Every finding on record at Apostolic Christian Skylines

Based on observation, interview, and record review, the facility failed to issue a written notice of room moves for two of three residents (R1 and R2) reviewed for room moves in a sample of 3. Findings include: The facility's Room Change Policy, undated, documents, It is the policy of (the facility) to promote a resident's right to make choices and to promptly receive written notice of a room change or change in an assigned roommate. The facility supports the resident's right to refuse a room change made for the purpose solely for the staff's convenience. B. Room Change (Transfer Room to Room). f. If the facility requests the resident to move to a different room, within the provisions of Federal and State Regulations, the facility will give prompt notice to the resident and representative. i. The issuance of the notice, the reason for the room changes and the resident's and representatives' response to the move will be documented in the resident's record. R1 and R2's current Census Sheet documents R1 and R2 both moved from the Dementia Unit to the Skilled Nursing Unit on 4/8/25. R1's Electronic Medical Record does not include a notice of room change issued to R1 or V7/R1's Power of Attorney. R2's Electronic Medical Record does not include a notice of room change issued to R2 or V9/R2's Power of Attorney. On 4/11/25 between 10:52 AM and 11:10 AM, V6/Memory Care Coordinator, V7/Social Service Director, and V8/Admission Coordinator, denied giving any notice in writing for the room moves to R1 and R2's resident representatives, and confirmed the room moves were facility initiated. On 4/11/25 at 12:03PM, V9/R2's Power of Attorney confirmed R2 had a room move this week. V9 stated she was notified face to face by V6/Memory Care Coordinator and not in writing. On 4/11/25 at 2:15PM, V1/Executive Director stated V8/Admission Coordinator is new and did not give a written move/transfer notice to R1 and R2's resident representatives and should have.

Based on observation, interview, and record review, the facility failed to develop a careplan to include oxygen and edema with compression hose for four (R5, R6, R11, R43) of 15 residents reviewed for care plan development in a sample of 24. Findings include: Facility Care Plan Process, dated 3/4/24, documents, (Facility) will create a resident-centered plan of care for each skilled resident residing at the facility. 1. R6's current physician orders for October 2024 documents, Oxygen 2-4 L (liters) per NC (nasal cannula) as needed with an initial order date of 5/14/24. R6's online medical record documents R6 has Chronic Pulmonary Edema. On 10/8/24 at 1:18 PM, R6 had oxygen and an oxygen concentrator in her room. On 10/9/24 at 10:05 PM, R6 was in bed with 2 Liters of oxygen on by nasal cannula. R6's current careplan has no documentation R6 uses oxygen. On 10/10/24 at 11:44 AM, V4, Regional Nurse, verified R6 did not have oxygen on her careplan, and it should be. 2. R11's current physician orders for October 2024 documents, (Trade name/Compression Dressing) to bilateral lower legs on in AM off at HS (hour of sleep- from just above toes to back of knee [NAME]) twice a day, with an initial order date of 3/17/23. R11's online medical record documents R11 has a history of Edema. On 10/8/24 at 12:47 PM, R11 was in her wheelchair, and R11's bilateral legs had compression hose on and were edematous (swollen). On 10/09/24 at 10:02 AM, R11 was in her wheelchair, and R11's bilateral legs had compression hose on and were edematous. R11's current careplan has no documentation R11 has edema and wears bilateral compression hose. On 10/10/24 at 11:36 AM, V4, Regional Nurse, stated, I don't see edema or (Trade name/Compression Dressing) on R11's careplan and it should be. She has been wearing her (Trade name/Compression Dressing) since 2023. 33973 3. On 10/8/24, at 9:59 AM, R5 was lying in bed with an oxygen concentrator at the bedside. R5's current careplan does not include the use of or cares for oxygen. On 10/10/24, at 1:53 PM, V4, Regional Nurse, stated R5 returned from the hospital with the oxygen after a respiratory illness. At this time, V4 confirmed oxygen is not listed on V5's current careplan and should be. 4. On 10/8/24, at 10:56 AM, R43 was lying in bed with oxygen infusing per nasal cannula. R43's current careplan does not include the use of or cares for oxygen. On 10/10/24, at 1:55 PM, V4, Regional Nurse, stated R43 uses oxygen for comfort and confirmed that oxygen is not listed on R43's current careplan and should be.

Based on interview and record review, the facility failed to notify resident/resident representative in writing of hospital transfers for two (R14 and R36) of two residents reviewed for hospitalization in a sample of 24. Findings include: The facility's undated Transfer to Hospital Checklist documents, A resident must have the below listed items prior to transferring to the hospital. Please check off and sign at the bottom indicating these were given. Place this form in Medical Records to be scanned into resident chart. This checklist includes Bed Hold & Return to Facility Policy and Transfer Referral Form (nurse to keep a copy). The facility's undated Transfer Referral Form includes but is not limited to Date of Transfer and Reason for Transfer with a place for nurse's signature at the bottom. 1. R14's Nurse Progress note, dated 10/24/23, documents R14 was transferred out to a local hospital per ambulance. R14's clinical record does not document written notification was given to the resident/resident's representative. On 10/10/24, at 10:50am, V7, Social Service Director, could not locate a written notification to representative for R14's 10/24/23 hospital transfer. 34131 2. R36's medical record documents R36 went to the hospital on 9/19/24. R36's medical record has no documentation R36 and R36's representative was notified of the transfer or discharge, and the reasons for the move in writing. On 10/10/24, at 10:55 AM, V7, Social Service Director, could not produce written notification to R36 and R36's representative for R36's 9/19/24 hospital transfer.

Based on observation, interview, and record review, the facility failed to perform perineal care in a way to prevent cross contamination of environmental objects for one resident (R53) of two residents reviewed for perineal care in a total sample of 24. Findings Include: The Facility's undated Enhanced Barrier Precautions policy documents, Enhanced barrier precautions are designed to help reduce the transmission of multidrug-resistant organisms. Infection or colonization with an MDRO (Multidrug Resistant Organism) when Contact Precautions do not otherwise apply. During High Contact Resident Care Activities PPE (Personal Protective Equipment) Must be Used: Transferring and Providing hygiene. The Facility's undated Gloving policy documents, Gloves are to be worn in the following situations: non-intact skin, blood or body fluids, residents in isolation and potential or known contaminated surfaces or equipment. Change gloves when moving from a contaminated body site to a clean body site on the same resident Soiled gloves should always be changed before touching any clean surfaces. The Facility's Perineal Care policy, dated 10/28/22, documents, Perineal care, the washing of the genital and rectal areas of the body is an important basic care that helps prevent UTIs (Urinary Tract Infections) as well and other infections and irritation. The policy also documents Remove gloves before touching clothing, bed rail, curtain etc. R53's current Physician Order Sheet, dated October 2024, documents, Enhanced Barrier Precautions for colonization of ESBL (Extended Spectrum Beta-Lactamases) and VRE (Vancomycin Resistant Enterococci) in the urine. Throughout the survey R53's door had a sign on it documenting Enhanced Barrier Precautions. 10/09/24 at 9:00 AM, V5(Certified Nursing Assistant/CNA) donned gown, gloves, mask, and eye protection. V5 pushed R53 into the bathroom, R53 stood, V5 pulled R53's brief and pants down, and R53 sat on the toilet and urinated. When R53 stood up, V5 wiped her perineal area with wipes from front to back two times, then threw the wipes in the trash can. V5 then proceeded to pull up R53's brief and pants. V5 zipped up R53's pants and then held both of her hands with R53's gloved hands and assisted her to sitting position in wheeled recliner. V5 then fixed R53's shirt, necklace, and head turban. V5 then put her hands on both arms of the wheeled recliner and backed R53 out of the bathroom, and then V5 removed PPE and washed her hands. On 10/9/24 at 2:30 PM, V5 (Certified Nurse Aid) confirmed she did not take her gloves off or perform hand hygiene throughout R53's toileting. V5 stated, I should have taken them (gloves) off after I wiped her, before I touched her clothes and chair.

