Health inspection·January 9, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review the facility failed to develop a comprehensive assessment for the use of oxygen for one of 17 residents (R33) reviewed for care plans in a sample of 17. Residents Affected - Few Findings include: A policy revised on June 25, 2024, and titled Comprehensive Care Plan documents, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. This policy further states that each resident's comprehensive care plan has been designed to incorporate identified problem areas. R33's Physician Order Sheet dated December 19, 2024, has an order for Oxygen at 2 liters per minute via nasal cannula for as needed for dyspnea or chest pain. On 01/07/25 at 10:15 AM and 01/08/25 at 9:22 AM R33 was lying in bed with oxygen on via nasal cannula. R33's current comprehensive care plan was reviewed and did not contain information or goals regarding oxygen usage. On 01/08/25 at 2:24 PM V4 (Care Plan Coordinator) confirmed R33's current care plan does not address R33's oxygen need. Page 1 of 16 146138 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0679 Provide activities to meet all resident's needs. 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 provide an ongoing program of activities for 15 residents (R13, R14, R19, R20, R25, R26, R28, R36, R41, R44, R47, R48, R49, R50, R51) that reside on the Memory Care Unit of 33 residents reviewed for activities in the sample of 33. Residents Affected - Some Findings include: Facility Policy/Programming for Resident with Cognitive Impairments dated/revised 11/5/24 documents: It is the Policy of this facility to: Offer meaningful activity programs to residents who display disorientation to time, place and/or person. Promote activity programs to reflect each resident's physical and mental status, and to promote cognitive health. Facility Policy/Activities Programs dated/revised 11/5/25 documents: An ongoing program of activities is designed to meet the needs of each resident. Our activities program consists of individual, and small and large group activities which are designed to meet the needs and interests of each resident. Facility assessment dated [DATE] documents: The facility serves long and short-term residents. It also has a Dementia Unit that is locked. Assessment indicates Services Provided Based on Resident Needs: Provide person-centered/directed care: Psycho/social/spiritual support: Provide opportunities for social activities/life enrichment (individual, small group). Facility Resources Needed to provide Competent Resident Support and Care Daily and During Emergencies: Activities - One Activity Director and 2.5 Activity Assistants. Resident Room Roster dated 1/7/24 indicates there are 15 residents who reside in the locked Memory Care Unit. January 2025 Memory Care Activity Calendar indicates: Tuesday (1/7/25) 7am Breakfast 9am Good Morning 9:30am Greetings 146138 Page 2 of 16 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0679 10am Balloon Swat Level of Harm - Minimal harm or potential for actual harm 10:30am Light Tunes 11am Lunch Residents Affected - Some 1pm Spa treatment 2pm Horseshoes 2:30pm Snack cart 3pm Walk with Me 4pm Sensory Dough 5pm Supper 6pm All hands-on deck 6:30pm Sounds of Nature 7pm Snack cart On 1/7/25 at 10:40am V6 (Licensed Practical Nurse/LPN) stated that activity staff come back on the unit when they can. V6 stated they had not been on the unit that morning and the unit was staffed with one CNA (Certified Nursing Assistant) and one nurse. On 1/7/25 at 10:45am V6 was monitoring several residents in the dining/common area while the assigned CNA was giving a shower to R14. V6 was attempting to redirect R36 who was dragging a table across the room. R50 and R51 were sitting at a table and staring into space. There was no music or television on at the time. No magazines or other type of table activities were on the tables or nearby. R25, R28 and R48 were in their rooms. R47 was sleeping in a chair by the nurse's station. Wednesday (1/8/25) Memory Unit Activity Calendar 7am Breakfast 9am Good Morning 9:30am Greetings 10am Wednesday Workouts 10:30am Songs of the past 11:30am Lunch 1pm Spa treatment 146138 Page 3 of 16 