Health inspection·November 18, 2022

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 avoid contamination of a stage 4 pressure ulcer during a dressing change for one (R6) of three residents reviewed for pressure ulcers in a sample of 23. Residents Affected - Few Findings include: Facility Clean Dressing Change Policy, undated, documents: it is the policy of this Facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination; loosen the tape and remove the existing dressing, then remove gloves, pulling inside out over the dressing and discard in to the appropriate receptacle, then wash hands and put on clean gloves; cleanse the wound as ordered, then wash hands and put on clean gloves; discard disposable items and gloves into appropriate trash receptacle and wash hands, then return Resident to comfortable position. The Facility Wound Log, dated 11/7/22, documents that R6 has a Left Buttock Pressure Ulcer (measuring 5.0 centimeters/cm by 8.0 cm x 1.0 cm) and is being treated daily with a medicated solution and a dry dressing. On 11/16/22 at 12:01 pm, V4 (Certified Nursing Assistant/CNA) and V5 (Licensed Practical Nurse/LPN) were in R6's room assisting with perineal care and wound care. V4 (CNA) entered R6's room, applied gloves, rolled R6, pulled back the covers, removed R6's urine soiled incontinence brief. V4 (CNA) retrieved clean incontinence wipes from a container that was in R6's bedside table drawer. V4 performed perineal care and disposed of the soiled wipes into the trash receptacle. V4 then placed the clean container of incontinence wipes back into R6's bedside drawer. V5 (LPN) entered the room with a bottle of medicated solution and a bottle of wound cleanser and placed them on R6's bedside table. V5 applied gloves and initiated the removal of R6's soiled pressure ulcer dressing, at the same time, V4 reached over R6 and assisted V5 (LPN) with removing R6's soiled Pressure Ulcer dressing, by peeling back the dressing. As V4 was helping position R6 for V5 to apply the clean dressing, V4's right hand was placed on R6's soiled coccyx and buttock. V5 (LPN) then retrieved the bottle of wound cleanser and cleansed R6's Pressure Ulcer, by spraying the cleanser into R6's wound and wiping with gauze pads. V5 (LPN) then retrieved and applied the medicated solution and covered the coccyx/buttocks pressure ulcer with a clean dry dressing. V4 and V5 did not perform any hand hygiene or glove change during R6's cares. On 11/16/22 at 12:10 pm, V4 (CNA) stated, We only change our gloves or wash our hands if our hands are visibly soiled. On 11/16/22 at 12:35 pm, V4 (CNA) stated, I always try and help the nurses take off the soiled dressings when I can. Page 1 of 9 146138 146138 11/18/2022 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/16/22 at 12:11 pm, V5 (LPN) stated, We do not have to wash our hands, put new gloves on or use hand sanitizer unless our hands are visibly dirty. On 11/17/22 at 1:30 pm, V1 (Administrator) stated, We will in-service them on handwashing and glove changes. They should be changing their gloves and washing their hands during cares, especially when they are soiled from wound care or incontinence care. 146138 Page 2 of 9 146138 11/18/2022 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review the facility failed to provide a palm guard for one resident (R26) with bilateral hand contractions of two residents reviewed for mobility in the sample of 25 residents. Findings include: On 11/15/22 at 10:30am R26 was in her room, both hands were severely contracted. R26 was wearing cloth arm/hand skin sleeves on both arms. R26 stated that she would like her nails trimmed because they can dig into her skin, but the cloth sleeves help protect her skin. R26 was seen on 11/15/22 and 11/16/22 without palm guards on either hand. PT (Physical Therapy)/OT (Occupational Therapy) Screen Form dated 8/29/22 indicates Reason for Screen: Decline in functional mobility and worsening of contracture of right hand. Screen indicates right hand contracture worse Has bilateral palm guards in order to decrease possible skin irritation. Contractures are worse due to not wearing palm guards during day and removing. Screen indicates Recommend therapy to address device for right hand contracture. Resident Concern Form dated 10/20/22 indicates R26 has missing palm guards and that palm guards were ordered. On 11/16/22 at 3:15pm V2 (Director of Nursing) stated that the concern for R26's palm guards came up at R26's last care conference by R26's family. V2 stated she ordered them and was still waiting for them. On 11/17/22 at 10am V10 (Certified Occupational Therapy Assistant) stated R26 should still being using a palm guard on her left hand. The right is too contracted to get anything in there anymore. I recommended and gave elastic/cloth sleeves to wear to protect R26's skin from her nails. It's all that will fit into her right hand. V10 stated that R26 has had four palm guards and they all ended up missing. V10 stated that R26 can't tolerate anything in her right hand anymore but she will keep the left palm guard in her hand. Nursing is responsible to ensure R26 has a palm guard for her left hand. Current Care Plan did not include R26's bilateral severe hand contractures or interventions including palm guards. On 11/18/22 V1 (Administrator) stated they have no policy for contractures or splints. 