Health inspection·September 28, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide and implement interventions to prevent resident falls for 4 of 4 residents (R11, R19, R29, R32) reviewed for resident safety in the sample of 27. This failure resulted in R32 transported to the hospital for a facial laceration with sutures and a fractured humerus on one incident, and a fractured hip with surgery on another incident. The Findings Include: 1. R32's Face Sheet, undated, documents R32 was admitted to the facility on [DATE]. R32's medical diagnosis include Major depressive disorder, Dementia with behavioral disturbances, Anxiety Psychotic disorder, Hypertension, (HTN), Gastroesophageal reflux disease, (GERD), and Insomnia. The facility's Fall Analysis Log, undated, documents, R32 had a fall on 7/26/23, 7/27/23, and 8/28/23. R32's Fall Risk was entered into the Care Plan on 9/5/23 after R32 had several falls. There were no interventions added after each fall. R32's Care Plan, dated 9/5/23, documents, Falls: R32 admitted Hospice due to medical and physical decline. Diagnosis: Dementia, resident is non-mobile, assist with transfers, sits in geriatric reclining wheelchair, has risk factors that require monitoring and intervention to reduce potential for self-injury. Interventions: Attempt to anticipate needs - toileting, hydration, hunger and provide cares before resident attempts to fulfill on own, bring to nurses station when out of bed for observation, assist resident to clean and place prescribed eyewear when awake, fall risk assessment quarterly and as needed with change in condition or fall status, keep call light within reach at all times, answer promptly and notify resident that help is coming, check every two hours when in bed for safety, side rails in up position while in bed to facilitate safe and more independent bed mobility. R32's Minimum Data Set, (MDS), dated [DATE], documents, R32 is cognitively intact and requires extensive assistance from two staff members for bed mobility, transfers, locomotion, toilet use, and bathing. R32 is occasionally incontinent of urine and always continent of bowel. R32's Nurses Note, dated 7/27/23 at 6:25 AM, documents, Called to room to assess resident. Upon entering room, resident observed on floor sitting with back against bedside table. Incontinent of urine and shoes next to bed instead of on feet, lighting adequate, no apparent injuries noted at this time other than redness to left upper extremity (bicep) and to left side/back. VS, (Vital Signs): T, (temperature), 99.7, P, (pulse), 60, R, (respirations), 16, BP, (blood pressure), 115/77, SpO2, Page 1 of 22 146040 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0689 (oxygen saturation), 96% RA, (room air). Resident transferred to bed with gait belt X two assist. CNAs, (Certified Nursing Assistants), report she is weaker than normal. Neuro checks initiated at this time. Level of Harm - Actual harm Residents Affected - Few R32's Nurses Note, dated, 7/28/23 at 3:45 PM, documents, Returned from (local ER), tetanus shot given, Suture (6) to left eyelid, F/U, (follow-up), with provider in five days for removal and wound check. CT, (Cat Scan), of spine and head, Chest and Pelvic X-Rays which showed closed nondisplaced fracture of surgical neck of right humerus (likely old); No medication order except OTC, (over the counter), Tylenol for Motrin take as according; Resident brought back to facility by Ambulance and two EMTs, (Emergency Medical Technicians), resident resting VS 98.2, 82, 18, 122/52, no signs of discomfort or pain, continue to monitor. R32's Nurses Note, dated 8/28/23 at 1:00 AM, documents, Called to assess resident in room. Observed her sitting on floor next to bed facing lights on wall. C/O, (complained of), severe right hip pain. RLE, (right lower extremity), noted to be externally rotated and shortened. Unable to do ROM, (Range of Motion), or move it at all. R32's Nurses Note, dated 8/28/23 at 1:05 AM, documents, EMS, (Emergency Medical Service), called to transport resident to ER, (Emergency Room), for evaluation. R32's Nurses Note, dated 8/28/23 at 1:15 AM, documents, VS T-98.1, P-106, R-22, BP-140/102, SpO2-96%. R32's Nurses Note, dated 8/28/23 at 1:30 AM, documents, EMS here and resident lifted from floor to stretcher via draw sheet and X two EMS with X three NH, (Nursing Home), staff. R32's Nurses Note, dated 8/28/23 at 1:35 AM, documents, Report called to hospital. POA, (Power of Attorney), called and updated. R32's Nurses Note, dated 8/28/23 at 2:20 AM, documents, (Local Hospital), called and admitting resident with Dx, (diagnosis): Right hip fracture. Message sent to MD, (Medical Doctor), DON, (Director of Nursing), POA said to call in AM, (morning), with updates. On 9/27/23 at 11:30 AM, V2, DON, stated, We only do a Quality Assurance Fall Analysis for residents fall. We don't do any other investigation on the falls. R32's Quality Assurance Fall Analysis, documents, R32's had falls 7/26/23, 7/27/23, and 8/28/23. This document provides the Root Cause Analysis Identified from the Investigation and the Prevention Plan for each date of a fall. There is no fall investigation done on resident falls. R32's Quality Assurance Fall Analysis, for fall on 7/26/23, documents, Root Cause Analysis Identified from the Investigation, as Resident had previously returned from (regional hospital) where they said she fell on Psych unit. Had been given IM, (intramuscular), Haldol at hospital and has been unsteady since. Prevention Plan: Med check and labs done by (Physician). R32's Quality Assurance Fall Analysis, for fall on 7/27/23, documents, Root Cause Analysis Identified from the Investigation, as Resident on high dose of Depakote, unsteady. Was found to have gotten self out of bed, Prevention Plan: (Physician) D/C's, (discontinued), Depakote with continued behavior monitoring. 146040 Page 2 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0689 Level of Harm - Actual harm R32's Quality Assurance Fall Analysis, for fall on 8/28/23, documents, Root Cause Analysis Identified from the Investigation, as Got self out of bed without assistance. Bed alarm going off, Prevention Plan: Low bed initiated. Residents Affected - Few R32's Physician Order, dated 9/5/23, documents, D/C Pressure Alarm while in bed and up in chair. On 9/27/23 at 10:30 AM, V10, MDS Nurse, stated, I am the one who puts in the fall risk assessments on residents. I do them quarterly. I don't do one after a resident fall, I only do them quarterly. R32's Fall Risk Assessment, dated 9/5/23, documents, R32 is a High Fall Risk with a score of 19. A score of 10 points or more = High Risk Score. R32's Fall Risk Assessment, dated 8/11/23, documents, R32 is a High Fall Risk with a score of 21. A score of 10 points or more = High Risk Score. R32's Fall Risk Assessment, dated 5/4/23, documents, R32 is a High Fall Risk with a score of 16. A score of 10 points or more = High Risk Score. On 9/25/23 at 9:48 AM, R32 is sitting in geriatric reclining wheelchair in her room by herself. R32 was not interviewable. On 9/26/23 at 3:40 PM, R32 is sitting at the Nurses desk in her Geriatric reclining wheelchair. 