Aledo Rehab & Health Care Center

F-F698 Residents Affected - Few Based on observation, interview and record review the facility failed to obtain a physician's order for dialysis treatments, update a plan of care, for a resident receiving dialysis services and failed to assess a resident's dialysis fistula for hemorrhage post-dialysis for one of one residents (Resident R26) reviewed for dialysis, in a sample of 43.

FINDINGS INCLUDE:

The facility policy, Comprehensive Care Planning, dated (revised) 7/20/22 directs staff, It is the (facility) policy to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care .The care plan shall be reviewed and revised as necessary to reflect the resident's current medical, nursing and mental and psychological needs as identified.

The facility policy, Dialysis, dated (revised) 01/02 directs staff, Dialysis is another name for artificial kidney treatment. It is a medical procedure, which is substituted for normal kidney function when the kidneys fail. For dialysis, two large needles are placed. One needle brings blood from the body into the dialysis machine.

The other needle takes the cleansed blood back from the dialysis machine to the resident's body. After dialysis, the needles are removed and firm pressure must be maintained over the puncture site for approximately 15 to 20 minutes until all bleeding has stopped. A bandage is then applied. The bandage should be kept in place until the evening of dialysis or until bleeding from the needle sites has definitely stopped. Fistula: If a resident has a fistula, contact the physician and/or hemodialysis center for specific directions on care of the fistula. It is acceptable for a resident to bathe or shower with a fistula. Blood pressures and blood sampling are not to be taken in the fistula arm. Complications with a fistula are clotting and infection with the same principles applied as with a graft.

Resident R26's current Minimum Data Set Assessment, dated 3/6/24 documents in Section C- Cognitive Patterns, BIMS (Brief Interview for Mental Status) Summary Score: 15:15 (Cognitively Intact).

Resident R26's current Physician Order Sheet, dated June 2024 includes the following diagnosis: ESRD (End Stage Renal Disease). No current physician's order for Resident R26's dialysis treatments is documented.

Resident R26's current Care Plan, dated 12/7/21 contains no documented Problem/Need Areas, Goals or Approaches/Interventions to address the required care of Resident R26's dialysis needs.

On 06/04/24 at 9:25 A.M., Resident R26 stated, I have been receiving thrice weekly dialysis for many years. I return to

the facility with a pressure bandage in place which I remove when I feel enough time has lapsed. The nurse never monitors the fistula after dialysis for signs of hemorrhage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 20 145886 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145886 B. Wing 06/05/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 On 06/04/24 at 2:05 P.M., V2/Director of Nurses (DON) verified the missing physician's order for Resident R26's current dialysis treatment and a Care Plan to address Resident R26's. At that time, V2/DON confirmed nursing staff Level of Harm - Minimal harm or should be monitoring Resident R26's dialysis fistula for hemorrhage upon return to the facility from dialysis. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 20 145886 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145886 B. Wing 06/05/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Minimal harm or 49187 potential for actual harm Based on observation, interview and record review, the facility failed to post the daily direct care staff hours Residents Affected - Many and resident census. This has the potential to affect all 44 resident's residing in the facility.

On 6/2/24 at 9:15 AM a tour was conducted of (the facility). No daily nursing hour data and census sheet was observed throughout the entire building.

On 6/2/24 at 12:00 PM V2 (DON/Director of Nursing) stated, I was not aware that I was supposed to be filling out a sheet that includes the census for the day and the total number of staff and actual hours worked per shift for RN's (Registered Nurses), LPN's (Licensed Practical Nurses), and CNA's (Certified Nursing Assistants). V2/DON verified she has not posted the daily nursing staff data since she started as DON in March 2024. V2 stated, I would post the daily census for the day and the total number of staff and actual hours worked in the glass case outside of V1's/Administrator's office.

On 6/3/24 at 10:00 AM there was no daily nursing staff data posted in the glass case on the wall or anywhere else within the building.

On 6/4/24 at 10:15 AM there was no daily nursing staff data posted in the glass case on the wall or anywhere else within the building.

On 6/5/24 at 10:00 AM there was no daily nursing staff data posted in the glass case on the wall or anywhere else within the building.

A policy on staff posting was not provided by the time of Exit Conference on 6/5/24.

The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 6/5/24 and signed by V1/Administrator documents 44 residents currently reside within the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 20 145886 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145886 B. Wing 06/05/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 49187 Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure medications were kept stored

in their original packaging with labels until administered for four of forty-three residents reviewed (Resident R7, Resident R20, Resident R27, and Resident R43) for medication administration, storage, and labeling in the sample of 43.

