Health inspection·August 29, 2024

F 0574 The resident has the right to receive notices in a format and a language he or she understands. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to post ombudsman contact information. This has the potential to affect all 41 residents at the facility. Residents Affected - Many Findings include: On 8/27/2024 at 1:00PM, R2, R7, R20, and R15 all stated they were not aware of ombudsman contact information being posted. On 08/27/24 01:16 PM surveyor was unable to locate ombudsman contact information within the facility. On 8/28/2024 at 12:16PM V1, Administrator, stated the facility does not have a policy regarding posting of ombudsman information. V1 stated she would expect the information to be posted. V1 stated the facility does not have a specific policy, but the facility does follow Illinois Department of Public Health (IDPH) guidelines. The facility's Long-Term Care Application for Medicare and Medicaid, CMS 671 dated 8/26/2024 documents a census of 41 residents. Page 1 of 20 146040 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation, interview and record review the facility failed to post survey results. This failure has the potential to affect all 41 residents residing at the facility. Residents Affected - Many Finding include: 1. On 8/27/2024 at 1:00PM during resident council R2, R7, R20 and R15 all stated unaware of survey results being available. Throughout the survey, the survey results of the last standard survey were not available. On 08/27/24 at 1:16 PM V1, Administrator stated the results of the state inspection are not available to read. V1 stated I have them. On 8/29/2024 at 8:10AM, V1, Administrator stated the facility does not have a policy in regard to posting survey results. V1 stated she would expect the information to be posted. V1 stated the facility follows Illinois Department of Public Health (IDPH) guidelines. The Illinois Long-Term care ombudsman program residents rights for people in long term care facilities dated revised 11/18 documents your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life, rights to dignity and respect. The facility's Long-Term Care Application for Medicare and Medicaid, CMS 671 dated 8/26/2024 documents a census of 41 residents. 146040 Page 2 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

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 interviews, observations, and record reviews the facility failed to report an alleged allegation of abuse to Illinois Department of Public Health for 1 of 1 resident (R35) reviewed for reporting of alleged abuse in a sample of 34. Findings include: R35 was admitted to the facility on [DATE] with diagnosis of, in part, hypertension, arthritis, osteoarthritis, spinal stenosis, chronic heart failure. R35's Minimum Data Set (MDS) dated [DATE] documents R35 is cognitively intact. On 08/26/24 at 9:40 AM, R35 stated V15, prior director of nursing (DON), kicked the back of her legs causing her to fall and become a full body mechanical lift and V15 has threatened to do it again to her. R35 stated she does not remember how long ago this took place, but she reported it to her doctor and other staff members at the facility. R35 stated V15 does not provide care to her any longer but still works at the facility as needed (PRN). Record review of R35's chart shows no reported incident took place. On 08/27/24 at 8:33 AM, after review of the facility's reported abuse investigations, no report was found for the incident R35 reported. On 8/27/24 at 8:35 AM, V1, Administrator, was notified of R35's allegations of abuse. V1 stated this is the first time she is hearing this report. On 8/28/24 at 9:40 AM, V1 stated she did not report the incident to Illinois Department of Public Health (IDPH). V1 stated she spoke with R35 and V15 about the incident but did not do any further investigation. V1 stated after speaking with R35 and V15, she did not need to report anything. V1 stated nothing new has been done on the situation. The facility's Resident Rights Policy dated 11/28/16 documents, If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse shall be made to at least one law enforcement agency of jurisdiction and Illinois Department of Public Health (IDPH) immediately after forming the suspicion (but no later than two hours after forming the suspicion), otherwise, the report must be made not later than 24 hours after forming the suspicion. 146040 Page 3 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

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 interviews, observations, and record reviews the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 resident (R35) reviewed for abuse investigations in a sample of 34. Residents Affected - Few Findings include: R35 was admitted to the facility on [DATE] with diagnosis of, in part, hypertension, arthritis, osteoarthritis, spinal stenosis, chronic heart failure. R35's Minimum Data Set (MDS) dated [DATE] documents R35 is cognitively intact. On 08/26/24 at 9:40 AM, R35 stated V15, prior director of nursing (DON), kicked the back of her legs causing her to fall and become a full body mechanical lift and V15 has threatened to do it again to her. R35 stated she does not remember how long ago this took place, but she reported it to her doctor and other staff members at the facility. R35 stated V15 does not provide care to her any longer but still works at the facility as needed (PRN). Record review of R35's chart shows no reported incident took place. On 08/27/24 at 8:33 AM, after review of the facility's reported abuse investigations, no report was found for the incident R35 reported. On 8/27/24 at 8:35 AM, V1, Administrator, was notified of R35's allegations of abuse. V1 stated this is the first time she is hearing this report. On 8/28/24 at 9:40 AM, V1 stated she did not have any documentation of initiating an investigation on the incident