Health inspection·June 5, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 prevent elopement by failing to identify behaviors of wandering/exit seeking and elopement, re-evaluate for risk of elopement, notify the physician and family of exit seeking behaviors, and develop/implement targeted behavior tracking and person-centered interventions to address exit seeking behavior for one resident (R11) reviewed for elopement in the sample list of 14. This failure resulted in R11, a resident with a known history of exit seeking and diagnosis of Dementia, leaving the facility alone and unnoticed by climbing through a window. R11 was found by a member of the community, approximately two tenths of a mile on a residential street/roadway without sidewalks, a state highway and railroad tracks approximately a quarter mile away, wearing dark clothing, while using a walker, by himself(R11) on the side of the road. R11 had the potential for serious injury and/or death of being struck by a motor vehicle or falling. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/11/23 when R11 eloped from the facility unnoticed after repeatedly exhibiting exit seeking behavior within the previous three months. V1 Administrator was notified of the Immediate Jeopardy on 5/31/23 at 3:34 PM. The surveyor confirmed by observation, interview, and record review that the immediacy was removed on 5/31/23, but noncompliance remains at Level Two because additional time is needed for the facility to continue staff education and evaluate the implementation and effectiveness of the in-service training. Findings include: The facility's incident summary of R11's elopement documents on 5/11/23 at approximately 8:10 PM another resident (R12) notified staff that R12 observed R11 exit the facility. The Elopement Policy was activated, a search was initiated, and R11 was found at approximately 8:20 PM and returned to the facility. The incident investigation dated 5/11/23 and 5/12/23 document V10 Labor & Delivery Nurse brought R11 back to the facility, and R11 had been found on [NAME] Street (approximately two tenths of a mile away from the facility). R11 told V10 that R11 was going to R11's hometown. R12 was interviewed and recalls seeing R11 climb out of the window. R12 did not notify staff because R12 did not want R11 upset with R12. A local web based weather application documents sunset was at 8:00 PM on 5/11/23. R11's Minimum Data Set (MDS) dated [DATE] documents R11 has a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, and R11 did not have any wandering behaviors noted during the 7 day review period. R11's MDS dated [DATE] documents R11 has a BIMs score of 3, Page 1 of 12 145979 145979 06/05/2023 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0689 indicating severe cognitive impairment, and wandering occurred 4-6 days during the 7 day review period. Level of Harm - Immediate jeopardy to resident health or safety R11's Nursing Notes document the following: On 3/7/23 at 2:06 PM R11 attempted to walk out the front door of the facility twice. On 3/12/23 at 5:09 AM R11 set off the door alarm and was found by the door. R11 stated R11 wanted to go out to R11's car to get something. On 3/15/23 at 2:46 AM R11's departure alert system activated the door alarm near the facility's entrance and R11 was redirected to the living room area. R11 stated R11 wanted to leave. On 3/16/23 at 3:18 AM R11 wandered down the east hall and attempted to open the door to the garden. On 3/18/23 at 4:34 AM R11 went outside to look for R11's car and was brought back into the facility. R11's departure alert system had not activated the door alarm. A second departure alert device was added to R11's wheeled walker. On 4/7/23 at 6:56 PM staff observed R11 exiting the building and intercepted R11 in the parking lot. On 4/14/23 at 11:30 PM R11 insisted on leaving the facility to go to R11's hometown. Residents Affected - Few R11's Care Plan dated 5/23/23 does not document any new interventions were developed/implemented to address R11's wandering and exit seeking behaviors after 3/20/23 until 5/11/23. The intervention dated 3/20/23 documents R11 has a departure alert device on R11 and on R11's walker, staff are to redirect R11 to R11's room after supper, and turn on western television shows. There is no documentation that R11's wandering/exit seeking behaviors were routinely tracked and monitored including the development