe from this container and placed it in R42's gluteal cleft. (Not on R42's hemorrhoids). V10 said that R42 likes these wipes placed on her hemorrhoids because they make R42 feel better. V10 said, But R42 doesn't have any. and R42 said that she did have hemorrhoids. On 1/26/22 at 11:24 AM, V3 DON (Director of Nursing) said hemorrhoid wipes should not be kept at resident's bedside unless they have pass a self administration assessment. V3 said R42 would not be able to self administer hemorrhoidal wipes. V3 said the nurse should be applying the medicated wipes. R42's Treatment Administration History shows the medicated hemorrhoidal wipes were not documented as given in the month of January. The facility's Medication Administration Policy dated April 2013 shows, Medication may not be left at bedside without MD (Medical Doctor) order and documentation of understanding and compliance. 145652 Page 2 of 11 145652 01/26/2022 Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 feed and transfer residents in a safe manner for five of twenty-two residents (R5, R6, R11, R25, R46) reviewed for safety in the sample of 22. The findings include: 1. On 01/24/22 at 12:00 PM, at the noon meal, R11 was being spoon fed a pureed diet by V13 Accounting Assistant. On 01/26/22 at 9:20 AM, V2 Assistant Administrator said R11 took the Resident Attendant class. V2 said Resident Attendants are not allowed to feed residents that require 1:1 assistance with eating, anyone with specialized diet, or anyone with swallow precautions. On 01/26/22 at 10:55 AM, V11 Dietician stated R11 is on pureed diet due to trouble swallowing, that's why she needs 1:1 assistance. R11's Physician Orders dated 10/13/22 shows R11 has diagnoses of Parkinson's disease, vascular dementia, hemiplegia and hemiparesis following cerebral infarction, and a diet order general, pureed diet, 1:1 supervision, swallow precautions. The facility's Resident Attendants List dated 8/2021 shows V13 is a Resident Attendant and Residents that need 1:1 assistance at meals will not be assigned a Resident Attendant. 2. On 01/24/22 at 12:50 PM, R46 was assisted to the bathroom by V14 Certified Nursing Assistant (CNA). V14, without using a gait belt, helped R46 stand up and pivot. V46's legs were shaky while standing. V14 stated to R46 your legs are wobbly today, stand up all the way and then V14 pulled R46's pants down and had R46 sit on the toilet. When R46 was done, V14, again without a gait belt, had R46 stand up while V14 performed peri care and pulled up R46's brief and pants. V14 then had R46 pivot and sit down in her wheelchair. R46's Fall Risk assessment dated [DATE] shows R46 has diagnoses of Alzheimer's, dementia, Parkinson's disease and is a high risk for falls. R46's Care Plan for falls shows Can stand to transfer but has balance issues. Has Parkinson's Disease which could affect gait and balance as well as endurance which could put her at risk for falls. 3. On 01/24/22 at 11:27 AM V7, CNA, was observed bringing R25 from the bathroom to her wheelchair via a sit to stand (mechanical) lift. V7 did not have any assistance. R25 said she cannot stand on her own and they have to use the lift. R25 said one CNA helps her transfer with the lift. On 01/24/22 at 12:56 PM, V7 answered R25's call light. R25 was in the bathroom sitting on commode alone, hooked to the sit to stand lift. V7 raised R25 from the commode using the mechanical lift and provided peri-care. Then, R25 used the lift alone to transfer R25 out of bathroom to the wheelchair in the room. On 01/24/22 at 01:00 PM, V7 said she was trained on how to use the mechanical lifts. V7 said they 145652 Page 3 of 11 145652 01/26/2022 Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098

F 0689 recommend two people to operate the lifts, but we don't have enough staff. Level of Harm - Minimal harm or potential for actual harm On 01/25/22 at 01:45 PM, V6, Rehab Coordinator, said staff is instructed on use of the mechanical lifts, including the sit to stand lift, upon hire and annually. V6 said they are instructed to always use two people to operate the lifts. Residents Affected - Some R25's Care Plan (last reviewed 11/15/21) shows R25 transfers with a sit to stand lift and continues to be at risk for falls. R25's MDS (Minimum Data Set) dated 11/11/21 shows R25 requires extensive assistance with transfers and toilet use by two or more persons physical assist. R25's Fall Risk Assessment (completed 1/17/22) shows R25's Total Fall Risk score is a 10 and a score of 10 or higher represents a high risk for falls. The facility's Transfer and Positioning Policy (updated 5/2017), shows the sit to stand lift .You need two people to operate this lift . 