Based on interview and record review, the facility to provide a copy of their bed hold policy for two (R14 and R36) of two residents reviewed for bed holds in a sample of 24. Findings include: The facility's Bed Hold and Return to Facility Policy, revised 10/21/19, documents, It is the policy of (named facility) to ensure that each resident (living in the Skilled Nursing and Memory Care) and their resident representative are made aware of the facility's and the State of Illinois bed-hold and reserve bed payment policy upon admission and before a resident is transferred to a hospital or goes on a therapeutic leave. For emergency transfers, notice must be given within 24 hours. 1. R14's Nurse Progress note, dated 10/24/23, documents R14 was transferred out to the local hospital; R14 returned on 10/31/23. R14's clinical record does not document a bed hold policy was given to the resident or resident representative. On 10/10/24, at 10:50am, V7, Social Service Director, could not locate the bed hold notice for R14's 10/24/23 hospital transfer. 34131 2. R36's medical record documents R36 went to the hospital on 9/19/24. R36's medical record has no documentation R36 and R36's representative was notified of the facilities bed hold in writing. On 10/10/24 at 10:55 AM, V7, Social Service Director, could not produce written notification of the bed hold policy to R36 and R36's representative for R36's 9/19/24 hospital transfer.

Based on observation, interview, and record review, the facility failed to provide safe transfer during a bath for one (R1) of three residents reviewed for transfers in a sample of three. This failure resulted in R1 being hospitalized and suffering from fractures to his right proximal humerus and C2 (cervical vertebrae). Findings include: The facility's Fall Occurrence Policy, dated 2/2/2022, documents, Policy: (Named facility) wants to create an environment that is free from accident hazards as much as possible for residents, provide supervision when needed, and assist with detecting and preventing hazardous situations. The facility's undated (Named) Transfers and Stretcher Safe Operation & Maintenance Manual documents, System Preparation (Before Transferring or Lifting): 9. All residents must always be securely safety belted at the waist when using any of the (Named) Lift Systems. Ensure that the safety belt is routed through the loose buckle end as shown in the picture to the left. Pay close attention to the placement of the serrations of the buckle. If routed the opposite way, the safety belt will slip. Tighten safety belt by pulling on the loosed end of the safety belt. Warning: Failure to secure the resident properly with the safety belt could result in injury to the resident or operator. Warning: Failure to ensure hands, arms and legs are clear of any objects when transporting or lifting could result in injury to the resident or operator. Push the emergency stop button, on the Control unit at any time during raising and lowering of resident. 17. Upon completion ensure the residents hands, arms, and legs are clear before raising the lift. Push the up button to raise the resident slightly if needed, and then drain the water from the spa. 21. Before you move the Transfer away from the spa, make sure the lower extremities have been toweled dry so the bath floor stays dry. Ensure the Transfer is raised high enough to clear the spa seat. You may now unlock the casters and move the Transfer out of the spa and away, ensuring the resident is still safety belted correctly and the resident's hands, arms, and legs are all clear. R1's Minimum Data Set/MDS assessment, dated 9/12/23, documents R1 has Vascular Dementia, requires limited assist of one assist for transfers, requires physical help of one assist for bathing, is not steady and only able to stabilize with staff assistance during transitions and walking. This same assessment documents in Section C Cognitive Patterns: B. Inattention - Did the resident have difficulty focusing attention, for example being easily distractible, or having difficulty keeping track of what was being said? 2 = Behavior present, fluctuates (comes and goes, changes in severity). C. Disorganized thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, our unpredictable switching from subject to subject)? 2 = Behavior present, fluctuates (comes and goes, changes in severity). R1's current Care plan includes the following: R1 has a diagnosis of dementia and is exhibiting some cognitive loss; approaches include to Provide verbal cues and reminders as required related to orientation and time. R1 is at risk for falls - approaches includes to Provide assistance with all mobility/ADL (Activities of Daily Living) care needs. R1's Progress note, dated 10/16/23 by V9, Social Service Director/SSD, documents (R1) requires frequent reminders due to decreased retention. R1's Progress note, dated 11/27/23 by V4, Registered Nurse/RN, documents, This nurse was called in to Spa room by (V2, Certified Nursing Assistant/CNA) stating resident is on floor and slipped out of tub chair. When this nurse went in saw resident face down in blood. Called another nurse to help. With help of couple CNA's and nurses, turned resident on to his back. He was alert and oriented, was able to respond stating help me. After turning resident on to his back we noticed lacerations on his forehead between his eyebrows, and on his nose. Looks like when he slid out of tub chair, he hit his forehead on the edge of the tub. cleansed the area, applied pressure dressing. Called 911. (Local ambulance service) stated not to lift him from the floor. Left him on the floor covered him up and was monitoring him until (local ambulance service) arrived. Resident was alert and communicating with staff. EMT (Emergency Medical Technicians) here. Resident was able to answer EMT staff appropriately. EMT staff stated he will need stitches and transported him to (named local hospital). Called and notified resident (Power of Attorney/POA/family member) regarding resident fall and sending him to ER (emergency room ). R1's Fall Event Report Work History, dated 11/27/23, and signed by V2, Director of Nursing/DON, documents description of fall: When bath was complete (V3, CNA) started moving the chair out of the tub while resident was sitting in secured chair to continue cares. Resident was irritated by seatbelt and was verbally aggressive to CNA to take the seat belt off and then he pulled seat belt undone. Resident simultaneously reached forward and tried to grab onto the far side of the tub and while doing this he slipped forward out of the tub chair, hitting his forehead on the edge of the tub and landing on the right side. R1's CT (Computed Tomography) Cervical Spine Without Contrast report, dated 11/27/23, documents, Impression: Minimally displaced type II fracture of the odontoid process, (part of the C2 vertebrae). R1's X-ray Shoulder Complete Right report, dated 11/27/23, documents Impression: Acute displaced proximal humeral fracture. On 12/20/23, at 11:06am, V3, CNA, stated, I was pulling the spa chair out of the tub and at that moment (R1) started to lean forward so I reminded him to lean back and that we were getting out of the spa tub. He did lean back so I continued to pull the chair from behind. I didn't realize that he had removed the seat belt from around his waist and he slipped out of the chair as he reached for the tub. He fell forward and his head hit the bottom of the tub. V3 also stated, (R1's) cognition varies day by day. He has periods of forgetfulness. That day he seemed his usual, nothing that would alarm me. He is a one assist gait belt wheeled walker for transfers and has been for awhile. I could have double checked everything that's what I learned from the situation. Make sure I didn't forget anything. I doubt I forgot to put it (seat belt) on. On 12/20/23, at 12:19pm, V4, RN, stated that while V4 was passing medications ,V3 called out to V4 and said (R1) was on the floor. I saw the blood on his face. I had her stay there and had the other nurse come. V4 also stated (R1) is forgetful. You constantly have to remind him. When I transfer him from wheelchair to recliner he has to be constantly reminded to take more steps and that he is not there yet. (R1) is often in a rush to sit down or if he wants to do something like stand up. He has put his (lift) chair all the way up then forgets what he was going to do and fell asleep with it up. We have to constantly watch him. V4 continued to state, He was holding onto the tub and if CNA is not watching his hands and the floor and chair are wet I think he slid out of the chair. It is easy to slide off the chair. There is a belt there, but I think it can come off. It is not a buckled type of belt, but a safety belt. Force can cause it to open up the belt like if forcefully falling forward. I believe the belt was on - (V3 CNA) said she put it on. They are regular CNAs that work with (R1). I think that when he was falling forward the belt opened up. Not when he was holding onto the tub. I don't think it is a belt that is able to hold them in the chair if they are falling out of the chair like sliding out while everything is wet. (R1) likes the spa and is ready for the bath. If he is agitated or restless, the CNAs don't give him one. Or if he doesn't want one. But on Mondays he likes it and is ready. He doesn't ever get agitated while in the spa. He is not aware of safety .(V3) should have made sure his hands were on his lap so he was not holding onto the tub. Or could ask for a second person if agitated, but (R1) wasn't. On 12/20/23, at 1:52pm, V5, CNA, stated V5 has given R1 a spa bath before, and R1 did fine. V5 stated, He didn't fidget, lean, or get agitated. On 12/21/23, at 2:10pm, V8, Staff Development, confirmed V8 trains staff upon hire how to use the spa tub and chair. V8 explained after staff undress the resident for the spa bath, they are to put the chair's attached belt around them, then they put the resident in the tub, guiding them giving verbal cues for arms and hands to remain inside the tub chair and in their lap. V8 stated, Then put them into the tub the way they are maneuvered, watch where their legs and feet are. Once completely in the tub, shut the door and lower them down onto the tub seat. Give their bath. Throughout this whole thing I am big on engagement, verbal cues, giving directions be sure they hear, physical, and verbal prompts as needed from start to end. After washed and rinsed, raise the spa chair up while letting water drain. Once water is out, can open the door. When coming out watch their legs and feet while guiding them out. Verbal cues for arms in throughout the exiting of the tub. Spa tub chair has grips in the back to pull back and guide. You can still see what they are doing while guiding them out. You can also stand where you can be on their side. It's easy to stand on the side of them. They should keep their eyes on their hands, arms, legs and feet at all times when entering and exiting the tub. V8 agreed that safety is a big concern during the spa bath. V8 also stated, If impulsive or forgetful, the CNAs should remind and give the cues. If behaviors they give reassurance and get them through it. If not safe they know not to do it. On 12/21/23, at 2:39pm, V8 and V3 were in the Spa room. V3 reenacted the incident, and demonstrated she was standing behind the back of the spa chair when bringing R1 out of the tub when R1 fell . V3 stated she was watching his legs and feet while coming out. V3 denied being able to see what (R1) was doing with his hands. V3 stated, I told him to just relax and we are getting out of the bath. I don't actually say to keep arms in or keep in their lap. On 12/21/23, at 1:38pm, V2, Director Of Nursing/DON, stated the following: (R1) had the belt on in the tub and somewhere in between as (V3, CNA) was behind (R1) coming out (R1) had gotten the belt off. (V3) asked if (R1) was ready to come out he said yes. It was when (R1) was getting out that whatever his trigger was he decided to reach for the other side of the tub. By the time (V3) realized what was happening, (R1) was too far away to grab it, was leaning over, fell , and hit his head on the bottom lip of the tub. That's when (V3) realized (R1) didn't have the belt. (V3) didn't see (R1) mess with the belt, but that doesn't mean he didn't. Not sure if maybe the pressure caused it to come off. The rep (from manufacturer) had said if anyone wanted to get out of it they could. (V3) thinks he took it off, but no time to react. If the straps were undone, they would fall in the lap and you wouldn't see it from behind the chair. (V3) would have had to peer around the resident to see the strap's placement and where his hands were. (V3) needs occasional reminders. (V3) said during the bath his mood was fine and (R1) wasn't agitated and was calm when he said he was ready to get out. Not sure if his demeanor changed, but something triggered and he wanted out of the chair.

