Health inspection·November 16, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide a SNF ABN Form (CMS-10055) for 1 of 3 residents (R26) reviewed for Beneficiary Protection Notification in the sample of 59. Residents Affected - Few Findings include: R26's face sheet documents diagnosis including: Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, Seizures, Central Pain Syndrome, Lymphedema, Anxiety Disorder, Pseudobulbar Affect, Type 2 Diabetes Mellitus with Hypoglycemia without coma and Morbid Obesity due to Excess Calories. R26's face sheet documents a admission date of 03/16/23. R26's SNF Beneficiary Protection Notification Review form documents a discharge from Medicare Part A services on 11/5/23, prior to exhaustion of his benefit day allotment. This form does not document that a written notice of the resident's potential liability for a non-covered stay (SNFABN - CMS-10055) form was provided to R26 to explain his right to appeal the decision of discharge from Medicare Part A services prior to exhaustion of his benefit days. On 11/16/23 at 11:45 AM, V1 Administrator stated they do not have the form (CMS-10055) for R26, it must have been missed. R26's Clinical records did not contain a CMS-10055 document. On 11/16/23 at 1:40 PM. R26 who was alert to person, place and time stated he does not remember if he received any forms about his therapy days. Page 1 of 14 146021 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview, observation, and record review the facility failed to develop and implement a person centered comprehensive care plan for tracheotomy care for 1 of 1 residents (R37) reviewed for care plans in a sample of 59. Findings include: Per R37's EHR (electronic health record) face sheet, R37 was admitted to this facility on 7/13/2021 with pertinent diagnosis of Tracheostomy, Chronic Obstructive Pulmonary Disorder, Dementia with Agitation, Delusional Disorders and Visual Hallucinations. The MDS (Minimum Data Set) for R37 dated 8/28/2023, documents R37 BIMS (Brief Interview for Mental Status) to be 00 out of a total of 15, which indicates R37 has severe cognitive impairment. R37's current physician's order sheet, dated 11/1/2023-11/31/2023, documents R37's doctor ordered R37 to receive tracheostomy care every dayshift and nightshift. R37's current care plan, initiation date of 7/14/2021, documents a focus area for R37 as: (R37) has a tracheostomy r/t (related to) impaired breathing mechanics. The goal for R37 is to have clear and equal breath sounds and R37 will have no abnormal drainage around trach (tracheostomy) site. Interventions listed in R37's care plan to help R37 achieve the goal are documented in part as: Resident performs own trach care. Staff to over see (dated 7/14/2021). On 11/15/2023 at 1:15 pm, V8 (Licensed Practical Nurse/LPN) said he knows R37's care plan says she will perform her own tracheostomy care, however R37 can not perform her own tracheostomy care. V8 said he observed R37 perform her own tracheostomy care, R37 pulled out the tracheostomy cannula, stuck it in her mouth, licked the cannula clean and places the cannula where it goes in her neck. V8 said he has not provided R37 with patient education on providing her own tracheostomy care and he feels R37 does not have the mental capability to be educated due to having dementia and severely impaired cognition. On 11/16/2023 at 12:30 pm, V20 (Social Service Director/Care Plan Coordinator) said she agrees R37 does not have the mental capacity to perform her own tracheostomy care and the intervention of Resident performs her own tracheostomy care with staff to over see is a very inappropriate intervention for R37's tracheostomy care plan. V20 said she does not know why this is listed in place of nursing staff to perform the care. V20 agreed the inappropriate intervention is not patient centered and she will schedule a care plan meeting to get this corrected. 146021 Page 2 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation and record review, the facility failed to ensure nursing staff signed off medications they administered by using their own electronic signature and failed to provide tracheostomy care in accordance with professional standards of practice for 3 of 5 residents (R27, R41, and R37) reviewed for medication administration and tracheostomy care in a sample of 59. Residents Affected - Few Findings include: 1. On 11/15/2023 at 7:50 am, V9 (Licensed Practical Nurse/LPN) said she was sorry she was slow and did not know the resident's medications very well. V9 said this was her first time passing meds (medications) at this facility. V9 said she works for the corporation that owns this facility and goes around to all their facilities helping out. V9 said today she is here at this facility helping out. V9 announced she would be preparing