2. R29's Face Sheet, undated, documents, R29 was originally admitted to the facility on [DATE]. R29's Medical Record, documents, R29's diagnosis include Dementia, Schizophrenia, Bipolar disorder, HTN, GERD, Myelodysplasia, COVID 19. R29's Care Plan, dated 8/4/23, documents, Falls: Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. Interventions: Insure that adaptive devices-walker/cane/wheelchair within reach and in good repair, encourage and assist placement of proper non-skid footwear, observe for non-verbal signs of restlessness that may precipitate movement and attempts to stand/walk unattended, attempt to anticipate needs-toileting, hydration, hunger and provide cares before resident attempts to fulfill on own, observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed, monitor resident for signs or fatigue during ambulation, fall risk assessment quarterly and as needed with change in condition or fall status, provide activity supplies in reach of resident to keep busy and distracted from getting up unassisted, keep environment well-lit and clutter free, keep call light within reach at all times, answer promptly and notify resident that help is coming, check every two hours while in bed for safety, keep bathroom light on at night to provide adequate safe lighting levels, encourage resident to wear brief during daytime hours to minimize risk of slipping on wet floor during toileting. There were no fall risk interventions in place prior to 8/4/23, with R29 having falls on 5/11/23 and 6/4/23. R29's MDS, dated [DATE], documents, R29 has a moderate cognitive impairment and requires supervision for personal hygiene and bathing and is independent for all other Activities of Daily Living, (ADLs). R29 is always continent of both bowel and bladder. 146040 Page 3 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0689 The facility's Fall Analysis Log, undated, documents, R29 had falls on 5/11/23 and 6/4/23. Level of Harm - Actual harm R29's Fall Risk Assessment, dated 1/20/23, documents, R29 was not a High Fall Risk with a score of 7. A score of 10 points or more = High Risk Score. Residents Affected - Few R29's Fall Risk Assessment, dated 4/30/23, documents, R29 was not a High Fall Risk with a score of 7. A score of 10 points or more = High Risk Score. R29's Fall Risk Assessment, dated 8/4/23, documents, R29 was not a High Fall Risk with a score of 7. A score of 10 points or more = High Risk Score. R29's Physician Order, dated 8/8/23, documents, D/C half rails. R29's 3-Day Incident Charting, dated 5/11/23, documents, Using walker, wheel got caught upon something on floor and she fell on butt. Did not hit head. Denies pain. Able to help herself up with CNA assist. No signs of injury. R29's 3-Day Incident Charting, dated 6/4/23, documents, Res, (resident), stood from dining room chair, stumbled backward and fell on buttocks. Res later said, also hit left elbow. Small superficial abrasion, just below left elbow. R29's Quality Assurance Fall Analysis for fall on 5/11/23, documents, Root Cause Analysis Identified from the Investigation, as Resident was looking behind her while walking forward. Prevention Plan as Educate resident on looking forward while walking. R29's Quality Assurance Fall Analysis for fall on 6/4/23, documents, Root Cause Analysis Identified from the Investigation, as Stumbled backwards when getting up from dining room table. Prevention Plan as Educate resident on getting up slowly and asking for assistance for walker. On 9/26/23 at 8:48 AM, R29 lying in bed, walker at bedside, tennis shoes on floor by walker. R29 got out of bed herself, no walker used, regular socks on, walked to restroom and back. On 9/27/23 at 12:35 PM, R29 was seen in dining room without a walker, cane, or wheelchair, then stood up and walked down the hall towards her room. 3. R19's Face Sheet, undated, documents, R19 was originally admitted to the facility on [DATE]. R19's Medical Record, documents, R19's medical diagnosis include Dementia, Depressive disorder, Schizophrenia, Anxiety, Repeat Falls, Dysphagia, Intertrochanteric fracture, HTN, Peripheral Vascular Disease, (PVD). R19's Care Plan, dated 3/10/23, documents, Falls: R19 does not understand mobility limits due to cognitive limitations. Resident has been known to attempt to get out of bed unattended. Risk factors include: unsteady gait, unable to regain balance by self, current cognitive level is: BIMS 00. Current transfer/mobility limitations are: Dependent assist X two with dressing, personal hygiene, and shower. Limited assist X three with bed mobility, and toilet use, and transfer. Interventions: Fall risk assessment quarterly and as needed with change in condition and fall status, attempt to anticipate needs-toileting, hydration, hunger and provide cares before resident attempts to fulfill on own., observe for unsteady/unsafe transfer, remind of safety precautions and limitations as necessary, 146040 Page 4 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0689 Level of Harm - Actual harm Residents Affected - Few assess cognitive deficits and accommodate forgetfulness regarding safety devices and environmental risks, toilet per schedule and as needed when restless or agitated, encourage resident to wear Depends during daytime hours to minimize risk of slipping on wet floor when toileting. R19's MDS, dated [DATE], documents, R19 has a severe cognitive impairment and requires extensive assistance from two staff members for bed mobility, transfers, and dressing. R19 is total dependence of two staff members for toileting and bathing. R19 is always incontinent of both bowel and bladder. The facility's Fall Analysis Log, undated, documents R19 had a fall on 5/22/23. R19's Physician Order, dated 5/27/21, documents, Safety Device: Low bed due to frequent falls. R19's Physician Order, dated 5/31/21, documents, D/C, (discontinue), low bed. Resident in Bolster mattress for safety. R19's Fall Risk Assessment, dated 12/8/22, documents, R19 was a High Fall Risk with a score of 19. A Score of 10 points or