Health inspection·March 19, 2024

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide or obtain the required specialized rehabilitative services for 1 of 3 residents (R2) reviewed for therapy services in a sample of 3. Residents Affected - Few The findings include: R2's admission Record documents that R2 was admitted to the facility on [DATE] with a diagnoses of chronic kidney disease, unspecified, chronic obstructive pulmonary disease, unspecified, hyperlipidemia, unspecified, essential (primary) hypertension, unspecified atrial fibrillation, gastro-esophageal reflux disease without esophagitis, depression, unspecified, anemia in chronic kidney disease, hypertensive heart disease without heart failure, edema, unspecified, and other seasonal allergic rhinitis. R2's Minimum Data Set (MDS) dated [DATE], documents Section C, a Brief Interview for Mental Status (BIMS) score of 13, indicating that R2 is cognitively intact. Section GG, Functional Abilities and Goals, of the same MDS documents that R2 requires setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, dependent with toileting hygiene, lower body dressing, putting on/off footwear, bed mobility, and transfers, and requires partial/moderate assistance with upper body dressing. R2's Physician's orders dated 2/6/2024 documents Physical Therapy (PT)/Occupational Therapy (OT): Skilled PT/OT 5 times/week x 30 days. Therapy to include Therapeutic Exercises, Therapeutic Activities, Neurological Re-Education, Gait Training, Group Therapy, Self-Care Management, Wheelchair assessment and management. R2's PT Treatment Note dated 2/05/2024 documents a medical diagnosis of cerebral infarction, unspecified, a treatment diagnoses of muscle wasting and atrophy, necrotizing enterocolitis (NEC), multiple sites, and unsteadiness on feet. R2's PT Treatment Note dated 1/22/2024 - 1/26/2024 documents medical diagnoses of heart failure, unspecified and personal history of COVID-19 (1/14/2024) and treatment diagnoses of muscle wasting and atrophy, NEC, multiple sites, and unsteadiness on feet. R2's PT Note dated 1/22/2024 documents this [AGE] year-old male hospitalized with COVID-19, 1/14/2024 - 1/19/2024, continues to be on isolation here at skilled nursing facility. (R2) was previously hospitalized secondary to heart failure (stage III to almost IV). (R2) presented today with deficits in overall activity tolerance, functional mobility, functional transfers, bed mobility, sitting and standing balance/tolerance, bilateral upper extremity strength, and increased need for assistance with self-care tasks. (R2) would benefit from skilled PT services to improve above deficits to increase independence and safety to prior level of functioning. R2's OT Treatment Noted dated 2/05/2024 documents this [AGE] year-old male was referred to skilled Page 1 of 3 145964 145964 03/19/2024 McLeansboro Rehab & Hlth C Ctr 405 West Carpenter McLeansboro, IL 62859

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few OT services after recent hospitalization secondary to stroke due to unknown causes. (R2) was also recently hospitalized due to COVID-19 and heart failure (stage III to almost IV). (R2) presented today with deficits in overall activity tolerance, functional mobility, functional transfers, bed mobility, sitting and standing balance/tolerance, bilateral upper extremity strength, and increased need for assistance with self-care tasks. (R2) would benefit from skilled OT services to improve above deficits to increase independence and safety to prior level of functioning. While at facility to complete evaluation nursing staff reported that (R2's) vitals fluctuate. (R2) would benefit from skilled OT services to improve above deficits to increase independence and safety as well as reduce caregiver burden. The Monthly Census for January 2024 documents R2 is receiving Medicare days for therapy services from 1/09/2024 - 1/13/2024; 1/19/2024 - 1/25/2024; and February 2024 documents R2 is receiving Medicare therapy services from 2/2/2024 - 2/22/2024. R2's Notice of Medicare Non-Coverage documents services (PT/OT) will end 2/22/2024 related to end of therapy services; reason Medicare may not pay. The facility's document titled Name of Previous Contracted Rehabilitation Service Company dated 2/13/2024 documents in part . Termination of Therapy Services Agreement . failure to maintain payment terms, pursuant to Section 5.2.5 of the Therapy Services Agreement .final date of service will be Sunday, February 18, 2024. The facility's therapy services agreement dated 3/13/2024, documents in part . This Agreement (Agreement) is made of the 12th day of March 2024, by and between newly contracted rehabilitation service company. On 3/14/2024, at 3:35 PM, R2 stated that the first go around he was getting therapy to help him walk better. R2 stated that his blood pressure drops at times and makes it a little hard at times. R2 stated the second go around here, therapy has not been here to give him any help. On 3/18/2024 at 1:05 PM, R2 stated that he gets around with his wheelchair well but can't get up and walk by himself and the staff won't help him walk without therapy approving it. R2 stated that he does not know how many therapy days he has missed. R2 stated that his family is working on getting him moved closer to them. On 3/18/2024 at 1:10 PM, V1 (Administrator) stated that there is no exact date yet when the new therapy service will start. V1 stated the facility is not accepting any new admissions that require therapy services. V1 stated that all primary physicians were notified of therapy services ending on 2/18/2024. V1 stated that V5 (Occupational Therapist) was here on 2/19/2024 - 2/23/2024 and did provide therapy services for R2. V1 stated that R2's last day of coverage for therapy services was 2/22/2024 with 17 days remaining. V1 stated that a referral was sent out to a local facility on 3/13/2024 to transfer R2 to but there has not been any response back yet. V1 stated that R2 was receiving therapy services 5 days a week. On 3/18/2024 at 1:40 PM, left message for V5 (OT) to return call with no call back during this survey. On 3/18/2024 at 1:55 PM, V6 (Family) stated that the facility notified her of R2's therapy services being stopped on 2/18/2024. V6 stated that they are in the process of getting R2 transferred back 145964 Page 2 of 3 145964 03/19/2024 McLeansboro Rehab & Hlth C Ctr 405 West Carpenter McLeansboro, IL 62859

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few closer to them to help take care of him. V6 stated that they are trying to acquire veteran benefits for R2 since he is a retired veteran. On 3/18/2024 at 5:55 PM, V7 (Primary Physician) stated that she would expect the facility to acquire therapy services as soon as possible or transfer any resident to another facility as soon as possible so that therapy services would not be disrupted and residents' activity level would not decline any further. On 3/14/2024 and 3/18/2024, there were no observations of therapy services being provided to any resident at the facility. 145964 Page 3 of 3