Health inspection·September 22, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to honor a resident's rights in 1 of 7 residents (R5) reviewed for resident rights in the sample of 12. Findings include: On 9/20/23 at 10:15 AM, R5 was observed in bed and was tearful. R5 stated, she must wait 45-50 minutes for her call light to be answered. R5 stated, this happens on day shift all the time. R5 stated, she is continent of her bladder & bowels but because she must wait, she goes on herself. R5 stated, now she has resorted to screaming out for help, so that someone will help her. R5 stated, she uses the bed pan and needs help getting on it. R5 stated, she feels humiliated and angry when she goes on herself. R5 stated, she has asked to talk to V1, Administrator, about her concerns. R5 stated, V1 came to her room this morning and told her she needed to talk with her this morning, because she would be out of the building this afternoon, and then she stated she would be back to talk with her. R5 stated, V1 has not returned to her room. R5 stated, she is here due to Terminal Cancer, and she has been to the facility before and wanted to come back here, because it was home. R5 stated, the Doctors gave her 2 months to 1 year to live, and she wants to have a good quality of life. R5 stated, she talked to V3, Registered Nurse, (RN), Infection Control Preventionist, (ICP), and V6, Minimum Data Set, (MDS), Nurse and V6 told her she had a Care Plan meeting on 11/3/23 and she needed to notify the person in charge of what issues she is having. R5 stated, she talked with V7, Social Services Director, (SSD), that she was having issues getting staff to put her on the bed pan and a lack of communication with V1. R5 stated, this is her home, she was welcomed by the prior Administrator, Director of Nurse, (DON), and staff, but they don't have enough staff now. R5 stated, the staff are wonderful to her and it's not their fault, they need more help. R5's Face Sheet, undated, documents, R5 has a diagnosis of Malignant Neoplasm of the Pancreas. R5's MDS, dated [DATE], documents, R5 is cognitively intact and is occasionally incontinent of urine and bowels. R5's Care Plan, dated 8/8/23, documents, R5 has bladder incontinence and utilizes incontinence briefs and to change as needed. The Resident Rights Policy, undated, documents, it is the policy of the facility that all residents have the right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility. Page 1 of 7 146051 146051 09/22/2023 Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312

F 0550 On 9/21/23 at 1:15 PM, V2, DON, stated, she would expect staff to respect the resident's rights. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146051 Page 2 of 7 146051 09/22/2023 Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312

F 0692 Provide enough food/fluids to maintain a resident's health. 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 identify, continued weight loss in 2 of 4 residents (R6, R8) reviewed for weight loss in the sample of 12. Residents Affected - Few Findings include: 1. R6's Face Sheet, undated, documents, R6 has an admitting diagnosis of Chronic Obstructive Pulmonary Disease. R6's Minimum Data Set, (MDS), dated [DATE], documents, R6 is cognitively intact and is independent with eating. R6's weights document the following: 3/21/23 - 174 lbs., (pounds), 6/21/23 - 152.4 lbs.; 8/23/23 - 149.3 lbs.; 9/20/23 - 140.6 lbs. - significant loss in 6 months, 3 months, and 30 days. R6's Physician Order Sheet, (POS), documents, an order dated 7/18/23 for a Regular Diet. R6's Progress Note, dated 7/6/23, documents, R6 is at 149 lbs. and is stable for 2 months after unusual loss. Med pass supplement was discontinued, due to resident refusal. Recommend to remove no concentrated sweets restriction from diet order and will continue to monitor for stable weight pattern or gain. There is no other documentation identified in R6's Progress Notes of R6's continued weight loss. On 9/21/23 at 8:50 AM, R6 stated, he started losing weight before he came to the facility, because he couldn't cook for himself any longer, so he started eating microwave food. R6 stated, since he's been at the facility, he's been eating better, but is still losing weight. 