involving V15 and R35. V1 stated she spoke with R35 and V15 about the incident but did not do any further investigation or write anything down. The facility's Resident Rights Policy dated 11/28/16 documents, The person in charge of the investigation will obtain a copy of any documentation relative to the incident and follow the Resident Protection Investigation Procedures. The policy further documents, Regardless of the specific nature of the allegation (physical, sexual, verbal/exploitation/mental, theft or neglect), the investigation shall consist of: A review of the initial written reports; completion of a written report on the status of the investigation of the occurrence. The policy continues to document, The Interview Process. Determine whether the interviewer will be asking the person being interviewed to write the details of the incident in their own handwriting, or whether the interviewer or witness will take notes, type up the interview, and have the witness sign the typed interview. 146040 Page 4 of 20 146040 08/29/2024 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** 4. On 08/27/24 at 08:50 AM during incontinent care V8, CNA with gloved hands undid R14's adult brief. R14's adult brief was wet with dark tan urine stain surrounding wet area on brief. V8 turned R14 on right side, sprayed peri wash on rag and wiped rectal area front to back. V8 did not dry R14's rectal area or cleanse buttocks. V8 then placed R14 on his back. V8 did not retract foreskin and cleanse penis. V8 did not dry peri area after cleansing R14. R14's Minimum Data Set (MDS) dated [DATE], documents R14 is dependent on staff for toileting. R14's care plan dated 8/14/2024 documents R14 has bladder incontinence related to confusion, dementia, impaired mobility with the following interventions dated 8/14/2024, clean peri area with each incontinent episode, check every 2 hours and as required for incontinence, wash, rinse, and dry perineum. Based on interview, observation, and record review, the facility failed to provide incontinent care to prevent Urinary Tract Infections for 5 of 6 residents (R4, R5, R14, R26, R30) reviewed for incontinent care in the sample of 34. Findings include: 1. On 8/27/24 from 8:50 AM until 12:12 PM, staff did not assist R30 with toileting based on 15 minute or less checks. On 8/27/24 at 12:12 PM, R30 propelled herself into the community bathroom. R30 waited in the bathroom with the door open. At 12:16 PM, V14, Certified Nurse Aide (CNA), entered the bathroom and questioned R30 what she was doing. R30 stated, I gotta go. V14 stated that she would get some help and left the room. V14 came back and began to put the partial mechanical lift sling on R30. V14 began to prepare the partial mechanical lift to use on R30. V9, CNA, entered the bathroom and stated, We have to take her to room A-7. R30 and the partial mechanical lift were taken down to A-7. R30 was transferred to the toilet and her incontinent brief was removed. V14 stated that the brief was wet. R30 stated, I hate to pee because it hurts. V9 stated that she would tell her nurse. When R30 finished, she was lifted with the partial mechanical lift. V14 wiped R30 twice with toilet tissue, placed a new incontinent brief on R30, and adjusted R30's clothes. R30 was transferred back to the wheelchair. R30's Face Sheet, undated, documents, that R30 was admitted on [DATE] and has a diagnosis of Dementia. R30's Minimum Data Set (MDS), dated [DATE], documents that R30 is severely cognitively impaired, frequently incontinent of bladder, occasionally incontinent of bowel, and requires substantial / maximum assistance from staff for toileting. R30's Care Plan, dated 5/1/24, documents, The resident has bladder incontinence r/t (related to) Confusion, Dementia, resident is assist with transfers, and assist with peri care. Interventions: Brief Use: The resident uses disposable briefs. Change every 2 hours and prn (as needed). Clean peri - are with each incontinence episode. Incontinent: Check 2 hours and as required for incontinence, Wash, rinse and dry perineum. 146040 Page 5 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0690 Level of Harm - Minimal harm or potential for actual harm R30's Physician Orders, dated 8/22/24, documents, N/O (new order) Gentamicin 80 mg (milligram) /2ml (milliliters) IM (intramuscular) BID (twice a day) for 5 days. for UTI (Urinary Tract Infection). R30's Physician Orders, dated 8/22/24, documents, Contact Isolation for ESBL (Extended Spectrum Beta Lactamase). Residents Affected - Some R30's Urine Culture Report, collection date of 8/20/24, documents, >100,000 cfu (colony forming unit)/ml Proteus mirabilis Extended Spectrum Beta Lactamase. Results called to V3, Licensed Practical Nurse (LPN) at 8/22/24 at 7:08 AM. 2. On 8/26/24 at 9:57 AM R26 was sitting in wheelchair in room. V5 CNA and V9 CNA both transferred her from the wheelchair to the toilet. V5 pulled down pants and removed incontinent brief. The brief was soiled with bowel movement smears and urine. R26 stood up, V5 cleansed from front to back. V5 did not cleanse the pubic area or the buttocks. V5 failed to dry the area. A new brief was placed, pants pulled up, and transferred back to wheelchair. R26 was transferred to bed, covered up, and positioned for comfort. On 8/26/24 at 10:05 AM, V5 stated that R26 does have a UTI (Urinary Tract Infection) and was recently in the ER (Emergency Room). R26's Face Sheet, undated, documents that R26 was admitted on [DATE] and has Dementia and need for assistance with care. R26's (Local Hospital) Emergency Documentation, dated 8/24/24, documents, Diagnosis from Today's Visit: COPD (Chronic Obstructive Pulmonary Disease) exacerbation and UTI. Instructions from Your Care Team: Start Z-Pack (antibiotic) tomorrow, August 25, 2024. R26's MDS, dated [DATE], documents that R26 is severely cognitively impaired, frequently incontinent of urine, occasionally incontinent of bowel, and requires substantial/maximum assistance from staff for toileting. R26's Care Plan, dated 6/12/24, documents, The resident has bladder incontinence r/t (related to) Confusion, Dementia, Poor toileting habits, decrease in cognition. Interventions: The resident uses disposable briefs. Change every 2 hours and prn (as needed). Check every 2 hours and as required for incontinence. Wash, rinse and dry perineum. 