Health inspection·October 28, 2024

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 R5 with incontinence care to prevent the saturation of her outer clothing for 1 of 5 residents (R5) reviewed for activities of daily living care for dependent residents in the sample of 8. Residents Affected - Few The findings include: R5's Minimum Data Set, dated [DATE], shows, Toileting: Dependent, Personal Hygiene: substantial/maximal assistance, Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair or wheelchair. Dependent. Toilet Transfer: The ability to get on and off a toilet or commode. Not applicable. Cognitive: Impaired. R5's Skin Assessment, dated 10/23/24 at 6:35PM, shows no new changes this week. Skin Impairment Documentation: No Skin Impairment Documented. On 10/28/2024 at 12:40PM, R5 was sitting in a reclining wheeled chair in her room. V8, admission Coordinator, was assisting R5 with eating. On 10/28/2024 at 12:40PM, V8, admission Coordinato,r said, (R5) was changed by the CNA-Certified Nursing Assistant before lunch. Lunch starts at 11:30AM. On 10/28/2024 at 3:19PM, R5 was sitting in the same position, in a reclining wheeled chair, in her room alone, moaning. R5 said, I have pain between my butt. On 10/28/24 at 3:25PM, V5, CNA-Certified Nursing Assistant, said, I did not get report on the last time (R5) was changed. I was not able to find (R5's) CNA. On 10/28/24 at 3:30PM, V6, CNA, said, I do not know the last time (R5) was changed. On 10/28/24 at 3:35PM, V7, CNA, said, I do not know the last time (R5) was changed. I work in the back; I just came to help. On 10/28/24 V5, V6, and V7 assisted R5 from the reclining wheeled chair to the bed with a mechanical sling lift. As R5 was lifted out of the chair, the outside of R5's pants were saturated with urine. When R5's pants were removed the strips that show the incontinent brief is wet were dark black and a yellow tint showed through the plastic exterior of the brief. The absorbent material in the incontinent brief was saturated throughout all areas including the thin absorbent areas of the brief that come up to the abdomen and lower back. The white absorbent material was stained dark yellow/brown. Page 1 of 3 145702 145702 10/28/2024 Fair Oaks Rehab & Healthcare 1515 Blackhawk Boulevard South Beloit, IL 61080

F 0677 Level of Harm - Minimal harm or potential for actual harm R5's left, and right coccyx area looked like, Moisture Associated Skin Disorder. When V5 CNA wiped R5's coccyx/sacral area, R5 moved away and winced in pain. On 10/28/24 at 3:35PM, V5, CNA, said, (R5's) pants are wet, the diaper is wet. R5 was asked, is the open/excoriated areas to the left, and right of the coccyx new? R5 stated, I do not know. Residents Affected - Few On 10/29/24 at 11:15AM, V10, CNA, said, Dependent residents that are incontinent are checked every two hours or a resident that is a heavy wetter could be sooner. On 10/28/24 at 11:41AM, V1, Administrator, said, zzz'I do not have a policy for Activities of Daily Living Care for Dependent Residents. We follow Standard Nursing Practice. 145702 Page 2 of 3 145702 10/28/2024 Fair Oaks Rehab & Healthcare 1515 Blackhawk Boulevard South Beloit, IL 61080

F 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to follow R3's dietary care plan for food preferences for 1 of 3 residents (R3) in the sample of 8. Residents Affected - Few The findings include: R3's Care Plan on 10/28/24 shows my dietary preferences will be honored. Foods I dislike are Peas. On 10/28/24 at 12:34PM, R3 was alone in his room, lying in bed with the head of the bed raised. R3's overbed table held the noon meal. R3 had soup, pasta salad, sandwich, and pea salad. R3 did not eat the pea salad. On 10/28/24 at 12:34PM, R3 shook his head when asked if he liked peas. 145702 Page 3 of 3