2. R8's Face Sheet, undated, documents, R8 has a diagnosis of Dementia. R8's MDS, dated [DATE], documents, R8 has severe cognitive impairment and is independent with eating. R8's weights document the following: 3/7/23 - 120 lbs.; 6/7/23 - 116 lbs.; 8/1/23 - 111.4 lbs.; 9/1/23 - 105.3 lbs. - Significant weight loss in 6 months, 3 months, and 30 days. R8's POS, documents, an order dated, 3/31/21 for a no added salt, Mechanical Soft Diet and 9/16/22 Med pass 60 milliliters, (ml), every morning and at bedtime for weight loss. R8's Progress Note, dated 7/6/2023, documents, R8 is at 111.8 lbs. with 5 lb. loss over 6 months. Recommended weight is 95-115 lbs. Diet is Mechanical Soft no added salt with 60 ml Med Pass Supplement twice daily. Would change supplement to 90 ml BID. Will monitor for stable weight pattern and adequate intake. There is no other documentation identified in R8's Progress Notes of R8's continued weight loss. On 9/21/23 at 1:00 PM, V11, Licensed Practical Nurse, (LPN), stated, the Nurses are the ones that 146051 Page 3 of 7 146051 09/22/2023 Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few put the weights in the computer, so they know if a resident has a weight loss or gain, and if so, they notify their Doctor and document it in the Nurse's Notes. On 9/21/23 at 1:10 PM, V12, Dietary Manager, stated, they get the information for the diet cards from the Physician Orders. V12 stated, they have Care Plan Meetings every week and she is notified if a resident has a weight loss in those meetings. Stated if they've had a weight loss, they have Nutritional Drinks they can give them to help them gain weight. V12 stated, she just recently took over the Dietary Manager position and has not met the Dietician yet. V12 stated, she is not sure if they review the residents monthly or quarterly or if they are notified of weight losses/gains. On 9/21/23 at 1:15 PM, V2, Director of Nurses, (DON), stated, she hasn't received any Dietary recommendations from the Dietician yet. V2 stated, the Dietician does not come to the building, she reviews the resident's information remotely and she isn't sure who they review monthly or quarterly. The Weighing and Measure the Resident Policy, dated 3/2011, documents, the purpose of this procedure is to determine the resident's weight to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. 146051 Page 4 of 7 146051 09/22/2023 Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to supply a sufficient number of staff, Certified Nursing Assistants, (CNA), to care for the residents. This failure has the potential to affect all 53 residents residing in the facility. Findings include: On 9/20/23 at 10:15 AM, R5 stated, she must wait 45-50 minutes for her call light to be answered. R5 stated, this happens on day shift all the time. R5 stated, she is continent of her bladder & bowels, but because she must wait, she goes on herself. R5 stated, now she has resorted to screaming out for help so that someone will help her. R5 stated, she uses the bed pan and needs help getting on it. R5 stated, she feels humiliated and angry when she goes on herself. R5 stated, they need more CNAs. R5 stated, she doesn't blame the CNAs or Nurses, because they cut the number of staff due to census. R5 stated, they only have 1 CNA on the 100-hall, 2 on the 300-hall and a floater. R5 stated, the floater is assigned to help on all the halls and go to the 200-hall as needed. R5 stated, 9 times out of 10, that CNA is busy on the 300-hall. R5 stated, she is here due to Terminal Cancer, and she has been to the facility before and wanted to come back here, because it was home. R5 stated, the CNAs are willing to help, but there's just not enough to care for her in a timely manner. R5's Minimum Data Set, (MDS), dated [DATE], documents, R5 is cognitively intact. On 9/21/23 at 8:45 AM, R9 stated, they need more CNAs on 1st and 2nd shift. R9 stated, occasionally it takes longer to get care, because they need more help. R9's MDS, dated , 9/18/23, documents, R9 is cognitively intact. On 9/21/23 at 8:50 AM, R6 stated, they need more CNAs, when they're short staffed it takes more time to get help and it takes longer for his call light to be answered. R6's MDS, dated [DATE], documents, R6 is cognitively intact. On 9/21/23 at 9:15 AM, V8, CNA, they started this morning