Health inspection·November 15, 2024

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R28's diagnosis list (printed 11/14/2024) documents diagnoses including: Severe Dementia, Cognitive Communication Deficit, Anxiety Disorder, Osteoarthritis, Depression, and Post Traumatic Stress Disorder. Residents Affected - Few R28's quarterly assessment (9/21/2024) documents R28 has severe cognitive impairment, does not have impaired upper or lower extremity range of motion, and does not use any type of physical restraint. R28's Physician Orders (11/14/2024) document: lap tray when up in reclining chair and release every two hours and when one-to-one with staff. The same record does not document any specific medical need for R28's lap tray restraint. On 11/12/2024 at 11:31 AM R28 was seated in a wheelchair in R28's room with a lap tray positioned in front of R28 with a belt attaching the tray to the wheelchair. R28 appeared to be actively attempting to remove the tray and twisting the tray upwards and side to side. On 11/12/2024 at 11:34 AM V13 (Certified Nurse Aide) reported the facility uses the lap tray when R28 is up in the wheelchair to keep R28 from trying to get out of the wheelchair. V13 reported staff recently removed R28's lap tray but R28 attempted to get out of the wheelchair three to four times so staff replaced the tray. On 11/12/2024 at 1:20 PM R28 was seated in R28's wheelchair in R28's room and was moving the lap tray around in upwards and side to side motions. R28's progress notes (10/31/2024) document attempted to remove lap tray. Resident did go three days without attempting to stand by self. On 11/4/24 resident was noted to be in room and had stood up. On 11/5/2024 resident was attempting to stand up again in dining room. Lap tray was re-applied for resident safety. He is able to move lap tray around and in different angles. On 11/14/2024 at 11:40 AM V3 (Minimum Data Set Coordinator) reported R28 is not able to remove the lap tray independently and the facility recently tried a trial removal of the lap tray but R28 tried to get up from R28's wheelchair so the tray was replaced. On 11/14/2024 at 2:50 PM V22 (Certified Nurse Aide) reported R28 attempts to get up from R28's wheelchair. V22 reported R28 is able to remove R28's socks without the tray in place but unable to do so with the tray present on R28's wheelchair. V22 reported the lap tray is used to keep R28 from attempting to get up from the wheelchair. Page 1 of 10 146039 146039 11/15/2024 Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V22 reported the pieces of pool noodles were recently placed on R28's lap tray because he was getting bilateral skin tears from the tray. Based on observation, interview, and record review, the facility failed to identify specific medical conditions or symptoms necessitating the use of physical restraints, failed to assess safe use of restraints, and failed to release a physical restraint every two hours per plan of care. This failure affects two residents (R24, R28) of two reviewed for restraints in the sample list of 22. Findings Include: The facility policy titled Physical Restraint/Enabler Policy revised 7/24/18 documents physical restraints are any manual method or physical or mechanical device, equipment or material attached, or adjacent to the resident's body which the individual cannot remove easily and which restricts freedom of movement or normal access to his or her body. A device that may constitute a physical restraint may include, but is not limited to: bed rails, self-release waist restraints, soft waist restraints, lap top cushions, vest restraints, Geri-chair with tray table, arm restraints, leg restraints, personal alarms and hand mitts. Allow a two-finger width between the resident's body and the physical restraint. Release the physical restraint at a minimum of every two hours. During this period the resident shall be ambulated (if applicable), repositioned, toileted or changed, and/or skin care and nursing care provided, as appropriate. 