Health inspection·April 4, 2025

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 follow their plan of care for potential skin impairment for one (R40) of three residents reviewed for pressure ulcers/skin breakdown in a sample of 29. Residents Affected - Few Findings include: Facility policy For the Prevention and Treatment of Skin Breakdown, undated, documents, It is the policy to implement preventative measures. R40's list of diagnoses include the following: Pressure Ulcer of the right heel stage 4; and Personal history of Venous Thrombosis and Embolism. R40's current plan of care for April 2025 documents, I have a potential for skin impairment related to fragile skin, limited mobility, high blood pressure, edema/swelling, terminal diagnosis, and Anemia where I require bilateral heel protectors while in my wheelchair, with a date initiated on 07/23/2024. R40's current plan of care for April 2025 documents, Follow facility policies/protocols for the Prevention/Treatment of Skin Breakdown, with a date initiated on 12/31/2024, and a revision on 01/02/2025. On 4/2/25, continuous observations were made from 10:15 AM to 10:43 AM. R40 was up in her positioning wheelchair in the dining room for activities where she was alert and drinking juice, with no heel protectors on her bilateral heels. On 4/2/25 at 10:44 AM, V11, CNA/Certified Nurse Aide, stated, (R40) doesn't wear heel protectors when up in the wheelchair, she only has a wedge for her feet when in bed. (R40) has a history of heel wounds that are heeled right now. At that same time, V11 verified there were no heel protectors in R40's room. On 4/4/25 at 9:20 AM, R40 was up in her positioning wheelchair in her bedroom and had no heel protectors on her bilateral heels. Page 1 of 3 146151 146151 04/04/2025 Clayberg, The 625 East Monroe Street Cuba, IL 61427

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to post the required staffing information to include the census and actual hours worked per shift for nursing staff. This has the potential to affect all 45 residents who reside in the facility. Residents Affected - Many Findings include: Facility policy Posting Direct Care Daily Staffing Numbers, revised July 2016, documents, Shift staffing information shall be recorded on The Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: The resident census at the beginning of the shift. The actual time worked during that shift for each category and type of nursing staff. Total number of licensed and non-licensed nursing staff working for the posted shift. On 4/1/25 at 10:00 AM, 4/2/25 at 10:41 AM, and 4/4/25 at 10:14 AM, nursing daily staffing was posted, but did not have the census or actual hours worked per shift for the nursing staff. Facility nursing daily staffing sheets, dated 3/1, 3/8, 3/9, 3/15, 3/16, 3/22, 3/23, 3/29, and 3/30/25 did not have the census or actual hours worked per shift for RN's/Registered Nurses, LPN's/Licensed Practical Nurses, and CNA's/Certified Nurse Aides. On 4/4/25 at 10:09 AM, V2, DON/Director of Nursing, verified no census and no actual hours worked per shift were on the above staffing sheets. At that same time, V2 stated, We usually put the census on the staffing sheets; it is posted by the midnight staff which is mostly agency now, but we need to get back to that; and I have reminded and put a posting up for staff to indicate that but it doesn't always get done. The Facility's Resident Bed List Report, dated 4/1/25, documents 45 residents reside in the facility. 146151 Page 2 of 3 146151 04/04/2025 Clayberg, The 625 East Monroe Street Cuba, IL 61427

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to follow standard precautions and perform hand hygiene before or after administration of oral medications for eight residents (R2, R4, R6, R15, R21, R25, R29, and R33) and failed to not touch medications with bare hands (R21) out of nine residents reviewed for medication administration in a sample of 29. Residents Affected - Some Findings include: The facility's Administering Oral Medications policy, dated 2010, under Steps in the Procedure documents the following steps: 1.) Wash your hands. e.) For tablets or capsules from a bottle .Do not touch the medication with your hands and after administration of the medication(s), 23.) Perform hand antisepsis. On 04/01/25 at 11:30am, during a medication pass, V9, RN/Registered Nurse, did not perform hand hygiene before or after oral medication administration for R2, R6, R25, R29, and R33. On 4/2/25 at 8:10am, during morning medication pass, V10, LPN/Licensed Practical Nurse, did not perform hand hygiene before or after oral medication administration for R4, R21 and R15. On 4/2/25 at 8:26am, V10, LPN, dropped R21's B-12 500 mcg/microgram tablet onto the surface of the medication cart. V10 then picked the tablet up with her bare hands, and placed it in the medicine cup, with several other oral medications already place in the medicine cup for R21. V10 then administered the oral medications in the medication cup to R21. On 4/4/25 at 8:50am, V2, DON/Director of Nursing, stated, Nurses are to perform hand hygiene between administration of medication for each resident and nursing staff are to perform hand hygiene before and after administering a resident's medications. On 4/4/25 at 1:05pm, V2, DON, stated when a nurse drops a tablet onto a surface, such as the medication cart, the medication is to be discarded, not administered. 146151 Page 3 of 3