Health inspection·May 11, 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 observation, interview, and record review the facility failed to ensure one resident (R22) was treated with dignity during dining. R22 was one of two residents reviewed for dignity in the sample list of 39. Residents Affected - Few Findings include: The Resident Council Meeting Minutes dated 4/10/23 document residents had concerns about Certified Nursing Asssistants (CNAs) using their cellular phones in the dining room during meal times. On 05/09/23 at 12:13 PM V26 CNA was sitting with R22 in the assisted dining room. R22 had R22's meal tray. V26 was typing on V26's personal cellular phone. On 5/9/23 at 3:26 PM V2 Director of Nursing stated employees are not to be using cellular phones when assisting residents. We have one CNA, V26, who we have repeatedly talked to about cellular phone usage. The facility's Quality of Life- Dignity revised August 2009 documents: Residents shall be treated with dignity and respect at all times. Page 1 of 23 145883 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to assess for the ability to self administer medications and keep medications at the bedside for one resident (R27) reviewed for self administration of medications in the sample list of 39. Residents Affected - Few Findings include: R27's medical record does not document an order for petroleum jelly treatment or to self administer Tums. There is no completed assessment in R27's medical record for the ability to self administer medications. R27's care plan revised on 3/26/23 does not document R27 may keep medications at the bedside and self administer medications. On 5/8/23 at 9:43 AM there was a bottle of Tums 1000 mg tablets and jar of petroleum jelly on R27's overbed table. On 5/9/23 at 12:22 PM the Tums and petroleum jelly were on R27's overbed table. R27 stated R27 applies the petroleum jelly to dry skin and takes the Tums as needed. On 5/09/23 at 12:30 PM V2 Director of Nursing (DON) stated residents have to have a physician's order to self administer medications and keep medications at the bedside. V2 confirmed R27 does not have an order to self administer medications/keep medications at the bedside. V2 instructed V4 Assistant DON to get an order for Tums and petroleum jelly to be kept at the bedside and to remove the medications from R27's room until the orders are received. The facility's Administering Medications policy dated January 2021 documents residents may self administer medications if the physician and interdisciplinary team has determined the resident has the capacity to self administer medications safely. Medications may be kept at the bedside if there is a physician's order, a completed self-administration assessment, and care plan for the self administration. 145883 Page 2 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review the facility failed to ensure a sanitary and homelike environment for one (R69) of 24 residents reviewed for homelike environment on the sample list of 39. Residents Affected - Few Findings include: On 5/08/23 at 10:50 AM, R69 stated they don't empty his urinal. R69's urinal was half full of urine and was sitting on the bedside table next to a banana and granola bar. R69 stated I wish there was another spot to put that. On 5/08/23 at 1:45 PM, R69's urinal was sitting on the bedside table. R69's urinal was a quarter full of urine. R69's water pitcher was sitting next to the urinal. R69's care plan dated 4/12/22 documents R69 had deficits in Activities of Daily living due to Parkinson's disease. On 5/10/23 at 12:43 PM, V2 Director of Nursing stated the staff should be emptying R69's urinal and ensuring it is not placed by food or water. 145883 Page 3 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interview the facility failed to document an investigation of resident's grievances and failed to notify residents of mitigation/resolution of the grievances as outlined in the facility's Grievance policy. This failure affects nine (R14, R57, R42, R62, R69, R23, R17, R60, R61) residents and has the potential to affect all 83 residents residing at the facility. Findings Include: The facility's Grievance Policy dated August 2018 states It is the policy of (the facility) that each resident has the right to voice to the facility or other agency that hears grievances without fear of discrimination or retaliation. The policy further states An investigation will commence, comprised of a review of the complaint, interviews with appropriate persons and witnesses, review of the medical record as appropriate, a permitted search of the resident's room and surrounding area, and a root cause analysis of all circumstances surrounding the incident. This will be completed utilizing the Grievance Investigation Form. (The facility) will ensure prompt resolution of all grievances, keeping the resident and his or her representative informed throughout the investigation and resolution process. The resident census and condition report dated 5/8/23 documents there are 83 residents residing in the facility. On 5/8/23 at 2:00 PM, a resident council meeting was attended by R14, R57, R42, R62, R69, R23, R17, R60, and R61. R14 stated I don't think V16 (Social Service Director) takes our complaints seriously. We go to her and things never change and we never hear what was done to correct what we complain about. Other residents present either nodded in agreement or commented in agreement with R14's concern. The meeting was attended by the Long-Term Care Ombudsmen (V31) On 5/9/23 at 3:00 PM, V16 stated When I get a grievance I just log it into the concern log and up date it as I find out more. I don't fill out a form for every concern. On 5/9/23 at 3:15 PM, V2 Director of Nursing stated I definitely look into residents' concerns if they come to me or members of the nursing staff. (V16) is the grievance official. I don't fill out a grievance form, but I take care of any concerns as soon as I'm aware. 