Based on observation, record review and interview, the facility failed to attempt a Gradual Dose Reduction of a psychotropic medication for one of five residents (R15) reviewed for psychotropic medication use, in a sample of 37. Findings include: The facility policy, titled Psychotropic Medication Use and Behavior Monitoring (revised 2/11/22) documents, Psychotropic medications refer to drugs which are used for antipsychotic, antidepressant, antimanic, Sedative-hypnotic, and/or antianxiety purposes. It is the policy of this facility to keep each resident's medication regimen free from unnecessary drugs. Psychotropic medications will not be administered for purposes of discipline or staff convenience and when not required to treat the resident's symptoms. The policy later documents, The pharmacist consultant will complete monthly medication reviews reporting to the physician: Drugs prescribed without a supporting diagnosis; Dosage in excess of maximum strength as recommended by guidelines for geriatric residents; Multiple use of psychotropic drugs; No periodic evaluation of the residents need for the psychotropic drugs. The DON (Director of Nursing) will complete the Psychotropic Medication Reduction Request form and send to the physician indicating any behaviors the resident has exhibited since the last dose reduction to assist the physician in determining dose reductions of psychotropic medications. The Electronic Medical Record documents R15 was transferred to the facility on [DATE] from the Hospital with the diagnosis of Vascular Dementia with Delusions and discharge orders to administer Zyprexa (Antipsychotic) 5 mg (milligrams) at bedtime. R15's Pharmacy Consult, dated 3/02/22 documents R15 had a failed Zyprexa reduction attempt in September 2021 and returned to the daily dose of 5 mg. R15's current Physician's Orders document R15 has continued to receive Zyprexa 5 mg at bedtime for the diagnosis of Vascular Dementia with Behavioral Disturbances, since 11/15/21, with no attempted reduction. R15 is also currently prescribed Lorazepam (antianxiety) 0.5 mg twice per day for Anxiety Disorder and Sertraline (antidepressant) 100 mg daily for Major Depressive Disorder. The Consultant Pharmacist documented he recommended a decrease in R15's Zyprexa 5 mg daily on 3/02/22 and 9/06/22, which were both declined by the physician. The most recent Consultant Pharmacist recommendation to reduce R15's Zyprexa, dated 3/03/23, documents the physician again declined a decrease due to Behavioral interventions continue to be attempted, except in emergency situation, and are included in the plan of care. The continued use is in accordance with relevant current standards of practice. A dose reduction at this time would likely impair resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder while continuing to pose a danger to the resident or others as supported by the following Clinical Rationale and Evidence of the following symptoms: Delusions. A Progress Note, dated 4/11/23, documents, (V8/Physician) disagreed to pharmacist recommendation GDR (Gradual Dose Reduction) of Olanzapine (Zyprexa) (due to resident) having delusions. R15's Behavioral Tracking Records from January 2023 to April 2023, document R15 was being monitored for the following behaviors: Spitting inappropriately (on floor), Depressed mood state, Delusions-Confrontation-Aggression, and Anxious Mood Distress (repetitive questions, fearfulness regarding family not knowing her location). During the January-April 2023 timeframe, R15 had only one occurrence under Delusions - Confrontations - Aggression, which was on 4/17/23 and there is no corresponding Progress Note to further expand on R15's exact behavior. R15's Minimum Data Set assessments, dated 11/29/22, 8/30/22, 2/28/23 and 5/30/23 document that R15 has no indicators of Psychosis, including hallucinations and delusions, and no behavioral symptoms that impact herself or others. Behavior Monitoring after April 2023 was to be documented in R15's Progress Notes and there is no documented evidence of R15 having delusions. On 7/18/23 at 10:40 am and 7/19/23 at 12:12 pm, R15 was observed sitting in her wheelchair in the common area of the Dementia Care Unit. On both days, R15 did not exhibit any behaviors that would indicate she was experiencing delusions. On 7/19/23 at 12:15 pm, V9 (Licensed Practical Nurse/Memory Care Coordinator) stated R15 only has behaviors of occasionally spitting on the floor and attempts to stand up or get out of bed, which staff can easily redirect. V9 stated R15 does not have delusions or behaviors of aggression that could harm herself or others. On 7/19/23 at 1:27 pm, V2 (Director of Nursing) confirmed they had not attempted to reduce R15's Olanzapine (Zyprexa) since she restarted on 5 mg daily on 11/15/21. V2 stated it is her understanding that R15 will exhibit almost like a paranoia, she's very anxious, not knowing what to do and described that R15 wants to be isolated. At that time, V2 provided R15's Progress Notes from 1/02/23 to 7/19/23, which she highlighted R15's documented behaviors. The highlighted behaviors consisted of attempts to stand independently (fifteen times total in that timeframe), resistance to taking medication (three times total during that timeframe, with R15's later compliance), spitting on the floor (once during that time frame), and refusal of a bath (once during that timeframe). The Progress Notes did not document R15 exhibiting paranoia, delusions or anxious behavior as described by V2. On 7/20/23 at 10:18 am, V2 also confirmed that she did not have a Psychotropic Medication Reduction Request form, as instructed in the facility Psychotropic Medication Use and Behavior Monitoring policy, which would assist the physician in determining if R15's Zyprexa dose could be reduced. V2 explained that the form is filled out, describing resident behaviors that would either support a decision to change or maintain a residents' current medication dosage, then attached to the Consultant Pharmacist dose reduction request for the physician to review.