3. R4's Face Sheet, undated, documents R4 was admitted on [DATE] and has diagnoses of Chromosomal abnormality and Gastrostomy. R4's MDS, dated [DATE], documents that R4 is severely cognitively impaired, always incontinent of bowel and bladder, and is totally dependent on staff for toileting. On 8/27/24 at 10:06 AM, V10, CNA and V8 CNA entered R4's room to provide incontinent care. V8 stated that yesterday R4 was spotting from menstruation. R4's incontinent brief was removed. The brief was wet with urine and blood. R4 was rolled onto the right side, V8 with a washcloth moistened with water only, wiped the rectal area with the washcloth four times. V8 then placed a protective cream on R4's left buttock. R4 was then rolled to the left side, V10 wiped the right buttock with a moistened with water wash cloth. V10 put barrier cream on the right buttock. R4 was placed on her back. With a moistened washcloth, flipping to clean areas, the labia and meatus were wiped, the washcloth had 146040 Page 6 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0690 Level of Harm - Minimal harm or potential for actual harm visible blood on it and V8 wiped up the left groin. A new incontinent brief was placed and R4 was positioned for comfort. On 8/27/24 at 1:25 PM, V1, Administrator, V1 stated that soap should have been used to provide incontinent care. Residents Affected - Some 5. R5's Face Sheet, undated, documents R5 was admitted on [DATE] with diagnosis of Chronic Systolic (Congestive) Heart Failure, Hypertension, Rheumatoid Arthritis, and Anemia. R5's Care Plan, dated 7/18/24, documents R5 has bladder incontinence. Interventions: R5 uses disposable briefs, change every two hours, and as needed (PRN), clean peri-area with each incontinence episode, check every two hours and as required for incontinence, wash, rinse, and dry perineum, change clothing PRN after incontinence episodes, monitor/document for signs/symptoms of Urinary Tract Infection (UTI), monitor/document/report PRN and possible causes of incontinence: bladder infection. R5's MDS, dated [DATE], documents R5 is cognitively intact and requires partial/moderate assistance from staff for toileting, bathing, and transfers. R5 is frequently incontinent of urine and always continent of bowel. R5's Urine Culture, dated 7/1/24, documents R5 has a UTI with ESBL (Extended Spectrum Beta-Lactamase) in her urine. R5's Physician Order (PO), dated 7/2/24, documents Levofloxacin 250 MG (milligram) Q (every) Day X 5 days. R5's PO, dated 7/4/24, documents Ertapenem 1 MG IM (Intramuscular) X 3 days. R5's Urine Culture, dated 7/12/24, documents R5 has a UTI with VRE (Vancomycin-Resistant Enterococcus) in her urine. R5's PO, dated 7/14/24, documents Keflex 500 MG BID (twice a day) X 5 days. R5's PO, dated 8/7/24, documents Ciprofloxacin 250 MG BID for 10 days: UTI. On 8/26/24 at 10:00 AM, R5 stated I have a UTI and I am on antibiotics for it. When I have to urinate, it comes so quickly that there is no time for staff to help me before I go. On 8/28/24 at 10:00 AM, V11, MDS Nurse, stated I would expect staff to perform complete and timely incontinent care, including hand hygiene and glove changes when appropriate, and using appropriate supplies needed. On 8/28/24 at 10:05 AM, V16, CNA, stated When doing peri-care, I would change my gloves when they are dirty and in between care. If doing peri-care on a female, I would always wipe from front to back. On 8/27/24 at 8:15 AM, V10, CNA, was seen walking into R5's room to assist her to the restroom. V10 did not put any personal protective equipment on upon entering the room to assist, put a gait belt around R5 in her wheelchair, then donned gloves and pushed R5 into the restroom. V10 placed R5's walker in front of her and assisted R5 to stand and grab onto her walker. R5 walked to the toilet and 146040 Page 7 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some V10 assisted via gait belt to sit on the toilet. V10 pulled R5's pants and incontinent brief down to her ankles. R5's incontinent brief was wet and V10 stated that R5 just went in her brief. At 8:22 AM, R5 stated she was done. V10 donned gloves and took off R5's pants and wet brief, doffed gloves, and washed hands, R5 stated she still must go some more so allowed to sit longer. At 8:30 AM, R5 stated she was ready. V10 donned gloves, put a clean incontinence brief on R5 up to her knees, put R5's pants on up to her knees, then assisted R5 to stand while holding onto the gait belt and R5 holding onto her walker. V10 then used toilet paper to wipe R5's anal area due to BM, then used same gloves to wipe the front side of R5, reaching between her legs and wiping from back to front. V10 then pulled R5's brief and pants all the way up. R5 stated she felt weak and needed to sit down, V10 held onto gait belt and assisted R5 back to the toilet. V10 doffed his soiled gloves, then assisted R5 to stand again and pivot to her w/c to sit down. V10 used hand gel and exited the room. When asked why R5 was on isolation, V10 stated, I was told she has an infection in her urine. 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. Equipment: 1. Washcloth and towel, 2. Soap, other cleansing agent. 3. Gloves. 4. Wash basin. 5. Plastic bag. Procedure: Female - 4. Wet washcloth with cleansing agent chosen. 5. Wash pubic area including upper inner aspect of both thighs and frontal portion of perineum. a) Use long strokes from the most anterior down to the base of the labia. b) After each stroke refold the cloth to allow use of another area. 6. Follow same sequence for rinsing area. 8. Dry Thoroughly. 