Inspection·August 9, 2023

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's pain was managed before providing care and changing the dressing on his wound. Residents Affected - Few This applies to 1 of 15 residents (R24) reviewed for pain management in a sample of 15. The findings include: On 8/8/23 at 10:05 AM V6, V7, and V8 (CNAs) assisted R24 with his personal care by rolling him back and forth in the bed. With each roll R24 moaned with pain. V8 repeated over and over, I'm sorry, I'm sorry. R24 was asked if he was in pain and he stated, yeah. The CNAs continued by turning R24 and placed him onto his right side. V9(RN) entered the room to change the soiled dressing on R24's coccyx. V9 removed the old dressing and R24 yelled out with pain. V8 and V9 both told R24 that they were sorry. V9 cleaned the wound and R24 continued moaning with pain. When all care was completed R24 was positioned on his back and stated that his right leg was hurting. V6 looked at R24's leg, stated that is was positioned ok and covered R24 with the sheet. Surveyor spoke with R24 and he stated that he has pain all the time but more with movement. R24 was asked where his pain was and he stated he had pain in his back. R24 was asked if the staff offered him pain medication. R24 stated, Not today. R24 was asked if he wanted something for pain and R24 stated, yes. At 10:35 AM, V9(RN) stated that R24 has an order for Oxycodone 10 mg every 6 hours PRN (as needed) and the last time he had received it was on 8/6/23 (2 days prior). On 8/09/23 at 8:59 AM V2 (Director of Nursing) stated, (V9) said (R24) absolutely didn't need a pain pill yesterday. The humming and the moaning that he does is just a behavior. He gets a scheduled Tylenol and scheduled Alprazolam (Antianxiety), His moaning is a self comforting behavior and he also has Tourette's so you can't tell by his facial expressions if he is having pain. (V9) said she thought it would be easier if she could just give him something before his treatment. R24's Physician's Order Sheet dated 8/9/23 shows that R24 has diagnoses including Quadriplegia, Tourette's Syndrome, Pressure Ulcer of the Sacral Region and Generalized Anxiety Disorder. R24's Pain assessment dated [DATE] states, What makes pain worse? Movement/repositioning and Describe all methods of alleviating pain and their effectiveness: Immobility and pain meds are effective when left alone/not moving. R24's Minimum Data Set assessment dated [DATE] shows that R24 has no short term or long term memory problems and that R24 is totally dependent on two staff for bed mobility. The undated facility policy entitled, Management of Pain states, Our mission is to facilitate residents' independence, promote resident comfort and preserve resident dignity. The purpose of the policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence and enhance dignity and life involvement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146071 If continuation sheet Page 2 of 3 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 146071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Place of Belvidere 1701 5th Avenue Belvidere, IL 61008 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure the facility's ice machine was free of a black mold like substance. This has the potential to impact all 53 residents residing in the facility. Residents Affected - Many The findings include: The CMS 672 Resident Census and Conditions of Residents form dated 8/7/23 shows the total number of residents within the facility is 53. On 8/9/2023 at 10:40AM, the facility's ice machine was observed to have black mold like spots on a plastic piece of the machine above the ice hopper full of ice. There was also a black mold like substance on a seal at the top of the ice hopper folding door. On 8/9/2023 at 10:50AM, V4 said the ice machine was the only ice machine in the building. V4 Dietary Manager said the ice machine was used for all the residents in the facility. V4 said maintenance staff are responsible for cleaning the ice machine. On 8/9/2023 at 11:02AM, V5 Maintenance used a paper towel to wipe the seal and plastic piece inside of the ice hopper with black mold like spots. A dark brown or black color appeared on the paper towel after V5 wiped the paper towel past those areas. V5 said I eat that ice all day and that's gross, that shouldn't be that way after wiping the ice machine with a paper towel. The facility provided Ice Machine Cleaning Log states, . clean and sanitize parts of the ice machine considered food contact surfaces . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146071 If continuation sheet Page 3 of 3