Health inspection·May 4, 2023

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 observation, interview, and record review, the facility failed to provide wound care treatment as prescribed by the physician and in manner to promote resident comfort. This failure applies to 1 of 1 (R126) residents in the sample of 13. Residents Affected - Few The findings include: R126's Transfer/Discharge Report (Face Sheet) showed an admission date of 4/25/23, with diagnoses to include: venous insufficiency, obesity, right artificial hip joint. On 5/2/23 at 2:20 PM, R126 had a dressing to her right hip, left calf, and right calf. R126 was alert and oriented to person, place, time, and her condition. V4, Licensed Practical Nurse (LPN), entered R126's room to provide wound care. V4 provided wound care to R126's right hip and completed the care at 2:30 PM. V4 then proceeded to R126's right leg wound. Prior to removing the right leg dressing, R126 asked if V4 was going to soak the dressing prior to removal; V4 did not respond. After V4 removed R126's right leg dressing she applied an antimicrobial/petroleum based gauze dressing. V4 covered this dressing with an absorbent pad and gauze wrap. V4 completed the right leg dressing change at 2:48 PM. At 2:53 PM, prior to starting the left leg dressing change, R126 stated the left leg was her most painful leg, and she again asked V4 to soak the dressing prior to removal. V4 did not respond. R126 stated soaking the dressing with saline solution allows the dressing to come off more easily, and with less pain. V4 did not soak R126's left leg dressing and began removing the dressing. As V4 removed the antimicrobial/petroleum dressing, the dressing was adhered to an open area on R126's left outer shin area. As V4 reached this area R126 yelled Owww. R126 shut her eyes covered her face, and again asked V4 to soak the dressing. V4 soaked the area with wound cleanser and attempted to remove the dressing; R126 again yelled Owww. R126 stated other nurses soak it with water, let it soak for a time, then remove the dressing. At 3:12 PM, V4 returned to R126's room with saline solution, soaked the wound, and removed the dressing. V4 again applied a antimicrobial/petroleum based dressing; then absorbent pad; then covered with a gauze wrap. V4 completed the wound care at 3:30 PM. (An hour and 10 minutes later.) On 5/03/23 at 8:44 AM, R126 stated, I've never had a dressing change hurt like that before, at least not since I was in the hospital. I told her to soak the dressing. That makes the dressings come off so much easier. The other nurse that does the dressing change on nights will soak the dressing and they come right off and it doesn't hurt. If she had offered me a pain pill before the dressing change, I wouldn't have accepted it, because it never hurt like that before. All the nurses should know how to take care of my dressing. There was an agency nurse that did my dressing change, and she was even aware of soaking the dressing. I think she was aware of it because of how badly the dressing change went yesterday. Normally, they can change all three dressings in about 20 minutes; that took too long. Yes, all nurses should know how to do my dressing changes and they should know to soak both Page 1 of 7 146147 146147 05/04/2023 Allure of Stockton 501 Front Street Stockton, IL 61085

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few legs dressing to make it less painful. I did tell her many times to soak the dressings. Normally they soak them before they remove them, long before it gets to the point of it hurting. On 5/03/23 at 1:31 PM, V2, Director of Nursing, stated dressing changes can be painful because the wounds are sensitive and inflamed. V2 stated some techniques to minimize pain during dressing changes are to pre-medicate with pain medication; moisten the dressing; and to remove the dressing slowly and gently. V2 stated if a resident requested the dressing be soaked prior to removal. she would check for an order to do so. and if there was not order, she would obtain the order. V2 stated while reviewing R126's wound care orders, V4 should have applied the antimicrobial/petroleum dressing as well as a second petroleum only dressing. V4 stated the additional petroleum based dressing could aid in the dressing removal, and possibly be more comfortable for the resident. R126's Medication Review Report (Physician Order Sheet) showed an active order starting on 4/26/23 to apply a antimicrobial/petroleum based dressing as well as a petroleum only based dressing. The facility's Wound Treatment Management policy (Implemented 9/2021) showed, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . The policy showed, Treatment decisions will be based on .Goals and preferences of the resident . 146147 Page 2 of 7 146147 05/04/2023 Allure of Stockton 501 Front Street Stockton, IL 61085