10. Rinse cloth and apply cleansing agent. 11. Wash peri-anal area thoroughly with each stroke beginning at the base of the labia and extending up over the buttocks. 13. Rinse cloth and entire area. 14. Dry area thoroughly. 15. Remove gloves and wash hands with soap and water. 16. Apply new incontinent product, clothes or reposition comfortably. 17. Wash hands with soap and water, cleansing gel or Theraworx. Male 4. Wet washcloth with 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. 6. Rinse area in same sequence. 8. Dry carefully, remembering to draw foreskin of uncircumcised male back over the head of the penis. 10. Rinse cloth and proceed with the cleansing of the anal area. 12. Rinse cloth and entire area. 14. Dry area thoroughly. 15. Remove gloves and wash hands with soap and water, cleansing gel, or Theraworx. 16. Apply clean incontinent product, clothes, or position resident comfortably. 17. Wash hands with soap and water, cleansing gel, or Theraworx. 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 8 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow plan of care and provide supplements as ordered to maintain acceptable parameters of nutrition for 1 of 4 residents (R1) reviewed for nutrition in the sample of 34. Residents Affected - Few Findings include: 1. Registered Dietitian's (RD) quarterly review, dated 6/24/2024, documents Height (HT) 67 inches, weight (wt) 146 # (pounds). Currently showing a gradual weight loss x 6 months; 12/23 154, 3/24 152, 5/24 147. The Review documents R1 remains on regular diet with cut up meat, super cereal at breakfast. intakes at meals around 75% with occasional 100's noted and fluids 240-480cc/meal. Notes documents suggest to please consider adding ice cream to lunch/supper meals for added calories with varied intakes and weight loss reported. Monitor and refer to RD as needed. R1's monthly weight for July 2024 documents weight of 141.8 # August monthly weight documents a weight of 137.2. R1's Physician Order (PO) dated 7/26/2024 documents add ice cream to lunch and supper. R1's Care Plan dated 6/19/2024 documents at risk for weight loss related to poor oral food intake, resident has poor intake, feeds self. R1's care plan documents interventions dated 6/19; alert dietitian if consumption is poor more than 48 hours, if weight decline contact physician and dietitian as soon as practical, monitor and evaluate any weight loss, offer substitutes as requested or indicated, weigh monthly to monitor weight. On 8/27/2024 at11:46AM during the noon meal R1 was served chocolate milk, orange drink, roast turkey with gravy, diced potatoes, peas and roll, and pears. R1 did not receive ice cream per physician's order. At no time did staff intervene or prompt R1 to eat. R1 pushed plate away from and was playing with toilet paper off roll sitting on the table. At 12:30 PM, tray remained untouched. Staff did not provide attempt to offer R1 a substitute at this meal. On 8/29/2024 at 8:50 AM V1, Administrator stated R1 baffles the facility as R1 has not lost weight. On 8/29/2024 at 10:15AM V3, Licensed Practical Nurse (LPN) stated she always offers substitutes but R1 will not eat them. On 8/29/24, at 11:30 AM, V4, Certified Nursing Assistant (CNA) stated that she offers R1 sandwiches and R1 will not eat them. The facility policy meal alternatives dated revised 4/17 documents is the policy of the facility to provide appropriate alternatives to those residents who dislike or do not eat the main entree and vegetable to help ensure adequate nutritional intake. The policy documents if a resident refuses the original entree and/or the alternate, the nurse shall be informed. Refusal to eat or poor intake should be documented in the resident's medical record. The facility policy nutritional supplements and nourishments dated revise d10/13 documents it is the policy of the facility to provide additional calories and/or protein to residents who cannot 146040 Page 9 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0692 and/or are not capable of consuming adequate nutrients through their regular meals. The policy documents nutritional supplements are a supplement to the diet and are not meant to replace regular scheduled meals. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146040 Page 10 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to check the residual from a Gastrostomy tube (G-tube) before administering a water flush and medications and turn off the feeding pump while R4 was lying flat for 1 of 1 resident (R4) reviewed for tube feeding in the sample of 34. Findings include: On 08/26/24 at 12:01 PM, V3, Licensed Practical Nurse (LPN), entered the room to give medications and a water flush through R4's G-tube. V3 did not check for residual before giving R4 65 milliliters of water. V3 then gave the medication and another flush of 65 milliliters of water. On 8/27/24 at 10:15 AM, V10 Certified Nurse's aide (CNA) lowered the head of the bed to flat to prepare for incontinent care. R4's tube feeding pump was running. V10 and V8, CNA, performed the incontinent care with the feeding pump running. On 8/27/24 at 10:19 AM, V10 was questioned why he lowered the head of bed with the feeding pump running, V10 stated that he was unaware that the feeding pump should be off if the resident is flat. On 8/27/24 at 10:20 AM, V8 was questioned if she knew the head of the bed should not be flat with the feeding pump running, V8 stated, I did go to my nurse, V3, she told me I was not allowed to touch it and the pump does not need to be stopped. On 8/28/24 at 12:38 PM, V3, stated, V15, past Director of Nurses, told us that we did not need to check for residual. V3 further stated that should she had been told they were going to lay (R4) flat because the feeding pump needed to be turned