Health inspection·February 5, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify a resident's representative of a new Physician's Order for a chest xray, and failed to notify the resident's representative of the results of that chest xray for one of three residents (R1) reviewed for notification in the sample list of eight. Findings include: The facility's Significant Condition Change & (and) Notification policy with a reviewed date of November, 2019 documents, Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: A significant change in the resident's physical, mental or psychosocial status. Sudden onset of shortness of breath Symptoms of an infectious process Change in level of consciousness such as agitation, lethargy, sudden lack of responsiveness or manic behavior Other abnormal assessment findings Calls will be made to the resident's representative until they are reached. R1's Progress Notes, dated 2/5/24, document diagnoses including Metabolic Encephalopathy, Dysphagia, Oropharyngeal Phase, and Unspecified Dementia. R1's Nurse's Note, dated 1/16/24 at 11:24 AM, by V3, Director of Nursing, documents R1 is experiencing a change in condition, and is currently experiencing a cough and congestion with COVID exposure, and documents the physician and family were notified. R1's Nurse's Note, dated 1/17/24 at 1:25 PM, by V16, Licensed Practical Nurse (LPN), documents there was a new order received to obtain a chest xray with two views. There is no documentation the resident's representative was notified of this new order. R1's Nurse's Note, dated 1/18/24 at 1:11 PM by V16, documents R1's chest xray results are back, and there was no acute cardiopulmonary disease. This note documents the results were faxed to the physician, but there is no documentation that the resident's representative was notified of the results. On 2/5/24 at 10:50 AM, V3 confirmed there is no documentation that anyone other than the physician was notified of the xray order on 1/17/24 and the results on 1/18/24. V3 confirmed the resident's representative should have been notified. Page 1 of 6 146162 146162 02/05/2024 Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to protect the confidential health information for one of one resident (R1) reviewed for confidentiality in the sample list of eight. Residents Affected - Few The findings include: R1's Healthcare Power of Attorney, dated 4/7/21, documents, I (R1) intend for the person named as my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records, including records or communications governed by the Mental Health and Developmental Disabilities Confidentiality Act. This release authority applies to any information governed by the Health Insurance Portability and Accountability act of 1996 (HIPAA) and regulation thereunder. I intend for the person named as my agent to serve as my personal representative as that term is defined under HIPAA and regulations thereunder. On 2/5/24 at 10:37 AM, V22, Licensed Practical Nurse/LPN confirmed she has notified V20, who is not R1's POA, for some issues. V22 stated V20 would call for updates on R1, and V22 would give V20 the information, even though she was not the POA. On 2/1/24 at 10:52 AM, V19, R1's family, stated the facility has called V20, R1's family who is not R1's Power of Attorney for Healthcare, and given personal information regarding R1. V19 stated V21, R1's spouse, is the POA and was not always contacted as he should have been. V19 stated V19 is concerned about HIPAA violations. R1's Nurse's Note, dated 1/11/24 at 2:46 PM, by V15, Social Services Director (SSD), documents V20, R1's family, was notified this day R1 will be moving rooms. R1's Nurse's Note, dated 1/16/24 at 11:24 AM by V15, documents V20 R1's family was notified R1 will be moving to a different room this day. R1's Nurse's Note, dated 1/26/24 at 12:34 PM, by V22, Licensed Practical Nurse (LPN), documents a call was made to the husband and the daughter (who is not the POA) at this time to update on R1. On 2/5/24 at 10:00 AM, V15 confirmed she notified V20, R1's family, who is not the POA of R1's room moves. On 2/5/24 at 10:37 AM, V22, LPN, confirmed she has notified V20, who is not R1's POA, for some issues. V22 stated V20 would call for updates on R1, and V22 would give V20 the information, even though she was not the POA. On 2/5/24 at 2:45 PM, V1, Administrator, confirmed R1's family, that is not POA, had been notified regarding R1. V1 stated upon admission, they document emergency contacts in the computer, and V20 is documented as an emergency contact, so she thought they could contact her. 146162 Page 2 of 6 146162 02/05/2024 Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550

