Health inspection·June 27, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on interview, document review and observation, the facility failed to ensure residents retained their personal items. This failure has the potential to affect all 54 residents residing in the facility. Residents Affected - Many Findings include: 06/25/24 11:51 AM, Resident council meeting three residents (R2, R5, R144) complained of missing items and a slow response to return clothes because a washing machine part is broken and hasn't worked in a year. The Resident Council Monthly Meeting minutes dated October 2023 through June 2024 documents complaints of missing clothes and slow response return clothing/items. On 6/24/24 at 9:20 AM, V9 (Housekeeping Supervisor) stated Once a month V8 (Activity Director) fills out a form and gives it to me. I look for the missing items and write down what items I cannot find and give it back to her. It (Washing Machine) has been broken for over a year. They have been telling me the parts are going to be here for 6 months now. I can't keep up. We used to have two laundry people now it's just me and another person on second shift from 2:00 PM until 10:00 AM. We struggle keeping up. When a resident is admitted , either the family or the CNA's mark the residents clothing (with resident identifiers) but usually the clothes just get put in a bin and I don't know who's they are. I hang them and put them on the missing items rack. I purchased my own label maker. On 6/26/24 at 9:20 AM, resident items were observed to be hanging on a rack and a bin with miscellaneous resident items were labeled as missing items. The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated 6/24/24, documents 54 residents residing in the facility. Page 1 of 16 146123 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure prior survey investigations were available and signs were posted to notify residents/families of the availability of the survey investigations. These failures have the potential to affect all 54 residents residing in the facility. Residents Affected - Many Findings include: On 6/25/24 at 11:00 AM, three (R2, R5, R144) Resident Council Members were all in agreement that they were unaware state investigations were available to read. Throughout the survey on 6/24/24, 6/25/24 and 6/26/24 a posted notice of availability of prior survey investigation findings was not observed. A State survey inspection binder was not observed during observational tours of the facility. On 6/25/24 at 1:42 PM, V8 (Activity Director) stated I'll have to go ask V1 (Administrator) where it is at (survey investigation binder). At 1:52 PM, V8 located the survey investigation binder at the entrance way and was behind the guest sign in book and a sign asking guest to sign in. The survey investigation binder was not visible and was located in a non-patient care area. On 6/28/24 at 3:00 PM, V1 verbally agreed signs were not posted to notify residents/families of the availability of the survey investigation binder. The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated 6/24/24, documents 54 residents residing in the facility. 146123 Page 2 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review the facility failed to provide the resident and resident representative with a written notice of transfer, for one of one resident (R18) reviewed for hospitalizations, in a sample of 34. Findings Include: R18's medical record documents that R18 was transferred to a local hospital on 7/30/23. No evidence of a facility notification to R18 of a transfer/discharge was present on R18's chart. On 6/26/24 at 1:30 P.M., V1/Administrator verified that the facility did not provide R18 or his representative with a written notice of transfer. 146123 Page 3 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital, for one of one resident (R18), reviewed for bed holds, in the same of 34. Findings Include: R18's medical record documents that R26 was hospitalized on [DATE]. R18's medical record does not contain documentation of written notice to R18 or R18's resident representative, of the facility bed hold policy. On 6/26/24 at 1:30 P.M., V1/Administrator verified that the facility did not provide R18 or his representative with a Bed Hold Policy or a written Notice of Transfer. 146123 Page 4 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview, and record review the facility failed to update the Care Plan to reflect the bilateral lower edema and daily weights for one of three residents (R212) in a sample of 34. Residents Affected - Few Findings Include: The facility policy titled, Comprehensive Care Plan, revised June 25, 2020, documents the following: An individualized comprehensive care plan that includes measurable objectives and time able to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 3.) Each resident's comprehensive care plan has been designed to: a. Incorporate identified problem areas. 