4. On 01/24/22 at 11:36 AM, V7 transferred R6 to the commode from her wheelchair. V7 did not use a gait belt and held on to R6's waist of her pants. A gait belt was hanging next to V7's wardrobe, but was not utilized. R6's MDS (dated 1/5/22) shows R6 requires extensive assistance with transfers and toilet use by one person physical assist. R6's Care Plan (last reviewed 1/10/22) shows R6 will transfer to all surfaces with assist of one and remains at risk for falls due to weight bearing limitations. R6's Fall Risk Assessment (completed 1/24/22) shows R6's Total Fall Risk score is a 10 and a score of 10 or higher represents a high risk for falls. 5. R5's Minimum Data Set assessment dated [DATE] shows that she requires extensive assistance of one person for transfers and is not steady when moving on and off of the toilet. R5's Care Plan shows an intervention of Provide assistance with transfers. On 1/24/22 at 12:58 PM, V15 (Registered Nurse) brought R5 into the bathroom to assist her to the toilet. R5 had a knee brace on her left leg and no shoe on. Without a gait belt applied to R5, V15 helped R5 stand from her wheelchair by pulling on her pants. R5 was very unsteady when she stood up. R5 said, Oh, boy' as she stood. R5 was guided to sit on the toilet. When R5 was done, V15 helped her stand and told her to hold onto the bar next to the toilet. R5 kept letting go of the bar and trying to help pull her pants up. R5 appeared very unsteady. On 1/25/22 at 11:35 AM , V6 (Rehab Coordinator) said that since R5's fall, she is has been a one person assist for transfers. V6 said that gait belts are required for all assisted transfers for the safety of the resident and staff. The facility's Transfer and Positioning Policy dated 5/2017 shows, Staff must use a gait belt in all transfers and ambulation unless the set sheets say that resident is independent. Gait belts are not an option. It is in our policy to use them for your safety and the safety of our residents. 145652 Page 4 of 11 145652 01/26/2022 Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098

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 observation, interview, and record review the facility failed to provide peri-care in a manner to prevent urinary tract infections for one of four residents R42 reviewed for incontinence care in the sample of 22. The findings include: R42's Physician Order Report shows R42 was admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, morbid obesity, major depressive disorder, and urinary tract infections (UTIs). The report shows an order for macrobid 100 mg (Milligrams) twice daily for ten days for urinary tract infection. On 1/24/22 at 1:03 PM V10 CNA (Certified Nursing Assistant) removed R42's incontinence brief. There was urine and a moderate amount of soft stool in R42's incontinence brief. V10 used a wet wash cloth to wipe R42's buttock area. V10 wiped the stool from R42's buttock, folded the wash cloth, wiped R42's buttock again, folded the wash cloth, and continued to fold the wash cloth two more times. There was stool visible on the other side of the wash cloth. On 1/26/22 at 11:24 AM, V3 DON (Director of Nursing) said the wash cloth should not be folded during incontinence care with stool. The facility's Pericare Policy and Procedure dated 3/16 shows, Pericare will be provided to residents in the am, hs, whenever soiled, and as needed. Purpose: To keep resident's skin clean, to help prevent UTI's, infections and skin breakdown, to prevent resident from having bodily odors and to promote the resident's dignity. Change wash cloth as needed. 145652 Page 5 of 11 145652 01/26/2022 Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098

