Health inspection·December 12, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to use a gait belt, or a two person assist for a transfer for one resident (R3) of two residents reviewed for falls in the sample of 20. Findings include: The Fall Policy dated 7/2014 document To ensure that the resident's environment remains as free of accident hazards as possible, and that each resident receives adequate supervision and assistive devices to prevent accidents. The Gait belt Policy dated 3/16/2020 documents Purpose: To give guidance as to the proper use of a gait belt to reduce injury to staff and resident. Policy: Staff will utilize gait belt at all times while transferring or ambulating a resident as outlined in this policy. Procedure: 1. The gait belt is part of the C.N.A (Certified Nursing Assistant) uniform and is the responsibility of the C.N.A to have on their person at all times. R3's admission Record documents that R3 was admitted on [DATE] with diagnoses which included Parkinsonism, Unspecified Convulsions, Type 2 Diabetes Mellitus, and Alzheimer's Disease. R3's Minimum Data Set/MDS assessment dated [DATE] documents that R3 has a BIMs/Brief Interview of Mental Status of 6 (severe impairment). R3 has upper and lower extremity impairment on both sides, is dependent on staff for activities of daily living, and requires substantial assistance for transfers. R3's current Care Plan documents that R3 has an activity of daily living self-care performance deficit related to weakness (dated 10/10/2017). I require max assist of two with wheeled walker, and gait belt to move between surfaces safely and as necessary (dated 4/26/2024). Sometimes I have moments of weakness and difficulty transferring. I may use mechanical lift sit to stand with two assists. I have potential for falls as evidenced by history of falls in Morse Falls score related to seizure disorder, use of anti-seizure medication, antidepressants, history of falls and balance impairment. Morse Fall Risk Score is high. Staff education provided that resident is a two assist for care plan to help reduce falls (dated 5/17/2020). R3's Post Fall Investigation Report dated 8/2/24 documents that R3 was lowered to the floor with no injury during a transfer. The Root Cause was identified as R3 was transferred with an assist of one. R3 is to be transferred with an assist of two and a gait belt. Page 1 of 4 146100 146100 12/12/2024 Cass County Senior Living & Rehabilitation LLC 530 East Beardstown Street Virginia, IL 62691

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R3's Nursing Note dated 8/2/2024 at 10:17 PM, documents CNA (V8) called out for assistance. (V8) stated he had to lower (R3) to the floor. No injuries noted at this time. R3's Witnessed Fall Report dated 8/2/24 at 6:25 PM documents (R3) became weak suddenly and was lowered to the floor, (R3) is 2 (two) assist with gait belt for transfers, (R3) has history of seizure activity and bilateral lower weakness, nursing staff to assess (R3) before transfers and if too weak to transfer with 2 assist reattempt at a later time or use a third person to help with transfers to help prevent falls. On 12/11/24 at 11:25 AM, V3/Director of Nursing stated that R3 is an assist of two and R3 had a fall when a CNA transferred R3 without assistance. 146100 Page 2 of 4 146100 12/12/2024 Cass County Senior Living & Rehabilitation LLC 530 East Beardstown Street Virginia, IL 62691

F 0880 Provide and implement an infection prevention and control program. 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 implement Enhanced Barrier Precautions (EBP) for two residents (R19 and R24) of two residents reviewed for EBP in the sample of 20. Residents Affected - Few Findings include: The Enhanced Barrier Precautions policy (not dated) documents Purpose: Reduce the spread of Infection. Procedure Providers and staff must clean hands before entering and leaving the room, wear gloves and gown for the following high-contract resident care activities - dressing, bathing/showering, and transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting for residents with devices such as a central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. 1. R24's admission Record documents that R24 was admitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Essential (Primary) Hypertension. R24's Minimum Data Set/MDS assessment dated [DATE] documents that R24 has a BIMs/Brief Interview of Mental Status of 4 (severe impairment). R24 has an indwelling urinary catheter. R24's current Care Plan documents I have an indwelling catheter which increases my risk for UTI/Urinary Tract Infection. I have a catheter for: urinary retention. On 12/9/24 at 10:03 AM no EBP sign was observed on R24's door and no PPE was observed inside or outside of R24's room. On 12/10/24 at 10:12 AM, V4/Certified Nursing Assistant provided catheter care for R24. V4 did not wear Personal Protective Equipment/PPE while doing catheter care. V4 stated that he was never told that PPE should be worn when providing catheter care for R24. 2. R19's Progress Note, dated 4/4/2023 and signed by V5/LPN (Licensed Practical Nurse), documents (V5/LPN) called to (R19's) room. Upon assessment recurring stage two pressure ulcer to right buttock. R19's current Physician Orders documents an order to cleanse bilateral buttock, skin prep and apply a (foam dressing) every evening shift, Monday, Thursday, Saturday and as needed. On 12/9/24 at 10:52 AM V5/LPN stated that R19 has a pressure sore on (R19's) right and left buttock. On 12/9/24 at 10:55 AM no EBP sign was observed on R19's door and no PPE was observed inside or outside of R19's room. On 12/9/24 at 2:40 PM V5/LPN and V7/CNA prepared to provide treatment to R19's left and right buttock. V7/CNA had gloves on and rolled R19 onto R19's right side. R19's left, and right buttock were observed and had an open small pea sized area on each buttock. During R19's treatment V5/LPN nor V7/CNA wore a gown, only gloves. On 12/9/24 at 2:50 PM V5/LPN and V7/CNA both verified they were not wearing gowns during V19's 146100 Page 3 of 4 146100 12/12/2024 Cass County Senior Living & Rehabilitation LLC 530 East Beardstown Street Virginia, IL 62691

F 0880 wound treatment. V5/LPN and V7/CNA both stated they were unsure what EBP is. Level of Harm - Minimal harm or potential for actual harm On 12/11/2 at 11:05 PM V3/Director of Nursing/Infection Preventionist stated she was unaware of what EBP's were, and it has not been implemented. V3 verified R19 has a pressure wound and R24 has a urinary catheter. Residents Affected - Few 146100 Page 4 of 4