medications to administer to R27. V9 prepared R27's medications, administered the medications to R27 and signed the medications off electronically on R27's electronic MAR (medication administration record). Next, V9 announced she would be preparing medications to administer to R41. V9 prepared R41's medications, administered the medications and signed the medications off electronically on R41's electronic MAR. A review of R27's EHR under electronic MAR (medication administration record) documented the that she gave to R41 at 8:05 am on 11/15/2023. During this review, it was noted that V9 was using V8's (LPN) electronic signature to sign off the medications which erroneously indicated V8 (LPN) was the actual nurse administering the medications to R27 and R41. On 11/15/2023 at 9:10 am, V9 said when she arrived for duty this morning the facility's administration had neglected to provide her with her own electronic signature and access to the resident's EHR. V9 said she was temporarily using V8's until she received her own. On 11/15/2023 at 8:50 am, V1 (Administrator) and V2 (Director of Nursing) were informed of V9 signing off medications using V8's electronic signature. Both agreed V9 should not have been signing off medication administration using another nurse's electronic signature. Both V1 and V2 said it was their expectations for the nurses to administer the resident's medications, safely, correctly, and in accordance with the facility's policies. V1 said she agreed V9 using V8's electronic signature when passing medications was not in accordance with the facility's policy or professional standards of practice. A facility policy, with revision date of 11/21/2020, titled Charting and Documentation under bullet point #7 documents the following: Documentation of procedures and treatments will include care-specific details including: A.) The date and time the procedure/treatment was provided and B.) The name and title of the individual who provided the care. 2. Per R37's EHR (electronic health record) face sheet, R37 was admitted to this facility on 7/13/2021 with perinate diagnosis of Tracheostomy, Chronic Obstructive Pulmonary Disorder and Dementia. The MDS (Minimum Data Set) for R37 and dated 8/28/2023, documents R37 BIMS (Brief Interview for Mental Status) to be 00 out of a total of 15, which indicates R37 has severe cognitive impairment. R37's current physician's order sheet, dated 11/1/2023-11/31/2023, documents R37's doctor ordered R37 is to receive tracheostomy care every dayshift and every nightshift and as needed per nursing staff. 146021 Page 3 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/15/2023 at 1:40 pm, V8 (Licensed Practical Nurse/LPN) performed tracheostomy care for R37, with V2 (Director of Nursing/DON) present. After performing hand hygiene, V8 donned non-sterile blue colored gloves from a wall dispenser in R37's room. V8 opened a sterile tracheostomy care kit, removed and set up all the sterile supplies with his non-sterile gloved hands, contaminating all items and placed the supplies on a covered bedside table. V8 then opened the package of sterile gloves that came out of the sterile tracheostomy care kit. V8 removed his blue colored gloves and handled the sterile gloves with his bare hand and touched multiple surfaces of the sterile gloves. V8 then attempted to pull the sterile gloves onto his hand, however the gloves were much too small to fit on V8's hands. V8 ripped the sterile gloves and did not replace the gloves and continued to provide the tracheostomy care with the contaminated and ripped gloves. Next, V8 removed R37's tracheostomy cannula for cleansing. R37's tracheostomy cannula was noted to be a medical grade stainless steel curved tube about four inches long and was crusted inside and out with yellowish brown matter. V8 used the contaminated supplies to clean the tracheostomy cannula. After cleansing, V8 attempted to re-insert the curved metal tracheostomy cannula upside down causing R37 to gag, cough and choke violently. V8 removed the cannula and attempted to insert it again upside down, which caused R37 to gag, choke and cough more violently. Surveyor verbally alerted V2 (DON) of R37's tracheostomy cannula being upside down, but V2 (DON) made no effort to correct V8's actions. V8 then turned the tracheostomy cannula the correct direction and the curved metal cannula slipped immediately into correct placement and R37 quickly recovered from gagging and coughing. V2 (DON) was asked why she did not intervene when surveyor expressed verbal concern about V8 putting in R37's curved metal tracheostomy cannula in upside down and V2 (DON) said I did not see what V8 was doing. V2 (DON) and V8 were asked if tracheostomy care was a sterile procedure and both said I don't know. V8 was asked if he had received tracheostomy