Health inspection·September 7, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure hand hygiene was performed during a dressing change for one of one resident (R182) reviewed for pressure ulcers in a sample of 20. Residents Affected - Few Findings include: The CDC (Center for Disease Control website documents Keep PPE (Personal Protective Equipment) available in all sizes for staff and providers. Wear gloves during all stages of wound care including when applying new dressings. [NAME] gloves after performing hand hygiene. During an individual resident's wound care, doff gloves every time when going from dirty to clean surfaces or supplies. On 09/06/23 at 11:30AM V7 Licensed Practical Nurse (LPN) entered R182's room, put gloves on, took keys out of shirt pocket, unlocked cart, opened multiple drawers and removed supplies. V7 removed dressing from resident's right heel, sprayed gauze 4x4 with normal saline and rubbed in a circular motion. V7 removed gloves, put new gloves on, removed dressing from packaging, cut approximate amount and returned the rest to the package, and applied new dressing. On 9/6/23 at 11:38 AM V7 (LPN) stated I should have washed my hands before I started, used hand sanitizer in between and I shouldn't have touched the clean gauze with my gloves that had just taken off the dirty dressing. Page 1 of 7 146111 146111 09/07/2023 Golden Good Shepherd Home 101 Prairie Mills Road Golden, IL 62339

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 ensure two staff members were present and a safety transfer (gait) belt was used during a resident transfer for one resident (R27), and failed to ensure falls were thoroughly investigated to determine a root cause of the falls and develop new fall prevention interventions for one resident (R18) of two residents (R27, R18) reviewed for accidents in a sample of 20. Findings include: 1. A Resident Handling Policy (Limited Lift Policy) dated 11/1/2008 states, Mandatory gait (safety transfer belt) belt usage for all resident handling with the exception for bed mobility (and) medical contraindications. R27's Minimum Data Set (MDS) assessment dated [DATE] documents R27 requires the extensive assistance of two staff to transfer between surfaces including to or from bed, chair, wheelchair and standing position. R27's fall risk assessment dated [DATE] documents R27 is at high risk for falling because of risk factors that include a balance problem while standing or walking, has decreased muscular coordination, and requires use of assistive devices. On 9/5/23 at 11:31a.m. V5 (Certified Nurse Aide/CNA) was in R27's room preparing to transfer R27 from the recliner to the wheelchair. Without calling for a second staff member to assist or placing a safety transfer belt around R27's waist, V5 placed R27's walker in front of R27, then assisted R27 to stand. R27 appeared unsteady on her feet and required extensive assistance and cueing to take a few steps from the recliner to the wheelchair before V5 assisted R27 to sit back down. At 11:40a.m. V5 verified V5 transferred R27 from the recliner to the wheelchair without the assistance of a second staff member and without using a safety transfer belt. V5 stated she usually uses a safety transfer belt for all resident transfers. On 9/6/23 at 10:55a.m. V2 (Director of Nurses) stated that if a resident is assessed as requiring extensive assistance, a safety transfer belt should be used by staff to transfer that resident from place to place. 2. The Facility's Fall Prevention Program dated 8/1/2008 documents It is the policy of (this facility) that the resident's environment remain free of accident/fall/injury hazards as possible and that each resident receive appropriate assessment, supervision and assistance to prevent accidents/falls/injuries with the implementation of a fall prevention program. The program will include environmental/safety precautions, generic resident care strategies, resident specific assessment, quality assurance review and staff education. R18's Nurse's Notes dated 6/20/23 document resident was observed with legs and partial buttocks off bed and was assisted to the floor by staff. R18's Current care plan dated 7/4/23 does not address any incident on 6/20/23. 146111 Page 2 of 7 146111 09/07/2023 Golden Good Shepherd Home 101 Prairie Mills Road Golden, IL 62339

