Health inspection·June 15, 2023

F 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview, and record review, the facility failed to provide sufficient staff to care for dependent residents. This failure has the potential to affect all 79 residents residing in the facility. Residents Affected - Many Findings include: The facility Assessment, no date available, documents, Nursing, nutrition services, and housekeeping staffing is evaluated at the beginning of each shift and adjusted as needed to meet the care needs and acuity of the resident population. The facility's Resident Council Minutes/Report, dated 5/18/23, documents, The CNAs (Certified Nursing Assistants) should not be giving showers on Wing 1 when there is only one CNA. On 06/12/23 at 10:45 AM, V12 (R16's family) stated, (R16) was left in pool of urine, the bed, the mattress, and the sheets. This happened on 3rd shift 6/3/23 into 1st shift 6/4/23. (R16) is on a memory care unit. There are residents who wander all night long. They have one CNA and one nurse, but the nurse covers multiple halls on third shift. They set off the alarm to exit so that one CNA runs after them and leaves the floor unattended. So how is that CNA supposed to take care of residents turning and changing them as well as supervising the wandering resident on this locked hallway all by herself. On 06/13/23 at 10:00 AM, As a group when asked if there were staffing issues, R183, R43, R29, and R18 all stated yes. Then, when asked about call light response times they all laughed. R183 stated, There are times that we wait a quite a bit longer for our call lights to be answered, especially when they work short staffed. R43 stated, The call light wait times can be pretty long at times, but I try to tell myself over and over again to be patient. On 6/14/23 at 10:40 a.m., V6 CNA stated, We are supposed to have one CNA on 100 wing, two CNAs scheduled on 200 wing, and two CNAs on 300 wing. The nurse that works 200 wing also works 100 wing. So, we go with no nurse on our floor for a while at times. I've only worked with myself being the only CNA on the floor. If it's just one, I feel like it hurts the residents, and they don't get the care they should. There are residents that take two staff to turn and change. If the nurse isn't on the floor. Those residents can't be turned or changed. Luckily, with it being the dementia unit we really don't have to worry about call lights. If there was an emergency and no nurse was on the floor, I don't know what I would do if I couldn't leave the resident. We also have (R99) who wanders all through the night and attempts to go out the door. So, on top of everything else I have to make sure and supervise (R99) as well. On 6/04/23, I came in at 2:00 a.m. and the other CNA left at 2:00 a.m. The nurse was stuck on 100 wing for a long time. So, I was by myself. (R16) is a two assist to change her. I didn't have any help, so I wasn't able to change her that night. I know she was incontinent, but I couldn't safely change her by myself. On 06/14/23 at 11:55 AM, V7 (CNA) stated, There are times that we work short. I've came in and there's only been one CNA working on the hall. Depending on who is working will determine how much the CNA was or wasn't able to do on their own. A more inexperienced CNA may not be able to check and change everyone with it being just that one person. If there was an emergency on our hallway on third shift, the nurse was on the 100 hall, and I was all by myself I don't know what I would do if there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145697 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knox County Nursing Home 800 North Market Street Knoxville, IL 61448 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many was an emergency and I couldn't leave the resident. There are residents on this hall that require two people to change them. If it's just one CNA, you hope that the nurse is on the hall to help. On 06/14/23 at 11: 56 AM, V8 (CNA) stated, Staffing can be an issue at times. There's been one CNA on third shift when I've came in. With only one person there's times that there are more people wet and needing changed. It just depends on how much experience the CNA has. There are residents on our hall who require two of us to change them. On 06/14/23 at 12:06 PM, V9 (Licensed Practical Nurse), stated, We are short staffed here, both nurses and CNAs. When we are short all of the staff are stressed out and anxious trying to get double the work done. With working short things get missed and not done which affects the residents. A resident may not get changed timely or gotten up on time things like that. It's hard on us and the residents. I've worked third shift and covered both 100 and 200 hall. It's hard going back and forth and making sure everything is taken care of. If there's an emergency on one hall that means I'm going to be pulled from the other hall for a while. Then, if you throw in that there is only one CNA on this hallway that's even worse. With only one that means the nurse is the 2nd person for all of the two assist, but what about the time I'm on the other hall. Also, with doing more CNA work that's pulling me from the regular nurse duties. (R99) is a wanderer. It's scary when we are short and knowing you've got to keep an eye on her. She is exit seeking. We are so relieved the nights she may sleep through the night that's one less stressor on the nights we are short. On 6/15/23 at 9:30 a.m., V14 (CNA) stated, In the morning, if I'm alone I can't get the mechanical lifts up for their get up. I dress them and wait for day shift to get to the facility. There are a lot of two assist residents for get up. I just don't get them up when I'm