Every finding on record at Avira Health Pavilion

Based on interview and record review the facility failed to ensure a residents authorized representative was provided medical information upon request. This applies to 1 of 7 (R1) residents reviewed for resident rights in the sample of 7. Findings include: R1's face sheet shows V8 (R1's daughter) listed as an emergency contact with special instructions that R1 gave permission for V7 to have any/all information including medications, labs and ETC. On 8/14/26 at 10:22 AM, V1 (Administrator) said R1's family member complained about V4 (Former LPN) for not releasing medical information to an authorized family member. She was not the staff who followed up on the concern but said it was resolved. V1 said V4 was terminated yesterday (8/13/26) after another complaint was made, she was not a good fit for us. On 8/14/26 at 10:48 AM, V3 (Social Services) said V8 (R1's daughter) reported a complaint about V4. V4 would not release R1's medical information to her even though she was listed as an authorized person to receive medical information. It was indicated on her chart she (V8) could have the information. She said she told V4 there was a note in R1's chart that V8 was authorized to receive medical information, but she did not get a response from V4 and did not follow up. I don't know who followed up. On 8/14/26 at 11:38 AM, V2 (DON) said V8 reported to her V4 was not releasing medical information to her. The POA listed or any authorized person listed on the residents medical chart should receive release of medical information if requested. The facility's Protected Health Information (PHI), Management and Protection of Policy states, (PHI) shall not be used or disclosed except as permitted by current federal and state laws. A person acing in the role of representative must be treated as the individual access to relevant PHI.

Based on observation and interview, the facility failed to ensure residents were treated with respect and dignity. This applies to 2 of 7 residents (R1, R6) reviewed for resident rights in the sample of 7. The findings include: On 8/14/26 at 10:22 AM, V1 (Administrator) stated, the facility had received a couple of complaints about V4 (Former LPN). V1 stated, R1's family complained about V4's attitude and R6 made a complaint about her being rude. V4 was terminated on 8/13/26, She was not a good fit for us. On 8/14/26 at 10:48 AM, V3 (Social Services) said she received a complaint from V8 (R1's daughter) that V4 was rude and would not release medical information to her even though she was listed as authorized representative. On 8/14/26 at 11:38 AM, V2 (DON) stated, on 8/13/26, R6 reported V4 was rude to him. V2 stated, she spoke with V4, who reported having personal issues going on, and V2 instructed V4 to go home. V2 stated, V4 was terminated on 8/13/26, Her personality was not fitting. V2 added there were prior reports from co-workers that V4 had shown attitudes towards staff but V2 had not observed V4 being rude towards residents or families until the recent reports. V2 stated, residents should be treated with respect and staff should leave their personal issues at home. On 8/14/26 at 1:05 PM, R6 was in his room with external leg fixator on his left leg. R7 said on 8/13/26, he reported V4 was rude and had an attitude with him. R6 said he reported the incident to V2 (DON) and it was taken care of.