Based on interview and record review the facility failed to document an antibiotic indication for use, end date, conduct an Antibiotic Timeout, and implement a care plan for the continued use of an antibiotic for one of one resident (R26) reviewed for unnecessary medications in a sample of 32. Findings include: The facility's Antibiotic Stewardship policy, 2/11/2022, documents every antibiotic order prescribed will have documentation of dose. route, durations and indication. Duration will include start date, end date, and planned days of therapy. This policy documents an Antibiotic Timeout-is the formal process designed to prompt a reassessment of the ongoing need for and choice of an antibiotic once more data is available including: the clinical respond, additional diagnostic information, alternate explanations for the status change which prompted the antibiotic start. R26's Admission Order sheet, dated 8/2/22, documents to take Niftrofurantoin (Antibiotic -used to treat urinary tract infections) 50mg (Milligrams) daily, (no discontinue date or a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/5/22 at 11:10am, V2, Director of Nursing, verified that R26 has been on the antibiotic [MEDICATION(S)] since she was admitted to the facility. V2 stated that R26's antibiotic use has not been followed up on since she has resided in the facility. V2 stated that R26's antibiotic use does not follow the criteria needed for the use of an antibiotic. and also stated that R26's Antibiotic use should be care planned with urinary goals and interventions, but is not.

Based on observation, interview, and record review, the facility failed to provide services and/or treatments to increase range of motion/mobility and/or prevent further decrease in range of motion/mobility for three of seven residents (R8, R11, R43) reviewed for limited range of motion in the sample of 32. Findings include: The facility's Range of Motion and Physical Therapy policy dated 3/18/22, states Each resident will receive (Active/Passive) ROM (Range of Motion) twice a day and Physical Therapy will be provided as ordered by the physician and per written instruction of the P.T. (Physical Therapy) consult after evaluation. 1. On 10/03/22 at 10:59 a.m., R8 demonstrated her inability to completely extend all her fingers on her left hand without the assistance of her right hand. R8 stated she has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 states she still ambulates independently with a walker but needs assistance with most of her cares. R8 stated at this time, she does not receive any type of services/treatments for her limitations of range of motion that exercises all her joints on a routine basis. R8's electronic medical record, documents R8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Nurse Practitioners Progress Note dated 6/21/22, states R8 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Minimum Data Set assessment dated [DATE], documents the following: R8 is cognitively intact with a Brief Interview for Mental Status score of 15 out of 15; R8 requires extensive assistance from staff with dressing, toilet use, personal hygiene and bathing; R8 has functional limitation in range of motion in her bilateral upper and lower extremities; and R8 is not receiving any type of range of motion program/services. R8's Contracture Profiles dated 3/2018 and 3/24/2020, document R8 had no loss of functional range of motion (Total Scores=0). R8's Contracture Profiles dated 7/29/20, 11/4/20, 4/14/21, 8/10/21, 10/6/21, and 1/5/22 document R8 has loss of active range of motion in her neck, bilateral shoulders, bilateral hips/knees, and bilateral feet (Total Scores=4). R8's Contracture Profiles dated 4/13/22, 7/13/22, and 10/3/22, document R8 has loss of active range of motion to her neck, bilateral shoulders, bilateral hips/knees, and spine and also a loss of passive range of motion to R8's bilateral feet (Total Scores=6). R8's Care Plan last reviewed/revised on 10/5/22, documents the following: R8's overall abilities to care for own personal/mobility needs has declined and is reliant on others to assist her with her care needs; and R8's abilities are potentially on the decline related to [CONDITION(S)]. This same care plan does not address R8's limitation of range of motion to her bilateral upper and lower extremities/joints or any services, treatments, or interventions to ensure no further loss of range of motion. R8's electronic medical record does not include documentation that R8 is currently receiving a rehabilitation program or skilled therapy to address R8's limitations of range of motion. R8's electronic medical record does not document the reason that range of motion services are not being provided for R8. 2. On 10/2/22 at 12:15 p.m., R11 was sitting in a wheelchair with foot pedals in the dining room eating lunch. R11 was alert with confusion. R11 did not attempt to move her legs when asked if she was able to do so. R11's electronic medical record, documents R11 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's Minimum Data Set assessment dated [DATE] documents the following: R11 has severely impaired cognition with a Brief Interview for Mental Status score of 7 out of 15; R11 is unable to ambulate and requires extensive to total assistance for all activities of daily living (ADL's); R11 has limitations of range of motion in her bilateral lower extremities; and R11 is not receiving any skilled therapy services or range of motion programs to address R11's limitations of range of motion. R11's Contracture Profile dated 7/13/22, documents R11 has loss of active range of motion in her bilateral hips/knees and bilateral feet and loss of passive range of motion in the spine. R11's Care Plan last reviewed/revised on 7/27/22, does not address R11's limitations of range of motion in her bilateral lower extremities or include any interventions, programs, or services to ensure R11 has no further decline in her range of motion. R11's current electronic medical record does not document R11 is receiving any skilled therapy or rehabilitation programs for range of motion limitations. R11's electronic medical record does not document the reason that range of motion services are not being provided for R11. 3. On 10/04/22 at 9:59 a.m., R43 states he has limitation of range of motion in all extremities and most of his joints. R43 states he used to go to therapy but hasn't gone for quite some time. R43's electronic medical record documents R43 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R43's MDS dated [DATE], documents the following: R43 has moderately impaired cognition with a Brief Interview for Mental Status score of 10 out of 15; R43 is able to make himself understood and understands others; R43 is unable to ambulate and requires total assistance from staff for bed mobility and transfers; R43 has limitation of range of motion to bilateral upper and lower extremities; R43 does not receive range of motion services or skilled therapy. R43's Contracture Profile dated 7/13/22, documents R43 has loss of active range of motion to bilateral shoulders, bilateral wrists and hands, right knee, and spine. R43's Care Plan last reviewed/revised on 10/5/22, does not document R43's limitation of range of motion to bilateral upper and lower extremities/joints or any services, treatments, or programs provided to prevent further decline in R43's range of motion. This same care plan documents R43's abilities are potentially on the decline. R43's electronic medical record does not include any documentation that R43 is currently receiving any treatment, services or interventions to address R43's limitations of range of motion to his bilateral upper and lower extremities/joints. R43's electronic medical record does not document the reason that range of motion services are not being provided for R43. On 10/5/22 at 1:30 p.m., V2 (Director of Nursing) stated the total scores at the end of each Contracture Profile Assessment is used to determine whether a resident is improving, maintaining, or declining in their range of motion compared to previous assessment scores. V2 also stated there was no further documentation in R8, R11, or R43's medical records, including care plans, that they are currently receiving any documented range of motion services to specifically address their individualized loss of range of motion documented on the Contracture Profiles.

