Health inspection·August 22, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 treat 8 residents with dignity. This applies to 4 of 4 residents (R6, R11, R12, R17) reviewed for dignity in the sample of 13 and 4 residents (R2, R9, R22, R23) outside of the sample. The findings include: On 8/21/24 at 11:35AM, R2, R6, R9, R11, R12, R17, R22, and R23 were being served their noon meal. All residents received their water, fruit cups, pasta salad, and cucumber tomato salads in disposable plastic cups. On 8/21/24 at 12:42PM, V12 (Dietary Manager) stated, The kitchen staff measured the food and placed them in plastic cups. They should have then placed the food into the small bowls we have but they forgot to. It's a dignity concern that they left everything in plastic cups because they should feel like they are eating with normal dishes. We only use disposable dishes if a resident is on isolation or if we have a malfunction with our dish machine. This was not the case today and my staff should know better. Any reasonable person would want to eat with regular dishes, not disposable. The facility's policy titled, Resident Dignity revised 9/2023 showed, (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 7 146101 146101 08/22/2024 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 8/21/24 at 9:45 AM, R10 was lying in bed on his back. R10's left heel was offloaded with a pillow. R10's right heel was laying on the bed. R10 had dressings intact to his bilateral legs. R10 stated he had a wound to his buttock. R10 declined having his dressing change to his buttock observed. R10 stated he has very little privacy and would like a few minutes in private for the dressing change to be done. R10 stated the dressing is changed on night shift. Residents Affected - Few On 8/21/24 at 1:12 PM, V8 (Certified Nursing Assistant/CNA) and V9 (CNA) transferred R10 from his recliner to his bed. R10 had gauze dressings wrapped around his bilateral lower legs. V8 and V9 turned R10 onto his side to remove the mechanical lift sling. A wrinkled, square dressing was on his upper, medial left buttock. A review of R10's record was conducted on 8/20/24 - 8/22/24. The wound documentation in the skin area on the electronic medical record was not up to date. R10 did not have complete weekly skin assessments for his pressure injury to his buttock and coccyx area. On 8/22/24 at 12:15 PM, V15 (DON) presented all the information she could find related to R10's wounds and was documented below in the record review. V15 stated they don't have a wound nurse in the building. V15 stated the NP (Nurse Practitioner) is overseeing treatment orders for wounds. V15 stated on resident's TARs (Treatment Administration Records) there are orders for weekly skin checks. V15 stated the nurse manager on each unit oversees the wound program for their unit. V15 stated hospice is overseeing wounds for their residents. V15 stated R10 had wounds upon admission to the facility. V15 stated weekly wound measurements and assessments should be done. V15 stated the assessments should be documented weekly in the skin care tab or wound notes. The NP only looks at a wound when they ask her to. On 8/22/24 at 12:55 PM V7 (Licensed Practical Nurse/Nurse Manager) stated there isn't a wound program at the facility. V7 stated right now the nurses are measuring wounds and documenting on them weekly. V7 stated they should be measuring the wound, describing the wounds appearance, if there is and pain and/or odor present. V7 stated R10 has an unavoidable stage 3 wound to his buttock; he is non-compliant with care. The Nurse's Notes for R10 showed, 4/8/24 at 10:48 PM showed R10 was admitted to the facility with multiple open areas noted At 11:22 PM the note showed multiple open areas including the left buttock 5.5 cm (centimeters) x 3 cm and 4 cm x 6 cm. No other description was given. The Wound Rounds notes for R10 showed, 4/15/24 - left buttock 9 cm x 9 cm x 0.1 clustered. No additional description or stage was documented. On 4/22/24 - left buttock measured 7 cm x 6.5 cm x 0.1 cm, clustered. No additional description or stage was documented of the wound. On 4/29/24 - left buttock 7 cm x 6 cm x 0.1 cm; coccyx 2 cm x 0.6 cm x 0.1 cm, stage 2 wound. There were no additional descriptions of the wounds given and no staging of the left buttock wound. The Wound Visit Report for R10 showed, 5/6/24 - wound #6 left medial buttock is stage 3 pressure injury ; 3 cm x 3 cm x 0.1 cm. There is a moderate amount of serosanguinous drainage noted. Wound bed has 51-75%, pink, granulation, 1-25% slough, no eschar, and no epithelialization present. Two open areas to buttock. Medial buttock wound erythema, 1 cm peri wound maceration present. Wound #7 left lateral buttock is stage 3 pressure injury ; Measurements are 1 cm x 2 cm x 0.1 cm There is a moderate amount of serosanguinous drainage noted. Wound bed has 76-100%, pink granulation, 1-25% slough, no eschar, and no epithelialization present. 