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0679 2pm Crafter's Club Level of Harm - Minimal harm or potential for actual harm 2:30pm Snack cart 3pm Walking Club Residents Affected - Some 4pm Button Sorting 5pm Supper 6pm What's in the bag. 6:30pm Soothing Sounds 7pm Snack cart On 1/8/25 at 2:25pm V7 (Nurse) and V11 (CNA) stated that earlier today, activity staff dropped off a package of craft pieces for the residents to make snowmen. At that time V7 displayed a clear plastic bag full of stick-on eyes, small fabric and paper pieces and multiple other small piece craft supplies. V7 stated We can't do this activity with them. We don't have enough staff to help them with this activity and monitor the other residents too. V7 stated some of the residents would put the pieces in their mouth as that is what happened when activities dropped off some beads for residents to string. V7 stated activities staff expect the nursing staff to do the activities with the residents. V7 stated Otherwise, activity staff doesn't come back here anymore. V11 (CNA) stated my shift started at 2pm and V11 works until 10pm. V11 stated she will be the only CNA assigned to the unit and there is only one nurse for the Memory Care Unit. Thursday (1/9/25) 7am Breakfast 9am Good Morning 9:30am Greetings 10am Parachute Fun 10:30am Morning Melodies 11:30am Lunch 1pm Spa treatment 2pm Kickball 2:30pm Snack cart 3pm Making tracks. 146138 Page 4 of 16 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0679 4pm Adult coloring Level of Harm - Minimal harm or potential for actual harm 5pm Supper 6pm Puzzles Residents Affected - Some 6:30pm Mindful melodies 7pm Snack cart On 1/9/25 at 9:25am R50 was noted to be walking down the hallway without any clothes and holding a pillow in front of her naked body. V14 (Nurse) was near the nurse's station passing medications and V8 (CNA) was assisting residents in the dining area. V8 responded and provided assistance to R50 when notified by this surveyor that R50 needed immediate assistance. On 1/9/25 at 9:40am eight residents were sitting in the day area, four of those residents were sleeping. R13 was being redirected from behind the nurse's station by V8 after V8 returned with R50 and assisted her to a table with R51. R50 was noted to be sitting at the table looking down and staring at a blank table. Five residents were in their rooms. On 1/9/25 at 9:50am V8 turned on music in the dining area. Shortly after the music started playing, R51 began tapping her foot to the music. R51's care plan dated 4/4/24 indicates It is very important to me to listen to music. I enjoy reminiscing with others. I enjoy watching comedies, westerns and shows that involve animals. Please turn this on the television. Three days of random observations on the Memory Care Unit - 1/7,1/8, and 1/9/25 found no music playing in the dining area except on 1/9/25 at 9:50am. The television in the same area where the residents sit for most of the day, was not on during any of the observations. No magazines, books or any type of activity materials were accessible to residents in the common/dining area where the majority of the residents spent most of their time. No activity staff arrived on the Memory Care Unit on 1/8/25 at 10am to provide Parachute Fun as listed on the activity calendar for that day. On 1/9/25 at 1:05pm V13 (Activity Aide) was observed painting fingernails for three of the residents R13, R14 and R20. R13 had a busy board in her lap and was intently engaged in working the various objects on the board. V13 stated Yes, (R13) really likes that. I keep it on my cart. I don't leave it back here. I keep my supplies on my cart which I take with me when I leave the unit. On 1/9/25 at 3:30pm V9 (Activity Director) stated V13 only works eight hours per week and V10 (Activity Aide) works full time So, I really only have one other activity employee besides myself. V9 stated Last year there were five of us. V9 stated the expectation is that the CNAs on the unit lead the activities But I know that's not always possible. V9 stated there are totes behind the nurse's station with activity supplies. V9 acknowledged the snowman crafts project was not suitable for most of the residents