145883 Page 4 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review the facility failed to notify the state agency, local law enforcement, and adult protective services of an allegation of sexual abuse for one of one residents (R7) on the sample list of 39. Findings include: On 5/08/23 at 11:50 AM, R7 stated a Certified Nurse's Assistant (V27) stroked his penis a couple times in the shower room before the water was even on. R7 stated V27 no longer gets to work on R7's hallway. R7 stated the Administration of the facility has talked to him about it. On 5/8/23 at 1:13 PM, V1 Administrator stated a concern was brought to me that V27 had touched R7 inappropriately in the shower. V1 stated V1 interviewed V27 along with V16 (Social Service Director) and R7 stated he didn't have any problems. V1 stated then I asked R7 outright if he had a sexual encounter with a V27 in the shower room and he said yes it was with V27, so I asked what happened and he said that V27 stroked his penis twice while washing him and it made him feel uncomfortable. V1 stated V27 told me it happened 4 to 6 months ago and that V27 didn't have a lot of details. V1 stated, everyone I talked to stated that V27 doesn't want male caregivers and he makes comments to the female staff. V1 stated my initial interview with him was 2/24/23. V1's handwritten notes dated February 24th documents, an initial concern that R1 was making comments to a Certified Nurse's Assistant (V17) that V27 was touching R7 in the shower. These notes document an investigation but this note does not document that the state agency, local law enforcement, or adult protective services was notified. On 5/11/23 at 9:43 AM, V1 Administrator stated that he did not notify the state survey agency, the local law enforcement, or the Ombudsmen of the allegation of sexual abuse made by R7 on 2/24/23. The facility's Policy and Procedure Regarding Abuse and Neglect with a revision date of 2/2021 documents, 33. If the incident involves alleged abuse, neglect or incident of unknown origin, the incident will immediately be reported to the Administrator and the Administrator shall provide the Illinois Department of Public Health with the initial notice of the alleged abuse, neglect, or incident of unknown origin by telefaxing to the Department a copy of report of the incident completed immediately after the incident becomes known. This policy also documents, 76. If you have reasonable suspicion that a crime has occurred against a resident or person receiving care at this facility, Federal Law requires that you report your suspicion directly to both law enforcement (number) and the state survey agency (number). 145883 Page 5 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 4) On 5/8/23 at 12:15 PM R16 was lying in bed with a urinary drainage bag attached to the bed rail, with dark yellow urine in the drainage bag. Residents Affected - Some R16's physician orders document Change Foley (indwelling urinary drainage device) catheter, #20French/30 cubic centimeters every 30 days and as needed, start date: 1/23/23. R16's medical record did not contain a comprehensive care plan for the use of an indwelling urinary drainage device. On 5/10/23 at 2:00 PM V2 DON confirmed R16 did not have a care plan for indwelling catheter use. Based on observation, interview, and record review the facility failed to develop a care plan for urinary catheter, edema, and wounds for three (R52, R45, R16) of 18 residents reviewed for care plans in the sample list of 39. Findings include: The facility's policy, with a revision date of December 2016, titled Care Plans, Comprehensive Person-centered documents, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8- The comprehensive, person centered care plan will: g- Incorporate identified problem areas. k- Reflect treatment goals, timetables and objectives in measurable outcomes. 10Identify problem areas, their causes, and developing interventions that are targeted and meaningful to the resident. 13- Assessments of residents are ongoing and care plans are revised as information about the resident and the residents condition change. 1.) On 5/08/23 at 9:39 AM R52 was lying in bed and R52's urinary catheter collection bag was touching the floor, and not secured to the bed. R52 stated R52 has had the catheter for several months. R52's Care Plan dated 5/1/23 documents R52's urinary catheter use and interventions. There is no documentation that a care plan for R52's catheter was developed/implemented prior to 5/1/23. R52's urinary catheter order dated 1/17/23 documents R52's catheter was ordered/inserted due to chronic wounds. On 5/9/23 at 3:17 PM V8 Care Plan Coordinator confirmed R52's care plan did not include R52's urinary catheter prior to 5/1/23. 2.) R45's Skin & Wound Evaluation dated 4/28/23 documents R45 has a new abrasion to the right forearm that measured 2.9 centimeters (cm) long by 2.6 cm wide. R45's May 2023 Order Summary documents an order to cleanse R45's right forearm wound, apply a petroleum gauze dressing, and cover with a dry dressing three times weekly. R45's Care Plan revised on 5/3/23 does not include R45's wound and interventions. On 5/08/23 at 11:35 AM there was a dressing on R45's forearm dated 5/6/233. R45 stated the wound started a few weeks ago and was the size of a dime. On 5/10/23 at 11:01 AM V30 Licensed Practical 145883 Page 6 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Nurse administered R45's wound treatment. R45 had a large, circular, pink, moist wound to the right forearm. On 5/9/23 at 3:17 PM V8 Care Plan Coordinator confirmed R45's care plan does not address R45's wound. 3.) On 5/08/23 at 11:37 AM R45 had swelling noted to hands and bilateral feet. R45 stated R45 takes a diuretic and R45's edema/swelling has not gotten any worse. On 5/09/23 at 10:43 AM R45 was sitting in a recliner and R45's feet were not elevated. R45's feet, ankles, and calves were swollen. R45's May 2023 Order Summary documents to administer Furosemide (diuretic) 60 milligrams (mg) daily since 11/2/22 and administer Spironolactone 50 mg daily since 8/30/22. R45's Care Plan revised 5/3/23 does not document R45's edema and interventions. On 5/09/23 at 3:17 PM V8 Care Plan Coordinator confirmed R45's care plan does not include R45's edema. 145883 Page 7 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide activities of daily living assistance for shaving for three of 18 residents (R46, R53, R54) reviewed for activities of daily living on the total sample list of 39. Residents Affected - Few Findings include: 1) On 5/8/23 at 10:40 AM R46 was sitting up in wheelchair in room, R46 had stubble covering R46's bilateral cheek area, upper lip and chin area. R46 stated, I shave myself, they give me the stuff, I am not sure when I did last. On 5/9/23 at 10:00 AM R46's continued to have stubble covering R46's cheek area, upper lip and chin areas. R46's care plan documents, R46 has activities of daily living deficits related to Congestive Heart Failure, Diabetes, Obesity, Anemia, Chronic Kidney Disease, Anxiety and Depression. R46's MDS (Minimum Data Set) assessment dated [DATE] documents, R46 requires supervision with set up help for personal hygiene. 