Health inspection·March 21, 2025

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to only allow residents in the resident council meeting, failed to record attendance at resident council meeting minutes, failed to identify residents who had concerns during resident council meeting minutes and failed to resolve concerns voiced in the resident council meeting. These failures have the potential to affect all 62 residents who currently reside in the facility. Residents Affected - Many Findings Include: The Illinois Long Term Care Ombudsman Resident Council Tool Kit for Staff Liaison documents A resident council is an independent group of long term care facility residents who typically meet at a minimum of once a month to discuss concerns and suggestions in the facility and to plan activities that are important to them. Resident Councils are structured in various ways, but usually every resident living in a facility is an automatic member of the council. All grievances raised during the meeting should be recorded in the minutes. Responses to grievances should be received in a timely manner as indicated in the facility's grievance policy. Responses should be specific and should be reflected in subsequent minutes. The Illinois Long Term Care Ombudsman Program Resident Council Tool Kit for Staff Liaison documents Families and friends of residents who live in the community retain the right to form family councils. If there is a family council in the facility, or if one is formed at the request of family members or the ombudsman, a facility shall make information about the family council available to all current and prospective residents, their families and their representatives. The information shall be provided by the family council, prospective members or the ombudsman. The Facility's Resident Council Minutes dated 4/6/24 document We had 14 residents at council. Also in attendance were two family members. The Resident Council Minutes did not document the names of anyone present other than V8 (Activity Director). The Facility's Resident Council Minutes dated 5/2/24 document Environmental Services: sides of toilets not being cleaned and wiped down. 3 out of 6 residents had this problem. The Resident Council Minutes did not document the names of the residents with this concern or what the plan was to address this concern. The Resident Council Minutes for the next month dated 6/6/2024 did not document any resolution to this concern. The Facility's Resident Council Minutes dated 5/2/24 document We had 6 residents at council. Also in attendance was the food and nutrition director. The Resident Council Minutes did not document the names of any of the residents at the meeting, nor did the minutes address the reasoning for the food and nutrition director in the meeting or who invited that person. Page 1 of 5 145703 145703 03/21/2025 Silvis Center for Nursing Rehab & Care 1455 Hospital Road Silvis, IL 61282

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The Facility's Resident Council Minutes dated 6/6/24 document Maintenance: sink was making a noise in two of the resident's rooms. The Resident Council Minutes do not document which residents had this concern or what the plan was to address the concern. The Facility's Resident Council Minutes for the next month dated 7/11/24 does not document any resolution to this concern. The Facility's Resident Council Minutes dated 6/6/24 documents We had 8 residents at council. The minutes do not identify the name of any of the residents present. The Facility's Resident Council Minutes dated 7/11/24 documents We had 5 residents at council. Also in attendance was the ombudsman, the food and nutrition director and the head chef. The minutes do document the names of any of the residents present. The minutes do not document the name or the reasoning for the food and nutrition director and the head chef to be in the meeting, nor who invited them. The Facility's Resident Council Minutes dated 8/1/24 document Environmental Services: All 7 residents at the council said their floor needs to be scrubbed; Nursing: All 7 residents at the council said they are concerned about the CNA's long nails. Both concerns had (V8/Activity Director) will write up grievance form and submit to the appropriate department. The Resident Council Minutes did not identify the names of which residents had concerns. The next months Resident Council Minutes dated 9/5/24 do not document any resolution to these concerns. 145703 Page 2 of 5 145703 03/21/2025 Silvis Center for Nursing Rehab & Care 1455 Hospital Road Silvis, IL 61282

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, and interview, the facility failed to ensure resident privacy was protected by not closing the door, during nursing care, for one resident (R262) of 16 residents (R5, R8, R18, R20, R21, R34, R35, R39, R40, R45, R268, R312, R313, R314, and R315), reviewed for privacy, in a total sample of 29. Residents Affected - Few FINDINGS INCLUDE: On 03/18/25, at 12:00 p.m., while standing in the hallway by R262's room door, the State Agency observed R262's door to be open. R262 was heard vomiting and complaining to V4/Licensed Practical Nurse that her stomach was hurting. V5/R262's Daughter was standing in the hallway by R262's door. On 03/18/25, at 12:00 p.m., V5 stated, The door should be closed. On 03/18/25, at 12:03 p.m., at 12:03 V4 came out of R262's room. When asked about R262's door being open and R262 being heard in the hallway vomiting and complaining about pain, V4 stated, [the door] should have been closed for privacy. 145703 Page 3 of 5 145703 03/21/2025 Silvis Center for Nursing Rehab & Care 1455 Hospital Road Silvis, IL 61282

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to reweigh a resident after a significant change for one resident (R8) of three residents reviewed for weight change in a total sample of 29. Residents Affected - Few Findings Include: R8's Medical Record documents her weight on 11/3/24 as 125.8 pounds. R8's Medical Record documents her weight to be 173 pounds on 11/22/24 and again on 12/1/24. R8's Progress Note dated 12/27/24 documents that the Registered Dietician did not make any new recommendations for R8's diet because she questioned the accuracy of the weight. Registered Dietician documented This weight was possibly done with her wheelchair. On 3/19/25 at 2:25 PM V2 (Director of Nursing) stated (R8) did not have any significant weight gain. She should have been reweighed after the 11/22/24 weight of 173. We have no specific policy to say that, but good nursing judgement should have told (staff) that (R8) did not gain almost 50 pounds in one month. 145703 Page 4 of 5 145703 03/21/2025 Silvis Center for Nursing Rehab & Care 1455 Hospital Road Silvis, IL 61282

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 record review and interview the facility failed to attempt a gradual dose reduction of a psychotropic medication for one resident (R39) of five residents reviewed for unnecessary medications in a total sample of 29. Findings Include: The Facility's Psychotropic Drugs Usage policy dated 11/2017 documents Psychotropic drug use is based upon the comprehensive assessment of the resident. Psychotropic medications are given as necessary to treat a specific condition that is diagnosed and documented. Residents receiving psychotropic medications will have gradual dose reductions and behavioral interventions implemented unless contraindicated. The Facility's Psychotropic Drugs Usage policy dated 11/2017 documents Dosage reduction of antipsychotics, anxiolytics, and hypnotics are attempted per CMS guidelines unless clinically contraindicated. The physician weighs the risk versus the benefit and documents it in the medical record if the gradual dose reduction is causing an adverse effect on the resident or is deemed a failure, the gradual dose reduction is discontinued. Documentation of this decision and the reason for it are included in the clinical record. R39's Physician Order Sheet documents 06/22/2023 Olanzapine (antipsychotic) 12.5 mg (milligrams) every day for Schizoaffective type Bipolar. R39's Medical Record did not include any documentation of any attempts to gradually reduce R39's Olanzapine since 06/22/2023. On 6/20/25 at 2:00 PM V1 (Registered Nurse/Administrator) stated that she is the person currently responsible for the facility's psychotropic medication program. V1 confirmed that R39 had not had any gradual dose reductions since 2023. V1 confirmed that CMS guidelines would have been to attempt a gradual dose reduction every year so R39 should have at least one GDR (gradual dose reduction) done by July 2024 or documentation of why we don't think it should be done. V1 confirmed neither documentation was available for R39. 145703 Page 5 of 5