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** Based on observation, interview, and record review, the facility failed to ensure interventions to prevent weight loss were implemented for one of nine residents (R15) reviewed for weight loss in the sample of 22. Residents Affected - Few The findings include: R15's Physician Order Report dated 1/26/22 shows R15 was admitted to the facility on [DATE] with diagnoses including: Heart disease, dementia, and diabetes. Diet: Magic Cup dietary to provided at lunch and dinner 11:00 AM and 5:00 PM ordered on 6/22/21. On 12/01/2021, R15 weighed 127.7 pounds. On 01/01/2022, R15 weighed 119.6 pounds which is a 6.34% weight loss. On 1/25/22 at 11:53 AM during the lunch meal, R15 had water, regular chips, toast, butter, jelly, coffee, and soup on her meal tray. The was no supplement (Magic Cup/ice cream) on R15's meal tray. R15's Care Plan edited 7/18/21 shows, Ensure 237 ml (milliliters) daily, two cal 90 mls daily, and magic cup at lunch and dinner. Provide prescribed diet. R15's Progress Note dated 10/21/21 shows, Observed in dining room and does not always complete meals. Ensure ordered 237 ml daily as well as Magic Cup at lunch and dinner which has stabilized further weight loss. On 1/26/22 at 10:47 AM, V11 Registered Dietitian said she comes to the facility weekly to assess residents. V11 said when residents experience weight loss, she makes the recommendations and the nurses get the order from the doctor. V11 said some interventions that are used for weight loss are magic cup, super cereal, 2-cal, ensure, and extra food. V11 said if she makes recommendations and the doctor orders them, then staff should be following them. V11 said the food service manager ensures residents are getting the dietary supplements. V11 said magic cup should be on the residents' meal cards. R15's Meal Card did not contain an intervention of Magic Cup. The facility's Supplements policy dated 2017 shows, Nutritional supplements will be provided as ordered to clients whose nutrient needs may be increased. 145652 Page 6 of 11 145652 01/26/2022 Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to act upon the pharmacist's recommendation made on a monthly medication regimen review for two consecutive months for 1 of 5 residents (R53) reviewed for pharmacy services in the sample of 22. The findings include: 1. R53's Pharmacist Recommendations to Prescriber/Physician dated 12/13/2021 and 1/18/2022 showed a recommendation of, may we attempt a trial reduction of this mediation to pantoprazole 20mg once daily before food? R53's Physician Order Report from January 2022 showed on 1/6/2022 an order for pantoprazole 40 milligrams PO by mouth daily one hour before breakfast was initiated. On 1/26/2022 at 10:50AM V3 (Director of Nursing) said the recommendations on the Medication Regimen Review (MRR) for R53's pantoprazole had not been addressed yet by the physician. The facility's Medication Regimen Reviews (MRR) Scheduled and Interim policy with a copyright date of 2005-2022, states The Consultant Pharmacist shall review the medication regime of each resident on a regular basis. Any findings noted will be reported to the Director of Nursing (or designee), who in turn will report to the prescribing physician and medical director. 145652 Page 7 of 11 145652 01/26/2022 Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098

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 ensure PRN (as needed) anti-anxiety (psychotropic) medication had a duration/end date for 1 of 5 residents (R44) reviewed for unnecessary medications in the sample of 22. The findings include: 1. R44's Physician Order Report from January 2022 showed an order initiated on 8/27/2021 for alprazolam (anti-anxiety medication) 0.5 milligram twice a day as needed. There was no duration/end date for the medication. On 1/27/2022 at 10:15 AM, V3 (Director of Nursing) said after the initial 14-day period from the original order the end date is left blank on the reordered medication , it should have been reviewed to make sure that it's necessary. The facility's Antipsychotic Drug Use Policy doesn't address a duration/end date for PRN psychotropic medications. 145652 Page 8 of 11 145652 01/26/2022 Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098

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 dispose of an expired multi-dose medication vial and failed to label the multi dose vial with the correct expiration date for one of 22 residents (R42) reviewed for medications in the sample of 22. The findings include: On 1/24/22 at 11:54 AM, there was a multi dose insulin vial for R42 that had an open date of 12/14/21 and an expiration date of 1/14/22 (31 days after opening). V17 RN (Registered Nurse) said opened insulin is good for 30 days. V17 retrieved a new insulin vial but put an expiration date of 2/24/22. (31 days after opening). On 1/26/22 at 11:24 AM, V3 DON (Director of Nursing) said insulin vials should the open date and nurse should know when the vials are expired. V3 said insulin vials are good for 30 days after opening. The facility's Medication Administration Policy dated