5.) Care plans are revised as changes in the resident's condition dictate. R212's Diagnosis Sheet, dated 5/9/2024, documents R212's admission date as 5/9/2024. The Order Summary Report, dated 6/26/2024, documents the following diagnoses: Chronic Obstructive Pulmonary Disease, Solitary Pulmonary Nodule, Non-Rheumatic Mitral Valve Insufficiency, Coronary Artery Disease, Acute Kidney failure Congestive Heart Failure, Presence of Heart Assist Device related to Left Ventricular Dysfunction and Edema Bilateral Lower Extremities. The Order Summary Report, dated 6/26/2024, documents, Daily weight due to Left Ventricular Assist Device, contact the LVAD team with 5-pound weight gain one time a day related to Heart Failure. R212's Progress Notes, dated 6/18/2024, documents, A fax has been received from the cardiologist team with orders from V14/ Cardiologist for Metolazone 2.5MG (fluid retention) take 2 tablets by mouth daily for one day give 30 minutes prior to the Lasix (antidiuretic). R212's Progress Notes dated 6/18/2024 at 9:34PM R212's Progress Notes documents, The cardiology. team called back because of R212's edema and wants pictures of legs emailed to them to show V14/Cardiologist. The Weights and Vitals Summary for R212, dated 5/9 through 6/26/2024, documents daily weights starting 5/9/2024 on admission. The following daily weights were missing: 5/10 through 5/17, 5/18, 5/19, 5/21, 5/28,6/1, 6/4, 6/5, 6/10, 6/11, 6/15, 6/16, and 6/24/2024. On 6/28/2024 at 11:15AM V2(Director of Nurses) stated, R212's Care Plan needs to be specific for those daily weights. The doctor's order is to call the cardiovascular team if she has a gain of 5 pounds daily. The weights also need to be obtained every day as ordered. I was told from staff that they are getting the weights daily. I don't know what happened. I tried to locate them but cannot. 146123 Page 5 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

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 obtain physician ordered daily weights for two of two residents (R18), reviewed for edema, and failed to ensure Hospice plans of care were available to staff and kept updated in the resident's record for one of two residents (R14 and R32) reviewed for Hospice in the sample of 34. Residents Affected - Few FINDINGS INCLUDE: The facility's (undated) Hospice Nursing Facility Hospice Service Agreement documents, . (The) Hospice will furnish a copy of each Hospice patient's Plan of Care to the facility at the times of the resident's admission into the Hospice program. A Plan of Care is a written individualized plan of services necessary to meet the patient-specific needs for palliation or management of Hospice patient's terminal illness and related conditions necessary to meet the patient-specific needs which includes all patient care physician orders and planned interventions for problems identified during patient assessments; delineates the services to be provided by Hospice and Facility; is consistent with Hospice's philosophy; is based on an assessment of Hospice patient's current medical, physical, psychological and social needs and living situation; reflects the participation of Hospice, Family, Hospice patient's family and/or legally authorized representative, as appropriate and complies with applicable federal and state laws and regulations, established, maintained, reviewed and modified, if necessary, at intervals identified by the IDT (Intra Disciplinary Team). The Hospice Care Policy, dated 11/5/23, documents This facility will work in coordination with the contracted hospice agency to provide a safe continuum of care for the resident's end of life. The hospice agency will participate in the resident's plan of care and provide services/supplies outside the general PRN (as needed) procedures and be available to the resident, family and this facilities staff 24 hours/day. 1. R18's current Physician Order Sheet, dated June 2024 includes the following diagnoses: Acute Kidney Failure with Acute Cortical Necrosis; Edema. This same Physician Order Sheet includes the following physician orders: (3/21/24) daily weights and administer an additional 40 MG (Milligrams) Lasix if 2 (pound) weight gain.; Aldactone 25 MG one time daily for pitting edema; Lasix 40 MG one time daily for edema. R18's current Care Plan, dated March 2024 includes the following Focus areas: (R18) is currently on diuretic therapy related to edema. Also included are the following Intervention areas: Administer medications and treatments ordered by the physician. R18's Daily weights for April, May, June 2024 document 11 missing daily weights for April, 17 missing daily weights for May and 14 missing daily weights for June 2024. On 6/26/24 at 2:10 P.M., V2/Director of Nurses verified the missing daily weights for April, May and June 2024. 