Every finding on record at Arcadia Care Kewanee

Based on observation, interview, and record review the facility failed to ensure staff signed out controlled medications at the time of administration, failed to ensure medication administration records matched administration records for controlled medications, and failed to have accurate documentation of liquid morphine for 3 of 3 residents (R1, R2, & R3) reviewed for medications in the sample of 4.The findings include:1. On 3/8/26 at 9:40 AM, the B/C hall Narcotic Book was reviewed and showed the Shift Change Controlled Substance Inventory Sheet in the book had not been signed by the night nurse at 6:00 AM. The count sheet was to have two nurse sign off at shift change. The day nurse signed the sheet.On 3/8/26 at 9:42 AM V3 (Licensed Practical Nurse/Assistant Director of Nursing) reviewed the Shift Change Controlled Substance Inventory Sheet with a start date of 3/7/26. V3 reviewed the 3/8/26 at 6:00 AM entry and stated V4 (Licensed Practical Nurse/LPN) was the off going nurse and she did not sign the form. V3 stated both nurses are to sign the form at shift change. V3 stated at shift change they count the number of sheets (controlled substance proof of use forms) and the number of cards and document that on the form (Shift Change Controlled Substance Inventory Sheet).On 3/9/26 at 3:45 PM, V1 (Administrator) and V3 reviewed the B/C hall Shift Change Controlled Substance Inventory Sheet for 3/8/26 at 6:00 AM and they confirmed that both nurses should have signed the form. They stated nurses were to sign off on the form as they do the narcotic count. This is to verify that everything is correct, and they are both okay with the counts.The facility's Narcotic/Controlled Substances - Counting Policy (3/2026) showed, always participate in the counting of the controlled substances at the beginning and ending of your shift. General Procedure for Counting Controlled Substances, follow your facilities specific guidelines and use their specific log sheet.2. On 3/8/26 at 10:28 AM, V5 (LPN) reconciled narcotic medications with the surveyor. There was a card in the medication cart locked drawer for R2's hydrocodone/APAP (Norco), take 1-2 tablets every four hours as needed for severe pain. There wasn't a Controlled Substance Proof of Use form in the narcotic book for this medication. The form was on the nurse's desk and showed the nurse signed out the 11:00 AM medication - 2 pills which brought the count to zero on the form. The medication had not been given yet but was signed out. V5 confirmed she pre-signed the medication as being given to the resident. R3's card of pregabalin (Lyrica) 75mg showed there were 16 pills in the card. The card was compared to the Controlled Substance Proof of Use form which showed V5 signed out the 12:00 PM dose and dropped the count to 15 pills on the form. V5 confirmed she signed out the medication ahead of time. V5 stated she knows they are not supposed to do that.On 3/8/26 at 3:45 PM, V3 (Assistant Director of Nursing/LPN) and V1 (Administrator) stated staff are not to pre-sign medications; they are to be signed as they are being administered. V3 stated you never know if something will happen or if they will be here the whole shift. V1 stated staff are supposed to sign the medication out as they go, that's how it is supposed to be.3. On 3/8/26 at 10:43 AM, V5 (LPN) reconciled R1's liquid Morphine 100 mg/5 ml with the Controlled Drug Receipt/Record/Disposition Form dated 10/9/25 for R1's liquid Morphine 100 mg/5 ml. R1's morphine bottle showed there was 24 ml in the bottle. The Controlled Drug Receipt/Record/Disposition Form dated 10/9/25 for R1's liquid Morphine showed on 12/26/25 at 4:00 AM there was 27.5 ml of morphine in the bottle; on 12/27/25 at 11:00 AM .25 ml was given, and it went to 27.25 ml; on 12/30/25 at 12:00 AM 0.25 ml was given and there was 26.75 ml documented as being in the bottle. There should have been 27 ml in the bottle. There was no documentation as to why there was a discrepancy. The Controlled Drug Receipt/Record/Disposition Form dated 10/9/25 for R1's liquid Morphine showed the doses were signed out on the form on 12/22/25 and 12/27/25. R1's Medication Administration Record for December 2025 did not show the doses documented as being given. R1's Progress notes were reviewed and on 12/22/25 there weren't any notes showing morphine had been given to R1. There was a note on 12/27/25 at 10:49 AM that showed that morphine was given.The Controlled Drug Receipt/Record/Disposition Form dated 10/9/25 for R1's liquid Morphine showed a dose of medication was signed out on the form on 1/19/25. R1's January 2026 MAR did not show any dose of morphine given on 1/19/25. R1's Progress Notes were reviewed and did not show any note on 1/19/26 for the administration of morphine.The Controlled Drug Receipt/Record/Disposition Form dated 10/9/25 for R1's liquid Morphine showed on 2/27/26 there was 25 ml of morphine in the bottle. On 3/2/26 it was documented that there was 24 ml in the bottle and said count correction next to the entry done by V2 (Director of Nursing/DON). There was no documented administration of the medication between 2/27/26 and the count correction on 3/2/26.On 3/8/26 at 10:43 AM, V5 (LPN) stated a clarification of the amount of morphine was done with V2 (DON) because it looked like there was 24 ml in the bottle of morphine. They thought maybe the morphine wasn't being subtracted correctly. V5 stated she did not know what V2 found out when she looked into it.On 3/8/26 at 3:45 PM, V1 (Administrator) and V3 (Assistant Director of Nursing/LPN) reviewed the Controlled Drug Receipt/Record/Disposition Form dated 10/9/25 for R1's liquid Morphine and stated they should have noticed the other discrepancy on the form and not just the one reconciled by the DON. V1 stated whenever there is a discrepancy, whoever is on call is notified. The discrepancy is investigated. V1 stated their Regional Corporate person looked at R1's morphine and said that staff were subtracting wrong in comparison to the liquid morphine in the bottle. V1 stated the residents MAR, and narcotic sheet should match for administration of the medications.The facility's Medication Administration Policy (3/2026) showed documentation of medication administration is recorded on the Medication Administration Record - MAR or Treatment Record and includes the date, time, and initials of the licensed nurse or certified medication aide who administered the medication. When class II medications are administered, the medication is a. recorded on the medication administration record by a licensed nurse and b. accounted for on the resident's individual Control Substance Record by a licensed nurse.

Based on observation, interview, and record review the facility failed to ensure a resident was provided with an appropriately sized wheelchair and appropriate equipment to receive showers for one of three residents (R57) reviewed for accommodation of needs in the sample of 35. This failure resulted in R57 being confined to her room, unable to access the shower room, receiving bed bathing in lieu of scheduled showers, and being required to sit on the side of the bed to eat, negatively impacting R57's safety, dignity, comfort, and quality of life.Findings include: The Ombudsman's undated Resident Rights policy documented, As an individual living in a long-term care facility, you retain the same rights as every citizen of Illinois and of the United States. The following regulations provide clarity on specific rights granted to residents living in long-term care facilities: You have the right to make your own choices. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health at their highest practical levels.R57's Census Line documents R57 was admitted to the facility on [DATE].R57's Medical Diagnosis List documents R57 has Morbid (severe) Obesity and Depression.R57's Minimum Data Set (MDS), dated [DATE], documents R57 is cognitively intact, requires two staff with transfers, and one to two assists for showers. This same MDS documents R57 requires a wheelchair for mobility.R57's current Care Plan documents R57 has Depression and the target goal for R57 is that R57 will not refuse to come out of her room, get out of bed and socialize with others. This same Care Plan documents R57 requires one to two assistances from staff for showers.R57's Shower and Bathing Task, dated 12/12/25 through 1/4/26, documents R57 has only received one shower on 12/19/25.R57's Occupational Therapy Treatment Encounter Note, dated 12/25/25, does not contain documentation that a wheelchair assessment was completed for R57.R57's Medical Record does not include a wheelchair assessment for R57. There is no further documentation of a wheelchair assessment documented for R57.On 1/3/26 at 9:45 AM, R57 stated, The facility does not have a wheelchair that will fit me so I'm stuck in my room and can't get around. R57 further stated the facility did not have appropriate equipment to provide showers and reported, I (R57) had to bring my own shower chair from home because the facility had no way to give me a shower, but they still can't use the one I brought in because they said it wasn't safe. R57 stated she had only been showered one time since admission and reported, I (R57) was supposed to receive a shower last night and the aide told me they were too busy so it would have to be done another time. R57 stated she feels very secluded in her room and has no other option but to lay in bed most of the time because she has no way to leave her room. R57 further stated she was able to get up in a recliner at home and take a shower and would like to be able to get up out of bed and go to the shower room to take a shower.On 1/4/26 at 10:00 AM, V1 (Administrator) stated two different wheelchairs were purchased when R57 was admitted to the facility but neither of them fit R57 comfortably. V1 confirmed the facilities Vendor Rental History Report for R57 documents two bariatric wheelchairs were delivered to the facility for R57 on 12/9/25 and 12/12/25 and that there have been no further wheelchair deliveries for R57. V1 verified R57 was unable to utilize the two bariatric wheelchairs ordered and still does not have an appropriate fitting wheelchair for R57.On 1/4/26 at approximately 11:00 AM, V3 (Assistant Director of Nursing/ADON) stated the wheelchair available was too tall for R57 and caused discomfort. V3 stated the facility was limited to wheelchair sizes, while R57 required a larger size, stating, So far we have been unable to find one. V3 stated R57's family provided a shower chair that was not safe to use, and the facility was unable to locate a shower chair to safely accommodate R57.On 1/6/26 at 10:50 AM, V9 (Certified Nursing Assistant/CNA) stated R57 does not have a wheelchair at the facility that fits her.On 1/6/26 at 11:00 AM, V10 (CNA) stated R57 is unable to go to the shower room because R57 does not have a wheelchair or shower chair, stating, So we wash (R57) in her bed in the morning.On 1/6/26 at approximately 11:10 AM, V11 (CNA) stated R57 has no wheelchair at the facility so R57 sits on the side of the bed when she eats.On 1/6/26 at 12:45 PM, R57 pivot transferred from her bed with a walker and assistance of V3 (ADON) and V11 (CNA) to a bariatric wheelchair. R57 was unable to scoot to the back of the chair and stated that she could not get comfortable and breathe in the chair. V3 verified at this time R57 would not be safe to sit in the wheelchair by herself.On 1/6/26 at 2:10 PM, V3 (ADON) verified there was only one shower documented as being given to R57 since R57's admission. V3 stated, If the staff didn't document any other showers, then it didn't happen.On 1/6/26 at 3:00 PM, V2 (Interim Director of Nursing) verified R57's medical record and therapy notes does not contain evidence of wheelchair assessment being completed to recommend a proper wheelchair and proper wheelchair positioning for R57.

Based on observation, record review, and interview the facility failed to provide Registered Nurse/RN services eight consecutive hours daily for 7 days a week and failed to employ a full-time DON (Director of Nursing) to oversee the operation of the Nursing Department and ensure quality of care. This failure has the potential to affect all 53 residents residing within the facility. Findings include:The facility's Director of Nursing Job Description, dated 7/2023, documents Director of Nursing Job Description Summary: The primary purpose of the Director of Nursing position is to plan, organize, develop, and direct the overall operation of our Nursing Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical director, to ensure that the highest degree of quality care is always maintained.The Facility Assessment, dated 1/4/2026, documents a Director of Nursing is required to care for the resident's needs.On 1/5/26 at 12:10 PM a facility Days without RN (Registered Nurse) coverage as of 1/5/26 list was provided by V1 (Administrator). This list documents there was no RN coverage for 12/10/25, 12/14/25, 12/25/25, 12/27/25, 12/28/25, and 1/2/26. V1 verified at this time there was no RN coverage at the facility for 12/10/25, 12/14/25, 12/25/25, 12/27/25, 12/28/25, and 1/2/26 and that the facility should have a minimum of eight consecutive hours of RN coverage 7 days a week. V1 stated, We (the facility) have trouble now with getting RN coverage and the company does not allow me to utilize agency RN's.On 1/5/26 at 12:14 PM V1 (Administrator) stated V2 is a Regional Nurse and is the current Interim DON. V1 stated, (V2) is in our building around twice a week. This started around a month to a month and a half ago. We (the facility) are currently searching for a DON.On 1/6/25 at 11:45 AM V2 (Interim Director of Nursing) provided a list for December 2025 of the days V2 worked in the facility as the Director of Nursing. This list documents V2 worked 12/5/25, 12/12/25, 12/15/25, 12/19/25, 12/22/25, and 12/29/25. V2 stated, I only am at the facility one to two times per week, but I do read over the 24-hour nursing report every day. We are still searching for a full time Director of Nursing.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 1/4/26 and signed by V1 (Administrator) documents 53 residents reside within the facility.