more = High Risk Score. This was the last Fall Risk completed on R19. R19's 3-Day Incident Charting, dated 5/22/23, documents, Res, (resident), observed lying on right side next to low bed with blanket. Res was incontinent. No s/s, (signs/symptoms), of discomfort, no visible injuries noted, ROM, (Range of Motion), is WNL, (within normal limit). There were no updated interventions placed in R19's care plan after the fall on 5/22/23. R19's Quality Assurance Fall Analysis, for fall on 5/22/23, documents, Root Cause Analysis Identified from the Investigation, as CNA found resident laying on floor next to her bed from rolling out on floor on right side. Prevention Plan: Placed bed against the wall to prevent resident from rolling out of bed (favors right side). On 9/25/23 at 9:32 AM, R19, lying in bed, not interviewable/non-verbal, call light hanging over headboard. There is a sign on R19's restroom door Remember to sit down when changing. On 9/28/23 at 10:40 AM, R19 seen sitting in living area in her wheelchair by herself, regular socks on, no shoes. 4. R11's Face Sheet, undated, was originally admitted to the facility on [DATE]. R11's Medical Record, documents, R11's medical diagnosis include: Depression, Anxiety, Dementia, Bipolar, and HTN. R11's Care Plan, start date of 5/4/23, however was entered by V10, MDS Nurse, on 7/3/23, documents, Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. Interventions: Review quarterly and PRN, resident's ADL, mobility, cognitive, behavior, and overall medical status, encourage and assist placement of proper non-skid footwear, assist resident to clean and place prescribed eyewear when awake, monitor resident for signs of fatigue during ambulation, Fall risk assessment quarterly and as needed with change in condition or fall status., keep environment well-lit and clutter free, add additional lighting at night, keep call light within reach at all times, answer promptly and notify resident that help is coming, check every two hours when in bed for safety, keep bathroom light on at night to provide adequate safe lighting levels, encourage 146040 Page 5 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0689 Level of Harm - Actual harm resident to wear brief during daytime hours to minimize risk of slipping on wet floor during toileting, encourage resident to use call light and ask for help when feeling weak or lightheaded, 2/26/23: monitor BP for one week, ensure resident is wearing tennis shoes, not slippers, resident provided walker with green sign, removed high riser from toilet, low height bed. Residents Affected - Few R11's MDS, dated , 8/3/23, documents, R11 has a severe cognitive impairment and requires limited assistance of one staff member for dressing, toilet use, personal hygiene, and bathing. R11 requires supervision for all other ADLs. R11 is occasionally incontinent of both bowel and bladder. The facility's Fall Log, documents, R11 had a Fall on 3/4/23, 3/31/23, 4/20/23, 5/11/23, 6/13/23, and 8/27/23. R11's Fall Risk Assessment, dated 10/7/22, documents, R11 is not a high fall risk with a score of 9. A Score of 10 or more = High Risk Score. There is no other fall risk completed and in R11's Medical Record. R11's 3-Day Incident Charting, dated 3/31/23, documents, Resident was getting cup of coffee at kitchen window, as she was turning, feet got twisted and went down. No injuries at this time. R11's 3-Day Incident Charting, dated 6/13/23, documents, Fall in room. C/O right shoulder and knee pain and cut on right eyebrow, sent to (local hospital) ER For eval. No fractures. R11's 3-Day Incident Charting, dated 7/25/23, documents, Resident fell in room attempting to get up without walker. Res heard yelling help. Staff observed res on floor. Neuro VS started, no injuries noted, ROM, WNL, awake and alert. R11's 3-Day Incident Charting, dated 8/27/23, documents, Laundry aid hollered, stated res fell. Res sitting on hallway floor with head against wall. Neuro checks initiated. Res alert and able to move all extremities without difficulty. On 9/25/23 at 9:36 AM, R11, was asleep in bed, walker on side of bed, R11 stated, that she fell down so now has to use her walker to get around. R11 stated, that she has fallen around three times now. There is a sign posted on the wall Use call light for help. On 9/26/23 at 9:05 AM, R11 was sitting in a chair in her room, walker next to her, sign on the walker read, (R11), pick up your feet when you walk. Take your walker with you at all times. On 9/27/23 at 10:00 AM, R11 lying in bed, legs hanging off the bed, walker in the room close to restroom and not next to bed. R11's Quality Assurance Fall Analysis for fall on 3/4/23, documents, Root Cause Analysis Identified from the Investigation, as Not picking up her feet with house shoes on, Prevention Plan: House shoes taken and replaced with tennis shoes during the day and grippy socks at night. R11's Quality Assurance Fall Analysis for fall on 3/31/23, documents, Root Cause Analysis Identified from the Investigation, as Walking around dining table and tripped over own feet, Prevention Plan: OT, (Occupational Therapy), pick up for gait and balance training. 146040 Page 6 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0689 Level of Harm - Actual harm Residents Affected - Few R11's Quality Assurance Fall Analysis for fall on 4/20/23, documents, Root Cause Analysis Identified from the Investigation, as Walking up hallway, yelled out, she was unsteady, grabbed handrail and lowered self to floor yelling she fell, Prevention Plan as Given walker for unsteady gait. R11's Quality Assurance Fall Analysis for fall on 5/11/23, documents, Root Cause Analysis Identified from the Investigation, as While sitting on toilet seat riser, slid off and resident slid to floor., Prevention Plan as Seat riser removed from bathroom. R11's Quality Assurance Fall Analysis for fall on 6/13/23, documents, Root Cause Analysis Identified from the Investigation, as Resident couldn't say, found wrapped in blankets on floor next to bed., Prevention Plan as Given a low bed. R11's Quality Assurance Fall Analysis for fall on 8/27/23, documents, Root Cause Analysis Identified from the Investigation, as Shuffling feet while walking up hall with walker., Prevention Plan as Sign attached to walker to remind resident to pick up her feet while walking. On 9/28/23 at 12:46 PM, V2, DON, stated, I would expect the staff to perform Fall Risk Assessments during admission, quarterly, and after a resident fall. There should be fall interventions placed in the resident's care plan after each fall, and the staff should be following these interventions. The Facility's Fall Prevention Policy, dated 11/10/18, documents, To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. 