Health inspection·August 11, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an injury of unknown origin in 1 of 1 resident (R4) reviewed for abuse in the sample of 23. Findings include: R4's Face Sheet documents, R4 was admitted to the facility on [DATE] and has diagnoses including chronic kidney disease stage 3; schizoaffective disorder, bipolar type; bipolar disorder; type 2 diabetes mellitus without complications; anxiety disorder; and pain, unspecified. R4's Minimum Data Set, (MDS), dated [DATE] documented, R4 was cognitively intact, required extensive two or more-person physical assistance with bed mobility and transfer, and had no documented skin conditions. R4's Care Plan, undated, does not address risk of abuse. The Facility's Unusual Occurrence Reports/Quality Assurance Review Log for the month of July 2023 documents R4 had a bruise to her left forearm on 07/12/23 that could have happened during transfer. The Date IDPH (Illinois Department of Public Health) Notified column documented, N/A. The Facility's Unknown Injury Report dated 07/12/23 documents, Nursing Description: Resident has a dark purple bruise measuring 2.5 x 3 on her left forearm as well as two small dark purple bruises under her watch. Resident Description: Resident states, she has no idea what happened to cause the bruises. MD, (Medical Doctor), POA, (Power of Attorney) and Admin, (Administrator), Nurses informed. There are no documented witness statements. The Notes added on 07/21/23 document, Could have been during transfer. R4's Progress Note dated 07/12/23 at 11:31 AM documents, Note Text: Resident called this nurse to her room and showed me a bruise to her left forearm. Bruise is located on her left forearm and is 2,4 x3 cm, (centimeters), color is dark purple. Resident states it is not painful but itches. R4's Progress Note dated 07/12/23 at 2:03 PM documents, Bruise remains dark purple in color. No pain reported with bruise. Resident states it kind of itches. On 08/10/23 at 9:47 AM, R4 stated, she thinks the bruising on her forearm last month was probably just from scratching. Page 1 of 13 146025 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/10/23 at 10:35 AM, V13, Certified Nurse Assistant, (CNA), stated, she remembers the bruising on R4's forearm. She said R4 didn't remember what happened but said she had been bruising a lot easier. V13 stated she and R4 both reported it to V16, Licensed Practical Nurse, (LPN). On 08/10/23 at 10:00 AM, V2, Director of Nursing, (DON), stated V16, LPN, was on leave from the Facility due to illness. On 07/12/23 at 1:55 PM, V6, MDS Coordinator, stated there were no witnesses to explain what happened to R4's forearm. On 08/09/23 at 2:30 PM, V2, DON, stated the bruise of unknown origin to R4's forearm was not reported to IDPH. On 08/10/23 at 3:43 PM, V1, Administrator, stated she always reports injuries of unknown origin, but she did not report R4's bruise. The Facility's Abuse Investigation and Reporting Policy revised July 2017 documents, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) or Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: two (2) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 146025 Page 2 of 13 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to investigate an injury of unknown origin in 1 of 1 resident (R4) reviewed for abuse in the sample of 23. Residents Affected - Few Findings include: R4's Face Sheet documents R4 was admitted to the facility on [DATE] and has diagnoses including chronic kidney disease stage 3; schizoaffective disorder, bipolar type; bipolar disorder; type 2 diabetes mellitus without complications; anxiety disorder; and pain, unspecified. R4's Minimum Data Set, (MDS) dated [DATE] documented R4 was cognitively intact, required extensive two or more-person physical assistance with bed mobility and transfer, and had no documented skin conditions. R4's Care Plan, undated, does not address risk of abuse. The Facility's Unusual Occurrence Reports/Quality Assurance Review Log for the month of July 2023 documents R4 had a bruise to her left forearm on 07/12/23 that could have happened during transfer. The Date IDPH (Illinois Department of Public Health) Notified column documented N/A. The Facility's Unknown Injury Report