Based on observation, interview, and record review the facility failed to label/date opened and prepared food items, ensure food items were not expired, maintain clean storage cabinets, repair damaged cabinet doors, and ensure cooking equipment was free of old food splatter. These failures have the potential to affect all 53 residents residing in the facility.Findings Include: The facility's Labeling and Dating Foods policy dated/revised 09/2023 documents, 2. Date marking for refrigerated storage food items. Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in- first out method of rotation. Once opened, all ready to eat, potentially hazardous foods will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date. 3. Date marking for freezer storage food items. Frozen food packages removed from the case will be dated with the date the item was received into the facility and will be stored using the first in- first out method of rotation. Once package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. Prepared food or opened food items should be discarded when: the food item does not have a specific manufacturer expiration date and has been refrigerated for seven days. The food item is leftover for more than 72 hours. The food item is older than the expiration date.The facility's Dietary Policies and Procedures Drawers and Cabinets policy (un-dated) documents, The drawers and cabinets in the department should be cleaned weekly or more often if needed. Clean the inside and the outside of the drawers and cabinets.On 1/4/2026 at 9:40 AM, during initial kitchen visit with V16 (Dietary Aide) there was a cabinet lacking a door, with accumulated debris and loose wood pieces found at its base; clean dishes were observed being stored in this compromised area. Additionally, other kitchen cabinets were in a state of disrepair, also containing food and debris on the outside of the cabinets. V16 confirmed the kitchen cabinets had dirt and debris with clean dishes stored on them and stated, my manager knows the cabinets is an issue.On 1/4/2026 at 9:50 AM, the facility refrigerator had an open bottle 3/4 full of (food and liquid thickener mix) with no opened date, 1/4 of a package of sliced cheese opened and not dated, one package of sliced ham opened and not dated, one package of sliced turkey opened and not dated, an open plastic condiment container 3/4 full of French dressing labeled expires on 1/2/26, one opened full bag and another 1/4 full bag of carrots labeled expires on 12/29/25, five condiment containers of unlabeled/dated unknown sauces, one large sheet cake pan with three-five pieces of cake left were labeled expires on 1/2/26, and an opened 3/4 full of scrambled egg mix with no opened date. V5 (Dietary Manager) verified the food and liquid thickener mix was opened and undated, the package of sliced cheese was opened and not dated, the package of sliced ham was opened and not dated, the package of sliced turkey was opened and not dated, the 3/4 full container of French dressing was expired and should have been discarded, the opened bags of carrots were expired and should have been discarded, the condiment containers were unlabeled and did not have an open or expired date, the pieces of cake were expired and should have been discarded, and the carton of scrambled egg mix was opened and not dated.On 1/4/2026 at 10:00 AM, the facility freezer had one opened bag (1/2 full) of frozen bread sticks not labeled or dated, one opened small bag (1/4 full) of cinnamon rolls not labeled or dated, and one opened small bag (1/4 full) of mixed vegetables not labeled or dated. V5 (Dietary Manager) verified at this time the bread sticks, the cinnamon rolls, and the mixed vegetables bags were all opened, not labeled or dated.On 1/4/2026 at 10:10 AM, the facility's dry food storage room had 1/2 of a bag and 1/4 of a bag of opened bread with no opened date, one opened bag of stuffing bag mix (3/4 full) with no opened date, and three large containers of various types of cereal stored not labeled or dated. V5 (Dietary Manager) verified at this time the bread and stuffing bag mix were opened and not dated, and the three large containers of cereal were not labeled or dated with an expired or opened date.On 1/4/2026 at 10:15 AM, V5 (Dietary Manager) stated all foods should be labeled and dated, all expired foods should be discarded, and all cabinets should be cleaned daily and in good repair.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 1/5/26 and signed by V1 (Administrator) documents 53 residents reside within the facility.

Based on interview and record review, the facility failed to document and track employee COVID-19 education, vaccine administrations and vaccine refusals. This failure has the potential to affect all 53 residents residing in the facility.Findings Include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 1/5/26 and signed by V1 (Administrator) documents 53 residents reside within the facility.The facility's Interim COVID-19 Vaccination Guidelines-Residents and Employees dated 12/2025 documents, Purpose: To minimize the risk of residents acquiring, transmitting, or experiencing complications from (COVID-19). Guidelines: The facility shall provide pertinent information about the significant risks and benefits of the vaccine to residents (or resident's legal representative) and employees. Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine. The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine and change their decision. The facility maintains documentation related to staff COVID-19 vaccination and includes at a minimum, the following: A. That staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. B. Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine. C. The COVID-19 vaccine status of staff and related information as indicated by NHSN (National Healthcare Safety Network). If a staff member is not eligible for COVID-19 vaccination because of previous immunization at another location or outside of the facility, the facility may request vaccination documentation from the staff member to confirm vaccination status.On 1/6/2026 at 10:14 AM, V3 (Infection Preventionist) stated I do not have a log of employees who have the COVID-19 vaccine or keep a record of employees who refuse the COVID-19 vaccine.On 1/6/2026 at 10:19 AM, V1 (Administrator) confirmed the facility does not keep COVID-19 logs for employees who have taken the COVID-19 vaccination, and stated the facility does not have employees sign a refusal form. V1 also confirmed there is no tracking for the education given to new employees who refuse the COVID-19 vaccination.

Based on interview and record review, the facility failed to ensure resident's electronic medical records, care plans, and physician order sheets matched their Physician's Order for Life-Sustaining Treatment (POLST) for scope of treatment for four of 24 residents (R2, R8, R34, R58) reviewed for Advanced Directives in the sample of 35.Findings include:The facility's Advance Directives policy, dated 10/2024, documents For purpose of this policy and procedure Advanced Directives means a written instrument, such as a living will or life prolonging procedure declaration, appointment of health care representative and power of attorney for health care purposes. These directives are established under state law and relate to the provision of medical care when the individual is incapacitated. This same policy documents If a resident or health care representative indicates an Advanced Directive regarding CPR (Cardio-Pulmonary Resuscitation) or Scope of Treatment (POLST, Physician's Order for Life-Sustaining Treatment, form), the appropriate forms will be completed. A written physician's order is required in response to the Advanced Directive(s). Physician's order shall be specific and address each Advanced Directive(s). Advanced Directive(s) shall be included in the resident's plan of care and will be reviewed during the care plan meeting with the resident and/or the resident's legal representative when present.1. R2's electronic medical record face sheet and physician order sheet, dated [DATE], documents Advanced Directives: DNR (Do Not Resuscitate).R2's current Care Plan, dated [DATE], documents I (R2) have signed a valid DNR. Do not resuscitate should I stop breathing, display no pulse as a result of failure of the heart to contract effectively or at all. Ensure DNR is noted on chart. This care plan does not address any further advanced directives.R2's Physician Order for Life-Sustaining Treatment, dated [DATE] and signed by R2, documents R2 wishes to be a Do Not Attempt Resuscitation (DNAR) if found with no pulse. This form also documents if R2 is not in cardiac arrest and has a pulse to follow Selective Treatment: Primary goal is treating medical conditions with limited medical measures. Do not intubate or use invasive mechanical ventilation. May use non-invasive forms of positive airway pressure, including CPAP (Continuous Positive Airway Pressure) and BiPAP (Bilevel Positive Airway Pressure). May use IV (Intravenous) fluids, antibiotics, vasopressors, and antiarrhythmics as indicated. Transfer to the hospital if indicated.2. R8's electronic medical record face sheet and physician order sheet, dated [DATE], documents Advanced Directives: DNR.R8's current Care Plan, dated [DATE], documents (R8) has chosen advanced directives: (R8) has signed a Do Not Resuscitate order. This care plan does not address any further advanced directives.R8's Physician Order for Life-Sustaining Treatment, dated [DATE] and signed by R8, documents R8 wishes to be a DNAR if found with no pulse and is not breathing. This form also documents if R8 is not in cardiac arrest and has a pulse and/or is breathing to follow Limited Additional Interventions: In addition to care described in Comfort Measures Only, use medical treatment, antibiotics, IV fluids and cardiac monitor as indicated. No intubation or mechanical ventilation. May consider less invasive airway support (CPAP, BiPAP). Transfer to the hospital if indicated. Generally, avoid the intensive care unit. Treatment Plan: Provide basic medical treatments. Artificially Administered Nutrition, six months defined trial period of artificial nutrition by tube.3. R34's electronic medical record face sheet and physician order sheet, dated [DATE], documents Advanced Directives: DNR.R34's current Care Plan, dated [DATE], documents DNR. I (R34) have signed a valid DNR. Do not resuscitate should I stop breathing, display no pulse as a result of failure of the heart to contract effectively or at all. Ensure DNR is noted on chart. This care plan does not address any further advanced directives.R34's Physician Order for Life-Sustaining Treatment, dated [DATE] and signed by R34, documents R34 wishes to be a DNAR if found with no pulse. This form also documents if R34 is not in cardiac arrest and has a pulse to follow Selective Treatment: Primary goal is treating medical conditions with limited medical measures. Do not intubate or use invasive mechanical ventilation. May use non-invasive forms of positive airway pressure, including CPAP and BiPAP. May use IV fluids, antibiotics, vasopressors, and antiarrhythmics as indicated. Transfer to the hospital if indicated.4. R58's electronic medical record face sheet and physician order sheet, dated [DATE], documents Advanced Directives: DNR.R58's current Care Plan, dated [DATE], documents DNR. I (R58) have signed a valid DNR. Do not resuscitate should I stop breathing, display no pulse as a result of failure of the heart to contract effectively or at all. Ensure DNR is noted on chart. This care plan does not address any further advanced directives.R58's Physician Order for Life-Sustaining Treatment, dated [DATE] and signed by R58, documents R58 wishes to be a DNAR if found with no pulse. This form also documents if R58 is not in cardiac arrest and has a pulse to follow Selective Treatment: Primary goal is treating medical conditions with limited medical measures. Do not intubate or use invasive mechanical ventilation. May use non-invasive forms of positive airway pressure, including CPAP and BiPAP. May use IV fluids, antibiotics, vasopressors, and antiarrhythmics as indicated. Transfer to the hospital if indicated.On [DATE] at 10:30 AM, V8 (Licensed Practical Nurse) stated When a resident has an emergent code situation, we (nurses) go into the status board (electronic medical record face sheet) and look at the advanced directives on the face sheet. If they are a DNR with selective treatment, then I think it will say it on that face sheet/ main (electronic) screen as well, to alert staff.On [DATE] at 12:15 PM, V1 (Administrator) and V2 (Interim Director of Nursing) confirmed that a resident's POLST should be reflected in the electronic medical record and specific instructions should match. V1 stated If someone has elected to be a DNR but then marks selective treatment, those specific treatment directives should at least be noted on the resident's care plan. V1 confirmed that staff look at the electronic medical record face sheet and physician order sheet to see a resident's code status and those should all match the residents wishes.

Based on interview and record review, the facility failed to offer bedtime snacks to six of six residents (R17, R18, R27, R30, R38, and R52) reviewed for bedtime snacks in the sample of 35.Findings include: The facility's Bedtime Care (HS Care) policy, dated 10/2024, documents Purpose: To promote comfort and relaxation before sleep. Guidelines: Provide bedtime snack and/or fluids as appropriate.R17, R18, R27, R30, R38, and R52's electronic health records do not contain documentation of R17, R18, R27, R30, R38, and R52 being offered or receiving bedtime snacks.On 1/5/26 at 1:46 PM R17, R18, R27, R30, R38, and R52 were in the resident' council meeting. R17, R18, R27, R30, R38, and R52 all stated staff do not come around and offer bedtime snacks. R17, R30, R38, and R52 stated they have to request a bedtime snack if they want one and sometimes the staff forget to bring it down. R18 and R27 stated they weren't aware they could even request a bedtime snack but would like them to be offered to them.On 1/6/25 at 10:35 AM V5 (Dietary Manager) stated the dietary staff bring a sealed box of bedtime snacks for the residents and place them on the nurse's desk around 8:00 PM every night. V5 stated, Dietary staff do not go around and offer snacks. I am unsure if the nurses or the CNAs (Certified Nursing Assistants) do that.On 1/6/25 at 12:15 PM V2 (Interim Director of Nursing) stated the bedtime snacks are being brought onto the halls around 7:30 to 8:00 PM but they are placed at the desk. V2 stated The CNAs should be offering a bedtime snack to all residents appropriate to receive a bedtime snack. V2 verified there is no documentation of R17, R18, R27, R30, R38, and R52 receiving any bedtime snacks.

