Health inspection·May 22, 2024

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 obtain a physician's order, failed to obtain consent, and failed to perform an assessment for a resident using a seat belt in a motorized wheelchair for one of one resident (R44) reviewed for restraints in the sample of 14. Residents Affected - Few The findings include: R44's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including muscle weakness, contractures to both knees, tracheostomy status, hemiplegia, malnutrition, anxiety disorder, and contracture to her left hand. On May 21, 2024 at 10:10 AM, R44 was in her room in her motorized wheel chair. R44 had a seat belt in place to her lower abdomen. R44 said she uses the seat belt because she slides out of the chair. The Self-Releasing Seat Belt Informed Consent for Use was signed by R44 on May 21, 2024. R44's Restraint Enabler was entered on May 21, 2024 at 3:41 PM. R44's Order Summary Report does not show any orders for a self-releasing seat belt prior to May 21, 2024. R44's Care Plan that showed R44 uses a seat belt was not initiated until May 21, 2024. R44's Care Plan shows document self-releasing seat belt and release and ensure valid consent is on the chart prior to use of the self-releasing seat belt. R44's Care Plan also shows the resident is able to release the seat belt by herself, assess at quarterly and as need, which was initiated on May 21, 2024. On May 22, 2024 at 9:50 AM, V2 (Director of Nursing) said R44 has used a seat belt since she came to the facility. V2 said that there should be a doctor's order, consent by the residents, and assessments should be done quarterly and as needed. The facility's Restraint Free Environment policy implemented on May 2, 2023 shows, Residents may use devices per request for positioning and safety purposes that they are able to freely remove on their own with a signed consent. The resident/resident's representative may request the use of a physical restraint; however the facility is responsible for evaluating the appropriateness of the request. The facility shall explain to the resident/resident's representative, the potential risks and benefits of using a restraint, not using a restraint, and alternatives to restraint use. Page 1 of 10 145770 145770 05/22/2024 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 reassess a resident for safe swallowing after the resident had a choking episode in the facility. The facility failed to supervise a resident, with a history of falls, while the resident was seated on the toilet. The facility failed to ensure residents were transferred by staff in a safe manner. These failures apply to 3 of 14 residents (R14, R23, R42) reviewed for safety and supervision in the sample of 14. The findings include: 1. R14's admission Record showed R14 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, dementia, and cognitive impairment. R14's Progress Note dated 5/19/24 showed, Resident found to be purple in color with airway obstruction. Performed Heimlich maneuver, after a few thrusts resident gasped for air. Resident sat in wheelchair and was tearful. The note showed R14 choked on her evening medications. R14 was not sent to the hospital for an evaluation after the incident. R14's physician was notified on 5/19/24. On 5/20/24 at 12:24 PM, R14 propelled herself in her wheelchair into her room. On R14's bedside table was a box of chocolates. R14 was asked about her choking incident. R14 stated, My nurse gave me my evening meds (medications). I take them whole, one by one. She watched me take them. The nurse walked out of my room. I took a sip of water and suddenly I couldn't breathe. I guess I let out a gasp or a noise. The nurse came in and hit me on my back. I am not sure what I coughed up. R14 stated, since her choking incident, R14 still takes her medications whole and there have been no changes in the type of diet she receives. R14 denied having any previous choking episodes in the facility. R14's physician orders dated 5/20/24 were reviewed. These orders showed no orders to crush R14's medications, no orders for R14 to be evaluated by speech therapy, and no changes in diet orders for R14. On 5/21/24 at 9:10 AM, V5 (Registered Nurse) stated, (R14) doesn't get her meds crushed. She just got her medications this morning. She takes them whole, one by one. On 5/21/24 at 10:27 AM, V6 (Speech Therapist/ST) stated, Parkinson's disease can put a resident at increased risk for swallowing problems. If a resident has a choking episode, on foods or meds, staff must notify the physician and refer the resident to me for an evaluation. Staff should immediately downgrade the resident's diet. Residents, that have swallowing problems or choke, are to be referred to me because I am the one that assesses the resident for safe swallowing or any swallowing problems. V6 stated she had never seen R14 and had not received an order to evaluate R14 as of 5/21/24 at 10:27 AM. On 5/21/24 at 10:39 AM, V2 (Director of Nursing/DON) stated, If a resident chokes in the facility, we notify the doctor, downgrade the resident's diet, and refer the resident to speech therapy