2) On 5/8/23 at 10:36 AM, R53 was lying down in bed, R53 had long stubble covering R53's bilateral cheek area, upper lip and chin area. R53 stated I need shaved, my electric razor is broken and my son was going to get a new one, they (Staff) help me shave now. On 5/9/23 at 11:00 am R53 continued with long facial stubble covering R53's cheek, upper lip and chin areas. R53's care plan documents, R53 has ADL deficits related to diabetes, poliomyelitis, hypertension, osteoarthritis, A-fib, Congestive Heart failure. Interventions: Grooming/Oral Care Program: Explain task, provide brushing supplies (mouth swabs, mouthwash, water, cup and basin). Staff to set up supplies cue/assist to begin brushing. Cue/assist to rinse. Document participation, assess progress monthly. R53's MDS assessment form dated 3/16/23 documents, R53 requires extensive assistance of one staff member for personal hygiene. 3) On 5/8/23 at 11:49 AM R54 was sitting up in wheelchair in dining room. R54 had a goatee. R54 also had stubble covering R54's bilateral cheek areas. R54's MDS dated [DATE] documents R54 requires extensive assist of one staff member for personal hygiene. R54's care plan documents, R54 has ADL deficits related to Cerebral Vascular Accident with right sided weakness, Diabetes, Congestive Heart Failure, Anxiety, Depression and Spinal Stenosis. On 5/9/23 at 10:34 AM V5 Certified Nursing Assistant and V6 CNA stated R54, R46 and R53 need assistance with shaving, either full shaving or setting up supplies for them for shaving and assisting as needed. 145883 Page 8 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to obtain a treatment order upon identification of a wound for one resident (R45) of two reviewed for skin conditions in the sample list of 39. Residents Affected - Few Findings include: On 5/08/23 at 11:35 AM there was a dressing on R45's forearm dated 5/6/233. R45 stated the wound started a few weeks ago as a dime size and is getting bigger. R45 was not sure what caused the wound. R45 stated the nurses didn't start changing the dressing regularly until a few days ago. On 5/10/23 at 11:01 AM V30 Licensed Practical Nurse administered R45's wound treatment. R45 had a large, circular, pink, moist wound to the right forearm. On 5/09/23 at 3:07 PM V3 Infection Preventionist stated R45 did not know what caused the wound. Initially we thought R45 scraped R45's arm on the full mechanical lift sling, like an abrasion. V10 Wound Physician took a biopsy of the wound and thinks it may be skin cancer. V3 stated V3 was the first person to document on the wound. R45's Skin & Wound Evaluation dated 4/28/23 documents R45 has a new abrasion to the right forearm that measured 2.9 centimeters (cm) long by 2.6 cm wide. There is no documentation that a treatment order was initiated for this wound prior to R45 being evaluation by V10 on 5/1/23. R45's Wound Evaluation & Management Summary dated 5/1/23 completed by V10, documents R45's non-pressure related wound measured 4 cm wide by 4 cm long by 0.05 cm deep. A petroleum dressing was ordered to be applied three times weekly. On 5/10/23 at 10:25 AM V2 Director of Nursing stated a treatment order should be initiated when a wound is identified and until V10 assesses the wound. V2 confirmed R45 did not have a treatment ordered for the right forearm wound prior to 5/1/23. The facility's Care of Skin Tears- Abrasions and Minor Breaks policy revised September 2013 documents to notify the physician, obtain a treatment order, and document in the medical record. 145883 Page 9 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

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 reduce the risk for falls by failing to ensure the wheels on a bed were locked, the mattress on the bed did not slide, and a cushion on a wheelchair did not slide for two (R69) of three residents reviewed for falls on the sample list of 39. Findings include: R69's care plan dated 4/20/22 documents R69 is at risk for injury related to Parkinson's Disease. R69's fall risk assessment dated [DATE] documents R69 is at high risk for falling. On 5/8/23 at 11:30 AM, R69 was sitting on the edge of his bed. R69 stated his wheelchair is not comfortable and the cushion slides. R69 stated my mattress slides around on bed frame too. R69 stated the wheels on my bed are not locked. R6 stated, I am afraid I will fall. At that time, the head of the bed was not locked and could easily move. The mattress was overhanging the bed frame by half a foot and easily slid around on the bed frame. The cushion in R69's wheelchair slid very easily across the seat. On 5/10/23 at 12:40 PM, V2 Director of Nursing stated the beds should always be locked and stated V2 would have the mattress and cushion secured. 145883 Page 10 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview and record review the facility failed to properly perform and complete catheter care, and maintain urinary drainage collection chambers off of the floor. The facility also failed to treat and complete physician ordered recommendations after the development of a penile wound for two of three residents (R53 and R52) reviewed for indwelling catheter use on the total sample list of 39. This failure resulted in R53's penile wound worsening and becoming split from the urethral opening to the scrotal sac area. Findings include: 1) R53's medical record documents the following diagnosis: Retention of Urine, Benign Prostatic Hyperplasia without lower Urinary Tract Symptoms. On 5/8/23 at 1:26 PM R53's urinary drainage collection chamber bag was laying on the floor at the end of the bed. R53's medical record did not contain a comprehensive care plan for the use of an indwelling urinary drainage device or a comprehensive care plan after the development of the wound to R53's penis. R53's medical record documents on 2/8/23, (V10 Wound Physician) here on 2/6/23 to assess wounds. Resident has a urethral split to penis due to foley. Area measures 1x0.5cm with light serous drainage. 