Health inspection·March 28, 2024

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to notify a medical provider of an out of therapeutic range PT/INR (Prothrombin Time/International Normalized Ratio) lab result for one (R7) of five residents reviewed for unnecessary medications in the sample of 18. Residents Affected - Few Findings include: R7's Face Sheet documented an admission date of 12/4/23 and listed diagnoses including a history of Cerebral Infarction and Unspecified Atrial Fibrillation. R7's Physicians Order Sheet for March 2024 documented an order dated 3/18/24 for Coumadin 4mg (milligrams) by mouth at bedtime Monday, Wednesday, and Friday, alternating with Coumadin 3mg. by mouth at bedtime on Sunday, Tuesday, Thursday, Saturday, and a 12/26/23 order for, PT/INR (to be drawn) weekly. A Lab Report dated 3/26/24 documented, Coagulation: PT-37.6 (reference range 9.8-12.2 seconds). INR-3.8 (reference range 0.9-1.2). Handwritten on this document was, 3/26/24, 18:00. Called (V10/Physician's) office. Awaiting call back, and 3/27/24 14:25: Spoke with (V10's) Nurse, states (she) will call back (when) (V10) is in the office. On 3/26/24 at 9:45am, R7 was in her room lying in bed. R7 was alert but oriented only to herself. On 03/28/24 at 09:10 AM, V9 (Registered Nurse/RN) stated R7 gets her PT/INR drawn weekly to monitor the Coumadin. V9 stated R7 is at baseline functioning and is not showing any side effects of coumadin therapy. V9 stated V10 was in the building on 3/26/24 to sign order sheets and did not give any new orders on R7. V9 stated they had not yet received the lab result when V10 was there. V9 stated staff unsuccessfully attempted to contact V10 on 3/26/24 and 3/27/24. V9 stated he has not tried to call V10 today, but he will now do so. On 3/28/24 at 9:26 AM, V2 (Director of Nurses/DON) stated V10 is also the facility's Medical Director. V2 stated staff should have tried calling V10's cell number or contacting the on call physician. On 3/28/24 9:34 AM, this surveyor was present when V9 called V10's office. V9 told V10's staff he needed to speak to V10 emergently and gave staff the lab results. V9 stated V10's staff consulted with V10 who gave orders to hold one dose of the coumadin and resume it at 3mg. daily thereafter. V9 then documented the interaction on a Telephone Order Sheet. A Notification for Change in Resident Condition or Status Policy dated 12/7/17 stated, The facility and/or facility staff shall promptly notify appropriate individuals (Administrator, Director of Nurses, Physician, Guardian, Health Care Power of Attorney) of changes in the residents medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been: M. Abnormal lab findings. Page 1 of 4 145978 145978 03/28/2024 Axiom Healthcare of Harrisburg 1000 West Sloan Street Harrisburg, IL 62946

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to hold quarterly Quality Assurance and Performance Improvement (QAPI) meetings. This has the potential to affect all 19 residents residing in the facility. Residents Affected - Many The Findings Include: On 3/26/24 at 1:00 PM, V1 (Administrator) stated she is not able to provide any documentation of minutes or attendance sheets for the facility's quarterly QAPI meetings. V1 further stated she started her employment at this facility in September 2023 and no QA information was available because she has not held a QAPI meeting since being employed. During the survey, a review of facility records revealed no documentation quarterly QAPI meetings were held. No meeting minutes or attendance sheets were found. The facility was unable to provide reproducible evidence QAPI meetings had been scheduled or occurred. The facility's QAPI Plan revised on 12/1/2022, documents Aspects of services and care are measured against established performance goals. Key monitors are measured and trended on a quarterly basis. The QAPI Committee analyzes performance to identify and follow-up on areas of opportunity. The Long Term Care Facility application for Medicare and Medicaid dated 3/26/2024, documents 19 residents reside in the facility. 145978 Page 2 of 4 145978 03/28/2024 Axiom Healthcare of Harrisburg 1000 West Sloan Street Harrisburg, IL 62946

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide at least 80 square feet of living space for 8 of 8 residents (R2, R7, R9, R11, R12, R14, R15, R16) reviewed for room size in a sample of 18. Findings include: On 3/27/24 at 12:20 PM, this surveyor accompanied V3 (Maintenance Supervisor) for the purpose of measuring the 10 resident rooms that are dually certified (Medicare and Medicaid) for 4 beds per room. The 10 rooms measured less than 80 square (sq.) feet (ft.) of living space per bed. The 10 room's measurements are as follows: room [ROOM NUMBER]: 311.5 sq. ft. (77.9 sq. ft. per bed) room [ROOM NUMBER]: 302.8 sq. ft. (75.7 sq. ft. per bed) room [ROOM NUMBER]: 305.7 sq. ft. (76.4 sq. ft. per bed) room [ROOM NUMBER]: 304.4 sq. ft. (76.1 sq. ft. per bed) room [ROOM NUMBER]: 310.2 sq. ft. (77.6 sq. ft. per bed) room [ROOM NUMBER]: 289.6 sq. ft. (72.3 sq. ft. per bed) room [ROOM NUMBER]: 304.1 sq. ft. (76 sq. ft. per bed) room [ROOM NUMBER]: 315.7 sq. ft. (78.9 sq. ft. per bed) room [ROOM NUMBER]: 314.6 sq. ft. (78.7sq. ft. per bed) room [ROOM NUMBER]: 307.1 sq. ft. (76.8 sq. ft. per bed) A Daily Roster provided by the facility and dated 3/26/24 documents that R2, R7, R9, R11, R12, R14, R15, and R16 reside in the rooms listed above. There were no residents assigned to rooms 106, 109, 211 or 212. During the survey from 3/26/24 to 3/28/24, no residents were observed to reside in rooms 106, 109, 211 and 212, confirming these rooms were unoccupied. room [ROOM NUMBER] was equipped with only 2 beds, an oversized recliner, 2 nightstands, and 2 dressers (rather than the 4 beds for which that room is certified). Rooms 103, 104, 105, 107, 109, 110, 211, and 212 were each equipped with only 2 beds, 2 nightstands, and 2 dressers (rather than the 4 beds per room for which these rooms are certified). Observations of the undersized resident rooms found the rooms adequate to meet the medical and personal needs for the residents assigned to these rooms, as they were not currently being utilized as 4-bed rooms. Inquiries regarding the size of these rooms during the survey from 03/26/24 to 03/28/24, found no concerns or negative interviews from residents or families of residents who reside in the waivered 145978 Page 3 of 4 145978 03/28/2024 Axiom Healthcare of Harrisburg 1000 West Sloan Street Harrisburg, IL 62946

F 0912 Level of Harm - Potential for minimal harm rooms. During interview, on 3/26/24, R2, R7, R9, R11, R12, R14, R15, and R16 all voiced no concerns with the size of their rooms during interviews. Review of Resident Council meeting minutes from the past 6 months indicated no concerns related to the size of the rooms. Residents Affected - Some 145978 Page 4 of 4