1. Conduct Fall Assessments on the day of admission, quarterly, and with a change in condition. 2. Identify, on admission, the resident's risk for falls. All staff must observe residents for safety. If residents with a high-risk code are observed up or getting up, help must be summoned, or assistance must be provided to the resident. 3. Assessments of Fall Risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. 5. Immediately after any resident fall, the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM for Wellness form along with any new interventions deemed to be appropriate at the time. The unit nurse will also place any new interventions on the CNA assignment worksheet. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. 146040 Page 7 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 complete and timely incontinent care for 3 residents (R21, R27 and R32) of 4 residents reviewed for incontinence in the sample of 27. The Findings include: 1. On 9/26/2023 at 11:34 AM R21 ambulating to dining room V8, Certified Nursing Assistant, (CNA), assisting by holding onto gait belt around R21's waist. R21's pants are visibly wet. R21 seated in chair in the dining room. On 09/26/23 at 12:28 PM, V9, CNA assisted R21 from chair to standing in dining room with use of a gait belt. V9 assisted R21 from dining room to his room. R21's pants are visibly soaked. V9 sat R21 on the toilet and removed adult diaper that was saturated with urine. R21 stood up in bathroom holding on to his walker. V9 CNA then sprayed no rinse peri wash on wash cloth. V9 then swiped across R21's buttocks with washcloth wash. V9 used another washcloth with no rinse peri wash and wiped R21's peri area. V9 did not cleanse R21's scrotum or penis. V9 did not cleanse inner thighs nor did V9 dry R21 prior to putting adult diaper on R21. R21's care plan dated 6/ 29/2022 documents, R21 has alteration in bladder elimination related to incontinence. R21's care plan documents the following interventions dated 6/29/2022; contact R21 every 2 hours from 7am - 7pm, or during waking hours, focus R21's attention on voiding by asking R21 whether wet or dry, check R21 for wetness and give perineal care after each episode, assist /remind R21 to toilet upon arising, within an hour before and after meals and before going to bed. R21's Minimum Data Set, (MDS), dated [DATE] documents, that R21 is cognitively intact. R21's MDS documents, that R21 requires limited assistance and one-person physical assistance for toileting. 21's Face Sheet documents in part a diagnosis of dementia, and chronic kidney disease, (CKD). 2. R32's Face Sheet, undated, documents that R32 was admitted to the facility on [DATE]. R32's medical diagnosis include Major depressive disorder, Dementia with behavioral disturbances, Anxiety Psychotic disorder, Hypertension, (HTN), Gastroesophageal reflux disease, (GERD), and Insomnia. R32's Care Plan, dated 9/5/23, documents, R32 admitted hospice due to medical and physical decline. Diagnosis: Dementia, resident is non-mobile, assist with transfers, sits in geriatric reclining wheelchair, has risk factors that require monitoring and intervention to reduce potential for self-injury. Interventions: Attempt to anticipate needs - toileting, hydration, hunger and provide cares before resident attempts to fulfill on own, bring to Nurses Station when out of bed for observation, assist resident to clean and place prescribed eyewear when awake, fall risk assessment quarterly and as needed with change in condition or fall status, keep call light within reach at all times, answer promptly and notify resident that help is coming, check every two hours when in bed for safety, side rails in up position while in bed to facilitate safe and more independent bed mobility. The Fall Risk was entered into the Care Plan on 9/5/23 after R32 had several falls. There were no interventions after each fall. 146040 Page 8 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R32's MDS, dated [DATE], documents, R32 is cognitively intact and requires extensive assistance from two staff members for bed mobility, transfers, locomotion, toilet use, and bathing. R32 is occasionally incontinent of urine and always continent of bowel. 9/26/23 at 10:58 AM, R32 lying in bed. V3, and V9, CNAs, along with V2, Director of Nursing, (DON), entered to perform peri-care on R32. Strong smell of urine noted upon entrance to the room. Both CNAs donned gloves, no hand hygiene was done. There was a basin of water and washcloths at bedside. R32's brief was unfastened and tucked between her legs. R32 was rolled to the side and V9 used wet washcloths to clean R32's anal area. R32 was rolled back over and V9 using same gloves, got another wet washcloth from the clean water and wiped R32's bilateral groins and vagina. R32 was rolled to other side and V3 washed R32's buttock. There was no drying of R32 observed. The soiled pad and incontinence brief were removed. R32 sat on side of bed with incontinence brief and pants put on her legs. V3 and V9's gloves were changed, but no hand hygiene done. Gait belt was around R32 and R32 was assisted to stand and pivot to geriatric chair. There was no drying of R32, no moisture barrier put on, and no hand hygiene done before care and between glove changes. 3. R27's Face Sheet, undated, documents, R27 was admitted to the facility on [DATE]. R27's Medical Record documents R27's medical diagnosis include Dementia, Depression, Anxiety, Peripheral neuropathy, HTN, Diabetes Mellitus, (DM), GERD, Osteoporosis, Hyperlipidemia, Hypercalcemia. R27's Care Plan, dated 9/18/23, documents R27 has an Alteration in Bladder Elimination as related to incontinence, resident has dementia and used diuretic. Interventions: Pad appropriately for dignity and comfort, toilet and/or change padding and give proper hygiene before/after meals, upon arising, upon request, before retiring for the evening, after napping, and PRN for incontinence, use verbal reminders for urine control, check frequently for incontinence and provide perineal care after each episode. It continues R27 has a Self-care deficit - needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADL, (Activities of Daily Living), resident is self-mobile walks with cane, feeds self after tray set up, resident has difficulty making decisions, cognitive impairment, Diagnosis: Dementia, Depression, Anxiety. Interventions: Assist with ADLs as necessary with staff assist of