dated 07/12/23 documents, Nursing Description: Resident has a dark purple bruise measuring 2.5 x 3 on her left forearm as well as two small dark purple bruises under her watch. Resident Description: Resident states she has no idea what happened to cause the bruises. MD (Medical Doctor), POA (Power of Attorney) and Admin (Administrator) Nurses informed. There are no documented witness statements. The Notes added on 07/21/23 document, Could have been during transfer. R4's Progress Note dated 07/12/23 at 11:31 AM documents, Note Text: Resident called this nurse to her room and showed me a bruise to her left forearm. Bruise is located on her left forearm and is 2,4 x3 cm, (centimeters), color is dark purple. Resident states it is not painful but itches. R4's Progress Note dated 07/12/23 at 2:03 PM documents, Bruise remains dark purple in color. No pain reported with bruise. Resident states it kind of itches. On 08/10/23 at 9:47 AM, R4 stated she thinks the bruising on her forearm was probably just from scratching. On 08/10/23 at 10:35 AM, V13, Certified Nurse Assistant, (CNA), stated she remembers the bruising on R4's forearm. She said R4 didn't remember what happened, but R4's watch was tight on her risk near the location of the bruise. V13 stated she told V16, Licensed Practical Nurse, (LPN) and stated, Any time there is an injury of unknown origin we are supposed to do a write up. On 08/10/23 at 10:00 AM, V2, Director of Nursing, (DON), stated V16, LPN, was on leave from the Facility due to illness. On 07/12/23 at 1:55 PM, V6, MDS Coordinator, stated, That (the unknown origin report) is the investigation. There were no witnesses so it must have happened during transfer. So, am I just supposed to 146025 Page 3 of 13 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0610 Level of Harm - Minimal harm or potential for actual harm write down their names and say they didn't know anything about it? Should I start making them a skin injury instead of an unknown origin? On 08/09/23 at 2:30 PM, V2, DON, stated she would expect the investigation to include statements from staff. Residents Affected - Few On 08/10/23 at 3:43 PM, V1, Administrator, stated she expects the Facility to conduct an investigation for all injuries of unknown origin. The Facility's Abuse Investigation and Reporting Policy revised July 2017 documents, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 146025 Page 4 of 13 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and treat 1 of 4 residents (R22) in the sample of 23. This failure resulted in the resident sustaining a significant weight loss of over 24 lbs. (approx. 15%) in 2 months. Residents Affected - Few Findings include: R22's Face sheet documents, an admission date of 6/2/2023. Diagnosis includes: Fracture of Unspecified Part of Neck of Left Femur, Displaced Oblique Fracture of Shaft of Humorous Right Arm, Atherosclerotic Heart Disease, Chronic Kidney Disease. R22's Minimum Data Set, MDS, dated [DATE] documents, R22 has no cognitive impairments. MDS dated [DATE] documents, R22 had no issues with eating, drinking, or choking. No recent weight loss and no special diet order documented. R22's Care Plan dated 6/8/2023 documents, Nutrition, Interventions include: Registered Dietician to monitor per protocol. R22 chooses to wear clothing protector. Monitor per protocol. High calorie supplement twice daily and health shakes three times daily. R22's admission weight dated 6/2/2023 documents 161#, (pounds). R22's weight dated 6/4/2023 documents 162.8#. R22's weight dated 6/23/2023 documents 152.6#. A steady decline in R22's weight is documented throughout. R22's 8/4/2023 weight 142.2#. R22's weight on 8/10/2023 138.2#. R22's order sheets dated 8/8/2023 documents, health shakes three times daily. R22's order sheets dated 8/8/2023 documents, Magic cup bid, (twice daily), ordered. R22's order sheets dated 8/9/2023 document, Remeron Oral Tablet 15 MG (Mirtazapine) give 0.5 tablet by mouth at bedtime. R22's Progress Notes dated 7/23/2023 at 1:44AM documents, local hospital called for an update and per staff nurse, (R22) has mild malnutrition and has nasogastric, (NG), tube providing feedings at this time until (R22) can reach 50% meal consumption. On 8/9/2023 at 2:00PM V2, Director