on the unit and acknowledged some of residents do put the supplies in their mouth. V9 stated that V10 works every other weekend but does not work on the Memory Care Unit at all on the weekends so there are no activities on the weekends for that unit. V9 also stated there are no 146138 Page 5 of 16 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0679 Level of Harm - Minimal harm or potential for actual harm activities in the Memory Care Unit on alternating Mondays and Fridays because V10 does not work on those days and I am the only one here and can't get back there on those days. V9 acknowledged the Activity Calendar programming often does not get done due to lack of activity staff. Residents Affected - Some 146138 Page 6 of 16 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

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 weigh a resident daily and report weights to the doctor as ordered for one resident (R23) of 17 residents reviewed for weight loss or gain in a total sample of 33. Residents Affected - Few Findings Include: R23's hospital discharge instructions dated 08/20/24 documents weigh daily with same scale and at the same time of the day if possible. Report weight gain of 3 pounds in one day or 5 pounds in one week to the cardiologist/CHF (Congestive Heart Failure Clinic) (phone number listed) every day shift for cardiac health. R23's MAR (Medication Administration Record) dated 08/20/24-8/31/24 does not document any weight for R23 on 8/22/24,8/23/24,8/24/24.8/25/24,8/27/24, 8/28/24 and 8/30/24. R23's MAR for August 2024 documents her weight on 8/20/24 as 158.2 and her weight on 8/21/24 as 163.5 which would indicate a weight gain of 5.3 pounds in one day. R23's documented weight on 8/26/24 was 160 pounds and her weight on 9/29/24 was 165 pounds which indicates a weight gain of 4 pounds in one week. R23's Medical Record did not contain any documentation of Cardiology/CHF Clinic being notified of those weight fluctuations as ordered. R23's MAR (Medication Administration Record) dated 09/01/-24-09/30/24 does not document any weight for R23 on 09/07/24,09/08/24, 09/24/24,09/26/24, and 09/27/24. R23's MAR for September 2024 documents her weight on 09/05/24 as 165.5 pounds and her weight on 09/06/24 as 168.5 which indicates a 3-pound weight gain in one day. R23's Medical Record did not contain any documentation of Cardiology/CHF (Congestive Heart Failure Clinic) being notified of those weight fluctuations as ordered. R23's MAR dated 09/01/24-09/30/24 documents her weight on 9/23/24 as 146.5 pounds and her weight on 9/29/24 as 160.5 which indicates a 14-pound weight gain in one week. R23's Medical Record did not contain any documentation of Cardiology/CHF Clinic being notified. R23's MAR dated 10/01/24-10/31/24 does not document any weight for R23 on 10/8/24,10/9/24,10/10/24,10/14/24,10/15/24,10/18/24,10/22/24,10/27/24 and 10/30/24. R23's MAR for October 2024 documents her weight on 10/21/24 as 163 pounds and her weight on 10/26/24 as 169.5 which indicates a weight gain of 6.5 pounds in one week. R23's Medical Record did not contain any documentation of Cardiology/CHF Clinic being notified. R23's MAR for 11/1/24-11/30/24 does not document any weight for R23 on 11/1/24,11/5/24,11/6/24,11/9/24,11/12/24,11/14/24,11/15/24,11/17/24 and 11/25/24. R23's MAR for November 2024 documents her weight on 11/10/24 as 163.5 pounds and her weight on 11/16/24 as 169.5 pounds, indicating a 6-pound weight gain in one week. R23's November MAR documents her weight on 11/19/24 as165 pounds and on 11/20/24 as 168.5 pounds, indicating a 3.5-pound weight gain in one day. R23's November 2024 MAR documents R23's weight on 11/26/24 as 168.5 pounds and on 11/27/24 173 pounds, indicating a 5-pound gain in one day. R23's Medical Record did not contain any 146138 Page 7 of 16 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0684 documentation of Cardiology/CHF clinic being notified. Level of Harm - Minimal harm or potential for actual harm R23's MAR for 12/1/24-12/31/24 does document any weight for R23 on 12/6/24,12/8/24,12/15/24,12/19/24,12/20/24,12/22/24 and 12/26/24. Residents Affected - Few R23's MAR for December 2024 documents that on 12/2/24 R23's weight was 