Based on observation, interview, and record review the facility failed to maintain a resident's sink in a safe, functional manner for 1 of 3 residents (R1) in the sample of 3.The findings include:On 3/17/26 at 8:50 AM, R1 was sitting up in her wheelchair. The surveyor asked R1 if she had access to warm water in her sink. R1 stated, Why don't you go check the sink? The surveyor entered R1's bathroom and the hot water knob appeared loose. When the surveyor attempted to turn on the hot water, the knob fell off the sink and onto the floor. The resident laughed and said, You see what I'm talking about. It's been broken since I got here. I can get warm water if I mess with it. It's annoying for sure. I'd think they would have fixed it by now. When I first came, I had a roommate and she said it was broken before that, but I don't know how long. R1 said she didn't recall maintenance coming in to fix it. R1 said the Certified Nursing Assistants (CNAs) knew it was broken.R1's Face Sheet dated 3/17/26 showed she was admitted to the facility on [DATE] and had diagnoses to include, but not limited to disorder of the muscles, difficulty walking, reduced mobility, osteoporosis, open wound of abdominal wall, thrombocytopenia, PVD (peripheral vascular disease), hypothyroidism, and hypertension.R1's facility assessment dated [DATE] showed she was cognitively intact.On 3/17/26 at 10:54 AM, V7 (Maintenance Director) entered R1's bathroom with the surveyor to check water temperatures. V7 reached for the hot water knob to turn on the water and the entire knob moved. V7 was able to hold down firmly and get the warm water to turn on. The surveyor asked if the knob was broken and was able to lift the entire knob off the hot water side. V7 replied, Yea, I glued it, and it must have come off. It (the knob) shouldn't come off like that. I guess I'll need to replace it. I don't think they make those sinks anymore, so we will need to find a whole new sink. It would be best to replace the entire sink, but I have to get approvals for that. V7 said he told V1 he needed a new sink but didn't know what the purchasing process was.On 3/17/26 at 2:36 PM, V1 (Administrator) said the knob on a resident's sink should be intact so it functions properly. V1 said she didn't know that R1's sink was broken. V1 said R1's sink can be fixed, but she would need to look into it. V1 said V7 (Maintenance Director) had mentioned it needed a new sink. V1 said now it makes sense why. V1 said the sink should be replaced and in proper working order for R1.The facility's Preventative Maintenance & Inspections Policy dated 3/26 showed in order to provide a safe environment for residents, employees and visitors, a preventative maintenance program has been implemented to promote the maintenance of equipment in a state of good repair and condition. This policy showed Preventative Maintenance (PM) is the care and servicing by personnel for the purpose of maintaining equipment and facilities in a satisfactory operating condition by providing for systemic inspection, detection and correction of incipient failures either before they occur or before they develop into major defects. Maintenance includes tests, measurements, adjustments and part replacement that is performed specifically to prevent faults from occurring. This showed replacement and/or repair of all furnishings and equipment is completed as soon as possible.

Based on observation, interview, and record review, the facility failed to adequately store food items by not properly labeling and/or dating items; and failed to ensure the sanitizing solution was at the recommended level. This failure has the potential to affect all 29 residents currently residing in facility.Findings include:On 07/22/2025, upon entering facility, V1 (Administrator) indicated resident in-house census of 29. Facility provided a completed CMS 802 form that indicated resident census of 29.On 07/22/2025 at 10:40 AM, initiated kitchen tour with V4 (Food Service Director) with the following observations. At 10:51 AM, red sanitation bucket near the three compartment sink was tested by V4 (Food Service Director) and test strip read 150 ppm (parts per million). V4 indicated that the sanitizer level should be at 200 ppm. V4 added that staff have been using this same sanitizing solution all morning. At 11:40 AM, observed in storage refrigerator, a jar of marble glaze and minced garlic both opened and undated, and both visibly used. At 11:43 AM, observed in storage freezer an undated bag of fish filets that was not properly closed with visible ice crystals on several filets. V5 said food items should be labeled with an open and discard date. On 07/24/2025 at 1:56 PM V3 (Infection Preventionist) said the red bucket sanitation solution should be at the recommended levels to kill any bacteria. Undated Labeling and Dating Foods policy reads in part: to decrease the risk of food borne illness and to provide the highest quality, food is labeled with the date received, the date opened and the date by which the item should be discarded.Undated Sanitation Buckets/Wiping Cloths Policy reads in part: in the red sanitation bucket mix the water and the chemical sanitizer. The most common chemical sanitizers include but not limited to quaternary ammonia. Sanitizing of food contact surfaces and equipment is accomplished according to the following.quaternary 200-400 per manufacturer's directions.