of Nursing, DON, stated, We just had a care plan meeting for R22 and just started high calorie drinks and Remeron to stimulate her appetite. R22 has been in and out of the hospital and had pancreatitis and gall stones. She just hasn't had an appetite. On 8/10/2023 at 10:15AM V6, Minimum Data Set Coordinator, stated, (R22) gets full fast and will complain of nausea. She needs a lot of encouragement. On 8/10/2023 at 10:20AM V14, Resident Assistant, stated, (R22) needs a lot of encouragement when eating, to keep eating. She does not usually eat well. On 8/10/2023 at 10:40AM, V15, Registered Dietician, stated, I just reviewed (R22)'s case yesterday. We started the high calorie supplements three times daily, and the facility was going to start Remeron. (R22) had been in and out of the hospital with pancreatitis. 146025 Page 5 of 13 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0692 Level of Harm - Actual harm Residents Affected - Few Facility Nutrition Assessment policy dated 10/2017 states, As part of the comprehensive assessment, a Nutritional Assessment, including current nutritional status and risk factors for impaired nutrition shall be conducted for each resident. The Dietician, in conjunction with the Nursing staff and Healthcare Practitioners, will conduct a nutritional assessment for each resident upon admission with current baseline assessment time frames and as indicated by a change in condition that places the resident at risk for impaired nutritional. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. 146025 Page 6 of 13 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 21 residents living in the facility. Residents Affected - Many Findings include: On 08/08/23 at 11:20AM V5, Cook, was removing items from the standing refrigerator. One container was labeled mechanical ham and was dated 07/31/23. On 08/08/23 at 11:22AM in the walk-in refrigerator there was an opened bag of mozzarella cheese that was sealed with plastic wrap but was not dated. On 08/08/23 at 11:24AM in the walk-in freezer there was a plastic bag containing round slices of meat, each approximately two inches in diameter. The bag was dated 07/13 but was not labeled. There was a plastic bag of corn on the cob that was sealed but was not labeled or dated. There was a bag of breaded meat that was sealed, but not dated or labeled. There was an unknown cylindrical shaped item wrapped in brown paper and plastic wrap that was not dated or labeled. On the top shelf of the freezer, there was a fifteen-pound box of chicken breasts, a twelve-pound box of panko shrimp and three boxes of breaded catfish. The lower levels of shelving below contained various types of foods, including vegetables and mozzarella cheese sticks. V5, Cook, stated, the items on the top shelf are not pre-cooked. On 08/08/23 at 11:30AM, V4, Dietary Manager, stated, items can be arranged any way in the freezer because they are frozen. On 08/08/23 at 11:44AM the resident refrigerator in the dining room held a container of diced fruit with no label or date. There was a half empty container of blackberries with no date. There was a plastic bag containing half a cucumber and another plastic bag with a whole cucumber, neither of which were labeled or dated. There was an opened eight-ounce carton of chocolate milk that was not resealed, labeled with resident information, or dated. There was a container with a name written in black marker, but the contents inside were not labeled or dated. There was a foam container labeled R22 with no food item label or date. There was stack of sliced white cheese approximately one inch thick and a stack of sliced yellow cheese approximately two inches thick that were wrapped in plastic wrap. The dates written in black marker were not legible, and there were no item labels. On 08/08/23 at 11:47AM the freezer in the resident dining room had ice crystals on the shelves that were approximately one-half inch thick. There were four waffles in a plastic package that was not resealed after opening. The waffles were open to air and were not labeled or dated. There was a plastic bag containing several square breaded items with no label or date. On 08/08/23 at 12:05PM, V5, Dietary Manager, (DM), poured a can of tomato soup into a