167.5 pounds and on 12/3/24 her weight was 170.5 pounds, indicating a 3-pound weight gain in one day. R23's Medical Record did not contain any documentation of Cardiology/CHF Clinic being notified. On 01/09/24 at 1:00 PM V2 (Registered Nurse/Director of Nursing) confirmed the missing weight documentation on the August, September, October, November, and December Medication Administration Records. V2 acknowledged the order from Cardiology/CHF (Congestive Heart Failure) Clinic. V2 stated They (Cardiology/CHF Clinic) should have been notified per the parameters that the gave on 08/20/24 and they have not been notified of any of these weight changes. 146138 Page 8 of 16 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

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 thoroughly assess and measure a pressure ulcer for one resident (R23) of two residents reviewed for wounds in a total sample of 33. Residents Affected - Few Findings Include: The Facility's Skin Prevention, Assessment and Treatment policy dated 11/1/2015 documents that the purpose of the policy is to identify factors that place the residents at risk for the development of pressure ulcers, to implement appropriate interventions to prevent the development of clinically avoidable wounds, to promote a systematic approach and monitoring process for the care of the residents with existing wounds and for those who are at risk for skin breakdown and to promote healing of existing pressure ulcers. The Facility's Skin Prevention, Assessment and Treatment policy dated 11/1/2015 documents Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, in the Medical Record. a) Documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surround tissues, and a description of any drainage, eschar, necrosis, odor, tunneling, or undermining. R23's current Physician Order Sheet documents Cleanse area on buttocks with normal saline, pat dry, apply calcium alginate and cover every day and as needed. On 01/08/25 at 1:00 PM R23's coccyx area was noted to be red with areas noted that were approximately 2 centimeters long and less than a half a centimeter wide open area noted directly across her coccyx. There were 4 of these small slit looking areas. R23's Wound Care assessments on 11/22/24,11/27/24,12/6/24,12/11/24, 12/18/24 and 12/26/24 refer to R23's wound as irritant contact dermatitis. The Wound Care assessments document Wound Measurements: not applicable. None of the Wound Care assessments document that there is more than one open area on R23's coccyx. On 01/08/25 at 9:00 AM V2 (Director of Nursing/DON) stated that the facility uses Telehealth wound care doctors that do not come on site or do any hands-on assessments of the wound. V2 reports that she takes a computer tablet and uses the camera function to show the provider the area and then the provider will document an assessment. On 01/09/25 at 11:15 AM V2 (DON) stated that the facility does not measure non pressure ulcers that is why there were no wound measurements done weekly. V2 stated that the wound doctor stated that wound is Moisture Associated Skin Dermatitis therefore not pressure. V2 confirmed that R23's wound is from inability to move and incontinence V2 also confirmed that R23s wound is directly over the pressure point of her coccyx. V2 also confirmed that there is no documentation of how many of the little open areas on R23's coccyx there have been or currently are on R23. CMS website: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. 146138 Page 9 of 16 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was changed as ordered for one (R33) of two residents reviewed for respiratory care in a total sample of 33. Residents Affected - Few The findings include: An Oxygen Administration and Storage policy and procedure revised on March 8, 2024 documents a nasal cannula or mask should be changed weekly or when soiled and the humidifier bottle is to be labeled with the date of application and changed weekly if refillable. R33's POS/Physician Order Sheet dated 12/19/24 has orders to change oxygen water bottle on night shift every Sunday night and as needed, date and initial bottle and to change oxygen tubing on Sunday and as needed for infection