Based on record review and interview, the facility failed to ensure a cognitively impaired resident with increased physical behaviors towards other residents was supervised, for one of three residents (R1) reviewed for behaviors, in a sample of three. Findings include: The electronic medical record documents R1 was admitted to the facility on [DATE] with the diagnoses of Dementia with Behavioral Disturbances, Generalized Anxiety Disorder, [CONDITION(S)] Disorder and Alzheimer's Disease. A Plan of Care, initiated on 2/07/22, documents (R1) has physical behavioral symptoms toward others (e.g., hitting, kicking, pushing, scratching) and advised staff to maintain a calm environment and approach with (R1), avoid power struggles with (R1), avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), and when (R1) is physically combative, remove other residents from the vicinity. A Minimum Data Set assessment dated [DATE] documents R1 has severe cognitive impairment, disorganized thinking, and physical and verbal behaviors directed towards others, that put others at significant risk for physical injury, intrudes on the privacy or activity of others and significantly disrupts care or the living environment. Incident Reports document R1 began having physical behaviors directed towards residents on 3/31/22, when R1 struck R3 in the back as R1 was being removed from the dining area for being combative with staff. On 4/03/22, an Incident Report documents R1 was attempting to propel her wheelchair around R2's wheelchair to exit the dining room, and when R1 could not get around R2, she pulled R2's hair. Another Incident Report, dated 4/08/22, documents R1 became agitated as she sat next to R2 in the dining room and made contact with R2's arm. A Nursing Note, dated 4/09/22, documents R1's Daughter (V6) observed R1 being aggressive to another resident and V6 had to separate them. An Incident Report, dated 4/11/22, documents V2 (Director of Nursing) was notified of a third incident that occurred on 4/09/22 at 7:50 pm involving R1 and R2. According to V6's documented witness statement, R1 was in her(R1) wheelchair near the lounge area, when R2 propelled around the fireplace into R1's wheelchair. The Incident Report documents R1 grabbed R2's wheelchair and would not let go. R2 tried to get away from R1, which led to R1 grabbing R2's arm and them tugging back and forth. According to the incident report, V6 (R1's Daughter) had to separate the residents and notify the staff. On 4/13/22, V6 (R1's Daughter) stated on the evening of 4/09/22 she (V6) had been visiting V6 Father in the Assisted Living section and went by the window of the Memory Care Unit to check on R1. V6 stated she(V6) observed R1 squeezing (R2's) forearm with R1 hands. V6 indicated there were no staff visible in the area, so she (V6) ran around to the front doors and entered the Memory Care Unit. V6 separated R1 from R2, moving R1 out of R2's proximity. V6 reported the incident to V7 (Registered Nurse), who was near the activity area around the corner. V6 stated the three CNAs (Certified Nursing Assistants) were putting other residents to bed at that time and did not witness the incident. On 4/13/22 at 12:40 pm, V2 (Director of Nursing) stated she found out on the morning of 4/11/22 that there had been another physical incident between R1 and R2. V2 indicated she reviewed the video surveillance from the evening of 4/09/22 and observed R2 propelling through the unit. V2 stated R2 seemed to loose her(R2) momentum as R2 wheeled herself closer to R1 and their wheelchairs became entangled. V2 stated R2 grabbed R1's wheelchair to pull herself through and R1 grabbed R2's forearm with both of R1 hands. V6 could be seen entering the unit and separating R1 from R2. V2 confirmed that the staff on the unit, which consisted of three CNAs and one Registered Nurse, were not present in the area at the time of the incident and were assisting other residents. On 413/22 at 3:45 pm, V2 stated that the Memory Care Unit is staffed with three CNAs, to allow for increased supervision and monitoring of residents in the common areas. V2 indicated there is enough staff for the CNAs to take turns providing care in resident rooms and supervising those that are out on the unit.

Based on observation, interview and record review, the facility failed to answer call lights in a timely manner for four of five residents (R234, R137, R136, R16) reviewed for call light wait times in a sample of 27. Findings include: A Dignity policy dated 12/20/10 states, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. This policy further states that staff should assist residents by, Promptly responding to the resident's request for toileting assistance. 1. R234's Minimum Data Set (MDS) assessment dated [DATE] documents R234 is cognitively intact and requires assistance of one person for toileting. R234's current Care Plan documents for R234 is to have staff assistance to the bathroom. On 4/5/21 at 11:18 a.m. R234 stated she was upset about how long it takes for staff to answer her call light. R234 stated, Sometimes it can be too long and that can be a big mess if you need the toilet. On 4/6/21 at 1:55 p.m., R234 was seated in a wheelchair while being pushed by staff to the activity room. R234 stated that it takes a long time for her call light to be answered. R234 stated that, recently, she sat in the bathroom for one hour, after engaging her call light, for staff to respond to assist her back to bed. R234's call light monitoring log dated 3/23/21 to 4/5/21 documents how long R234 had to wait for her call light to be answered during those dates. R234 waited at least 20 minutes for her call light to be responded to on 16 occurrences during those dates. There were two dates, 3/24/21 and 3/29/21, which showed R234 waited 59 minutes and 70 minutes for her call light to be answered. 2. R137's Minimum Data Set (MDS) assessment dated [DATE] documents R137 requires extensive assistance of one person for toileting. R137's current Care Plan dated 3/16/21 documents that R137 requires one person to assist with transfers. On 4/5/21 at 1:37 p.m., R137 was lying in bed with one-quarter bedrails in the up position on each side of the bed. R137 stated she requires assistance from staff to go into the bathroom. R137 stated that call lights often take a long time to be answered by staff. R137 stated that recently she had to wait so long for her call light to be answered that she was incontinent of urine. R137's call light monitoring log dated 3/23/21 to 4/7/21 documents how long R137 had to wait for her call light to be answered during those dates. R137 waited at least 20 minutes for her call light to be responded to on six occurrences during those dates. 3. R136's Minimum Data Set (MDS) assessment dated [DATE] documents R136 is cognitively intact and requires extensive assistance of one person for toileting. R136's current Care Plan documents for staff to provide R136 with assistance with all mobility and activities of daily living needs. On 4/6/21 at 1:55 p.m., R136 was seated in a wheelchair while being pushed by staff to the activity room. R136 stated that it takes a long time for her call light to be answered. R136 stated that she frequently waits approximately 20 minutes for her call light to be answered. R136 stated that 20 minutes is too long to wait to go to the bathroom or for assistance with other activities of daily living needs. R136's call light monitoring log dated 3/23/21 to 4/6/21 documents how long R136 had to wait for her call light to be answered during those dates. R136 waited for at least 20 minutes for her call light to be responded to on seven occurrences during those dates. 4. R16's Minimum Data Set (MDS) assessment dated [DATE] documents R16 is cognitively intact and requires extensive assistance of two staff for toileting. R16's current Care Plan documents R16 requires a standing mechanical lift with two staff for transfers. On 4/5/21 at 11:43 a.m. R16 was seated in her room in a recliner. R16 stated she requires staff assistance and a mechanical lift to transfer. R16 stated that when she uses her call light, It can take a while, to be answered. R16 stated she has waited 20 minutes for her call light to be answered, which is too long. R16's call light monitoring log dated 3/23/21 to 4/8/21 documents how long R16 had to wait for her call light to be answered during those dates. This log documents R16 waited at least 20 minutes for her call light to be responded to on four occurrences during those dates. On 4/7/21 V10 (Licensed Practical Nurse/LPN) stated she is the nurse on R234's hallway. V10 stated that sometimes residents must wait a little longer for their call lights to be answered because, at times, multiple call lights alarm at the same time. V10 stated that there are several residents on her hall who require two people for transfers and toileting which means some residents will have to wait for their call light to be answered. V10 stated, What are we supposed to do? We have several two person assists. On 4/7/21 at 10:55a.m. V2 (Director of Nurses) stated that she would not give a specific amount of time for how long is too long for residents to wait for their call lights to be answered. V2 stated that she has told the facility's nursing staff that call lights should be answered in a timely manner. On 3/7/21 at 8:40a.m. V1 (Administrator) verified R234, R137, R136, and R16's call light logs included documentation that each of these residents waited at least 20 minutes for their call lights to be answered. V1 also verified that R234's call light log documents R234 has also had to wait one hour for her call light to be answered.