one. Have necessary items in place. Offer supervision and verbal cues. Ensure clothing is clean, ensure resident is appropriately dressed and groomed with supervision. R27's MDS, dated [DATE], documents, R27 has a severe cognitive impairment and requires extensive assistance from one staff member dressing, personal hygiene, bathing, and toileting. R27 is always continent of both bowel and bladder. On 9/25/23 at 9:27 AM, R27 was not in her room, noted bed sheet has dried feces. R27 sitting in a chair in the living area, strong urine odor and/or body odor noted. On 9/25/23 at 11:55 AM, R27 was eating lunch at dining room table, still has strong smell of urine/body odor. R27 stood up to walk with her walker and the back side of her grey pants appeared wet. On 9/25/23 at 3:25 PM, R27 was lying in bed, same grey pants as seen wet on her before. When asked if she was currently wet, R27 replied, yes. On 9/26/23 at 8:58 AM, R27 was lying in bed, strong smell of urine upon entrance to her room, different clothes on today. 146040 Page 9 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/26/23 at 10:57 AM, R27 walked out of room to living area and sat in recliner. R27's blanket on top of her bed, where R27 was lying, has a wet spot where her buttocks would be while R27 was lying in bed. On 9/26/23 at 11:10 AM, R27 was sitting in the living area recliner with a strong odor of urine. R27 stood up from the recliner and walked to the dining room and sat in a chair at a table. The living area chair that R27 was sitting on, had a wet spot on the chair after she stood up. On 9/26/23 at 12:10 PM, R27 got up from dining room chair, ambulated to her room. When R27 got up from the dining room chair, a wet spot was noticed and the back of R27's pants appeared to be wet. R27 walked to her room and got into her bed with wet pants on. On 9/26/23 at 1:42 PM, R27 remains in her bed, same clothing on she had all day, including her wet pants. On 9/26/23 at 3:45 PM, R27 remains in bed, a strong odor of feces that was noticeable from the hallway in front of her room and became extremely strong upon entrance to her room. When asked if she was incontinent or if she soiled her pants, R27 stated, Yes. R27 still has the same clothes on that she had all day, including previously wet pants. On 9/26/23 at 3:47 PM, two different housekeepers and a CNA walked down the A-hall (R27's hall) to the end of the hall and no one stopped to ask or check on R27, even with the odor noticeable out in the hall. On 9/27/23 at 12:20 PM, R27 seen sitting in dining room chair for lunch. R27's room was seen with a large amount of feces sitting in the chair next to her bed and drops of feces from the chair to the entrance to her room. On 9/27/23 at 12:30 PM, R27 was seen sitting in a dining room chair and when she stood up and started walking towards her room, feces were seen on the dining room chair and on the entire back of R27's pants. V11, CNA, noticed R27 walking with feces on her pants and escorted her to her room and walked R27 down the hall to the shower room to clean R27. On 9/28/23 at 12:45 PM, V2, DON, stated, I would expect the staff to check on the residents every two hours and PRN, and to provide timely and complete incontinent care to the residents. I would expect the staff to perform hand hygiene before, during, and after resident care, as well as glove changes when soiled. The Facility's Hand Hygiene Policy, dated 8/14/23, documents, All staff will comply with current CDC hand hygiene guidelines to reduce the incidence of healthcare associated infections. Indications for hand washing: When hands are visibly soiled or contaminated with blood or other body fluids, before and after eating and using the restroom. Hand washing can also be used routinely in the following clinical situations: 1. After contact with body fluids, excretions, mucous membranes, non-intact skin, and wound dressings. 2. Before and after direct resident care. 3. Before and after inserting invasive devices. 4. When moving from contaminated body site to clean body site during resident care. 5. After contact with intact skin. 6. After removing gloves. The Facility's Perineal Cleansing Policy, dated 12/2017, documents, To eliminate odor; to prevent irritation or infection and to enhance resident's self-esteem. Procedure: Female - 4. Wet washcloth 146040 Page 10 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with cleansing agent chosen. 5. Wash pubic area including upper inner aspect of both thighs and frontal portion of perineum. 8. Dry thoroughly. 11. Wash peri-anal area thoroughly with each stroke beginning at the base of the labia and extending up over the buttocks. 14. Dry area thoroughly. 15. Remove gloves and wash hands with soap and water, cleansing gel or Thera Worx. 16. Apply new incontinent product, clothes or reposition comfortably. 17. Wash hands with soap and water, cleansing gel, or Thera Worx. Procedure: Male - 4. Wet washcloth and apply cleansing agent chosen. 5. Wash pubic area, including upper inner aspect of both thighs as well as the penis and scrotum. a) Retract foreskin and wash carefully to remove secretions. b) Wash area under scrotum. 8. Dry carefully, remembering to draw foreskin of the uncircumcised male back over the head of the penis. 10. Rinse cloth and proceed with the cleansing of the anal area. 11. Washing should alternate side to side, ending with the center anal area. 14. Dry area thoroughly. 15. Remove gloves and wash hands with soap and water, cleansing gel or Thera Worx. Note: The basic infection control concept for peri-care is to wash from the cleanest to the dirtiest area and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items. 146040 Page 11 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on interview, observation and record review, the facility failed to maintain the medication refrigerator at the proper temperature. The failure has the potential to affect all 35 people living in the facility. Findings include: On 9/26/23 at 10:15 AM, the medication room was entered with V2, Director of Nurses, (DON). The medication refrigerator had a thermometer in it, and it was reading 25 degrees. There was a temperature log on the refrigerator door. The last date entered was 9/26/23 and it reads 24 degrees. There are 3 epinephrine pens. There are 8 multi-use vials of Tubersol. There are 7 boxes with 10 single use injections of Influenza vaccine. V2 stated, that all 3 of these medications are stock medications. On 9/27/23 at 10:15 AM, V2, stated, The midnight nurse is supposed to check and log the medication refrigerator temperature and if it is wrong then the nurse is expected to adjust the refrigerator and recheck it. The Refrigerator Temperature Log, dated September 2023, documents 3 days of 24 degrees, 1 day of 26 degrees and 3 days of 28 degrees. This Log fails to document temperatures on 17 days. The epinephrine pens documents, DO NOT STORE IN THE REFRIGERATOR on the label. The Tubersol box documents, This product should be stored between 2 degrees and 8 degrees C (Celsius) (36 degrees and 46 degrees F (Fahrenheit)). The Influenza vaccine box documents, Store refrigerated a 2 - 8 degrees C (36 - 46 degrees F). The Resident Census and Conditions of Residents, CMS 672, dated 9/18/23, documents, that the facility has 35 residents living in the facility. 