control. R33's December 2024 TAR/Treatment Administration Record documents Sunday, December 15th 2024 night shift was the last date in December R33's humidification bottle was changed. The two other Sundays (December 22 and December 29, 2024) have no documentation. On 01/07/25 at 10:15 AM, R33 was lying in bed asleep. R33 was receiving oxygen via nasal cannula from a concentrator. R33's nasal cannula tubing was dated 12/16/24 and the date on the refillable humidifier bottle was 12/16/24. On 01/08/25 at 9:22 AM, R33's nasal cannula tubing and refillable humidifier bottles were still dated 12/16/24. On 01/08/25 at 1:39 PM V2 (Director of Nursing) confirmed R33's nasal cannula was dated 12 something (day not legible) 24 (2024) and R33's refillable humidity bottle was dated, 12/16/24. V2 confirmed both should be changed weekly. 146138 Page 10 of 16 146138 01/09/2025 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 ensure an appropriate indication for use to administer antipsychotic medications and failed to identify and document target behaviors for six residents (R25, R26, R36, R48, R50, R51) of seven residents reviewed for unnecessary psychotropic medications in the sample of 33. Findings include: Facility Policy/Psychotropic Medication Management dated 12/4/24 documents: The medical record documentation must reflect the specific behaviors/symptoms and the resident's response to non-pharmacological interventions to manage the behaviors/symptoms. The physician should evaluate use of antipsychotic medication use if one or more of the following is/are the only indication: Wandering; Poor self-care; Restlessness; Impaired Memory; Anxiety; Depression (without psychotic features); Insomnia; Unsociability; Indifference to surrounding; Fidgeting; Nervousness; Uncooperativeness; Agitated behaviors which do not represent danger to resident or others. 1.) Current Physician Orders Summary Report indicates R25 is [AGE] years old with diagnoses that include Frontotemporal Neurocognitive Disorder, Frontotemporal Dementia, Unspecified Dementia, Bipolar Disorder, Schizophrenia, Schizoaffective. Summary Report also indicates R25 has orders to receive Haloperidol (antipsychotic) 0.5mg (milligram) two time per day related to bipolar disorder and Schizophrenia (date initiated 2/2/23) and Quetiapine (antipsychotic) 150mg at bedtime related to bipolar disorder (date initiated 12/24/24). Pharmacy Recommendations dated 9/29/24 indicates (Psych) recently increased Seroquel (Quetiapine) due to hallucinations. Psychiatric Evaluation and Consultation dated 12/17/24 indicates R25 continues to appear confused, is crying and calls her family a lot of times. Evaluation indicates R25 Still sometimes makes up false stories about her family based off the television show however her family can help redirect her through those thoughts. Evaluation indicates R25 is showing signs of increased anxiety and depression; no symptoms of psychosis or mania; no evidence of auditory or visual hallucinations. Evaluation indicates R25 has some exit seeking behaviors, follows the nurses around and has been crying a lot. On 1/9/25 at 10:13am V8 (Certified Nurse Assistant/CNA) stated she only works in the Memory Care Unit and stated that 25's behaviors are confusion, sometimes tries to elope, cries to leave and go home and is unsteady on her feet. Behavior Monitoring 12/13/24 to 1/8/25 indicates R25 exhibited: Frequent crying 6 times 146138 Page 11 of 16 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0758 Wandering 8 times Level of Harm - Minimal harm or potential for actual harm Repeats Movement 3 times Rejection of care 2 times Residents Affected - Some Pacing 3 times Disrobe in Public 2 times Current Care Plan indicates R25 is on anti-psychotic therapy related to Schizophrenia. R25's Current Care Plan does not include target behaviors requiring the use of antipsychotic medications. 