Health inspection·October 20, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review the facility failed to provide timely staff response to call lights for five residents of five residents (R12, R40, R45, R46, R53) reviewed for call lights in the sample of 34. Residents Affected - Some Findings include: 1. On 10/17/23 at 10:48 am, R45, who is alert and oriented, stated call lights take a long time, too long, but could not indicate how long. R45's Face Sheet documented an admission date of 4/17/23 and diagnoses including Hemiplegia and Hemiparesis of the Right Dominant Side and Epilepsy. 2. On 10/18/23 at 9:45 am, R46 was alert and oriented. R46 stated call lights often take up to 40 minutes to be answered. R46's Face Sheet documented an admission date of 7/21/23 and diagnoses including Polyneuropathy, Hypertension, Chronic Pain, and Chronic Non Pressure Ulcers of the Lower Extremities. 3. On 10/17/23 at 12:53 pm, V5 (family member of R53) was observed ambulating R53 out of the bathroom. R53 was alert but oriented only to self. V5 stated she had been trying for 45 minutes to get staff to help her take R53 to the bathroom, but, They kept saying they would but they never did, so I decided to take him myself. V5 stated she visits R53 daily from early in the morning until bedtime, and waiting 45 minutes or more for staff assistance is an ongoing problem. V5 stated because of this issue, at the end of October 2023 she plans to take R53 back home. R53's Face Sheet documented an admission date of 9/1/23 and diagnoses including Parkinsons Disease, Hypertension, and Unspecified Dementia. 4. On 10/17/23 at 1:45 pm, R40 was in her room lying in bed. R40 who was alert and oriented stated call lights routinely take up to 45 minutes to be answered. R40 activated her call light, which was answered by staff 21 minutes and 29 seconds later. R40 stated some of the call light system on that hall has been inoperable for over a month. R40 stated sometimes staff do not hear the residents bells ringing so she has to go get staff herself to go help them. R40's Face Sheet documented an admission date of 1/14/22 and diagnoses including Hypertension, Diabetes Type 2, Major Depressive Disorder, and Difficulty Walking. Page 1 of 9 145760 145760 10/20/2023 Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. On 10/18/23 at 10:36 AM, R12 stated the bell call system is not always effective in providing timely assistance, especially when the door to his room is closed. R12 stated that at times he has had to wait longer than 30 minutes for staff to answer his call bell request. R12 stated that staff do apologize and express they were busy assisting other residents. R12 stated he is able to state the 30 minute response time, by evidence of watching the clock in his room. R12 stated that he uses just the hand bell, and not the electronic call light system as it does not function properly. R12 confirms that the facility has attempted to make repairs and is awaiting installation of a new call light system. R12 was alert and oriented to person, place and time during this interview. Grievance Logs documented the following: 9/15/23: Call lights (not) fixed. 8/18/23: Call lights. 5/19/23: Too long to answer call lights. 4/21/23: Too long for call lights. A Resident Call Bells Policy dated 11/5/20 stated, The facility will be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each residents bedside, toilet, and bathing facilities. Calls for assistance shall be answered timely. 145760 Page 2 of 9 145760 10/20/2023 Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure that call bells are placed within reach of residents for 2 of 15 residents (R3 and R25) reviewed for call lights in a sample of 34. Residents Affected - Few The Findings Include: 1. R25's admission record documents an admission date of 1/27/20. This record also lists medical diagnosis that include: paralytic gait, anxiety disorder, contracture of the left and right hand and hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side. R25's Quarterly Minimum Data Set, dated [DATE] documents that R25's Brief Interview for Mental Status score is a 9 indicating he has a moderate impairment of cognition. This same document in Section G indicates that R25 requires extensive assistance of two persons for: bed mobility, transfers, toilet use, persona hygiene, and dressing. On 10/17/23 at 10:30 AM, R25 was observed in bed watching television and his call bell was over on a bedside dresser not within reach. When asked how he notifies staff of his needs, R25 stated that the call lights don't