146040 Page 12 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview, observation and record review, the facility failed to store food to prevent contamination and food borne illness, ensure the dishwasher, refrigerator and freezer are operating properly and ensure the refrigerators, freezers, equipment, and walls are clean. This failure has the potential to affect all 35 residents living in the facility. Findings include: On 9/27/23 at 10:30 AM, the kitchen was entered and toured. V4, Dietary Manager is present for the tour. The dry storage room had a box containing 7 boxes of oatmeal pies on the floor and a plastic storage container containing 20-pound bag of powder sugar which had a measuring cup in it with the handle in the powder sugar. There is a non-commercial refrigerator has a sign on it that documented, the refrigerator is for resident food only, not for employee use. V4 stated the facility has no residents that have families or friends that bring food in for the residents. The freezer portion of the refrigerator had a case of magic cups for the residents, 2 packages of eye of round steaks with freezer burn, 2 cartons of ice cream and a variety of single serve frozen food items. V4 stated the facility has an employee that is having a hard time and employees will bring in food for her and place the food in the freezer. The freezer has multiple areas of brown debris on the freezer floor and door. The refrigerator portion has 8 Premier Protein drinks that expired on 9/5/23, 10 mini waters, 1 open half empty single apple juices, 2 open half empty Dr Pepper cans, a carry out drink in a Styrofoam cup with a lid and straw and 1 open half empty orange soda. The open beverages did not have a date or a name on them. The shelves and the door had multiple brown spillage areas and food debris. In the main kitchen, there was a plastic storage container with an open 20-pound bag of sugar. The sugar bag had a measuring cup with the handle in the sugar. The 2 doors stand up freezer had an open large bag of pepperoni that was freezer burnt and the bag was not dated as to when it was opened. The bottom of the freezer had multiple frozen food particles and debris. The single door stand-up freezer bottom had multiple frozen food particles and debris. The walk-in refrigerator had a large bag of lettuce that had rotted. The lettuce was mushy and had tan liquid in the bottom of the bag. The walk-in fridge contained a 5-pound package of ground beef that had been opened and wrapped in aluminum foil that was not dated or use by date, an open undated package of single sliced American cheese which had aluminum foil around it, but it was not wrapped. The foil was just around the package of cheese. A large stainless-steel pan that was covered in aluminum foil that was dated 9/26/23 meatloaf. V4 stated the meatloaf was leftovers from the previous days lunch. V4 was questioned if there was a cooling log for the meatloaf. V4 stated, No. V4 was questioned why not, V4 stated, Because (V5 cook) knows everything and he doesn't think he needs one. V4 stated that open products should be dated and wrapped properly, meat should be dated, and rotten food should be thrown away. Still in the main kitchen, the dishwasher was observed. It is a low temperature wash with chlorine sanitation. The chlorine-based product label documents, 200 ppm, (parts per million), of chlorine needed for sanitation. The dishwasher was run and tested with a chlorine test strip, and it read 100 ppm. V4 agreed the strip read 100 ppm and stated she was unsure how many ppm of chlorine was needed, because recently all her products had been changed. None of the dishwashers or refrigerators or freezers had logs showing the equipment was checked for proper operation. The stainless-steel range hood had grease and dust build up on it. The wall above the kitchen door had an in the wall air unit that blows directly onto the range hood. The top of wall, the air unit and under the air unit has black, brown dust and grease bunnies. V4 stated the employees are supposed to do cleaning tasks daily but 146040 Page 13 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0812 that it is difficult to get them to do it. V4 stated, I am the only one that cleans really. Level of Harm - Minimal harm or potential for actual harm On 9/28/23 at 9:00 AM, V4 stated, that the refrigerators and freezers should have logs that document the temperatures. The dishwasher should have a log that documents wash temperature and chlorine ppm. V4 stated, Usually we do but nobody put new logs up on the first of September. Residents Affected - Many The facility policy food cooling, dated 3/18, documents, hot foods will be cooled to the proper temperature using a two-stage cooling process. Stage 1: Cool foods from 135- 70 degrees Fahrenheit, (F), within 2 hours. Stage 2: Cool foods from 7-41 degrees F or below within 4 hours (total of 6 hours). If the food has not been cooled to 70 degrees F or below within first 2 hours, the needs to be thrown out or reheated one time only to 165 degrees F for 15 seconds. The cooling process will start overusing an alternate method to cool from what failed initially. If the food does not reach 70 degrees F or below the second time, the food item must be discarded. Use the food cooling log for temperature monitoring and recording. The dietary manager will review and monitor the food cooling process and log for completion. The facility policy refrigerator and freezer storage, dated 10/14, documents it is the policy of (facility) that any item to be placed in the refrigerators and freezers must be covered, labeled, and dated with a date-marking system that tracks when to discard perishable food. The policy documents, mark container with name of item. [NAME] the date that the original container is opened or date of preparation. Label refrigerated