1.) R24's undated Face Sheet documents medical diagnoses as Dementia, Insomnia and Hypertension. This same face sheet documents R24 admitted to facility on 10/24/24. R24's Physician Order Sheet (POS) dated November 2024 documents a physician order starting 10/31/24 to apply a self releasing seat belt when R24 is up in her wheelchair. R24's Minimum Data Set (MDS) dated [DATE] documents R24 is severely cognitively impaired. This same MDS documents R24 is dependent on staff for toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R24's Care Plan intervention dated 11/13/24 instructs staff to apply self releasing seat belt due to R24 leaning forward. This same care plan documents an intervention dated 11/13/24 to Release device and assist to reposition at least every two hours and PRN for restlessness. R24's Physical Restraint/Enabler assessment dated [DATE] documents R24's physical restraint is treating the conditions of leaning forward, attempting to stand and proper body positioning. This same assessment documents R24 is ambulatory, has no weight bearing restrictions, and has no Musculoskeletal or Neurological Disorder that interferes with ambulation. On 11/12/24 at 12:00 PM R24 sitting at her dining room table eating lunch with seat belt connected to itself via Velcro straps. R24's seat belt sat loosely between R24's mid thighs and knees. On 11/12/4 at 1:30 PM R24 was sitting in her wheelchair with a seatbelt attached laying on R24's Left Knee between her mid thigh and knee. R24 was sitting in her wheelchair with her legs crossed. R24's buttocks and legs were entirely to the side of the raised pommel. On 11/13/24 at 8:30 AM R24 sitting at her dining room table eating breakfast with seat belt connected to itself via Velcro straps. R24's seat belt sat loosely between R24's mid thighs and knees. 146039 Page 2 of 10 146039 11/15/2024 Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/13/24 at 3:45 PM V5 Licensed Practical Nurse (LPN)/Resident Care Coordinator (RCC) asked R24 to remove her seatbelt. R24 looked at V5 and smiled. R24 did not attempt to remove her seatbelt. R24's seatbelt was fastened with Velcro with a personal alarm sewn into the back of the seatbelt. On 11/14/24 at 11:55 PM R24 was sitting at her dining room table eating lunch with a seat belt connected to itself via Velcro straps. R24's seat belt sat loosely between R24's mid thighs and knees. On 11/13/24 at 2:00 PM V6 Certified Nurse Aide (CNA) stated R24's seatbelt has not been released since before breakfast when R24 was assisted out of bed. V6 stated V6 did offer toileting to R24 before lunch and R24 declined. V6 stated R24's seatbelt is so loose R24 can reposition herself without staff having to do it for R24. On 11/14/24 at 4:00 PM V5 LPN/RCC asked R24 to remove her seatbelt. R24's seatbelt was fastened with Velcro with a personal alarm sewn into the back of the seatbelt. R24 looked at V5 and smiled. R24 did not attempt to remove her seatbelt. V5 removed R24's personal alarm which sounded and then reconnected R24's personal alarm again. R24 stood up with her seatbelt in connected. R24 felt her seatbelt with her Right hand and then immediately sat back down. V3 Minimum Data Set (MDS)/Licensed Practical Nurse (LPN) approached R24 at this time and asked R24 to remove her seatbelt. R24's seatbelt was fastened with Velcro with a personal alarm sewn into the back of the seatbelt. R24 looked at V3 and smiled. R24 did not attempt to remove her seatbelt. V3 MDS/LPN stated R24 should not have a personal alarm in her wheelchair. V3 MDS/LPN stated We (facility) aren't supposed to have that many restraints. (R24) can stand and take a few steps but we (facility) are afraid she will fall so that is why she has the seatbelt and pommel cushion. V3 stated R24 would scoot her buttocks forward in her wheelchair under the seat belt to attempt to stand so the pommel cushion was placed in R24's wheelchair to prevent her from standing. On 11/14/24 at 12:46 PM V2 Regional Director of Operations stated any resident utilizing a physical restraint should have a medical diagnosis documented as the primary reason for use. V2 stated any resident who is using a physical restraint should have that restraint released every two hours for repositioning. V2 stated R24's seatbelt restraint should not be so loose. V2 stated R24's seatbelt restraint being so loose could cause a safety hazard. 146039 Page 3 of 10 146039 11/15/2024 Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951

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 observation, interview and record review the facility failed to provide timely incontinence care and incontinence care in accordance with facility standards for two of two residents (R22 and R10) reviewed for incontinence care in a sample list of 22 residents. Findings Include: The facility policy titled Perineal Cleansing reviewed 12/17 documents staff should wash pubic area including upper inner aspect of both thighs and frontal portion of perineum prior to washing resident buttocks and to dry areas thoroughly after cleansing. The basic infection control concept for perineal care is to wash from the cleanest to the dirtiest and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items. 