Health inspection·July 13, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a physician was notified of a change in condition for 1 of 3 residents (R25) reviewed for hospitalizations in the sample of 15. The findings include: R25's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include systolic congestive heart failure, acute eosinophilic pneumonia, personal history of COVID-19, paroxysmal atrial fibrillation, and hypertension. R25's facility assessment dated [DATE] showed she has severe cognitive impairment and extensive assist for most cares. On 7/13/23 at 9:59 AM, R25 was in common area sitting in her wheelchair, covered with a blanket, and resting with her head down. R25's acute care hospital documents dated 6/15/23 showed she was admitted to the hospital on [DATE] and discharged back to the facility on 6/15/23. The same documents showed, . presented to the hospital on 6/7 from nursing home with cough, chills, shortness of breath . Patient was subsequently admitted to the hospital for pneumonia . R25's 5/30/23 eMAR (electronic medication administration record) entered at 9:34 AM showed, Acetaminophen 500 mg given for complaint of lower back pain. R25's 5/30/23 eMAR note entered at 4:41 PM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . resident requested for cough. R25's 6/3/23 eMAR note entered at 5:00 PM showed, Acetaminophen 500 mg . complains of headache and all over aches. R25's 6/4/23 eMAR note entered at 3:22 AM showed, Acetaminophen 500 mg . complains of aches all over. R25's 6/4/23 eMAR note entered at 10:30 AM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . Resident has a nonproductive cough . R25's 6/4/23 eMAR note entered at 10:30 AM showed, Acetaminophen 500 mg . Resident requested for overall feeling of general discomfort . Page 1 of 6 145770 145770 07/13/2023 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R25's 6/4/23 Health Status Note entered at 7:20 PM showed, Resident complains of overall general feeling of discomfort today. Overall general appearance lethargic, poor appetite. Has nonproductive cough . PRN (as needed) APAP (acetaminophen) given, and cough syrup given . will continue to monitor. R25's 6/5/23 eMAR note entered at 10:02 AM showed, Acetaminophen 500 mg Resident complains of overall general discomfort. 'I just don't feel good today.' R25's 6/5/23 eMAR note entered at 10:03 AM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . Resident has nonproductive cough. R25's 6/6/23 eMAR note entered at 9:39 AM showed, Acetaminophen 500 mg . Resident requested for join pain. R25's 6/6/23 eMAR note entered at 9:55 AM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . nonproductive cough. R25's 6/6/23 eMAR note entered at 5:20 PM showed, Guaifenesin Liquid (Cough Syrup) 100 mg . resident requested for cough. R25's 6/7/23 Health Status Note entered at 11:07 AM, Resident requesting to go to the ER (emergency room) as she is feeling weak, cough and SOB (shortness of breath). Resident requests I call daughter in law and ask what she thinks . ambulance called for transport to [acute care hospital] . R25's 6/7/23 progress note showed, Situation: . Shortness of breath . Nursing observations, evaluation, and recommendations are Resident is talking slowly due to her feeling SOB . nonproductive cough and sitting with eyes closed . On 7/13/23 at 10:01 AM, V3 (Registered Nurse/RN) said the nurses should notify the provider if there is a change in the resident's treatment. V3 said they notify the physician through their electronic medical record unless they are notifying the physician of something urgent which they would call to the physician. On 7/13/23 at 10:10 AM, V6 (RN) said she sent R25 to the hospital when assessed her and heard fluid on her lungs. V6 said R25's general overall appearance was poor; she was pale and withdrawn. V6 said they call the physician if there is a significant change in a resident but for non-urgent notifications, they use the electronic record to notify. V6 said there was no documentation of notification to R25's physician between 5/11/23 and 6/7/23. On 7/13/23 at 10:49 AM, V2 (Director of Nursing) said if the nurse notes a change of condition, it is determined on a case-by-case situation if the physician is notified. If a resident starts to not feel well the nurse should do an assessment which would include vitals, lung sounds, all of it and then if they are depending upon the assessment, you will notify the physician or monitor the resident. V2 said if the resident's condition