10% devitalized tissue, 90% subcutaneous noted. Will apply petroleum jelly to area daily, V10 recommends an urology consult. (V7 Physician) notified, states to continue to monitor. R53's Wound Evaluation and Management summary completed by V10 Wound Physician documents, on 2/6/23, NON - PRESSURE WOUND PENIS FULL THICKNESS, Etiology - Trauma/Injury Duration less than 1 day, Wound Size (L x W x D): 1 x 0.5 x 0 cm, Surface Area: 0.50 cm², Exudate: Light Serous, Thick adherent devitalized necrotic tissue: 10 %, Other viable tissues: 90 % (SubQ) DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 30 days, PLAN OF CARE REVIEWED AND ADDRESSED, Recommendations: Urology consult. Chronic stable wound with insignificant amount of necrotic tissue and no signs of infection. Monitor closely for now. R53's Wound Evaluation and Management summary dated 2/13/23, completed by V10 documents Non-Pressure Wound Penis, Full Thickness, Etiology: Trauma/Injury, Wound Size: 1 x 0.5 x 0 cm. Periwound radius: turbid exudate, Exudate: Moderate Serous, Thick adherent devitalized necrotic tissue: 10 %, Other viable tissues: 90 % (SubQ) (subcutaneous), Wound progress: Deteriorated, DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult. R53's physician order summary documents, Petrolatum Gel (White Petrolatum), Apply to HEAD OF PENIS topically every night shift for urethral split, start date: 2/8/23, discontinue date: 2/14/23. R53's Treatment Administration Records dated February 2023 documents the completion of physician ordered treatment of Petrolatum Gel from 2/8/23 through 2/14/23. 145883 Page 11 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0690 Level of Harm - Actual harm R53's medical record documents on 2/16/2023 at 2:53 PM, by V5 Physician, Examined residents penis due to long term foley placement, the urethral opening has elongated and eroded inferlaterally. There also appears to be either a growth on distal posterior foreskin or simple hypertrophy - hard to tell. Have given ok for urology referral. Residents Affected - Few R53's Wound Evaluation and Management summary's, completed by V10, dated 2/20/23, 2/27/23, 3/13/23, 3/20/23, 3/27/23 document: Non Pressure Wound Penis, Full Thickness, Etiology (quality) Trauma/Injury, Wound Size (L x W x D): 1 x 0.5 x 0 cm. DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult. R53's medical record did not document the initiation or completion of physician ordered recommendation of Petroleum jelly apply once daily from 2/20/23 through 5/7/23. R53's medical record documents on 4/7/23 at 1:17 PM, Resident unable to go to urology appointment related to unable to fit in the van in chair. (V7) notified that resident's chair will not fit in transport van, Resident had previously used a wheelchair with a high back and had issues with sliding out and leaning to the side. (V7) asked staff to cancel the appointment for resident. R53's Wound Evaluation and Management summary's, completed by V10, dated: 4/10/23, 4/24/23 and 5/1/23, documents Non Pressure Wound Penis, Full Thickness, Etiology (quality) Trauma/Injury, Wound Size (L x W x D): 1 x 0.5 x 0 cm. DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult. R53's medical record did not document R53's physician recommended Urology appointment was rescheduled after the cancellation of R53's urology appointment on 4/7/23. R53's medical record documents on 5/8/2023 at 3:21 PM, V3 Registered Nurse wrote to V7 Physician (V10 Wound Physician) recommended a urology consult for penile wound, (R53) was unable to go in the van in current wheelchair. (V10) is still concerned and wants you to take a look at wound or allow him to go to urologist if we can find him a wheelchair he can go in. Please advise. V7 responded on 5/8/23 at 5:03 PM, (R53) really needs to see urology. R53's medical record documents on 5/8/23 at 9:47 PM, V12 Registered Nurse wrote to V7 Physician, Resident's Foley catheter has been changed 3 times in one week for non-patency. Current Foley size is 18Fr, may we increase to 20Fr? Resident may also benefit from a suprapubic catheter as the shaft of the penis is torn all the way to his scrotum. R53's Wound Evaluation and Management Summary dated 5/8/23 completed by V10 documents, NON PRESSURE WOUND PENIS FULL THICKNESS, Etiology (quality) Trauma/Injury, Duration > 83 days, Wound Size (L x W x D): 2 x 0.5 x 0.05 cm, Surface Area: 1.00 cm², Exudate: Light Serous, Other viable tissues: 100 % (SubQ), Wound progress: Deteriorated. DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult. On 5/09/23 at 10:45 AM V3 Registered Nurse stated, I just returned from (medical leave), (R53) developed the (penis wound) when I was off, (R53) had a urology appointment but the wheelchair wouldn't work in the van so it was cancelled. (V10 Wound Physician) wants (R53) to see a urologist, (R53) needs a urethral splint. (R53's) catheter caused the wound. 145883 Page 12 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0690 Level of Harm - Actual harm Residents Affected - Few On 5/09/23 at 1:10 PM V3 RN stated, I found out (R53) admitted to us in January 2023 and from taking a look at the record, (R53) had catheter issues at the other nursing facility he came from, we did not document that we identified the (penile wound) until February 2023. V3 stated, I think the April Urologist appointment was the first appointment that was available for (R53), I was not able to find any further documentation that the appointment has been rescheduled or if (V10) was notified. I saw the order for the Petroleum jelly was stopped on 2/14/23, I have no idea why. On 5/9/23 at 1:15 PM during wound care observations, R53's penis was fillet opened from the tip of the urethral opening down to the scrotum. The wound bed had light pink tissue. When asked R53's if the penile wound was sore (causing pain), R53 replied yes, more than you know. On 5/10/23 at 4:00 PM V10 Wound Physician stated, urethral splits are caused from chronic long term catheter use, the friction of the catheter rubbing causes it, they start out as small slits and can get bigger, when patients get these type of things they need to see a urologist. (R53's) was pretty stable for a long time and recently got worse. V10 confirmed R53 needs to be seen by a urologist. V10 stated, patients with these need to have the catheter repositioned frequently and petroleum jelly applied. On 5/10/23 at 2:00 PM V3 RN stated, the only time we go over (V10's) recommendations with (V7) is if it is medications, otherwise we start the the other recommendations. The petroleum jelly and the urology consult should have been initiated. I spoke to (V9 Licensed Practical Nurse- Wound Nurse) and she said they had applied the petroleum jelly for a few days and it was causing more drainage to the open area, so they discontinued it, I dont know if it was a miscommunication or what, I did not see a follow up or documentation if (V10) had been notified. On 5/10/23 at 12:00 PM V2 DON stated, catheter bags should be placed on the bottom of the bed rail, not on the floor. The facility's policy, with a revision date of November 2020, titled Pressure Ulcers/Skin Breakdown - Clinical Protocol documents, Treatment/Management: 1- They physician will authorize pertinent orders related to wound treatments. 