Inspection·May 17, 2023

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 ensure a resident's oral appliance was applied correctly for a resident who requires extensive assist with personal hygiene/oral care. This applies to 1 of 12 (R29) residents reviewed for activities of daily living in the sample 12. Residents Affected - Few The findings include: R29's face sheet shows she is an [AGE] year-old with diagnosis including bilateral osteoarthritis of first carpometacarpal joints, hemiplegia affecting left and right side, and contractures to left and right hand. R29's Minimum Data Sheet assessment dated [DATE] shows she requires extensive assist with transfers, personal hygiene, eating, and has limited range of motion to both upper extremities. On 5/15/23 at 12:50 PM, R29 was in the dining room during the noon meal. She was served chopped pot roast, potatoes, and broccoli. V6 (Certified Nursing Assistant/CNA) was feeding R29 her noon meal. R29 said to V6 something is stuck in the back of my throat, it's scaring me. V6 wheeled R29 to her room. V6 said R29 reported the glue from her dentures is stuck in her mouth. V6 asked R29 to open her mouth and the adhesive from her top dentures was oozing out from the back of her upper palate. A clump of adhesive was removed from the back of her tongue. V6 stated, Oh my gosh, a lot was in there. V6 removed R29's dentures and removed another round globe of adhesive. V5 (Licensed Practical Nurse) entered the room with a mouth swab and removed two additional chunks of adhesive from R29's mouth. R29 said when the staff put in her dentures and pressed down the glue was coming out, they used too much glue, it was all over my tongue, It's scary. On 5/15/23 at 1:50 PM, V6 (CNA) said staff apply R29's dentures because she cannot use her hands. Whoever put on her dentures put too much adhesive. V6 said she did not apply R29's dentures. On 5/15/23 at 2:08 PM, V2 (Director of Nursing) said R29 had an excessive amount of adhesive in her mouth, and it was uncomfortable for her. She explained to the staff when applying the adhesive to place four small pea size amounts on the dentures and it will expand when you apply it to the gums securing it in place. R29's current care plan shows she has a self-care performance deficit related to osteoporosis and the unable to use her bilateral upper extremities with interventions for staff to assist her personal hygiene and oral care. The facility's Care of Dentures Policy dated May 2023, states, 1. Determine which nursing staff (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 146127 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Florence Nursing Home 546 East Grant Highway Marengo, IL 60152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)