work and that 'little bell' is of no use that far away. R25 stated that he will just have to yell when he needs something, and that happens frequently because they forget to move the bell close to him. 2. On 10/19/23 at 10:35 AM, R3 was observed lying in bed, sleeping, rolled on her side, with the side of face in direct contact with the partial side rail. R3's call light button was observed in her reach, attached to the partial side rail. A bell was also observed on her bedside table, which was out of R3's reach. R3's call light was pushed by surveyor, attempting to be activated, with no light illuminating in the hall above the resident's door or sounding. Staff were observed walking by the room for 5 minutes as evidence by watching a clock and continuous observation, with none stopping to assist R3 away from the rail. On 10/19/23 at 10:48 AM, R3 was observed as being repositioned in bed, still sleeping, with her face off of the bed rail. R3's call light button as well as the bell were observed out of her reach. On 10/19/23 at 10:58 AM, V1 (Administrator) confirms that R3's call light was not functioning and the bell was out of her reach. V1 acknowledges that R3's cognition is not such that she could potentially utilize a call light consistently, but despite a resident's cognition status, a functioning call system should be available for resident use. V1 stated that she would expect staff to check on R3 more frequently due to her low cognition to ensure her well being. Review of R3's Minimum Data Set (MDS) dated [DATE] documented as Brief Interview for Mental Status (BIMS) score of 7, indicating she is cognitively impaired. Review of this same MDS documents in section G0110 for bed mobility that R3 requires extensive assistance of 2 plus persons physical assistance. Review of the facility policy titled, Policy & Procedure Resident Call Bells with a revised date of 11/5/20 documents, .5. If a resident is unable to utilize the communication system, it should still remain within reach of resident however staff will check resident at an increased frequency which will be based on nursing's assessment of the residents needs. 145760 Page 3 of 9 145760 10/20/2023 Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on record review and interview the facility failed to update the comprehensive care plan with new focus areas and interventions for 1 of 15 residents (R47) reviewed for care plans in a sample of 34. Residents Affected - Few The Findings Include: R47's admission record documents an admission date of 1/23/23. This same document includes the following diagnosis: Alzheimer disease, anxiety, and depression. On 9/24/23 a dietary recommendation note for R47 written by V6 (Registered Dietitian) documents r/t (related to) wt (weight loss) and current intakes , rec (recommend) mighty shakes bid (twice daily). R47's current physician order sheet has an order for mighty shakes with meals twice a day with a start date of 9/25/23. On 10/19/23 at 12:30 PM, V4 (Minimum Data Set Coordinator/Care Plan Coordinator) verified that R47's weight loss and mighty shake were not on the comprehensive care plan and stated that she will speak with the Dietary Manager to see about updating the care plan to ensure all problem areas are included. The Comprehensive Care Plan Policy dated 6/25/20 states that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident 5. Care Plans are revised as changes in the resident dictate. Care Plans are reviewed at least quarterly. 145760 Page 4 of 9 145760 10/20/2023 Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a residents medication regimen was free from unnecessary medications for one of five residents (R33) reviewed for unnecessary medications in the sample of 34. Residents Affected - Few Findings include: R33's Face Sheet documented an admission date of 11/19/22 and diagnoses including Alzheimer's Dementia and Unspecified Psychosis. R33's Physicians Orders documented an order for Risperdal 0.25mg (milligrams) one tablet at bedtime with a start date of 9/11/23. R33's Psychopharmacological Medication Flow Sheet documented an entry dated 6/23/21,Risperdal 0.5mg give one at bedtime, and the next entry dated 9/11/23, (decrease) Risperdal to 0.25mg. at bedtime. A 9/11/23 Medication Review Request documented,Risperdal 0.5mg Can we possibly do a GDR (Gradual Dose Reduction) or place her on a different medication?, with the Physicians response,Decrease Risperdal to 0.25mg. daily. There was no documentation in R33's chart to indicate a GDR was attempted between 6/23/21 and 9/11/23. On 10/20/23 at 09:32 