care training and he said yes. V8 was asked how often he performs tracheostomy care and V8 said 4-5 times per week. During this tracheostomy care procedure, V8 did not have a stethoscope, never assessed R37's lung sounds and never assessed R37's oxygen levels during or after the procedure. V2 said V8 should have had a stethoscope, should have assessed R37's lung sounds and should have checked R37's oxygen levels after the tracheostomy care was performed. A document titled: In-service Monthly Attendance Form, dated 8/19/2022, Course Title: Trach (Tracheostomy) and Oxygen training with 12 names and signatures was presented as the most recent tracheostomy training received by the nursing staff, including V8. V2 (DON) is listed as the instructor. On 11/15/2023 at 2:15pm, V14 (Corporate Nurse) said Yes, tracheostomy care is supposed to be a sterile procedure and We will re-educate the nursing staff on tracheostomy care procedures and move forward from here. R37's current care plan, initiation date of 7/14/2021, documents a focus area for R37 as: (R37) has a tracheostomy r/t (related to) impaired breathing mechanics. The goal for R37 is to have clear and equal breath sounds and R37 will have no abnormal drainage around trach (tracheostomy) site. Interventions listed in R37's care plan to help R37 achieve the goal are documented in part as: Monitor/document respiratory rate, depth and quality. Check and document every (q) shift/as ordered. A non-dated facility policy titled Tracheostomy Care Procedure, under General Guidelines documents: Aseptic (sterile) technique must be used A.) during cleaning and sterilization of reusable tracheostomy tubes, B.) During all dressing changes . C.) During tracheostomy tube changes, either reusable or disposable. Under Procedure Guidelines documents: Assess resident for respiratory distress: A.) Measure resident's oxygen saturation with pulse oximeter, B.) Listen to lung sounds with a stethoscope, C.) Observe for asymmetrical chest expansion. Maintain sterile field and document the procedure, condition of the site and the resident's response. 146021 Page 4 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

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 Based on interview, observation, and record review, the facility failed to keep a resident requiring assistance with Activities of Daily Living hair clean and well groomed for 1 of 9 residents (R11) reviewed for Activities of Daily Living in a sample of 59. Residents Affected - Few Findings include: Per the face sheet in R11's EHR (electronic health record) R11 was admitted to this facility on 6/28/2021 with pertinent diagnosis of Left sided hemiplegia and left sided hemiparesis following a Cerebral Infarction (Stroke ), left sided breast Cancer, Diabetes Mellitus type 2, Poly-Osteoarthritis and Dementia. An MDS (Minimum Data Set) in R11 EHR and dated 11/19/2023, documents R11's BIMS (Brief Interview for Mental Status) as being 03 out of 15 total, which indicates R11 has severe mental impairment and is not interviewable. This same MDS, under section titled H documents R11 is always incontinent of bowels and bladder and under section titled GG documents R11 has impairment to both upper and lower extremities on one side. The Care Plan in R11's EHR with initiation date of 6/29/2021 documents R11 has a Self-care Deficit of: Needs extensive assistance with ADL's (Activities of Daily Living) with goal of care documented as: (R11) will be clean, dry, well groomed and (R11) will participate with ADL's daily and ADL status will improve by target date of 1/30/2024. The care plan documents interventions to achieve R11's self-care deficit goals as: Bathing-One person physical assistance required. On 11/13/2023 at 11:30am, R11 was observed in the facility's dining room waiting for her noon meal to be served. R11 was noted to be appropriately dressed, however R11's hair looked very greasy and had not been recently combed. On 11/14/2023 at 8:45am, R11 was observed in the facility's dining room in her wheelchair. R11 was observed with greasy looking, non-combed hair. At 12:30 pm, R11 was observed in the facility's dining room waiting for her noon meal to be served. R11 was observed with greasy looking, non-combed hair again. A undated facility form titled Shower Schedule documents R11 is scheduled to receive showers on Wednesday and Saturday based on her assigned room number. On 11/15/2023, at 10:30 am, V19 (Licensed Practical Nurse) said residents are to receive two showers per week. V19 said showers are to be documented in the resident's EHR and if residents refuse showers, this information is to be documented in the resident's EHR. On 11/15/2023 at 9:00 am, V2 (Director of Nursing) said showers are not documented in the resident's EHR, but instead are documented on Shower