Based on observation, interview, and record review the facility failed to ensure residents were able to operate their televisions for 2 of 2 residents (R31 & R8) reviewed for choices in the sample of 14. The findings include:1. On 7/23/25 at 8:17 AM, R31 was sitting in a wheelchair in the dining room at the table. R31's right lower extremity was elevated up on a footrest with an elastic wrap around her leg. R31 had a wound vacuum in place and a device to provide cold therapy to her knee. R31 stated she was admitted to the facility a few days ago and her television (TV) did not work; it would not turn on with her remote. R31 stated someone came in, got up on a ladder, and pushed the button on the tv to turn it on. She stated after that the TV remained on; it couldn't be turned off, changed, or the volume controlled. R31 stated told staff about it. She said she hasn't been able to sleep because the TV stayed on. At 8:20 AM the surveyor went to the resident's room with her permission. There were two remote controls sitting on her bedside table and neither one would control the TV; the TV was on in her room. On 7/23/25 at 8:22 AM, V11 Maintenance Director was asked if he knew anything about R31's TV/remotes. V11 stated the remote just needed to be programmed. V11 stated staff know how to get the TV's working and they should have let him know the remote wasn't working. On 7/23/25 at 8:25 AM, V2 Director of Nursing (DON) stated she got a text this morning that R31 was really complaining about her TV last night and it is staying on. R31 stated she couldn't sleep. V2 stated the patient needs their sleep. V2 stated normally residents complain about their TV's not coming on. The Face Sheet dated 7/24/25 for R1 showed she was admitted on [DATE] with diagnoses including aftercare following joint replacement surgery, hypothyroidism, type 2 diabetes mellitus, hyperlipidemia, hypertension, depression, atherosclerotic heart disease, chronic kidney disease, presence of right artificial knee joint, infection, and inflammatory reaction due to internal right knee prosthesis. The Care Plan dated 7/21/25 for R31 showed, I am a new resident at this facility for short term rehabilitation. My leisure interests include watching TV, being with family, going outside, and music. My focus is therapy so I can go back home. I have a potential for falls and injury from falls related to deconditioning. The facility's Notice of Resident Rights and Responsibilities policy (2/1/25) showed the facility shall inform the resident both orally and in writing of his or her rights as a resident, and the rules and regulations governing the resident's conduct and responsibilities during his or her stay in the facility. The policy did not show anything related to resident choices. The facility did not have a resident choices policy. 2. On 7/23/25 at 8:29 AM, R8 stated that her remote for her television (tv) has been missing since yesterday. R8 stated before her remote came up missing it worked just fine. R8 stated she always kept it on her over the bed table. R8 told someone about it yesterday but they were busy, and no one located her remote. R8 stated she likes to watch tv, so she doesn't get bored; it keeps her mind off things. R8 said she noticed her remote was gone around lunch time on 7/22/25 and it is still missing. At 8:38 AM, V11 Maintenance Director came stated the extra remote in R31's room was the remote for R8's television. The Face Sheet dated 7/24/25 for R8 showed diagnoses including unspecified cord compression, muscle weakness, difficulty walking, gastro-esophageal reflux disease, hyperlipidemia, intervertebral disc disorder, spinal stenosis, spondylosis with myelopathy, and anterior spinal artery compression syndromes of the thoracic region. The Minimum Data Set, dated [DATE] for R8 showed no cognitive impairment; partial/moderate assistance for bed mobility, sit to stand, chair/bed transfer, toilet transfer, and walking 10 feet. The Care Plan dated 7/11/25 for R8 showed, I am a new resident to this facility for short term rehabilitation. My leisure interests include talking to my family when they come to visit, watching movies on TV, reading magazines my family bring in, talking to others about my horses I own. Continue to Assess and explore my leisure preference with me and/or my family. Remind me that independent activities are always available such as crosswords, television, games, puzzles, magazines, and books, etc.