2) Current Physician Orders Summary Report indicates R26 is [AGE] years old with diagnoses that include Moderate Severity Dementia and Mood (Affective) Disorder. Summary Report indicates R26 receives Risperidone (antipsychotic) 0.5mg two times per day (date initiated 11/18/24) related to Mood (Affective Disorder). On 1/9/25 at 2:45pm V2 (Director of Nursing/DON) stated R26 has not yet been seen by any psychiatric services. On 1/9/25 at 10:10am V8 (CNA) stated R26's behaviors are wandering and not sleeping at night. Behavior Monitoring 12/13/24 to 1/8/25 indicates R26 exhibited: Wandering 10 times Pacing 2 times Rejection of care once Yelling/screaming/disruptive sounds 2 times Repeats Movement 2 times Current Care Plan indicates R26 is on anti-psychotic therapy related to Affective Disorder. R26's Current Care Plan does not include target behaviors requiring the use of antipsychotic medications. 3) Current Physician Orders Summary Report indicates R36 is [AGE] years old with diagnoses that include Depression, Anxiety, Dementia without Behavioral Disturbance. Summary Report indicates R36 receives Risperidone 0.5mg twice daily related to aggressiveness and irritability (date initiated 10/23/24). 146138 Page 12 of 16 146138 01/09/2025 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 Psychiatric Evaluation and Consultation dated 12/24/24 indicates R36 has had no aggressive behaviors, and she is doing well; no anxiety out of the ordinary; no symptoms of psychosis or mania were observed or reported; no evidence of auditory or visual hallucinations. Eval indicates to continue Risperdal for irritability and aggressiveness. On 1/9/24 at 10:12am V8 (CNA) stated R36's behaviors are poor sleep, sometimes not sleeping for two days. Behavior Monitoring 12/1/24 to 1/8/25 indicates R36 exhibited: Kicking/Hitting/Pushing/Grabbing 2 times Yelling/Screaming/Disruptive Sounds/Rejection of Care 6 times Frequent Crying 8 times Wandering 9 times Disrobing in public twice Current Care Plan indicates R36 is on anti-psychotic therapy related to Major Depressive Disorder, recurrent and Generalized Anxiety Disorder. Disorder. R36's Current Care Plan does not include target behaviors requiring the use of antipsychotic medications. 4) Current Physician Order Summary Report indicates R48 is [AGE] years old and has the following diagnoses: Unspecified Dementia with Agitation and Behavioral Disturbance. Order Summary indicates R48 receives Risperdal 1mg twice daily related to Unspecified Dementia with Agitation (date initiated 8/23/24). Psychiatric Evaluation and Consultation dated 12/24/24 indicates R48 had no symptoms of psychosis or mania reported or observed; no evidence of auditory or visual hallucinations; no reports of mood instability. On 1/9/24 at 10:10am V8 (CNA) stated R48 has no behaviors other than refuses toileting and/or incontinent care at times. Behavior Monitoring 12/1/24 to 1/9/25 indicates R48 exhibited: Rejection of Care twice. Current Care Plan indicates R48 is on anti-psychotic therapy related to Aggression. Care Plan indicates R48's Target behaviors are: Thinking he is in the military at war, telling staff people are going to shoot through the window, wanting to speak with his sergeant, believing his fire alarm is a camera and he is being watched. 146138 Page 13 of 16 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0758 These target behaviors were not added to R48's care plan until 1/7/24 (Survey Day 1). Level of Harm - Minimal harm or potential for actual harm 5) Current Physician Orders Summary Report indicates R50 is [AGE] years old with diagnoses that include Dementia without Behavioral Disturbance (3/23/24), Anxiety, Insomnia; Schizoaffective Disorder (12/27/24). Residents Affected - Some Summary Report also indicates R50 has orders to receive Risperidone - 1mg twice daily related to Hallucinations/Aggressive Behavior (date initiated 12/26/24). Psychiatric Evaluation and Consultation dated 12/2424 indicates R50 is hitting people in the face, still hallucinating, and speaking to people who aren't there; believes she is running a business and has to run to meet people. Evaluation indicates R50 is having some auditory and visual hallucinations. Evaluation indicates R50's Risperdal was increased on 12/26/24 from 0.5 mg twice daily to 1mg twice daily. On 1/9/24 at 10:15am V8 (CNA) stated R50's behaviors are that R50 screams at self in mirror, disrobes, is mean to other residents/verbal and physical, paranoid/suspicious. On 1/9/24 at 9:50am R50 was seen coming out of her room naked holding a pillow in front of her. R50 accepted redirection from staff to go back to her room to get dressed. A short time later, R50 was assisted to a table in the dining area and given a snack. R50 also took her scheduled medications when offered by the nurse. Behavior Monitoring 12/1/24 to 1/8/25 indicates R50 exhibited: Rejection of Care once Wandering 3 times Frequent Crying once Current Care Plan indicates R50 is currently on Antipsychotic therapy related to schizoaffective disorder. R50's Current Care Plan does not include target behaviors requiring the use of antipsychotic medications. 