bowl, placed bowl in the microwave, and began heating. On 08/08/23 at 12:07PM, V5, DM, removed soup from the microwave and placed on the meal cart to be served. V5 did not check the temperature of the soup. 146025 Page 7 of 13 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 08/08/23 at 12:11PM, V5, DM, stated, Soup is more of a side item, so we normally don't check it (for temperature). I don't know if we should be, but we try to get it nice and hot. On 08/08/23 at 12:13PM, temperatures were obtained from the steamtable after the last resident tray was served using a metal calibrated thermometer. The pureed pork measured 134°F (Fahrenheit), the pureed turnip greens measured 127ºF, and the mechanical soft pork measured 125°F. The Facility's Diet Type Report dated 08/09/23 documented, R1, R10, and R12 were on pureed diets, and R3, R7, R8, R14, and R22 were on mechanical soft diets. On 08/10/23 at 3:43PM V1, Administrator, stated, she expects staff to follow food service policies. The Facility's Food Receiving and Storage revised October 2017 documents, Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in refrigerator or freezer will be covered, labeled and dated (use by date). Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Beverages must be dated when opened and discarded after twenty-four (24) hours. Other opened containers must be dated and sealed or covered during storage. Partially eaten food may not be kept in the refrigerator. The Facility's Food Preparation and Service revised April 2019 documents, The danger zone for food temperatures is between 41°F and 135°F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Fresh, frozen or canned fruits and vegetables are cooked to a holding temperature of 135ºF. Mechanically altered hot foods prepared for a modified consistency diet remain above 135°F during preparation or they are reheated to 165ºF for at least 15 seconds. The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff. The Facility's Resident Census and Condition of Residents Form CMS-672 dated 08/08/23 documents there are 21 residents living in the facility. 146025 Page 8 of 13 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to adequately develop an ongoing infection control program that adequately collects data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practices in the facility. The facility staff also failed to utilize appropriate Personal Protective Equipment, (PPE), when entering a COVID-19 rooms. This has the potential to affect all 21 residents living in the facility. Residents Affected - Many Findings Include: 1. The facility's Antibiotic Surveillance Tracking Form for the month of January documents, R6 was given Cipro for a Urinary Tract Infection, (UTI) from 1/23/23 through 1/30/23, and no culture was ordered. The Antibiotic Surveillance Tracking Form did not document the organism causing the infection. R6 Physician Order Sheet, (POS), dated 1/23/23 documents, Cipro 250mg, (milligrams), BID, (twice daily), for bladder pain related to, benign Prostatic Hyperplasia for 7 days. 2. The facility's Antibiotic Surveillance Tracking form for the month of May documents R15 was treated from 5/16/23 through 5/23/23 for a UTI. R15 was on hospice and was treated for signs and symptoms. A Culture and Sensitivity, (C/S), was not completed. The resident (R15) was on Macrobid. R15's POS dated 5/16 through 5/23 documents, R15 was on Macrobid 100mg BID, related to UTI. The Antibiotic Surveillance form did not document the organism causing this infection. 3. The facility's Antibiotic Surveillance Tracking Form for the Month of April documents, R16 was placed on Cipro and a culture was not completed. The organism causing the infection was not found on the form. R16's POS dated 4/9/23 through 4/16/23 documents, R16 was on Cipro 500mg BID for 7 days related to, a personal history of UTI. 4. The facility's Antibiotic Surveillance Tracking Form for the month of April documents R176 was on Macrobid. The Antibiotic Surveillance Tracking Form did not document the organism causing the infection. R176's POS documented, R176 was ordered Macrobid 100mg twice daily from 4/19/23 to 4/21/23 for a UTI. The Antibiotic Surveillance Tracking Form for the month February documented, that R176 