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed administer the correct dose of an antipsychotic medication and failed to notice an antipsychotic medication on the floor of the facility. Residents Affected - Few This applies to 1 resident (R15) outside the sample. The findings include: On 5/2/23 at 2:00 PM, a white and brown, oblong capsule was seen on the floor next to the medication cart parked by the dining area. The medication cart showed the only resident in the facility taking that medication was R15. The blister card listed that medication as Thiothixene 5 mg (milligrams) with 2 capsules in each blister. R15's Face Sheet showed her diagnoses includes, schizoaffective bipolar type, anxiety and dementia with agitation. R15's 5/2023 POS (Physician Order Sheet) shows, she (R15) is ordered Thiothixene 5 mg, 2 capsules, by mouth, every morning for schizoaffective disorder. On 5/4/23 at 10:20 AM, V1 (Administrator) said, (R15) is the only resident to get Thiothixene, and if a pill was found on the floor, it means she didn't get her full dose. V1 said it's important to administer medications as ordered by the Physician so the resident can get the full benefits from the medication. On 5/4/23 at 11:15 AM, V5, RN (Registered Nurse), said, The nurse should inspect the med cup before giving the cup to the resident to make sure all pills made it into the cup. The Nurse should inspect the med cart surface and the floor for accidental spills of medication and waste any dropped medication, so no other residents take medication not prescribed to them. The 9/2021 Medication Administration Policy and Procedure shows, the MAR (Medication Administration Record) should be reviewed to identify all medication to be administered, all medications should be administered 60 minutes prior or after scheduled time, and all medication should be administered as ordered by a Physician. 146147 Page 3 of 7 146147 05/04/2023 Allure of Stockton 501 Front Street Stockton, IL 61085

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 27 opportunities with 9 errors, resulting in a 33.33% medication error rate. Residents Affected - Some This applies to 4 of 4 residents (R7,R15,R28,R126) observed in the medication pass. The findings include: 1) R7's electronic face sheet printed on 5/3/23 showed R7 has diagnoses including but not limited to heart disease, major depressive disorder, hypertension, and venous insufficiency. R7's medication administration record (MAR) for May 2023 showed R7 receives Carvedilol 25mg and Sacubitril-Valsartan 97-103mg at 8AM and 5PM. On 5/2/23 at 9:35AM, V4 (Licensed Practical Nurse-LPN) administered R7's Carvedilol 25mg and Sacubitril-Valsartain 97-104mg. (1 hour and 35 minutes past the scheduled administration time) On 5/2/23 at 9:40AM, V4 stated, My whole screen is red and I'm late on all of my remaining medications. I was busy this morning doing skin checks and wound treatments so that is why I am late giving medications. I probably should have prioritized my time better but there's nothing I can do about it now. 2) R15's electronic face sheet, printed on 5/3/23, showed R15 has diagnoses including but not limited to altered mental status, major depressive disorder, schizoaffective disorder, disorder or psychological development, anxiety disorder, and dementia with agitation. R15's MAR for May 2023 showed R15 receives amantadine 100mg and oxcarbazepine 600mg at 8AM and 8PM, benztropine 0.5mg, lithium 150mg, and Haldol 1mg at 8AM and 5PM. On 5/2/23 at 10:14AM, V5 (Registered Nurse) administered R15's amatadine 100mg, benztropine 0.5mg, Haldol 1mg, lithium 150mg, and oxcarbazepine 600mg. (2 hours and 14 minutes past the scheduled administration time) 3) R28's electronic face sheet, printed on 5/3/23, showed R28 has diagnoses including but not limited to anxiety disorder, psychotic disorder, and major depressive disorder. R28's MAR for May 2023 showed R28 receives Dilantin 100mg at 8AM, 12PM, and 8PM. On 5/2/23 at 9:41AM, V4 administered R28's Dilantin 100mg. (1 hour and 41 minutes past the scheduled administration time) 4) R126's electronic face sheet, printed on 5/2/23, showed R126 has diagnoses including but not limited to hypertension, venous insufficiency, acute cystitis, and severe sepsis. R126's MAR for May 2023 showed R126 receives Potassium Chloride 10meq at 8AM and 5PM. On 5/2/23 at 10:03AM, V4 administered R126's Potassium Chloride 10meq. (2 hours and 3 minutes past 146147 Page 4 of 7 146147 05/04/2023 Allure of Stockton 501 Front Street Stockton, IL 61085