for an evaluation. V2 stated, The night (R14) choked. The nurse has just given (R14) her pills. The nurse watched her take the pills. I am not sure how many pills (R14) took. The nurse walked out of (R14's) room and heard a strange noise coming from (R14). The nurse ran back into the room. She saw that (R14) was choking so she did the Heimlich on (R14). After a couple of thrusts, the nurse was able to 145770 Page 2 of 10 145770 05/22/2024 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0689 Level of Harm - Minimal harm or potential for actual harm get pill products out of (R14's) mouth. (R14) was upset but she could breathe. She was able to drink water. V2 stated, (R14) is still getting her meds whole. She hasn't been seen by or referred to speech therapy yet. She should have been. We got busy and didn't get these things done (crushing meds and referral to speech therapy). When V2 was asked how the facility could ensure that R14 could still safely swallow medications and foods since her choking incident, V2 stated, We don't know that she can. Residents Affected - Few The facility's Foreign Body Airway Obstruction Management (Choking) policy dated 5/30/23 showed, Residents with impaired swallowing, neurological disorders or dental issues are at an increased risk for foreign body airway obstruction . Residents should be assessed to determine if they are at a higher risk for foreign body obstruction/choking episodes and care planned accordingly. Consult the speech language pathologist as needed . 2. R42's care plan current care plan showed R42 was at risk for falls due to his diagnoses of impaired cognition related to dementia, weakness, hypotension (low blood pressure), and anxiety. The care plan showed R42 had three unwitnessed falls in the facility, from 2/9/24-5/20/24, because of R42 trying to self-transfer. R42's resident assessment dated [DATE] showed R42 required partial to moderate assistance of staff for toileting and transfers. On 5/20/24 at 8:55 AM, R42 was seated on the toilet in his bathroom with no staff present in R42's room or bathroom. At 9:00 AM, V7 (Certified Nursing Assistant/CNA) entered R42's room to check on R42. From 9:00 AM-9:15 AM, V7 CNA stood outside the bathroom door as R42 remained on the toilet. At 9:20 AM, V7 transferred R42 from the toilet to his wheelchair by holding onto R42's arms. No gait belt was used. On 5/21/24 at 8:49 AM, V8 (CNA) stated R42 should not be left alone on the toilet because he is at risk for falls. V8 stated staff are use a gait belt on any resident that needs assistance from staff to transfer or ambulate. On 5/21/24 at 8:56 AM, V4 (Licensed Practical Nurse) stated, (R42) should not be left alone in the bathroom. He tends to wander and get up on his own. 3. R23's Face Sheet showed R23 had the diagnosis of weakness. A facility assessment done on 3/26/24 showed R23's cognition was intact. The same assessment showed R23 needed partial/moderate assistance to go from sitting to standing and to walk. R23's Witnessed Fall report dated 4/19/24 showed R23 was oriented to person, situation, time, and place. The same document showed R23 fell in her room during a transfer and a predisposing factor was gait imbalance. On 5/21/24 at 1:26 PM, R23 said she had a fall in her room while staff were assisting her to transfer to a scale. R23 said she stood up from her bed and had to take several steps to get to the scale. R23 said the scale was about 4 to 5 feet away. According to R23, her shoe caught the edge of the scale causing her to fall. R23 said staff were present during the fall and staff did not use a gait belt. R23 said staff did not lower her to the floor during the fall. R23 added sometimes staff used a gait belt to assist her to transfer. 145770 Page 3 of 10 145770 05/22/2024 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 On 05/21/24 at 9:21 AM, V12 (CNA) said she was with R23 on 4/19/23 when R23 fell in her room. V12 said the day R23 fell she assessed R23 to stand up from bed by supporting R23 under her arm. V12 said when R23 stood and walked she needed help balancing. V12 said she helped R23 balance by holding onto R23's arm. According to V12, R23 took several steps and attempted to step onto the scale. V12 said as R23 stepped onto the scale V12 was not holding onto R23 and R23 fell. V12 said she did not use a gait belt while assisting R23 to transfer onto the scale. V12 said she only used a gait belt with R23 when walking outside of R23's room. On 05/21/24 at 11:39 AM, V2 (Director of Nursing) said a gait belt should be used when staff provide balance assistance during a transfer. On 05/21/24 at 12:43 PM, V13 (CNA) said gait belts are used to safely transfer residents. On 5/21/24 at 10:46 AM, V14 (R23's Physician) said given R23's comorbidities, she has weak bones putting her at risk for fractures. R23's Care Plan with an initiated date of 1/15/24 showed R23 had limited physical mobility related to weakness and at risk for falls related to noncompliance with assistance with transfers. The facility's Use of Gait Belt policy with a revised date of 5/21/24 showed it is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. 