Based on observation, interview and record review, the facility failed to document a diagnosis, identify behaviors and monitor for identified targeted behaviors to warrant the use of Risperidone (antipsychotic medication), and document a care plan to address behaviors and antipsychotic use for one of five residents (R9) reviewed for psychotropic medications in the sample of 35.Findings include: The facility's Behavioral Health Services Program policy dated 1/2023 documents, Purpose: To establish a system for identifying behaviors and implementing appropriate interventions consistent with the individualized plan of care and to ensure that each resident receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Development and Review of Care Plan: For psychotropic medications include indication/rationale for use, specific target behaviors, monitoring for efficacy and/or adverse consequences.R9's Care Plan dated 1/6/2026 does not document a psychosis medical diagnosis.R9's Physicians Order sheet dated 1/6/2026 documents, risperidone oral tablet 1mg (milligram) related to vascular dementia, mild, with other behavioral disturbance.R9's Care Plan dated 1/6/2026 does not document the use of an antipsychotic medication or targeted behaviors.On 1/4/2026 at 10:10 AM, R9 was in his room, lying in bed resting and watching his cell phone. R9 voiced he had no concerns with the facility. R9 was pleasant and polite.On 1/6/2026 at 11:15 AM, R9 was in the dining room, in his wheelchair, eating lunch peacefully, with another resident at the table.On 1/6/2026 at 12:30 PM, V11 (Certified Nurse Assistant) stated R9 is not violent or aggressive with other residents. V11 stated the most R9 will do is yell help if you do not answer his call light immediately.On 1/6/2026 at 12:35 PM, V7 (Licensed Practical Nurse) stated R9 is known to want to get in and out of bed immediately when he wants to. V7 stated R9 is just impatient but he is never violent or aggressive, especially not with other residents.On 1/6/2026 at 12:51 PM, V14 (Certified Nurse Assistant) stated R9 wants to get up a lot and sometimes will yell help if he is not up after a minute or two after turning his call light on. V14 stated R9 is not violent or aggressive towards other residents.On 1/6/2026 at 1:00 PM, V9 (Certified Nurse Assistant) stated R9 will push his call light here and there several times a lot in a day and yells out if he is not assisted quickly. V9 stated R9 is not mean or aggressive towards other residents. V9 stated R9 is sweet and polite.On 1/6/2026 at 1:40 PM, V2 (Interim Director of Nursing) stated if there is no psychosis medical diagnosis, targeted behaviors, or care plan mentioning the use of antipsychotics in R9's record, then we don't have it. V2 was unable to provide any evidence of R9 having a mental diagnosis to warrant the use of an antipsychotic medication or any behavior tracking monitoring targeted behaviors.

Based on interview and record review, the facility failed to ensure a resident with a diagnosis of Bipolar Disorder was provided a level two PASRR (Preadmission Screening and Resident Review) screen upon admission for one of three residents (R2) reviewed for PASARR screening in the sample of 35.Findings include:R2's level one PASRR (Preadmission Screening and Resident Review), dated 7/23/25, documents Diagnoses: No mental health diagnosis is known or suspected. This same form documents No level two required, no SMI/ID/RC (Serious Mental Illness, Intellectual Disability, Related Conditions). Rational: The level one screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/ developmental disability or serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted.R2's current Care Plan, dated 1/6/26, documents R2 was most recently admitted to the facility on [DATE] with diagnoses of Bipolar Disorder, Major Depressive Disorder (MDD) and Attention-Deficit Hyperactivity Disorder (ADHD).On 1/6/26 at 11:00 AM, V12 (Licensed Practical Nurse/Minimum Data Set coordinator) confirmed that R2 has not had a level two PASSR completed. V12 stated At the time (R2) was (originally) admitted in July of 2025, (V13, Former Social Services Director) would have been the one responsible for looking at the records and PASRR results. (R2's) Mental illness diagnoses were not listed on the level one screening and I am not sure why. The screening will have to be re-done, and a level two will need completed for (R2). V12 confirmed R2's diagnoses of Bipolar, MDD and ADHD were all present on admission.

Based on observation, interview, and record review, the facility failed to ensure a resident was provided thorough skin assessments to monitor for pressure injury with the use of a CPAP (Continuous Positive Airway Pressure) device, identify a new pressure wound, and provide a proper treatment and care plan interventions for a pressure injury for one (R57) of three residents reviewed for pressure injury out of a sample list of 35. Findings include:The facility's Pressure Injury and Skin Condition Assessment policy revised 1/2018 documents pressure ulcers and other ulcers will be assessed and measured at least every seven days by a licensed nurse and documented in the resident's clinical record. A wound assessment will be initiated and documented in the resident chart when a pressure ulcer is identified by a licensed nurse. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. At the earliest sign of a pressure injury or other skin problems, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes.The facility's Pressure Ulcer Prevention revised 1/2018 documents to prevent pressure sores/pressure injury inspect the skin several times a daily during bathing, hygiene, and repositioning measures.R57's census and clinical record documented admission to the facility on [DATE].R57's MDS (Minimum Data Set) assessment dated [DATE] documented that R57 was cognitively intact.R57's Braden Scale Assessments dated 12/15/25, 12/23/25, 12/27/25, and 01/05/26 documented that R57 is at a moderate risk for developing pressure ulcers. These same assessments did not document a pressure ulcer to the bridge of R57's nose.R57's admission Skin assessment dated [DATE] does not document a pressure ulcer or skin alteration on the bridge of R57's nose.On 1/04/26 at 9:30 AM, R57 was lying in bed asleep with a CPAP device in place.On 1/04/26 at 9:45 AM, R57 was sitting on the edge of her bed with a bright red area approximately the size of a dime noted on the bridge of her nose. R57 stated the area had been present for over one week, was painful, and R57 reported it to staff approximately one week earlier. R57 stated the only thing that was done was someone put a band aide over the area. R57 further stated the skin breakdown was caused by her CPAP mask due to the absence of a cushion, and reported the area hurt when touched or when R57's mask was touching the area.R57's electronic medical record does not contain documentation of the area on R57's nose or that a band aide was applied to the bridge of R57's nose.On 1/04/25 at 1:00 PM, V3 (Assistant Director of Nursing) stated that the previous Friday, R57 had a bandage over the bridge of her nose. V3 also stated she was not aware that R57 had developed an ulcer on the bridge of her nose and confirmed the area on R57's nose. V3 stated she would complete a skin report and notify the wound physician so a treatment could be put in place. At this same time, R57 reported to V3 that the area was painful.

Based on observation, interview and record review the facility failed to ensure Oxygen tubing and a humidification bottle was changed weekly for one of two residents (R2) reviewed for oxygen therapy in the sample of 35. Findings Include: The facility's Oxygen and Respiratory Equipment- Changing/ Cleaning policy, dated 12/2025, documents Purpose: To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. To minimize the risk of infection transmission. Nasal cannulas are to be changed once a week and PRN (as needed). Oxygen humidifiers should be changed weekly or as needed and will be dated when changed.R2's current Physician Order Sheet, dated 1/5/26, documents R2 has orders for Oxygen at two to four liters per nasal cannula as needed. Change Oxygen tubing weekly and PRN.On 1/5/26 at 11:05 AM, R2 was in his room lying in bed with Oxygen nasal cannula tubing lying on the bed. R2's Oxygen was on at two and a half liters with humidity. The tubing was dated 12/28 and the humidity bottle did not contain a date. At this time, R2 stated he took his Oxygen off and that's why it was on his bed. On 1/6/26 at 11:25 AM, R2 was in his room sleeping in bed with humidified Oxygen being administered per nasal cannula. R2's Oxygen tubing remained dated 12/28 and the in-use humidity bottle did not contain a date. On 1/6/26 at 12:15 PM, V2 (Interim Director of Nursing) confirmed that residents on Oxygen should have their tubing and humidity changed weekly. V2 stated They usually change them on Sunday nights. I am not why (R2's) would have been missed.

Based on observation, interview, and record review, the facility failed to ensure a resident with a diagnosis of Diabetes Mellitus was administered physician ordered insulin and blood glucose monitoring for one (R57) of three residents reviewed for medication administration out of a sample of 35.Findings include:The facility's Medication Administration Policy dated 1/2015 documents medications must be administered in accordance with a physician's order, the right resident, right medication, right dosage, right route, and right time. Documentation of medication administration is recorded on the Medication Administration Record.R57's Census Line documents R57 was admitted to the facility on [DATE].R57's Medical Diagnoses dated 12/11/25 documents Type 2 Diabetes Mellitus and Long-Term Insulin use.R57's MDS (Minimum Data set) dated 12/25/25 documents R57 is cognitively intact.R57's Physician Orders dated 12/11/25 documents Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart) Inject 30 unit subcutaneously after meals for Type two Diabetes.R57's Hospital Discharge Medication List dated 12/11/25 documents R57 was prescribed 30 units of Insulin Aspart this evening because an evening dose was not given in hospital.On 1/04/25 at 9:45 AM, R57 stated that on 12/11/25, the facility did not have her medications or her scheduled insulin. R57 stated it took two days before she received her medications.R57's Electronic Administration Record (eMAR) dated 12/11/25 does not contain documentation that R57 received her scheduled 30 units of insulin Aspart or received her bedtime blood sugar check.On 1/06/25 at 2:10 PM, V3 (Assistant Director of Nursing) stated that if medications are not marked off the eMAR, they were not given and V3 confirmed that R57 did not receive her evening or bedtime medications on 12/11/25, including Insulin Aspart 30 units as ordered on her hospital discharge medication list. V3 confirmed R57 admitted to the facility on [DATE] at 6:49 PM.

Based on observation, interview, and record review the facility failed to ensure greater than 80 square feet per resident in multiple resident rooms. This failure has the potential to effect 31 residents that could reside in these 31 rooms.Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 1/4/26 and signed by V1 (Administrator) documents 53 residents reside within the facility.An Illinois Department of Public Health Letter, addressed to (the facility) and dated 4/1/2025, documents The waiver is granted for rooms 107-112, 115-119, 201-209, 301-306, 307-311 and is subject to annual review or review at any time the facility does not meet the conditions under the waiver which the waiver was granted.On 1/4/26 at 2:15 PM V1 (Administrator) stated the facility does have rooms that do not meet the 80 square foot per resident requirement and gave a floor plan with highlighted rooms that were less than 80 square feet. Those rooms were 107, 108, 109, 110, 111, 112, 115, 116, 117, 118, 119, 201, 202, 203, 204, 205, 206, 207, 208, 209, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, and 311.On 1/5/26 at 10:32 AM V1 (Administrator) stated the waiver gets sent every year to the State Agency. V1 stated the facility does put two residents in the rooms with the waivers and any resident could be moved to those rooms with a roommate.