2- The physician will help identify medical interventions related to wound management. The wound nurse/designee will initiate a care plan which will include the location/type of area in the problem statement, a realistic goal, and any/all interventions that are pertinent to the treatment and healing of the wound. The facility's policy, with a revision date of September 2014, titled Urinary Catheter Care documents, Infection Control: 2-b: Be sure the catheter tubing and drainage bag are kept off the floor. Steps in the procedure: 13- With nondominant hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. 15- For female: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. 17- Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. The following items should be documented in the residents medical record: 1- The date and time that catheter care was given. 2.) On 5/08/23 at 9:39 AM R52 was lying in bed. R52's urinary catheter collection bag was touching the floor, and not secured to the bed. R52 stated R52 has had the catheter for several months and it was inserted after admission. R52's catheter cleaning/care is performed by the Certified Nursing 145883 Page 13 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0690 Assistants (CNAs) 3-4 times per week. Level of Harm - Actual harm R52's Care Plan dated 5/1/23 and R52's May 2023 Order Summary do not document to perform routine catheter care/cleaning. R52's urinary catheter order dated 1/17/23 documents R52's catheter was ordered/inserted due to chronic wounds. Residents Affected - Few R52's catheter care report dated 1/8/23 - 5/9/23 do not consistently document catheter care as being completed each shift three times daily. On 5/09/23 at 9:46 AM V32 and V17 CNAs performed R52's catheter care/cleaning. V17 cleansed R52's inner and outer labia with a wash cloth. V17 wiped across the top of the catheter approximately 1/2 inch, near the insertion site. V17 did not wrap the cloth around the catheter and clean the length of the catheter in a downward motion. R52 asked if V17 was going clean R52's catheter. V32 then provided catheter care in the same way as V17. V32 did not clean R52's catheter. On 5/09/23 at 9:56 AM V17 stated V17 was hired approximately 5 months ago and received training on catheter care. V17 stated cleaning the length of the catheter was not part of the training. V17 confirmed V17 did not clean the catheter during R52's catheter care. On 5/09/23 at 10:00 AM V2 Director of Nursing stated catheter care is done by the CNAs at least once per shift/three times daily and documented on the catheter care task report. V2 expects the catheter to be cleaned during catheter care. V2 confirmed the urinary drainage bag should be kept off of the floor and hooked on the bedframe. 145883 Page 14 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

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 observation, interview, and record review the facility failed to identify significant weight loss, notify the physician and Registered Dietitian, implement nutritional interventions, complete nutritional assessments, and record nutritional supplement intake for two (R13, R16) of four residents reviewed for nutrition in the sample list of 39. These failures resulted in R13 experiencing an additional significant weight loss of 6.65 % in one month. Residents Affected - Few Findings include: The facility's Impaired Nutrition/Unplanned Weight Loss Clinical Protocol revised October 2020 documents the nursing department are responsible for monitoring resident weights. Significant weight loss is identified as a loss of at least 5% in one month, 7.5 % in 3 months, and 10 % in 6 months. The physician will review possible causes of weight loss. Interventions will be implemented to address weight loss. The Dietitian and Physician will determine the resident's diet including if nutritional supplements need to be added. Monitoring weight loss/nutrition includes evaluating the care planned interventions, evaluating the resident's response to the interventions, determine weight monitoring intervals, identifying additional risk factors such as pressure ulcers, fever, or acute illness, and observing/reporting significant weight loss. The facility's Nutritional Assessment policy revised September 2011 documents nutritional assessments will be conducted upon admission and with changes in condition that include a risk for impaired nutrition. These assessments will be used to develop interventions to address the resident's risk for impaired nutrition. The Dietitian's component of this assessment will include the estimated calorie, protein, nutrient and fluid needs, and if the resident's intake is adequate to meet nutritional needs. 1. R13's Minimum Data Set, dated [DATE] documents R13 has short and long term memory impairment, had a significant weight loss within the last month, and is not on a prescribed weight loss regimen. R13's Care Plan revised 4/25/23 documents R13 had significant weight loss noted 1/9/23 and 4/5/23. Interventions dated 1/7/22 include to notify the family and physician of significant weight loss, review diet, intakes, disease process, and behaviors to determine cause, and the dietitian should assess the resident annually and as needed to ensure needs are met. R13's Care Plan dated 7/2/19 documents R13 is at risk for nutritional deficit and includes an intervention revised on 5/4/23 that documents the dietitian evaluated R13 on 2/10/23 with no recommendations, on 3/14/23 with no recommendations, and on 4/28/23 with recommendations. R13's dated 5/10/23 documents R13 weighed 169.2 pounds (lbs.) on 12/1/22, 163.6 on 1/9/23, 153.8 on 1/31/23 (5.64 % loss since 1/9/23), 160 on 2/7/23, 159 on 3/2/23, 156.2 on 3/8/23, 153 on 3/16/23, and 150.4 on 4/3/23 (5.41% loss since 3/2/23). There are no recorded weights again until 5/4/23 when R13 weighed 140.4 lbs (an additional 6.65 % loss since 4/3/23, and a 17% loss since 12/1/22). There are no documented nutritional assessments after 12/15/22 in R13's medical record. There is no documentation that R13 was assessed by V25 Registered Dietitian between 1/1/23 and 2/9/23, or that R13's physician was notified of R13's significant weight loss noted on 1/31/23. R13's Dietary Notes document on 2/10/23, R13 has an unstageable pressure ulcer of the right heel. R13's weight was 145883 Page 15 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0692 Level of Harm - Actual harm Residents Affected - Few stable between 160-170 lbs with