am, V2 (Director of Nurses) confirmed that R33 did not receive a GDR for R33's Risperdal between 6/23/21 and 9/11/23. V2 stated the interdisciplinary committee meets usually once per month to discuss resident GDRs. V2 stated residents on psychotropic medications should be reviewed for a possible GDR at least quarterly. V2 stated after the committee meets and a GDR is recommended, a GDR Review Request is sent to the prescribing MD (Medical Doctor). V2 stated they have had difficulty with getting the Review Requests back from the doctor so V2 recently submitted a Quality Assurance plan to address this issue. An Unnecessary Medications Policy dated 11/9/19 stated,The purpose of this procedure is to ensure the resident is free from unnecessary medications. An unnecessary medication is an excessive dose, for excessive duration, without adequate monitoring, (or) without adequate indications for use. 145760 Page 5 of 9 145760 10/20/2023 Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for two of 14 residents (R33, R47) reviewed for medication errors in the sample of 34. Residents Affected - Few Findings include: 1. R33's Face Sheet documented an admission date of 6/8/21 and diagnoses including Cerebral Infarction, Unspecified Psychosis, Alzheimer's Dementia, and Hypertension. R33's Physicians Orders documented an order for Trazodone 50 mg (milligrams) one tablet twice daily with a start date of 9/11/23. R33's Medication Administration Record for September and October 2023 indicated R33 was receiving Trazodone 50mg one tablet twice daily. A Medication Review Request dated 9/11/23 and signed by R33's Physician documented, Increase Trazodone to 50mg one half tablet twice daily, (diagnosis), Other Depressive Episodes. On 10/20/23 at 09:32 am, V2, Director of Nurses, acknowledged the 9/11/23 medication order for R33 had been incorrectly entered into the medical record. V2 stated she would call R33's Physician immediately to report the error and obtain further instructions. V2 stated R33 has had no adverse effects from the medication increase. 2. R47's admission record indicates an admission date of 1/23/23. This same document lists R47's medical diagnosis that include: Alzheimer's Disease, Depression, and Anxiety. R47's October 2023 Physician Order Sheet listed an order for Alprazolam 0.25 milligrams 1 tablet every 8 hours as needed for anxiety, with a start date of 10/4/23 for 14 days. R47's medication administration record documents that a Alprazolam 0.25 milligrams was administered as a PRN (as needed dose) on 10/19/23. On 10/19/23 at 1:00 PM, V2 (Director of Nursing) verified that the Alprazolam given on 10/19/23 did not have a current order and that she would call the physician to report a med error and find out if he would like to renew the prescription. A Medication Error Management Policy dated 11/5/19 documented, It is the policy of this facility to establish and follow a uniform process of medication error management. It is the responsibility of every employee to report any known, suspected, or potential medication error. It will be the responsibility of nursing administration to monitor these reports and initiate any appropriate action. 145760 Page 6 of 9 145760 10/20/2023 Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454

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 store controlled medications under double locks per current standards of practice for 1 of 4 residents (R29) reviewed for controlled medication storage in the sample of 34. Findings Include: On 10/20/23 at 9:47 AM, observation of the locked medication storage room with V3 (Licensed Practical Nurse) present revealed a refrigerator labeled for medication storage only. This refrigerator was not observed as being locked. Present inside the refrigerator was an open bottle of Lorazepam oral concentrate 2 milligrams / milliliter labeled for R29. V3 confirms that this refrigerator is not kept locked, although the Lorazepam is acknowledged to be stored in this refrigerator. Other medications such as insulin and vaccinations were also noted to be stored in this refrigerator. On 10/20/23 at 10:41 AM, V2 (Director of Nursing), confirms that Lorazepam is a controlled medication and despite receiving conflicting information from their pharmacy, should be kept under a double lock system. V2 stated that nursing staff have previously been instructed not to store the Lorazepam in that refrigerator, due to the inability for the medication to be double locked. As found at https://www.deadiversion.usdoj.gov/schedules/, Lorazepam is listed as being a Schedule IV medication. Review of the facility policy for Controlled Substance Storage, dated November 2021 documents, Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medication or per state regulation . 