Health inspection·July 12, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 7/10/23 at 9:31 AM there was a container of chewable antacid tablets on the bedside table in R4's room. R4 stated that R4's family brings in R4's medications to the facility. Residents Affected - Few R4's Order Summary dated 7/12/23 does not document an order for a chewable antacid. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact. On 7/11/23 at 1:32 PM, V2 Director of Nursing stated that if a resident is able to self administer medications, they can keep them in their room and they would complete a self administration of medication assessment and it would be entered into the resident's electronic medical record. On 7/11/23 at 3:24 PM, V2 confirmed that R4 does not have a self administration of medication assessment completed at this time. V2 stated that they discussed with R4 and R4's Power of Attorney that if R4 would like to keep the antacids in R4's room they could complete a self administration of medication assessment. V2 stated at this time the medication is in the nurse's medication cart. Based on observation, interview and record review, the facility failed to complete a self administration of medication assessment for residents with medications at bedside for two of two residents (R4, R29) reviewed for self administration of medications on the sample list of 18. Findings Include: The facility's undated Self Administration of Medication Policy documents residents in our facility who wish to self administer their medications may do so if it is determined that they are capable of doing so. The staff and practitioner will assess each resident's mental and physical abilities to determine whether a resident is capable of self administering medications and document their findings and the choices of the residents who are potentially capable of self administering medications. Self administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible, the medications will be kept in the medication cart and nursing will transfer the unopened medication to the resident when the resident requests them. The resident's ability to self administer medications will be reevaluated periodically (for example, during quarterly MDS (Minimum Data Set) reviews). 1.) On 7/10/23 at 11:54 AM, R29 was sitting up in the recliner in R29's room, without staff present, with a medication cup containing three pills; a white capsule, a white tablet and black gel coated pill sitting on the over bed table. When asked about the pills, R29 stated I will take them and dumped them out of the cup and onto a tray but didn't take them at this time. Page 1 of 6 145794 145794 07/12/2023 Fairview Haven 605 North 4th Street Fairbury, IL 61739

F 0554 The only Self Administration of Medication Assessment in R29's medical record is dated 1/26/23. Level of Harm - Minimal harm or potential for actual harm On 7/10/23 at 11:57 AM, V4 LPN (Licensed Practical Nurse) stated V4 left R29's vitamins and cranberry pill in the room with R29 because V4 had already prepared them however R29 wanted to wait to take them. V4 stated the facility used to be able to leave medications with R29 but they are not supposed to anymore because R29 isn't limber enough to take them independently. Residents Affected - Few On 7/11/23 at 3:23 PM, V2 DON (Director of Nursing) stated a Self Administration Medication Assessments should be completed quarterly, at the time of the MDS, and if a resident is able to self administer medications, there should be a physician's order for that. R29's July 2023 Physician Order's do not contain an order for R29 to self administer medications. R29's Care Plan dated 5/17/23 does not document that R29 is able to self administer medications. 145794 Page 2 of 6 145794 07/12/2023 Fairview Haven 605 North 4th Street Fairbury, IL 61739

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 prevent injury during care transfers for a resident requiring total assist and protective sleeves to both arms. This failure affects one (R12) of three residents reviewed for transfers from a total sample list of 18. Findings include: R12's Minimum Data Set, dated [DATE] documents R12 as cognitively intact and requiring total assistance for transfers, including a mechanical lift. R12's skin care plan dated 6/19/23 documents R12 is to wear protective sleeves to both arms and may remove for hygiene. R12's progress notes document the following: 3/11/23 document a skin tear approximately one centimeter on the left leg 4/12/23 documents during a shower, R12 sustained a skin tear on the left elbow from the yellow (transfer) sling which had scraped R12's left elbow, approximately 1.5 cm .0.5cm. in size 5/9/23 document that R12' sustained a skin tear to R12's right forearm when transferring the resident. 5/25/23 documents, Bruising and skin tear noted to right upper arm. Bruise is dark purple in color. 6/18/23 document, Resident noted to have a skin tear to left forearm measuring at one centimeter. Small amount of blood. 6/20/23 document, During (bedtime) cares (Certified Nursing Assistant) noted a spot on the back of (R12's) right leg, lateral under the crease of her knee. It appears to be scabbed. The area is 1cm x 1cm x 0.1cm. On 7/10/23 at 11:35 AM, R12 stated that she had a skin tear on her leg. At this time multiple bruises were visualized on both arms and no protective sleeves were being worn. On 7/11/23 at 12:00PM, R12 was eating in the dining room and no protective sleeves were being worn. On 7/12/23 at 9:50AM, R12 showed a healing wound on her right forearm with a purple bruise on her right forearm. No protective sleeves were being worn. On 7/12/23 at 9:52AM, R12 stated, I get these (pointing to the right forearm bruise) when they grab me to move me in the (mechanical lift). On 7/12/23 at 10:00AM V16 Certified Nursing Assistant stated, (R12) is one who gets skin tears and bruises easily. 145794 Page 3 of 6 145794 07/12/2023 Fairview Haven 605 North 4th Street Fairbury, IL 61739