decrease to 153 on 1/31/23 and returned to 160 on 2/7/23. R13 was started on a frozen nutritional supplement two days prior on 2/8 (of the prior year). On 3/14/23 R13 receives a frozen nutritional supplement twice daily. R13's wound healed and weight has been stable for 60 days. No nutritional changes were recommended. On 4/28/23 V25 recommended the addition of a nutritional shake twice daily. There is no documentation that V25 assessed R13 after 3/14/23 until 4/28/23 (25 days after R13's significant weight loss noted on 4/3/23). R13's Nursing Notes document on 4/12/23 R13's significant weight loss was reported to the practitioner with no new orders given. On 5/4/23 the practitioner was notified and gave orders for 60 cc (Cubic Centimeters) of (nutritional supplement) twice daily and obtain weekly weights for one month. R13's May 2023 Order Summary includes physician orders to administer a frozen nutritional supplement twice daily for weight loss initiated on 2/23/23 and to administer 60 cc of (nutritional supplement) twice daily initiated on 5/4/23. R13's January 2023 through May 2023 Medication Administration Records (MARs) document R13 received a frozen nutritional supplement once daily, that was ordered from 2/8/22 until 2/23/23. The MAR does not document the amount consumed of the 60 cc nutritional supplement initiated on 5/4/23. There is no documentation that any new nutritional supplements/interventions were implemented to address R13's January weight loss prior to 2/23/23 when the frozen nutritional supplement was increased to twice daily, and then no additional nutritional supplements were implemented to address R13's April 2023 weight loss until 5/4/23 when the nutritional supplement 60 cc was ordered. On 5/08/23 at 11:54 AM R13 was sitting in R13's room eating. R13's meal ticket documented a frozen nutritional supplement as part of R13's noon meal. R13's meal tray included [NAME] sandwich, peas, potato salad, and cheesecake, and did not contain a frozen nutritional supplement, and R13 had only ate 1/4 of a [NAME] sandwich. On 05/08/23 at 12:06 PM R13's meal tray did not contain a frozen nutritional supplement, and R13 had not ate any more of R13's food, besides the 1/4 sandwich. On 5/9/23 at 12:08 PM V17 Certified Nursing Assistant (CNA) delivered R13's meal tray to R13's room. The meal tray contained a hot dog, cake, bag of chips, and 2 % milk, and did not contain a frozen nutritional supplement. R13's meal ticket included a frozen nutritional supplement. R13's meal tray did not contain a frozen nutritional supplement at 12:21 PM and 12:27 PM. On 5/9/23 at 12:35 PM V17 stated the frozen nutritional supplements are served by the dietary department with the meal trays. V17 confirmed R13 was not given a frozen nutritional supplement as part of the noon meal. V20 CNA stated if the frozen nutritional supplement is listed on the meal ticket, then R13 should be getting it. On 5/09/23 at 12:37 PM V19 Licensed Practical Nurse stated (nutritional supplement) is given by the nurses and the amount consumed is recorded on the MAR. The frozen nutritional supplement is served by dietary, and the nurse is responsible for documenting the amount consumed. On 5/10/23 at 1:00 PM V25 Registered Dietitian stated V25 began employment at the facility in January 2023. The facility sends a weekly list of resident names for V25 to see. The information submitted to V25 does not include the amount of weight lost. V25 does not give any recommendations until V25 rounds at the facility. V25 was not sure what V25 would expect the facility to do to address resident weight loss in the interim until V25 evaluates the resident. V25 stated V25 completes nutritional assessments documented under the assessments section of the electronic medical record. The assessments are completed upon admission, annually, and with any significant changes. V25 confirmed the 145883 Page 16 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0692 Level of Harm - Actual harm Residents Affected - Few frozen nutritional supplement is ordered for R13's weight loss. V25 stated V25 evaluated R13 on 2/10/23 and V25 did not order any new interventions since the frozen nutritional supplement was implemented two days prior by the physician. V25 evaluated R13 in March and R13's weight had stabilized. V25 did not evaluate R13 again until 4/28/23 and recommended the addition of a nutritional shake twice daily. V25 stated V25 did not receive notification in April of R13's significant weight loss until 4/28/23. Additional supplements may have prevented R13's weight loss and confirmed not receiving the frozen nutritional supplement may have affected R13's weight. V25 stated if residents are trending weight loss V25 would expect the facility to follow their weight monitoring policy. In the past V25 has made recommendations to monitor weights weekly, but V25 recently stopped doing that because V25 wasn't sure it was something V25 should be doing. On 5/09/23 at 3:36 PM V2 Director of Nursing stated weights are obtained monthly unless otherwise ordered. If the resident triggers for a significant weight loss then we notify the physician and dietitian. V25 rounded on 4/26 and 4/28/23 during April. Per R13's care plan, V25 evaluated R13 on 2/10/23 with no new recommendations, 3/14/23 with no new recommendations, and on 4/28/23 with the recommendation to add nutritional shakes twice daily. V2 reviewed monthly dietitian reports and stated V2 did not see documentation that R13 was evaluated by a dietitian in January 2023. On 5/1/23 we increased the frozen nutritional supplement and stopped the shakes due to R13 not liking the shakes. The nurses are responsible for documenting the amount consumed of each supplement. On 5/10/23 at 10:25 AM V2 stated we ran a weight report on 1/24/23 and R13 did not flag for weight loss at that time. The next weight report was not done until 2/16/23 and R13 triggered a significant weight loss. V2 stated weight reports are only done on a monthly basis and that is how R13's significant weight loss on 1/31/23 was missed. There is no documentation that R13's January significant weight loss was reported to the physician and dietitian, and confirmed there were no new nutritional interventions implemented until February 2023. R13 had a significant weight loss on 4/5/23 and V25 did not evaluate R13's weight loss until 4/28/23. There were no new nutritional interventions implemented in March or April until 4/28/23. On 5/10/23 at 1:28 PM V2 stated nutritional assessments should be completed quarterly, annually, and with any significant changes including significant weight loss. V2 confirmed R13's medical record does not document a nutritional assessment was completed after December 2022. 