and implementation of nonpharmacological interventions to respond to R11's behaviors. There are no documented elopement risk assessments completed in R11's medical record after 3/8/23 until 5/23/23. There is no documentation that R11's physician and family were notified of R11's exit seeking and wandering behaviors until 5/11/23 after R11 eloped from the facility. On 5/30/23 at 1:23 PM the perimeter of the facility near the sunroom was observed. There is a concrete slab adjacent to the windows, landscape rock and bushes, and a grassy 45 degree berm that leads to an uneven, grass yard. The concrete slab does not connect to a sidewalk. There is a sidewalk to the east of the sunroom, across the grass yard, that does not connect to the street. On 5/30/23 at 4:15 PM 19th Street (East/West street where facility is located) does not contain sidewalks. There is no shoulder or curb and approximately 1 foot of gravel on each side of the road with grassy ditches. 19th Street intersects with [NAME] Street approximately 1/4 mile away from the facility. There is no stop sign when heading North on [NAME] Street at this intersection. [NAME] Street does not contain a sidewalk, shoulder, or curb. There is approximately 1 foot of gravel on each side of the road with grassy ditches. Railroad tracks and Highway 54 are South of where R11 was found, approximately 1/4 mile away. On 5/30/23 at 1:03 PM R11 stated R11 recalls getting out of the facility a few weeks ago. R11 stated R11 climbed out the facility window when no one was looking, and R11 was trying to get to R11's hometown. R11 stated R11 walked down the road that evening and someone picked R11 up and brought R11 back to the facility. R11 stated there were no sidewalks, so R11 had to walk on the edge of the road. On 5/30/23 at 11:20 AM V9 (R12's Family) stated V9 received a call from R12 around 8:15 PM on 5/11/23 reporting that R11 got out of the facility through the sunroom window, and no staff had witnessed R11 leave the facility. R12 told V9 that R11 knew not to go through the doors due to R11's departure alert device, and R11 was wanting to go to R11's hometown. V9 stated R12 reported the incident to the nurses prior to calling V9. 145979 Page 2 of 12 145979 06/05/2023 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 5/30/23 at 11:30 AM V8 (R11's Power of Attorney) stated the facility notified V8 that R11 escaped out of the sunroom window and was found down the road from the hospital. V8 stated R11 has a history of going near the exit doors, but had never tried to leave the facility prior to this incident. On 5/30/23 at 11:47 AM V10 Labor & Delivery Nurse stated V10 was on V10's way home from work on 5/11/23 at approximately 8:20 PM-8:30 PM. V10 was driving on [NAME] Street and saw R11 in dark clothing, walking South, with R11's walker on the side of the road in the gravel. V10 stated V10 thought it was abnormal, was concerned that R11 was going to get hit by a vehicle, and V10 offered R11 a ride. R11 told V10 that R11 lived around the bend. V10 stated R11 got into R11's van, and V10 drove R11 around asking if any of the houses were R11's. V10 then asked R11 for R11's address and R11 gave R11's hometown as R11's address. R11 was unaware of what town R11 was currently in. V10 asked about R11's family, discovered R11 was a resident of the facility, and brought R11 back to the facility. On 5/30/23 at 11:58 AM V11 Registered Nurse stated V11 was conducting door alarm checks in March, R11 was out in the parking lot and was trying to get back into the facility through the main entrance. V11 stated no staff had witnessed R11 leave the facility and R11's departure alert device did not alarm. The device was functional, but V11 believed it did not activate due to R11 wearing multiple shirts. V11 stated the 4/7/23 incident was witnessed by staff, and R11 was looking for R11's car. V11 could not recall if V11 notified R11's family of R11's exit seeking behaviors or elopement on 3/18/23, and V11 stated V11 did not notify V7 (R11's Physician). V11 stated R11 is alert and oriented to person, not place and time, and does not have good safety awareness and decision making ability. R11's exit seeking behaviors seem to be close to the first hour of change of shift from days to evenings, and V11 believes R11's behaviors are triggered by watching staff leave. On 5/30/23 at 5:39 PM V15 Certified Nursing Assistant (CNA) stated