potentially hazardous food prepared and held for more than 24 hours with the day/date by which the food shall be consumed or discarded (maximum of 7 days from time of preparation). Place meats for thawing in a pan and store on the lowest shelf in the refrigerator. Label with the date the item was removed from the freezer and the thawing process started. Clean up any spills immediately. Designated dietary employee is to check, pull and throw away any potentially hazardous foods that have been in the refrigerator for 7 days. Use or discard food according to the manufacturer's use by date. The facility policy storage, dated 6/06, documents it is the policy of (the facility) that food shall be stored on shelves in areas that provide the best preservation. Food shall be stored at the proper temperature and for appropriated lengths of time to protect quality of food and food cost. The policy documents all items will be dated upon receipt. Individual cans or bags shall each be dated to ensure that stock is rotates properly. Store leftovers in covered, labeled, and dated containers under refrigeration or frozen. 146040 Page 14 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0812 Level of Harm - Minimal harm or potential for actual harm When using only part of a product, the remaining product should be in the original package or airtight container and labeled and dated. The Resident Census and Conditions of Residents, CMS 672, dated 9/18/23, documents the facility has 35 residents living in the facility. Residents Affected - Many 146040 Page 15 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. 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 provide a Licensed Nursing Home Administrator as V1's temporary license expired on 5/2022 and has not been working with a current license since. This has the potential to affect all 35 residents in the facility. Residents Affected - Many The Findings Include: On [DATE] at 1:38 PM, V1, Administrator, stated, I was working under a temporary license, and it expired in May of 2022. I took the Federal test and passed it, but I failed the state test. I am working under the Regional Director of Operations, who is in the facility once a month. I am aware that I am listed as the Licensed Administrator for this facility. On [DATE] at 12:45 PM, V1, stated, We really don't have a policy that states, the Administrator must be licensed. We have a Staffing Policy that states, Licensed Nurses are required to be licensed by the State in which they are practicing. Copies of the current licensees shall be displayed in the facility. The only thing that I have is my job description that tells me I need to be licensed. Yes, I should have a License to be the Nursing Home Administrator. V1's State of Illinois, Department of Financial and Professional Regulation, Licensed Nursing Home Administrator, Temporary documents, an expiration date of [DATE]. The Resident Census and Conditions of Residents form (CMS-672), dated [DATE], documents, there are 35 residents residing at the facility. 146040 Page 16 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to disclose Quality Assurance and Performance Improvement, (QAPI) documents to verify the facility is actively participating in a QAPI program. This failure has the potential to affect all 35 residents living in the facility. Residents Affected - Many Findings include: On 09/28/23 at 10:06 AM, V1, Administrator, stated the facility does have Quality Assurance Assessment, (QAA) /QAPI meeting minutes and notes. The QAA/ QAPI meeting minutes / notes were requested for review. V1 refused to provide the documents. The facility failed to provide QAA /QAPI meeting minutes and notes. The Resident Census and Conditions of Residents, CMS 672, dated 9/18/23, documents the facility has 35 residents living in the facility. 146040 Page 17 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to ensure to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors to problems. This failure has the potential to affect all 35 residents living in the facility. Findings include: On 09/28/23 at 10:06 AM, V1, Administrator, stated the facility has meeting daily and each day of the week has a high-risk topic, which is discussed at that time. V1 said, We evaluate the problem and see if we can put in interventions or review the resident to figure out what the problem is and to make it better. The daily meeting information is evaluated, weekly to see if it has been resolved. If the problem has not been resolved, it will go to the quarterly meeting. V1 stated the facility will identify a problem and they will work on it, but there is no formal plan or program they use to correct or identify problems. V1 stated, (V12 Medical Director) is a part of the QAA committee. (V12) has not participated in the meetings in person or via phone for the last 2 meetings. (V12) gets the information that we talked about in the quarterly meeting when he comes in and makes his rounds. (V12) does bring problems to us, but we do not QAPI them we just fix them. At this time, the QAA meeting minutes were requested for review, V1 refused to provide the documents. A year's worth of QAA meeting signatures were requested at this time also. On 09/28/23 at 11:25 AM, V1 stated the facility did not hold a July 2023 QA meeting. The QAA meeting signature page, dated 1/10/23 and 9/7/23, fails to document, V12's signature of attendance. The QAA meeting signature page, dated 4/6/23, documents V12 attended over the phone. The Quality Assurance Plan, undated, documents, (Facility) works to continuously improve the way residents are cared for, safety and operations within the facility through the Quality assurance process. Quality Assurance activities are to be completed continuously and objectively to provide a comprehensive review of the facility's activities. Quality Assurance Committee will conduct Quarterly meetings (at a minimum). This policy fails to document how the facility will identify and analyze problems, how the problems will be monitored for improvement or worsening, how to identify a systemic problem. The Resident Census and Conditions of Residents, CMS 672, dated 9/18/23, documents that the facility has 35 residents living in the facility. 146040 Page 18 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

