Health inspection·September 21, 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. Based on observation, interview, and record review, the facility failed to provide feeding assistance to residents in a dignified manner. This applies to 2 of 3 residents (R9, R14) in the sample of 12 and 1 resident (R6) outside of the sample reviewed for dignity. The findings include: On 9/20/23 at 8:05AM R6, R9, and R14 were being assisted with their breakfast meal. V12 (Registered Nurse) assisted R9. V13 (Certified Nursing Assistant/CNA) assisted R14. V14 (CNA) assisted R6. V12, V13, and V14 were all standing over residents while feeding them. No chairs were present for the staff to sit with each resident they were assisting. V13 stated, We sit sometimes with the residents but today we just decided to stand. It depends on how many residents we have to feed and how busy we are. We should sit with them to make them feel like we aren't rushing them. On 9/21/23 at 9:30AM V2 (Director of Nursing) stated, CNAs should be sitting when feeding residents for dignity purposes. Residents should feel like staff are not rushing them and when they stand, I can see how residents would feel rushed. It probably feels like the staff are just shoveling food in their mouth when they are standing over them. I wouldn't want anyone doing that to me. The facility's policy titled, Resident Dignity reviewed 01/2023 showed, Purpose: To maintain the sense of dignity for each resident as the individual defines. (Facility) understands and believes each resident has a right to receive services and be addressed in a manner that maintains their dignity . Page 1 of 11 146101 146101 09/21/2023 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide incontinence care for dependent residents prior to their briefs and clothing becoming soiled for 2 of 5 residents (R1, R3) reviewed for incontinence in the sample of 12. Residents Affected - Few The findings include: 1) R1's electronic face sheet printed on 9/21/23 showed R1 has diagnoses including but not limited to Alzheimer's disease, hypertensive chronic kidney disease, dementia without behaviors, and vascular dementia with behaviors. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment and is always incontinent of bowel and bladder. R1's care plan dated 2/19/19 showed, Urinary incontinence related to decreased independence with mobility activities and cognitive status. Provide for adult clothing protectors and monitor for incontinence every 2 hours. Dependent on staff with incontinence care. On 9/20/23 at 12:53PM, V11 and V13 (Certified Nursing Assistants/CNA) provided incontinence care to R1. V11 rolled R1 over and R1 had a large, wet area on the back of her pants. V13 stated R1 is a heavy wetter and wets through her clothing sometimes. V11 and V13 removed R1's pants and a foul urine smell was noted to be coming from R1. R1 had a urinary incontinence brief and a large incontinence pad applied that were both saturated with urine. V11 stated she is unsure why the facility utilizes 2 incontinence products on residents but that is how she was trained. V13 stated she thought R1 had been provided incontinence care sometime after breakfast but could not verify a time. (R1 was observed at 9:00AM sitting in activity area after breakfast). On 9/21/23 at 11:48AM, V2 (Director of Nursing) stated, We have always used 2 incontinence products on residents. Not all of them have it, just the heavy wetters. I know that's not the correct term but that is how we refer to them. Some residents just need extra protection but that is not a replacement for toileting and incontinence care. Residents should be toileted every 2 hours and more often if they are heavy wetters. The facility's policy titled, Incontinence Care with a review date of 06/2023 showed, Purpose: To implement a system to assist in the maintenance of the skin integrity of the residents. To cleanse the perineum and surrounding areas after an incontinent episode in order to assist the resident with keeping their skin clean, intact and dry. Perineal care will be done with AM and PM care and after each incontinent episode. 2) R3's electronic face sheet printed on 9/21/23 showed R3 has diagnoses including but not limited to left femur fracture, osteoporosis, chronic pain, pain in left leg, and history of falls. R3's facility assessment dated [DATE] showed R3 has severe cognitive impairment, is frequently incontinent of bladder, and always incontinent of bowel. R3's care plan dated 6/16/23 showed, Urinary Incontinence related to neurogenic bladder and bladder spasms. I have urge incontinence. Provide perineal care after each episode of incontinence. 146101 Page 2 of 11 146101 09/21/2023 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/20/23 at 9:01AM, V15 (Certified Nursing Assistant) provided incontinent care to R3. R3 was sitting up in her wheelchair with feces coming out of the bottom of her pant leg and onto her sock. V15 stated he was not assigned to R3 today and did not know the last time she was changed but he is assuming around 6:00AM. V15 removed R3's pants as well as an incontinence brief and incontinence pad that were saturated with urine and had feces on them. V15 stated he is unsure of why the facility utilizes an incontinence pad and brief, but he is assuming R3 is a heavy wetter. 