with only 3 CNAs and then pulled a CNA that works in Dietary to come and work the floor. V8 stated, they need more CNAs on all shifts. V8 stated, the residents aren't getting the care they should, because they have too many residents and not enough CNAs. V8 stated, she believes they have applications and hired one that started on nights last night and she trained one on days for 2 days, she was off and when she came back, the new CNA had a circle around her name on the schedule, so she is not sure if she called off or quit. V8 stated, staff have voiced to Management about the need for more CNAs, but it hasn't happened. On 9/21/23 at 1:00 PM, V11, Licensed Practical Nurse, (LPN), stated, they need more CNAs on all shifts. V11 stated, they can't give the proper care that is needed due to staffing. On 9/21/23 at 1:15 PM, V2, Director of Nurses, (DON), stated, staffing hasn't been bad, but she hopes it gets better. V2 stated, they are recruiting and V1, Administrator, has went to different hiring events. V2 stated, they just placed open positions on a hiring website and had around 15 applicants that they have called. 146051 Page 5 of 7 146051 09/22/2023 Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312

F 0725 Level of Harm - Minimal harm or potential for actual harm On 9/21/23 at 2:25 PM, V13, Registered Nurse, (RN), stated, they need more CNAs, and because of this they are slower to answer the call lights. On 9/21/23 at 2:35 PM, V14, CNA, stated, there isn't enough staff, but that is all around, and they do the best they can to make sure the residents are taken care of. Residents Affected - Many On 9/21/23 at 2:40 PM, V15, CNA, stated, they need more CNAs. V15 stated, this evening they only have 2 CNAs, and the DON is supposed to be staying over to help. V15 stated, this happens all the time so it's hard to give quality care to the residents. V15 stated, she's not sure what the facility is doing to get more staff. On 9/22/23 at 8:40 AM, V9, CNA, stated, they need more CNAs, it makes it harder to get showers done. On 9/22/23 at 8:45 AM, V16, LPN, stated, they need more CNAs, because of the staffing it makes it harder to give showers, timely care, and answer call lights. On 9/20/23 at 1:00 PM, there were 4 CNAs observed in the building working, 1 on 100-hall, 2 on 300-hall and 1 mainly on 300-hall but going over to 200-hall to answer call lights. On 9/21/23 at 9:10 AM, there were 4 CNAs observed working in the facility, 2 on 300-hall, 1 on 100-hall and 1 on 200-hall. On 9/21/23 at 2:30 PM, there were 2 CNAs observed working in the facility. V2, DON, was observed in the dining room assisting with the ice cream social. The Reporting Direct Care Staffing Information Policy, dated 8/2022, documents, direct care staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The Resident Census and Conditions of Residents form dated 9/20/23, documents, there are 53 residents residing in the facility. 146051 Page 6 of 7 146051 09/22/2023 Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide a Therapeutic Diet as ordered by the Physician in 1 of 4 residents (R11) reviewed for Therapeutic Diets in the sample of 12. Findings include: On 9/20/23 at 12:05 PM, R11 was observed in the dining room eating lunch. R11 was eating a Regular cheese sandwich and cheese puffs, the meal was not Pureed as per orders. R11's drinks were Regular Consistency and not Nectar Thick as ordered. On 9/21/23 at 12:15 PM, R11 was observed in the dining room. R11 was served and was eating a cheese sandwich, mashed potatoes with gravy and pumpkin pie. R11's drinks were regular consistency. R11 was not served a Pureed Diet or nectar thick liquids as ordered. R11's Face Sheet, undated, documents, R11 has a diagnosis of Dysphagia, Oropharyngeal Phase. R11's Minimum Data Set, (MDS), dated [DATE], documents, R11 has severe cognitive impairment, is independent with eating and is on a Mechanically Altered Diet. R11's Care Plan, dated 3/22/21, documents, R11 is at risk of choking. R11's Physician Order Sheet, (POS), documents, an order dated 8/4/22, for a Regular Diet, Pureed Texture, and Nectar Consistency Liquids. On 9/21/23 at 1:15 PM, V2, Director of Nurses, (DON), stated, she would expect the residents to be served the Diet Ordered by the Physician. 146051 Page 7 of 7