off. On 8/28/24 at 3:00 PM, V11, Licensed Practical Nurse/ Minimum Data Set Nurse stated that she did not think tube feeding needed to be stop if a resident is lying flat and that V3 knows that residual needs to be checked before giving water or medications. R4's Face Sheet, undated, documents that R4 was admitted on [DATE] and has diagnoses of Chromosomal abnormality and Gastrostomy. R4's Minimum Data Set, dated [DATE], documents that R4 is severely cognitively impaired and has a feeding tube. The policy Enteral Feedings, dated 2/08, documents, 10. Placement of tube will be confirmed via aspiration of residual. If unable to confirm placement via aspiration, air instillation method may be used. 11. Placement will be confirmed: Prior to instillation of flush / medication administration. It continues, 16. Resident will be maintained with head of bed at minimum 30 - 40 degrees during and for at least 30 minutes after each feeding. 146040 Page 11 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0727 Level of Harm - Minimal harm or potential for actual harm 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 interview and record review, the facility failed to employ a Registered Nurse as Director of Nursing (DON). This failure has the potential to affect all 41 residents residing in the facility. Residents Affected - Many The findings include: On 8/26/24 at 8:37 AM, when asked who the DON was, V1, Administrator, stated, We currently do not have a DON. On 8/27/24 at 3:00 PM, V1 stated, We have been without a DON for a little over a month. We are running an ad and refreshing the ad weekly. I have interviewed one person so far. On 8/28/24 at 8:13 AM, V2, Registered Nurse (RN), stated, We have not had a DON for a couple of months. If I had any nursing issues, I would go to the Minimum Data Set (MDS) Nurse (V11). I know she is doing the nursing schedule and some of the other duties of the DON. On 8/28/24 at 8:15 AM, V1 stated, Our DON's last day was 6/28/24. Between myself and (V11, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Nurse), we are covering the duties of the DON. I do things that don't require a nursing license and she does the rest. On 8/28/24 at 9:40 AM, V11 stated, I am doing most of the duties of the DON. I investigate all the incidents that happen, do the scheduling for both the CNAs and the Nurses, and keep up with the infection book. (V1) does a lot of the other duties. On 8/28/24 at 1:50 PM, V1 stated, I am a salaried employee and incorporate all of my duties into my 40 hours per week. I do not have specific hours set aside for the DON duties. A review of the facility schedule, dated August 2024, does not list any hours for a DON. On 8/28/24 at 9:15 AM, V1 stated, The facility does not have a staffing policy. We follow the Illinois Department of Public Health (IDPH) guidelines. The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 8/26/2024, documents the total number of residents in the facility was 41. 146040 Page 12 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview the facility failed to provide assistive device or adaptive eating equipment resulting in R22's inability to use eating utensils effectively and eating with hands for 1 of 16 residents (R22) reviewed for assistive devices/eating equipment/utensils in the sample of 34. Residents Affected - Few Findings include: 1. On 8/26/2024 at 11:40AM R22 was eating pork fritter, scalloped potatoes, green beans, and pears. R22 was using a regular spoon and used his left had to scoop food on to his spoon, then with his left-hand placed on spoon and places in his mouth. On 8/27/2024 at 11:44AM R22's plate contained diced potatoes, peas, roll, and turkey with gravy. R22 used left hand to push food on spoon and placed food in mouth. On 8/27/2024 at 12:01PM R22 observed picking peas up off the table that had dropped from spoon in his mouth and observed picking peas up off his bib and placing in his mouth. R22's Care Plan, dated 5/6/2024 documents self-care deficit-needs supervision and or assist to complete quality care and/ or poorly motivated to complete activities of daily living (ADL), feeds self after set up. R22's Care Plan documents the following interventions: 5/6/2024 serve diet as ordered /desired. set up tray as needed and unwrap silverware, assist with hands on feeding if resident is unwilling or unable to complete the task. R22's Minimum Data Set (MDS) dated [DATE] documents R22 is cognitively intact. R22's MDS documents functional abilities for eating, supervision and touching assistance. On 8/29/2024 V22, Therapy director, stated she was not aware of R22 using his hands to assist with eating. V22 stated she would screen R22. 146040 Page 13 of 20 146040 08/29/2024 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 serve food in a sanitary manner, label, and date open food, ensure equipment is clean, and perform hand hygiene before donning gloves to prevent food borne illness. This has the potential to affect all 41 residents living in the facility. Finding include: 1. On 8/26/24 at 8:45 AM, the kitchen was entered. The stand-up freezer had a box of pre-made omelets. The bag was not sealed, and the omelets had freezer burn. The walk-in refrigerator has a storage container of red liquid that was not labeled or dated, 2 opened paper cartons of tomato juice that was dated 7/18, an opened package of hot dogs dated 8/22/24 no expiration date, a plastic container of what appeared to be mandarin oranges that is not labeled or dated with the lid covered in a thick liquid substance, a stainless steel container of tomatoes that was covered in foil that was not labeled or dated, 4 storage bags that had meat that were not dated or labeled. On 8/26/24 at 9:00 AM, V19, Dietary Manager, stated that everything should be labeled and dated with an open date and an expiration date. 2. On 8/26/24 at 11:25 AM, V21, Cook, donned gloves without hand hygiene first and began to serve the noon meal from the steam table. 