1.) R22's undated Face Sheet documents medical diagnoses as Dementia, Cognitive Communication Disorder, Acute Kidney Failure and Diabetes Mellitus Type II. R22's Minimum Data Set (MDS) dated [DATE] documents R22 as severely cognitively impaired. This same MDS documents R22 as dependent on staff for toileting, bathing, dressing, transfers and requires maximum assistance for personal hygiene. R22's Care Plan intervention dated 7/22/24 documents R22 requires extensive assistance of two staff for toileting. On 11/12/24 observations were made every 15 minutes of R22 sitting her wheelchair from 10:30 AM through 1:00 PM without staff offering or assisting R22 with incontinence care. On 11/13/24 from 11:00 AM through 3:00 PM R22 sat in her wheelchair without staff offering nor assisting R22 with incontinence care. At 2:00 PM R22 was sitting at the end of her hallway in her wheelchair. R22's pants were saturated with urine from front perineal area up to her upper hip area. R22's mechanical lift sling was saturated with urine. R22 had two softball sized urine puddles on the floor underneath her wheelchair. V5 Licensed Practical Nurse (LPN)/Resident Care Coordinator (RCC) stated R22 is fully saturated with urine and should be provided incontinence care. On 11/13/24 at 3:00 PM V9 and V12 Certified Nurse Aide (CNA's) provided incontinence care for R22. R22's seat of her wheelchair was wet with urine. R22's pants and mechanical lift sling were saturated with urine. R22's incontinence brief was grossly saturated with foul smelling urine. On 11/13/24 at 3:30 PM V9 and V12 Certified Nurse Aide (CNA's) stated neither V9 nor V12 had offered or assisted R22 with incontinence care since they started their shift. V9 CNA stated I came in early today at 11:00 AM and haven't had time to do anything with (R22). (R22) should have been checked before lunch but I just didn't get to her. 2.) R10's undated Face Sheet documents medical diagnoses as Dementia and History of Urinary Tract Infections (UTI). R10's Minimum Data Sheet (MDS) dated [DATE] documents R10 as severely cognitively impaired. This 146039 Page 4 of 10 146039 11/15/2024 Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few same MDS documents R10 is dependent on staff for toileting, bathing, dressing, personal hygiene, bed mobility and transfers. On 11/13/24 at 1:35 PM V6 and V10 Certified Nurse Aides (CNA) provided incontinence care for R10. V6 CNA cleansed R10's buttocks, assisted R10 to her back and then cleansed her front perineal area. V6 did not dry R10's buttocks nor front perineal area after cleansing with no rinse cleanser. V6 did not change gloves or use hand hygiene throughout entire process. V6 did not provide barrier cream to R10's buttocks. R10's incontinence brief was thoroughly saturated, light brown in color and had a strong urine smell. On 11/13/24 at 1:50 PM V6 Certified Nurse Aide (CNA) stated V6 should have used hand hygiene, applied barrier cream and cleansed R10's front perineal area prior to cleansing R10's buttocks. V6 CNA confirmed R10's incontinence brief was saturated with urine. V6 CNA stated (R10's) incontinence brief was so wet and heavy because she hasn't been changed (provided incontinence care) since before lunch around 11:00 AM. (R10) has had a UTI before so we (staff) probably shouldn't wait so long with (R10) because sitting in urine can cause UTI's. On 11/14/24 at 12:45 PM V2 Regional Director of Operations stated residents who are incontinent and rely on staff to provide cares should be provided incontinence care every two hours. V2 stated staff should change their gloves when their gloves become contaminated. V2 stated staff should follow the incontinence care policy by cleansing the front perineal area prior to cleansing the back perineal area. V2 stated improper incontinence care and residents sitting in urine for long periods of time could cause a resident to get a UTI. 146039 Page 5 of 10 146039 11/15/2024 Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 properly store and date nebulizer tubing for one of one resident (R5) reviewed for oxygen in a sample list of 22 residents. Residents Affected - Few Findings Include: The facility policy titled Nebulizer Therapy dated 10/07 documents staff should store Nebulizer tubing in a plastic bag and change mouthpiece tubing and nebulizer weekly. R5's undated Face Sheet documents medical diagnoses as Dementia, Intellectual Disabilities, Chronic Obstructive Pulmonary Disorder (COPD), Glaucoma, Chronic Systolic Heart Failure, Dependence on Wheelchair and Need for Assistance with Personal Care. