Health inspection·May 10, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the call light was within the reach of a resident to call staff for assistance for 1 of 1 resident (R5) reviewed for call light accessibility in a sample of 12. Residents Affected - Few The findings include: R5's Face Sheet printed 5/9/23 showed diagnoses to include but not limited to Type 2 diabetes mellitus without complications, hypertension, muscle wasting, cognitive communication deficit, and benign prostatic hyperplasia with lower urinary tract symptoms. R5's MDS (Minimum Data Set) dated 4/15/23 showed he is severely cognitively impaired. R5 requires extensive assist of one person with bed mobility and toileting and requires total physical assistance of two or more persons with transfers. R5's Care Plan last reviewed/revised on 3/2023 showed R5 was re-educated on using his call light to alert staff of needing assistance with activities of daily living (ADL's) and that his call light was to be within his reach. On 5/8/23 at 9:48 AM, R5 was observed sitting in his wheelchair on the right side of the bed. R5's call was on the left side of his bed. R5 was unable to reach the call light when asked if he could reach the call light. On 5/9/23 at 10:47 AM, R5 was lying in bed, but his call light was lying on the floor on the right side of the bed and out of his reach. On 5/8/23 at 9:51 AM, V10 (Registered Nurse) RN came into R5's room and stated they placed R5's call light too far away from him. On 5/8/23 at 10:01 AM, V8 (Certified Nursing Assistant) CNA stated the call lights should be in reach of the residents because it is important for them to call when they need help. The facility's policy titled Call System, Resident, dated September 2022 states, 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/ bathing facilities and from the floor. Page 1 of 11 145917 145917 05/10/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

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 ADL (Activities of Daily Living) assistance for residents requiring assistance with incontinence care for 2 of 12 residents (R21, R281) reviewed for activities of daily living in the sample of 12. Residents Affected - Few The findings include: 1. R21's care plan dated January 24, 2023, showed R21 required the extensive assistance of staff for toileting and transfers. R21's care plan states R21is incontinent of bowel and bladder with a history of urinary tract infections and to provide incontinence care after each incontinent episode. On May 8, 2023, at 8:47 AM, V8 Certified Nursing Assistant (CNA) entered R21's room to provide care. As V8 CNA pulled down R21's bedding, it was noted that R21 was wearing two incontinence briefs. The incontinence brief, that was closest to R21's body, was saturated with urine. This surveyor observed urine that leaked onto the second incontinence brief. R21's buttocks and scrotum were reddened in color. V8 CNA stated, This is the first time I have changed him today. I am not sure when he was last changed on nights. They know they are not to put two incontinence briefs on residents. 2. R281's resident assessment dated [DATE], showed R281 required the extensive assistance of two staff for toileting and repositioning. The assessment showed R281 was always incontinent of stool. On May 8, 2023, at 9:27 AM, V9 Certified Nursing Assistant (CNA) repositioned R281 on his right side. R281 was incontinent of stool. R281's incontinence brief was soiled with stool. V9 CNA then repositioned R281 on his back, per R281's request, and then left the room. At no time did V9 CNA provide any perineal care to R281 or remove R281's soiled incontinence brief. On May 9, 2023, at 10:10 AM, V2 Director of Nursing stated, Residents should be rounded on every 2 hours and provided with incontinence care during those rounds, as needed. Staff should never put two incontinence briefs on a resident. That puts a resident at a huge risk for infection and skin breakdown. The facility's Activities of Daily Living (ADL) policy dated March 2018 showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .c. Elimination (toileting) . 145917 Page 2 of 11 145917 05/10/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pressure injury treatments were in place for 2 of 4 residents (R281, R21) reviewed for pressure injuries in the sample of 12. Residents Affected - Few The findings include: 1. R281's Face Sheet printed May 9, 2023, showed R281 was admitted to the facility on [DATE], with diagnoses including a Stage IV sacral pressure injury, Stage III pressure injuries to his left and right buttocks, osteomyelitis to his sacral pressure injury, and Type 2 Diabetes Mellitus. R281's initial wound assessment dated [DATE], showed R281 had a Stage IV pressure injury to his sacrum that measured 10 cm (centimeters) x 14 cm x 4 cm with bone, muscle, and tendon exposed. The note showed, There is a medium amount of necrotic tissue within the wound bed including adherent slough, necrosis of muscle and necrosis of bone. The note also showed R281 had Stage III pressure injuries to his right and left gluteus (buttocks). R281's physician order dated May 8, 2023, showed R281's Stage IV sacral pressure