Based on observation, interview, and record review the facility failed to follow a resident's prescribed diet for 1 of 3 residents (R3) reviewed for prescribed diets in the sample of 6.Findings include:On 7/26/25 at 11:55 AM, R2 was sitting in his wheelchair at the dining room table with his lunch tray in front of him. R2 had ham, mixed vegetables, creamed corn, dinner roll, butter, chocolate cream pie, water, and apple juice. R2 stated he just eats and drinks whatever they put in front of him. R2 confirmed that he was drinking apple juice that was given to him. The meal ticket next to R2 showed he was to have a carbohydrate controlled low concentrated sweet diet (LCS), regular texture, thin liquids and sugar free hot chocolate. V5 (Certified Nursing Assistant/CNA) came over to tie R2's clothing protector and his meal ticket was shown to her. V5 stated she just looks at the name on the meal ticket and gives the resident what is ordered. V5 stated the cook is the one that looks at the ticket and puts the food and beverages on the tray. On 7/26/25 at 12:10 PM, V4 (Dietary Manager) stated residents are served food based on what is on their meal tickets. V4 stated R2's wife and physician prefer he have sugar free drinks. V4 stated on today's dietary flowsheet residents on LCS diets can have the pie and dinner roll but at dinner when the sherbet is served, they would get mandarin oranges. V4 stated the dietary flowsheet shows how many and the types of carbohydrates they can have per day.The Dietary Flowsheet for the day of 7/26/25 showed for residents on Carbohydrate Controlled/LCS diets for lunch they can have brown sugar glazed ham, creamed corn, vegetable medley, dinner roll with margarine, chocolate cream pie and a diet beverage. The only difference between the regular diet and LCS is the beverage for lunch. LCS say diet beverage and the regular diet just said beverage.On 7/26/25 at 1:15 PM, V4 stated she asked the cook why she gave R2 apple juice, and the cook stated because it was high in fiber. V4 stated she did not know where the cook pulled that from. V4 stated R2 should not have been given the apple juice. V4 stated it was not an appropriate choice for R2 especially since his wife and doctor want him to have sugar free options.On 7/26/25 at 5:20 PM, V1 (Administrator) stated R2 is on the LCS diet related to his neurological disorder. R2's wife likes his weight to be maintained, and this diet helps with his weight and disorder because when he gains weight his disorder is worse. The Face Sheet dated 7/26/25 for R2 showed diagnoses including cerebral infarction, sleep apnea, multifocal motor neuropathy, polyneuropathies, obstructive sleep apnea, allergic purpura, and osteoarthritis. The Physician Order Summary dated 7/26/25 for R2 showed a no added salt/low concentrated sweet diet.The Care Plan for R2 dated 3/26/25 showed he has a potential risk for altered nutritional status related to diagnoses of cerebral vascular accident, multifocal motor neuropathy, and neuropathies. R2 is on a no added salt/carb-controlled diet and no additional sweets. Follow the recommendations of the dietician. The Dietary Note dated 3/26/25 for R2 showed no added salt/carb-controlled diet, 2000 calories, and no additional sweets.The facility's Diet Orders policy (8/2023) showed, all diet orders are documented in the health record by the physician, or Registered Dietitian (where allowed). In some cases, the electronic medical record generates a diet order listing, and this is used in the communication and maintenance of diet orders for each resident.

Based on observation, interview and record review, the facility failed to ensure a multidose insulin pen injector and a multidose tuberculin vial were labeled and dated when opened. These failures have the potential to affect all 56 residents residing in the facility. Findings include: The facility's Medication Storage Policy, dated 10/2024, documents Purpose: To ensure proper storage, labeling, and expiration dates of medications, biologicals, syringes, and needles. Guidelines: 5. Once any medication or biological package is opened, Facility should follow manufacturer supplier guidelines with respect to expiration dates for opened medications. Facility should record the date opened on the medication container when the medication has a shortened expiration date once opened. The Manufacturer Guidelines for Aplisol (Tuberculin), undated, documents Aplisol vials should be inspected visually for both particulate matter and discoloration prior to administration and discarded if either is seen. Vials in use for more than 30 days should be discarded. The facility's Pharmacy Audit Assistance Service, dated 1/22/2019, documents Tresiba FlexTouch (insulin) 100 units/ml (milliliter) expiration date 56 days after opening. R18's current Physician Order Sheet, dated 3/20/25, documents the following Physician Order: Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml (insulin)- Inject 40 units subcutaneously one time a day. On 03/17/25 at 11:40 AM V11 (Licensed Practical Nurse) opened the top right drawer to B and C Wing medication cart where residents' insulin pens and vials were stored. In this drawer R18's Tresiba FlexTouch 100units/ml insulin pen injector, 1/3 full was not labeled with an open date. V11 then opened the refrigerator located in the B and C Wing medication storage room. Located in the refrigerator was Aplisol (Tuberculin) 5TU (Tuberculin) units/0.1ml,1/2 full and not labeled with an open date. On 3/17/25 at 11:44 AM V11 verified R18's multidose insulin pen and the multidose vial of (Tuberculin) were both open and not labeled with an open date and should have been. V11 stated, The vial of (Tuberculin) is used for any resident in the facility. On 3/17/25 at 1:30 PM V2 (Director of Nursing) verified multidose insulin pens or vials and (Tuberculin) vials should be labeled and dated with an open date.

Based on interview and record review, the facility failed to ensure a resident with new diagnoses of mental illness after admission was referred to the state agency for a level II PASARR (Preadmission Screening and Resident Review) evaluation for one of one resident (R25) reviewed for PASARR screening in the sample of 35. Findings include: The facility's Preadmission Screening and Annual Resident Review (PASARR), dated 11/2018, documents It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in PASARR level I for all new and readmissions per requirements to determine if the individual meets the criterion for mental disorder (Severe Mental Illness/Severe Mental Disability), intellectual disability or related condition. Annually and with any significant change of status, the facility will complete the PASARR level one screen for those individuals identified per the Level II screen requiring specialized services. R25's current electronic medical record profile and Face Sheet, documents R25 was admitted to the facility on [DATE]. R25's most recent Level I PASARR (PASRR) evaluation, dated 6/23/22, documents at the time of evaluation R25 had mental health diagnoses of: Depression/Depressive Disorder. This same evaluation documents Review Date: 6/23/2022, Level I Outcome: No Level II Required. Resolved symptoms rationale: The Level I screen indicates that a PASRR disability is not present because of the following reason: Low level symptoms are present. However, submitted information supports that they are well controlled and there is no history of serious mental illness. If the individual's symptoms increase or other information suggests a potential serious mental illness, then the nursing facility must submit an updated screen to reevaluate the need for a PASRR Level II behavioral health evaluation. R25's Current Medical Diagnosis list, dated 3/20/25, documents R25 has been diagnosed with following diagnoses at or after admission, Bipolar on 6/25/22, Psychophysiologic Insomnia on 6/25/22, Vascular Dementia with Severe Psychotic Disturbance on 10/1/22, Unspecified Affective Mood Disorder on 1/31/24, Delirium due to known Physiological Condition on 6/25/22, and Unspecified Psychosis not due to Substance or Known Physiological Condition on 9/5/23. R25's medical record does not document that R25 has had any further PASARR screening or evaluation since admission to the facility or after R25's new diagnosis of new Severe Mental Illness. On 3/20/25 at 11:35 AM, V8 (Licensed Practical Nurse/Minimum Data Set) confirmed that R25 has not had a PASARR re-screen since admission or a level II screening at all. V8 stated, (R25) was admitted in June 2022 and from the hospital record she only had the diagnosis of Dementia. The PASARR screen was done at the hospital prior to admission and only listed depression for a diagnosis. V8 confirmed R25 has new diagnoses since admission and stated, I don't ever redo the PASARR after they have been admitted and did not realize that it needed to be redone with new diagnoses.

Based on observation, interview and record review, the facility failed to complete hand hygiene prior to and during urinary catheter care for one of two residents (R38) reviewed for indwelling urinary catheters in the sample of 35. Findings include: The facility's Urinary Catheter Care policy, dated 10/2024, documents Purpose: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Guidelines: 2. Hand hygiene shall be performed before and after touching any part of the urinary catheter drainage system. The facility's Infection Precaution Guidelines, dated 10/2024, documents Standard Precautions combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions (except sweat), mucous membranes may contain transmissible infectious agents. Standard Precautions consist of a group of infection prevention practices that apply to all residents, regardless of suspected or confirmed infection status, in any stetting in which healthcare is delivered. These include hand hygiene. Standard precautions will be employed by all personnel for all residents at all times. R38's current computerized medical record documents R38 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Retention of Urine, Benign Prostatic Hyperplasia, and Obstructive and Reflux Uropathy. R38's Physician Order Sheet, dated 3/20/25, documents R38 has an indwelling urinary catheter. On 3/19/25 at 2:02 PM V6 (Certified Nursing Assistant/CNA) and V7 (CNA) were preparing to perform R38's urinary indwelling catheter care. V6 and V7 assisted R38 to his bed with gloved hands. V7 pulled R38's privacy curtain with her right hand once R38 was in bed. V6 and V7 both assisted in removing R38's pants and brief with their gloved hands. V7 removed her gloves and reapplied new gloves without washing or sanitizing her hands. V7 then performed urinary catheter care. After V7 performed R38's urinary catheter care, V7 readjusted R38's catheter, removed her gloves and applied new gloves without washing or sanitizing her hands. V7 then applied a new brief on R38. V7 never washed or sanitized her hands throughout R38's entire indwelling urinary catheter care procedure. On 3/19/25 at 2:25 PM V6 and V7 verified they should have washed their hands prior to performing catheter care and in between glove changes when going from dirty to clean areas. V7 stated, I knew I was supposed to use an alcohol-based sanitizer or wash my hands, but I didn't want to bring the huge bottle of alcohol-based sanitizer we (the facility) have into (R38's) room. On 3/20/25 at 9:43 AM V3 (Assistant Director of Nursing/Infection Preventionist) verified that V7 (CNA) should have washed her hands before providing urinary catheter care and during R38's indwelling urinary catheter care procedure.

Based on observation, interview, and record review the facility failed to obtain an order and follow a physician order for oxygen use and ensure an oxygen care plan was developed for two of three residents (R16 and R21) reviewed for oxygen in the sample of 35. Findings include: The Facility's Oxygen Concentration, dated 10/2024, documents Procedure: 1. Verify and understand the physician's order. 2. Know the flow rate and duration of use. The Facility's Medication Administration Policy, dated/revised 01/2015, states Medications must be administered in accordance with a physician's order, e.g. (for example), the right resident, right medication, right dosage, right route, and right time. The Facility's Comprehensive Care Plan Policy, dated/revised 11/2017, states The purpose of this policy is to develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 1. On 3/17/2025 at 10 AM, R21 was lying in bed with oxygen flowing at 4.5L (liters) per nasal cannula. R21's current Physician Order Sheet, dated 3/17/25, does not contain a physician order for the use of oxygen. On 3/17/2025, at 9 AM R21's current care plan did not address R21's oxygen use. On 3/17/2025 at 10:15 AM, V9 (Licensed Practical Nurse/LPN) confirmed R21's oxygen per nasal cannula was set at 4.5 liters. V9 also confirmed R21 had no order for oxygen via nasal cannula. On 3/17/2025 at 10:35 AM V2 (Director of Nursing) verified R21 did not have a current physician order for oxygen or a care plan that address R21's oxygen use. V2 stated, I do not see an order for (R21) to have oxygen. (R21) should have an order for oxygen in order for (R21) to receive oxygen via nasal cannula. V2 added an order for R21 to receive oxygen and updated R21's care plan to reflect R21 receiving oxygen after being made aware. 2. On 3/17/2025 at 10 AM, R16 was lying in bed with oxygen flowing at 4L per nasal cannula. On 3/18/2025 at 1:35 PM, R16 was lying in bed with oxygen flowing at 4L per nasal cannula. R16's current Physician Order Sheet, dated 3/20/2025, states Oxygen at 2L via nasal cannula (wean as tolerated) as needed for prophylactic. On 3/18/2025 at 1:40 PM, V10 (LPN) confirmed R16's oxygen per nasal cannula was set at 4L. V10 also confirmed R16's order states Oxygen at 2L via nasal cannula (wean as tolerated) as needed for prophylactic.

Based on observation, interview, and record review the facility failed to ensure greater than 80 square feet per resident in multiple resident rooms. This failure has the potential to effect 31 residents that could reside in these 31 rooms. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 3/18/25 and signed by V1 (Administrator) documents 56 residents currently reside within the facility. An Illinois Department of Public Health Letter, addressed to (the facility) and dated 7/17/2024, documents The waiver is granted for rooms 107-112, 115-119, 201-209, 301-306, 307-311 and is subject to annual review or review at any time the facility does not meet the conditions under the waiver which the waiver was granted. On 3/17/25 at 1:00PM V1 (Administrator) stated the facility does have rooms that do not meet the 80 square foot per resident requirement and gave a floor plan with highlighted rooms that were less than 80 square feet. Those rooms were 107, 108, 109, 110, 111, 112, 115, 116, 117, 118, 119, 201, 202, 203, 204, 205, 206, 207, 208, 209, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, and 311. On 3/20/25 at 11 AM V1 (Administrator) stated the waiver gets sent every year to the State Agency. V1 stated the facility does put two residents in the rooms with the waivers and any resident could be moved to those rooms with a roommate.