6) Current Physician Orders Summary Report indicates R51 is [AGE] years old with diagnoses that include Moderate Unspecified Dementia without Behavioral Disturbance, Alzheimer's Disease, Metabolic Encephalopathy. Summary Report also indicates R50 has orders to receive Quetiapine 50mg twice daily related to Dementia. Psychiatric Evaluation and Consultation dated 11/26/24 indicates (R51) has no current significant behavioral issues that needs medication changes. Evaluation indicates R51 has no auditory or visual hallucinations. 146138 Page 14 of 16 146138 01/09/2025 Mercer Manor Rehabilitation 309 N W 9th Avenue Aledo, IL 61231

F 0758 Progress Note dated 6/11/24 indicates R51 moved from South unit to Memory Care room, has displayed no untoward behaviors this far, continues to wander about in her wheelchair as is her habit. Level of Harm - Minimal harm or potential for actual harm On 1/9/24 at 10:16am V8 (CNA) stated R51's behaviors are She just wants to be left alone. Residents Affected - Some Behavior Monitoring 12/1/24 to 1/8/25 indicates R51 exhibited no behavioral symptoms. Current Care Plan indicates R51 is currently on antipsychotic therapy related to Unspecified Dementia without Behavioral Disturbance. R51's Current Care Plan does not include target behaviors requiring the use of antipsychotic medications. On 1/9/24 at 10:30am V2 (Director of Nursing) stated that she is responsible for the residents who are on psychotropic medications. V2 stated the residents in the Memory Care Unit have Tele-Health Psychiatric services that started about 2 months ago. V2 stated that the Psychiatric services get the information about the residents from the staff And some of the staff think the answer to behaviors is more medications, so they are part of the problem. V2 stated I think it's gotten out of hand back there - as far as the number of residents receiving antipsychotic medications. V2 stated I knew this was going to happen. I haven't been able to get back there to clean this up. V2 stated the care plans should have target behaviors as part of the reason the psychotropic medications are needed. 146138 Page 15 of 16 146138 01/09/2025 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 Based on observation, interview, and record review the facility failed to prepare medications without cross contaminating the pills for one resident (R23) of four residents observed during a routine medication pass. Residents Affected - Few Findings Include: The Facility's Standard Precautions policy dated 11/1/2015 documents It is this Facility's policy that Standard Precautions will apply to the care of all residents in all situations regardless of their suspected or confirmed infection disease process. Standard Precautions assume all blood, body fluids and secretions/excretions, non-intact skin and mucous membranes may contain transmissible infectious agents. On 01/08/24 at 10:30 AM V5 (Registered Nurse) had all R23's 9:00 AM medication in a medicine cup that she sat on R23's bed on a clean field while she unclamped and flushed R23's gastric tube. The medicine cup tipped over and spilled two pills directly onto R23's fitted sheet. V5 picked the pills up with her gloved hand and put them back in the cup with the rest of R23s medication. V5 then administered all the medications in the cup via R23's gastric tube. On 01/08/25 at 1:30 PM V5 confirmed that the two pills did roll out of the medicine cup when it tipped over in R23's room. V5 stated I should have thrown those two pills away and got new ones because (R23's) bedsheet would not be considered clean. 146138 Page 16 of 16