146101 Page 3 of 11 146101 09/21/2023 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to timely obtain an antibiotic order for a resident with symptoms of a urinary tract infection. This applies to 1 of 3 residents (R4) reviewed for quality of care. Residents Affected - Few The findings include: R4's Profile Face Sheet showed a current admission date of 1/27/23 with diagnoses to include heart failure, Alzheimer's disease, and chronic pain. On 9/19/23 at 2:24 PM, V18 (R4's Daughter/Power of Attorney) stated R4 became septic (blood infection) from a urinary tract infection, and she is now on hospice care. V18 stated regarding the urinary tract infection, R4 was having mental status changes. R4's Nurse's Note from 8/8/23 at 4:43 AM showed, [On 8/7/23 at 6:00 PM] R4 was in bed fully dressed over her blankets. CNA (Certified Nursing Assistant) attempted to assist resident with HS (Bedtime) care; became verbally aggressive. CNA stepped away allowed resident to rest. Approached several times through the night. By 10:00 PM resident continued to refuse. The nurse approached, resident was hallucinating, reaching, and scratching at the wall. Resident continued to repeat Just get that out of here continued to refuse care. The note continued, [on 8/8/23 at 2:00 AM] resident was incontinent of bladder, strong foul odor noted. NP (Nurse Practitioner) emailed updating on hallucinations, confusion, increased incontinence . The note showed a urinalysis with culture and sensitivity (urine sample used to determine if bacteria are present, the type of bacteria that are present, and antibiotics that would be effective at killing the bacteria) was ordered and the sample was collected at 2:30 AM. R4's Preliminary Culture and Sensitivity shows it was faxed to the facility on 8/11/23 at 3:24 PM. The report showed R4 had two types of bacteria in her urine in addition to normal skin bacteria. The preliminary report showed several antibiotics that were effective against R4's bacteria growth. The bottom of the report showed it was faxed to R4's providers on 8/11/23 at 3:54 PM. At the top of the culture report was a typed order to Start Keflex 500 mg bid x 5 days. (Start a Keflex, an antibiotic, at 500 milligrams twice daily for 5 days.) The order was signed by V16 (R4's Nurse Practitioner). (The culture report does not indicate when the antibiotic order was typed onto the report. The antibiotic order was not on the report when initially sent to the facility.) On 9/20/23 on 3:11 PM V16 (Nurse Practitioner) stated increased confusion, hallucinations, foul smelling urine, and increased incontinence are signs and symptoms of a urinary tract infection (UTI). V16 stated, while reviewing her documentation, she had received from the facility, R4's preliminary culture and sensitivity report. V16 stated she can type an order onto the fax then sign it from her phone. V16 stated she then sent this document to her secretary at approximately 4:50 PM on Friday, August 11, 2023. V16 stated her secretary is responsible for sending the order back to the facility. V16 stated her secretary then replied to the email indicating there were no attachments in the email. V16 stated she does not have a record of responding to this email from her secretary. V16 stated her office closes at 5:00 PM and it is possible her secretary left without addressing the email/fax issues; however, V16 stated the staff should have recognized there was no reply to the culture and sensitivity report. V16 said staff should have called the on-call provider on or before the morning of Saturday 8/12/23 and obtained a verbal order. V16 stated R4 is chronically colonized with bacteria; however, she is treated when she becomes symptomatic such as mental status changes. V16 stated, It 146101 Page 4 of 11 146101 09/21/2023 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would have been prudent to start the antibiotic sooner and they should have started it sooner. If the fax did go through on 8/11/23, it should have been started that night or the at least by the next morning. It is important to treat UTIs. The urinary tract is meant to be sterile. The bacteria can travel up the ureters and can go the kidneys. V16 said it is possible for a person to become septic from a urinary tract infection. The facility provided an email sent to V16 on 8/12/23 at 1:59 PM. The email stated, Please see attached results and advise. Thank you! V16 responded to the email on 8/13/23 at 6:26 AM, Hey sorry I didn't see this yesterday. On 9/21/23 at 10:44 AM, V16 stated it was her intention, on 8/11/23 to begin antibiotic therapy with R4 to treat a urinary tract infection. V16 said she was not working the weekend of 8/12/23 and she just happened to check her email on 8/13/23. V16 stated, I don't feel that delaying treatment changed her outcome because the [type of] antibiotic needed to be changed anyway. R4's Physician Orders showed an order, on 8/13/23 for Keflex as previously stated to begin at 4:00 PM. (Two days after the culture and sensitivity report was sent to V16 and two days after she intended antibiotic therapy to begin.) A provider notification policy was requested; the facility provided Change in Condition Notification policy dated 12/22/20. The policy does not address how or when providers should be notified following a failed response to facility communication. 146101 Page 5 of 11 146101 09/21/2023 Willows Health Center 4054 Albright Lane Rockford, IL 61103