2) R16's physician order summary documents, Mighty Shakes Sugar Free with meals for skin support, start date: 11/15/2022. R16's wound evaluation and management summary dated 5/8/23 documents Moisture Associated Skin Damage to Sacrum, 2 centimeters by 2 centimeters by 0.3 cm. R16's Dietary Meal ticket documents, Supplement: Might Shakes- No sugar. On 5/8/23 at 12:17 PM R16's lunch meal tray was on R16's over the bed table in front of R16. The tray contained a [NAME] Sandwich, Peas, Salad in a cup, cheesecake, milk and tea. There was no might shake on R16's tray. On 5/9/23 at 11:53 AM R16's lunch meal tray was on R16's over the bed table in front of R16. The tray contained chicken, rice, turtle cake, milk and tea, There was no mighty shake on R16's tray. On 5/9/23 at 11:54 AM V11 Dietary Aide stated, we give the mighty shakes if someone has an order, we sent the mighty shakes out on the hall trays if they eat in their room. On 5/10/23 at 12:00 PM V2 DON stated, dietary serves mighty shakes and nurses should follow up if 145883 Page 17 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0692 (the resident) received them and how much they drank. Level of Harm - Actual harm R16's care plan documents R16 has potential for Nutritional Deficit related to history of Colitis, Diverticulitis, Gastro Esophageal Reflux Disorder, weakness. Interventions: Serve Nutritional supplements as ordered. Residents Affected - Few 145883 Page 18 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 2.) On 5/08/23 at 2:14 PM, R7's CPAP (Continuous Positive Airway Pressure) mask was lying on the bedside table directly on top of the surface of the table. Residents Affected - Few On 5/9/23 at 10:15 AM, R7's CPAP mask continued to lie on the beside table directly on top of the surface of the table. On 5/10/23 at 12:44 PM, V2 Director of Nursing stated CPAP masks should be placed in a bag when not in use. Findings Based on observation, interview and record review the facility failed to properly store, change and label respiratory equipment for three of three residents (R44, R52 and R7) reviewed for respiratory care on the total sample list of 39. Findings include: 1) On 5/8/23 at 10:31 AM and on 5/9/23 at 11:34 AM R44's aerosol generating delivery system (mask and tubing) was lying on R44's night stand in room on top of the nebulizer machine. R44's aerosol generating delivery system (mask and tubing) was not stored in a bag. R44's physician orders documents, change nebulizer equipment and tubing weekly and place in new bag with name and date, start date: 3/5/21. On 5/10/23 at 10:50 AM V2 Director of Nursing stated, nebulizer equipment (mask and tubing) should be stored in a bag when not in use. The facility's policy, with a revision date of February 2021, titled Administering Medications Through a Small Volume Nebulizer documents, Steps in procedure: 29- When equipment is completely dry, store in a plastic bag with the residents name. 3.) On 5/8/23 at 9:39 AM and 1:39 PM R52 was lying in bed wearing oxygen per nasal cannula at 2 liters/minute. R52's oxygen tubing and humidification bottle was dated 4/29/23. R52' May 2023 Order Summary documents an order to change oxygen tubing and humidifier bottle weekly. R52's May 2023 Treatment Administration Record documents R52's oxygen tubing was scheduled to be changed on 5/5/23. On 5/9/23 at 10:00 AM V2 Director of Nursing stated oxygen tubing should be changed weekly. The facility's undated Oxygen Policy/Procedure documents to change the oxygen cannula/tubing when the humidification bottle is changed. 145883 Page 19 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 identify targeted behaviors, implement interventions, complete assessments, attempt gradual dose reductions and/or justify the duplicity of psychotropic medications for four residents (R52, R53, R66, and R75) of five residents reviewed for psychotropic medications in a sample list of 39 residents. Findings include: The facility's Psychotropic Medication Policy and Procedure dated March 2021 documents to determine underlying causes of behaviors to implement appropriate treatment including environmental, medical, and/or behavioral interventions. The physician should document the rationale and diagnosis for psychotropic use and identify targeted symptoms. Gradual dose reductions will be attempted in two separate quarters and annually thereafter unless clinically contraindicated. The interdisciplinary team will review the use of psychotropic medications quarterly and determine targeted behaviors and adverse effects. 1.) R66's Physician's Order Summary printed 5/10/23 includes the following orders for psychotropic medications: 1. Risperdal (Antipsychotic) 0.5 milligrams. Give 1 tablet by mouth two times a day related to Unspecified Dementia with Behavioral Disturbance (Originally ordered 2/22/22), 2. Seroquel (Antipsychotic) 50 milligrams 0.5 tablet by mouth one time a day related to Unspecified Dementia with Behavioral Disturbance (Originally ordered 5/10/22), and 3. Lexapro (antidepressant) 10 milligrams Give 1 tablet by mouth one time a day related to Other Specific Depressive Episodes. (Originally ordered 3/9/22) R66's medical record documents psychotropic assessments dated 11/22/22 and 3/15/23. R66's medical record does not contain assessments for the quarters prior to this. R66's medical record does not contain documentation of tracking of targeted resident specific behaviors for R66 or the interventions attempted for behaviors. R66's medical record does not document a justification for the use of duplicative antipsychotic medication. On 5/10/23 at 1:05 PM, V2 Director of Nursing verified R66's duplicative antipsychotics had not been addressed and that R66 had missing quarterly assessments. 2.) R75's Physician's Order Summary printed 5/11/23 includes the following orders for psychotropic medications: 1. Risperidone (antipsychotic) 0.25 milligrams, Give 1 tablet by mouth two times a day related to Vascular Dementia, Unspecified Severity with Other Behavioral disturbance, 2. Sertraline HCl (Hydrochloride) 50 milligrams, Give 1 tablet by mouth one time a day related to Depression Unspecified. R75's medical record does not contain documentation of tracking of R75's targeted resident specific behaviors or interventions attempted for behaviors. On 5/10/23 at 1:00 PM, V16 Social Service Director a verified that she had been tracking diagnoses rather than resident specifics behaviors. V16 stated Social Service is a fairly new roll for me. I was not aware we have to track resident specific behaviors. 