alone. There is a few residents that I have difficulty with turning at time. When I'm doing rounds some of the resident end up being wet longer than they should. I have at least 21 residents that I have to change on rounds plus answer call lights, So, I'll change all of them on one side then head to the other side. When I'm done with the second side, the first side is wet, and I start all over again while I'm still trying to answer call lights as well. It's hard to get it done. The facility Staffing Assignment Daily, dated 6/03/23, documents that on 3rd shift one CNA is assigned to each hallway, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. The facility Staffing Assignment Daily, dated 6/04/23, documents that on 3rd shift one CNA each is assigned to 100 and 200 hall, two CNAs are assigned to 400 hall, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. The facility Staffing Assignment Daily, dated 6/07/23, documents that on 3rd shift one CNA each is assigned to 100 and 200 hall, two CNAs are assigned to 400 hall until 2:00 a.m. when one CNA leaves, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. The facility Staffing Assignment Daily, dated 6/08/23, documents that on 3rd shift one CNA is assigned to each hallway until 2:00 a.m. when one of those CNAs is moved to 400 hall and another CNA comes in to work alone on 200 hall, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. The facility Staffing Assignment Daily, dated 6/09/23, documents that on 3rd shift one CNA is assigned to each hallway until 2:00 a.m. when another CNA comes in to work 400 hall, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145697 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knox County Nursing Home 800 North Market Street Knoxville, IL 61448 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility Staffing Assignment Daily, dated 6/10/23, documents that on 3rd shift one CNA is assigned to each hallway, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. On 6/15/23 at 10:30 a.m., V17 (Social Services Director) stated, The resident complained about only one CNA on the floor during the resident council meeting because she felt like it wasn't safe since no other CNA was available if they were in the shower room. On 6/15/23 at 10:15 a.m. V11 (Human Resources) stated, I use the State calculator for the minimum staffing. However, I try to schedule two nurses, one works 100 and 200 hall and the other works 400 hall, and five CNAs, one on 100 hall, two on 200 hall, and two on 400 hall. With our staffing issues lately though sometimes it's only one CNA on 200 hall and one CNA on 400 hall. V11 confirmed the required minimum hours the facility was following for 3rd shift on 6/03, 6/04, 6/07, 6/08, 6/09, and 6/10/23 was two nurses and four CNAs. V11 also confirmed: 6/03 three CNAs were working, one for each hallway; 6/04 one CNA was working on 200 hall; 6/07 one CNA was working on 200 hall; 6/08 3.5 CNAs working with one on 200 hall; 6/09/23 3.5 CNAs working with one on 200 hall; three CNAs were working, one for each hallway. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents form 672, dated and signed by V13 (Minimum Data Set Coordinator) on 6/13/23, documents the following assistance required for residents: Dressing: 72 require one to two staff assist, 7 are dependent; Transferring: 61 require one to two staff assist, 12 are dependent; Toilet use: 72 require one to two staff assist, 7 are dependent. The 672 also documents that at the time of the survey 79 residents resided in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145697 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knox County Nursing Home 800 North Market Street Knoxville, IL 61448 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and record review, the facility failed to document behaviors to warrant the initiation of an antipsychotic medication for one of one resident (R16) reviewed for antipsychotics in the sample of 30. Findings include: The facility's Antipsychotic Medication Use policy, dated 7/22, documents, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; AND: the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity; or behavioral interventions have been attempted and included in the plan of care, except in an emergency. Antipsychotic medications will not be used if the only symptoms are one or more of the following: Wandering; poor self-care; restlessness; impaired memory; mild anxiety; insomnia; inattention or indifference to surroundings; sadness or crying alone that is not related to depression or other psychiatric disorders; fidgeting; nervousness; or uncooperativeness. On 06/12/23 at 12:44 PM, R16 was alert sitting up in her high back reclining wheelchair. R16 was nonverbal and was not displaying any behaviors. R16's Physician's orders, dated 6/13/23, documents that R16 was started on Seroquel (antipsychotic) 25 mg (milligrams) by mouth twice a day for Anxiety (5/02/23). The orders also document that R16 is currently receiving Seroquel 25 mg by mouth daily. R16's Behavior note, dated 3/14/23 at 12:27 p.m., documents, R16 continues to yell and swear at staff when they attempt to speak with her or offer her food. Sits quietly when left alone at her table. R16's Behavior note, dated 3/14/23 at 2:33 p.m., documents, R16 observed crawling out of bed, attempted to place feet back into bed, R16 begins screaming/crying. R16 gotten up and toileted. Continues screaming/crying. Sitting at table at this time, when staff attempt to converse/calm her offering food/fluids R16 becomes upset and yelling at staff. R16's Behavior note, dated 3/15/23 at 2:48 a.m., documents, During repositioning R16, R16 called this nurse a n****r. R16 redirected with no effect. R16's