145770 Page 4 of 10 145770 05/22/2024 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to perform peri care in a manner to prevent urinary tract infections for one of six residents (R1) reviewed for peri care in the sample of 14. The findings include: R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, influenza, pneumonia, psychotic disorder, muscle wasting, obesity, fluid overload, weakness, and history of falling. R1's Care Plan initiated November 29, 2023 shows the resident uses disposable briefs. Change every two hours and as needed. On May 20, 2024 at 12:57 PM, V9 and V10 (Certified Nursing Assistants/CNA) provided incontinence care for R1. R1's incontinence brief was saturated with urine and a large amount of stool. V10 CNA wiped a large amount of stool from R1's buttocks with a thin wet wipe. R1's stool was visible through the wet wipe. V10 folded the wet wipe in half and wiped R1's stool from her buttocks again. V10 folded the wet wipe a second time and wiped the stool from R1's buttocks with the same wipe a third time. R1 was turned onto her back. V9 wiped stool from R1's front peri area. V9 folded the wet wipe three times and wiped R1 four times with the same wet wipe prior to disposing of the wet wipe. On May 22, 2024 at 8:30 AM, V11 (CNA) said if stool is noted on a wet wipe, then it should be disposed of and a new wet wipe should be used. On May 21, 2024 at 10:17 AM, V2 (Director of Nursing) said wet wipes can be folded during incontinence care unless there is a large amount of stool. V2 said if there is a large amount of stool, then one wipe should be used and then thrown away and use a new wipe in order to prevent the spread of infection. The facility's Perineal Care policy reviewed May 20, 2024 shows, It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. 145770 Page 5 of 10 145770 05/22/2024 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement weight loss prevention interventions prior to a resident (R32) experiencing a significant weight loss. This failure resulted in R32 experiencing a significant weight loss of 9.6% in three months. This failure applies to 1 of 5 residents (R32) reviewed for weight loss in the sample of 14. Residents Affected - Few The findings include: R32's admission care plan dated 12/29/23 showed R32 was at risk for malnutrition and weight loss related to her diagnoses of dementia, dysphagia (trouble swallowing), depression, and a history of pneumonia. R32's Weights and Vitals Summary showed R32's weights as 156 pounds (lbs.) on 2/6/24, 151 lbs. on 3/4/24, 147 lbs. on 4/17/24, and 141 lbs. on 5/3/24. The record showed R32 experienced a significant weight loss of 9.6% in three months, from 2/6/24 - 5/3/24. R32's Mini Nutritional assessment dated [DATE] showed R32 was deemed at risk for malnutrition and weight loss by V3 (Registered Dietician/RD). The assessment showed V3 RD documented R32's weight as 147 lbs., which showed R32 had experienced a nine-pound weight loss since 2/6/24, but no weight loss preventions, such as supplements and/or supervised dining, were initiated at that time. R32's dietary note dated 5/8/24 showed R32 had sustained a significant weight loss in three months (2/2024-5/2024). The note showed R32 would benefit from ONS/tray additions (supplements added to food tray) to aid in weight management/caloric intakes. The note showed supervised dining, nutritional juice, nutritional shakes, and house supplements were to be initiated at that time. R32's May 2024 physician orders showed a house supplement, nutritional juice, and nutritional shakes were started on 5/9/24. R32's current care plan showed supervised dining for R32 was started on 5/21/24. On 5/21/24 at 11:05 AM, V3 (Registered Dietician) stated prior to 5/21/24, she had last assessed R32, in-person, in January 2024. V3 stated the Mini Nutritional Assessment she completed on R32 in April 2024, was completed remotely. V3 stated, I completed her assessment by reviewing (R32's) information via the computer. I didn't see her in-person. V3 stated the facility monitors residents weight loss, weekly, to intervene before any weight loss becomes significant. V3 stated, I did document she was at risk for weight loss in April (2024). She had also been recently hospitalized which could potentially put her more at risk. When V3 was asked why R32 was not started on weight loss supplements and supervised dining until after R32 had sustained significant weight loss, V3 stated, I don't have a wonderful answer for you. I should have started her on supplements sooner . The facility's Nutrition at Risk policy dated 9/16/23 showed, Weight loss, poor nutritional status, or dehydration should be considered avoidable unless the facility can prove it has assessed/reassessed the resident's needs, consistently implemented related care planned interventions, monitored for effectiveness, and ensured coordination of care among the disciplinary team. Early identification of risk factors, regardless of the presence of any associated weight changes, can help the facility choose appropriate interventions to minimize any subsequent complications . 