injury was to be cleansed, packed with gauze, and covered with a gauze dressing, that was to be taped in place, twice a day and as needed. R281's physician order dated May 3, 2023, showed a foam dressing was to be in place over R281's Stage III pressure injury to his left buttock. R281's physician order dated April 27, 2023, showed, Check for placement of dressings to bilateral buttocks and coccyx every shift. On May 8, 2023, at 9:27 AM, V9 Certified Nursing Assistant (CNA) repositioned R281 on his right side. R281 was incontinent of stool. No dressing was noted over R281's pressure injury to his left buttock. No dressing was noted over R281's sacral pressure injury. A fist-sized open wound was noted to R281's sacral area. A 4-inch (in) x 4 in gauze dressing that was soiled with stool, was noted inside of R281's sacral wound. A soiled square gauze dressing was noted, lying loosely, in R281's soiled incontinence brief. V9 CNA repositioned R281 on his back, per R281's request, and then left the room. At no time did V9 CNA provide any perineal care to R281 or remove R281's soiled incontinence brief. On May 8, 2023, at 12:40 PM, V6 Wound Nurse stated, (R281) was just admitted here with pressure injuries to his buttocks and a large wound to his sacral area with bone exposure noted in the wound. He is to have foam dressings to his buttock wounds and a gauze dressing to his sacral wound. He had a rectal tube in the hospital because he was having frequent stools. He was on IV (intravenous) antibiotics due to his sacral wound . He is still having frequent stools, so staff need to be checking on him frequently and providing incontinence care as soon as possible. They are to let the nurse know if dressings are missing from the pressure injuries. On May 10, 2023, at 9:50 AM, V6 Wound Nurse stated, (V9 CNA) should have at least placed a clean pad under (R281) (on May 8, 2023) before she repositioned him on his back. That would have gotten him off the soiled incontinence brief. 145917 Page 3 of 11 145917 05/10/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. R21's Face Sheet printed May 9, 2023, showed R21 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease, dementia, a pressure injury to his right foot, and chronic osteomyelitis to his right ankle/foot. R21's Wound Management Report dated May 3, 2023, showed R21 had a Stage III (pressure injury), measuring 2 cm x 2 cm x 0.2 cm, to the bottom or R21's right foot, below his right pinky (5th) toe. R21's physician orders dated March 22, 2023, showed a foam dressing was to be applied to R21's right plantar foot wound. The foam dressing was then to be secure to R21's foot with a gauze dressing. The orders showed a foam boot was to be on R21's right foot, at all times. On May 8, 2023, at 8:38 AM, R21 was observed in bed. R21 wore socks, with his feet directly on the mattress of his bed. No foam boot was noted to R21's right foot. A circular brown stain was noted to the bottom of R21's right sock, directly below his fifth toe. On May 8, 2023, at 8:47 AM, R21's socks were removed from R21's feet. A nickel-sized open wound was noted to bottom of R21's right foot, directly below his fifth toe. No dressing was noted to the wound. No dressing was found in R21's sock. A small amount of dried blood was noted around the wound. On May 8, 2023, at 12:40 PM, V6 Wound Nurse stated, (R21) has had a Stage III (pressure injury) to his right foot for months with a history of osteomyelitis to the wound. He should have a foam dressing in place over the wound. He should wear a foam boot on his right foot and/or at least make sure his heels are off loaded. The facility's Policy/Procedure for Pressure Ulcers (undated) showed, STANDARD: To ensure that a resident who is admitted to the facility without a pressure ulcer does not develop a pressure ulcer unless clinically unavoidable. A resident who has been admitted with a pressure area receives services to promote healing, prevent infection, and any additional ulcers from developing . 145917 Page 4 of 11 145917 05/10/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure fall prevention measures were in place for 1 of 1 resident (R15) reviewed for safety and supervision in a sample 12. The findings include: R15's Face Sheet printed on 5/9/23 showed the resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the right dominant side, congestive heart failure (CHF), anxiety disorder, osteoarthritis, and legal blindness. R15's MDS (Minimum Data Set) assessment dated [DATE] showed she is severely cognitively impaired. She required extensive assist of one person with bed mobility and toileting and required one-person physical assistance for transfers. R15's care plan, last reviewed on 4/6/23 showed staff were to ensure her bed was in a low position. On 5/8/23 at 9:39 AM, R15 was observed resting in bed with her eyes closed. The resident's bed was in a high position. On 5/8/23 at 12:05 PM, V8 CNA (Certified Nursing Assistant) came into R15's room to reposition her. V8 CNA stated, (R15's) bed should be in a low position but it is in the high position. I should probably put it in the lower position. On 5/8/23 12:57 PM, V12 LPN (License Practical Nurse) stated it is for the resident's safety for the bed to be in a low position, so they don't get injured from a fall. They could break a hip or hit their head and/or get a skin tear. On 5/9/23 at 10:50 AM, R15 was observed resting in bed with her eyes closed, and her bed was in the high position. On 5/9/23 at 12:35 PM, V6 ADON (Assistant Director of Nursing) said R15's bed should be in a lower position. She could fall out of bed. The facility's fall protocol revised March 2018 showed: 3. The staff .will review each resident's risk factor for falling . and examples of risk factor for falling include .gait and balance, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension, and medical conditions affecting the central nervous system. 