April 2013 shows, Discontinued and expired medications must be removed from the medication cart and refrigerator. The facility's Use of Multi-Dose Vials (MDVs) policy dated 3/18 shows, To provide for the appropriate use and disposal of injectable medications packaged by the manufacturer in multi dose vials. The opened and beyond use dates will be noted and initialed at the time the vial cap is removed. In general, MDVs may be used for 28 days after the initial opening of the vial, unless the manufacturer specifies a longer or shorter duration of use. If the vial has been opened longer than 28 days, or has expired per the manufacturer's expiration date, it should no longer be used and should be discarded in a sharps container and a new vial of medication should be obtained. 145652 Page 9 of 11 145652 01/26/2022 Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to encourage social distancing and masks during an outbreak to prevent the spread of COVID-19; also failed to ensure staff removed their gloves and washed their hands to prevent cross-contamination during incontinence care. Residents Affected - Some This applies to 10 of 22 residents (R4, R5, R11, R23, R24, R35, R42, R46, R51 and R57) reviewed for infection control in the sample of 22. The findings include: 1. The facility provided email dated 1/25/22 shows that the county transmission rate was high on 1/12/22, 1/20/22 and 1/25/22. The facility provided Line List for COVID-19 Outbreaks in Long Term Care Facilities shows that their outbreak started on 10/26/21. The facility provided list dated 1/24/22 shows that R11 is unvaccinated. On 1/24/22 at 11:09 AM, R4, R5, R11, R23, R24, R35, R46, R51 and R57 were all in the dining room. They were seated around two 4 foot tables that were pushed together. They were not six feet apart. None of the residents had a mask on. They were singing Happy Birthday song. On 1/24/22 at 11:09 AM, V16 (Activity Aide) said the activity started at 10:15 AM and all residents participated. V16 said they did the activities of balloon ball and sing-a-long. On 1/25/22 at 2:00 PM, V5 (Infection Preventionist) said they have been in outbreak status since October of 2021. V5 said activities are being done in smaller groups and the residents should social distance by being at least six feet apart and should wear a mask outside of their room regardless of their vaccination status. V5 said they follow the CDC (Center for Disease Control) and the local health departments guidance. On 1/26/22 at 9:39 AM, V1 (Administrator) said they do not have a specific policy for social distancing and mask usage during activities but it should be in their COVID Policy. The facility's COVID-19 (Novel Coronavirus 2019) Response Plan revised on 11/23/21 discusses social distancing and mask usage regarding re-admissions and visitations but does not discuss social distancing during other activities. The CDC Infection Control Guidance dated 9/21/21 shows, Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission . 2. On 1/24/22 at 1:03 PM, V10 CNA (Certified Nursing Assistant) performed incontinence care to R42's front peri area, turned R42 to her side, and proceeded to clean a moderate amount of stool from R42's buttocks. V10 touched R42's skin, the clean incontinence brief, and R42's bed, did not change her gloves or perform hand hygiene. 145652 Page 10 of 11 145652 01/26/2022 Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/26/22 at 11:24 AM V3 DON (Director of Nursing) said, gloves should be changed after cleaning dirty items and before touching clean items. The facility's Hand Washing Policy and Procedure revised 5/2013 shows, Hand washing is recognized as the most basic yet most effective means of preventing and controlling the spread of infection. The purpose of hand washing in health care facilities is to remove contaminants that have been acquired by recent contact with infected residents or environmental sources. Personnel who have contact with resident excretions, secretions, or blood either directly or through contaminated articles may acquire contaminants. Hand washing is indicated after touching a source that is likely to be contaminated, such as bedpans, urinals, emesis basins, soiled linens, waste receptacles, soiled dishes, thermometers, etc. After touching excretions (feces, urine, or material soiled with them). Before and after changing an incontinent residents, and after handling soiled linens/laundry and before handling clean linens/clothes. 145652 Page 11 of 11