on 5/11/23 V15 last saw R11 at approximately 7:00 PM in the living room area with R12. V15 was first made aware that R11 was out of the facility when R12 stopped V15 in the hallway at about 8:10 PM. V15 stated R12 told V15 that R12 was upset because R12 and R11 got into an argument and R12 saw R11 leave the facility through the sunroom window. R11 had exited the facility sometime between 7 and 8:00 PM. V15 stated V15 immediately went to the sunroom and the middle window was open with the screen removed. V15 immediately went outside to see if V15 could see R11, V15 did not see R11 and reported the incident to V14 Registered Nurse (RN). V15 stated an elopement check was initiated and V14 and V15 continued to search for R11 outside of the facility. V15 stated it was just starting to get dark around 8:10 PM, and V10 located and returned R11 at approximately 8:30 PM. On 5/31/23 at 7:19 AM V14 RN stated during the evening medication pass V15 told me that R12 witnessed R11 leave the facility through the sunroom window. We went outside near the window, and were unable to locate R11. V14 stated V14 instructed the other nurse and CNA to conduct a head count of all other residents while V14 and V15 continued to search for R11 outside. V14 had last seen R11 between 6:30 PM and 7:00 PM. On 5/30/23 at 2:28 PM V3 MDS Coordinator confirmed R11's care plan does not identify new interventions to address R11's exit seeking behaviors after 3/20/23 until 5/11/23. On 5/30/23 at 11:01 AM V2 Director of Nursing stated R11 left the facility through the sunroom window on 5/11/23, and R12 witnessed the incident but did not report to staff right away. V2 stated R12 called and reported the incident to V9 (R12's Family) who is also an employee of the facility. R11 was found down the road near the stop sign, East of the hospital. On 5/30/23 at 12:43 PM V2 stated elopement risk assessments are documented in the resident's paper chart and completed quarterly and as 145979 Page 3 of 12 145979 06/05/2023 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few needed. V2 stated if the resident has a change in cognition or a change then an elopement risk assessment is done. V2 stated R11 has always been at risk for elopement since R11 admitted and wears a departure alert device. On 5/30/23 at 2:06 PM V2 stated V2 reviewed the surveillance camera footage and R11 went down the grassy berm, and walked to the sidewalk by the building. V2 stated physician and family notification would be documented in a progress note and confirmed R11 had no targeted behavior tracking for R11's wandering/exit seeking behaviors. On 5/31/23 at 9:57 AM V2 stated the video surveillance inside the facility showed R11 heading to the dining room at 7:45 PM, and there were two CNAs at the desk. V2 stated at 7:46 PM R11 headed towards the sunroom and R12 was in the living room area, and at 7:56 PM R11 showed up on the camera outside of the facility near the sunroom. V2 confirmed there is no documentation of interventions implemented between 3/20/23 and prior to 5/11/23 or that the physician and family were notified to address R11's exit seeking and wandering behaviors. The facility's Wandering Resident/Elopement policy revised 10/3/18 documents: Wandering behaviors will be documented in the medical record. Observations of wandering behaviors will determine the level of supervision needed. Residents will be assessed for elopement risk quarterly and with significant changes in condition, and the care plan updated as needed. Residents at risk for elopement will have interventions that include the use of a departure alert device, and their care plan updated to include behaviors with specific goals and interventions. Residents who have eloped from the facility will have interventions including visual checks every 30 minutes for 24 hours initiated when the resident attempts to leave the facility more than once in a 24 hour period. Notify the family and physician of the behavior. The Immediate Jeopardy that began on 5/11/23 was removed on 5/31/23 when the facility took the following actions to remove the immediacy: 1. R11's Elopement Risk Assessment was completed and R11's Care Plan was updated on 5/31/23 by V3 MDS Coordinator. 2. On 6/1/23 at 1:28 PM V24 Director of Facilities stated on the morning of 5/12/23, V25 installed brackets on the windows to limit opening width. V24 stated an audit of all windows and doors was conducted on 5/12/23. On 5/30/23 at 1:23 PM the sunroom windows were secured with brackets to restrict opening width of approximately 4 inches. 