Health inspection·April 3, 2024

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** Based on observation, interview, and record review, the facility failed to have pressure relieving devices in place for one of one resident (R3) with high risk of pressure injuries in the sample of 12. Residents Affected - Few The findings include: R3's Transfer Discharge report dated April 1, 2024 shows R3 was admitted to the facility on [DATE] with diagnoses including acquired absence of right foot, pressure injury of left heel, and congestive heart failure. R3's Care Plan shows R3 has potential for pressure injury development related to peripheral vascular disease, advanced age, poor safety awareness, and chronic pain. Follow facility policies/protocols for the prevention/treatment of skin breakdown. R3's Scale for Predicting Pressure Injury Risk for that R3 has a moderate risk for developing pressure injuries. R3's Wound Weekly Observation Tool dated March 20, 2024 shows that R3 had a pressure injury to his coccyx that healed. R3's Wound Weekly Observation Tool dated April 1, 2024 shows that R3 developed a stage II pressure injury to his coccyx. R3 Wound Weekly Observation Tool dated March 27, 2024 shows that R3 has a wound to his left heel. Special equipment/Preventative Measures include air mattress and foot protectors. R3's Treatment Medications dated March 1, 2024-March 31, 2024 shows an order for prevalon boot-continue to wear at all times. On April 1, 2024 at 9:16 AM, R3 was laying in bed. There was a heel boot noted to his night stand next to the head of his bed. R3 was laying on his left side with his left foot directly on the bed. At 11:58 AM, V6 and V10 CNAs (Certified Nursing Assistants) performed peri care to R3. There was an air mattress pump at the foot of R3's bed that was not buzzing, nor were there any lights on to indicate the air mattress was on. R3's heel boot was still on the night stand. R3's left foot had a dressing present. There was a small open area noted to R3's coccyx. At 2:24 PM, V5 LPN (Licensed Practical Nurse) came into R3's room. The air mattress pump at the foot of R3's bed still had no on indicator lights on. There was a medical grade surge protector at the head of R3's bed. The plug of the air mattress was halfway out of the outlet. V5 pushed the plug in and a green light turned on on the pump. V5 said the air mattress was off. On April 3, 2024 at 10:22 AM, V5 said that R3 should have foot protection on and an air mattress. Page 1 of 4 146127 146127 04/03/2024 Florence Nursing Home 546 East Grant Highway Marengo, IL 60152

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V5 said if the air mattress is off, then the mattress will deflate. V5 said the light on the pump is green when the mattress is turned on. The facility's Pressure Injury Prevention Guidelines dated June 1, 2023 shows Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assess at risk or who have a pressure injury present. Interventions will be implemented in accordance with physician order, including the type of prevention devices to be used and, for tasks, the frequency for performing them. Prevention devices will be utilized in accordance with manufacturer recommendation (e.g., heel flotation devices, cushions, mattresses). 146127 Page 2 of 4 146127 04/03/2024 Florence Nursing Home 546 East Grant Highway Marengo, IL 60152

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 interview and record review, the facility failed to safely perform ADL (Activities of Daily Living) assistance for one of 12 residents (R21) reviewed for safety in the sample of 12. The findings include: R21's Transfer/Discharge Report dated April 3, 2023 shows R21 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, muscle wasting and atrophy, cognitive communication deficit, fall, morbid obesity, and dementia. R21's Care Plan shows R21 requires extensive assistance by two staff to turn and reposition in bed. R21's Monthly Nursing Screen dated December 19, 2023 shows R21 requires extensive assistance with two staff members for bed mobility. R21's Progress Note dated December 23, 2023 at 5:45 AM shows, the nurse was told by CNA (Certified Nursing Assistant) R21 had a fall and had two skin tears. R21's right elbow and left forearm had a skin tear. R21 had a large knot on his forehead. 911 was called, the paramedics came. R21's Progress Note dated December 23, 2023 at 10:15 AM, shows R21 returned to the facility with a head contusion noted to the right side. R21 was alert to his name and able to verbalize that he fell this morning and hurt his head. The facility Incident/Accident Report dated December 23, 2023 shows, CNA reported resident had fallen from the bed during cares. This writer assessed resident and found skin tear to left forearm, right elbow, left knee abrasion, redness to right forehead. Cat scan head and neck no abnormalities, CNA counseled, staff in-serviced. On April 3, 2024 at 9:43 AM, V2 DON (Director of Nursing) said that V7 CNA was performing cares and getting R21 ready for the morning. V2 said that R21 was rolled onto his side when V7 went to grab washcloths and R21 rolled out of the bed. V2 said the bed was elevated and there was no floor mats in place because V7 was performing cares. V2 said that V7 was performing cares on R21 by himself. Two attempts were made to interview V7 (R21's CNA) and V8 (R21's nurse) on April 3, 2024 unsuccessfully. The facility's Safe Resident Handling/Transfers policy dated 2023 shows, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Resident lifting and transferred will be performed according to the resident's individual plan of care. 146127 Page 3 of 4 146127 04/03/2024 Florence Nursing Home 546 East Grant Highway Marengo, IL 60152

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to implement an Enhanced Barrier Precautions Procedure which applies to all 30 residents in the facility. Residents Affected - Many The findings include: The federal form 671 completed by the facility on 4/1/24 showed the facility census was 30 residents. On 4/1/24 the facility had no Enhanced Barrier Precautions (EBP) signs up or Personal Protective Equipment (PPE) carts out for EBP residents. The facility's EBP list dated 4/1/24 showed R13, R16, and R26 had feeding tubes. R3, R23, R30, and R83 had indwelling urine catheters. R3 also has a daily wound dressing change. On 4/1/24 at 11:20 AM, V6 and V10 Certified Nursing Assistants (CNAs) provided incontinence care to R16 without wearing PPE gowns during care. No EBP sign was noted on the door at that time. On 4/1/24 at 11:58 AM, V6 and V10 provided peri care for R3. At that time, V5 Licensed Practical Nurse entered R3's room to provide wound care. V5, V6, and V10 did not wear gowns while providing cares for R3. No EBP sign was posted at the time of the cares. On 4/2/24 at 8:50 AM, V9 Registered Nurse said they had not received any education prior to 4/2/24 in regards to EBP. On 4/2/24 at 1:00 PM, V1 Administrator said the facility did not utilize EBP prior to the 4/1/24 implementation date. V1 stated, We do not have a EBP procedure in place at this time. We have a policy and staff education which will be in place by 4/8/24. On 4/3/24 at 9:56 AM, V2 Director of Nursing stated, We will be educating staff on EBP procedures for PPE for residents who should be on EBP. We did not have procedures in place on 4/1/24. The facility's Enhanced Barrier Precautions Policy revised on 4/1/24 showed residents with indwelling medical devices should be on EBP. This Policy showed medical devices include: central lines, urinary catheters, feeding tubes, and tracheotomy/ventilator tubes. 146127 Page 4 of 4