Health inspection·July 17, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility to ensure a treatment dressing was in place for a resident with stage 2 coccyx pressure injury, and failed to ensure pressure relieving interventions were in place for a resident at risk for developing pressure injuries. This applies to 2 of 4 residents (R19, R12) reviewed for pressure ulcers in the sample of 15. Residents Affected - Few The findings include: 1. R19's Braden Scale Pressure Score Risk, dated 7/7/24, documents she is HIGH risk for developing pressure ulcers. R19's Wound Weekly Evaluation, dated 7/11/24, documents a stage 2 coccyx pressure ulcer measuring 1 cm (centimeter) x 2 cm x 0.1 cm, currently on treatment for MRSA (Methicillin-resistant Staphylococcus aureus- a type of infection that is resistant to many antibiotics) in the wound. R19's Physician Orders, dated July 2024, shows orders to cleanse left buttocks with normal saline or wound cleanser, pat dry. Apply medihoney to wound, cover wound bed with calcium alginate, cover with hydrocolloid dressing every three days and contact isolation precautions for MRSA in the wound. On 7/15/24 at 10:30 AM, R19's room had a contact isolation sign posted on the door. V8 (Certified Nursing Assistant-CNA) said R19 is on isolation for an infected wound on her bottom. V8 provided incontinence to R19; an open area was observed to her bottom without a dressing in place. On 7/16/24 at 1:18 PM, V6 (Registered Nurse-RN) said, (R19) has a wound to her coccyx and should have a treatment order in place. If the dressing comes off, staff should report to the nursing if the dressing is not in place. (R19) is on isolation for an infection in her wound. 2. R12's Medical Record on 7/16/24 shows multiple diagnosis including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side. R12's Current Care Plan on 7/16/2024 shows float heels when in bed, initiated 03/02/2023. On 7/16/24 at 9:38 AM, R12 was lying in bed on a regular mattress. R12's right arm was held close to her body. R12's left and right heels were resting on the bed. On 7/17/24 at 11:41 AM, R12 was lying in bed with her left and right heels resting on the bed. On 7/17/24 at 11:19 AM, V5 (Licensed Practical Nurse-LPN) said, Floating the heels relieves pressure off of the heels. Page 1 of 8 145702 145702 07/17/2024 Fair Oaks Rehab & Healthcare 1515 Blackhawk Boulevard South Beloit, IL 61080

F 0686 The facility's Pressure Injury Prevention policy revised March 2022 shows, Minimize Pressure: Relieve pressure to heels by using pillows or other devices. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145702 Page 2 of 8 145702 07/17/2024 Fair Oaks Rehab & Healthcare 1515 Blackhawk Boulevard South Beloit, IL 61080

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R24's face sheet shows he is [AGE] year old male, with diagnoses including parkinson's disease with dyskensia, arthritis, dysphagia, major depressive disorder, and muscle weakness. The Physician Order Sheets, dated July 2024, shows orders for bilateral palm guards to be worn at all times unless hygiene is being completed, wash and replace palm protectors daily. R24's Occupational Therapy Discharge summary, dated [DATE], documents R24 will safely wear a hand roll on and palmar guard on right fingers and will wear finger separator on and palmar guard on left hand and fingers. Discharge instructions: hands washed with wash cloth am/pm with soap and well rinsed and dried-hand palmar guide removed and then replaced afterwards. Restorative and Splint Program. R24's Restorative Nursing Functional Maintenance Plan, dated 6/1/24, documents bilateral palm guards; wash and replace palm protectors daily, finger separators, restorative to complete ROM (range of motion) shoulders, wrist and fingers. Palm protectors and finger separators .reviewed by restorative coordinator is not signed or dated. On 7/15/24 at 11:23 AM, R24 was observed in his room in his recliner chair. His right hand clenched with a wash cloth and his left hand with a hand splint, his left fingers were tightly close together. V15 (R24's Power of Attorney/POA) said he was in therapy for his contracted hands and he used to have a splint on his right hand. On 7/16/24 at 2:38 PM, R24 was observed lying in his bed. His right hand was clenched, there was no hand guard in place. A hand guard was in place to his left hand with his fingers tightly close together; there was no finger separator in place. V9 (Certified Nursing Assistant-CNA) said, (R24) used to have a palm guard to his right hand, but they lost it. On 7/17/24 at 9:24 AM, R24 was observed in the lounge room sitting in his recliner chair. His right and left hand clenched without palm guards in place. On 7/16/24 at 10:57 AM, V3 (Director of Therapy) said R24 was receiving occupational therapy for contractor management. He should have palm guards to both hands and should be receiving restorative services. Staff reported today they were having a hard time getting the palm guards on. On 7/16/24 at 9:54 AM, V3 said, (R24) should have palm guards with finger separators in place. Palm guards have a certain thickness then a wash cloth and that's what therapy recommended is best for him. V3 said he was not aware of R24 not having the correct palm guard in place. On 7/16/24 at 1:02 PM, V5 (Licensed Practical Nurse-LPN) said R24 should have splint devices in place to both hands. He does not know if they have restorative services at the facility. The facility did not provide documentation of R24's restorative services were provided. Based on observation, interview, and record review, the facility failed to provide range of motion for a resident with left sided weakness and pain, failed to have a restorative nurse to monitor 145702 Page 3 of 8 145702 07/17/2024 Fair Oaks Rehab & Healthcare 1515 Blackhawk Boulevard South Beloit, IL 61080