Based on observation, interview and record review the facility failed to ensure infection control was maintained and prevent any cross contamination during wound care for 1 of 1 residents reviewed for wounds in the sample of 14. Findings include:On 7/23/25 at 7:56 AM, V10 Licensed Practical Nurse (LPN) went into R38's room to provide wound care to his right elbow and right knee. V10 put gloves on, removed normal saline and triple antibiotic ointment from the treatment cart and placed it on a small disposable tray next to some gauze. V10 changed her gloves, took the tray into the resident's room, and sat it on the over the bed tray table next to R38. V10 opened a small pink saline tube and squirted it onto the gauze and then cleaned off scabs and abrasion to his right elbow. V10 used the second pink tube of saline and squirted it over his right elbow. V2 Director of Nursing (DON) walked into the room. V10 put antibiotic ointment on her gloved finger and applied it to the scabs and abrasion on R38's right elbow. V10 removed her gloves, left the room to get more saline tubes. V2 went out into the hall just prior to the nurse leaving the room and spoke with the nurse when she exited the room. V10 grabbed more saline tubes, and a cotton tipped applicator. V10 put gloves on and placed the cotton tipped applicator on the bedside table and not on the disposable tray taken in for wound care. R38 lifted his right pant leg up and had scabbed area to his right knee. V10 cleaned the area with saline. V10 removed her gloves, put new gloves on, and grabbed the cotton tipped applicator from the bedside table V10 put antibiotic ointment on the cotton tipped applicator and applied it to his right knee. V10 removed her gloves. V10 stated V2 told her when she left the room to use a cotton tipped applicator to apply the antibiotic ointment because she had used her finger before to put it on and it is important to keep it sterile. On 7/23/25 at 8:02 AM, V2 DON stated she talked to V10 LPN because she didn't change her gloves after cleaning the area and before putting the ointment on. V10 also applied the ointment with her fingers. This is for infection control. V2 stated she expects gloves to be changed and cotton tipped applicators to be used. The Face Sheet dated 7/24/25 for R38 showed diagnoses including right pubic fracture, muscle weakness, difficulty walking, unsteadiness on feet, lack of coordination, depression, hypothyroidism, hypertension, congestive heart failure, chronic respiratory failure with hypoxia, chronic kidney disease, and unspecified open wound of the right elbow. The Physician Order Summary Report dated 7/24/25 for R38 showed, right elbow and bilateral lower extremity abrasions, clean with normal saline and apply triple antibiotic ointment daily. Every day for wound care. On 7/24/25 the facility presented some policies from the facility's Infection Control Policy and Procedure manual (2012) such as Employee Training on Infection Control which showed the facility shall provide staff with appropriate information and instruction about infection control through various means, including initial orientation and ongoing training programs. Policies and Practices - Infection Control - the facility's infection control policies and practices are intended to facilitate a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The facility did not provide a policy regarding general wound care. The facility provided a policy for Dry/Clean Dressings and Soiled/Contaminated Dressings; neither policy related to wound care and infection control practices without a dressing.

