Health inspection·July 2, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately document (breathing machine) refusals for one resident (R1) out of three residents reviewed for oxygen therapy in the sample of four. Findings include: The Resident Care Policy and Procedure dated 5/2022, documents It is the policy of this facility to maintain current physician orders to provide treatment according to the attending physician for each resident of the facility. a) All medications and treatments shall be given only upon the written order of the physician. All such orders shall be written in the medical record and shall be given as prescribed by the physician at the designated times. g) If for any reason, a physician's medication or treatment order cannot be followed, the physician shall be notified as soon as is reasonable, depending upon the situation, a notation of this will be made into the medical record. The Job Description for Licensed Practical Nurses dated 11/10/17, documents Essential Job Function: Responsible for nursing care of assigned residence in accordance with new nursing facility and nursing service policies and procedures. Chart medications and treatments according to procedure. R1's current Medical Record, documents R1 was admitted to the facility on [DATE] with diagnoses which included Primary Central Sleep Apnea and Chronic Obstructive Pulmonary Disease. R1's Physicians Order dated 2/10/23, at 11:08 AM, documents (Breathing machine) per home settings on at all times when sleeping or napping. R1's Care Plan dated 1/24/23, documents that R1 has chronic obstructive pulmonary disease and OSA (Obstructive Sleep Apnea). The intervention is that R1 will use a (breathing machine) as ordered when napping and in bed at night. On 6/30/23 at 9:55 AM, V2 (Director of Nursing) stated that V12 (R1's Family Member #1) complained that the (breathing machine) was not being used as ordered for R1, however the nursing documentation showed that the (breathing machine) was being used as ordered. V12 brought in a Sleep Therapy Report that showed the use of the (breathing machine). There were days that the report showed the (breathing machine) was not used and it did not match the facility Treatment Administration Records (TAR) documentation. There were also a couple of nursing notes written by V8 (Licensed Practical Nurse) that documented the (breathing machine) was used on her shift that did not match the Sleep Therapy Report. V8 was asked about the documentation and stated that she would check off the breathing machine task before she applied the machine to R1. When V8 went to R1's room to apply the (breathing machine) (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146042 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE H & J Vonderlieth Lvg Ctr, The 1120 North Topper Drive Mount Pulaski, IL 62548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)