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 follow up with the physician to ensure timely care for one of three residents (R1) reviewed for COVID 19 infection in the sample list of eight. Residents Affected - Few Findings include: The facility's Significant Condition Change & (and) Notification policy with a reviewed date of November/2019 documents, Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: A significant change in the resident's physical, mental or psychosocial status. The medical practitioner will be contacted immediately for any emergencies regardless of the time of evening or night shift. This applies to any day of the week including holidays. If the medical practitioner cannot immediately be reached in any emergency, the medical director will be called. If that medical practitioner cannot be reached, the director of nursing or the charge nurse can make arrangements for transportation to the emergency department. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. In a non-emergency situation, the primary medical practitioner will be called unless he/she has left an alternate name to call. If after two attempts, there is no response to the calls, the medical director will be contacted. R1's Progress Notes, printed on 2/5/24, document diagnoses including Metabolic Encephalopathy, Dysphagia, Oropharyngeal Phase, and Unspecified Dementia. R1's Nurse's Note, dated 1/24/24 at 8:32 AM by V23, Licensed Practical Nurse (LPN), documents, (R1) tested (positive) for COVID-19 on 1/19. Today, (R1) has harsh, productive sounding cough. Lungs are diminished all lobes. O2 (oxygen) 92% (percent) on RA (room air), BP (blood pressure) 70/54, HR (heart rate) 100. (R1) alert & (and) acknowledges writer but not willing to eat breakfast this morning nor take a drink. Concerns for dehydration & COVID pneumonia. Faxed MD (medical doctor) (V24 R1's Physician) suggesting IV (intravenous) fluids and CXR (chest X-ray). Awaiting response. There is no further documentation on 1/24/24 in R1's Nurse's Notes regarding contact or attempted contact with V24 regarding R1's status or request for chest X-ray and fluids. R1's Nurse's Note, dated 1/25/24 at 6:54 PM by V22, LPN, documents, (R1) continues with droplet isolation dt (due to) COVID + (positive), (R1) continues to be lethargic and poor appetite, pushing fluids, vs (vital signs) wnl (within normal limits). There are no other Nurse's Notes documented on 1/25/24, no contact or attempted contact with V24. R1's Nurse's Note, dated 1/26/24 at 10:30 AM by V22, documents a new order was received from V24's office to obtain a portable chest X-ray, CBC (complete blood count) and CMP (complete metabolic profile). V22 documents at 12:39 PM on 1/26/24, V24 ordered Levaquin (antibiotic) 500 mg (milligrams) daily for 10 days. R1's Medication Administration Record for January 2024 documents R1 received one dose of Levaquin 500 mg on 1/26/24 at 2:00 PM. R1's Nurse's Note, dated 1/27/24 at 12:40 PM by V16, LPN, documents R1 is experiencing a change in condition of lethargy, lung sounds diminished, and non-productive cough, and R1 is not eating or 146162 Page 3 of 6 146162 02/05/2024 Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550

F 0684 drinking. Level of Harm - Minimal harm or potential for actual harm R1's Nurse's Note, dated 1/27/24 at 12:40 PM by V16, documents V16 spoke to V21, R1's POA (Power of Attorney), and he gave permission to send R1 to the Emergency Room. V16 documents V16 received an order by V24, Physician, to send R1 to the hospital if R1 got worse. V16 documents V16 notified the ambulance for transportation. V16 documents at 12:49 PM on 1/27/24, the ambulance was there to transport R1 to the hospital. Residents Affected - Few On 2/5/24 at 10:37 AM, V22, LPN, stated she had spoken to V21, R1's POA, and he wanted R1 to stay at the facility as long as possible. V22 confirmed she entered the order for the chest X-ray and laboratory work on 1/26/24 when she received it. On 2/5/24 at 2:31 PM, V3, Director of Nursing, confirmed there is no documentation of physician contact or attempted contact between the 1/24/24 at 8:32 AM request by V23, and the documented order received on 1/26/24 at 10:30 AM, more than 48 hours later. V3 stated she does not know why it took so long, or why no one attempted to contact V24 again. 146162 Page 4 of 6 146162 02/05/2024 Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550