Based on interview and record review the facility failed to accommodate residents' food preferences and choices for 4 of 6 residents (R2, R3, R5, R6) reviewed for residents' food preferences and choices in the sample of 6. The findings include: The facility's daily menus dated 6/11/25-6/24/25 showed primarily cold foods and/or room-temp foods, such as cold cereal, canned fruit, deli meat sandwiches, potato chips, salads, ice cream, and pudding, were listed as the available food items on the menus. A limited selection of hot foods were listed as menu choices which included scrambled eggs, oatmeal, hamburgers, mashed potatoes, and grilled cheese sandwiches. The menus showed, Due to complication in the kitchen we will be in emergency mode until further notice we do apologize for the inconvenience. On 6/26/25 at 8:59 AM, V3 (Registered Dietician) stated on 6/11/25, the facility began serving primarily cold foods, including sandwiches, salads, and fruit to residents at meals because the dumbwaiter (elevator that carries food from the kitchen to the facility's dining room) had broken. V3 stated the facility was concerned about the safety of their kitchen staff if they required the kitchen staff to carry hot meals/dishes up the stairs from the kitchen to the facility's dining room, while the dumbwaiter was broken. V3 stated that due to this potential safety concern for their kitchen staff, they initiated an emergency cold food plan to serve primarily cold foods to the residents until the dumbwaiter was fixed. However, due to resident complaints related to the cold food menu/service, the facility resumed their regular hot food menu on 6/25/25. V3 stated, The dumbwaiter is still broken but we went back to serving hot foods yesterday because so many residents complained about the cold food. People said they were tired of getting bread and sandwiches. I was here when the dumbwaiter went down and did approve the emergency cold food menus. We did offer some hot foods during that time such as oatmeal and instant mashed potatoes . On 6/26/25 at 8:48 AM. R2 was asked about the foods served to her last week in the facility. R2 stated, I ate a lot of turkey sandwiches, tuna, and chicken salad. They said no hot foods because a lift was down. That's not what I wanted to eat. Last Friday night, I was served 10 pieces of watermelon, cottage cheese, and pudding. I couldn't eat that. I sent my boyfriend to go get me food. On 6/26/25 at 8:40 AM, R3 stated last week he was served all cold foods. R3 stated, I ate what they brought but it was mostly sandwiches. We kept getting the same foods over and over. I understand getting cold foods for a couple of days, but it went on far too long. A couple of days ago, I said I wasn't going to eat that stuff anymore. I had my son bring me food. On 6/26/25 at 8:26 AM, R5 stated they told us the waiter was down and they couldn't bring up hot foods from the kitchen. R5 stated, I'm a meat and potatoes guy. A couple of days of sandwiches I can understand but not a whole week. On 6/26/25 at 11:44 AM, R6 was asked about the foods served to him last week in the facility. R6 stated, I couldn't eat anymore sandwiches or oatmeal. Every day it was a sandwich for lunch and dinner. One night they tried to serve me a tray of fruit and cottage cheese. I prefer hot foods for at least one meal. I spent most of the week having food brought in by my daughter or ordering out. A facility Complaint/Grievance Report dated 6/24/25 showed a complaint from R3 and his family in regard to foods served while the facility's emergency cold food plan was in place. The facility's Therapeutic Diets Client's Right to Choose policy (dated 2021) showed, Client's right to be served food they choose and prefer will be honored.

Based on observation, interview, and record review the facility failed to ensure the breakfast meal was a smooth pureed consistency for 1 of 1 residents (R1) reviewed for pureed diets in the sample of 6. The findings include: R1's Swallow Screening Note dated 5/13/25 showed R1 had diagnoses of dementia and an unspecified muscle disorder. The note showed during the swallow evaluation, R1 remained inconsistent in his ability to swallow and adequately clear (food) bolus, resulting in expectorating (coughing up) bites . It is recommended that the patient's diet be downgraded to a pureed consistency for safety and improved nutritional intake. R1's Dietary Note date 5/23/25 showed R1 was evaluated by V3 Registered Dietician for weight loss. The note showed R1's diet had been downgraded to a pureed consistency for safety. On 6/26/25 at 8:00 AM, V5 [NAME] plated R1's breakfast tray. At 8:01 AM, R1 was served breakfast which included scrambled eggs, pureed sausage, applesauce, and oatmeal. Clumps of eggs were noted in the scrambled eggs. Clumps of oatmeal were noted in the oatmeal. R1 picked up his fork and began eating his eggs. R1 appeared to be chewing his eggs. When R1 was asked if he needed to chew his food, R1 stated, Yes, I have to chew it. What else would I do? At 8:05 AM, V5 [NAME] walked over to R1's table and was shown the clumps of food in R1's eggs and oatmeal. V5 stated, I see the clumps in his eggs. I did blend them when I made them, but they got clumpy on the steam table. I want my purees with no clumps in them. I should not have served his eggs. I should have blended them with milk to smooth them out. V5 stated she also saw clumps in R1's oatmeal but stated, I don't puree his oatmeal because he won't eat it if I do. On 6/26/25 at 8:59 AM, V3 Registered Dietician stated the consistency of pureed foods should be silky smooth with no clumps. V3 stated residents should not have to chew pureed foods. The facility's Guidelines for Pureed Preparation policy (dated 2021) showed, The pureed diet provides food with a semi-liquid to semi-solid consistency (i.e. pudding-like) . If the pureed food appears to be thick you may add more liquid or if it appears thin you may add more thickener until desired consistency is achieved .