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R5's Physician Order Sheet (POS) dated November 2024 documents a physician order for Oxygen at 3 Liters (L)/minute via nasal cannula continuously. This same POS documents a physician order dated 8/21/24 to Change Hand Held Nebulizer (HHN)Tubing, reservoir and Respiratory bag weekly and as needed (PRN) when in use. Date and initial tubing, reservoir and respiratory bag. On 11/12/24 at 11:30 AM R5's Nebulizer machine was sitting on top of R5's bedside dresser with a clear plastic bag attached that was labeled 10-23-24 (initials) (R5) nebs. R5's nebulizer tubing was sitting in R5's top drawer bedside dresser with multiple other personal items. On 11/13/24 at 8:40 AM R5's Nebulizer tubing was connected to the nebulizer machine sitting on R5's bedside dresser with the tubing inside the top drawer of the dresser. On 11/13/24 at 8:45 AM V7 Licensed Practical Nurse (LPN) confirmed R5's Nebulizer tubing was in R5's top bedside dresser drawer. V7 stated the tubing should be changed every week on night shift and should be kept in a plastic bag when not in use. On 11/14/24 at 12:55 PM V2 Regional Director of Operations stated the facility is supposed to change every resident's Oxygen and Nebulizer tubing weekly. V2 stated all the respiratory tubing should be stored in a clean plastic bag when not in use. 146039 Page 6 of 10 146039 11/15/2024 Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview, and record review the facility failed to employ a full time Director of Nurses and failed to provide eight consecutive hours of Registered Nurse coverage for four of fourteen days reviewed. These failures have the potential to affect all 42 residents residing in the facility. Findings Include: Facility Nursing Staff Daily Assignment Sheets reviewed from 11/1/24 through 11/14/24 document four days (11/5/24, 11/8/24, 11/9/24, 11/10/24) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 11/14/24 at 2:28 PM V2 Regional Administrator confirmed the facility currently has no Director of Nurses (DON) employed by the facility and the previous DON's last day was 9/18/24. V2 also confirmed there were four days since 11/1/24 that the facility did not have the required eight consecutive hours of Registered Nurse (RN) coverage. From 11/12/24 through 11/15/24 there was no DON observed working in the facility. The Long-Term Care Facility Application for Medicare and Medicaid dated 11/12/24 documents the facility currently has 42 residents residing in the facility. 146039 Page 7 of 10 146039 11/15/2024 Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure required personnel attended the Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 42 residents in the facility. Residents Affected - Many Findings Include: The January 2024 QAA meeting attendance signature sheet does not document the facility Director of Nursing or Infection Preventionist was present for the meeting. The April 2024, July 2024, and November 2024 QAA meeting attendance signature sheets do not document the facility Director of Nursing was present for any of these meetings. On 11/14/24 at 2:28 PM V2 Regional Administrator confirmed the facility's Quality Assessment and Assurance Committee meets at least quarterly and the required members include the facility Administrator, the Director of Nurses (DON), the Infection Preventionist (IP), the Medical Director or Designee, and two other staff members. V2 confirmed after review of the last four quarterly QAA sign in sheets, there was no DON present at any of the last four meetings and no IP present at the January 2024 meeting. The Long-Term Care Facility Application for Medicare and Medicaid dated 11/12/24 documents the facility currently has 42 residents residing in the facility. 146039 Page 8 of 10 146039 11/15/2024 Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 11/13/24 at 12:28 PM V6 Certified Nurses Assistant (CNA) was observed in R26's room standing directly in front of R26's chair assisting her with eating the noon meal. R26 is Covid positive. The only PPE V6 was wearing was a surgical mask covering only her mouth and not her nose. V6 CNA stated she doesn't know what she is supposed to be wearing in a room with droplet precautions because she has never worked during a Covid outbreak. There was Droplet Precaution sign on R26's door with instructions on what Personal Protective Equipment (PPE) should be worn in R26's room. Residents Affected - Many On 11/13/24 at 12:34 PM V7 Licensed Practical Nurse (LPN) confirmed V6 CNA should have been wearing gloves, gown, eye protection, and a N95 mask while feeding a resident with Covid On 11/13/24 at 12:38 PM V5 Infection Preventionist confirmed V6 CNA should be wearing gloves, gown, eye protection, and a N95 mask while providing care or feeding a resident with Covid. On 11/15/24 at 1:45 PM V2 Regional