146101 Page 2 of 7 146101 08/22/2024 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0686 Level of Harm - Minimal harm or potential for actual harm A Progress Notes for R10 showed, on 5/19/24 - left buttock 0.3 cm x 0.3 cm, 1 cm x 0.5 cm. There was no description of the wound or staging. On 5/23/24 showed, coccyx 0.5 cm x 1.5 cm. No other wounds were documented. There wasn't a description or stage of R10's coccyx wound. The Wound Rounds dated 6/25/24 for R10 showed, sacral wound 6 cm x 6 cm x 0.1 cm; slough 100%? Residents Affected - Few The Nurses Note's for R10 showed, on 8/1/24 at 9:13 AM - wound to left buttock measures 1.6 cm x 1.0 cm. On 8/15/24 at 9:10 PM - wound on left buttock measures 1.9 cm x 2.0 cm. Wound bed is covered with slough. Report written to nurse practitioner. The Physician Orders dated 8/21/24 for R10 showed diagnoses including anemia, gout, non-pressure chronic ulcers to lower leg, adult failure to thrive, paroxysmal atrial fibrillation, osteoporosis, pressure ulcer left heel, osteoarthritis, pressure ulcer left buttock, and localized edema. R10's current Care Plan dated 4/8/24 showed, at risk for impaired skin integrity related to decreased movement. Observe for any changes in skin condition and notify nurse. Nurse to monitor skin and document on Weekly Skin Assessment. Based on interview and record review, the facility failed to complete weekly wound assessments for a resident (R17) with a stage 2 pressure ulcer, failed to ensure complete weekly wound assessments were done for a resident (R10) admitted with a stage 3 pressure ulcer. These failures apply to 2 of 2 residents reviewed for pressure ulcers in the sample of 13. The findings include: 1. R17's electronic face sheet printed on 8/22/24 showed R17 has diagnoses including but not limited to pressure ulcer of sacral region, dysphagia, dementia with behaviors, and anxiety disorder. R17's facility assessment dated [DATE] showed R17 has a Stage 2 pressure injury. R17's care plan dated 3/19/20 showed, At risk for Impaired Skin Integrity. Wound to buttocks .monitor wound progress and document and measure weekly. R17's weekly wound assessments from 6/2/24-8/2/24 showed R17 did not receive a weekly wound assessment from 6/25/24-8/2/24 (4 weeks). On 8/22/24 at 12:33PM, V15 (Director of Nursing/DON) stated, We do not have all of the weekly assessments for (R17). We thought hospice was doing them, but they were just doing a note saying, wound continues and documenting if they did a dressing change. I didn't realize we had to do our own wound assessments if they were a hospice patient. We definitely need to improve our process because wounds should be diligently monitored so they don't worsen. The facility's policy titled, Documentation and Treatment of Wounds revised on 6/2023 showed, It is the policy of (facility) to document wound status weekly. Wound status will be documented on the back of the treatment sheets. Pressure sore status will be documented on the pressure sore sheet .1. Documentation will include: i. description of size, color, drainage and odor at the time of discovery and a weekly progression thereafter. ii. Assess skin turgor, elasticity, and fragility of skin. iii. Last documentation will describe healed area. iv. Documentation will be done by the day shift unless treatment is only done by P.M. shift of night shift. Then shift doing treatment will do 146101 Page 3 of 7 146101 08/22/2024 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0686 documentation . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146101 Page 4 of 7 146101 08/22/2024 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to ensure a catheter tubing remained free of kinks and the catheter tubing secure device was in place for 1 of 1 resident (R25) reviewed for catheters in the sample of 13. The findings include: On 8/20/24 at 1:35 PM, R25 was in his room in his recliner. R25 had an indwelling urinary catheter drainage bag attached to the lower part of his wheeled walker. R25 had thick white sediment and cloudy yellow urine in his catheter tubing. R25 did not have a catheter tubing secure device in place. R25 stated he has not had one (catheter secure device) on for two weeks. R25 stated they must have run out of them. R25 stated he wouldn't mind having one (catheter secure device) on now. R25 said it would help prevent his catheter from coming out. R25 stated his catheter is leaking right now. On 8/20/24 at 1:47 PM, V10 (Licensed Practical Nurse) stated, R25 had some pressure so to be on the safe side they collected a urine sample. V10 stated R25's tubing was kinked and that is why they took a urinalysis. V10 stated sometimes when R25 sits or moves the tubing gets kinked. V10 stated he thought this happened over the weekend. V10 stated staff should monitor R25 closer so his catheter tubing doesn't get kinked. V10 stated they use a catheter secure device for R25. V10 stated he did not recall if the facility ran out of the devices or had problems obtaining them. V10 stated he doesn't know if R25 has a catheter secure device in place or not. V10 stated the last time R25's catheter came out was on 8/15/24 and it came out during AM care. The Physician Orders dated 8/21/24 for R25 showed an order dated 4/1/24 for a catheter tubing secure lock device every shift. The Care Plan dated 8/18/24 for R25 showed, Indwelling catheter use with potential for infection. 18 French Coude, 10 cc (cubic centimeter) balloon. Secure catheter to leg to avoid tension on urinary meatus. The August 2024 TAR (Treatment Administration Record) for R25 showed secure lock for catheter every shift. The secure lock device was documented on 8/8/24, 8/17/24, 8/20/24 and 8/21/24 to show that it was in place. It is to be documented on the day shift that it is present. The Face Sheet dated 8/21/24 for R25 showed diagnoses including Parkinson's disease, mechanical complication of other urinary catheter, benign prostatic hyperplasia with lower urinary tract symptoms, restless leg syndrome, hypothyroidism, hyperlipidemia, gastro-esophageal reflux disease, history of falling, lack of coordination, muscle weakness, general anxiety disorder, weakness, and insomnia. The facility's Catheter Care policy (6/2023) showed, Purpose: To provide nursing measures to prevent infection and maintain the unobstructed flow of urine through catheter drainage system. Checks for patency of the tubing is to be checked with care each shift. The policy did not have anything in place for catheter secure devices. 146101 Page 5 of 7 146101 08/22/2024 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3. On 8/21/24 at 1:14 PM, R10 was sitting in the recliner in his room. V8 (Certified Nursing Assistant/CNA) and V9 (CNA) had mask and gloves on when entering R10's room. V8 and V9 used a mechanical lift device to transfer R10 from his recliner to his bed. Once R10 was transferred to bed, V8 and V9 rolled him back and forth to remove the sling and adjust the linen under him. R10 had a wrinkled dressing to his left buttock, a dressing to his right knee, and dressings to his bilateral lower legs. V8 and V9 stated there was no reason to wear gowns for this activity. V8 stated there wasn't a sign on the door saying they needed to wear anything. V9 stated she just goes by whatever the sign that is posted states to do. V9 stated she didn't see any signs or isolation cart outside R10's room. Residents Affected - Many On 8/21/24 at 1:26 PM, V7 (Licensed Practical Nurse/Nurse Manager) stated they did not have anyone on enhanced barrier precautions. V7 stated R10 has wounds but has not needed to be on any precautions. V7 stated she did not know about enhanced barrier precautions. V7 stated they have never worn gowns and gloves for him the entire time he has had wounds. The Physician Orders dated 8/21/24 for R10 showed, left buttock, medial and lateral wounds, cleanse daily, apply thin layer of Santyl to wound beds, and cover with bordered dressing every day. Right knee - once daily cleanse, apply thin layer of Santyl to wound beds. Cover with bordered dressing every day. The Nurses Note's for R10 showed, on 8/1/24 at 9:13 AM - wound to left buttock measures 1.6 cm x 1.0 cm. On 8/15/24 at 9:10 PM - wound on left buttock measures 1.9 cm x 2.0 cm. Wound bed is covered with slough. Report written to nurse practitioner. The Physician Orders dated 8/21/24 for R10 showed diagnoses including anemia, gout, non-pressure chronic ulcers to lower leg, adult failure to thrive, paroxysmal atrial fibrillation, osteoporosis, pressure ulcer left heel, osteoarthritis, pressure ulcer left buttock, and localized edema. On 8/21/24 the facility did not have a policy for Enhanced Barrier Precautions. Based on