145883 Page 20 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3) R53's physician order summary documents, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsules (250 milligrams total) by mouth two times a day related to Dementia with other behavioral disturbance, start date: 1/26/23. R53's medical record documents on 1/26/2023 at 10:48 AM by V7 Physician, Nurses report agitation, yelling, throwing things, turning over nightstand etc. He does have decubitus under treatment and suspected Urinary Tract Infection. Urine specimen being sent for Culture and Sensitivity. Start Bactrim until urine results back, start Depakote 250mg BID for aggression/agitation. R53's medical record did not contain a psychotropic medication assessment after the initiation of Depakote or a reassessment since the initiation of Depakote on 1/26/23. R53's Behavior Evaluation Form documents, Behavior Tracking: experiences difficulty sleeping (yelling out at night). R53's medical record did not contain a comprehensive care plan for the use of Depakote or targeted behaviors being monitored for the use of Depakote with individualized interventions. On 5/10/23 at 10:25 AM V2 Director of Nursing stated, (R53) has no psychotropic medication assessment because (V8 MDS coordinator) thought since Depakote is an anticonvulsant an assessment does not need to be done, but he is not receiving it for seizure treatment. 4.) R52's Discontinued Order Summary dated 5/11/23 and May 2023 Order Summary document orders to administer Seroquel (antipsychotic) 50 milligrams (mg) by mouth daily since 2/7/22. There is no documentation that a gradual dose reduction of the Seroquel was implemented. R52's Care Plan revised 2/12/23 documents R52 receives Seroquel 50 mg daily and includes an intervention for the interdisciplinary team to review for gradual dose reduction if appropriate. R52's Nursing Notes document on 2/16/23 an order was received to reduce R52's Seroquel to 25 mg daily, and R52 refused to have R52's Seroquel decreased. The Note To Attending Physician/Prescriber dated 1/31/23 documents R52 has received Seroquel 50 mg daily since February 2022, and the pharmacy recommended a reduction to 25 mg daily. This note is signed by the practitioner on 2/6/23 and notes that R52 declined the reduction on 2/16/23. There is no documented clinical rational by the practitioner as to why the current dose is medically necessary or contraindicated in R52's medical record. On 5/9/23 at 10:00 AM V2 Director of Nursing stated R52 admitted to the facility on Seroquel for Major Depressive Disorder. R52's behaviors include being tearful and restless. V2 stated there was an order to reduce R52's Seroquel, but R52 refused. V2 confirmed a gradual dose reduction was not attempted. On 5/11/23 at 9:50 AM V2 confirmed R52's pharmacy recommendation to reduce the Seroquel does not document a clinical rational by the practitioner as to why the current dose should be continued and contraindications to reduce the medication. 145883 Page 21 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to maintain sanitary food cooking areas. These failures have the potential to affect all 83 residents in the facility. Residents Affected - Many Findings include: On 5/08/23 at 9:11 AM, V13 Assistant Dietary provided a tour of the kitchen where residents food is prepared. During the tour, accumulated dust was covering the vents and the recessed lights cages above the above the cooking range and griddle. Grease and food particles was covering the edges of the fryer. Floating particles of food was floating in the oil in the fryer. The fryer was on. V13 stated it was supposed to be cleaned yesterday and they were getting ready to make chicken strips in the fryer. On 5/9/23 at 9:54 AM, the dust on the vents and the recessed light cages above the range and griddle was still present. The resident census and condition report dated 5/8/23 documents there are 83 residents residing in the facility. 145883 Page 22 of 23 145883 05/11/2023 Piatt County Nursing Home 1111 N State St Monticello, IL 61856

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess for appropriate use of an antibiotic for one resident (R50) reviewed for antibiotic stewardship in the sample list of 39. Residents Affected - Few Findings include: R50's May 2023 Order Summary documents an order dated 7/9/21 to administer Azithromycin (antibiotic) 250 milligrams by mouth three times weekly on Monday, Wednesday, and Friday for diagnosis of Chronic Obstructive Pulmonary Disease (COPD). R50's Care Plan revised 9/21/22 documents in the problem category that R50 receives a prophylactic antibiotic for COPD and in the interventions it lists that R50 receives the prophylactic antibiotic to prevent Urinary Tract Infections (UTIs). R50's Hospital Discharge summary dated [DATE] documents R50 receives Azithromycin three times weekly to prevent bronchitis. There is no documentation that the use of this antibiotic was assessed or re-evaluated for appropriate use. On 05/09/23 at 2:59 PM V3 Infection Preventionist stated the facility uses McGreer's criteria (infection control resource) to determine appropriate use of antibiotics and V3 notifies the provider if appropriate criteria is not met. R50 receives prophylactic Azithromycin to prevent UTIs and confirmed COPD is not an appropriate diagnosis to warrant the use of an antibiotic. On 5/10/23 at 9:11 AM V3 stated R50 admitted to the facility with the Azithromycin order and it was prescribed to prevent bronchitis. V3 stated prior to yesterday, there was no assessment to evaluate appropriate use of this antibiotic in R50's medical record. The facility's Antibiotic Stewardship policy dated 1/29/19 documents the facility will closely monitor the use of antibiotics. When antibiotics are prescribed, the order will include the duration for treatment with a start and stop date. The facility will utilize the McGreer's Definition of Infection, and this will also be used to notify the physician. The Infection Control nurse/designee is responsible for reviewing antibiotic use. This policy does not reference the use of prophylactic antibiotics. This policy includes the undated Centers for Disease Control and Prevention brochure titled Get Smart Know When Antibiotics Work, documents: To avoid the threat of antibiotic-resistant infections, the Centers for Disease Control and Prevention (CDC) recommends that you avoid taking unnecessary antibiotics. 145883 Page 23 of 23