Behavior note, dated 3/23/23 at 7:24 p.m., documents, R16 became agitated when nurse attempted to give eye drops, R16 grabbing at bottle and trying to put in her mouth. When nurse attempts to re-explain what is happening R16 gets even more agitated, cursing and threatening to kill nurse. Grabbing at nurses clothing. Repeatedly kicking feet off the side of footrests. R16's Behavior note, dated 4/3/23 at 1:18 p.m., documents, Staff attempted to lay R16 down after lunch. R16 became agitated, refused. Yelling/screaming/cursing/grabbing at staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145697 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knox County Nursing Home 800 North Market Street Knoxville, IL 61448 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R16's Behavior note, dated 4/15/23 at 1:42 p.m., documents, R16 brought to dayroom at this time. Repeatedly crawling out of her bed. Toileted and repositioned without effect. Sitting at table fidgeting with clothing/blanket at this time. R16's Behavior note, dated 4/15/23 at 11:38 p.m., documents, R16 crawling out of bed at this time, when staff attempt to assist her to get repositioned, she begins screaming and grabbing. Swearing at staff/name calling. R16's Behavior note, dated 4/16/23 at 1:19 a.m., documents, R16 crawled out of her bed onto her floor mats. Incontinent of small amount of urine. Assisted back to bed with two staff and gait belt. Toileted and brought to dayroom for closer monitoring. R16's Communication with physician note, dated 5/2/23 at 10:21 a.m., documents, Situation: Physician faxed back stating that Ativan, Ambien, and valium are all benzodiazepines and would not help. He gave orders for Seroquel 25 mg BID (twice a day). R16's Communication with family note, dated 5/3/23 at 11:59 p.m., documents, Spoke with (V12 R16's family) per phone asking how R16 is sleeping. I assured her that she has been sleeping soundly since I got here at 10:00 PM. She is concerned that physician started R16 on Seroquel today and that it is causing her to be too sleepy as she slept through her supper. R16's Nurses' notes, dated 5/10/23 at 4:33 a.m., document, Behaviors: yelling out; resisting cares; restlessness. 1:1 ineffective. R16's Psychiatric Evaluation note, dated 5/11/23, documents, Type of Visit: Initial Psychiatric Evaluation. Chief Complaint: Establish care, initial evaluation of dementia with behaviors and insomnia. R16's Order Administration note, dated 5/14/23 at 7:27 a.m., documents, V12 didn't want R16 to have it (Seroquel) this AM due to family coming she didn't want her sleepy. R16's Nurses' notes, dated 5/17/23 at 12:43 p.m., documents, R16 was yelling out very loudly while CNA's (Certified Nursing Assistants) were getting R16 out of bed this morning. R16's Care plan, dated 6/5/23, documents, R16 has episodes of verbal and physical agitation towards staff. She will yell, curse, call them names and will become combative by hitting/grabbing when staff is trying to assist her related to Alzheimer's/dementia. R16's Care plan, dated 6/5/23, documents, R16 will resist care-will become combative, yell/cry out when staff, caregiver and family try to assist her related to anxiety, Alzheimer's Disease/Dementia. R16's Order Administration note, dated 5/28/23 at 10:32 a.m., documents, V12 wanted med (Seroquel) held this AM due to the med making her so sleepy. R16's Nurses' notes, dated 6/10/23 at 2:59 p.m., document, Note Text: Behaviors-Crawling out of bed and yelling out during cares. On 6/12/23 at 10:45 a.m., V12 (R16's family) stated, (R16) is now getting a sleeping pill, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145697 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knox County Nursing Home 800 North Market Street Knoxville, IL 61448 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Seroquel, that knocks her out for the night. She sleeps through the night. The only behavior she has is attempting to get out of bed. That's why she is on the Seroquel so she will sleep through the night and not try to get out of bed. With only one staff member they get her up when she's trying to get out of bed. (R16) needs to sleep at night. She dangles her feet over the side of the bed, but when staff see her like that, they think she's trying to get up. Residents Affected - Few On 6/14/23 at 2:45 p.m., V10 (Director of Nursing) stated, I've had the policy to have staff let me know if they are considering an antipsychotic. I was pretty irritated when I found out about (R16) getting started on Seroquel without consulting with me. In early May, I tried to explain to (V12) that (R16) shouldn't be on this type of medication. I felt like (R16) needed to be on a mood stabilizer and explained the risks. We agreed to (V12) contacting the physician about changing the antipsychotic. I never did hear anything back about it. Later in May, (V12) was unhappy with how lethargic (R16) was with the Seroquel twice a day so she had the morning dose discontinued. If she would just let us deal with her dementia and behaviors things would be fine, but she won't. I've tried to explain that (R16) should not be on the Seroquel. Antipsychotics should be the last resort. (V12) didn't even let us try anything non-pharmacological interventions before starting the Seroquel. (V12) demanded the physician start (R16) on the Seroquel. (R16) is the sweetest resident. She is so easy to take care of. The behaviors are aggression, hitting/pinching/biting staff, yelling at staff, and restless. (V12) was worried about her not getting any sleep at night. I didn't feel like the behaviors needed treated with an antipsychotic. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145697 If continuation sheet Page 7 of 7