146138 Page 3 of 9 146138 11/18/2022 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 an appropriate indication for use of an antipsychotic medication. The facility also failed to identify specific target behaviors for administration of an antipsychotic medication for three residents with a diagnosis of dementia (R19, R46, R100) of seven residents reviewed for unnecessary medications in the sample of 25. Findings include: Facility Psychotropic Medication Policy dated 12/4/19 documents: 1. An assessment must be made to identify specific behaviors/symptoms, potential causative factors, and recommendations for managing identified behaviors. 2. The medical record documentation must reflect the specific behaviors/symptoms and the resident's response to non-pharmacological interventions to manage the behaviors/symptoms. 4. The physician should evaluate the use of antipsychotic medications if one or more of the following are the only indication: Wandering Poor self-care Restlessness Impaired Memory Anxiety/ Depression Insomnia, Unsociability Indifference to surroundings Fidgeting/nervousness Uncooperativeness Agitated behaviors which do not represent danger to resident or others. 12. A plan of care will be developed including precipitating factors, non-pharmacologic interventions, and potential side effects. 1.) Facility diagnosis Sheet indicates R19 was admitted to the facility 2/23/17 with diagnosis of Dementia with Lewy Bodies and Delusional Disorder. In 2019 R19 was diagnosed with Schizophrenia and in 2021 diagnosed with Unspecified Dementia with Behavioral Disturbance and General Anxiety Disorder. 146138 Page 4 of 9 146138 11/18/2022 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0758 Level of Harm - Minimal harm or potential for actual harm Physician Order Sheets indicate Seroquel (antipsychotic) was initiated on admission at 25mg (milligram) at bedtime for Dementia with Lewy Bodies and increased as follows: 10/9/21 Seroquel increased to 25mg twice daily and diagnosis changed to Long Term Usage related to Delusional Disorder. Residents Affected - Some 11/22/21 Seroquel increased to 50mg at bedtime, 25 mg daily and diagnosis changed to Schizophrenia. 12/21/21 Seroquel increased to 50mg twice daily 2/15/22 Seroquel increased to 75mg twice daily 8/5/22 Seroquel increased to 100mg twice daily 10/7/22 Seroquel Increased to 125mg twice daily 11/11/22 Seroquel increased to 150mg twice daily Current Seroquel order (11/11/22) indicates Schizophrenia, Unspecified as diagnosis for Seroquel. Progress Notes dated 10/2022 thru 11/16/22 do not include justifications or documentation of an increase in behaviors other than (R19) continues to hear voices. On 11/17/22 at 1:30pm V8 (Licensed Practical Nurse/LPN) stated (R19) has multiple versions of herself and talks to (an alternate R19). V8 stated that they used to argue sometimes, now they just talk. V8 stated R19 also has OCD (obsessive compulsive disorder) and has very ritualistic behaviors at times. V8 stated that R19 has never been violent or aggressive. V8 stated that the residents are seen by a Nurse Practitioner for psychiatry needs thru a Telehealth company. Telehealth Note dated 10/3/22 at 1:30pm indicates (R19) has reported significant symptoms related to dementia and psychosis. (R19) reports talking to voices she refers to as her friends. Note indicates R19 continues to talk under her breath with a voice and states everyone talks to her as they are her friends. Note indicates R19 denies the voices are commanding stating They just talk to me. Note indicates R19 reports difficulty hearing, reports hallucinations, memory loss and dementia; denies depression, no sleep disturbances, no suicidal thoughts, and normal appetite. R19 was observed in the community areas of the memory care unit as well as in her room at various times on 11/15/22 and 11/16/22. R19 was accepting of care, mostly stayed to herself, and ambulated between the dining area and her room with a walker. R19 did seem preoccupied, however was not distressed. Current Care Plan indicates on 2/15/22 R19's Seroquel was increased to 75mg twice daily. No target behaviors, diagnosis or indication for use are identified in the care plan. Care Plan was not updated to reflect the continued increases of Seroquel after 2/15/22. Behavior Tracking Sheets dated 10/1/22 thru 11/16/22 indicate R19 is being monitored for refusing care, insomnia, restlessness, yelling out when anxious related to hallucinations and delusions and talking in third person to her friends. 