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 observation, interview, and record review the facility failed to complete a fall assessment and implement fall prevention measures for a resident at risk for falls for 1 of 1 resident (R3) reviewed for falls in the sample of 12. The findings include: R3's electronic face sheet printed on 9/21/23 showed R3 was admitted to the facility on [DATE] and has diagnoses including but not limited to left femur fracture, osteoporosis, chronic pain, pain in left leg, and history of falls. R3's facility assessment dated [DATE] showed R3 has severe cognitive impairment, has had a fall in the past 2-6 months, and has had a fall with a fracture. The facility's accident/incident reports showed R3 experienced a fall on 3/7/23, 4/18/23, 5/16/23, and 5/20/23. R3's sustained a hip fracture with her fall on 5/20/23. R3's care plan dated 6/16/23 (4 months after R3 was admitted ) showed, Potential for falls related to history of falling, requires assistance for transfers & ambulation, generalized weakness, recent fall with a fracture. R3's nursing progress notes showed, 4/18/23 Resident found sitting on floor in front of her entertainment center. Resident stated she put herself on the floor looking for a doll from her doll collection. 5/16/23 Certified Nursing Assistant observed resident sitting on the floor in front of her wheelchair. Physical assessment completed with no apparent injuries. 5/20/23 Resident observed lying on the floor on her back in her room .Resident stating pain in her left hip and unable to straighten her leg out .informed her that she was going to be sent to the emergency department for evaluation and treatment .1535 call received from resident's son, states resident has been admitted to hospital due to left femur fracture. R3's fall risk assessment dated [DATE] showed R3 has a history of falls, loss of balance while standing, balance problems while walking, and poor vision. (No fall risk assessments were able to be provided by the facility prior to 8/18/23). On 9/21/23 at 8:51AM, V19 (Certified Nursing Assistant) stated, I don't think (R3) has an alarm, we just keep a close eye on her. On 9/21/23 at 8:55AM, V20 (Licensed Practical Nurse) stated, (R3) has had a few falls here but nothing since May when she fell and got a hip fracture. We do have interventions in place for her that started after her last fall. I know she has an alarm on when she is up in her chair or in bed now too. On 9/21/23 at 11:45AM, V2 (Director of Nursing) stated, There should have been a fall assessment completed for (R3) upon admission to the facility, after each fall, and on a quarterly basis. That is our policy and there is no reason why it wasn't done. She is a high fall risk and has had a fall with injury so she should have had several done at this point. The fall risk assessments guide us as to 146101 Page 6 of 11 146101 09/21/2023 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few what interventions we are going to put into place so without those being completed we are just putting random interventions in place. The facility's policy titled, Fall Prevention Policy revised 06/2023 showed, Purpose: To provide a prevention and intervention program that provides individualized interventions for those assessed as a high risk or frequent falling resident .1. On admission, quarterly, and with a significant change, nursing does a fall assessment on residents not residing on the Medicare unit. Residents assessed at a high risk for falling or have fallen two or more times in the past 30 days will be placed on the falling star program .3. Residents will be evaluated quarterly for their continuation on the program . 146101 Page 7 of 11 146101 09/21/2023 Willows Health Center 4054 Albright Lane Rockford, IL 61103