Sheets and kept in the V2's office. V2 said shower refusals are also documented on Shower Sheets and kept in V2's office. Facility documents titled Shower Sheets for R11 documented the following care was given: On 10/4/23 R11 was showered and hair washed On 10/7/23 R11 was given a bed bath 146021 Page 5 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0677 On 10/14/23 R11 was given a bed bath Level of Harm - Minimal harm or potential for actual harm On 10/21/23 R11 was given a bed bath On 10/25/23 R11 was given a bed bath Residents Affected - Few On 10/28/23 R11 was given a shower On 11/4/23 R11 was given a shower On 11/11/23, R11 was given a bed bath On 11/16/2023 at 10:00 am, V18 (Certified Nursing Assistant) said if the resident's Shower Sheet says they received a bed bath, then the resident did not get their hair washed. V18 said resident's get their hair washed when they are given a shower. V18 reviewed R11's shower sheets and agreed R11 did not have her hair washed when given a bed bath on 10/7/23, 10/14/23, 10/21/23, 10/25/23 and 11/11/23. V18 said R11 has not had her hair washed since being showered on 11/11/23 which was 5 days ago. V18 said showers or shower refusals are not documented in the resident's EHR, but instead are documented on Shower Sheets and turned into the nursing office. On 11/16/2023 at 10:55 am, V17 (Business Office Manager) reviewed R11's resident funds account and said no funds from R11's account have been used for beauty shop services since before September 6, 2023. On 11/16/2023 at 11:20 am, V1 (Administrator) said the facility has not had beautician services due to not having a person willing to come to the facility since September 18, 2023. 11/15/2023 at 3:00 pm, V2 said she gave the surveyors all the Shower Sheets for R11 that she could locate. A non-dated facility policy titled Bath or Shower Procedure, documents under the section labeled Purpose: The purpose of this procedure is to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin. Under the section labeled Documentation: Document procedure in the resident's electronic health record. Under the section labeled Reporting: Notify the supervisor if the resident refuses the shower/tub bath or any abnormalities noted to the resident's condition or skin integrity. 146021 Page 6 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review the facility failed to provide tracheostomy care per facility policy/professional standards of practice and failed to implement a care plan with appropriate interventions to provide tracheostomy care for 1 of 1 resident (R37) reviewed for tracheostomy care in a sample of 59. Residents Affected - Few Findings include: Per R37's EHR (electronic health record) face sheet, R37 was admitted to this facility on 7/13/2021 with perinate diagnosis of Tracheostomy, Chronic Obstructive Pulmonary Disorder and Dementia. The MDS (Minimum Data Set) for R37 and dated 8/28/2023, documents R37 BIMS (Brief Interview for Mental Status) to be 00 out of a total of 15, which indicates R37 has severe cognitive impairment. R37's current physician's order sheet, dated 11/1/2023-11/31/2023, documents R37's doctor ordered R37 is to receive tracheostomy care every dayshift and every nightshift and as needed per nursing staff. On 11/15/2023 at 1:40 pm, V8 (Licensed Practical Nurse/LPN) performed tracheostomy care for R37, with V2 (Director of Nursing/DON) present. After performing hand hygiene, V8 donned non-sterile blue colored gloves from a wall dispenser in R37's room. V8 opened a sterile tracheostomy care kit, removed and set up all the sterile supplies with his non-sterile gloved hands, contaminating all items and placed the supplies on a covered bedside table. V8 then opened the package of sterile gloves that came out of the sterile tracheostomy care kit. V8 removed his blue colored gloves and handled the sterile gloves with his bare hand and touched multiple surfaces of the sterile gloves. V8 then attempted to pull the sterile gloves onto his hand, however the gloves were much too small to fit on V8's hands. V8 ripped the sterile gloves and did not replace the gloves and continued to provide the tracheostomy care with the contaminated and ripped gloves. Next, V8 removed R37's tracheostomy cannula for cleansing. R37's tracheostomy cannula was noted to be a medical grade stainless steel curved tube about four inches long and was crusted inside and out with yellowish brown matter. V8 used the contaminated supplies to clean the tracheostomy cannula. After cleansing, V8 attempted to re-insert the curved metal tracheostomy cannula upside down causing R37 to gag, cough and choke violently. V8 removed the cannula and attempted to insert it again upside down, which caused R37 to gag, choke and cough more violently. Surveyor verbally alerted V2 (DON) of