3. The facility's purchase order dated 4/11/23 documents the facility purchased a new departure alert device tester. 4. The Treatment Record documents the nurses checked all door alarms for functioning twice daily between 3/1/23 and 5/31/23. 5. V3 MDS Coordinator completed Elopement Risk Assessments on 5/31/23 for all residents identified to be at risk for elopement, and care plans were updated. 6. On 6/1/23 at 1:44 PM V2 stated on 5/31/23 V2 placed the list of residents with departure alert devices was placed in the binder at the nurses station, and V2 will be responsible for updating the list. at 1:52 PM V2 stated V2 placed behavior tracking sheets in the binder at the nurses station on 5/31/23. On 6/01/23 at 1:52 PM the binder at the nurses station contained a list of residents with departure alert devices and behavior tracking sheets for the identified residents. 7. The Staff Sign In Sheets for In-Service dated 5/11/23 documents staff were trained on wandering 145979 Page 4 of 12 145979 06/05/2023 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few residents/elopement by V1 Administrator. The Staff Sign In Sheets for In-Service dated 5/31/23 documents the facility initiated staff training on residents with departure alert devices conducted by V1 on 5/31/23. The staff training log dated 6/5/23 documents staff received training on wandering/elopement policy, behavior tracking forms, and residents with departure alert devices. 8. The facility's Wandering Resident/Elopement policy with a revised date 5/31/23 documents the policy was reviewed and updated. On 6/1/23 at 2:08 PM V1 confirmed the facility reviewed and updated the Wandering Resident/Elopement policy on 5/31/23. 9. The facility's audit tool documents V2 or designee will audit the completion of behavior tracking and effectiveness of interventions for three residents per week for a total of four weeks. On 06/01/23 at 1:36 PM V2 stated the behavior tracking forms will be completed for any residents with exit seeking behaviors and the nurses will communicate the behaviors to V2. V2 stated V2 will conduct audits to ensure behavioral interventions are in place and effective. At 1:44 PM V2 stated the audits will be conducted weekly for four weeks, or longer if needed, and reviewed at the facility's Quality Assurance meetings. 10. The facility's audit tool documents V1 or designee will audit staff response to door alarms three times per week for four weeks, and audits were conducted on 6/1/23, 6/2/23, and 6/3/23. On 6/1/23 at 1:44 PM V1 stated the door alarm audits will be continued for four weeks or longer if needed, and reviewed at the facility's Quality Assurance meetings. On 6/5/23 at 8:53 AM V1 confirmed V1 conducted elopement drills on 6/1/23, 6/2/23, and 6/3/23. 145979 Page 5 of 12 145979 06/05/2023 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to treat a Urinary Tract Infection with a positive Urinalysis and confirmed symptoms for one of one residents (R10) reviewed for Urinary Tract Infections in the sample list of 14. Findings include: R10's Face Sheet documents an admission date of 2/24/23 with diagnoses including Unspecified Fracture Upper End of Humerus and Muscle Wasting and Atrophy. R10's Minimum Data Set (MDS) dated [DATE] documents R6 has severe cognitive impairment and documents that R10 is always incontinent of bowel and bladder. R10's Nurse's Notes dated 4/20/2023 at 5:28 PM by V12 Licensed Practical Nurse (LPN) documents (R10) had an unresponsive episode this afternoon. (R10) was sitting in (reclining geriatric chair) with (spouse) by side. When staff was in room checking on (R10), (R10) went unresponsive and eyes rolled back. Spoke with (Nurse at V7's/R10's Physician's office) and made aware of episode. New order received to straight cath (catheterize) resident for UA (Urinalysis) and C&S (Culture and Sensitivity). (Spouse) here and aware of new orders. Will continue to monitor (R10). R10's Nurse's Notes dated 4/21/2023 at 7:18 AM by V21 LPN documents, UA C&S collected by straight cath using sterile technique per order. R10's Nurse's Notes dated 4/21/2023 at 2:22 PM by V13 LPN documents, UA result faxed to (V7's) office. Tylenol given this morning for flank pain and is effective. Continues to be incontinent of B&B (bowel