F 0689 R18's Nurse's Notes dated Level of Harm - Minimal harm or potential for actual harm 7/18/2023 document R18 was found lying on the floor next to his bed. Residents Affected - Few R18's Current care plan dated 7/4/23 documents keep my bed in low position with wheels locked when not attending to me. R18's Current care plan with an update dated 7/18/23 documents maintain bed in low position. On 9/6/23 at 11:30 AM V2 (Director of Nursing) stated I don't know why (staff) repeated an intervention that was already in place, they shouldn't have. R18's Nurse's Notes dated 7/19/23 document R18 was found face down on the floor in his room. R18's Current care plan dated 7/18/23 does not include any intervention regarding fall on 7/19/23. R18's Nurse's Notes dated 7/29/23 document R18 was observed sliding out wheelchair while sitting in his room. R18's Current care plan dated 7/18/23 does not include any new intervention regarding R18 sliding out of his wheelchair on 7/29/23. R18's Nurse's Notes dated 8/4/23 document R18 was found on the floor in his room. R18's Current care plan dated 7/18/23 does not include any new interventions regarding R18 being found on the floor on 8/4/23. Throughout the survey, R18 had a fall alarm on his wheelchair. R18's medical record does not include any mention of R18 having a fall alarm. On 9/6/23 at 11:30 AM V2 (Director of Nursing) confirmed that she did not have any investigations into any of R18's fall to determine why he continues to fall or any new interventions after each fall. V2 stated she didn't know where the fall alarm intervention came from. 146111 Page 3 of 7 146111 09/07/2023 Golden Good Shepherd Home 101 Prairie Mills Road Golden, IL 62339

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify adverse target behaviors or document a diagnosis to warrant the use of an antipsychotic medication for one of four residents (R27) reviewed for psychoactive medication use in a sample of 20. Findings include: A Psychotropic Medication Program policy (undated) gives as its purpose, To prevent the use of unnecessary medications. Under procedures and key points, this policy states, Assessment will begin when facility staff determines the resident is exhibiting untoward behaviors that place the resident, or their peers in danger. The social services department shall be alerted when noting any untoward behavior. Upon the noting of behaviors focus charting will be initiated for ongoing assessment. The nursing staff along with the IDT (interdisciplinary team) will attempt to identify any potential causes for the untoward behavior. This may include but not limited to, acute health conditions, social settings, personal choices and interests, etc. (etcetera). In addition, this policy states, The initial plan for treatment of behaviors will include such alternatives as: diversional activities, change in environment, psycho-social programming, treatment of acute medical conditions, etc. Treatment will be added to care plan. When alternatives have been exhausted, the use of a psychotropic may be deemed necessary by the attending physician. R27's list of current diagnoses includes Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety; and Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, and Urinary Tract Infection (UTI). R27's physician's orders (POS) dated 5/10/23 documents R27 was prescribed the antipsychotic medication Olanzapine 5mg (milligrams) daily at bedtime for the diagnosis of Dementia without behavioral disturbance. R27's admission Minimum Data Set (MDS) assessment dated [DATE] and quarterly MDS dated [DATE] document R27 is severely cognitively impaired and has exhibited no indicators of psychosis and no behavioral symptoms. R27's care plan dated 5/17/23 documents R27 has behavior tracking for the behavior of depression, feeling down or hopeless, and trouble with sleep. R27's nursing progress notes dated 6/5/23 to 8/10/23 document R27 had three behaviors during that time. R27's first Behavior nursing progress note dated 6/5/23 documents that R27 refused pain medication and scheduled medications by stating, Those aren't my pills. R27's second Behavior nursing progress note dated 8/1/23 documents that R27 was found situated sideways in her recliner because R27 tried to get up without assistance. R27's third Behavior nursing progress note dated 8/10/23 stated that R27 was anxious, suspicious of staff, and spit out her medications. This note also documents R27 read the nurse's name tag and asked, What is this? In addition, this note documents that R27 refused to eat her supper stating, I don't know what this is. I don't know what any of this is! R27's nursing progress note dated 8/12/23 documents that at that time R27 was being administered the antibiotic 146111 Page 4 of 7 146111 09/07/2023 Golden Good Shepherd Home 101 Prairie Mills Road Golden, IL 62339