146138 Page 5 of 9 146138 11/18/2022 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Psychotropic Medication Consent dated 11/11/22 indicates consent was received on that date to increase R19's Seroquel to 150mg BID with Indication for Use: Schizophrenia. Consent dated 10/7/22 indicates Seroquel was increased to 125mg with Indication for Use: Antipsychotic. Consents indicates Antipsychotics are used to treat behavior problems such as combativeness, explosiveness, manic behaviors, and treatment of psychotic disorders. Consent does not indicate specific target behaviors or conditions to justify the use of an antipsychotic medication. Consent also include Black Box Warning: Elderly patients with dementia-related psychosis treated with antipsychotics are at increased risk of death compared to placebo. No consents were found or presented for the increase in Seroquel on 2/15/22 or 8/5/22. 2.) Physician's Order Summary Report (POS) indicates R46 was admitted to the facility on [DATE] with diagnoses that include Unspecified Dementia without Behavioral Disturbance, Psychotic and Mood Disturbance and Anxiety. Physician Order Sheet indicates Seroquel (antipsychotic) 25mg (milligram) every night at bedtime for Unspecified Dementia without behavioral disturbance; Restlessness/Agitation was ordered on 9/11/22. Physician Order Sheet indicates Seroquel 25mg every night at bedtime was revised on 10/27/22 with diagnosis changed to Delusional Disorder. Current Physician Order Sheet indicates Seroquel 25mg was increased to be given twice daily on 11/9/22 for Delusional Disorder. Telehealth Note dated 11/7/22 indicates R46 had increased exit-seeking, wandering into other resident's rooms, yells and refuses care and had been verbally/physically aggressive with staff. Note indicates R46 wanted a gun to kill herself and was sent to the hospital, diagnosed with Cystitis, and started on antibiotics. Note indicates R46 reported feeling better. Telehealth recommendations on 11/7/22 were to increase R46's Seroquel to 25mg twice daily with diagnoses of Conduct Disorder, Restlessness/Agitation, Depressive and Delusional Disorder and Anxiety. Current Care Plan indicates R46 is currently on antipsychotic therapy related to dementia without behavioral disturbance. Care Plan does not include target behaviors, specific indications for use or specify Seroquel as the antipsychotic medication. Psychotropic Medication Consent indicates consent was received on 9/12/22 for Seroquel 25mg at bedtime with Indication for Use: Dementia with Aggression. Psychotropic Medication Consent indicates consent was received on 11/9/22 for Seroquel 25mg twice daily with Indication for Use: Delusional Disorder. Behavior Tracking 10/1/22 to 11/16/22 indicates incomplete monitoring of behaviors identified as exit-seeking and agitation. 3.) Physician's Order Sheet (POS) indicates R100 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia without Behavioral Disturbance, Anxiety and Alzheimer's Disease. 146138 Page 6 of 9 146138 11/18/2022 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0758 Level of Harm - Minimal harm or potential for actual harm POS indicates Risperdal (antipsychotic) 0.5mg once daily was ordered on 11/10/22 with diagnosis of Dementia with other behavioral disturbance. Psychotropic Medication Consent indicates consent for Risperdal 0.5mg was received on 11/10/22 with Indication for Use: Dementia with Behavioral Disturbance. Residents Affected - Some Progress Notes dated 10/1/22 thru 11/16/22 indicate R100 was having a difficult time adjusting to the locked unit, was exit-seeking and attempting to take screens off windows in empty rooms. Telehealth Note dated 11/8/22 at 2:34pm indicates Recommend starting Risperdal; Diagnosis Dementia with Behavioral Disturbance. Current Care Plan indicates R100 is on an antipsychotic therapy related to Dementia. Care Plan does not identify target behaviors. On 11/15/22 at 10:15am R100 was working on a puzzle with a staff member. R100 was pleasant, smiling and engaged. Several minutes later a hairdresser asked R100 if she wanted a haircut and R100 thanked the hairdresser and allowed her to cut her hair. R100 seemed very happy to be getting her hair cut. On 11/16/22 at 1:15pm R100 was smiling and interacting with staff. At that time V8 (LPN) stated that both R46 and R100 are fairly new and can become very intent on going back home. On 11/17/22 at 1:30pm V1 (Administrator) stated that they are aware the Telehealth practitioners are ordering more antipsychotic medications for residents with dementia than they should and are looking to get a psychiatrist who will come to the facility and be part of the team. 146138 Page 7 of 9 146138 11/18/2022 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3.) On 11/16/2022 at 12:00 pm, V4 (CNA) and V6 (CNA) entered R43's room and stated they were there to clean her up and help her lay down for a nap. Neither V4 nor V6 washed their hands upon entering the room. Once in the bed, R43 rolled on her left side, V4 (CNA) washed bowel movement off her buttocks with disposable wipes and V4 then applied skin protectant cream and then took off her right glove. Residents