R37's tracheostomy cannula being upside down, but V2 (DON) made no effort to correct V8's actions. V8 then turned the tracheostomy cannula the correct direction and the curved metal cannula slipped immediately into correct placement and R37 quickly recovered from gagging and coughing. V2 (DON) was asked why she did not intervene when surveyor expressed verbal concern about V8 putting in R37's curved metal tracheostomy cannula in upside down and V2 (DON) said I did not see what V8 was doing. V2 (DON) and V8 were asked if tracheostomy care was a sterile procedure and both said I don't know. V8 was asked if he had received tracheostomy care training and he said yes. V8 was asked how often he performs tracheostomy care and V8 said 4-5 times per week. During this tracheostomy care procedure, V8 did not have a stethoscope, never assessed R37's lung sounds and never assessed R37's oxygen levels during or after the procedure. V2 said V8 should have had a stethoscope, should have assessed R37's lung sounds and should have checked R37's oxygen levels after the tracheostomy care was performed. A document titled: In-service Monthly Attendance Form, dated 8/19/2022, Course Title: Trach (Tracheostomy) and Oxygen training with 12 names and signatures was presented as the most recent tracheostomy training received by the nursing staff, including V8. V2 (DON) is listed as the instructor. On 11/15/2023 at 2:15 pm, V14 (Corporate Nurse) said Yes, tracheostomy care is supposed to be a 146021 Page 7 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sterile procedure and We will re-educate the nursing staff on tracheostomy care procedures and move forward from here. R37's current care plan, initiation date of 7/14/2021, documents a focus area for R37 as: (R37) has a tracheostomy r/t (related to) impaired breathing mechanics. The goal for R37 is to have clear and equal breath sounds and R37 will have no abnormal drainage around trach (tracheostomy) site. Interventions listed in R37's care plan to help R37 achieve the goal are documented in part as: Resident performs own trach care. Staff to oversee and Monitor/document respiratory rate, depth and quality. Check and document every (q) shift/as ordered with initiation dates of 7/14/2021. The same Care Plan documents a focus are for R37 of (R37) has a self-care deficit as evidenced by: needs assistance with ADL's (Activities of Daily Living) related to deconditioning. Documented interventions include that R37 requires one-person physical assist with personal hygiene and oral/dental care with initiation dates of 7/14/2021. On 11/15/2023 at 1:15 pm, V8 (Licensed Practical Nurse/LPN) said he knows R37's care plan says she will perform her own tracheostomy care, however R37 cannot perform her own tracheostomy care. V8 said he observed R37 perform her own tracheostomy care, R37 pulled out the tracheostomy cannula, stuck it in her mouth, licked the cannula clean and places the cannula where it goes in her neck. V8 said he has not provided R37 with patient education on providing her own tracheostomy care and he feels R37 does not have the mental capability to be educated due to having dementia and severely impaired cognition. On 11/16/2023 at 12:30 pm, V20 (Social Service Director/Care Plan Coordinator) said she agrees R37 does not have the mental capacity to perform her own tracheostomy care and the intervention of Resident performs her own tracheostomy care with staff to oversee is a very inappropriate intervention for R37's tracheostomy care plan. V20 said she does not know why this is listed in place of nursing staff to perform the care. V20 agreed the inappropriate intervention is not patient centered and she will schedule a care plan meeting to get this corrected. A non-dated facility policy titled Tracheostomy Care Procedure, under General Guidelines documents: Aseptic (sterile) technique must be used A.) during cleaning and sterilization of reusable tracheostomy tubes, B.) During all dressing changes . C.) During tracheostomy tube changes, either reusable or disposable. Under Procedure Guidelines documents: Assess resident for respiratory distress: A.) Measure resident's oxygen saturation with pulse oximeter, B.) Listen to lung sounds with a stethoscope, C.) Observe for asymmetrical chest expansion. Maintain sterile field and document the procedure, condition of the site and the resident's response. 