F 0758 Keflex 500mg three times daily for the diagnosis of UTI. Level of Harm - Minimal harm or potential for actual harm R27's Pharmacy Consultation Report dated 7/18/23 under the comment section states, (R27) receives an antipsychotic, Olanzapine 5mg at bedtime, for a potentially inappropriate indication: dementia without behavioral disturbance-medication was initiated at recent hospital admission. This report does not indicate that R27's physician ever reviewed or signed this recommendation. R27's Pharmacy Consultation Report dated 8/8/23 under the comment section states, (R27) receives an antipsychotic, Olanzapine 5mg at bedtime, for a potentially inappropriate indication: dementia without behavioral disturbance-medication was initiated at recent hospital admission. In addition, this report recommended that R27's Olanzapine be reduced to 2.5mg at bedtime. R27's physician's response was to agree to the reduction in Olanzapine, however, R27's physician did not provide an indication to warrant the use of this medication. Residents Affected - Few On 9/5/23 at 11:00a.m. R27 was in her room seated in a recliner. R27 was pleasantly confused and unable to make conversation. V5 (Certified Nurse Aide) entered R27's room and assisted R27 to transfer from the recliner to the wheelchair so R27 could go to the dining room for lunch. Once R27 was seated in the dining room, she sat quietly at her table while being fed by staff. During these observations, R27 did not exhibit any behaviors including behaviors that placed R27 or her peers in danger. At 11:10a.m. V5 stated that R27 does not usually have any behaviors. V5 stated that R27 does not have any behaviors that place herself or her peers in danger. At 11:17a.m. V4 (Registered Nurse) stated she is R27's nurse. V4 stated that R27 gets more confused in the evening. V4 stated that when R27 is more confused, R27 is in her own world. V4 stated that R27 is not a danger to herself or her peers. On 9/6/23 at 9:30a.m. V3 (Assistant Director of Nurses/ADON) stated that she manages psychoactive medications for the facility. V3 stated she is new to this position. V3 stated that R27's diagnosis indicating the need for an antipsychotic medication is Dementia without behavioral disturbance. V3 was not sure what behaviors R27 exhibited to warrant the use of an antipsychotic medication. V2 (Director of Nurses/DON), who was in the same office, stated that Dementia without behavioral disturbance isn't a diagnosis which warrants the use of an antipsychotic medication. V2 stated that target behaviors are determined by V9 (Social Services). V2 and V3 were unable to provide documentation of what non-pharmacological measures were attempted or exhausted before R27 was prescribed and administered Olanzapine. On 9/6/23 at 1:27p.m. V9 stated she does not determine what target behaviors warrant the use of an antipsychotic medication. V9 stated that is V3's responsibility. V9 stated she just adds behaviors to the care plan based on nurses' behavior tracking progress notes. V9 stated R27 has had few behaviors since she was admitted to the facility in 5/2023. V9 stated none of the behaviors R27 does have seem to be distressing to R27. V9 stated she believes any behaviors R27 has had were related to R27's recent UTI. 146111 Page 5 of 7 146111 09/07/2023 Golden Good Shepherd Home 101 Prairie Mills Road Golden, IL 62339