3. On 8/28/24 at 11:15 AM, the cooling unit fan cover in the walk-in refrigerator has thick black layer of debris. The cooling fan is on the top of back wall, so it blows out onto the food. On 8/28/24 at 11:40 AM, the wall mounted kitchen air conditioner has thick black layer of debris. The air conditioner blows over the griddle and the stove top. On 8/28/24 at 1:59 PM, V19 stated that food should be dated for 6 or 7 days after the repackaging or making of. V19 further stated that he knows that the in the walk-in refrigerator cooling unit grate needs to be cleaned but he has not figured out how to do it since it always runs. The policy, dated 10/14, documents, 2. [NAME] container with name of item. [NAME] the date that the original container is opened or date of preparation. 3. 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). The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 8/26/24, documents that the facility has 41 residents residing in the facility. 146040 Page 14 of 20 146040 08/29/2024 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 4. On 8/27/2024 at 8:50AM during incontinent care V8, CNA gloved when providing incontinent care to R14. After providing incontinent care to V8 and while wearing the same gloves, V8 put on protective cream on R14's buttocks and place a new incontinent brief on R14 without changing gloves. V8 then put on R14's TED (Thrombo-Embolic Deterrent ) hose, put clothes on and placed a mechanical lift sling under R14 while wearing these same gloves. Based on interview, observation, and record review, the facility failed to perform hand hygiene, wear personal protective gowns, disinfect multi-use equipment, and post isolation signs for 6 of 16 residents (R4, R5, R14, R26, R30, R38) reviewed for infection control in the sample of 34. Residents Affected - Some Findings include: 1. On 8/26/24 at 11:54 AM, V3, Licensed Practical Nurse while preparing R4's medications donned and doffed gloves 6 times without hand hygiene before or after. On 08/26/24 at 12:01 PM, R4's room had no signage indicating that Enhanced Barrier Precautions need to be used. V3, Licensed Practical Nurse (LPN), entered the room to give medications through R4's G-tube. V3 failed to wear a gown. On 8/27/24 at 10:06 AM, V10, Certified Nurse's Aide (CNA) and V8 CNA entered R4's room to provide incontinent care. R4's room had no signage indicating that Enhanced Barrier Precautions need to be used. Both donned gloves without hand hygiene. During the incontinent care, V8 was the cleaner, V8 applied barrier cream with the gloves, and never changed her gloves. V10 changed his gloves once during the care but failed to perform hand hygiene in between. At the end of care, a new incontinent brief was placed, and R4 was positioned for comfort. V8 never changed gloves during the care. Neither V8 nor V10 wore a gown for enhanced barrier precautions. On 8/27/24 at 1:25 PM, V1, Administrator/ Infection Preventionist, stated that she is unsure why R4 is not on Enhanced Barrier Precautions and that hand hygiene should be performed before and after gloves. On 8/28/24 at 12:38 PM, V3 stated she did not know anything about Enhanced Barrier Precautions being needed for R4 because she had a feeding tube. On 8/28/24 at 12:48 PM, V11, LPN/MDS (Licensed Practical Nurse/ Minimum Data Set), stated that she is the one working on infection control. V11 was questioned about Enhanced Barrier Precautions, V11 stated, I don't know anything about that. The policy Enhanced Barrier Precautions, dated 7/13/23, documents, Enhanced Barrier Precautions (EBP) should be used when contact precautions do not apply, for residents with any of the following: Open wounds that require a dressing change, Indwelling Medical Devices, and Infection or colonized with a MDRO (multi - drug resistant organism). Enhanced Barrier Precautions require use of a gown and gloves during high contact resident care activities that provide opportunities for the transfer of MDRO'S (multi drug resistant organism) to staff hands and clothing. It continues, High Contact care activities include: Changing briefs or toileting, caring for medical devices (i.e. (for example) central lines, urinary catheters, feeding tubes, tracheostomies, drainage tubes, ports). 2. On 8/26/24 at 9:57 AM, V5, CNA, and V9, CNA, provided transfers and toileting for R26. V5 donned 146040 Page 15 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0880 Level of Harm - Minimal harm or potential for actual harm and changed gloves 3 times without hand hygiene. V9 donned and changed gloves 3 times without hand hygiene. 3. On 8/26/24 at 11:30 AM, R30 room had a contact / droplet isolation sign and an isolation cart outside of the door. V5, was question who is on isolation, V5 stated, (R30) for her urine. Residents Affected - Some On 8/27/24 at 12:12 PM, R30 propelled herself into the community bathroom. R30 waited in the bathroom with the door open. At 12:16 PM, V14, CNA, entered the bathroom and questioned R30 what she was doing. R30 stated, I gotta go. V14 stated that she would get some help and left the room. V14 came back and began to put the partial mechanical lift sling on R30. V14 began to prepare the partial mechanical lift to use on R30. V9, entered the bathroom and stated, We have to take her to room A-7. R30 and the partial mechanical lift were taken down to A-7. V14 stated that it was an empty room, and no one uses the bathroom in the room, so they are using it for R30. V9 and V14 were questioned how long R30 had been using this bathroom, V14 stated, Today. V14 stated she worked all weekend and R30 was using the community bathroom and R30 was not on isolation precautions. V9 and V14 both donned gowns and gloves. Neither preformed hand hygiene before putting the gloves on. R30 was transferred to toilet using a partial mechanical lift and