Affected - Few V4 and V6 continued to wash R43's front and back sides, never washing their hands and never changing gloves. V4 (CNA) pulled up R43's covers, clipped her call light on her pillow and pulled her bedside table over across the bed while touching items on the table. V6 (CNA) pushed the electronic lift to the hallway and touched the door and touched roommate's bed with gloves still on from R43's incontinence care. On 11/17/22 V2 (Director of Nursing) stated Staff should always wash their hands before, during and after incontinence care before they touch anything else or leave the room. Based on observation, interview and record review the facility failed to perform hand hygiene and glove changes during incontinence care and wound care for three residents (R6, R12, R43) of five reviewed for infection control in a sample of 23. Findings include: Facility Perineal/Incontinence Care Policy and Procedure, revised 11/5/2019, documents: to provide hand hygiene and apply gloves; remove soiled brief/underpad and assure all area affected by incontinence have been cleansed then remove gloves and perform hand hygiene and apply clean gloves; apply protective ointment as a part of incontinence care, remove gloves and perform hand hygiene, discard contaminated items in container, remove gloves and perform hand hygiene then reposition resident. 1.) On 11/16/22 at 12:01 pm, V4 (Certified Nursing Assistant/CNA), V5 (Licensed Practical Nurse/LPN) and V6 (CNA) were in R6's room assisting with perineal care and wound care. V4 (CNA) entered R6's room, applied gloves, rolled R6 pulled back the covers, removed R6's urine soiled incontinence brief. V4 (CNA) removed clean incontinence wipes from a container that was retrieved out of R6's bedside table drawer. V4 performed perineal care and disposed of the soiled wipes into the trash receptacle. V4 then placed the clean container of incontinence wipes into R6's bedside drawer. V4 then assisted V5 (LPN) with R6's stage four coccyx/buttock pressure ulcer. V4 peeled back R6's soiled dressing, and as V4 was helping position R6 for V4 to change the dressing, R6's right hand was placed on R6's soiled coccyx and buttock. V4 then applied a new incontinence brief, repositioned R6 and pulled up R6's bed covers. Then V4 (CNA) proceeded to run V4's contaminated gloved hands through R6's hair and rubbed R6's ears and cheeks. V4 adjusted V4's face mask, and then adjusted R6's bed height and removed the contaminated gloves, and exited R6's room. V4 did not perform any hand hygiene or glove change during R6's cares. 2.) R12's Physician Order Sheet, dated 11/17/22, documents that R12 has a skin tear to the right lower leg (ankle) and has a treatment order for a daily dressing. R12's Hospital Microbiology Report, dated 11/2/22, documents that R12 has Methicillin Resistant Staphylococcus Aureus (MRSA) in the right leg (ankle). 146138 Page 8 of 9 146138 11/18/2022 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0880 On 11/16/22 at 12:25 pm, R12 was residing in an isolation room. Level of Harm - Minimal harm or potential for actual harm On 11/16/22 at 12:25 pm, V4 (CNA) and V5 (LPN) were performing wound care to R12. V5 was out of R12's room retrieving wound treatment supplies and V4 (CNA) entered R12's isolation room, and without performing hand hygiene, applied gloves. V4 (CNA) proceeded to attempt to remove R12's right ankle dressing, by inserting three middle fingers inside of R12's wound dressing. V4 then stated, I cannot get that off, I need to get some scissors. Residents Affected - Few V4 (CNA), without V5 (LPN) in the room, then removed R12's infected Left Shin (MRSA) outer dressing, and with the same contaminated gloves, attempted to remove the impacted wound bed dressing and was unsuccessful. Then without performing hand hygiene and/or a glove change, V4 (CNA) proceeded to remove R12's necklace and placed it on R12's bedside table. V4 (CNA) then adjusted R12's blankets and clothing, then caressed/rubbed R12's face and neck. V4 then touched items on R12's bedside table and walker. V4 then adjusted R12's bedroom slippers and walker. V5 (LPN) then entered R12's room and V4 (CNA) then helped position R12. V4 did not perform any hand hygiene or glove change during R12's cares. On 11/16/22 at 12:10 pm, V4 (CNA) stated, We only change our gloves or wash our hands if our hands are visibly soiled. On 11/16/22 at 12:35 pm, V4 (CNA) stated, I always try and help the nurses take off the soiled dressings when I can. On 11/16/22 at 12:11 pm, V5 (LPN) stated, We do not have to wash our hands, put new gloves on or use hand sanitizer unless our hands are visibly dirty. On 11/16/22 at 12:37 pm, V5 (LPN) stated, (R12) is in isolation for MRSA infection in (R12's) left shin. On 11/17/22 at 1:30 pm, V1 (Administrator) stated, We will in-service them on handwashing and glove changes. They should be changing their gloves and washing their hands during cares, especially when they are soiled from wound care or incontinence care. 146138 Page 9 of 9