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure their infection prevention antibiotic stewardship program addressed prophylactic antibiotic use. This has the potential to affect all 34 residents in the facility. Residents Affected - Many Findings include: An Antibiotic Stewardship Program policy excerpt dated 1/1/2018 instructs, Providers will utilize the Loeb Criteria when considering initiation of antibiotics. An excerpt of this policy dated 12/1/2017 states, At 72 hours after antibiotic initiation or first dose in the facility, each resident will be reassessed for consideration of antibiotic need, duration, appropriateness, and de-escalation potential. Within the Antibiotic Stewardship policy is the Loeb Criteria for determining presence of UTI. The Loeb Criteria instructs that residents with indwelling catheters are appropriate for antibiotic therapy if they demonstrate one of the following: a fever of 100 degrees Fahrenheit (100F) or repeated temperatures of 99F; new back pain or flank pain; acute pain; rigors/shaking chills; new dramatic change in mental status; hypotension (significant change from baseline blood pressure or a systolic (top number) of less than 90 mmHg (millimeters of mercury). For residents without catheters, this policy instructs the criteria for antibiotic use are met if residents demonstrate one of three situations: 1. acute dysuria (pain and/or burning during urination), 2. a single temperature of 100F and at least new or symptoms of worsening urgency, frequency, back or flank pain, suprapubic pain, gross hematuria (blood in urine), or urinary incontinence; 3. no fever, but two or more of the following symptoms: urgency, frequency, incontinence, suprapubic pain, gross hematuria. This Loeb Criteria policy documents that if any of the above criteria are not met, the resident does not need an immediate prescription for an antibiotic but may need additional observation because the resident's symptoms are insufficient to indicate an active Urinary Tract Infection. A Center's for Disease Control and Prevention recommendation guide titled Limited Prolonged Antibiotic Prophylaxis for Urinary Tract Infection (undated) states, Antibiotics are frequently prescribed for prolonged duration for the prevention of infection or prophylaxis in nursing homes. 1. While antibiotic prophylaxis may reduce recurrent UTIs in specific population, 2-3 there is no clear evidence on prevention of recurrent UTIs among nursing home residents with asymptomatic bacteriuria. 4 Furthermore, antibiotic use carries the risk of harm to residents, including adverse drug events and increased antibiotic resistance, which argue against the use of prolonged antibiotic therapy in nursing home residents. 1. On 9/5/23 at 11:00a.m. R27 was seated in a recliner in her room. R27 was pleasantly confused but did not complain of symptoms of pain or urgency to urinate and did not have a urinary catheter in place. R27's Physician Order Sheet dated 8/21/23 documents Keflex 250mg capsule in the morning for prophylactic (preventive), to start 8/29/23. This same order does not include a duration or stop date for this antibiotic. R27's nursing progress notes dated 8/21/23 to 9/7/23 do not include R27 had any symptoms listed on the Loeb Criteria which meets the criteria for antibiotic use. R27's log of temperatures documents that R27 has not had a fever of 100F or greater. 146111 Page 6 of 7 146111 09/07/2023 Golden Good Shepherd Home 101 Prairie Mills Road Golden, IL 62339

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 9/6/23 at 1:47p.m. V3 (Assistant Director of Nurses/ Infection Preventionist) stated that she monitors residents for signs of infection and for appropriateness of physician's orders for antibiotics. V3 stated that R27 was prescribed the antibiotic Keflex as a preventive measure because of recurring Urinary Tract Infections. V3 stated she does not believe there is any reason to prohibit the use of antibiotics prescribed for prophylactic use. V3 verified that R27 was not exhibiting any symptoms or criteria listed on the Loeb Criteria for antibiotic use. 2. R12's Physician Order Sheet dated September 2023 documents Cephalexin 250 mg (milligram) every day for reoccurring urinary tract infections. R12's Nurse's Notes document R12 was admitted to the facility on [DATE] with prophylactic antibiotic for reoccurring urinary tract infections. On 9/7/23 at 11:00 AM V2 (Director of Nursing) stated (R12) has not had any urinary tract infections since she has been here. We are trying to get the doctor to quit ordering prophylactic antibiotics. V2 stated that currently there are only two residents on prophylactic antibiotics. The Centers for Medicare and Medicaid Resident Census and Condition of Residents form 672 dated 9/5/23 and signed by V1 (Administrator) documents that at the time of the survey 34 residents resided in the facility. 146111 Page 7 of 7