The facility policy, Medication Administration dated (revised 7/3/13) directs staff, Medications must be prepared and administered as ordered (by the physician). All medications must be labeled with the resident's name, the medication, the dosage and instructions for administration.

On 6/2/24 at 8:25 AM V17 (Agency Licensed Practical Nurse) was standing at her medication cart next to the dining room on the Dementia locked unit. V17 opened the top left drawer of her medication cart where there were four medication cups labeled with a first name all full of medications. V17 stated, I pre-popped (Resident R7), (Resident R20), (Resident R27), and (Resident R43's) 8:00 AM medications. I did not administer the medications immediately and only labeled the medication cups with their first name. I know I am not supposed to pull medications ahead of time and store them in the cart, but I did.

6/2/24 at 10:58 AM V2 (Director of Nursing) verified the nurses should not be pre-pouring medications and storing them in the medication carts. V2 stated, When the nurses are preparing to administer medications to

the residents, they should immediately administer the medications after they verify the medication, the label, and the date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 145886 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145886 B. Wing 06/05/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 32061

Residents Affected - Many Based on observation, interview and record review the facility failed to ensure equipment in the facility kitchen was clean and free of debris, failed to date cooked food items to ensure use before expiration, and failed to monitor and record the required refrigerator, freezer temperatures, food temperatures of served foods and the required dishwasher sanitation levels. These failures have the potential to affect all 44 residents currently residing in the facility.

FINDINGS INCLUDE:

The facility policy, Refrigerator and Freezer Storage, dated (revised) 10/14 directs staff, It is the policy of (facility) that any item to be placed in the refrigerators and freezers must be covered, labeled and dated with

a date-marking system that tracks when to discard perishable food.

The facility policy, Storage, dated (revised) 10/20 directs staff, Store leftovers in covered, labeled and dated containers under refrigeration or frozen. When using only part of a product, the remaining product shall be in

the original package or air tight container and labeled and dated.

The facility policy, Dish machine, dated (revised) 10/09 directs staff, It is the policy of (facility) that utensils and dishes washed by a mechanical dishwasher will be clean and sanitized. Check the cleanliness of the machine. For low-temperature dishwashers (temperature of the wash water shall not be less than 120 degrees), before washing anything, use a test strip to check the sanitation level, for Chlorine sanitizers, the level should be 50-100 PPM (Parts Per Million). Record the sanitizer level on the Dish machine Temperature/Sanitizer Log.

On 06/02/23 at 8:36 A.M., upon entrance to the facility kitchen V3/Cook and V4/Dietary Assistant were washing dishes and preparing the facility noon meal. An observation of the facility refrigerator temperature show a 46 ounce bottle of thickener opened, but not dated. A stack of five slices of pepper cheese in a square, plastic container that was undated. An opened bottle of yellow mustard, 1/2 empty and undated. A cut apple pie with missing pieces, undated.

A separate food storage room, down the hall from the kitchen contained a large white chest freezer with boxes of meat products and no thermometer present to record the temperature of the stored food. At that time, V3/Cook verified the undated food items and the missing thermometer.

On 06/02/24 at 10:53 A.M., upon return to the facility kitchen, V3/Cook and V4/Dietary Assistant were present and preparing food for the noon meal. An exhaust fan currently running, above a metal food prep table had a thick build up of black dust. Multiple yellow plastic dishracks, on the floor in the dishwashing room, were smeared with a large build up of black grease. A green plastic dishrack with multiple metal steam table lids had a large build up of black greasy dirt, located under the facility steam table.

An observation of the facility Refrigerator Temperature Log Chart, dated 4/1/24 through 4/30/2024 documents missing refrigerator temperature logs on 4/1/24, 4/26/24 and 4/29/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 145886 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145886 B. Wing 06/05/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 An observation of the facility Freezer Temperature Log Chart, dated 4/1/24 through 4/30/2024 documents missing refrigerator temperature logs on 4/1/24, 4/10/24 and 4/25/24, 4/26/24 and 4/29/24. Level of Harm - Minimal harm or potential for actual harm An observation of the facility Sanitizing Solution Log Chart, dated 4/1/24 through 4/30/2024 documents missing sanitizing solution checks on 4/25/24, 4/26/24 and 4/29/24. And for 5/1/24 through 5/31/24, missing Residents Affected - Many sanitizing solution checks for 5/1/24, 5/2/24, 5/3/24, 5/6/24, 5/7/24, 5/8/24, 5/9/24, 5/16/24, 5/19/24, 5/22/24, 5/23/24, 5/28/24 and 5/29/24.