and bladder) urine is dark and foul smelling. Fluids encouraged but intake is poor and has difficulty swallowing without coughing. R10's Nurse's Notes dated 4/23/2023 at 2:17 PM by V22 LPN documents, U/A C&S results came in from lab and were faxed to both (V7's) office and (V23 Physician's) office as (V23) is on call for (V7). (V23) paged and returned call re: (regarding) results with instructions given to take results to hospital pharmacist and have him call (V23), which was done. (Spouse) asked about results and was informed of the above. R10's Laboratory report dated 4/22/23 documents results of the Urine Culture as >100,000 CFU/ml (Colony forming unit/milliliter) Gram Negative Rods and organism identified as Proteus Mirabilis ESBL (Extended Spectrum Beta-Lactamase). This report documents that it was faxed to the physician on 4/22/23 and 4/23/23. R10's Nurse's Notes dated 4/24/2023 at 11:43 AM by V13 documents, Spoke with (V7's) nurse regarding urine culture result and actions taken by (V23) over the weekend. States the culture is on (V7's) desk for (V7's) review. Urine continues dark with strong odor some drops of blood noted on (incontinent brief) at times. Does complain of lower back pain at times. Tylenol given with some relief. Contact precautions for ESBL in urine. R10's Nurse's Notes dated 4/25/2023 at 2:15 PM by V13 documents, Urine continues unchanged. 145979 Page 6 of 12 145979 06/05/2023 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R10's Nurse's Notes dated 4/26/2023 at 01:48 PM by V13 documents, (V7) here this morning to assess. No new orders at this time. Contact precautions remain in place for ESBL in urine no treatment at this time other than encouraging fluids. Urine is foul and dark on (incontinent brief) scant amounts of blood noted at times. Tylenol given this morning to promote comfort. R10's Nurse's Notes dated 5/04/2023 at 1:54 PM by V13 documents, (R10) continues weak with frequent complaints of pain in random places legs and feet to lower back. Tylenol helps for short periods. Appetite continues to decline eating only a few bites at a meal. Fluids encouraged but little taken. Night shift had report blood tinged urine in brief in the night. Message left for (V7). R10's Nurse's Notes dated 5/05/2023 at 1:53 AM by 21 documents, Call back from (V7's) office. New orders received for Cipro (Ciprofloxacin/antibiotic) PO (by mouth) BID (two times a day) x (times) 10 days. First dose given this shift. No adverse reactions noted from ABT (Antibiotic) for UTI (Urinary Tract Infection). (R10) complaining about lower back pain. PRN Tylenol given' R10's Laboratory Report dated 4/23/23 documents the Proteus Mirabilis ESBL is resistant to Ciprofloxacin. R10's medical record does not document any further urinalysis after the one collected on 4/21/23 before treatment on 5/5/23 (14 days later). On 5/31/23 at 12:45 PM, V13 stated that (R10) was not treated with an antibiotic for the UTI with ESBL on 4/23/23. V13 stated the (V7) decided not to treat. (V13) stated that (V7) went off (R10's) symptoms and (R10) is allergic to all kinds of antibiotics. V13 stated that (V7) did not want a recheck of the urine either. V13 stated that V7 believes (R10) was treated with an antibiotic after that but no UA was done if it's not in the chart and V13 confirmed there is not a UA in the chart after 4/21/23. On 6/01/23 at 9:36 AM, V2 Director of Nursing confirmed that the Physician didn't want to order an antibiotic he thought it was a fluke. He was going to retest but he ended up treating (R10) later. V2 confirmed there was not a new UA completed before starting the antibiotic. 145979 Page 7 of 12 145979 06/05/2023 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

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 interview and record review the facility failed to attempt Gradual Dose Reductions of psychotropic medications, document clinical rational why dose reductions were not attempted, and care plan nonpharmacological behavioral interventions for four (R4, R8, R9, R11) of five residents reviewed for unnecessary medications in the sample list of 14. Findings include: 1.) R4's Diagnoses List dated 6/1/23 documents R4 has Dementia and Major Depressive Disorder. R4's Physician Order dated 4/25/23 documents administer Lorazepam (antianxiety) 0.5 milligrams (mg) by mouth daily. R4's Physician Order dated 10/27/22 documents to administer Paxil 40 