145770 Page 6 of 10 145770 05/22/2024 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0692 The facility's Weight Monitoring policy dated 2/22/23 showed, A significant change in weight is defined as: 5% change in weight in 1 month, 7.5% change in weight in 3 months, 10% change in weight in 6 months. Level of Harm - Actual harm Residents Affected - Few 145770 Page 7 of 10 145770 05/22/2024 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to measure the external length of a peripherally inserted central catheter (PICC) for 1 of 2 residents (R52) reviewed for intravenous (IV) access in the sample of 14. Residents Affected - Few The findings include: R52's Hospital Discharge Instructions dated 4/26/24 showed R52 had a PICC line placed to receive antibiotics for osteomyelitis (bone infection). On 05/20/24 at 12:30 PM, R52 had a PICC line to her right upper arm. R52 said she had a bone infection in her back and was getting IV antibiotics. R52 said the facility had been doing weekly dressing changes to her PICC line. However, R52 said she did not believe the facility was measuring the external length of the PICC. On 05/21/24 at 11:39 AM, V2 (Director of Nursing) said PICC measurements are done to see if the PICC has migrated. V2 added the measurements are documented in the Treatment Administration Record (TAR). R52's TAR showed the PICC dressing was changed 5/2/24, 5/9/24, and 5/16/24. There was no documented PICC measurements on the TAR. The facility's PICC/Midline/CVAD Dressing Change policy with a reviewed date of 5/20/24 showed measuring the external length of the PICC is done to ensure that it has not migrated and should be done with the weekly dressing changes. 145770 Page 8 of 10 145770 05/22/2024 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review the facility failed to provide residents receiving puree diets with smooth consistency to 5 of 5 residents (R15, R6, R18, R20, R25) receiving pureed diets in the sample of 14. The findings include: The Facility provided a document entitled Diet Type Report, dated 5/20/24 show R15, R6, R18, R20, and R25 were receiving pureed textured diet. On 5/20/24 at 11:50 AM, the facility provided a test tray of puree diets that included pureed lasagna, pureed garlic bread, and pureed mixed vegetables. The pureed garlic bread was thick, chunky, and clumpy, and the pureed mixed vegetables was watery, and required chewing. V15 (Dietary Manager) who was with the surveyor during the test tray process also tasted the pureed test tray. After tasting, V15 pointed to the pureed garlic bread and stated, this is so thick, it needs more liquid to get the texture of a mashed potato. V15 said the pureed mixed vegetables can be thickened and needed to be smoother. Pureed foods should be smooth in consistency. On 5/20/2024 at 11:00 AM, V16 (Cook) said a puree texture should be similar to the mashed potato consistency. The facility policy entitled Puree Food Preparation dated 2/22/23 show It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor and attractive in appearance. Puree means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth thick paste similar to a thick pudding. 2. Puree foods should be prepared in such a manner to prevent lumps or chunks, the goal is soft, smooth similar to a soft mashed potato. 145770 Page 9 of 10 145770 05/22/2024 Allure of MT Carroll 1006 North Lowden Road Mount Carroll, IL 61053

F 0880 Provide and implement an infection prevention and control program. 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 perform hand hygiene and change their gloves in a manner to prevent cross contamination for one of 14 residents (R1) reviewed for infection control in the sample of 14. Residents Affected - Few The findings include: R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, influenza, pneumonia, psychotic disorder, muscle wasting, obesity, fluid overload, weakness, and history of falling. R1's Care Plan initiated November 29, 2023 shows the resident uses disposable briefs. Change every two hours and as needed. On May 20, 2024 at 12:57 PM, V9 and V10 (Certified Nursing Assistants/CNA) provided incontinence care for R1. R1's incontinence brief was saturated with urine and a large amount of stool. R1 was laying on her back when V10 folded R1's incontinence brief in between her legs. There was stool noted to R1's front peri area. V10 then touched R1's body to help her to turn onto her right side. V10 did not change her gloves or perform hand hygiene prior to touching R1 body to help her turn. V10 then wiped the large amount of stool from R1's buttocks. V10 then helped R1 to turn onto her left side by touching her body. V10 did not change her gloves or perform hand hygiene prior to assisting R1 to turn. On May 22, 2024 at 8:30 AM, V11 (CNA) said glove should be changed after touching bodily fluids to prevent cross contamination. The facility's Hand Hygiene policy reviewed May 20, 2024 shows, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The facility's Hand Hygiene Table shows either soap and water or alcohol-based hand rub should be used after handling contaminated objects. 145770 Page 10 of 10