An observation of the facility Dishwasher Temperature/Sanitizer Log, dated 4/1/24 through 4/30/2024 documents missing sanitizing solution checks on 4/1/24 through 4/5/24, 4/7/24, 4/8/24 and 4/11/24 through 4/30/24. An observation of the May 2024 logs document missing checks on 5/1/24, 5/2/24, 5/7/24 through 5/10/24 and 5/13/24 through 5/31/24.

An observation of the facility Food Temperature Logs for May 2024 documents facility kitchen staff failed to obtain food temperature logs prior to serving meals on 5/26/24 through June 1, 2024.

On 6/2/24 at 12:30 P.M., V3/Cook verified the missing food temperature logs, required refrigeration checks and sanitation solution and dishwasher checks.

The facility Room Roster, dated 6/2/24 and verified by V1/Administrator documents 44 residents currently reside in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 145886 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145886 B. Wing 06/05/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 32189 potential for actual harm Facility failures resulted in two deficient practices. Residents Affected - Many A. Based on record review, and observation, the facility failed to place signage in a conspicuous location to clearly identify the category of transmission-based precautions, instructions for PPE (Personal Protective Equipment) and/or instruction to see the nurse prior to entering the resident's room for 1 of 1 (Resident R32) residents that required transmission-based precautions in a sample of 43 residents.

B. Based on interview and record review the facility failed to have interventions in place to mitigate the growth and spread of legionella and failed to maintain logs of interventions. This has the potential to affect all 44 residents that reside at the facility.

Findings include:

A. The Multidrug-Resistant Organisms in Non-Hospital Healthcare Settings, revised 11/30/09, documents 2. Multi-resistant drug organisms are bacteria and other microorganisms that have developed resistance to antimicrobial drugs. Common examples of these organisms include: MRSA- Methicillin/Oxacillin-resistant Staphylococcus aureus.

The Transmission-Based Precautions, revised 12/14/09, documents Contact Precautions: Are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact.

The Isolation Room Set Up policy, revised 5/30/14, documents It is the policy of this facility to set up isolation for communicable diseases. Procedure: 7. Place sign on door to resident's room for visitors to inquire at nurse's desk prior to entering room.

On 5/18/24, Resident R32 was readmitted to the facility with a diagnosis of MRSA in Resident R32's leg wounds on 5/14/24 which required Intravenous Antibiotics and daily dressing changes.

Between 6/2/24 at 10:30 AM and 6/5/24 at 1:00 PM, Resident R32's room lacked signage to identify the category of transmission-based precautions, instructions for PPE (Personal Protective Equipment) and/or instruction to see the nurse prior to entering the residents room.

B. On 6/5/24 at 1:30 PM, V2 (Director of Nursing/Infection Preventionist) stated V25 (Maintenance Supervisor) oversees Legionella management and this was all V25 has and then provided a log of water flushes every two weeks dated 10/3/20 through 5/24/24.

The Infection Control Plan Index, no date, lacked inclusion of a Legionella prevention policy.

The Quality Assurance Performance Improvement (QAPI) Agenda, updated 8/3/17, lacked inclusion of Legionella monitoring. The QAPI scope documents Maintenance We provide comprehensive building safety, repairs, and inspections to ensure all aspects of safety are enforced, assuring the safety and well being for each resident, visitor and staff who enter the building.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 145886 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145886 B. Wing 06/05/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The facility lacked a flow diagram of the buildings water system, measures to prevent the growth of Legionella by implementing control measures such as disinfection, water temperatures and inspections and Level of Harm - Minimal harm or policies and procedures of ways to monitor measures and identify acceptable ranges. potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 145886 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145886 B. Wing 06/05/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 32189 potential for actual harm Based on interview and record review the facility failed to: implement an antibiotic stewardship program that Residents Affected - Many included assessing and monitoring residents for signs and symptoms of infections; ensure antibiotic usage was appropriate, and use of a nationally recognized surveillance criteria to define infections for 3 of 3 (Resident R34, Resident R57, Resident R58) residents reviewed for the Antibiotic Stewardship Program in the sample of 43 residents. This failure has the potential to affect all 44 residents who reside at the facility.