1. Based on assessment, the staff .will identify pertinent interventions to try to prevent subsequent falls and to address the risks . 2. Staff will try various relevant interventions, based on assessment of the nature or category of falling . (for example, if the individual continues to try to get up and walk without waiting for assistance). 145917 Page 5 of 11 145917 05/10/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0692 Provide enough food/fluids to maintain a resident's health. 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 monitor and record weights for residents who had sustained weight loss and/or were at risk for weight loss for 3 of 6 residents (R6, R281, R21) reviewed for weight loss in the sample of 12. Residents Affected - Few The findings include: 1. R6's Face Sheet printed May 9, 2023, showed R6 was admitted to the facility on [DATE], with diagnoses including dementia and muscle wasting/atrophy. R6's care plan dated November 29, 2022, showed, Monitor and record weight. Notify physician of significant weight change. R6's Vitals Report dated May 9, 2023, showed R6 weighed 218 pounds (lbs) on 12/22/22, 213.4 lbs on 1/26/23, and 204.6 lbs on 3/1/23. The report showed R6 lost 13.4 lbs (6.2 % of her weight) from December 2022-March 2023. The report showed no recorded weights for R6 in February 2023 or April 2023. On May 9, 2023, at 9:30 AM, V7 Registered Dietician (RD) stated, All long-term residents should be weighed once a month unless they have an order that says otherwise. V7 stated checking monthly weights and monitoring residents' oral intakes are a part of monitoring residents for weight loss. (R6) could be considered at risk for weight loss based on some of the diagnoses she has. I see she did not have weights done in February (2023) or April (2023). I would have expected she would have had her weight checked in April. She did have some weight loss from January 2023-March 2023 . 2. R281's Face Sheet printed May 9, 2023, showed R281 was admitted to the facility on [DATE], with diagnoses including a Stage IV pressure sacral pressure injury, Stage III pressure injuries to his left and right buttocks, osteomyelitis to his sacral wound, sepsis, heart failure, and protein-calorie malnutrition. R281's Physician Order Report dated May 5, 2023, showed, Weekly weights times 4 weeks .Special Instructions: Obtain and record a reweigh if a 2 or more-pound difference from the last recorded weight. R281's Vitals Report dated May 9, 2023, showed no recorded weights for R281. R281's progress notes dated April 27, 2023-May 9, 2023, showed no documentation that R281 ever refused to be weighed. On May 9, 2023, at 9:30 AM, V7 RD stated, All newly admitted residents should be weighed upon admission to the facility and then once a week for the next 4 weeks . (R281) is a new admission. I saw him last week and his admission weight had not been done yet. He's at risk for weight loss due to his severe pressure wounds. 3. R21's Face Sheet printed May 9, 2023, showed R21 was admitted to the facility on [DATE], with diagnoses including parkinson's disease, dementia, a pressure injury to his right foot, and chronic osteomyelitis to his right ankle/foot. R21's care plan edited May 8, 2023, showed, Monitor and record weight. Notify significant weight 145917 Page 6 of 11 145917 05/10/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0692 change. Level of Harm - Minimal harm or potential for actual harm R21's Vitals Report dated May 9, 2023, showed no record weights for R21 in December 2022, February 2023, or April 2023. Residents Affected - Few On May 9, 2023, at 9:30 AM, V7 RD stated R21 should be weighed once month. V7 stated, (R21) is at risk for weight loss due to his diagnoses and his right foot wound. He was recently on IV (intravenous) antibiotics due to his foot wound. On May 8, 2023, at 11:45 AM, V2 Director of Nursing stated all residents should be weighed at least once a month. The facility's Weighing and Measuring the Resident policy dated March 2011 showed, The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident . 145917 Page 7 of 11 145917 05/10/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