2. R32's current Hospice Plan of Care, dated 4/26/24, documents that R32 was admitted to hospice services on 11/13/23 with the diagnoses of Senile Degeneration of the Brain and Malignant Neoplasm of the Bladder Neck. R32's facility care plan, dated 11/13/23, documents, (R32) is currently on Hospice r/t bladder 146123 Page 6 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0684 cancer. R32's care plan is not specific to Hospice services or what Hospice cares R32 should receive. Level of Harm - Minimal harm or potential for actual harm On 6/26/24 at 9:35 A.M., V2/Director of Nurses stated We didn't have the Care Plan from Hospice in the building until today. Hospice just emailed me the updated Hospice care plan for (R32). Residents Affected - Few 3. On 5/28/24, the Physician ordered R14 to be admitted to Hospice and a Hospice contract was signed. On 5/28/24, the Care Plan documents currently on Hospice Care related to Senile Degeneration of the Brain and Dementia. On 6/24/24 at 12:30 PM, R14's Hospice record was unable to be produced for review. On 6/24/24 at 1:00 PM, V10 (Licensed Practical Nurse/LPN) stated the Hospice staff documents electronically on their own software and the facility does not have access to the hospice's plan of care or other visit documentation. V10 stated there is usually an on-call schedule for the hospice nurse and certified nurse aid at the desk although the schedule could not be located. 4. The Order Summary Report, dated 6/26/2024, documents, Daily weight due to Left Ventricular Assist Device, contact the LVAD (Left Ventricular Device Team with 5-pound weight gain one time a day related to Heart Failure. The Weights and Vitals Summary for R212, dated 5/9 through 6/26/2024, documents daily weights starting 5/9/2024 on admission. The following daily weights were missing: 5/10 through 5/17, 5/18, 5/19, 5/21, 5/28,6/1, 6/4, 6/5, 6/10, 6/11, 6/15, 6/16, and 6/24/2024. On 6/26/2024 at 11:15AM V2/DON (Director of Nurses) stated, R212 has a doctor's order to call her cardiovascular team if she has a gain of 5 pounds in a day. R212 also has a doctor's order to get her weight daily. I spoke with nursing, and they are telling me the weights are obtained in the morning, but I am not able to find all of them. 146123 Page 7 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 follow their elopement policy, failed to document the testing of the elopement device and failed to ensure an elopement device was in place for three of five residents and reviewed for elopement (R14, R18, R32) and failed to provide supervision for high fall risk residents (R24, R40) residents for 5 of 5 residents reviewed for supervision, in a sample of 34. Findings include: 1. R18's current Physician Order Sheet, dated June 2024 documents R18's diagnoses as Alzheimer's Disease. R18's current Minimum Data Set Assessment, dated 5/8/24 indicates R18's Skills for Daily Decision Making are Severely Impaired (C1000) and Behavioral Symptoms E0200) of Daily Wandering. R18's current Wandering/Elopement Risk Assessment, dated 5/9/24 documents R18 as High Risk for Elopement. R18's current Care Plan, dated 4/19/21 includes the following Focus area: (R18) is at risk for wandering/elopement related to cognitive impairment. Also included are the following Interventions: (R18) wears a wander-guard for safety. R18's Treatment Administration Records for April, May, and June 2024 document, Wander guard to right ankle. Chart site every shift and check functionality every shift for safety. From June 1, 2024, through June 25, 2024, staff failed to document placement/functionality seven of twenty-five opportunities. On 6/26/24 at 11:50 A.M., V2/Director of Nurses verified the missing wander guard documentation for R18. At that time V2/DON stated, The nurses are supposed to check placement and functionality of all wander guards each shift and they document their findings in the TAR (Treatment Administration Record). 2. R32's current Physician Order Sheet, dated June 2024 documents R23's diagnoses as Cognitive Impairment. R32's current Minimum Data Set Assessment, dated 5/2/24, indicates R32's Skills for Daily Decision Making are Severely Impaired (C1000) and Behavioral Symptoms E0200) of Daily Wandering. R32's current Wandering/Elopement Risk Assessment, dated 5/9/24 documents R32 as High Risk for Elopement. R32's current Care Plan, dated 6/22/21 includes the following Focus area: (R32) is at risk for wandering/elopement related to cognitive impairment. Also included are the following Interventions: (R32) wears a wander-guard for safety. R32's Treatment Administration Records for April, May, and June 2024 document, Wander guard to 146123 Page 8 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some right ankle. Chart site every shift and check functionality every shift for safety. From June 1, 2024, through June 25, 2024, staff failed to document placement/functionality eight of twenty-five opportunities. On 6/26/24 at 11:50 A.M., V2/Director of Nurses verified the missing wander guard documentation for R32. At that time V2/DON stated, The nurses are supposed to check placement and functionality of all wander guards each shift and they document their findings in the TAR (Treatment Administration Record). 