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 have the Medical Director attend meetings and have input into the Quality Assurance (QA) meetings and to hold quarterly meetings. This failure has the potential to affect all 35 residents living in the facility. Residents Affected - Many Findings include: On 09/28/23 at 10:06 AM, V1 stated, (V12 Medical Director) is a part of the QA committee. (V12) has not participated in the meetings in person or via phone for the last 2 meetings. (V12) gets the information that we talked about in the quarterly meeting when he comes in and makes his rounds. (V12) does bring problems to us but we do not QAPI (Quality Assurance and Performance Improvement) them we just fix them. On 09/28/23 at 11:25 AM, V1 stated the facility did not hold a July 2023 QA meeting. The QA meeting signature page, dated 1/10/23 and 9/7/23, fails to document V12's signature of attendance. The QA meeting signature page, dated 4/6/23, documents V12 attended over the phone. The Quality Assurance Plan, undated, documents, Quality Assurance Committee will conduct Quarterly meetings (at a minimum). This policy fails to document that the Medical Director will attend and participate in the meetings. The Resident Census and Conditions of Residents, CMS 672, dated 9/18/23, documents the facility has 35 residents living in the facility. 146040 Page 19 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

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 maintain a program to ensure water safety. This failure has the potential to affect all 35 residents living in the facility. Residents Affected - Many Findings include: On 9/27/23 at 11:40 AM, V1, Administrator, stated the facilities maintenance worker is on vacation this week. V1 was asked to review the water policy to see how maintenance manages the empty rooms and the water temperature logs. V1 stated she would look for that information. On 9/27/23 at 1:00 PM, V1 was questioned if she had any water information available for review. V1 stated, It is on its way. V1 was questioned as to why the information was not in the facility. V1 stated, My computer crashed, and it is slowly coming back up. On 9/27/23 at 3:30 PM, V1 stated, she has the water information. V1 presented the water temperature policy and 3 log sheets. It again was explained what documents were being requested, V1 stated, I will have to look. On 0/28/23 at 8:30 AM, V1 present a policy on how to handle the facilities water system. V1 was asked for the information to prove the measures in the policy were being addressed. V1 stated that she would look some more. The facility policy Water management policy and procedures, undated, documents, water systems, devices and are to be inspected, cleaned, and maintained to reduce any risks of possible waterborne pathogens. With the possibility of waterborne pathogens such as Legionella and other germs that may grow in drinking water distribution systems. It is especially important for health care facilities proper implementation of water management procedures to reduce risk of infection among vulnerable patient populations, staff, and visitors. Factors that may lead to waterborne risks are construction, water main breaks, change in municipal water quality, biofilm, scale and sediment, water stagnation, and water temperatures (Legionella grows best within temperature ranges of (77 degrees F-113 degrees (Fahrenheit). The policy documents the following items are specific to the facilities water system: Water heaters, faucets, shower heads/ spray-off nozzles and hoses, pipes, valves and fittings, eyewash stations, ice machines and medical equipment (Nebulizers, concentrators, BI/Cpaps (bilevel positive airway pressure/ continuous positive air pressure). The facility, undated, water temperature monitoring policy-resident areas documents, ensure warm water temperatures are within the range of 100-110-degree F for resident areas and warm water is delivered to each faucet in timely manner. Water temps (temperatures) are to be taken at least once a week to ensure temperatures are within proper parameters. Any adjustments necessary will be immediately made to ensure comfortable and safe water temps. The facility Water Temp log, dated April 2023, fails to document, any water temperatures for A hall. One temperature recorded for B and C hall on 4/16/2023. The facility Water Temp log, dated May 2023, documents on 5/18/2023 and 5/31/23 2 temperatures and on 5/24/2023 one temperature. The log documents on B hall 5/18/2023 2 temperatures, 5/24/2023 2 temperatures, and 5/31/2023 2 temperatures. C hall 5/18/2023 2 temperatures, 5/24/2023 two temperatures and 5/31/2023 2 temperatures. 146040 Page 20 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0880 Level of Harm - Minimal harm or potential for actual harm The facility water temp log, date June 2023, documents, on A hall 2 temps for 6/7/2023, 2 temps for 6/13/2023 two temps for 6/15/2023, and 2 temps for 6/22/2023. B hall 6/7/2023 2 room temps, 6/13 two room temp, 6/15 2 room temps and 6/22 2 room temps. C hall 6/7 2 room temps, 6/13 2 room temps, 6/22 2 room temps, and 6/29/2023 two room temps. The facility was not able to provide water temperatures for the facility form July 2023- September 2023. Residents Affected - Many The Resident Census and Conditions of Residents, CMS 672, dated 9/18/23, documents that the facility has 35 residents living in the facility. 146040 Page 21 of 22 146040 09/28/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0947 Level of Harm - Minimal harm or potential for actual harm Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to provide Alzheimer's Dementia training for nursing staff. Residents Affected - Many Findings include: On 9/26/23 at 10:00 AM, V2, Director of Nurses, (DON), stated, When Covid hit there was CMS, (Central Management System), training that everyone had to take and it covered a little bit of dementia and that is the only training they got. 1. V9, Certified Nurse Aide, (CNA), In-Service Record documents, V9's hire date was 10/28/19. The record fails to document, any Dementia training. 2. V3, CNA, In-Service Record documents, V3's hire date was 08/15/09. The record fails to document, any Dementia training. 3. V14, CNA, In-Service Record documents, V14's hire date was 11/16/21. The record fails to document, any Dementia training. 4. V7, CNA, In-Service Record documents, V7's hire date was 7/22/22. The record fails to document, any Dementia training. 5. V16, CNA, In-Service Record documents, V16's hire date was 8/8/22. The record fails to document, Dementia training. On 9/28/23 at 9:15 AM, V2, Director of Nurses, stated she did not know that Alzheimer's Dementia training needed to be included in the yearly in-services. The (Facility's) Annually Mandated In-services, dated 7/22/13, documents, Alzheimer's. 146040 Page 22 of 22