mg by mouth daily. R4's Care Plan dated 4/25/23 documents R4 receives Paxil for depression and symptoms include feeling down and increased fatigue. R4 has anxiety and symptoms include yelling, mocking staff/residents, and throwing items. R4's behaviors also include yelling, hooting, and cussing. This care plan does not include specific nonpharmacological interventions to respond to R4's behaviors. R4's Psychotropic Medication Assessments dated 2/28/23 and 4/25/23 document R4 receives Ativan 0.5 mg daily for yelling out and mocking staff/residents, and interventions include one to one, snacks, and resting in the recliner. R4's Psychotropic Medication Assessments dated 8/18/22, 11/9/22, 2/2/23, and 4/25/23 document R4 receives Paxil 40 milligrams due to feeling down, increased fatigue, and yelling out, and interventions include activities, one to one, and family visits. These assessments document R4's behaviors have shown improvement and appear controlled. The Note to Attending Physician/Prescriber dated 2/24/23 documents the pharmacy recommended reducing R4's Paxil to 30 mg daily, and includes to document clinical rationale and symptoms exhibited if the reduction is declined. This form is signed by the physician as declined, but does not document the clinical rationale and evidence of behavioral symptoms. 2.) R8's Physician Order dated 6/1/23 documents to administer Clonazepam (antianxiety) 1 mg daily at bedtime. R8's Physician Order dated 4/7/22 documents to administer Duloxetine Hydrochloride (antidepressant) 30 mg twice daily for Restless Leg Syndrome. R8's Care Plan dated 3/30/23 documents R8 has a diagnosis of anxiety and symptoms include complaints of pain, asking to go home, and getting upset about no one visiting R8. R8 currently receives Clonazepam and takes Duloxetine for Restless Leg Syndrome. This care plan does not identify specific nonpharmacological interventions to respond to R8's behaviors. R8's Psychotropic Medication Assessments dated 4/20/22, 7/25/22, 10/5/22, 1/5/23, and 3/30/23 document R8 receives Clonazepam 1 mg daily for anxiety, symptoms of increased complaints of pain, wanting to go home, and upset about no one visiting R8. Interventions include one to one, reassurance, and pain medication. These assessments document R8's behaviors have shown improvement and appear controlled. R8's Psychotropic Assessments dated 1/5/23 and 3/30/23 document R8 receives Duloxetine 30 mg twice daily for Restless Leg Syndrome and symptoms include insomnia and feeling like bugs are on R8's 145979 Page 8 of 12 145979 06/05/2023 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some legs. Interventions include one to one, repositioning, redirection, and watching television. These assessments document R8's behaviors appear controlled. The Notes to Attending Physician/Prescriber dated 12/22/22 and 4/24/23 document the pharmacy recommendation to reduce R8's Duloxetine to 20 mg twice daily, and includes to document clinical rationale and symptoms exhibited if the reduction is declined. These forms are signed by the physician as declined, but do not document the clinical rationale and evidence of behavioral symptoms. There are no documented behaviors in R8's medical record in December 2022 and April-May 2023. On 6/01/23 at 9:59 AM V2 Director of Nursing stated R8's behaviors are documented on R8's Medication Administration Record, and V2 confirmed R8's May MAR does not prompt the nurse to document R8's behaviors for the use of Clonazepam. 3.) R9's Physician Order dated 5/19/23 documents to administer Fluoxetine (antidepressant) 20 mg by mouth daily and the order dated 5/24/23 documents to administer Fluoxetine 40 mg by mouth daily. R9's Physician Order with a start date of 12/15/22 documents to administer Alprazolam (antianxiety) 0.5 mg daily. R9's Care Plan dated 5/30/23 documents R9 has diagnoses of depression and anxiety, and symptoms that include general complaints, restlessness, insomnia, verbalized depression, and health complaints. R9 takes Prozac and Alprazolam to manage R9's symptoms. This care plan does not include specific nonpharmacological interventions to respond to R9's behaviors. R9's Psychotropic Medication Assessments dated 6/30/22, 9/22/22, 12/19/22, and 3/9/23 document R9 receives Alprazolam 0.5 mg daily for anxiety and behavioral symptoms of increased complaints, restlessness, and insomnia. These assessments document R9's behaviors appear controlled. There are no documented behaviors in R9's nursing notes with nonpharmacological interventions attempted in August-October 2022 or in April-May 2023, prior to initiating Prozac on 5/20/23. R9's MARs do not document R9's behaviors in October 2022, April 2023, or May 2023. The Note to Attending Physician/Prescriber dated 10/24/22 documents a pharmacy recommendation to decrease Alprazolam to 0.25 mg daily, and includes to document clinical rationale and symptoms exhibited if the reduction is declined. This form is signed by the physician as declined, but does not document the clinical rationale and evidence of behavioral symptoms. 