Based on interview and record review the facility failed to have funds available for 18 of 18 residents (R1-R18) reviewed for personal funds in the sample of 18. Findings Include: The Facility's Resident Funds policy dated 04/2019 documents This facility manages the personal funds of residents when such a request is made by the resident. Resident requests for access to their funds should be honored by facility staff as soon as possible but no later than: The same day for amounts less than $100 ($50 for Medicaid residents); Three banking days for amounts of $100 ($50 for Medicaid residents) or more. On 12/11/24 V3 (Licensed Practical Nurse/MDS Coordinator) provided a list of residents whose money is managed by the facility. This list included R1-R18. On 12/11/24 at 9:00 AM R15 stated I have been asking for $150 out of my trust because I would like to buy some Christmas cards and other things for Christmas, and I've been told they are waiting on a check from corporate. They said that they do not have the money to give to me. On 12/11/24 at 9:30 AM R18 stated They told me that all of our money is on hold until a check gets here from corporate. I would like to buy a Christmas gift. I hope they can get the cash before then. On 12/11/24 at 10:50 AM V1 (Administrator) stated The resident trust is not on hold and has never been. I am sure we would be able to give money to residents that ask. V1 denied knowledge of any residents requesting money and not receiving it. The Facility's Resident Council meeting minutes dated 10/3/24 document Need a new business office manager. (V3 LPN) is standing in. Trust is on hold. The Facility's Resident Council meeting minutes dated 11/11/24 documents (V3 LPN) helping while we look to hire a Business Office Manager. Trust is open but limited to what cash we have on hand. The Cash Disbursements Form dated 12/3/24 documents that the starting balance was $204. On 12/3/24 R2, R15, and R18 withdrew cash leaving the balance $0. On 12/11/24 at 11:00 AM V3 confirmed that there had not been any cash available to residents since 12/3/24. V3 stated I submitted a request to corporate and we are waiting on a check to be able to have funds to give residents that have asked. V3 confirmed knowledge of R15 requesting cash and not having access to it.

Based on interview and record review, the facility failed to adequately manage a resident's Coumadin (anticoagulant medication) dosage to ensure the medication was reaching therapeutic levels, develop a policy on anticoagulant medication management, and obtain treatment adjustment from the physician for a non-therapeutic INR (International Standardized Ratio for clotting in the blood) lab result for a resident with a history of a high risk blood clotting disorder for one of three residents (R3) reviewed for High Risk Medications. This failure resulted in R3 requiring emergency medical services followed by a medical transfer and admission to a tertiary critical care (higher level/specialized) hospital for treatment of Acute Ischemic Stroke Left MCA (Middle Cerebral Artery) territory with right facial droop and weakness, Lactic Acidosis (lactic acid in the bloodstream) and Subtherapeutic INR, resulting in R3 experiencing aphasia, dysphagia, right sided weakness, mental anguish, and hospitalization for 17 days. These failures resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy started on 1/26/24 when the facility received R3's Laboratory result of a subtherapeutic INR and failed to inform the resident's primary Physician of the result and need to alter the current anticoagulant medication dosage, and did not record the INR result on the Protime flowsheet, resulting in R3 suffering a change in cognition and being transferred to the emergency room then subsequently transferred the a tertiary critical care hospital for treatment of Acute Ischemic Stroke Left MCA territory with right facial droop and weakness, Lactic Acidosis and Subtherapeutic INR. V1 (Administrator in Training) was notified of the Immediate Jeopardy on 2/27/24 at 1:07 PM. While the immediacy was removed on 2/27/24, the facility remains out of compliance at a severity Level II as the facility continues to have members of the IDT (Inter-Disciplinary Team) including a nurse review all admissions for anticoagulant medication and ensure proper lab orders during Quality Assurance meetings, review all current admitted residents with anticoagulant medication for lab orders during Quality Assurance meeting weekly, and audit all other residents with high-risk medications for adequate lab monitoring. R3's Physician Order Sheet, dated 11/1/23-2/29/24, documents R3 has diagnoses including but not limited to Hypertension, History of Pulmonary Embolism, History of other Venous Thrombosis and Embolism, Antiphospholipid Syndrome and Heart Failure. This order sheet documents R3 has a laboratory order for PT (Prothrombin)/INR one time only related to Personal History of Pulmonary Embolism, Personal History of other Venous Thrombosis and Embolism, until 1/25/24. This order has a start date of 1/25/24. This order sheet also documents a medication order for Warfarin Sodium (Coumadin) two and a half milligrams to give 1 tablet by mouth one time a day every Monday, Wednesday, and Friday for blood thinner, start date 1/12/24. This order sheet also documents a medication order for Warfarin Sodium five milligrams to give 1 tablet by mouth one time a day every Tuesday, Thursday, Saturday, and Sunday for blood thinner, start date 1/11/24. No other Warfarin orders were started after 1/12/24 for R3. R3's Laboratory report, dated 1/26/24, documents R3's INR result was 1.3. This report also documents an INR range for Standard Anticoagulant is 2.0-3.0 and Aggressive Anticoagulant is 2.5-3.5. On 2/21/24 at 12:10 PM, V13 (R3's Family Member) stated I am going off what the neurologist doctor said to me. When we were in the emergency room , I don't know his name but after she was taken there, I asked specifically what caused her stroke and he said likely medication management. Her level was too low for the Coumadin to be considered therapeutic. (R3) is still having left side weakness, aphasia (difficulty formulating thoughts into words and speaking) and dysphagia (difficulty swallowing). She has to eat soft foods only which she cries about. She was able to eat regular food before this. (R3) also has suffered memory loss with her stroke. On 2/21/24 at 1:40 PM, V1 (Administrator in Training) stated I don't know if (V8 R3's Primary Physician) was notified of the 1/26/24 laboratory result for (R3's) PT/INR. If he was notified it should be in the progress note or a new updated order would be in place. On 2/21/24 at 2:00 PM V9 (V8's Medical Office Licensed Practical Nurse) stated I do not see where we (doctor office) were ever notified of the PT/INR results for (R3) on or after 1/26/24. R3's Physician visit history, provided by V1 on 2/21/24, documents that the last visit from V8 was on 12/12/23. R3's Nursing Progress notes, dated 1/11/24-2/9/24 do not document that V8 was ever notified of R3's PT and INR results that were completed on 1/26/24. R3's Nursing Progress note, dated 2/10/24 at 8:15 AM, documents R3 was transferred to a local hospital after appearing to have experienced a change in Cognitive Ability. R3's Nursing Progress note, dated 2/10/24 at 1:27 PM, documents Informed by emergency room nurse That (R3) had Stroke with Left sided weakness and sepsis. Resident will be re-transferred to (tertiary critical care hospital). R3's emergency room provider notes, dated 2/10/24 at 9:22 AM, documents This [AGE] year-old woman sent from (the facility) because mental status change concerning for possible stroke. The (facility) said that the right sided face is drooping compared to normal, and (R3) is not speaking as she normally does. R3's emergency room hospital record, dated 2/10/24 at 12:15 PM, documents R3 is being transferred to a tertiary hospital for Acute ischemic stroke left MCA (Middle Cerebral Artery) territory with right facial droop and weakness, Lactic acidosis rule out sepsis and Subtherapeutic INR. This record also documents Brief Summary: Work up in emergency room shows INR subtherapeutic at 1.3. Patient had a CTA (Computed Tomography Angiography) of the head which showed acute ischemic infarct in the left MCA territory in the left temporal lobe region, no hemorrhage. On 2/26/24 at 11:20 AM V19 (Pharmacist) stated, (R3's) INR of 1.3 is not within therapeutic range. A physician should have been notified to possibly adjust (R3's) Warfarin dose. On 2/26/24 at 12:45 PM V15 (R3's Primary Hospital Physician) stated, (R3) is currently in the hospital being treated for the effects of her stroke. (R3's) sub-therapeutic INR levels contributed to (R3's) stroke. (R3) had a history of developing blood clots. On 2/26/24 at 12:55 PM V16 (R3's Neurologist) stated, (R3) had a history of a disorder called Anti-Phospholipid Syndrome which is a disorder that puts (R3) at a high risk for developing blood clots. (R3) also has a history of a Pulmonary Embolism and Venous Thrombosis. (R3's) INR levels should have been watched closely and as soon as the facility knew (R3's) INR levels were 1.3 (sub-therapeutic) on 1/26/24 the facility should have notified the physician to get (R3's) Warfarin (anti-coagulant) dose adjusted to ensure (R3's) INR levels were therapeutic to prevent blood clots. Sub-therapeutic INR levels would have caused a clot to throw and caused (R3's) stroke. On 2/27/24 at 10:15 AM, V1 (Administrator in Training) stated We do not have a Coumadin specific policy or one for anticoagulant monitoring. We use the Protime (PT) Flowsheet for residents on Coumadin and that is where nurses will document INR results and then dose changes and when the Physician was notified of them. V1 confirmed R3's Protime flowsheet has not been documented on since December of 2023. The facility's Notification of Change in Resident Condition or Status policy, dated 10/12/05, documents The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing, Physician, Guardian, Health Care Power of Attorney, etcetera) of changes in the resident's medical/mental condition and or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been; A need to alter the resident's medical treatment significantly, Abnormal lab findings. The facility's Laboratory Tests policy, dated 9/27/17, documents Appropriate laboratory monitoring of disease processes and medication requires consideration of many factors including concomitant disease(s) and medication(s), wishes of the resident and family and current standards of practice. On 2/29/24 the surveyor confirmed through interview, and record review that the facility took the following actions to remove the immediacy: 1. All nursing staff including agency nurses in-serviced on proper monitoring of anticoagulant use and ensuring high risk medication labs are reported and adjusted to ensure the resident reaches therapeutic levels by V1 on 2/27/24. 2. Staff In-service on the policy to monitor and complete the PT/INR flow sheet by V1 on 2/27/24. 3. All nursing staff including agency educated on notification to physician immediately with lab results by V1 on 2/27/24. 4. R3 no longer lives at facility, all other charts reviewed for any residents receiving anticoagulant therapy by V3 (Care Plan/MDS Coordinator) on 2/27/24. 5. MD reviewed policy for lab monitoring and signed off on policy on 2/27/24.