145760 Page 7 of 9 145760 10/20/2023 Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed ensure a functioning or equivalent notification call system was available for resident use. This failure has the potential to effect all 60 residents residing in the facility. Residents Affected - Many Findings Include: On 10/17/23 at 10:00 AM, V1 (Administrator) stated that the electronic call light system is not working. V1 stated after ordering new parts which failed to correct the problem, a whole new call light system has been ordered. The current plan is that they are telling residents to ring their hand bell, along with using the call light. V1 stated that the call light system will light up, but it doesn't make a sound. Residents are told to use both the call light and the bell, or just the bell. The staff then go down the hall to find who's bell it is, and if they use the call light it helps them respond quicker. The system will take a couple weeks to install once it comes in. There is not a definite date on when this will occur due to waiting on the system to be delivered. 1. On 10/19/23 at 10:35 AM, R3 was observed lying in bed, sleeping, rolled on her side, with her side of face in direct contact with the side rail. R3's call light button was observed in her reach, attached to the side rail. A bell was also observed on her bedside table, which was out of R3's reach. R3's call light was pushed, attempting to be activated, with no light illuminating in the hall, above the resident's door. Staff were observed walking by the room for 5 minutes as evidence by watching a clock, with none stopping to assist R3. On 10/19/23 at 10:58 AM, V1 confirmed that R3's call light was not functioning and the bell was out of her reach. V1 acknowledges that R3's cognition is not such that she could potentially utilize a call light consistency, but despite a resident's cognition status, a functioning call system should be available for resident use. V1 stated that she would expect staff to check on R3 more frequently to ensure her well being. V1 confirms that R3's call light was not properly functioning. 2. On 10/18/23 at 10:36 AM, R12 stated the bell call system is not always effective in providing timely assistance, especially when the door to his room is closed. R12 stated that at times he has had to wait longer than 30 minutes for staff to answer his call bell request. R12 stated that staff do apologize and express they were busy assisting other residents. R12 stated he is able to state the 30 minute response time, by evidence of watching the clock in his room. R12 stated that he uses just the bell, and not light system as it does not function properly. R12 confirms that the facility has attempted to make repairs and is awaiting installation of a new call light system. R12 was alert and oriented to person, place and time during this interview. 3. On 10/17/23 at 1:45 PM, R40 was in her room lying in bed. R40 who was alert and oriented stated call lights routinely take up to 45 minutes to be answered. R40 activated her call light, which was answered by staff 21 minutes and 29 seconds later. R40 stated some of the call light system on that hall has been inoperable for over a month. R40 stated sometimes staff do not hear the residents bells ringing so she has to go get staff herself to go help them. Grievance Logs documented the following: 9/15/23: Call lights (not) fixed. 8/18/23: Call lights. 5/19/23: Too long to answer call lights. 4/21/23: Too long for call lights. Review of the facility policy with a revision date of November 5, 2020 documents, The facility will 145760 Page 8 of 9 145760 10/20/2023 Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many be adequately equipped to allow resident to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, toilet and bathing facilities. Calls for assistance shall be answered timely. The same policy goes on to state, .2. A tap bell supply/hand bell will be available to be used in the case of a communication system malfunction. In the event the primary communication system malfunctions, a tap/hand bell shall be issued to each resident to call for assistance with and shall serve as the new communication system until the primary communication system is functioning again. Review of the Resident Matrix dated 10/17/23 documents 60 residents reside in the facility. 145760 Page 9 of 9