3. R14's Care plan, dated 6/4/24 documents R14 is at risk for Wandering/Elopement is Medium Risk 4-6 and safety will be monitored every shift by all staff and will comply with wearing an elopement device as needed. R14's Treatment Administration Record for June 2024 lacked elopement device monitoring. On 6/4/24 at 4:58 AM, the Progress Note documents R14 roaming in wheelchair and set off alarm on North door. No attempt to leave just freewheeling and feeling good. On 6/4/24 at 9:21 AM, the Progress Note documents Writer made aware by Administrator that R14 pushed the doors on North Hall open, which put R14 at risk for elopement. Administrator requested an elopement device be put on R14's wheelchair. On 6/5/24 at 10:40 PM, the Progress Note stated When this nurse walked out of medication room, R14 noted to be in another recliner in Saint [NAME] Wing lounge. R14 noted to have transferred self. On 6/16/24 at 5:25 PM, the Progress Note documents R14 trying to self-transfer to stationary chair in dining room. On 6/26/24 at 2:00 PM, R14's was observed with an elopement device attached to R14's wheelchair. R14 lacked an elopement device secured to R14's person. On 6/26/24 at 2:01 PM, V13 (Licensed Practical Nurse/LPN) stated R14 does try to get up and has self-transferred to other chairs. V13 stated the elopement device should be secured to V14 and not V14's chair. The facility's Fall Reduction policy, dated 11/5/19, documents that the purpose of this policy is to provide an environment that remains as free of accident hazards as possible. To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. 4. On 6/24/24 at 10:00am R24 was in the main lounge area, unattended. At 12:30pm, R24 was again in the front hallway, unsupervised. On 6/25/24 at 9:00am, R24 was propelling herself around the facility unattended. At 11:26am, R24 was observed sitting on the floor in the front lobby, unsupervised. On 6/26/24 R24 was observed wandering throughout the facility unsupervised. R24's Fall Risk Assessment, dated 12/25/23, documents that R24 high risk for falls. 146123 Page 9 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R24's current care plan documents that R24 is at risk for falls due to weakness, cognition, and other pre-disposing conditions. R24's fall interventions include frequent rounding at night. (R24) is to be in common areas with staff visibility. (R24) is to be in the dining rooms when staff are present. R24's medical record, dated 1/6/24 through 6/25/24 has 19 Unwitnessed Fall without Injury Reports documented. 5. R40's Brief Interview for Mental Status, dated 6/9/24, documents that R40 is severely cognitively impaired. R40's current care plan documents that R40 is as risk for falls due to cognitive deficits, weakness, and other pre-disposing conditions. R40's interventions document to increase rounding on R40 while in bed. R40 is to be in high traffic areas to be monitored by staff as R40 allows. On 6/24/24 through 6/27/24, R40 was observed ambulating in the front hallway and lounge area with no staff in the area. R40's medical record has four Unwitnessed Fall without Injury reports documented. On 6/26/24 at 1:00pm, V10, Licensed Practical Nurse, verified that both R24 and R40 are to be in high visibility areas at all times. V10 stated that they wander and it is hard to keep track of them. 146123 Page 10 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 develop a person-centered dementia plan of care for one of one resident (R50) reviewed for dementia care, in the sample of 34. Residents Affected - Few Findings Include: The facility policy, Care of resident with Dementia, dated November 5, 2019, directs staff, A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practical physical, mental and psychosocial well-being. The facility will provide dementia treatment and services which may include, but are not limited to the following: Ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety and utilizing individualized non-pharmacological approaches to care. R50's current Physician Order Sheet dated June 2024 documents that R50 was admitted to the facility on [DATE] with the following diagnosis: Dementia with Agitation. R50's current Care Plan, dated 10/20/23, only includes the following Interventions to address R50's dementia, I will be monitored for a change in condition and the MD (Medical Doctor) will be notified and Use task segmentation to support short term memory deficits. Break tasks into one step at a time. On 6/26/24 at 9:40 A.M., V3/Care Plan Coordinator verified R50's current Care Plan does not include individualized person-centered interventions. 146123 Page 11 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to monitor refrigerator/freezer temperatures to ensure safe storage of resident's medications. This failure has the potential to affect 24 residents (R5, R7, R9, R10, R14, R17, R19, R20, R22, R26, R27, R30, R34, R35, R36, R46, R47, R48, R49, R53, R55, R56, R162, R212) who reside on the Saint [NAME] Wing and R15, R18, R21 on the Saint [NAME] Wing. Findings include: The Refrigerators and Freezers policy, dated 11/15/21, documents The facility will ensure safe refrigerator and freezer maintenance, temperature, and sanitation, and will observe food expiration guidelines. 