146021 Page 8 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to accurately document the administration of medication for 2 of 4 residents (R27 and R41) reviewed for medication administration in a sample of 59. Findings include: On 11/15/2023 at 7:50 am, V9 (Licensed Practical Nurse/LPN) said she was sorry she was slow and did not know the resident's medications very well. V9 said this was her first time passing meds (medications) at this facility. V9 said she works for the corporation that owns this facility and goes around to all their facilities helping out. V9 said today she is here at this facility helping out. V9 stated she would be preparing medications to administer to R27. V9 prepared R27's medications, administered the medications to R27 and signed the medications off electronically on R27's electronic MAR (Medication Administration Record). Next, V9 stated she would be preparing medications to administer to R41. V9 prepared R41's medications, administered the medications and signed the medications off electronically on R41's electronic MAR. off that she administered to R27, at 7:50 am, on 11/15/23. A review of R41's EHR, under the electronic 11/15/2023. During this review, it was noted that V9 was using V8's (LPN) electronic signature to sign off the medications which erroneously indicated V8 (LPN) was the actual nurse administering the medications to R27 and R41. On 11/15/2023 at 9:10 AM, V9 said when she arrived for duty this morning the facility's administration had neglected to provide her with her own electronic signature and access to the resident's EHR. V9 said she was temporarily using V8's until she received her own. On 11/15/2023 at 8:50 am, V1 (Administrator) and V2 (Director of Nursing) were informed of V9 signing off medications using V8's electronic signature. Both agreed V9 should not have been signing off medication administration using another nurse's electronic signature. Both V1 and V2 said it was their expectations for the nurses to administer the resident's medications, safely, correctly, and in accordance with the facility's policies. V1 said she agreed V9 using V8's electronic signature when passing medications was not in accordance with the facility's policy or professional standards of practice. A facility policy, with revision date of 11/21/2020, titled Charting and Documentation under bullet point #7 documents the following: Documentation of procedures and treatments will include care-specific details including: A.) The date and time the procedure/treatment was provided and B.) The name and title of the individual who provided the care. A facility policy, with a revision date of 9/27/22, titled Medication Administration Policy/ Procedure under Policy it documents the following: Medications will be administered safely to residents within the facility by licensed nurses at the specified time/ timeframe, following the recommended administration method and will be documented as required. Under bullet point #12 it documents the following: Chart the medication administered on the electronic medication administration record. 146021 Page 9 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation and record review, the facility failed to ensure a medication error rate of less than 5%. There were 30 medication passing opportunities with 4 errors, resulting in a 13.33% error rate. The errors involved 1 of 4 residents (R27) reviewed during medication administration in the sample of 59. Residents Affected - Few Findings include: On 11/15/2023 at 7:50 am, V9 (Licensed Practical Nurse) she would be preparing meds for R27. V9 gathered R27's medication cards and compared them to the meds listed in R27's EHR (electronic health record) that were to be given and stacked the med cards up together. V9 read the medications out loud and showed the surveyor the med cards before she popped the medication from the medication cards. The medications popped out by V9 to administer to R27 were as follows: Buspirone 5mg (milligram), 2 tabs (tablets), Calcium 600mg, 1 tab, Folic Acid 1 mg, 1 tab, Levetiracetam 1000mg, 1 tab, Potassium 20meq (millequivilants), 1 tab, Omeprazole 20mg, 1 cap (capsule), Multivitamin, 1 tab, Prednisone 10mg, 1.5 tabs, Quetiapine 300mg, 1 tab, Torsemide 20mg, 1 tab, Vitamin D 3000mg, 1 tab, Senna-Docusate Sodium 8.6/50mg, 1 tab, Paxlovid 150/100mg, 2 tabs. All medications are to be taken whole by mouth. V9 before going into R27's room to administer his medications. R27 orally took all the medications prepared by V9. V9 performed hand hygiene and preceded to prepare medications for the next resident due medications. A review of R27's EHR, under the MAR (Medication Administration Record) documented the medications V9 had omitted 3 of R27's prescribed medications, which were Pyridoxine 50mg (Vitamin B6), 1 tab, Polysaccharide Iron complex 150mg, 1 capsule and Ingrezza 40mg, 1 capsule. This same MAR documented R27 was to receive 3 tablets of Paxlovid 150/100mg, however V9 was observed only administering 2 tablets. On 11/15/2023 at 8:50am, V1 (Administrator) and V2 (Director of Nursing) were informed of the medication administration errors made by V9. Both V1 and V2 said it was their expectations for the nurses to administer the