Based on interview and record review, the facility failed to document a rationale and ongoing adverse behaviors for the continued use of an as needed sedative/antianxiety medication and failed to obtain informed consent for two residents (R27 and R191) of seven reviewed for [MEDICAL CONDITION] medications in a sample of 27. Findings include: The facility's [MEDICAL CONDITION] Medication Protocol, revised 3/5/2021, documents that [MEDICAL CONDITION] drug therapy will be instituted at the lowest dosage for the shortest duration of time to control specific and documented behavioral problems or other conditions/diagnosis. This policy also documents that Care Plans will reflect [MEDICAL CONDITION] drug use and include: adverse reactions, other nursing interventions, dosage reductions if indicated, prescribed or refused. 1. R27's current POS, Physician order [REDACTED]. This form documents that [MEDICATION NAME] order was initiated on 2/24/21. R27's progress notes have no documentation of adverse behaviors to warrant the continued use of an as needed [MEDICAL CONDITION] medication. R27's medical record does not contain an informed consent or a rational to continue an as needed [MEDICAL CONDITION] medication. R27's current care plan does not have interventions or goals for specific behaviors or side effects to monitor for concerning a [MEDICAL CONDITION] medications. R27's quarterly assessment dated [DATE], documents that R27 is sleepier than usual. On 4/5/21 from 10:00am to 11:00am, R27 was observed sleeping in her wheel chair in the main living area. At 11:30am, R27 had to be awakened and encouraged to eat lunch. At 1:30pm, R27 was in bed sleeping. On 4/6/21 at 10:30am, R27 was in the living area sleeping in her wheel chair. At 2:00pm, R27 was in bed sleeping. On 4/7/21 at 10:30am, R27 was sleeping in her wheel chair, during church services. 2. On 4/5/21 at 10:30am, R191 was in her room working with therapy. R191 was cooperative and no adverse behaviors were seen. At 1:30pm, R191 was in her room visiting with family. On 4/6/21 at 11:00am, R191 was in her room, visiting with family. At 2:00pm, R191 was in bed, resting quietly. On 4/7/21 at 11:15am, R191 was being assisted to the chair, with no adverse behaviors noted. R191's current Physician order [REDACTED]. This form documents that the ordered was initiated on 3/25/21. R191's Progress Notes, dated 3/11/21 through 4/8/21, contain no documentation or a rationale for the continued use of an as needed [MEDICAL CONDITION] medication. R191's medical record does not contain an informed consent for the use of an [MEDICAL CONDITION] medication. R191's current care plan does not have interventions or goals concerning specific behaviors or side effects to monitor for [MEDICAL CONDITION] medications, On 4/7/21 at 9:50, V2, Director of Nursing, stated that neither R27 nor R191 had an informed consent in place for the [MEDICAL CONDITION] medications. V2 also stated that neither R27 nor R191 have specific behavior monitoring/tracking, or care plan interventions for the use of [MEDICAL CONDITION] medications. V2 verified that there is no documentation or rationale for the continued use of a [MEDICAL CONDITION] medications.

Based on observation, interview, and record review, the facility failed to change gloves during incontinence care and between resident cares and failed to ensure resident hand washing for four (R2-R5) of five residents reviewed for COVID-19 in a sample of five. Findings include: The facility's Standard Precautions policy, dated 6-5-2020, documents Purpose: Protect against the transmission of infection and includes Change gloves and perform hand hygiene when moving from contaminated to clean site and between resident care. The facility's Gloving policy, dated 6-17-2020, documents Purpose: Gloves will be used to prevent contamination of staff members' hands and to prevent cross-contamination and includes Notes: 1. Change gloves and discard after each resident contact. 2. Change gloves when moving from a contaminated body site to a clean body site on the same resident. 3. Soiled gloves should always be changed before touching any clean surfaces. 1. R4's clinical record documents R4 resides on the COVID unit due to a positive test result on 9-2-2020 and has a [DIAGNOSES REDACTED]. On 9-8-2020, at 11:57 am, V6 and V7 Certified Nursing Assistants/CNAs transferred R4 into bed to check R4's incontinent brief for soiling. With gloved hands, V6 lowered R4's pants and opened R4's incontinent brief and swept a gloved hand over the inside touching the lining to check for soiling. V6 closed R4's brief, pulled up R4's pants then with V7 transferred R4 back into a wheelchair. V7 removed V7's gloves, performed hand hygiene then wheeled R4 up to a dining room table for lunch. No hand hygiene was offered or performed for R4. With the same soiled gloves on V6 walked out of R4's room and into R5's room. R5 lay in bed on the COVID unit. V6 checked R5's respirations. V6 then left R5's room keeping the same soiled gloves on, reported to the nurse, returned and checked R5's temperature and oxygen saturation level. All of these tasks completed for R5 required touching of R5 with V6's same soiled gloves. On 9-8-2020, at 12:45pm, V6 CNA confirmed that V6 should have changed V6's gloves after cares with R4 and before starting R5's cares. 2. R2's clinical record documents R2 resides on the COVID unit due to a positive test result on 8-30-2020 and has a [DIAGNOSES REDACTED]. On 9-8-2020, at 10:56 am, V6 and V7 Certified Nursing Assistants/CNAs transferred R2 into bed for incontinence care then both CNAs performed hand hygiene and donned clean gloves. V6 lowered R2's pants and soiled incontinent brief. V6 then wiped a smear of stool from R2's bottom, then with the same soiled gloves applied a clean incontinent brief and pulled up R2's pants, touching R2's bare skin during this task (R2's left wrist, abdomen, shoulder). V6 tossed the soiled brief into the trash and removed V6's soiled gloves. After V6 and V7 transferred R2 to a wheel chair, V7 wheeled R2 out to a seat at a dining room table for lunch. No handwashing was offered or performed for R2. 3. R3's clinical record documents R3 resides on the COVID unit due to a positive test result on 9-1-2020 and has a [DIAGNOSES REDACTED]. On 9-8-2020, at 11:16 am, R3 sat in a chair on the COVID unit. V6 CNA assisted R3 to stand with R3's walker and walked with R3 to R3's bathroom. With gloved hands, V6 pulled R3's pants and brief down then R3 sat down on the toilet. When R3 was done urinating V6 wiped R3's bottom, pulled R3's brief and pants up, pulled R3's shirt down and flushed the toilet all with the same soiled gloves. V6 did not offer or remind R3 to wash her hands. R3 then ambulated to a seat at a dining room table for lunch. On 9-8-2020, between 12:25pm and 12:40pm R2, R3, and R4 were eating their French fries and Italian beef using their fingers to pick up the food. On 9-8-2020, at 12:45pm, V6 confirmed that V6 did not change V6's gloves after wiping R2's or R3's bottom. V6 stated That's what I do - that was one task. It was okay to touch her since it was the same task. I would change (gloves) before touching them again. V6 also stated at this time that V6 did not offer for R3 to wash R3's hands since R3 didn't wipe R3's own bottom. On 9-8-2020, at 12:46pm V7 CNA confirmed that V7 did not offer for R4 or R2 to wash their hands prior to the meal which V7 agreed consisted of some finger foods. V7 didn't think their hands needed washed since They aren't touching anything. On 9-10-2020, at 3:55pm, V2 Director of Nursing stated that staff should change their gloves when going from resident to resident. Staff should change gloves after wiping a resident during incontinence care and before putting on the clean brief. V2 also stated that staff should make sure residents hands are washed after toileting and before they go to the table to eat.

Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 3/13/20, the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH revised on 3/13/20, Nursing Home guidance from the Centers for Disease Control (CDC), interview, and record review, the facility failed to: ensure staff completed the facility's Employee Monitoring Tool for signs and symptoms of COVID-19 at the start of their shift and review the Employee Monitoring Tool for potential signs and symptoms of COVID-19 prior to the start of the staff's shift in order to prevent staff with potential signs and symptoms of COVID-19 from entering the facility. This had the potential to affect all 55 residents residing in the facility at the time of the survey. Findings include: An interview on 5/1/20 at 9 am, with the Administrator and the Director of Nursing (DON), revealed that the facility had no confirmed cases of COVID-19 and no persons under investigation for COVID-19 in residents or staff. Review of the facility's Employee Monitoring Tools (COVID-19), dated 5/1/20, revealed Nursing Assistant (NA1) marked Yes in the Do you have column for the following potential signs and symptoms of COVID-19: fever, new or worsening cough, shortness of breath, and sore throat. Review of the facility's nursing schedule, dated 4/25/20 to 5/1/20, revealed NA1 was scheduled to work on 5/1/20 from 6 am to 2:30 pm. During an interview on 5/1/20 at 9 am, with the Administrator, DON, Infection Preventionist, and Executive Director, when asked about the facility's process for monitoring staff for signs and symptoms of COVID-19, the Administrator and DON revealed, that staff were filling out the Employee Monitoring Tool (COVID-19) and taking their temperatures at the beginning of their shift. When asked who reviews the Employee Monitoring Tool (COVID-19) for potential signs and symptoms of COVID-19 prior to staff starting their shift, the Administrator confirmed that the facility's Infection Preventionist reviews the Employee Monitoring Tool (COVID-19). During the same interview on 5/1/20 at 9 am, with the Administrator, DON, Infection Preventionist, and Executive Director, when asked about NA1's Yes responses to potential signs and symptoms of COVID-19 on the Employee Monitoring Tool (COVID-19), dated 5/1/20, the DON stated, It's probably going to be education with her. When asked if NA1 was allowed to start her shift after answering Yes to potential signs and symptoms of COVID-19, the DON confirmed that NA1 was allowed to start her shift. When asked if anyone in the facility was reviewing staff's responses to potential signs and symptoms of COVID-19 prior to the start of their shift, the Executive Director revealed that the Employee Monitoring Tool (COVID-19) had an area for another staff member to witness the form. The Executive Director then confirmed that NA1's Employee Monitoring Tool (COVID-19), dated 5/1/20, had been signed by another unknown staff member on the Witness line. When asked what the witnesses' responsibility is if they see that the staff has answered Yes to potential signs and symptoms of COVID-19, the DON stated, They would notify the charge nurse who would then notify myself or (name of the Infection Preventionist). The DON then confirmed that the DON or Infection Preventionist would not allow the staff to begin their shift. The DON and Infection Preventionist then confirmed that they were not aware of NA1's Yes responses to potential signs and symptoms of COVID-19 on the Employee Monitoring Tool (COVID-19), dated 5/1/20. During an interview on 5/1/20 at 11:35 am, with the Activity Assistant, when asked what is the responsibility of the staff that witnesses another staff member complete the Employee Monitoring Tool (COVID-19) at the beginning of their shift, the Activities Assistant revealed that the witness verifies that the staff member has correctly documented their temperature on the form. When asked if the witness reviewed the other staff member's responses to potential signs and symptoms of COVID-19, the Activities Assistant revealed that the witness was only verifying the other staff member's temperature. Further review of the facility's Employee Monitoring Tools (COVID-19), dated 4/25/20 to 5/1/20 revealed the following: 4/25/20, seven Employee Monitoring Tools (COVID-19) had no witness signature. 4/26/20, three Employee Monitoring Tools (COVID-19) had no witness signature. 4/27/20, 11 Employee Monitoring Tools (COVID-19) had no witness signature and three Employee Monitoring Tools (COVID-19) did not have the potential signs and symptoms of COVID-19 answered. 4/28/20, one Employee Monitoring Tool (COVID-19) had no witness signature, one Employee Monitoring Tool (COVID-19) did not have a documented temperature, and two Employee Monitoring Tools (COVID-19) did not have the potential signs and symptoms of COVID-19 answered. 4/29/20, one Employee Monitoring Tool (COVID-19) did not have the potential signs and symptoms of COVID-19 answered. 4/30/20, one Employee Monitoring Tool (COVID-19) did not have the potential signs and symptoms of COVID-19 answered and one Employee Monitoring Tool (COVID-19) did not have a documented temperature. 5/1/20, two Employee Monitoring Tools (COVID-19) had no witness signature, one Employee Monitoring Tool (COVID-19) did not have a documented temperature, and one Employee Monitoring Tool (COVID-19) did not have the potential signs and symptoms of COVID-19 answered. Review of the facility's COVID-19 Infection Prevention and Control policy, revision date 4/29/20, revealed, .All staff should be educated, regardless of whether they have had a known COVID-19 exposure, to self-monitor by taking their temperature twice daily while at home and assessing for COVID-19 like illness .Staff having a fever of 100.0 or above and/or have a new onset of signs/symptoms of a respiratory infection should not report to work and notify their supervisor .Prior to the start of their shift and mid-shift, staff are required to have their temperature taken and verify they have no new onset of signs or symptoms of a respiratory illness at the location designated by the facility, and document it on the employee monitoring tool provided by IDPH. Staff with a temperature of 100.0 or greater and new onset respiratory symptoms will immediately notify the Director of Nursing for further instructions .A checklist may be used to show documentation of the screening process .

Based on observation, interview, and record review, the facility failed to utilize a two staff asist during resident cares for one resident (R41) and failed to utilize wheel chair foot pedals during resident transfer for one resident (R18) of 4 residents reviewed for falls in a sample of 25. This failure resulted in two resident falls each with injuries. Findings include: The facility's Fall Occurrence Policy, effective 2-21-19, documents (Named facility) wants to create an environment that is free from accident hazards as possible for residents, provides supervision when needed and assists with detecting and preventing hazardous situations. 1. On 6-27-19, at 12:40pm, R41 was laying in bed with a purplish bruised area noted to R41's left knee. R41's Progress Notes document the following: On 6-25-19, at 10:17pm a CNA (Certified Nurse Assistant) alerted the nurse that R41 was on the floor. On 6-26-19, at 10:07pm, facial grimacing was noted when R41's left knee is touched. On 6-27-19, at 4:18pm, R41 grimaces with touch to left extremities. On 6-27-19 between 11:41am and 1:43pm, R41 has bruising remaining to back of right hand, left fifth finger, left knee and left hip. On 6-27-19, at 9:46pm, facial grimacing noted. R41's Event Report documents that on 6-25-19 at 10:17pm, CNA (Certified Nurse Assistant) was doing cares and rolled resident, resident fell out of bed on to floor on left side. R41's Minimum Data Set/MDS assessment, dated 5-23-19, documents R41 as severely cognitively impaired with a functional status of extensive assistance with two person physical assist for toileting and personal hygiene. R41's Care Plan, dated 1-15-19, documents R41 is to have two assist for cares/mobility at all times. On 6-28-19, at 8:51am, V2 Director of Nursing/DON verified that R41 should have had a two staff asisst when performing cares at the time of R41's fall. 2. R18's Event Report documents that on 2-14-19 at 11:15am, R18 fell out of wheel chair when transporting down hallway to room. Resident has increased trunk flexion, forward lean in wheel chair. Wheelchair pedals removed as resident self propels. R18's Minimum Data Set/MDS assessment, dated 1-21-19, documents R18 as severely cognitively impaired with a functional status of limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with one person physical assist for locomotion on unit. R18's Care Plan, dated 1-10-19, documents (R18) is FWB (full weight bearing) and is unable to ambulate and/or transfer without help and has a wheel chair that she relies on others to transport her in about the facility. On 6-28-19, at 8:53am, V2 Director of Nursing/DON verified that staff should have applied foot pedals to (R18's) wheel chair prior to transferring R18 down the hallway. It is standard procedure for us.