continues to get worse the nurse would notify the physician. V2 said the nurse should have started a notification to the physician to say the resident is using the Tylenol and cough syrup when she started taking them regularly. V2 said the 6/4/23 Health Status Note should have been a notification to the physician so the physician would be aware of the resident's complaints, the medications given, and the nurse's assessment. The facility's policy implemented 2/1/22 titled Notification of Changes showed, . the purpose of 145770 Page 2 of 6 145770 07/13/2023 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification . Compliance Guidelines: The facility must inform the resident, consult with the resident's physician, and/or notify the resident's facility member or legal representative when there is a change requiring notification. Circumstances requiring notification include . 2. Significant change in the resident's physical, mental or psychosocial condition such as a deterioration in health . 3. Circumstances that require a need to alter treatment. This may include. new treatment . 145770 Page 3 of 6 145770 07/13/2023 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 assess an area of pressure after one was identified for 2 of 4 residents (R20, R48) reviewed for pressure in the sample of 15. Residents Affected - Few The findings include: The facility's 2/1/22 Pressure Injury Prevention and Management Policy showed the facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment. Assessments of pressure injuries will be performed by a licensed nurse and documented. 1. R48's face sheet showed an [AGE] year-old female with diagnosis of psychotic disorder, dementia, osteoarthritis, and muscle weakness. On 7/12/23 at 9:43 AM, V3 (Wound Nurse) performed wound care to R48's left heel wound. R48 complained of severe pain when the wound was cleaned and general pain aside from the wound itself. There was an oval shaped open area to the left lateral heel. The wound edges were very pale and well defined. Moderate serous drainage was noted from the wound. There was no odor and the wound measured approximately 1.5 centimeters X 1 centimeter with some depth. On 7/13/23 at 9:56 AM, V2 (Director of Nursing/DON) said R48's wound was found on 3/10/23 and a full wound assessment was not done. An initial wound assessment should include the location, color, shape, size, a description of the area around the wound, any odor, drainage, and if the skin is intact. A wound assessment should be done when it's found to establish a baseline to measure progression or improvement by. V2 said an assessment could be done by briefly visualizing the wound and noting any odor. The facility's 7/10/23 weekly wound report showed R48 had a Stage 3 (previous DTI-deep tissue injury) to the left outer heel that was facility acquired on 3/10/23. R48's 3/10/23 weekly skin assessment showed a small painful discolored area to the left outer heel. R48's first wound assessment dated [DATE] showed the wound was acquired 5/22/23 and was initially a suspected deep tissue injury and currently a Stage 2 pressure injury. This assessment showed it was the initial assessment and there was no previous assessment for reference. R48's 7/10/23 weekly wound assessment showed the left heel wound progressed to a Stage 4 pressure injury. R48's 6/6/23 facility assessment showed she was not cognitively intact and required extensive assistance of two plus persons physical assistance for bed mobility, transfers, toilet use, personal hygiene, and bathing. R48's care plan showed an alteration in skin integrity related to fragile skin as evidenced by a Stage 2 pressure injury to the coccyx on admission, a healed deep tissue injury to the sacrum that healed 5/29/23, and a Stage 3 pressure injury to the left outer heel (current). 145770 Page 4 of 6 145770 07/13/2023 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0686 Level of Harm - Minimal harm or potential for actual harm The National Institutes of Health website showed a wound assessment standard includes evaluation of the depth, length, and width of the wound. Evaluation of the wound bed for exposed bone, vessels, hardware, or subcutaneous fat. Survey for presence, type, and amount of exudate (drainage). Assess surrounding skin tissue for signs of injury. Check the wound margins. Evaluate for warmth, pain, odor, purulence, delayed healing, or other signs of infection. Residents Affected - Few 2. R20's face sheet showed a [AGE] year-old female with diagnosis of