resident's medications, safely, correctly and in accordance with professional standards of practice. On 11/15/2023 at 9:00am, V9(LPN) said she reviewed the medications she administered to R27 and found 3 medication she omitted and she was supposed to give 3 tablets of Paxlovid but only gave 2. V9 said after the error was brought to her attention by V2 (DON) she went back and administered the omitted medications correctly. V9 said the omitted medications were in bottles in the top drawer of the med cart and the other medications were in med cards in the med storage drawer and this is how she missed the medications. A facility policy, with a revision date of 9/27/22, titled Medication Administration Policy/ Procedure under Policy it documents the following: Medications will be administered safely to residents within the facility by licensed nurses at the specified time/ timeframe, following the recommended administration method and will be documented as required. Under Oral Medications, step #4 documents compare the medication record with the label to make sure they correlate. If there is a discrepancy, clarify with the physician before giving the medication. 146021 Page 10 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 follow their Pneumococcal Immunization Policy and failed to provide a Pneumococcal Immunization for 1 of 5 (R42) residents reviewed for Pneumococcal Immunizations in the sample of 59. Residents Affected - Few Findings include: R42's Face Sheet documents an admission date of 03/02/22, a date of birth of [DATE], and diagnosis to include: Type 2 Diabetes Mellitus with Hyperglycemia, Morbid Obesity due to excess calories, Body Mass index 45.0 - 49.9, Anxiety Disorders, Hypothyroidism, Posttraumatic Stress Disorder, Sleep Apnea, Schizoaffective Disorder, Bipolar Type, Diverticulitis of Large Intestine without Perforation or Abscess without bleeding, Panic Disorder, Bipolar Disorder, Hallucinations, Long term use of insulin, History of Transient Ischemic Attack, Cerebral Infarction without residual deficits, Shortness of Breath, Methicillin Resistant Staphylococcus Aureus Infection, Pediculosis due to Pediculus Humanus Capitis, Paralytic Ileus, Chronic Respiratory Failure with Hypercapnia, Hypoxemia, and Polyneuropathy. R42's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 15 indicating, R42 is cognitively intact. R42's, Immunization Audit Report documents: a date of pneumococcal vaccination given on 11/02/13. This report does not document which pneumococcal vaccine was given. R42's, Authorization and Release for Pneumococcal Vaccine dated 03/08/22 documents R42 checked the I accept the authorization and release for Pneumococcal vaccine with R42's signature. This form does not document which pneumoccal vaccine was to be given. On 11/16/23 at 1:15 PM, R42 stated she remembers signing the consent form for the pneumococcal vaccination but does not completely remember if she ever received the vaccination. On 11/16/23 at 12:30, V1 (Administrator) stated, she has brought all the documents on R42 for their pneumococcal vaccinations that she could find. On 11/16/23 at 1:30 PM, V2 (Director of Nursing) stated, she found the consent form for R42 from 03/08/22 that shows she accepted the pneumococcal vaccine but she can not find where she received it and she can not find any other more current consent forms or documentation that she received the vaccination since 11/02/2013. V2 stated, she thought R42 received the vaccination when she was out at the hospital, but she can not find documentation of that. The facility document titled, Standing orders for Administering Pneumococcal vaccines (PCV13 and PPSV23) to Adults dated 01/17 documents: Purpose: To reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Center for Disease Control and Prevention's Advisory Committee on Immunization Practices. Procedure: 1. Risk-based pneumococcal vaccination: age [AGE] through 64 years with an underlying medical condition or other risk factor as described in the following table: the table's column titled, Category of Underlying Medical Condition or other Risk Factor documents Diabetes Mellitus is a condition that is recommended vaccines of PPSV23 by being marked with an X, with an asterisk under the table documenting: a second dose 5 146021 Page 11 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0883 Level of Harm - Minimal harm or potential for actual harm years after the first dose of PPSV23. 6. Document Vaccination: Document each patient's vaccine administration information and follow up in the following places: Medical record, Personal immunization record card, Immunization information system or registry. Residents Affected - Few 146021 Page 12 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