her incontinent brief was removed. V14 stated that the brief was wet. When R30 finished, she was lifted with the partial mechanical lift. V14 wiped R30 twice with toilet tissue, placed a new incontinent brief on R30, and adjusted R30's clothes. R30 was transferred back to the wheelchair. V9 removed her gloves, performed hand hygiene, and went to get disinfecting wipes. V9 returned and gave a V14 a Sani-Cloth disinfecting wipe. With the same gloves that V14 used to perform incontinent care, V14 wiped down the partial mechanical lift. V14 touched the surfaces multiple times after cleaning. When V14 stated she was finished, she was questioned why she did not change her dirty gloves, V14 stated, I thought about it after I did it. V14 changed gloves and began to clean the partial mechanical lift again. R30's Physician Orders, dated 8/22/24, documents, Contact Isolation for ESBL (Extended Spectrum Beta Lactamase). R30's Urine Culture Report, collection date of 8/20/24, documents, >100,000 cfu (colony forming unit)/ml Proteus mirabilis Extended Spectrum Beta Lactamase. Results called to V3, Licensed Practical Nurse (LPN) at 8/22/24 at 7:08 AM. On 8/27/24 at 9:32 AM, V3, was questioned why she did not put R30 on isolation on 8/22/24, V3 stated, No, there is no reason. On 8/27/24 at 2:15 PM, V1, stated that R30 should have been put on isolation when she was diagnosed with ESBL. The policy Contact Precaution, dated 12/7/18, documents, Procedure: 2. Gloves: In addition to wearing gloves as outlined under Standard Precautions, wear gloves when entering a room. During the course of providing care for a resident, change gloves after having contact with infective material that may contain high concentrations of microorganisms. Remove gloves before leaving the residents environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. It continues, Resident care Equipment: If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another resident. This policy fails to address placing signage outside of the room. 6. On 8/27/24 at 8:15 AM, V10, CNA, was seen walking into R5's room to assist her to the restroom. 146040 Page 16 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some V10 did not put any Personal Protective Equipment (PPE) on upon entering the room to assist, which was outside the door. V10 put a gait belt around R5 while sitting in her wheelchair, then donned gloves and pushed R5 into the restroom. V10 placed R5's walker in front of her and assisted R5 to stand and grab onto her walker. R5 walked to the toilet and V10 assisted, via gait belt, to sit on the toilet. V10 pulled R5's pants and incontinent brief down to her ankles, showing a wet incontinent brief, with V10 stated that R5 just went in her brief. At 8:22 AM, R5 stated she was done, V10 donned gloves and took off R5's pants and wet brief, R5 stated she still has to go some more so allowed to sit longer. At 8:30 AM, R5 stated she was ready, V10 donned gloves, put a clean incontinence brief on R5 up to her knees, put R5's pants on up to her knees, then assisted R5 to stand while holding onto the gait belt and R5 holding onto her walker. V10 used toilet paper to wipe R5's anal area due to bowel movement, then used the same gloves to get toilet paper to wipe the front side of R5. V10 reached between the front of R5's legs and wiped R5's vagina from back to front once, then pulled R5's brief and pants all the way up using same soiled gloves. R5 stated she felt weak and needed to sit down, V10 held onto gait belt and assisted R5 back to the toilet with the same soiled gloves on. When asked why R5 was on isolation, V10 stated I was told she has an infection in her urine. When asked if he was supposed to wear the PPE while caring for R5, V10 stated, I don't know if I'm supposed to wear that stuff or not. On 8/27/24 at 9:15, V10 was seen taking the soiled and contaminated gait belt out of R5's room and handing it to V9, CNA. Unsure where V9 went to next, however, that CNA was seen with that belt in her pants pocket. On 8/28/24 at 9:45 AM, V2, Registered Nurse (RN), stated, The CNAs are supposed to be wearing full PPE when they are providing care to (R5), including incontinent care. On 8/28/24 at 10:00 AM, V11 stated, I would expect all staff to wear appropriate PPE when doing resident care to a resident who is on isolation. I would expect staff to perform complete and timely incontinent care, including hand hygiene and glove changes when appropriate, and using appropriate supplies needed. (R5) should have her own gait belt in her room and it should not be taken out of her room. On 8/28/24 at 10:05 AM, V16, CNA, stated, If a resident were on isolation, I would wear the PPE any time I do care for that resident. When doing peri-care, I would change my gloves when they are dirty and in between care. If doing peri-care on a female, I would always wipe from front to back. On 8/28/24 at 10:40 AM, V11 stated, The isolation signs placed on the resident doors says to contact the nurse for instructions. (R5) is on Contact/Droplet isolation because she has VRE in her urine, isn't VRE in the urine considered a droplet isolation also? I have worked several facilities and have never seen a sign that tells people what they should wear to enter the room. The Facility's Entering an Isolation Room Policy, dated 12/7/18, documents To ensure anyone entering a resident's room in isolation is dressed appropriately with required equipment as set forth per the Center for Disease Guidelines. The Facility's Contact Precautions Policy, dated 12/7/18, documents In addition to Standard Precautions, use Contact Precautions, or the equivalent for specific residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin to skin contact that occurs when performing resident care activities that require touching the residents dry skin) or indirect contact (touching with 146040 Page 17 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some environmental surfaces or resident care items in the residents environment). 