Based on observation, interview, and record review the facility failed to obtain a physician's order, assess and document on oxygen usage for one (R52) of one resident reviewed for oxygen in the sample of 25. Findings include: The facility's Oxygen-Concentrator policy, revised 6/16/19, documents Procedure: 6. Document the completed procedure in the resident's clinical record. Note: 5. Change the humidification bottle every 7 days and as needed. 6. Change the oxygen tubing every 7 days. On 6/25/19 at 10:08am, R52 sat in R52's room with an oxygen concentrator beside R52's chair. On 6/27/19, at 3:20pm, V11 Certified Nursing Assistant/CNA stated that R52 uses the oxygen only at night. On 6/27/19, at 3:25pm, V12 Licensed Practical Nurse/LPN stated that they use the oxygen as needed for R52. On 6/28/19 at 9:38am, V2 Director of Nursing/DON provided R52's current standing order for Oxygen Therapy. R52's POS (Physician Order Sheet), dated (MONTH) 2019, does not include an order for [REDACTED].>R52's Minimum Data Set/MDS assessment Section O, dated 6/6/19, documents a special treatment of [REDACTED]. R52's MAR (Medication Administration Record), dated (MONTH) 2019 does not list oxygen saturation guidelines or documentation of oxygen monitoring. R52's current Care Plan does not address R52's oxygen use, [DIAGNOSES REDACTED]. On 6/28/19, at 8:57am, V2 Director of Nursing/DON verified that they should have had an order and parameters for R52's oxygen and it should have been care planned.

Based on observation, interview, and record review the facility staff failed to change gloves during incontinence care for one resident (R41) of two residents reviewed for incontinence care in a sample of 25. Findings include: The facility's Gloving Policy, revised 10-26-18, documents Purpose: Gloves will be used to prevent contamination of staff members' hands and to prevent cross-contamination. This policy also states Remember to perform hand hygiene immediately after removing gloves. On 06/27/19, at 1:02pm, V6 and V9 Certified Nurse Assistants/CNAs performed incontinence care for R41. V6 and V9 lowered R41's wet incontinence brief, then V6 cleansed R41's perineal area. With the same soiled gloves, V6 touched R41's bare leg and clothed back to turn R41, cleansed R41's rectal area, placed a clean incontinence brief under R41, then touched the bedside drawer handle and cabinet door to put the incontinence wipes away. V6 removed V6's gloves then applied clean gloves without any hand hygiene. V6 taped up R41's incontinence brief, pulled R41's pants up, placed the mechanical lift under R41 and transferred R41 back into a reclining wheel chair. On 06/27/19, at 1:08pm, V6 sated that V6 normally keeps the same gloves on to roll the resident after cleansing, but would change gloves if there was stool or was applying cream. V6 stated that V6 usually changes gloves when looking for things in the cabinets/drawers. On 6/28/19, at 9:45am, V2 Director of Nursing/DON confirmed the glove policy and stated that V6/CNA should have changed gloves after cleansing and before touching the resident and other things.

Based on observation, interview, and record review the facility failed to provide PROM (Passive Range of Motion) and apply splints for one of two residents (R25) reviewed for limitations in range of motion in the sample of 25. Findings include: The facility's Restorative Nursing Policy and Procedure dated 1-15-19 documents, Purpose of Restorative Nursing: To promote the highest level of functional ability for each of our residents. Restorative nursing care shall be given 24 hours per day, seven days a week, and includes splint or brace assistance. The facility's ROM (Range of Motion) and Physical Therapy policy dated 5-30-19 documents, Each resident will receive active/passive ROM twice daily. R25's current Rehabilitation Care Plan documents the following approaches: Left hand splint on while in bed but not overnight. When up/out of bed, remove hand splint and place a stuffed carrot in left hand. Right hand splint on when up and out of bed and during overnight hours. Place stuffed carrot in right hand when R25 is not wearing his right hand splint. R25's Restorative PROM Program dated 4-25-19 documents, (R25) is totally dependent of staff for all cares and is at risk for contractures to further develop. Goal: (R25) will tolerate PROM's to all four extremities at least twice daily. On 06/25/19 at 09:43 AM, R25 was sitting up in a wheelchair in his room with a soft splint to the right hand. R25's left hand was contracted shut and did not have any type of splinting device (soft carrot) as directed by R25's restorative plan of care. On 06/26/19 at 01:25 PM, R25 was lying in a bed in his room with a soft splint to the right hand. R25's left hand was contracted shut and did not have any type of splinting device (soft carrot) as directed per R25's restorative plan of care. R25's bilateral lower extremities were also contracted at the knees. On 06/26/19 at 11:20 AM, V3 (CNA/Certified Nursing Assistant) and V4 (CNA) stated that R25 never has a splinting device to the left hand and never uses a carrot splint to the right hand. V3 and V4 also stated that R25 does not get passive range of motion exercises. On 06/26/19 at 02:00 PM, V5 (Restorative Nurse) stated, (R25) is suppose to have a carrot splint in both hands when out of bed and a when in bed should have a soft hand splint to both hands due to (R25) having contractures. (R25) should get passive range of motion every day to the upper and lower extremities. Staff are suppose to sign off within the restorative plan that PROM is being done. Staff have not signed off that PROM has been done with (R25) for at least three months.

Based on observation, interview, and record review the facility failed to accurately complete an MDS (Minimum Data Set) assessment for two of 17 residents (R25 and R24) reviewed for MDS accuracy in the sample of 25. Findings include: 1. On 06/25/19 at 09:43 AM, R25 was sitting up in a wheelchair in his room with a soft splint to the right hand. On 06/26/19 at 01:25 PM, R25 was lying in bed with a soft splint to the right hand. R25's current Rehabilitation Care Plan documents the following approaches: Left hand splint on while in bed but no overnight. When up/out of bed, remove hand splint and place a stuffed carrot in left hand. Right hand splint on when up and out of bed and during overnight hours. Place stuffed carrot in right hand when R25 is not wearing his right hand splint. R25's Minimum Data Sets Section O0500 Restorative Nursing Programs dated 1-31-19 and 4-25-19 document R25 does not receive splint/brace assistance. On 06/26/19 at 02:00 PM, V5 (Restorative Nurse) stated, (R25's) MDS's (Minimum Data Sets) dated 4-25-19 and 1-31-19 are inaccurately coded and should have been marked that (R25) received splint assistance daily. 2. The Fall Event for R24, dated 2/28/19, documents R24 fell while walking and went to the local hospital for an evaluation due to upper and lower lips bleeding. The Fall Event for R24, dated 4/7/19, documents R24 fell off the toilet and went to the local hospital for an evaluation due to laceration to right forehead and was admitted for a [MEDICAL CONDITION] which required surgical intervention. The Quarterly MDS (Minimum Data Set) for R24, dated 1/10/19 was the last assessment completed prior to R24's fall on 2/28/19 and fall with fracture on 4/7/19. R24's Significant Change MDS Assessment, dated 4/24/19, section J1700, J1800, and J1900 document R24 did not have any falls after the previous assessment on 1/10/19. On 6/28/19 at 10:00 am, V2 DON (Director of Nursing) verified R24's MDS was not coded to include R24's falls with injuries on 2/28/19 and 4/7/19.

Based on interview and record review, the facility failed to immediately notify a resident's responsible party of a fall occurrence for one of one resident (R18) reviewed for notification of change in a sample of 25. Findings include: The facility's Fall Occurrence Policy, effective 2-21-19, documents Procedure: 5. Notify doctor and POA (Power of Attorney) of a fall immediately. R18's Event Report, documents on 5/8/19 at 8:25pm that R18 had a fall; Family/POA (Power of Attorney) was notified on 5/9/18 at 2:03pm. On 06/25/19, at 9:27am, V7 (R18's family member/financial POA/Power of Attorney) stated that V7 was disappointed in that neither she (V7) nor V8 (R18's family member/healthcare POA) was notified of R18's fall until the day after on 5-9-19. On 6-28-19, at 8:54am, V2 Director of Nursing/DON, stated that R18's POA should have been notified immediately on the same day of the fall.