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few restorative interventions, and failed to ensure an ordered splint was in place for a resident with contractures. This applies to 2 of 4 residents reviewed for restorative interventions in a sample of 15. The findings include: 1.R15's current Care Plan on 07/16/2024 shows multiple diagnosis including, hemipalegia and hemiparesis following cerebral infarction affecting left non-dominant side. Intervention: Range of motion (passive) with am/pm care daily. Initiated 01/10/2023. R15's daily PROM to Left Ankle and Left Hand documentation, dated 06/19/2024 to 07/17/2024, shows the dates of 06/29/24 at 1:59PM, and 07/13/24 at 1:59PM. The amount of time performing the PROM was left blank and the box not applicable was checked for both days. No other documentation for R15's daily PROM was available during the time of the survey. On 07/16/24 at 9:45AM, R15 was sitting in a wheel chair in his room. R15's left arm was pulled into his waist. R15's fingers were contracted in towards his palm. R15 was not wearing a splint. On 07/16/24 at 9:45AM, R15 stated, My arm hurts. My pain is mostly on my left side; pain is my life now. On 07/16/24 at 11:22 AM, V13, CNA-Certified Nursing Assistant, and V14, CNA, agreed the resident's medical record has a task section that lists the resident's activities of daily living tasks. After assisting a resident with PROM-Passive Range of Motion exercises the CNA will document the date, time, and the amount of time that was spent with the resident in the medical record. On 07/16/24 at 2:10PM, V3, Therapy Director, said, (R15) was evaluated by therapy on 06/20/2024 and we set the goal for a splint. The splint was ordered last week. On 07/17/24 at 9:45 AM, V5, LPN-Licensed Practical Nurse, said, The resident's Care Plan will show if the resident needs ROM. On 07/17/24 at 9:48 AM, V2, Assistant Director of Nursing, said, Any resident without full movement will receive ROM exercises. It will be communicated in the Care Plan and documented by the CNA's in the tasks section of the resident's medical record. On 07/17/24 at 10:18 AM, V1, Administrator, said, We do not have a Restorative Nurse. The facility's undated Restorative Nursing Policy shows, Restorative Nursing Program include: Range of Motion (passive and active). Splint or brace assistance along with other training/maintaining of ADL's-Activities of Daily Living for the residents. 145702 Page 4 of 8 145702 07/17/2024 Fair Oaks Rehab & Healthcare 1515 Blackhawk Boulevard South Beloit, IL 61080

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 nutritional interventions were provided for a resident with weight loss. This applies to 1 of 6 (R33) residents reviewed for weight loss in the sample of 15. Residents Affected - Few The finding include: R33's face sheet shows he is a [AGE] year old male, with diagnoses including chronic kidney disease stage 4, hemiplegia and hemiparesis following cebreal infarction affecting left dominant side, dementia, neuromuscular dysfunction of the bladder, and hyperkalemia. R33's Dietary Note, dated 7/11/24, documents per chart weight documents between 130 lb (pounds)-140 lbs .spoke with (R33) seemed confused on what RD was explaining, asked him to try protein shakes and he refused. Encouraged him to increase oral intake and recommendations -offer OJ at breakfast, milk at all meals, offer extra protein during meals. R3's Physician Order Sheets, dated July 2024 ,shows orders for renal diet, cardiac NAS (low sodium), extra protein portion at all meals. R33's Diet Card shows Renal, Cardiac/NAS 2000 mg Potassium daily, Low Phosphorus diet. Avoid Foods high in K, (OJ/tomatoes/bananas/potatoes) and NA phosphorous (milk, sausage, bacon, cheese). The diet card does not list extra protein protion with meals. R33's Weight Report dated 7/16/24: 2/15/24- 142.5 lb 3/14/24- 143.5 lb 4/15/24- 142 lb 5/12/24- 143.2 lb 6/18/24- 141.2 lb 7/16/24- 133.7 lb (5% weight change in one month 6/18/24, 141.2 lbs,-5.3, -7.5 lb weight loss, -7.5% change comparison weight at three months 4/28/24- 145.2 lb -7.9%, -11.5 lbs) On 7/15/24 at 7:52 AM, R33 was observed in the dining room eating the breakfast meal. He was served eggs, cream of rice cereal, and toast. There was no yogurt on his tray. R33's diet card did not show extra protein on his meal ticket. On 7/16/24 at 2:24 PM, V10 (Dietitian) said R33 has some weight loss and recommended extra protein with each meal, his weight has been fluctuating and is at risk for weight loss. She notified V11 (Dietary Manager) of the extra protein with meals. On 7/17/24 at 8:11 AM, V11 (Dietary Manager) said, (R33) should be getting extra protein with each 145702 Page 5 of 8 145702 07/17/2024 Fair Oaks Rehab & Healthcare 1515 Blackhawk Boulevard South Beloit, IL 61080