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 observation, interview and record review, the facility failed to ensure that 11 multiple bed resident rooms on the East hall and 14 multiple bed resident rooms on the South hall provided the required 80 square feet per resident bed for 41 of 41 (R28, R48, R15, R3, R5, R1, R42, R9, R45, R8, R53, R31, R34, R24, R38, R35, R162, R6, R37, R4, R163, R41, R30, R16, R40, R27, R17, R19, R29, R26, R47, R36, R18, R33, R20, R7, R25, R23, R211, R39, and R12) residents reviewed for room size in the sample of 59. Findings include: On 11/13/21 at 2:10 PM, V14 (Regional Registered Nurse) stated, that all waivered rooms measure less than 80 square feet per resident and are Medicaid Certified. The waivered rooms are 100 - 109, 111, 201 213, and 215. On 11/16/23 at 2:00 PM, V1 (Administrator) stated, all rooms at the facility are certified for two people. On 11/16/23 at 11:30 AM, V21 (Maintenance) measured room [ROOM NUMBER] and 201 room [ROOM NUMBER] and 201 measured 12 feet by 11 feet equaling 132 square feet which is approximately 66 square feet per resident bed. Each room contained 1 dresser, 1 bed and 1 nightstand. On 11/16/23 at 11:30 AM, R28 stated he does not have any concerns with the room size. R28 is alert and oriented to person, place and time. On 11/16/23 at 11:40 AM, V21 measured rooms 101 - 109, 111, 202 - 209, and 211 measured 12 feet by 11 feet equaling 132 square feet total space which is approximately 66 square feet per resident per room. These rooms contained 1 dresser, 2 beds, and 2 nightstands. There were no concerns observed with space in any of these waivered rooms. On 11/16/23 at 11:43 AM, R42 stated she does not have any concerns with the room size. R42 is alert and oriented to person, place and time. On 11/16/23 at 11:45 AM, R45 stated she does not have any concerns with the room size. R45 is alert and oriented to person, place and time. On 11/16/23 at 11:47 AM, R8 stated he does not have any concerns with the room size. R8 is alert and oriented to person, place and time. On 11/16/23 at 11:50 AM, R34 stated she does not have any concerns with the room size. R34 is alert and oriented to person, place and time. On 11/16/23 at 11:52 AM, R38 stated she does not have any concerns with the rooms size. R38 is alert and oriented to person, place and time. On 11/16/23 at 11:54 AM, R35 stated she does not have any concerns with the rooms size. R35 is alert and oriented to person, place and time. 146021 Page 13 of 14 146021 11/16/2023 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0912 Level of Harm - Potential for minimal harm On 11/16/23 at 11:56 AM, R30 stated he does not have any concerns with the rooms size. R30 is alert and oriented to person, place and time. On 11/16/23 at 11:58 AM, R40 stated he does not have any concerns with the rooms size. R40 is alert and oriented to person, place and time. Residents Affected - Some On 11/16/23 at 12:00 PM, R17 stated he does not have any concerns with the rooms size. R17 is alert and oriented to person, place and time. On 11/16/23 at 12:03 PM, R26 stated he does not have any concerns with the rooms size. R26 is alert and oriented to person, place and time. On 11/16/23 at 12:05 PM, V21 measured rooms 210, 212, 213, and 215 measure 12 feet by 13 feet equaling 156 square feet total space which is approximately 78 square feet per resident. These rooms contained 1 dresser, 2 beds and 2 nightstands. There were no concerns observed with space in any of these waivered rooms. On 11/16/23 at 12:07 PM, R47 and R36 stated they do not have any concerns with the rooms size. R47 and R36 are alert and oriented to person, place and time. On 11/16/23 at 12:09 PM, R18 stated he does not have any concerns with the rooms size. R18 is alert and oriented to person, place and time. On 11/16/23 at 12:11 PM, R7 and R25 stated they do not have any concerns with the rooms size. R7 and R25 are alert and oriented to person, place and time. On 11/16/23 at 12:13 PM, R33 and R20 stated they do not have any concerns with the rooms size. R33 and R20 were alert and oriented to person, place and time. On 11/16/23 at 12:17 PM, R23 stated he does not have any concerns with the rooms size. R23 is alert and oriented to person, place and time. The facility Daily Roster, dated 11/12/23, documents R28, R48, R15, R3, R5, R1, R42, R9, R45, R8, R53, R31, R34, R24, R38, R35, R162, R6, R37, R4, R163, R41, R30, R16, R40, R27, R17, R19, R29, R26, R47, R36, R18, R33, R20, R7, R25, R23, R211, R39, and R12 reside in rooms 100 - 109, 111, and 201 215. Observations of the waivered room, from 11/13/23-11/16/23, shows these rooms provide adequate space to meet the medical and personal needs of these residents. The Resident Council Meeting Minutes, dated 8/23 through 10/23, documents no complaints regarding the waivered room space. 146021 Page 14 of 14