4.) R11's Physician Order dated 6/22/22 documents to administer Paxil (antidepressant) 20 mg daily. R11's Care Plan dated 5/23/23 documents R11 has anxiety, and symptoms include agitation, restlessness, and arguing. R11 takes Paxil for anxiety and effective interventions include one to one, activities and watching television. The Note to Attending Physician/Prescriber dated 11/18/22 documents a recommendation to consider reducing Paxil to 10 mg daily, and includes to document clinical rationale and symptoms exhibited if the reduction is declined. This form is signed by the physician as declined, but does not document the clinical rationale and evidence of behavioral symptoms. There are no documented behaviors in R11's nursing notes in October and November 2022, or on R11's November 2022 MAR. R11's Psychotropic Medication Assessments dated 6/28/22, 9/15/22, 12/2/22, 3/8/23, and 5/23/22 145979 Page 9 of 12 145979 06/05/2023 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documents R11 receives Paxil 20 mg daily for behaviors including agitation, restlessness, wandering, and R11's behaviors appear controlled. On 5/30/23 at 12:31 PM V2 Director of Nursing stated behaviors are documented by the nurses in the nursing notes or on the MAR (Medication Administration Record). On 6/1/23 at 9:59 AM V2 stated nonpharmacological behavioral interventions should be documented on the care plan. At 11:15 AM V2 confirmed the pharmacy recommendations that documents dose reductions declined for R4, R8, R9, and R11 do not document the clinical rational and behavioral symptoms as to why the reduction is contraindicated. The facility's Medication Management policy dated 3/17/23 documents gradual dose reductions of psychotropic drugs will be periodically conducted unless clinically contraindicated. The facility's Psychotropic Medication policy dated 11/28/17 documents the following: Indications for the use of psychotropic medications may include expressions/indicators of distress, symptoms that cause functional decline, and non-pharmacological interventions were implemented and ineffective. Gradual Dose Reductions (GDRs) should be attempted, unless clinically contraindicated, within the first in two separate quarters, and annually after the first year. GDRs may be contraindicated if targeted symptoms returned/worsened after last GDR attempt and the physician has documented the rational for why a reduction is contraindicated. 145979 Page 10 of 12 145979 06/05/2023 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

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** 2.) R10's Face Sheet documents an admission date of 2/24/23 with diagnoses including Unspecified Fracture Upper End of Humerus and Muscle Wasting and Atrophy. R10's Minimum Data Set (MDS) dated [DATE] documents R6 has severe cognitive impairment and documents that R10 is always incontinent of bowel and bladder. Residents Affected - Few R10's medical record documents R10 had a Urinalysis completed on 4/21/23. R10's Laboratory Report documents results of the Urinalysis dated 4/22/23 and documents >100,000 CFU/ml (Colony forming unit/milliliter) Gram Negative Rods and the organism identified as Proteus Mirabilis ESBL (Extended Spectrum Beta-Lactamase). This report documents that it was faxed to the physician on 4/22/23 and 4/23/23. R10's Laboratory Report dated 4/23/23 documents the culture and sensitivity results that Proteus Mirabilis ESBL is resistant to Ciprofloxacin. R10's Nurse's Notes dated 4/21/23 through 5/5/23 document complaints of flank pain, dark urine with a foul odor and blood tinged urine with some blood spots in the adult incontinent brief. These Nurse's Notes document that V7 Physician did not treat R10's Urinary Tract infection until 5/5/23 and then treated the UTI with Ciprofloxacin which was documented as being resistant. On 6/01/23 at 9:36 AM, V2 Director of Nursing confirmed that the Physician didn't want to order an antibiotic he thought it was a fluke. He was going to retest but he ended up treating (R10) later. V2 confirmed there was not a new UA completed before starting the antibiotic and confirmed the Physician treated with Ciprofloxacin which was resistant on the culture and sensitivity report. 