was placed on Bactrim DS 800mg /160mg BID for urinary tract infection for 6 doses, on 2/14/23. The Antibiotic Surveillance Tracking form did not document the organism for this UTI. The Antibiotic Surveillance Tracking Form For the month of February also documented, that R176 was ordered Bactrim DS 800mg/160mg BID x, (times), 10 days on 2/24/23. The Antibiotic Surveillance Tracking form did not document the organism for this UTI. 5. On 08/09/23 at noon, V12 Certified Nursing Assistant, (CNA), entered the room of R9 and R19 who are on contact and droplet precautions for being symptomatic for COVID-19. V12 CNA donned gloves, gown, and goggles but, did not put on a N95 mask. V12 entered the room wearing a surgical mask. 6. On 8/9/23 at 1:00 PM V13 CNA donned PPE, (Personal Protective Equipment), and entered the room of R14 and R11. R11 and R14 are both positive for COVID-19. V13 CNA took a sit to stand machine into the room. V13 wiped down the sit to stand with a bleach wipe and rolled it out of the room. V13 then took the sit to stand sling that was used in the room and placed it on top of the sit to stand that was in the hallway. On 8/9/23 at 1:30 PM V13 CNA stated, I don't know why I did that. I was going to put it in the 146025 Page 9 of 13 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0880 laundry, because they already have one in their room. Level of Harm - Minimal harm or potential for actual harm On 8/11/23 at 12:08 PM V2 Director of Nursing stated, Yes we do, we are going to make sure all hospice residents get a UA/culture before starting ABT, (antibiotics), and we are addressing/stopping the prophylactic ABT we have with family and doctor. It isn't working anyway. Residents Affected - Many The facility policy Infection Prevention and Control Program dated October 2018 documents surveillance tools are used for recognizing the occurrence of infections recording their number and frequency detecting outbreaks and epidemics monitoring employee infection monitoring adherence to infection control practices and detecting unusual pathogens with infection control implications. Prevention of Infections: educating staff and ensuing that they adhere to proper techniques and procedures. The Facility's Resident Census and conditions Form dated 8/8/23 documents the facility had a census of 21 residents. 146025 Page 10 of 13 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm 3-Facility's Infection Control log dated 5/16/2023 documents, R15 prescribed Macrobid 100mg 1 capsule by mouth twice daily given 5/16/2023-5/23/2023. No culture and sensitivity, (C&S), ordered. Residents Affected - Some Facility was asked for culture and sensitivity on 8/9/2023. No results given. R15's Order sheet dated 5/16/2023 Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro). Give 1 capsule by mouth two times a day related to Urinary Tract Infection, (UTI), for 7 days. R15's Medication Administration Sheets, (MAR), dated 5/1/2023-5/31/2023 documents, Macrobid Oral Capsule 100 MG. Give 1 capsule by mouth two times a day related to UTI. MAR documents dated administered 5/16/2023-5/23/2023. R15's Nurse's Notes dated 5/16/2023 documents, hospice nurse returned phone call, new order for Macrobid 100 mg two times daily x 7 days. Hospice nurse stated, if we see not see improvement within 48 hours to notify hospice. 4-Facility's Infection Control log dated 2/14/2023 documents, R176 ordered Bactrim DS and started on 2/14/2023-2-17/2023. UA and culture done at radiation appointment. No results obtained by facility. Facility's Infection Control log dated 2/24/2023 documents, R176 was ordered Bactrim DS which started on 2/24/2023-3/1/2023. No growth noted on culture. Antibiotic started based on initial UA results. R176's February 2023 medication administration sheets, (MAR), document Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG (Sulfamethoxazole Trimethoprim). Give 1 tablet by mouth two times a day related to UTI. MAR documents, dates administered 2/14/2023-2/17/2023, 2/24/2023-3/1/2023. R176's Progress Notes dated 2/14/2023 at 5:38PM documents, R176 returned from radiation with a bottle of 6 Bactrim DS pills for a UTI that was found while at radiation. First dose to be given this evening. R176 is alert and able to