2. (in part) After glove removal and handwashing, ensure that hands do not touch potential contaminated environmental surfaces or items in the resident's room to avoid transfer of microorganisms to other residents or environment. The Facility's Cleaning of Non-Critical Resident Care Items, dated 12/7/18, documents To ensure resident care items are cleaned appropriately to reduce the risk of transmission of microorganisms. 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: 1. After contact with body fluids, excretions, mucous membranes, non-intact skin, and wound dressings. 2. Before and after direct resident care. 4. When moving from contaminated body site to clean body site during resident care. 6. After removing gloves. The Facility's Removing Gloves Policy, dated 12/7/18, documents Disposable gloves (non-sterile) act as a barrier between the resident and you. To protect employee from pathogens in the resident's blood, body fluids, and body substances. Protection for the resident from microorganisms the employee may have on their hands. 5. On 08/27/24 at 09:36 AM, V8, CNA, assisted R38 to the community toilet with a gait belt wearing gloves. R38 stated she hasn't urinated since midnight but feels like she needs to go. V8 stated R38's incontinent brief was completely dry and threw the brief away. V8 helped R38 stand up with her walker and gait belt then wiped her peri-region using her right gloved hand with a wet towel. V8 then pulled R38's brief and pants up around her waist and removed her left glove. V8 continued to use her dirty right gloved hand to hold R38's gait belt as they walked to the door. V8 then used her dirty right gloved hand to open the door. V8 guided R38 to a chair in the hallway, used her dirty right gloved hand to adjust the chair and then touched R38's walker handle to hold it in place as R38 sat down. V8 then removed the gait belt from R38's waste with her dirty right gloved hand and walked to the restroom. V8 folded the gait belt and put it in her left leg pocket. 146040 Page 18 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to provide a qualified individual responsible for the Infection Prevention and Control Program. This failure has the potential to affect all 41 residents living in the facility. The findings include: On 8/28/24 at 8:15 AM, V1, Administrator, stated, Our DON's (Director of Nursing) last day was 6/28/24. Between myself and (V11, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Nurse), we are covering the duties of the DON, including infection control. I do things that don't require a nursing license and she does the rest. I am the certified Infection Preventionist, and I work with (V11) to get things done. On 8/28/24 at 9:40 AM, V11, MDS Nurse, stated ,I am doing most of the duties of the DON. I investigate all the incidents that happen, do the scheduling for both the CNAs and the Nurses, and keep up with the infection log. (V1) does a lot of the other duties. On 8/28/24 at 10:40 AM, V11 stated, I do not have an Infection Preventionist Certification, (V1) has one. The Pharmacy sends me a report of all residents on antibiotics every month. I also receive any resident new orders for antibiotics from the nurses and will go look through the resident's chart and review the C&S (culture and sensitivity) to determine if they were put on the correct antibiotic. If not, I will contact the Physician for a new order. (V1) is the one doing the infection control and antimicrobial log, I just give her the information and help her understand what the bug is and what drug is needed because she is not a nurse. The isolation signs placed on the resident doors says to contact the nurse for instructions. (R5) is on Contact/Droplet isolation because she has VRE (Vancomycin-Resistant Enterococci) in her urine. Isn't VRE in the urine considered a droplet isolation also? I have worked several facilities and have never seen a sign that instructs people what PPE (personal protective equipment) they should wear to enter the room. (R5) should have her own gait belt in her room and it should not be taken out of her room. (V1) just told me that I needed to get the Infection Preventionist Certificate also. On 8/28/24 at 11:55 AM, V1, Administrator, stated My only medical background was a BLS (Basic Life Support) course. I have been working with (V11) for the infection control log. When we had COVID, we all worked together as a team. When asked what Extended-Spectrum Beta-Lactamases (ESBL) and/or VRE was, V1 stated I know it is in the urine, it is contagious, and that person should be put on isolation. When asked about how she would handle a resident with ESBL/VRE, V1 stated That is why I work with (V11) so she can look at the labs and antibiotics and we discuss together. On 8/28/24 at 1:50 PM, V1 stated, I am a salaried employee and incorporate all of my duties into my 40 hours per week. I do a little bit of the Infection Control stuff at a time, so we don't have to wait until the end of the month to do everything. I do not have additional specific hours set aside for the DON duties nor the Infection Preventionist duties. The Facility's Infection Control Surveillance and Monitoring Policy, dated 4/11/22, documents It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. The facility shall employee, at a minimum, a part time Infection Preventionist. These duties maybe performed by the Director of Nursing 146040 Page 19 of 20 146040 08/29/2024 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0882 with an approved Infection Control Certification. Level of Harm - Minimal harm or potential for actual harm The Long-Term Care Facility Application for Medicare and Medicaid, dated 8/26/2024, documents the total number of residents in the facility was 41. Residents Affected - Many 146040 Page 20 of 20