Based on observation, interview, and record review the facility failed to provide an adequate amount of sit-to-stand mechanical lifts to transfer and toilet residents timely for nine of nine residents (R3-R11) reviewed for accommodation of needs in the sample of 12. These failures resulted in R3 soiling her brief and sitting in urine and feces for over an hour at a time on multiple occasions, causing R3 visible emotional distress, embarrassment, and anxiety, and resulted in R4 experiencing unwanted urinary incontinence and embarrassment. Findings include: The facility's Limited Resident Lift Program (undated) documents 1. Equipment: Must have enough lift, slings, etc. to effectively transfer all heavy residents in a timely manner. Goals: 4. Maximize safe, functional independence without compromising the resident's dignity and rights. Compliance: D. Mechanical lifting devices and other equipment /aids: b. Mechanical lifting devices and other equipment/aids will be maintained regularly and kept in proper working order. The Facility Assessment Tool dated 2-21-24 documents, Part 2: Services and Care We Offer Based on our Residents' Needs. Resident support/care needs- Bowel/bladder: Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. On 2-21-24 at 11:00 AM V1 (Administrator-In-Training) provided a list of current residents (R4-R11) requiring the use of a sit-to-stand mechanical lift machine for transfers and toileting. On 2-27-24 from 10:00 AM through 10:15 AM a tour of the building was done. During this tour the facility had one sit-to-stand mechanical lift machine within the building, to use for four hallways that occupied residents. 1. R3's BIMS (Brief Interview of Mental Status) dated 12-13-23 documents R3 is cognitively intact. R3's Care Plan dated 2-8-24 documents R3 requires staff assistance for transfers and toileting. R3's Progress Notes document R3 was hospitalized on [DATE] and still remains hospitalized . R3's Grievance/Complaint Report Form dated 2-8-24 and signed by V1 (Administrator-In-Training) documents, (R3) complaints of not being able to go to the bathroom as quick as she need to due to second stand-up lift broke down. (R3) states she has urgency when she needs to go. Method of correction or disposition of complaint: Staff in-serviced to take resident to the bathroom first or as quick as they can does have past history of chronic urinary symptoms and urgency. (R3) also educated that we could use bed pain if she desires as another means to toilet. On 2-21-23 at 12:10 PM, V13 (R3's Family Member) stated (R3) reported to me that they (the facility) only have one sit to stand so they have to wait a long time to go to the bathroom. She is not getting the help she needs. (R3) will not be going back there (the facility) because she is embarrassed. (R3) was visibly crying to me and my mother that the facility did not have a machine to get her up and toilet her. (R3) told us she had to sit in poop and pee for hours a lot of different days. (R3) voiced the concerns to (V1 Administrator-In-Training) and (V1) told (R3) she would have to use the bed pan. (R3) does not like having to use a bed pan and should not have to. 2. R4's current Care Plan dated 2-21-24 documents R4 requires full assistance of staff and a sit-to-stand as needed for transfers and toileting. On 2-27-24 at 10:40 AM R4 was sitting in her recliner. R4 stated she sometimes wets her pants waiting on someone to transfer her. R4 stated she tries to hold it but it just comes out after waiting so long for the machine (sit-to-stand). I do not like sitting in wet pants. It is embarrassing. 3. R5's current Care Plan dated 2-21-24 documents R5 requires full assistance of staff and a sit-to-stand for transfers and toileting. On 2/28/24 at 1:15 PM R5 was lying in bed in her room. R5 confirmed she needs assistance to get out of bed with a lift device. R5 stated I have to wait a long time. Sometimes an hour and it's usually when I hit my call light because they only have so many machines and other people use them too. It is a long time to wait when I have to go to the bathroom. 4. R6's current Care Plan dated 2-21-24 documents R6 requires full assistance of staff and a sit-to-stand for transfers and toileting. 5. R7's current Care Plan dated 2-21-24 documents R7 requires full assistance of staff and a sit-to-stand for transfers and toileting. 6. R8's current Care Plan dated 2-21-24 documents R8 requires full assistance of staff and a sit-to-stand lift as needed for transfers and toileting. 7. R9's current Care Plan dated 2-21-24 documents R9 requires full assistance of staff with a sit-to-stand lift for transfers and toileting. 8. R10's BIMS Evaluation dated 11-27-24 documents R10 is cognitively intact. R10's current Care Plan dated 2-21-24 documents R10 is unable to transfer independently due to the diagnoses of weakness and uses a sit-to-stand lift with staff assistance. On 2-28-24 at 1:25 PM R10 was sitting in his wheelchair in his room. R10 stated, There is only one lift (sit-to-stand) here and it is usually on the other side of the building. I try to put my call light on earlier than I think I will need it, so I don't pee myself. Sometimes it takes half an hour to over an hour for the staff to get me to the toilet once I use my call light. I wear an (adult brief) so I wet myself in it when I need to. I don't like wetting myself. What am I supposed to do? 9. R11's current Care Plan dated 2-21-24 documents R11 requires full assistance of staff and a sit-to-stand as needed for transfers and toileting. On 2-26-24 at 12:35 PM R11 stated, I just get myself up to the bathroom if staff do not help me in time. I do not wait for the lift. On 2-27-24 at 10:20 AM V20 (CNA/Certified Nursing Assistant) stated, There is not enough sit-to-stand lift to toilet the residents timely. We only have one lift for all four hallways. (R11) gets upset, yells, and screams and sometimes soils herself. Residents are also late getting up for meals at times. On 2-27-24 at 10:50 AM V21 (CNA) stated, The residents have to wait a long time sometimes to get up to the toilet because we only have one sit-to-stand lift. Residents will soil themselves at times before we can get to them. On 2-27-24 at 1:00 PM V1 (Administrator-In-Training) stated, The second sit-to-stand lift has been broken for about a month now and we are awaiting parts. There is one machine in the building. On 2-27-24 at 2:13 PM V25 (CNA) stated, Residents were having to wait longer periods of time due to only having one sit to stand lift. R3 would always get upset having to wait longer periods of time because she would have to use the restroom. R5 also got upset multiple times when it was time for her to lay down and she had to wait because we only had the one sit to stand. On 2-27-24 at 2:19 PM V24 (CNA) stated, I work second shift mostly. It is very difficult to get people up timely when we only have one sit-to-stand in the building. (R3) has requested to go to the bathroom before and had to wait for an hour and a half, because the sit-to-stand was being used on other residents. (R3) was very upset and very anxious about this and I don't blame her. Sometimes residents because they need a sit-to-stand lift must wait until its done being used on other residents. (R11) is a high fall risk and will get up on her own if we cannot get to her call light timely. There have been multiple times (R11) has transferred herself to the toilet and should not have had to.

Based on observation, interview, and record review, the facility failed to assess resident surroundings for a safe environment and failed to develop and implement interventions to promote a safe environment for one of three residents (R2) reviewed for accidents in a sample of 12. These failures resulted in R2 sustaining a right shin wound from hitting her right shin on an exposed sharp bolt located on R2's bedframe on two separate occasions 27 days apart. The first occurrence resulted in R2's right shin wound becoming infected, and the second occurrence resulted in R2 requiring an emergency room visit to obtain three staples to close a right shin laceration. Findings include: The facility's Quality Care Reporting policy dated 12-12-23 documents, Policy: (The Facility) works to continuously improve residents care, safety and operations within the facility. A Quality Care Reporting Form will be completed to assist in the Quality Assurance process. Purposes: To help identify problems or potential problems. To act as a record, when analyzed, will prevent similar mishaps or injuries. To improve quality of resident care and overall safety in the facility. Procedure: Charge Nurse will: 1. Complete a Quality Care Reporting Form for happenings out of the ordinary which results in a potential for injury, or actual injury or damage to: resident, visitor, employee or property. Administrator and/or DON (Director of Nursing) will: 1. Review the Quality Care Reporting form for completeness. 2. Investigate all reports upon receipt. 3. Obtain additional information from resident, staff, family, etc. (et cetera) as needed. The following list contains examples of action to be taken: h. Repair or replace equipment. R2's BIMS (Brief Interview Mental Status) dated 12-05-2023 documents R2 is Cognitively Intact. R2's A.I.M (Acute Illness Management) For Wellness Change in Status Record dated 6-22-23 documents R2 had a change in skin integrity/wound appearance. Right lower leg 7.5 cm (centimeter) by 3.5cm unstageable wound. This same form documents R2's comments/response to event was, I ran into my bed with the w/c (wheelchair) a week ago. I thought you knew. The third shift nurse knew. R2's A.I.M (Acute Illness Management) For Wellness Change in Status Record dated 6-22-23 documents R2 had a change in skin integrity/wound appearance. New or worsening pus at wound, skin, or soft tissue noted. R2 may need a prescription for an antibiotic. Event first noted on 6-12-23. Right lower leg 7.5 cm (centimeter) by 3.5cm unstageable wound. This same form documents R2's comments/response to event was, I ran into my bed with the w/c (wheelchair) a week ago. I thought you knew. The third shift nurse knew. R2's Electronic Medical Record did not include any documentation on R2's right shin area from 6-12-23 to 6-22-23. R2's MAR (Medication Administration Record) documents an order dated 6-23-23 for Keflex (antibiotic) 500mg three times a day until 7-7-23 for right leg. R2's Progress Note dated 6-24-23 and signed by V17 (Licensed Practical Nurse/LPN) documents Keflex continues for area on right leg with NAR (No Adverse Reactions) noted. Area remains red and swollen. R2's Progress Note dated 6-24-23 documents Antibiotic continues for cellulitis (infection) to right leg. Area remains red and warm to touch. R2's Physical Therapy and Rehab Specialist Initial Evaluation dated 6-27-23 documents, R2 states she recently ran her wheelchair into the bed and her big toe into the doorframe which has left a hematoma on her right shin and cut on her right big toe. R2's Care Plan 6-22-23 (date of injury) through 7-19-23 does not include an intervention to protect R2 from sustaining further injury from R2's exposed bed frame bolts. R2's Progress Note dated 7-19-23 and signed by V17 (LPN) documents, (R2) was going into her room and hit the edge of her bed causing a 1.5 cm (centimeter) laceration to her RLE (Right Lower Extremity). Resident sent out to local ED (Emergency Department). R2's Local ED Noted dated 7-19-23 documents (R2) to the ED today via EMS (Emergency Medical System) from (the facility) with c/o (complaints of) laceration to right lower leg on shin. Three staples applied by V18 (Local ED Physician). R2's Progress Note dated 7-19-23 and signed by V17 documents, (R2) returned to facility per facility van. Three sutures noted to RLE. Keep wound clean and dry. Put a thin layer of antibiotic ointment. Put ice pack on site if swelling occurs for 20 minutes. (R2) denies any pain or discomfort at this time. On 2-21-24 at 12:27 PM R2 was sitting in her room in her manual wheelchair beside her bed. R2's bed frame had a pool noodles (foam noodles) taped to her bedframe. Foam noodles were loose and sagging leaving R2's bed frame bolts exposed. On 2-26-24 at 10:00 AM R2 was sitting in her room in her manual wheelchair. R2 sitting in between her bed and an empty bed. The empty bed was noted to have two sharp bolts sticking out approximately two inches from the bed frame in close proximity to R2's right leg. On 2-26-24 at 10:05 AM R2 stated, The facility tries to blame everything on my electric wheelchair. I had two injuries because of the bolts located on my bed frame. I told (V1) (AIT/Administrator in Training) the first time about the bolts and they did nothing to fix the issue, just that I need to learn how to drive my electric wheelchair better. The second injury I had to my right shin was because of the same bolts sticking out. (The facility) had maintenance come to my room and pad my bed frame to cover the bolts, but they still won't pad this other bed frame. My room is tiny and it's hard to maneuver between two beds with my wheelchair and bolts sticking out of the frame. R2's right shin had two quarter size deep indentations where her previous injuries had occurred from the R2's bed frame. On 2-26-24 at 12:00 PM V14 (Former Maintenance Director) stated, A few months ago (V1) came and got me and asked me if we had pool noodles to cover up the bolts that were sticking out on (R2's) bed frame. (V1) said (R2) had hit her leg on the bolts before and had just hit her leg [NAME] on the bolts that were sticking out of (R2's) bedframe. (R2) busted her leg open and had to get stitches the second time. The beds at the facility are so old and there are four bolts that stick out approximately two inches from the bed frames. Those bolts were used to attach full side rails back in the day. Full side rails are not used anymore so the bolts just stick out. The facility did not provide me with any tools to cut the bolts off to make the bolts smooth. There are still beds there with exposed bolts. On 2-27-24 at 11:08 AM V17 stated, On 7-19-23 (R2) reported to me that she had hit her right shin on her bedframe. I was in the room but didn't inspect (R2's) bed frame fully. (R2) is alert and is able to tell you exactly what she hit her right shin on. On 2-27-24 at 11:15 AM V1 (AIT) stated there were no interventions developed or implemented to address R2's bed frame after R2 hit her shin on her bed and becoming infected on 6-22-23. R2 hit her shin again on the bed frame on 7-19-23 sustaining a laceration that required sutures.