1. Acceptable temperatures should be 35 degrees Fahrenheit to 40 degrees Fahrenheit for refrigerators and less than 0 degrees Fahrenheit for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 3. Monthly tracking sheets will include time, temperature, and initials. 4. The food service supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. On 6/24/24 at 2:14 PM, The Refrigerator/Freezer located in the Saint [NAME] Linen Room was observed to have multiple food and drink items with resident's initials written on the packages/containers. 06/24/24 02:14 PM, the Refrigerator/Freezer Temperature Record located in the Saint [NAME] Linen Room lacked temperature monitoring in June 2024, 25 out of 47 required times per day. On 6/25/24 at 1:45 PM, V15 (Certified Nurse Aide/CNA) stated the refrigerator/freezer located in the Saint [NAME] Linen Room is for resident's food only. On 6/27/24 at 9:40 AM, the Refrigerator/Freezer located in the Saint [NAME]'s Medication Room was observed to store the following medications which were labeled as to store in refrigerate: a) R15- Five (5) Injectable pens labeled, Basaglar 100 units (u) per milliliter (ml); b) R18- Two (2) Injectable pens labeled, Insulin Lispro 100 u/ml; c) R21- Nine (9) Injectable Pens labeled, Tresiba flex 100 u/ml; d) Two (2) multidose vials labeled, Tuberculin Purified Protein. On 6/27/24 at 9:40 AM, the Refrigerator/Freezer Temperature Record located in the Saint [NAME]'s Medication Room lacked temperature monitoring in May 2024, 37 out of 62 required times per day and in June 2024, 13 out of 50 required times per day. On 6/27/24 at 9:45 AM, the Refrigerator/Freezer located in the Saint [NAME]'s Medication Room was observed to store the following medications which were labeled as to store in refrigerate: a) R19- Six (6) Injectable pens labeled, Humalog 100 u/ml; 146123 Page 12 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0761 b) R36- Five (5) Injectable pens labeled, Glargin 100 u/ml; Level of Harm - Minimal harm or potential for actual harm c) R212- Six (6) Injectable pens labeled, Humalog 100 u/ml; d) One (1)- multidose vials labeled, Tuberculin Purified Protein. Residents Affected - Some On 6/27/24 at 9:45 AM, the Refrigerator/Freezer Temperature Record located in the Saint [NAME]'s Medication Room lacked temperature monitoring in June 2024,12 out of 53 required times per day. 146123 Page 13 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

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 a safe kitchen environment, failed to test the dishwasher sanitation system and failed to educate staff on the use of the dishwasher. This has the potential to affect all 54 residents residing in the facility. Findings include: The facility's Dish Machine Use policy, dated 4/23/21, documents that food service staff required to operate the dish machine will be trained in all steps of dish machine use by the supervisor or a designee in all aspects of proper use and sanitation. The dish machine hot water sanitation rinse temperatures may not be more than 194 degrees Fahrenheit or less than: 165 degrees Fahrenheit for stationary rack, single temperature machines. 180 degrees Fahrenheit for all other machines. The facility's (undated) Chemical Sanitizer policy documents to follow the directions precisely that are on the litmus paper vial and test the water on the surface of the bottom of the glasses. Concentration should be 50 ppm/parts per million to 100 ppm. On 6/24/24 at 9:30am, V4, Dietary Manager, stated that the dishwasher was a hot water sanitation washer. V4 stated that she does not test the machine, only watches the temperature gauge on the outside of the machine. V4 could not explain how to test the dishwasher. V6/Dietary Aid ran a test strip through a dishwasher cycle. The rinse cycle only reached 143 degrees Fahrenheit. V6, Dietary Aide, stated that a strip is tested every day. V6 performed the dishwasher test strip and it tested between 50ppm and 100ppm. V6 verified that the rinse cycle only indicated a temperature of 143 degrees Fahrenheit for the second and third testing attempts. At this time, multiple white ceiling tiles in the dish room were soaked with a brown substance. Three ceiling florescent lights were out in the dish room. V7, Maintenance Director, stated that there is a hole in the dishwasher exhaust fan that leaks into the ceiling and close to the light fixtures. V7 stated that Corporate has been notified about the broken kitchen equipment, but there has not been an approval to fix the issues. The portable steam table used for the west side of the building has black crumbly substances and a brown grease like substance all over the bottom of the different compartments. V4 stated that she does not know when the last time the steam table was cleaned. On 6/24/24 at 12:15pm, there was a large pool of water on the floor, going from the dishwasher room to the kitchen. V4 stated that is from the dishwasher. V4 stated that water splashes from the dish washer and pools in the area because it is a low spot. V4 pointed to the drainage system which was on the opposite side of the room. The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated 6/24/24, documents 54 residents residing in the facility. 