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 medication was administered as ordered for 1 of 1 resident (R126) reviewed for pain in the sample of 12. Residents Affected - Few The findings include: R126's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include encounter for surgical aftercare following surgery on the digestive system, osteoarthritis, obesity, moderate persistent asthma, benign neoplasm of ascending colon, and generalized anxiety disorder. R126's care plan initiated 9/14/23 showed, Pain . Alteration in comfort related to cervical spondylosis without myelopathy, OA (osteoarthritis), knee pain. Baclofen for muscle spasms. Pain control as evidenced by verbalizing satisfaction with level of comfort, ability to participate in ADL's (Activity of Daily Living) without discomfort. Early detection of pain for timely intervention to prevent escalation . Assess pain level as evidenced by reported pain, restlessness, pupil dilation, perspiration, changes in vital signs from baseline date. Report uncontrolled pain to the provider . R126's care plan initiated 9/14/23 showed, Health Conditions . Resident will be kept comfortable as evidenced by no complaints of discomfort through next review. Assess for pain as needed. Provide pain relief measures as ordered by the MD (medical doctor). Medicate as ordered by physician . R126's admission documents from the acute care hospital with discharge date of 9/14/23 showed, . Chronic back pain/knee pain Continue Percocet PRN (as needed) . Continue Baclofen 5 mg TID (three times daily) given good response. However due to worse pain at night, will add Baclofen 10 mg HS (bedtime) for better control. discharge on same . R126's 9/14/23 nursing note showed, . takes Percocet, Ativan, and Baclofen to manage anxiety and pain in her back. She is alert and oriented x 4 . R126's Pain Assessment completed 9/14/23 at 9:52 PM showed she experiences back pain daily throughout the day which is relieved with Percocet, Baclofen combo. This same assessment showed R126 exhibits facial grimacing and narrowed focus during times of pain. R126's September 2023 physician order sheet showed an order for Baclofen 5 mg three times daily for muscle spasms and an additional order for Baclofen 10 mg daily at bedtime for muscle spasms. R126's September 2023 Medication Administration Record showed the first dose of Baclofen she received was on 9/16/23 at bedtime. (2 days after hospital discharge orders) On 9/19/23 at 1:30 PM, R126 was sitting in her chair in her room. R126 made frequent position adjustments in her chair due to back pain throughout the interview. R126 said, While I was in the hospital, they started me on Baclofen because the doctor said it would be complimentary to my Percocet. I was supposed to get a knee replacement in two weeks and between the Percocet and the baclofen it was working really well for me. When I was admitted here, I was supposed to be getting the baclofen, but I wasn't getting any. I asked about it on Saturday and the nurse said that it had been ordered. She (the nurse) called the pharmacy, and the pharmacy said it wasn't ordered. Then they said it would be here at 2 PM. Come to find out the driver was leaving the pharmacy in Chicago at 2 and had to make 146101 Page 8 of 11 146101 09/21/2023 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0697 Level of Harm - Minimal harm or potential for actual harm many stops in between before getting here. I did finally get the Baclofen on Sunday night and it has been helpful. I was able to do therapy in the hospital because I had the Baclofen and was able to do more. I also had asked one of the nurses for a pain pill and she cut me off before I could finish telling her and told me that she had medications to pass, and she left. I kept asking so I did end up getting a pain pill. The pain is horrible. Residents Affected - Few On 9/21/23 at 11:13 AM, V2 (Director of Nursing) said, When coming from the hospital the residents come with a discharge summary with medications on them which is faxed to the pharmacy. The pharmacy enters them in the computer and when they come up in the system, we go through reconcile them and sign off on them. They weren't received in the facility until 9/16 . The facility's policy and procedure with review date of 6/2023 showed, Pain Management, Purpose: To promote best-practice pain management for the residents. Policy Statement: Pain assessment, observation, and intervention will be provided to manage the acute and or chronic pain needs of each resident, during each episode of pain . Practice: 1. Each resident will be assessed at admission and ongoing for the presence of pain, whether perceived or actual. 2. Pain is what a resident says it is. 3. Pain will be assessed using the 0-10 scale, the faces scale, and or by assessing non-verbal cues for pain, including, but not limited to the presence of a furrowed brow, moaning, restlessness, confusion, rapid heart rate, or pacing noted 5. All pain medications provided on an as needed basis will include the documentation of medication effectiveness to fully monitor pain management effectiveness . 7. Orders will be written by the MD/Provider and transcribed into the electronic record by the nurse promptly, following receipt of the order and in response to addressing or anticipation of Resident pain. 8. The nursing team, in coordination with the Director of Nursing (DON) will identify pain medication availability in the (convenience medication supply) for timely management of the resident's pain . 