Based on observation, interview and record review, the facility Administration and Governing Body failed to ensure the facility heating system was in working order after being made aware of significant issues with the heating system in residential areas for (R1, R2, R4, R5, R6, R7, R8 and R9), since November 2022. The facility failed to develop a plan for a cold weather emergency during a weather event where temperatures were negative 7 to 8 degrees and with windchill factor was negative 40 degrees with sustained winds at 31 miles/hour and temperatures in facility resident rooms were 55 to 64 degrees. These failures resulted in residents (R1, R2, R4, R5, R6, R7, R8 and R9) to experience uncomfortable and unsafe ambient air temperatures, which placed them at risk for loss of body heat and risk of hypothermia. R1, R2, R4, R5, R6, R7, R8 and R9 are one of 10 residents reviewed for safe, comfortable heating conditions, in a sample of 10. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 12/23/22 when residents were found to be residing in rooms where ambient temperatures were 63 degrees. On 12/25/22 at 10:45 A.M. V1 (Administrator in Training) was notified of the Immediate Jeopardy. While the immediacy was removed on 12/27/2022, the facility remains out of compliance at a Severity Level Two, as the facility implements the following: continued education of all facility staff on the facility Cold Weather Policy and Evacuation Plan. Every 15-minute ambient room air temperature checks and documentation. Continued monitoring of all residents for safety and comfort level. A review of the facility Heating System and implementation of necessary recommendations by a licensed Heating/Plumbing Company. The development of a facility QAPI plan to address Cold Weather Advisory and facility continued compliance. FINDINGS INCLUDE: The (undated) facility policy, Cold Weather Policy and Procedure directs staff, It is the policy of (Company) to provide continuing, safe and comfortable care to its residents in the event the facility power source becomes non-operational or the facility heating, and furnace systems fail during periods when unseasonably cold outside temperatures are present and such systems are required for resident safety and comfort. If the heating systems fail, facility personnel shall take the following action: Either the Administrator, DON (Director of Nurses) or nurse in charge will coordinate the response. A staff member will be designated to call the local Electric Department to determine the cause of the problem and the duration of the outage. If the problem is determined to be in the facilities own heating systems, the Maintenance Man or the Administrator will determine the appropriate course of action. Staff will be assigned to bring all residents to the central core of the building. Staff will collect all blankets in the facility and distribute extra blankets to all residents as needed. Staff will keep all doors and windows closed to retain as much heat as possible. Staff will be assigned to do 10-minute checks on all residents to determine their safety and comfort level. Staff will be assigned to do 15-minute temperature checks throughout all areas of the building. If the core temperatures of the area occupied by the residents and staff drops below 65 degrees, the facility will immediately implement the evacuation procedures outlined in the Facility disaster Plan. The (State Agency), Physicians, Families and Responsible parties will be notified as required by statue. On 12/23/22 at 3:10 P.M., R3 was seated in wheelchair in the facility B/C Hall Dining Room/Family Room with a coat on, watching the facility television. At that time, the air temperature was recorded as 59 degrees. R3 stated, It's cold in here (facility). It has been since earlier this week, but it's really bad now. Even though it's cold, I watch television out here, so I don't disturb my roommate. On 12/23/22 at 3:20 P.M., R3 was seated in a wheelchair in (Room AAA) resident room, on the facility C-Wing and stated, I know it's cold out there. The bathroom that we have to use, is freezing. It gets cold in this room, too. Only half of my register gets warm. Current air temperature recorded as 68 degrees. R3's roommate (R10) was seated on his bed wearing a hooded sweatshirt, pants, and socks. R10's hooded sweatshirt had the hood pulled up, covering R10's head. R10 had his hands in the pockets of his sweatshirt. At that time R10 stated, I'm freezing. It is so cold in here. On 12/23/22 at 3:21 P.M., the air temperature in the shared C-Hall Bathroom/Shower room was recorded as 67 degrees. On 12/23/22 at 3:25 P.M., the air temperature in facility Main Dining Room was recorded as 68 degrees. At that time, R2 was seated at table in MDR with two shirts on, pants, socks, shoes, and a winter coat. R2's hands were cold to the touch. R2 kept repeating, It's cold. I'm cold. On 12/23/22 at 3:26 P.M., V3 (Maintenance Director) stated, I have been the (facility) Maintenance Director for the past four months. We have been having some problems with cold (resident) rooms and even hallways, since about Monday or Tuesday (December 20, 2022/December 21, 2022). I have spent the night, the past two nights to make sure we don't lose heat altogether. Some of the windows are old and the cold air comes in. I have been putting up plastic on windows to try and cut down on some of that. Some of the PTAC Units (Packaged Terminal Air Conditioners- a type of single unit in a resident room that provides air conditioning or heat) on the Pathways Unit, have blown motors. The Heating and Cooling Company was out here in November and diagnosed the problem. The estimate to replace the units has been sent to the Corporate Maintenance Director (V5). I haven't heard anything more on it. I have been checking the generator periodically, but I haven't kept any records of those checks. I didn't know I needed to. I don't know anything about a Facility Cold Weather policy or what that involves. On 12/23/22 at 3:32 P.M., the air temperature at facility Pathways Hall Nurse's Station was recorded as 68 degrees. On 12/23/22 at 3:35 P.M., the air temperature in (facility) room AAB was currently 71 degrees. R5 was dressed in pants, shirt, coat, socks, and shoes. At that time, R5 stated, It has been so cold in here (facility) for the past three days. My room (Room AAC) was freezing. I just got moved. I was in one of the rooms where the register (heat) didn't work. I finally got moved, but the hallways are still cold. And nobody has had a shower because it's too cold. They need to get this fixed. On 12/23/22 at 3:46 P.M., the Pathways Hall Therapy Room air temperature was recorded as 65 degrees. And at 3:47 P.M., the Pathways Hall Dining Room air temperature was recorded as 64 degrees. On 12/23/22 at 3:48 P.M., the Pathways Hall, Room (AAD) air temperature was recorded as 67 degrees. R4 was seated in wheelchair at the side of the bed with a long-sleeved top, long pants, slippers and a thick coat that was zipped up with the hood pulled up. At that time, R4 stated, It's cold in here. It's been cold for the past few days. The register in my room doesn't work. On 12/23/22 at 3:49 P.M., the Pathways Hall, Room (AAE) air temperature was recorded as 67 degrees. R9 was seated in a wheelchair in the room with a tablet in her hand. R9 was wearing a shirt, pants, winter coat with hood up, shoes and socks . At that time, R9 stated, It's too cold. On 12/23/22 at 3:55 P.M., V1 (Administrator in Training) stated, We knew we were having some heating problems, back in November. We called (heating company) and they came out but said because we have boiler heat that we needed to call (another heating company). The tech (technician) came out some time in November and said the reason those first few rooms (room AAD- room AAF) were so cold is that the heater motors were bad. I don't have a copy of the visit. I forwarded it on to (V5 Corporate Maintenance Director). Evidently, they have been having trouble getting the motors for those units. I have never heard back from them. I think (V5 Corporate Maintenance Director) is taking care of it. It was cold in some of those rooms, and we started moving residents today, to other rooms. (V3 Maintenance Director) has been putting plastic on some of the resident room windows. I don't know if we have a cold weather policy. I will check and see. On 12/23/22 at 4:38 P.M., V4 (Heating Company Technician) stated, I am aware of the situation at (facility) with the PTAC (Packaged Terminal Air and Heating Units) in the resident rooms, back on the south hall (Pathways Hall). They are older and most of them have the motors blown. They won't produce any warm air for those rooms. The boss of the company has been working on trying to locate some used units. We gave the facility an estimate for new units for three rooms. They run around thirty-five hundred dollars each. No one has given us the go ahead to order new ones yet. We were out to the facility in November, I can't remember the exact date. I can get you a copy of the invoice from that visit, but it won't be until Tuesday (December 27, 2022). On 12/23/22 at 4:55 P.M., V1 (Administrator in Training) stated, I guess we do have a cold weather policy. Evidently (V8) sent it out to all of us, earlier this week. I haven't been having my staff do 10-minute checks on residents for safety and comfort, but I can start that. I also haven't been doing 15-minute temperature checks throughout the building. I can start that, too. On 12/23/22 at 5:20 P.M., V8 (Registered Nurse/Regional Corporate Staff) stated, This (facility) does have a Cold Weather policy. I sent them out to all the facilities earlier this week. When the heating system in the facility isn't working properly, staff are to do 10-minute checks on all residents for safety and comfort level and 15-minute temperature checks throughout all areas of the facility. I don't know why this policy wasn't began when we noticed how cold some of the resident rooms were. On 12/23/22 at 5:28 P.M., the Pathways Hall, Room AAF air temperature was recorded as 63 degrees. R6 was seated in an electric wheelchair, in the hallway, outside of room AAF. At that time R6 stated, It's been cold in this building all week. It's miserable. The unit in my room doesn't work. I only go in there to sleep. On 12/24/22 at 7:20 A.M. the air temperature in the B/C Hall Dining Room was recorded as 66 degrees. The air temperature in the facility C Hallway as recorded as 66 degrees. At that time, V9 (Certified Nursing Assistant/CNA) was seated in the B/C Hall Dining Room. V9 (CNA) was dressed in clothing, with a winter coat with the pulled hood up and boots. V9 stated, I worked 12 hours last night, starting at 6:00 P.M. I am waiting for my ride to pick me up. It is cold in here. It has been cold for a few days now. We try and keep the residents as bundled up as we can. We only have so many blankets to give them. We encourage them to stay in bed and eat. On 12/24/22 at 7:25 A.M., the facility thermostat in the Main Dining Room, was set at 73 degrees, and currently registered 68 degrees. The thermostat in the Pathways Hallway, across from the Nurse's Station was set on 79 degrees, and currently registered 68 degrees. On 12/24/22 at 7:28 A.M., the Pathways Hall, Room AAD air temperature was recorded as 67 degrees. R4 was in bed sleeping with multiple blankets on the bed. A portable, electric space heater was running in the room, with the temperature set at 81 degrees. On 12/24/22 at 7:30 A.M., the Pathways Hall, Room AAF air temperature was recorded as 64 degrees. The room PTAC Unit was cold to the touch. R1 was up in a wheelchair in the room. At that time, R1 stated, I am cold. This room is too cold. I would move to a different room, if someone asked me. On 12/24/22 at 7:32 A.M., V6 (Licensed Practical Nurse/LPN) was taking air temperatures with a gray/orange inferred thermometer on the Pathways Hall. At that time, V6 stated, I have been told to use this thermometer to check random room temperatures every 15 minutes and write them on this log. This is the first time I have done this. I don't know if I'm supposed to call (V1 AIT) with the results or not. I was just told to log them. At that time a review of the facility Room Temp (temperature) Log, dated 12/23/22 beginning at 6:00 P.M. documents that at 10:00 P.M. on 12/23/22 the air temperature in the Pathways Hall, Room AAD as 60.8 degrees. At 10:15 on the same date, the air temperature of the Pathways Hall, Room AAF was recorded as 55.4 degrees. Both of these temperatures were obtained by a staff member. This same staff member recorded the air temperature on 12/24/22 at 3:15 A.M. on the Pathways Hall, Room AAG as 61.4 degrees; at 4:00 A.M. on the Pathways Hall, Room AAF as 63.7 degrees and on 12/24/22 at 4:30 A.M. on the Pathways, room AAF as 63.8 degrees. These recorded temperatures were verified with V6. On 12/24/22 at 7:33 A.M., the Pathways Hall, Room AAH air temperature was recorded as 64 degrees. On 12/24/22 at 7:55 A.M., V1 (Administrator in Training) was reviewing the Pathways Hall Room Temperature Log and was observed with an ink pen, writing on the document. AT 7:58 A.M., V1 left the Pathways Hall. A review of the Pathways Room Temperature Log, at that time with V6 (LPN) present, documents the recorded temperatures on 12/23/22 at 10:00 P.M. and 10:15 A.M. were changed to 68.8 degrees and 65.4 degrees, respectively. The recorded air temperatures for 12/24/22 at 3:15 A.M. had been changed to 68.4 degrees, the 4:00 A.M. air temperature was changed to 68.7 degrees and the 4:30 A.M. recorded air temperature had been changed to 68.8 degrees. At that time V6 stated the Pathways Room Temperature Log had been in her possession from 6:00 A.M., until V1 (AIT) took possession of the document at 7:55 A.M., while V6 was present. V6 denied changing the recorded temperatures on the Pathways Hall Room Temperature Log. On 12/24/22 at 8:30 A.M., V7 (CNA) verified she had taken air temperatures for the facility Pathways Hall rooms on 12/23/22 at 10:00 A.M. and 10:15 A.M. and on 12/24/22 at 3:15 A.M., 4:00 A.M. and 4:30 A.M. and the current air temperature recordings had been changed to reflect warmer temperatures. V7 states, It was 55 degrees at 10:15 (P.M.) in room AAF. I reported it to the nurse. You can see where someone changed the temperatures on the log. On 12/24/22 at 8:45 A.M., V1 (Administrator In Training) stated, I was called three times in the night, last night, for different things. I don't remember if I was notified of fifty-five-degree air temperatures in a resident's room. I looked at the Pathways Room Temperature Log this morning. We are planning to move (R1 and R4) today. Their rooms are too cold. We moved (R9) yesterday. On 12/28/22 a letter to the facility from the (local HVAC) company documents, In reference to the service call we were called out on to (facility), on 11/18/2022, we have not invoiced the job yet but offer the following information. #1. The original call was for a boiler problem. I don't know if this was just a miscommunication, or what, but it wasn't the boiler. What we found was some PTAC units were not heating properly. #2. We pulled the blower motor from the unit in the dining room, with the intentions of either getting replacement motors. The local repair shop told us that they could not find a replacement motor, and the one we had could not be repaired. We suggested to the maintenance man at the time that we could take some of the motors out of PTACS that were working in some of the nonresident areas and put them in rooms that were occupied by residents. We were told that this work was going to be put out to bid, which suggested to us that this wasn't an emergency in their minds. #3. In the meantime, we have been trying to find a replacement unit that would fit the openings of the existing PTAC units. We did find a vendor in Tennessee that quoted us a unit that appeared as though it would fit the wall sleeve of the existing PTACS. Our superintended went to the job site on 12/27/2022 to discuss the matter further with the maintenance man and found another contractor on site working on the units, so we are no longer involved with the situation. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: * All facility staff in-serviced on the facility Cold Weather Policy on 12/23/22, 12/24/22 and on 12/25/22. by Administrator. * All facility staff in-serviced on the Facility Evacuation Plan on 12/23/22, 12/24/22 and on 12/25/22 by Administrator. * Ambient room temperature checks will be initiated on 12/23/22 every 15 minutes throughout the facility and recorded by assigned facility staff. * The facility B/C Hall Dining Room will be temporarily closed due to ambient room temperatures and all residents seating arrangements for dining and Activities will be moved to the facility Main Dining Room. * Rooms AAD-AAF, on the facility Pathways Hall were taken out of operation on 12/24/22 until a review of the facility heating system by a licensed Heating/Plumbing Company and implementation of necessary recommendations. * Residents who were residing in rooms AAD-AAF were relocated to appropriate rooms on 12/23/22 and 12/24/22. * A review of the facility Emergency Preparedness Plan and Tabletop Discussion on Cold Weather Policy and Evacuation Plan was performed on 12/23/22 with the Regional Clinical Director and facility IDT. * Residents are continually being monitored by IDT and Staff throughout 12/23/22 and 12/24/22. * The facility Governing Body was notified of the facility concerns on 12/23/22 by Administrator. * On 12/27/22 Licensed Heating/Plumbing Company did a review of the facility heating system. * On 12/27/22 Necessary parts needed for Rooms AAI, AAJ, and AAF are being ordered. AAI, AAJ, and AAF will remain out of operation until said parts are delivered, installed, and in working order. * Residents returned to rooms AAD, AAE, and AAC on 12/28/2022. * Ambient room temperatures on affected rooms to continue x 3 days to assure adjustments made maintain, and then IDT to monitor during facility daily rounds for a week to be completed by assigned staff member. *In servicing of nursing staff to notify Administrator immediately if room temperatures thought to be at a less than desired temperature on 12/28/2022 by Administrator.