make needs known. Vitals are within normal limits and in chart. Skin is warm and dry and bowel sounds are present. Respirations are even and nonlabored. Medications taken without difficulty. R176's Progress Notes dated 2/16/2023 at 11:33AM documents, Antibiotic for UTI. R176 has no signs and symptoms noted from antibiotic for UTI. Denies burning or discomfort. R176's Progress Notes dated 4/17/2023at 6:00PM documents, R176 reported burning upon urination and suprapubic discomfort when up to restroom. Will plan to obtain UA with culture and sensitivity per clean catch as per standing orders of Physician. R176 sitting up in bedside chair with call light in reach. R176's order sheets dated 4/18/2023 document, Macrobid Oral Capsule 100 MG (Nitrofurantoin Macro) Give 1 capsule by mouth two times a day related to UTI. R176's Progress Notes dated 4/18/2023 at 7:52PM, Physician in this evening and addressed residents UA. Received verbal orders from Physician to start Macrobid 100mg twice daily x 10 days. 146025 Page 11 of 13 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R176's Progress Notes dated 4/19/2023 at 12:51PM documents, Urinalysis results came back with preliminary culture which states there was no growth in 1 day. R176 on Macrobid 100mg by mouth twice daily. UA and preliminary sent to physician. R176's Progress Notes dated 4/21/2023 at 6:45AM document, Received UA with C&S with no indication of infection. Push PO fluids and cranberry juice. Update provider if symptoms arise or do not resolve. R176's Progress Notes dated 4/21/2023 at 1:36PM Note Text: Discontinued antibiotic. Urine culture came back and showed no signs of infection. Facility infection control log documents, on 4/21/2023 R176's antibiotic discontinued due to no UTI. No infection present. R176's MARS dated 4/1/2023-4/30/2023 documents; Macrobid Oral Capsule100 MG (Nitrofurantoin Macro) Give 1 capsule by mouth two times a day related to UTI. Start Date04/19/2023 0900-D/C Date04/21/2023. MARS document, dosage administered from 4/19/2023-4/21/2023. Facility policy dated 12/2016 states, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Appropriate indications for the use of antibiotics include: Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending. When a culture and sensitivity is ordered, it will be competed, and Lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotics therapy should be started, continued, modified, or discontinued. Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use in 4 of 4 residents (R6, R17, R15, and R176) reviewed for antibiotic stewardship in the sample of 23. Findings include: 1-The Facility's Antibiotic Surveillance Tracking Log for the month of January 2023 documents, No culture ordered for R6's urinary infection. R6's Order Summary Report printed 8/11/23 documents the order, Cipro Oral Tablet 250 mg (Ciprofloxacin HCl) - Give 1 tablet by mouth related to benign prostatic hypertrophy with lower urinary tract infection symptoms for 7 days until finished with Start Date of 1/23/23 and End Date 1/30/23. R6's MAR for January 2023 documents R6 received 14 doses of Cipro. On 8/9/23 at 4:15 PM, culture for R6's January 2023 UTI, (Urinary Tract Infection), was requested from V2, Director of Nursing, (DON). On 8/11/23 at 10:00 AM, no C&S was received from the Facility. 2-The Facility's Antibiotic Surveillance Tracking Log for the month of April 2023 documents, N/A 146025 Page 12 of 13 146025 08/11/2023 Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265

F 0881 for organism identified and UTI prophylaxis as site of R17's urinary infection. Level of Harm - Minimal harm or potential for actual harm R17's Order Summary Report printed 8/9/2023 documents, ordered Bactrim DS 800-160 MG, (milligram), (Sulfamethoxazole-Trimethoprim) - Give 1 tablet by mouth one time a day related to urinary tract infection, site not specified with Start Date of 5/4/23 and no End Date listed. Residents Affected - Some R17's Medication Administration Record, (MAR), for May 2023 through August 9, 2023, documents R17 received 98 doses of the antibiotic Bactrim DS. On 8/9/23 at 12:55 PM, culture for R17's UTI was requested from V2, DON. On 8/11/23 at 10:00 AM, no C&S was received from the facility. 146025 Page 13 of 13