F 0759 the scheduled administration time) Level of Harm - Minimal harm or potential for actual harm On 5/3/23 at 11:41AM, V2 (Director of Nursing) stated, Medications administered over 1 hour before or 1 hour after their scheduled time would be considered a medication error. (V4, LPN) did inform me of the late medications yesterday, but she notified the physician, so we thought that would be sufficient. I didn't realize she was that late on administering medications. She can always let us know so that a nursing supervisor can help her pass medications. Residents Affected - Some The facility's policy titled, Medication Administration, dated 09/2021, showed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .11. Compare medication source with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and time .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by a physician . 146147 Page 5 of 7 146147 05/04/2023 Allure of Stockton 501 Front Street Stockton, IL 61085

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 label food items, failed to ensure a functional thermometer was utilized in two freezers, and failed to maintain a freezer to prevent ice buildup. These failures have the potential to affect all residents in the building. The findings include: The Resident Census and Condition Report, dated 5/2/23, showed 29 residents residing in the building. On 5/2/23 at 8:59AM, The facility's standing freezer located in the dry storage room had an unlabeled fast food cup full of a pink frozen substance and 2 packages of unlabeled food. The thermometer in the freezer was unable to measure an accurate temperature, due to the scale line being broken and tilted, giving an inaccurate temperature reading. The freezer shelves were all lined with thick blocks of ice and packed full of bags of frozen food items. There was no additional room in the freezer and bags were falling off shelves during observation. On 5/2/23 at 9:09AM, containers of brown sugar, butter, and peanut butter were placed in a cabinet underneath the food preparation area. All 3 containers had no label showing the contents or date on them. On 5/2/23 at 9:20AM, the facility's free-standing freezer had 2 packs of unlabeled meat with no date, 3 bags of breaded meat that were unlabeled, and 1 bag of hamburger patties that did not have a date on it and was opened. The thermometer for the freezer was buried under 4 packs of bread and covered in ice. V3 (Dietary Manager) dug the thermometer out of the freezer and chipped the ice off the outside of the thermometer. V3 stated the thermometers should be in working condition, and able to be easily read to ensure that the freezers are at the appropriate temperature. On 5/2/23 at 10:45AM, V3 stated the freezers should be free of ice buildup to allow adequate cooling and freezing in the freezer. V3 stated if too much ice builds up, then the freezer will shut down and the food will not be kept frozen. V3 stated all food items should be labeled with a received date and when they are opened; that date and a use by date should be put on the package or container. V3 stated all items should have a label with what the item is so all staff know what they are pulling form the refrigerator or freezer to cook, and it will help them know how to thaw and prepare the food. The facility's policy titled, Food Safety Requirements, dated 09/2021, showed, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety .c .Practices to maintain safe refrigerated/frozen storage include: i. Monitoring food temperatures and functioning of the equipment daily and at routine intervals during all hours of operation. 146147 Page 6 of 7 146147 05/04/2023 Allure of Stockton 501 Front Street Stockton, IL 61085

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 provide incontinence care to prevent cross-contamination. This failure applies to 1 of 2 residents (R11) in the sample of 13. Residents Affected - Few The findings include: R11's Transfer/discharge Report (Face Sheet) showed and original admission date of 7/28/2020, with diagnoses to include: Alzheimer's disease, diabetes, and overactive bladder. R11's 4/6/23 Minimum Data Set (MDS) showed she had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 12 out of 15. The MDS showed R11 required extensive assistance of two staff for toilet use to include cleaning herself after elimination. The MDS showed she was always incontinent of bowel and bladder. R11's Medication Review Report (Physician Orders Sheet) showed an active order for an antibiotic to prevent urinary tract infections (UTIs). On 5/02/23 at 1:13 PM, R11 stated, I have had many UTIs (urinary tract infections). I'm not sure the last time I had one. On 5/02/23 at 10:28 AM, V6 and V7 Certified Nursing Assistants (CNAs) provided incontinence care for R11. While providing incontinence care, V7 wiped a bowel movement (BM) from R11's buttocks with a washcloth. Without changing gloves, V7 then touched R11 as well as R11's clean brief with the same gloved hand used to wipe the bowel movement. On 5/03/23 at 1:31 PM, V2, Director of Nursing, stated, The purpose of glove use is to protect us (staff) and the resident from cross-contamination. I would agree that when gloves are grossly contaminated, removing gloves is an easy way to remove a lot of contamination and should be followed up with hand hygiene. During incontinence care, staff should change gloves after wiping a BM prior to touching any clean surface including the resident. This is to prevent contamination of those surfaces. The facility's Helping a Resident with Toileting Needs policy (implemented 9/2021) showed .If the resident needs help with wiping when finished, put on new gloves. Help with wiping .removed your gloves and dispose of them in the trash bag . 146147 Page 7 of 7