F 0689 On 7/11/23 at 10:00AM, V2 Director of Nursing said that the facility was having some issues with mechanical lift transfers resulting in skin tears and bruises. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 145794 Page 4 of 6 145794 07/12/2023 Fairview Haven 605 North 4th Street Fairbury, IL 61739

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to dispose of unused medications from unknown residents. This failure has the potential to affect all 46 residents residing in the facility reviewed for medication disposal in the sample list of 18. Findings include: The facility's undated Discarding and Destroying Medications policy provided on 7/12/23 documents, Medications that cannot be returned to the dispensing pharmacy (e.g. {example} non unit-dose medications, medications refused by the resident, and/or medications left by residents upon discharge) shall be destroyed. Non-controlled and Schedule V controlled drugs must be destroyed in the presence of two (2) licensed nurses. Staff shall contact the provider pharmacy if they are unsure of proper disposal methods for a medication. On 7/12/23 at 10:41 AM during the medication room tour, V15 Registered Nurse opened an unlocked drawer labeled CD (hall cart CD) and there were medication cards in the front of the drawer. V15 stated that V15 did not know where those medication cards came from or why they were in the drawer. The medication cards had the resident's name blacked out with black marker and were unidentifiable. The first medication card was for Ondansetron (anti-nausea) 4 mg (milligrams). The residents name was marked out and the word stock handwritten on the card. There were 23 tablets left on the medication card. The second medication card was for Phenergan (anti-nausea). The strength of the medication and the resident's name were marked out in black marker and unidentifiable. The name of the medication Phenergan had black marker through it but was readable. There were 25 tablets left on the medication card. The third medication card was for Hyoscyamine (antispasmodic) 0.125 mg. The resident's name was marked out with black marker and unidentifiable. The word stock was handwritten on the card and there were 28 tablets left on the medication card. The fourth medication card was also for Hyoscyamine 0.125 mg with the resident's name marked out in black marker and unidentifiable. The word stock was handwritten on the medication card and there were 28 tablets left on this medication card. On 7/12/23 at 11:26 AM, V2 Director of Nursing stated that those medications should not have been left in the medication room in that drawer where they were. V2 stated that that is not their policy. V2 stated the nurse should have put them in the locked box in the medication room. V2 stated that two nurses go through those discontinued medications and dispose of them together in a drug disposal solution. V2 stated that V2 was not sure which resident those medications were prescribed for. V2 stated V2 assumes it was for a resident that has passed away recently. On 7/12/23 at 2:02 PM, V2 confirmed that all nurses that administer medications have access to the medication room and would have access to those medications in the drawer. The facility's Resident Census and Conditions of Residents form dated 7/10/23 documents 46 residents reside in the facility. 145794 Page 5 of 6 145794 07/12/2023 Fairview Haven 605 North 4th Street Fairbury, IL 61739

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete residents initial assessment for an antidepressant and failed to complete quarterly assessments for antidepressants and an antipsychotic medication. This failure affects one of five residents (R22) reviewed for unnecessary medications in the sample list of 18. Findings include: The facility's undated Psychotropic Medication Use policy provided on 7/12/23 documents, Physicians and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Discussion of non-medication behavior management strategies that could be implemented in an attempt to reduce/eliminate the behaviors prior to initiation of drug treatment as well as on an ongoing basis. Primary care physician, PA (Physician's Assistant) or APN (Advanced Practice Nurse) Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within one month of initiating, increasing or decreasing dose and during routine visits thereafter. Nursing Reviews the use of the medication with the physician and the interdisciplinary team on a quarterly basis to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use. R22's Order Summary dated 7/12/23 documents R22 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Altered Mental Status, Insomnia, Other Bipolar Disorder and Depression. This Order Summary documents orders for Remeron 30 mg (milligrams) (Antidepressant) at bedtime for Insomnia with a start date of 1/4/23, Risperdal 0.5 mg (Antipsychotic) one tablet twice a day for Bipolar Disorder with a start date of 1/4/23 and Trintellix 5 mg with the noon meal for Depression with a start date of 1/4/23. R22's medical record documents a Psychotropic Justification for Trintellix and Risperdal dated 1/4/23 but does not include an assessment for the Remeron. R22's medical record documents a Psychotropic Medication Review entered on 7/10/23 for Trintellix, Risperdal and Remeron. There is no Psychotropic medication assessment for these medications in April 2023 (the first quarter after initiation) in R22's medical record. R22's medical record documents a psychotropic medication assessment for these medications dated 4/13/23 but this assessment documents it was not completed until 7/10/23. On 7/11/23 at 1:32 PM, V7 Resource Nurse/Infection Control Nurse stated that R22 admitted with those medications. V7 stated that V18 Medical Director follows R22 and prescribes R22's medications now. V7 stated that they complete a medication justification when they enter the facility and complete quarterly assessments after that. On 7/12/23 at 12:40 PM, V2 Director of Nursing confirmed that R22's Psychotropic Justification dated 1/4/23 does not include Remeron. 145794 Page 6 of 6