11. Any delay in achieving pain management for the resident must be reported to the MD/Provider immediately and the DON/designee to follow . 146101 Page 9 of 11 146101 09/21/2023 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were received from pharmacy in a timely manner for 1 of 1 resident (R126) reviewed for medications. The findings include: R126's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include encounter for surgical aftercare following surgery on the digestive system, osteoarthritis, obesity, moderate persistent asthma, benign neoplasm of ascending colon, and generalized anxiety disorder. R126's care plan initiated 9/14/23 showed, Pain . Alteration in comfort related to cervical spondylosis without myelopathy, OA (osteoarthritis), knee pain. Baclofen for muscle spasms. Pain control as evidenced by verbalizing satisfaction with level of comfort, ability to participate in ADL's (Activities of Daily Living) without discomfort. Early detection of pain for timely intervention to prevent escalation . Assess pain level as evidenced by reported pain, restlessness, pupil dilation, perspiration, changes in vital signs from baseline date. Report uncontrolled pain to the provider . R126's September 2023 physician order sheet showed an order for Baclofen 5 mg three times daily for muscle spasms and an additional order for Baclofen 10 mg daily at bedtime for muscle spasms. R126's September 2023 Medication Administration Record showed the first dose of Baclofen she received was on 9/16/23 at bedtime. (R126 missed 7 doses of prescribed Baclofen.) The pharmacy requisition dated 9/16/23 showed R126's Baclofen arrived at the facility on 9/16/23. On 9/19/23 at 1:30 PM, R126 said, While I was in the hospital, they started me on Baclofen because the doctor said it would be complimentary to my Percocet. I was supposed to get a knee replacement in two weeks and between the Percocet and the Baclofen it was working really well for me. I was supposed to be getting the Baclofen, but I wasn't getting any, so I asked about it on Saturday and the nurse said that it had been ordered. She called the pharmacy, and the pharmacy said it wasn't ordered. Then they said it would be here at 2. Come to find out the driver was leaving the pharmacy in Chicago at 2 and had to make many stops in between before getting here. I did finally get the Baclofen on Sunday night I think it was and it has been helpful. R126's nursing note entered on 9/14/23 at 9:20 PM showed, . She brought her meds from home, but I did order the ones she does not have from our pharmacy. R126's nursing note entered on 9/15/23 at 5:09 PM showed, . Send copy of orders to the pharmacy in regards to patient's two orders for Baclofen 5 mg TID (three times daily) for muscle spasms and Baclofen 10 mg tablet at bedtime. R126's nursing note entered on 9/15/23 at 9:47 PM showed, . Attempted to call pharmacy x 3 with no answer attempting to check on status of patients medications. R126's complete medical record showed no evidence of the physician or nurse practitioner being notified of the missing medications. 146101 Page 10 of 11 146101 09/21/2023 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/20/23 at 2:26 PM V10 (Registered Nurse) said, Nurses enter the admission and order the medications. Our protocol is if there is an order from the hospital, we fax that to the pharmacy. The pharmacy would be the one entering the medications. We have to fax that, so it is immediate. Then we check within 30 mins or so and they might call and ask us questions. The medications delivery is once daily early morning. We would follow up with the nurse practitioner who is here 3 times a week regarding medications that are not available. On 9/21/23 at 11:13 AM, V2 (Director of Nursing) said when residents are admitted to the facility, they come from the hospital with their discharge summary that shows their medications. The nurse faxes that discharge summary to the pharmacy and they enter the orders. The nurse here goes into the resident's record and reconciles the medications and signs off on them. V2 said R126's medications should have arrived at the facility the next morning around 5:15 AM. V2 said she called the pharmacy to look into the medications not being sent. V2 said on 9/15 the nurse noted that she attempted to call pharmacy 3x with no answer and attempted to check on the status of R126's medications. V2 said on the resident's medication administration record the red V means it was not given. V2 said she called the pharmacy today to find out what happened with R126's Baclofen order and the pharmacy said they just 'missed it'. V2 said the facility does not have a policy or procedure for missing medications. The facility's policy supplied by the pharmacy with revision date of 1/15/2015 showed, Administration of Medications General Guidelines . 12. Medications are administered in accordance with written orders of the physician or other authorized prescriber . 146101 Page 11 of 11