146123 Page 14 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and interview, the facility failed to ensure enhanced barrier precautions (EBP) were implemented as ordered for 1 of 5 (R19) residents who had an order for enhanced barrier precautions in a sample of 34 residents. Residents Affected - Many Findings include: The Enhanced Barrier Precautions policy dated 3/27/24 documents EBP are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or the patient's environment. EBP is used during high-contact care activities for residents with indwelling medical devices. On 4/16/24, R19's Physician's Order documents Infection precautions-enhanced barrier staff wear gown/gloves when in direct patient contact every shift every shift: signage on door. Gown and gloves required for the following high-contact care activities: dressing, bathing/showering, transfer, changing linens, providing hygiene, changing briefs/assist with toileting, device care/use and or wound care. On 4/16/23, R19's Care plan documents Enhanced Barrier Precautions (EBP), educate resident/power of attorney/responsible person on reason for EBP; EBP during personal care; isolation PPE (Personal Protective Equipment) available at room entrance. On 6/24/24 09:50 AM, R19 did not have an Enhanced Barrier Precautions sign posted at the door and no available Personal Protective Equipment outside the door. On 6/24/24 at 10:15 AM, V10 (Licensed Practical Nurse/LPN) stated I didn't realize there was an order for Enhanced Barrier Precautions. 146123 Page 15 of 16 146123 06/27/2024 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm On 6/24/24 at 3:00 PM, R30's record was reviewed and lacked documentation of R30's 5/7/24 through 5/28/24's hospitalization. Residents Affected - Many On 6/26/24 at 9:00 AM, the hospital records were obtained by the facility per request and reviewed. The hospital's emergency department records dated 5/7/24 documents R30's problems addressed were acute respiratory failure, hypotension (low blood pressure), right middle lobe pneumonia, sepsis (bacteria in the bloodstream) and urinary tract infection. The hospital's Post Acute Transition Record documents R30 was discharged from hospital on 5/28/24 with a primary diagnosis of Sepsis, Infection MRSA (Methicillin-resistant Staphylococcus Aureus) and Isolation: Contact/Droplet for rhino/enterovirus 5/22/24. The Infection Control Monthly Log dated May 2024 lacked documentation of R30's infection (source, organisms, etc.). On 6/27/2024 at 8:20AM V2/DON (Director of Nurses) stated, The Antibiotic Stewardship Tracking is incomplete. Does not have any type of surveillance plan for the use of the antibiotic, no justification for the usage of the antibiotic the specific use for the usage. The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated 6/24/24, documents 54 residents residing in the facility. Based on interview and record review the facility failed to implement an antibiotic stewardship program that included assessment and monitoring of residents for signs and symptoms of infections and failed to ensure that the antibiotic usage was appropriate and failed to the use of a recognized surveillance criteria to define the infections. This deficiency has the potential to affect all 54 residents that reside in the facility. Findings include: The facility policy named, Infection Control with Antibiotic Stewardship, dated 1/23/2024, documents the following: The policy establishes directives for Antibiotic Stewardship at this facility to develop antibiotic use protocols and a system to monitor antibiotic use. The Antibiotic Stewardship Committee will:2.) Develop and maintain a system to monitor antibiotic use. Which includes a review of antibiotics prescribed to the residents. Would also have written documentation of clinical justification for the antibiotic use. The facility Infection Control Log, dated April 2024, documents, Page 3 of 7, 4 of 7 and 7 of 7 does not document the specific antibiotic usage, the justification of the use of the antibiotic, does not document any kind on going surveillance data for the use of the antibiotic, there is no monitoring for the signs and symptoms of the infection. The facility infection control log, dated May 2024, documents, Page 3 of 7, 4 of 7, and 7 of 7 does not document the specific antibiotic usage, the justification of the use of the antibiotic, and does not document any kind of ongoing surveillance plan for the ongoing use of the antibiotic, and there is no monitoring for signs and symptoms of the infection. 146123 Page 16 of 16