Based on observation, interview and record review the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure infection control practices were implemented during care for 1 of 7 residents (R7) reviewed for pressure ulcers in a sample of 21. This failure resulted in R41 acquiring multiple stage 2 pressure ulcers. Findings include: The facility's Decubitus Care/Pressure Areas policy, revised 1/18, documents that it is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. The pressure ulcer area will be assessed and documented on the TAR (Treatment Administration Record) or the Wound Documentation Record. Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the Physician). Notify the Physician for treatment orders. Documentation, of the pressure area must occur upon identification and at least once each week on the TAR or Wound Documentation Form. 1. R41's TAR, dated 3/1/21 through 3/31/21, documents to cleanse R41's coccyx with normal saline, pat dry, apply duoderm (hydrocolloid dressing), and change every 3 days, as a preventative treatment. R41's Braden Scale for Predicting Pressure Ulcer Risk, dated 3/18/21, documents that R41 is high risk for pressure ulcers. On 3/30/21 at 11:40 am, R41 was assisted to the bathroom by V8 CNA (Certified Nursing Assistant) and V6 CNA. At this time, V6 and V8 verified that R41 did not have a dressing on his coccyx. R41's wound on his coccyx had an open area 2 cm (centimeters) by 1 cm. The center of the wound was yellowish in color and the surrounding tissue was red and inflamed. V6 stated that she was going to tell V5 LPN (Licensed Practical Nurse) that R41's dressing was off his coccyx. On 3/30/21 at 12:40 pm, V5 LPN stated that she was not told that R41 had an open area on his coccyx or needed a new dressing. On 3/30/21 at 1:00 pm, R41 stated that no one had been in to apply a dressing to his coccyx. On 3/31/21 at 10:00 am V1 Administrator stated that R41 does not have an open area to the coccyx, and the dressing is in place as preventative measure. V1 verified that she was not notified of R41's open area on 3/30/21. 03/31/21 10:30 am, V11 RN (Registered Nurse) stated that R41 does not have any measurement for a wound because the treatment was supposed to be preventive. V11 RN stated that the facility was not aware that R41's wound was open. V11 RN and V12 LPN assisted R41 back to bed. R41 did not have a preventative dressing on his coccyx at that time. R41 stated that he has not had a dressing on his coccyx for a few days. V11 RN verified that R41's dressing was not in place, and that R41 now had 6 separate pressure ulcers on his coccyx in a crescent shape. V11 RN measured the six areas, the top number one wound measured 2.1cm by 1.5cm, the second measured 0.8cm by 0.4cm, the third measured 1 cm by 1.2 cm, the fourth measured 1 cm by 1 cm, the fifth measured 0.9 cm by 0.5 cm and the sixth measured 1 cm by 0.8cm. V11 RN stated that the first and third wounds have slough in the center and the surrounding tissue is red and inflamed. V11 RN stated that R41's Physician had not been notified. 2. R7's current TAR documents to cleanse the coccyx with wound cleanser, pat dry, apply hydrogel (medicated cream) and cover with a dry dressing daily and as needed. R7's current care plan documents that R7 is to be turned and repositioned every hour. R7's Braden Scale for Predicting Pressure Ulcer Risk documents that R7 is at high risk for pressure ulcers. On 3/29/21 at 10:00 am, R7 was lying in bed on her right side facing the wall. At 10:30 am, R7 remained facing the wall, and at 11:00 am R7 remained in the same position on R7's right side. On 3/30/21 at 7:30 am, R7 was in bed lying on her right side, facing the wall. From 7:30 am to 11:45 am, R7 remained in the same position. On 3/31/21 from 7:30 am to 11:00 am, R7 was in bed on her right side facing the wall. On 03/30/21 11:50 am, V9 CNA removed R7's soiled dressing from the coccyx. V9 CNA cleansed the wound with a clean washcloth then cleansed the feces and moved the contaminated washcloth with the feces into R7's open wound. R7's wound measured 2.0 cm by 2.2 cm round, center was yellowish and surrounding tissue was fiery red. V9 CNA verified that she should not have touched the open wound with the washcloth contaminated with feces. V9 CNA and V6 CNAs stated that R7 is turned and repositioned every two hours. Both V9 CNA and V6 CNA stated that they were not aware that R7 was supposed to be repositioned every hour. On 3/30/21, V5 LPN verified that V9 CNA should not have moved the washcloth containing feces into R7's wound during incontinence care. 3. R17's Weekly Wound tracking, dated 3/2021, documents that R17 has a Stage II pressure ulcer to R17's left ischium that measures 1.5 cm (centimeters) x 0.1 cm x 0.3 cm, and a Stage II pressure ulcer on R17's coccyx that measures 0.1 cm x 0.1 cm x 0.2 cm. R17's Wound Care Provider Orders, dated 3/19/21, document the following orders: [MEDICATION(S)] 2% topical gel applied to wound 10 minutes prior to procedure. Left ischium collagen double layered and covered with a [MEDICATION(S)] (silicone border foam) dressing changed daily. Coccyx apply hydrogel and cover with a [MEDICATION(S)] silicone border foam dressing daily. On 03/30/21 at 09:08 am, V4 LPN removed a silicone border foam dressing from R17's left ischium and a border gauze dressing from R17's coccyx. R17's left ischium had round open area with depth. V4 LPN cleansed the area with normal saline, folded a piece of collagen and packed into wound. R17 said Ouch while V4 LPN was packing the wound. R17's coccyx had a small irregular shape open area covered in white tissue. V4 LPN cleansed R17's coccyx with normal saline, applied hydrogel to the wound bed, and covered both wounds with a silicone border foam dressing. Barrier cream applied to reddened peri wound areas. V4 LPN stated the reddened areas are irritation related to the use of regular gauze tape. No [MEDICATION(S)] was applied to R17's wound prior to wound care. On 03/30/21 at 09:24 am, V4 LPN stated, I removed a border gauze dressing from R17's coccyx, and it should have been a silicone border foam dressing. R17 is supposed to have [MEDICATION(S)] applied to the areas prior to wound care and I did not do that. On 03/30/21 at 09:33 am, R17 stated, Both of my wounds are in bad places, right on a bony spot. It's sore because of that and hard to heal. I'm supposed to get [MEDICATION(S)] before they do the treatments. When I said ouch, it was a sharp stabbing pain when she packed it with that stuff. The treatment isn't comfortable.

Based on observation, interview and record review, the facility failed to provide justification for the use of antipsychotic medication above the daily recommended dosage for R4, R5(two of 3 residents on the selected sample receiving antipsychotic medication out of a total sample of fifteen) and failed to reduce or discontinue the antipsychotic in the presence of abnormal involuntary movements for R5 and increased sedation for R4. R5 has developed abnormal involuntary movements of the face, upper extremities, and trunk. Findings Include: 1) R5's physicians' orders dated 6/1/11 - 6/30/11 indicate R5 was admitted to this facility on 7/17/08. The Behavioral Health Consultation from the hospital dated 7/13/08 documents that R5 was seen on this date by a Psychiatrist for symptoms of depression and was diagnosed with [REDACTED]. R5 was ordered [MEDICATION NAME] 40 mg (milligrams) daily, [MEDICATION NAME] 10 mg daily, and [MEDICATION NAME] 1 mg three times a day. The physician's orders [REDACTED]. daily for depression and [MEDICATION NAME] 2 mg twice a day for [MEDICAL CONDITION]. There is nothing in the record that supports a [DIAGNOSES REDACTED]. The Minimum Data Sets dated 11/5/10 and 1/27/11 document that R5's cognition is severely impaired, all Activities of Daily Living is preformed by staff, and R5 requires being fed by staff. On 6/8/11 at 10:30 AM Z1(family member) verified that R5 was never diagnosed with [REDACTED]. Z1 stated that after R5 had her [MEDICAL CONDITION], she became increasing more depressed and expressed thoughts of suicide and was treated for [REDACTED]. The Abnormal Involuntary Movement Scale documents no abnormal involuntary movements from 8/16/10 through 4/19/11. On 6/6/11 through 6/9/11, R5 was at the noon meal each day with abnormal movements of the mouth, trunk, arms, and hands. On these dates, R5 was in bed asleep from 8:30 AM until lunch and then back in bed asleep right after lunch at approximately 12:30 PM until 3:30pm. the one exception was on 6/8/11 in the morning when R5 was in the beauty shop having her hair done. On 6/9/11 at 8:30 AM, E2 (Director of Nurses) stated that on 6/8/11, an abnormal involuntary movement assessment was done and scored with abnormal involuntary movements of the facial and oral movements, extremity movements, and trunk movements. On 6/9/11 at 10:30 AM, E3 (Minimum Data Set Coordinator) stated that E3 assessed R5 on 6/8/11 at the request of E2 and found abnormal involuntary movements of face, arms, hands, and trunk. E3 stated that when R5 becomes anxious the movements are more pronounced especially her hand and arms. E3 stated that they have never tried any scheduled pain medication because they don't notice any pain symptoms. The Behavior Monitoring Records for April and May 2011 document that R5's behaviors for the use of antipsychotic medications is yelling out, yelling at other residents/cursing. It was documented that R5 yelled out two times in April and 4 times in May at meal time. The Drug Information Handbook for Nursing 2007 in the Appendix/OBRA Guidelines for Long-Term Care dosing guidelines document that the daily dosage of [MEDICATION NAME] should be equal or less than 2 mg daily, unless documentation exists to support the need for higher doses to maintain or improve functional status. R5 is receiving 4 mg daily with no documentation to justify the need for this high dosage. 2) The physician's orders [REDACTED]. R4 is receiving [MEDICATION NAME] XR (an antipsychotic medication) 150 mg (milligrams) daily since 12/16/10, [MEDICATION NAME] 20 mg (antidepressant) since 12/1/10, Klonopin 1 (antianxiety) twice a day since 12/30/10, [MEDICATION NAME] 150 mg twice a day since 12/22/10 (anticonvulsant used to treat agitation), and [MEDICATION NAME] ER(antidepressant) since 5/11/11. The Behavior Sheets document that R4's behaviors being monitored for the use of these medications are sad, pained, worried facial expression and crying. The behavior monitoring record for April documents no behaviors and one behavior in May of crying. On 6/6/11 through 6/9/11, R4 was from 8:30 Am through 11:30 AM asleep in bed and from 12:30 PM through 3:30 PM asleep in bed. On these same dates, R4 was sitting in main dining room with eyes closed during lunch being fed by staff and was slow to respond when spoken to by staff. R4 was not crying. R4's affect was flat, no facial expression at all. The Drug Information Handbook for Nursing 2007 documents that the adverse side effects of the antipsychotic, antianxiety and antidepressants that R4 is receiving on a daily basis are: somnolence, agitation, dizziness, [MEDICAL CONDITION], lethargy and weight gain/loss. The daily dosage of [MEDICATION NAME] should be equal to or less that 100 mg a day unless documentation exists to support the need for higher doses to maintain or improve functional status.