3.) R12's Medication Administration Record dated 4/1/23 through 4/30/23 documents R12 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure and Type 2 Diabetes. R12's MDS dated [DATE] documents R12 is cognitively intact and is frequently incontinent of urine. R12's Nurse's Notes dated 4/1/23 documents R12 complained of not feeling well, pain and burning with urination, increased frequency of urination and little amounts of void at times. R12's Nurse's Notes dated 4/2/23 continue to document the same urinary complaints as 4/1/23. R12's Nurse's Notes dated 4/3/23 documents R12 reported blood tinged urine and the Physician was notified. R12's Nurse's Notes dated 4/03/2023 at 5:12 PM by V17 Licensed Practical Nurse documents that V23 R12's Physician returned the call and ordered Macrobid (antibiotic) 100 MG (milligrams) BID (twice a day) X (times) 5. Two capsules pulled from STAT (back up medication supply) safe, and started today. R12's Nurse's Notes dated 4/4/23 and 4/5/23 documents R12 complained of continued urinary urgency. R12's Nurse's Notes dated 4/6/23 documents R12 complained or burning upon urination. R12's Nurse's Notes dated 4/21/23 documents R12 complained of burning with urination and stated there was blood on the toilet paper after urination. R12's Electronic Medication Administration Record dated 4/1/23 through 4/30/23 documents R12 received Nitrofurantin Mono-MCR 100 mg (milligrams) one by mouth twice a day for five days. 145979 Page 11 of 12 145979 06/05/2023 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/31/23 at 11:01 AM, V13 stated that R12's Physician is V23 and V23 sometimes only goes by the symptoms. V13 stated that it's not very easy to get V23 to do any urine cultures. On 6/01/23 at 9:37 AM, V2 Director of Nursing stated that V23 hardly ever orders UA's (Urinalysis). On 6/05/23 at 8:08 AM, V2 confirmed that there was no UA ordered for R12 for the 4/3/23 antibiotic treatment and stated V23 treated R12 according to R12's symptoms and there is no culture. Based on interview and record review the facility failed to ensure for the appropriate use of antibiotics for residents. This failure affects three of four residents (R8, R10, R12) reviewed for antibiotic stewardship in the sample list of 14. Findings include: The facility's Antimicrobial Stewardship Policy and Procedure with a revised date of February 2022 documents, The purpose of this policy is to ensure the proper and safe use of antimicrobials throughout the facility. The objective of the Antimicrobial Stewardship Program will be to improve patient outcomes through optimization of antimicrobial therapy by selection of appropriate antibiotic dose, route and duration of treatment. 1.) R8's Nursing Note dated 05/06/2023 08:07 PM documents R8 returned from the emergency room with a diagnosis of Urinary Tract Infection (UTI) and orders for Amoxicillin (antibiotic) 250 milligrams (mg) by mouth twice daily for 7 days. R8's May 2023 Medication Administration Record documents R8 received Amoxicillin as ordered from 5/6/23 through 5/13/23. R8's Urine Culture dated as collected on 5/6/23 documents multiple organisms were noted and the urine was likely contaminated. There is no sensitivity report listed to determine if Amoxicillin is the appropriate antibiotic to treat the infection. There is no documentation that another urine culture was obtained. On 5/31/23 at 9:23 AM V2 Director of Nursing stated stated R8's urine culture resulted as probable contaminants and no organism was identified. V2 stated the results are faxed to the physician and the physician lets us know if they want to change the ordered antibiotic. V2 stated the facility utilizes cultures to determine if antibiotics are appropriate. V2 confirmed cultures determine if bacteria is susceptible to the prescribed antibiotic. V2 stated the physician will start an antibiotic and then change it if needed based on the culture results. 145979 Page 12 of 12