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 ensure staff wear the required PPE (Personal Protective Equipment) when entering an isolation room, failed to don procedure/isolation face masks in resident care areas, and failed to correctly wear procedure/isolation face masks in resident care areas. These failures have the potential to affect all 53 residents residing in the facility. Residents Affected - Many Findings include: The facility's Action Plan - COVID-19, updated on 5/22/23, documents, Source Control - refers to use of respirators, well-fitting face masks, or well-fitting cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Ensure everyone is aware of recommended IPC (Infection Prevention and Control) practices in the facility. When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of (a) resident for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g. {example} NIOSH Approved Particulate respirators with N95 filters or higher during the care of a resident with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a resident on Droplet Precautions), they should be removed and discarded after the resident care encounter and a new one should be donned. Source control is recommended more broadly as described in CDC's (Centers for Disease Control) Core IPC Practices in the following circumstances: By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over. Respiratory assessment to be performed when resident is in isolation every shift; vital signs and O2 (oxygen) saturation every 4 hours. On 2/1/24 at 8:58 AM, V2, Assistant Administrator, stated the facility has four active cases of COVID-19 in residents, and is not sure if all of the employees are back to work yet. V3, Director of Nursing, stated the residents with active COVID-19 are in isolation, and so are the residents with exposure. On 2/1/24 at 9:25 AM, V9, Certified Nursing Assistant/Transportation, was sitting at the nurse's station working on the computer with the face mask pulled down underneath V9's chin, not covering the nose or mouth. There was a resident on the outside of the nurse's station within five feet of V9. On 2/1/24 at 9:25 AM, V10, Certified Nursing Assistant (CNA), was walking down the hall to a resident's room with the face mask down below her nose only covering her mouth. On 2/1/34 at 10:52 AM, V19, R1's family, stated R1 has had COVID-19 three times since R1 has been at the facility. V19 stated R1 came in September of 2021. On 2/1/24 at 1:34 PM, V5, CNA, was at the nurse's station with her face mask down below her chin, not covering her nose or mouth. On 2/1/24 at 1:35 PM, V3, Director of Nursing (DON), was standing in the doorway of R7's room, with R7 present in the room, with her mask down below her chin, not covering her nose or mouth. V6, Rehab Tech, and V7, Therapy Assistant, both were in R7's room at this time, with no face masks on at all. 146162 Page 5 of 6 146162 02/05/2024 Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 2/1/24 at 1:37 PM, V8, Physical Therapy Assistant, was in R8's room without a mask on within five feet of R8 talking to R8. On 2/5/24 at 8:40 AM, V1, Administrator, stated they have seven new cases of COVID-19 in residents. On 2/5/24 at 9:31 AM, V17, Certified Nursing Assistant (CNA), was in R6's isolation room (contact and droplet), with no PPE donned, and her face mask was pulled below her chin. V17 was sitting in a chair next to R6, and was within one foot of R6 talking without a face mask covering her nose and mouth. On 2/5/24 at 9:35 AM, V14, CNA, was at the nurse's station with her face mask below her nose. On 2/5/24 at 9:35 AM, V10, CNA, had her face mask pulled down underneath her chin exposing her nose and mouth. V10 was loading the laundry cart with clean linens while her nose and mouth were exposed. On 2/5/24 at 10:00 AM, V2, Director of Nursing/DON, stated she has started re-education with staff regarding PPE use and wearing masks. V2 stated staff should be wearing gowns, gloves, face masks, and eye protection in an isolation room for COVID-19, and should not be pulling down their masks in resident care areas. V2 stated she was not aware therapy staff were not even wearing any face masks. On 2/5/24 at 2:23 PM, V11, CNA, was walking in the hallway by the nurse's station and near residents with no face mask on. The facility's Midnight Census report, dated 2/1/24, documents 53 residents reside in the facility. 146162 Page 6 of 6