Administrator confirmed Certified Nurses Assistants have access to all residents in the facility and if they do not utilize the required PPE while caring for residents with Covid, the risk for potentially exposing other residents and staff throughout the facility significantly increases. The Covid-19 Control Measures policy dated May 2023 documents in the event of a facility outbreak, all health care personnel must wear an N95 mask and eye protection when caring for all residents. The undated Contact Precautions sign documents staff are to wear gloves and gowns when entering a resident's room that is on Isolation Precautions. Then undated Droplet Precautions sign documents staff are to have their mouth, nose, and eyes fully covered when entering a resident's room that is on Droplet Precautions. The Long-Term Care Facility Application for Medicare and Medicaid dated 11/12/24 documents the facility currently has 42 residents residing in the facility. Based on observation, interview and record review facility staff failed to don appropriate Personal Protective Equipment (PPE) while providing resident care and failed to prevent cross contamination during medication administration for three of three residents (R11, R26, R5) reviewed for Infection Control in a sample list of 22 residents. This failure has the potential to affect all 42 residents residing in the facility. Findings Include: 1.) R11's undated Face Sheet documents medical diagnoses as Dementia, Alzheimer's Disease and active COVID-19. R11's Physician Order Sheet (POS) dated November 2024 documents a physician order dated 11/10/24 for R11 to be placed on Droplet and Contact Isolation for positive COVID-19 test to end on 11/20/24. R11's Minimum Data Set (MDS) dated [DATE] documents R11 as cognitively intact. 146039 Page 9 of 10 146039 11/15/2024 Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951

F 0880 Level of Harm - Minimal harm or potential for actual harm R26's undated Face Sheet documents medical diagnoses as Alzheimer's Disease and current COVID-19 infection. R26's Physician Order Sheet (POS) dated November 2024 documents a physician order starting 11/11/24 to obtain a full set of vital signs every four hours due to COVID-19 positive. Residents Affected - Many R26's Minimum Data Set (MDS) dated [DATE] documents R26 as severely cognitively impaired. On 11/13/24 at 11:10 AM V6 Certified Nurse Aide (CNA) obtained R11 and R26's blood pressure and pulse in R11 and R26's room (R11, R26 are roommates). R11 and R26's door displayed signs that indicated PPE for contact and droplet precautions is to be worn when entering R11, R26's room. R11, R26's room also had a three drawer dresser containing Personal Protective Equipment (PPE). V6 CNA was not wearing gloves nor a protective gown when obtaining R11, R26's vital signs. The front of V6 CNA's sweatshirt touched both R11, R26's bedside tables and R26's lap tray attached to the wheelchair R26 was sitting in. On 11/13/24 at 11:20 AM V6 Certified Nurse Aide (CNA) stated R11 and R26 are both COVID-19 positive and on contact and droplet isolation. V6 stated V6 should have worn a gown and gloves when obtaining R11, R26's vital signs. V6 stated V6 should have used hand hygiene between caring for COVID-19 positive residents and should have cleaned the equipment in between using it on separate COVID-19 positive residents. 2.) R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R5's Physician Order Sheet dated November 2024 documents a physician order for Symbicort 80-4.5 micrograms (mcg). Give two puffs every morning for Chronic Obstructive Pulmonary Disorder (COPD). On 8/13/24 at 8:25 AM V7 Licensed Practical Nurse (LPN) wore gloves to administer R5's Symbicort Inhaler in R5's room. V7 LPN wore the same gloves to pick up R5's Oxygen Nasal Cannula that was laying on R5's floor. V7 LPN then proceeded to administer R5's second puff of R5's Symbicort inhaler without using hand hygiene or change gloves. On 8/13/24 at 8:40 AM V7 Licensed Practical Nurse (LPN) stated V7 should have changed gloves and used hand hygiene prior to administering R5's second puff from her Symbicort inhaler. On 8/13/24 at 1:30 PM R5 stated That nurse (V7) touched her gloves to the floor and then pushed on my inhaler right at my mouth. I didn't like that but I need my inhaler. On 8/14/24 at 12:00 PM V2 Regional Director of Operations stated nurses should perform hand hygiene before and after touching anything possibly contaminated. V2 stated V7 should have either waited to finish R5's medication administration or washed her hands and performed hand hygiene before administering R5's second puff of R5's Symbicort inhaler. 146039 Page 10 of 10