observation, interview, and record review the facility failed to ensure their infection control policies and procedures were reviewed annually and update the policies to include Enhanced Barrier Protection (EBP) and failed to have measures to prevent the growth of Legionella in the facility water systems for all 30 residents residing in the facility reviewed for infection control. The findings include: 1. The facility's CMS form 671, the Long-Term care facility application for Medicare and Medicaid documents 30 residents reside in the facility. On 8/21/24 at 1:50 PM, V3 (Infection Preventionist) said no residents were on EBP and does not know about the requirements for EBP. She said there is no need for postings or signs on residents' doors to indicate the enhanced barrier precautions, the staff know what they are supposed to wear into the rooms. She said if residents have open wounds or catheters, the staff know to wear a gown and gloves. On 8/22/24 at 8:56 AM, V6 (Licensed Practical Nurse/LPN) said residents with catheters and open wounds should be on EBP. I do not think they have that in place here. She said she is aware of EBP from 146101 Page 6 of 7 146101 08/22/2024 Willows Health Center 4054 Albright Lane Rockford, IL 61103

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many working in other facilities. She said there were residents on the wing which should be under the EBP precautions, but no postings or signs have been placed. She did not recall if she received any information or training regarding EBP upon her hire 2 months ago. On 8/21/24, resident hallways were observed to have no residents on enhanced barrier precautions for oxygen or catheters, only contact or droplet isolation rooms have PPE and signs posted outside their doors. On 8/22/24 at 9:03 AM, V3 said she had since reviewed EBP procedures and said any resident with open wounds, urinary catheters or IVs should have signs on their door for EBP, with PPE (personal protective equipment) available such as gowns and gloves, and each resident should also have a care plan in place for the enhanced barrier requirements. V3 said she was not made aware of the changes, and therefore had not implemented EBP. V1 (Administrator) said there is no current policy for EBP. He said the previous administrator had been doing the infection control and did not share the updated information with V3 and did not update the policies in infection control. On 8/22/24 at 9:30 AM, V3 said the policy updates are issued to the medical director but could not say if all of the policies are reviewed annually. She said the policies and procedures are updated as needed and after quality assurance meetings every 3 months. The facility policy for Covid-19 was revised on 7/2024 but does not include EBP policies or procedures. Their policies for antimicrobial stewardship and flu and pneumovax were last reviewed 6/2023. The Infection control pathway was dated 5/2017. 2. On 8/22/24 at 9:30 AM, the facility water management program assessment was requested from maintenance. V4 (Maintenance Supervisor) said there has not been an assessment of the water systems and had no diagram of the water systems. He said there had been testing of the cooling tower, but no other measure put in place. He said no other monitoring/ protocols or policies were presented. On 8/22/24 at 10:00 AM, V1 said there is no policy for water management, and there has been no assessment for Legionella. He said if V4 and V5 (Director of Facility and Grounds) do not have the information, then there is none. 4. R17's electronic face sheet printed on 8/22/24 showed R17 has diagnoses including but not limited to pressure ulcer of sacral region, dementia with behaviors, hematuria, and anxiety disorder. R17's physician's orders showed no orders for Enhanced Barrier Precautions. R17's care plan did not contain any care plan related to Enhanced Barrier Precautions. On 8/21/24 at 12:39PM, R17's doorway did not have any signs posted that indicated R17 was on Enhanced Barrier Precautions. R17's doorway and room did not have any PPE (Personal Protective Equipment) cart accessible to staff with gowns and gloves. V13 (CNA) and V14 (Nurse Manager) provided incontinence care for R17. V13 and V14 wore gloves and no gown for the entirety of R17's personal cares. V13 stated the only PPE staff wear in R17's room is gloves. V13 stated she does not know anything about residents on her unit being on enhanced barrier precautions and if no sign is on the door then she just uses standard precautions. 146101 Page 7 of 7