Health inspection·September 9, 2022

F 0636 Level of Harm - Minimal harm or potential for actual harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review the facility failed to accurately code a Minimum Data Set (MDS) assessment for 1 of 8 residents (R22) reviewed for comprehensive assessments in a sample of 29. Residents Affected - Few Findings include: R22's admission Record documented, admission date of 7/30/2022 and initial admission date of 10/8/2022. Diagnosis included, Pressure ulcer of right elbow, stage 4 effective and Pressure Ulcer of sacral region, stage 4. R22's Minimum Data Set (MDS) dated on 7/18/2022 documented in part, section c. Brief Interview for Mental Status (BIMS) a score of 00 which indicates severe cognitive impairment. The Section G. for Functional Activities of Daily Living (ADL) assessment documented resident required extensive assistance of 2 staff for bed mobility, transferring, and toileting. On Section M. skin assessment resident was at risk for pressure ulcer development and no pressure ulcers or other skin issues were present. R22's Initial Skin Alteration Record dated on 7/18/2022 documented in part, wound to right elbow measuring 2 x 2 centimeter non blanchable ulcer with some slough and open. Stage 2, pressure injury, wound bed pink, slough (yellow/stringy/gray). Comments: Resident being sent out to hospital for Covid related symptoms. Signed by V7 (previous Director of Nurses). R22's Hospital Records dated on 7/30/2022 documented in part, Discharge Summery, Physical Exam: Skin: right elbow and sacrococcygeal area pressure injury pictures noted in Electronic Medical Record (EMR). R22's Physician Orders Sheet (POS) dated on 7/30/2022 documented in part, Barrier cream to buttocks as needed for minor skin irritation due to episodes of bowel and bladder incontinence. Every 6 hours for excoriation. R22's MDS dated on 8/3/2022 documented, on section G. totally dependent for bed mobility, and transfers. Section M. Skin assessment Documented 1 unstageable pressure ulcer had acquired in the hospital. Section M did not document any other skin issues were present. On 9/8/2022 at 12:20 PM, V7 Previous Director of Nurses (DON) stated, she assessed (R22)'s right elbow on 7/18/2022 before he was sent to the hospital for Covid symptoms, and she may have documented a stage 2 pressure ulcer in error and was not sure what the stage of it was, but it could have been unstageable or a stage 3. V7 also stated, (R22) was very sick and sent out to the hospital for Covid Page 1 of 4 146092 146092 09/09/2022 Integrity Hc of Herrin 1900 North Park Avenue Herrin, IL 62948

F 0636 symptoms on the same day of 7/18/2022. Level of Harm - Minimal harm or potential for actual harm On 9/8/2022 at 12:30 PM, V8 MDS Nurse stated, she completed (R22)'s MDS assessments on 7/18/2022 and 8/3/2022. V8 stated, she gathers assessment information by speaking with staff, reviewing notes, physician orders, and hospital records. V8 stated, she was not aware of (R22)'s right elbow pressure ulcer findings on 7/18/2022 by (V7) and thought the unstageable right elbow pressure ulcer was originated from the hospital stay. V8 also stated, she was made aware of the error and was currently completing a correction MDS for the 7/18/2022 MDS assessment. Residents Affected - Few On 09/09/22 at 7:41 AM, V2 Regional Nurse, stated, she agreed (R22)'s MDS inaccurately coded the 7/18/2022 assessment for skin and should have been documented. V2 stated, she would expect the MDS nurse to accurately code the MDS. According to CMS.gov resource dated copywrite 2017, entitled, Medicare-Required SNF PPS Assessments, documented in part, The MDS 3.0 is a core set of elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The screening, clinical, and functional status items in the MDS 3.0 standardize communication about resident problems and conditions. The MDS 3.0 contains items that reflect the acuteness of the resident's condition, including diagnoses, treatments, and functional status. MDS 3.0 assessment data is personal information SNFs must collect and keep confidential by Federal law Conducting the Assessment: Each assessment must include all of these: Accurately reflect the resident's status. -Be conducted or coordinated by a registered nurse with the appropriate participation of other health care professionals. -Include direct observation as well as communication with the resident and direct care staff on all shifts. -Cover the Observation (Look Back) Period, which is the time period when the resident's condition is captured by the MDS assessment. Do not code anything on the MDS that did not occur during the Observation Period. 146092 Page 2 of 4 146092 09/09/2022 Integrity Hc of Herrin 1900 North Park Avenue Herrin, IL 62948

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 observation, interview and record review the facility failed to maintain adequate levels of quaternary sanitizer used to sanitize food contact surfaces and stationary equipment. This has the potential to affect all 25 residents living in the facility. The Findings Include: On 9/6/22 at 9:30 AM, during the initial tour of the kitchen it was observed that there was a bucket of sanitizing solution setting in the sink with a rag in it. V3 (Cook) stated that this is a quaternary ammonium solution that is used to wipe down surfaces and stationary equipment. V3 checked the solution for the sanitizer level in the bucket with a hydrion test strip to detect quaternary levels. V3 stated the level was below manufacturer suggested level of 200 PPM (parts per million) likely due to being setting out for a few hours. V3 stated at this time she would dump out this bucket of solution and make a new one. On 9/7/22 at 11:15 AM, V3 checked the sanitizer level in the bucket used for sanitizing stationary surfaces and again it was found to be below suggested the manufacturer recommendations of 200 PPM for Quaternary Ammonium and a new solution was made using the dispenser and the level was within recommended level. The resident census and conditions of residents dated 9/6/22 documents 25 residents residing in the facility. 146092 Page 3 of 4 146092 09/09/2022 Integrity Hc of Herrin 1900 North Park Avenue Herrin, IL 62948

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, record review, and interview the facility failed to provide 80 square feet of space per resident for 25 of 25 residents (R1-R2, R4-R9, R11-R26, and R127) reviewed for room size in the sample of 29. The Findings Include: On 09/8/22 at 12:14 PM, V1 (Administrator) stated all rooms on A, B, and C Hall are covered under the room waiver. All of the rooms have been measured and do not provide the required 80 square feet per resident bed. V1 also stated at this time that the A Hall (rooms 1-12) are Medicaid Certified only and B and C Hall are dually certified for Medicare and Medicaid. These rooms (1-12, 14-26) were all double occupancy rooms measuring 73.4 square feet. Inquiries regarding these rooms throughout the survey from 09/6/2022 to 09/9/2022 found no negative interviews from residents or families of residents who reside in these rooms. Observations of the rooms found there was adequate space to meet the medical and personal needs of the residents living in the waiver rooms. Incident and Accident Records were reviewed for January 2022 to September 2022 did not identify any problems regarding room size. On 9/8/22 at 12:14 PM, V1 (Administrator) verified that the waivered rooms are occupied by R1-R2, R4-R9, R11-R26, and R127. 146092 Page 4 of 4