Findings include:

The Infection Control Surveillance and Monitoring policy, dated 4/11/22, documents It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. Monitoring of the day-to-day operations include: a. Investigation and implementation of controls to prevent infections in the facility. b. Determine and direct the correct procedures necessary for

the prevention of infections. c. Follows up on documentation of, and reporting of infection to physicians, through direct, random inspection of the clinical record with respect to: 1. Isolation techniques instituted and followed; 2. Evaluation of parameters involved in assessment of physical condition are evaluated and reported as appropriate; 3. Periodic observation of infection sensitive techniques, including soaks, irrigations, catheter procedures, intravenous infusions, tracheostomy procedures, and inhalation techniques. f. Updates

the infection Control Log on a daily basis in order to analyze data and identify trends that would indicate need for additional controls to prevent any further spread of an infection. g. Prepares quarterly Infection Control report for quarterly presentation to Quality Assurance committee. 3. Documentation of noncompliance of practices and corrective actions taken to ensure improvement will be conducted. 4. Responsibility of maintaining records of surveillance and monitoring will be the DON/ICP (Director of Nursing/Infection Control Preventionist) and/or Administrator.

On 6/3/24 at 11:00 AM, V2 stated I don't formally track and write down observations (of infection control practices). I look around as I'm in the halls but don't have a formal audit process. There haven't been any reports done since I started in March. I haven't had a chance yet. V2 stated V2 is notified of residents treated for infections but they are not tracked and/or trended according to caregivers, locations or any other sources that could be controlled and antibiotics have not been reviewed for use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 145886 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145886 B. Wing 06/05/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 32189

Residents Affected - Many Based on record review and interview, the facility failed to designate a qualified infection preventionist who is responsible for the facility's Infection Prevention and Control Plan. This failure has the potential to affect all 44 residents who reside at the facility.

Findings include:

The Infection Control Surveillance and Monitoring policy, dated 4/11/22, documents The facility shall employee, at a minimum, a part time Infection Control Preventionist. These duties maybe performed by the Director of Nursing with an approved Infection Control Certification.

The Infection Preventionist Job Description, dated 3/3/23, documents Qualifications: 2. Must have completed Specialty Training in Infection Prevention and Control through accredited continuing education.

On 6/3/24 at 11:00 AM, V2 (Director of Nursing/Infection Preventionist) stated V2 was the designated Infection Preventionist although no specialty training in Infection Prevention and Control had been completed at this time.

On 6/5/24 at 2:00 PM, V1 (Administrator) stated V2 was hired on 3/19/24 and has not had the time to complete the training for Infection Prevention and Control due to other responsibilities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 145886 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145886 B. Wing 06/05/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Aledo 304 S.W. 12th Street Aledo, IL 61231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32189 potential for actual harm Based on record review and interview, the facility failed to offer immunizations and vaccinations in 5 of 5 Residents Affected - Many residents (Resident R12, Resident R14, Resident R39, Resident R40, Resident R96) per policy. This failure has the potential to affect all 44 residents who reside at the facility.

Findings include:

The Immunization of Residents policy, dated 5/19/23, documents Verify the date of last vaccination. Obtain proof of previous Pneumococcal and Influenza vaccination for residents when able. Assess all newly admitted resident's pneumococcal and Influenza vaccination status upon admission and record last known immunization on the resident's Immunization Record. Offer the (Pneumonia Vaccination) unless contraindicated. Offer the Influenza annually from September 1st thru March 31st. Offer the current recommended COVID-19 Vaccine upon admission for those identified as not being up to date with recommended vaccination. Document immunization on the resident's Medication Administration Record and

on the Resident's Immunization Record.

Resident R12 was admitted on [DATE REDACTED]. Resident R12's Immunization Record lacked documentation the influenza vaccination was offered, given or refused.

Resident R14's was admitted on [DATE REDACTED]. Resident R14's Immunization Record lacked documentation the influenza vaccination was offered, given or refused.

Resident R39 was admitted on [DATE REDACTED]. Resident R39's Immunization Record lacked documentation the influenza and/or pneumococcal vaccination was offered, given or refused.

Resident R40 was admitted on [DATE REDACTED]. Resident R40's Immunization Record lacked documentation the influenza and/or pneumococcal vaccination was offered, given or refused.

Resident R96 was admitted [DATE REDACTED]. Resident R96's Immunization Record lacked documentation the pneumococcal vaccination was offered, given or refused.

On 6/3/24 at 1:30 PM, V2 (Infection Preventionist/Director of Nursing) stated all resident immunizations and vaccinations are documented on the residents Immunization Record and kept in the residents' chart. V2 stated Resident R39 and Resident R40 refused the Influenza Vaccination, although did not sign a declination nor was verbal refusal documented and stated, Do they have to sign a refusal?

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