dementia, acquired absence of left toe, osteomyelitis of the left foot and ankle, heart attack, dementia, and chronic kidney disease Stage 3. On 7/12/23 at 9:17 AM, V3 (Wound Nurse) performed a dressing change to R20's left medial ankle. The open area was circular, pale, and approximately 1 centimeter in diameter with some depth. There was a moderate amount of serous drainage which caused the dressing to come off in her stocking. There was no foul odor, and the wound edges were well defined. R20 tolerated the procedure without complaints of pain. On 7/13/23 at 9:56 AM, V2 (DON) said R20's pressure injury started out as a teeny tiny scab. I found it on 6/16/23 at 4:00 PM. It was on her left inner ankle. I had the wound nurse do full wound assessment on Monday morning (6/19/23). A full wound assessment should be done when a wound is identified. R20's 5/12/22 admission assessment does not show any impairment of skin integrity. R20's 5/20/22 pressure injury risk assessment showed she was at risk for developing pressure injuries. The facility's 7/10/23 weekly wound report showed R20 had a Stage 2 pressure injury to the left medial ankle that was facility acquired on 6/19/23 (wound was identified 6/16/23). R20's 6/16/23 weekly skin assessment authored by V2 (DON) showed an old scab to the left inner ankle. There was no wound assessment documented. R20's 6/19/23 weekly wound assessment showed a left medial ankle wound assessment was not completed until 3 days after identification. This assessment showed the pressure injury was a Stage 2. R20's 7/10/23 weekly wound observation showed the left medial ankle wound had progressed to a Stage 3. R20's care plan showed she was at risk for impaired skin integrity and had a Stage 2 pressure injury to the left ankle and a healed Stage 3 pressure injury to the left heel. R20's 5/21/23 facility assessment showed she was not cognitively intact and required extensive assistance of two plus persons physical assistance for bed mobility, transfer, toilet use, and personal hygiene. This assessment showed R20 was at risk for developing pressure injuries and did not have any unhealed pressure injuries. 145770 Page 5 of 6 145770 07/13/2023 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were in place for a resident at risk for falls for 1 of 4 residents (R54) reviewed for falls in the sample of 15. The findings include: R54's face sheet showed a [AGE] year-old female admitted to the facility on [DATE]. R54's diagnosis included a history of falling, dementia, physical debility, and polyosteoarthritis. On 7/13/23 at 09:49 AM, R54 was sitting in a high back reclining chair in the hall area outside her room. No staff were present. R54 was leaning and reaching forward. V9 (Certified Nursing Assistant/CNA) came down hall and saw R54 leaning for and reaching forward while in the chair. R54's chair pad alarm was disconnected thus inoperable. The wire was not connected to the transmittal box. On 7/13/23 at 9:49 AM, V9 said if the cord isn't plugged into the transmitter, it won't work. It won't alarm if she (R54) tries to get up. On 7/13/23 at 9:56 AM, V2 (Director of Nursing/DON) said it's important that fall interventions are in place and working to prevent falls, injury, and harm to the residents. R54 was in a wheelchair when she fell (forward out of the chair) in the chapel. Since R54's admission on [DATE], there were 4 fall incidents documented. R54's 5/17/23 fall incident showed she was found in her room, lying on her back in front of a recliner. R54's 5/23/23 fall incident showed she was in the chapel with other residents and a volunteer. All four resident witness statements showed R54 fell forward out of the chair and on to the floor. This report showed R54 complained of pain to the right shoulder and right elbow. R54 had a skin tear to the right elbow and a lump to the right shoulder. R54 was sent to the emergency room. Xray records showed a fracture to the right upper extremity and right pubis ramus. R54's 6/20/23 fall incident showed she was found in her room laying on the floor on her back in front of a recliner. R54's 7/7/23 fall incident showed R54 was found sitting on the floor next to the wheelchair in the hallway where her room was located. R54's care plan showed she was at risk for falls and to utilize a bed/chair alarm. R54's 5/15/23 facility assessment showed she was not cognitively intact. The facility's 9/2/22 Fall Prevention Policy showed the nurse will initiate interventions on the care plan. 145770 Page 6 of 6