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meal. He should get yogurt for extra protein for breakfast and gets an extra ounce for lunch and extra protein serving with dinner. The diet card does not show the extra protein listed for the breakfast meal. We added an extra ounce of protein to the noon meal and the staff should be measure the serving size and extra protein at dinner. On 7/16/24 at 11:32 AM, V7 (Certified Nursing Assistant-CNA) said R33 is alert to self, he can feed himself, and his appetite is better in the morning then the afternoons. The facility's Nutrition/Unplanned Weight Loss-Clinical Protocol, dated 2012, states, The staff and physician will identify pertinent interventions based on identified causes and overall resident condition .the physician will authorize and the staff will implement appropriate general or cause specific interventions. 145702 Page 6 of 8 145702 07/17/2024 Fair Oaks Rehab & Healthcare 1515 Blackhawk Boulevard South Beloit, IL 61080

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to perform COVID-19 testing after an exposure to a positive health care worker which applies to 5 of 5 residents (R13, R15, R16, R19, R33) reviewed for infection control in a sample of 15. Residents Affected - Some The findings include: On 7/15/24 at 10:30 AM, V3, Therapy Director, stated on 7/9/24, V14, Occupational Therapist Aide, had a runny nose and felt off. V3 stated V14 was tested for COVID-19 and was positive. V14 was sent home. V3 stated the Therapy Department is a 3rd party group with the facility. V3 stated the Therapy staff tested per their policy, and had no other positive results. V3 stated V14's therapy sessions for residents can last from 15-45 minutes depending on the resident's needs. V14 would have been in close proximity with the residents during the therapy sessions. V3 stated V2, Assistant Director of Nursing, V16, Director of Nursing, and then V1, Administrator, were notified of V14's positive COVID-19 result on 7/9/24. The facility's undated occupational therapy list for 7/8/24 and 7/9/24 showed R13, R15, R16, R19, and R33 were seen by V14 for occupational therapy. R13, R15, R16, R19, and R33's electronic medical records showed no mention of possible COVID-19 exposure or COVID-19 testing on or after 7/9/24. V16 was not available during the survey. On 7/16/24 at 10:00 AM, V2 stated, We were following our corporate guidance. The residents were not symptomatic so we did not do any testing. The residents should have been tested after they had an exposure with a positive person. On 7/16/24 at 2:00 PM, V1 stated they did not test the residents after V14 was positive. The facility's COVID-19 Policy, dated 3/6/24, showed the policy follows the Centers for Disease Control (CDC) guidance for COVID-19. This policy showed residents identified as having an exposure should be tested regardless of vaccinations status. Testing is recommended immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (day of exposure is day 0), day 3 and day 5. 145702 Page 7 of 8 145702 07/17/2024 Fair Oaks Rehab & Healthcare 1515 Blackhawk Boulevard South Beloit, IL 61080

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pneumococcal vaccinations were offered which applies to 3 of 5 residents (R13, R19, R33) reviewed for immunizations in a sample of 15. Residents Affected - Few The findings include: R13's Facesheet, printed on 7/16/24, showed R13 is an [AGE] year old female admitted to the facility on [DATE]. R33's Facesheet, printed on 7/16/24, showed R33 is an [AGE] year old male resident originally admitted to the facility on [DATE]. R19's Facesheet, printed on 7/16/24, showed R19 is a [AGE] year old male admitted to the facility on [DATE]. R13, R19, and R33's Electronic Record showed no documentation (consent or refusal) for the the PCV20 pneumonia vaccines. R19's On 7/17/24 at 12:00 PM, V1, Administrator, stated the facility had no documentation pertaining to R13, R19, or R33 being offered the pneumonia vaccinations. The facility's Pneumonia Policy, dated February 2023, showed the guidelines for residents older than the age of 65 may choose to receive a dose of PCV-20 if they have already received a complete series of PCV13 and PPSV23 pneumonia vaccine series (applies to R13 and R33). The guidelines show a resident over the age of 65 with no history of pneumonia vaccines should receive a dose of PCV 20 or PCV 15 and PPSV23 doses a year apart (applies to R19). 145702 Page 8 of 8