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. Based on interview and record review the facility failed to ensure a resident on psychotropic medications was assessed for a gradual dose reduction (GDR) for 1 of 5 residents (R15) reviewed for unnecessary medications in the sample of 12. The findings include: R15's Physician Order Report shows she has an active order for escitalopram oxalate (anti-depressant medication) 20 mg (milligrams) one time a day starting 1/27/2020, and alprazolam (anti-anxiety medication) 0.25 mg. twice a day starting 6/8/2021. R15's Medication Administration Summary (MAR) for 5/1/2023-5/10/2023 shows R15 is receiving both alprazolam and escitalopram oxalate as ordered. R15's electronic medical record (EMR) shows the only GDR that has been completed for R15 was done on 4/30/2021 (2 years ago). There are no documented GDR's for R15's escitalopram or her scheduled alprazolam. On 5/9/2023 at 1:40 PM, V2 (Director of Nursing) stated she recently took over the psychotropic medication program and was not aware when the GDRs were done for R15's psychotropic medications. V2 stated she could not find any recent notes that R15 was assessed for a GDR by a physician. On 5/10/2023 at 8:45 AM, V2 stated she reviewed the policy, and a GDR should be completed annually. V2 verified they were unable to find any documentation that R15 was assessed for a GDR, and one has not been completed for her psychotropic medications since 2021. V2 verified there were no recent notes from a physician prior to the one obtained yesterday (5/9/2023) indicating that a GDR is contraindicated for R15. The facility provided Tapering Medications and Gradual Dose Reduction policy revised July 2022 states, Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs . Within the first year after a resident is admitted on psychotropic medication or after the resident has been started on psychotropic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated. 145917 Page 8 of 11 145917 05/10/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to ensure menus were followed for a resident on a pureed diet. This applies to 1 of 1 residents (R279) reviewed for dietary services in the sample of 12. The findings include: The facility menus for 5/8/23 show the noon meal will be turkey ala king, biscuit, beets, and caramel apple graham dessert. The soup of the day offered to residents was split pea. The noon meal service was observed on 5/8/2023 on the acorn unit. At 11:50 AM, V11 (Dietary Aide) was plating resident meals. V11 stated that the facility has only one resident on a pureed diet (R279) and usually they get the same menu items as the rest of the residents, but the cook did not puree soup or the dessert for R279. V11 continued with meal service and R279's tray was given without soup or the dessert. On 5/9/2023 at 9:05 AM, V5 (Dietary Manager) stated menus should be followed and all residents should receive what is on the menu including those on pureed diets. The facility provided Pureed Diet policy (2022) states, The Pureed Diet follows the Regular Diet with alterations in the consistency of foods to a pureed consistency as needed. 145917 Page 9 of 11 145917 05/10/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 on a puree diet with the correct consistency. This applies to 1 of 1 residents (R279) reviewed for puree diets in the sample of 12. The findings include: On 5/8/2023 at 1:00 PM, the facility provided test tray of pureed turkey a la king and pureed beets to be evaluated. The pureed turkey a la king had a gritty consistency that required chewing. On 5/8/2023 at 10:31 AM, V3 (AM Cook) stated that the puree consistency should be smooth like pudding. On 5/8/2023 at 1:23 PM, V4 (PM Cook) stated that the puree food should be like baby food and smooth in texture. On 5/9/2023 at 9:05 AM, V5 (Dietary Manager) stated that the food should not be gritty or have any chunks and should be smooth like baby food. Facility Pureed Food Preparation policy (no date) states, . 6. Pureed foods will be the consistency of applesauce or smooth, mashed potatoes . 145917 Page 10 of 11 145917 05/10/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure medical equipment was disinfected between residents to prevent cross contamination for 3 of 12 residents (R9, R22 and R23) reviewed for infection control in the sample of 12. Residents Affected - Few The findings include: On 5/9/2023 at 8:00 AM, V10 (Registered Nurse/RN) was observed during morning medication pass. At 8:06 AM, V10 went into R9's room and placed her stethoscope under R9's clothing and listened to her abdomen for bowel sounds and her upper chest for lung sounds. V10 put the stethoscope around her neck and exited R9's room. At 8:15 AM, V10 without disinfecting it, used the same stethoscope on R23's bare skin to assess her bowel and lung sounds. After she finished, V10 again put the stethoscope around her neck and did not disinfect it. At 8:25 AM, V10 again without disinfecting it, used the same stethoscope on R22's bare skin and listed to her bowel and lung sounds. On 5/9/2023 at 8:38 AM, V10 stated she should have disinfected her stethoscope in between residents to prevent the spread of germs. The facility provided Cleaning and Disinfection of Resident-Care Items and Equipment policy revised October 2018 states, Resident-care equipment, including reusable items and durable medical equipment and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 145917 Page 11 of 11