Based on observation, interview, and record review the facility failed to have a full time Activity Director. This applies to all 32 residents in the facility. The findings include: The Facility census sheet dated 03/30/2025 at 11:59PM, shows, 32 residents in the facility. On 03/31/2025 at 11:25AM, V1 Administrator said, We do not have an Activity Director. On 03/31/2025 at 2:00PM, V2 DON-Director of Nursing said, We do not have an activity calendar for March (2025). The facility's Activity Programs policy revised June 2018 shows, Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board.

Based on observation, interview, and record review the facility failed to provide an activity program to meet the individual interests of the residents for 5 or 5 residents (R4, R5,R6,R8,R9) reviewed for activities in the sample of 9. The findings include: On 03/31/2025 at 9:09AM, R4 way lying in bed and R5 was sitting in a reclining chair. R4 and R5 did not have an activity calendar in their room. At 9:18AM, R6 was in an isolation room, alone, sitting in a reclining chair. R6 did not have an activity calendar in her room. At 9:40AM, R8 was lying in bed. R8 did not have an activity calendar in her room. At 9:55AM, R9 was sitting in a wheelchair in her room. R9 did not have an activity calendar in her room. On 03/31/2025 at 9:09AM, R4 said, There are not too many activities except for therapy. On 03/31/2025 at 9:13AM, R5 said, There are no activities. There is nothing to do on the weekends, we do not have therapy on Saturday or Sunday. On 03/31/2025 at 9:18AM, R6 said, I was here last year, they were going to start BINGO. For this stay I have been on isolation for most of the time. No activities for me this visit. On 03/31/2025 at 9:40AM, R8 said, We did play BINGO once last month, otherwise it's just therapy once a day for about 20 minutes. Therapy is Monday through Friday, if you miss a day during the week they will give it to you on Saturday. On 03/31/2025 at 9:55AM, R9 said, I get bored here. There are no activities. I have been here a long time. On 03/31/2025 at 11:25AM, V1 Administrator said, We have a very limited activity program. We do not have an Activity Director. On 03/31/2025 at 2:00PM, V2 DON-Director of Nursing said, We do not have an activity calendar for March (2025). R4, R5, R6, R8, and R9's current Care Plan on 03/31/2025 all showed, 'Resident is a new admission to the facility for short term rehab. Resident will engage in meaningful activities of choice and express satisfaction with leisure time pursuits by next review date. Assist resident with calling family/friends while they are in the facility to maintain relationships while in rehab. [Activities Director, C.N.A., N] Continue to assess and explore patient leisure preference with him/her and family. [SS, C.N.A., N] Inform patient that independent activities are always available such as crosswords, television, games, puzzles, magazines, and books, etc. [C.N.A., N, SS] Introduce patient to other residents with similar interests to promote socialization [C.N.A., N, SS] Provide adaptive equipment as needed and requested in order to improve quality of life and make leisure involvement easier. [C.N.A., N, SS]' (R4, R5,R6,R8,R9's Activity Care Plan is the same. No Individualized Activities were Care Planned for R4, R5, R6, R8, and R9.) The facility's Activity Programs policy dated June 2018 shows, Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board.

Based on interview and record review the facility failed to ensure two residents (R1, R2) received their evening medications in a timely manner. This applies to 2 of 10 residents (R1, R2) reviewed for nursing care in the sample of 10. The findings include: On 1/9/25 at 12:50 PM, R2 said on 1/4/25, R2 and R1 (R1's roommate) requested their evening medications from V7 multiple times and V7 argued with R1 and R2 insisting that V7 administered their evening medications. R1 and R2 both stated V7 did not appear to be under the influence during this discussion. R1's January Medication Administration Record (MAR) shows that all R1's evening medications for 1/4/25 were signed as given by V2 (Director of Nursing). R2's January MAR shows that all R2's evening medications for 1/4/25 were signed as given by V2. On 1/9/25 at 10:54 AM, V2 said on 1/4/25, V7 (LPN) sent V2 a text message at approximately 10:50 PM that read, I'm so k of these delusional ass home telling me I'm not giving them meds . I can drop me all day long they I wild b clean. (sic) V2 awoke at approximately 11:20 PM on 1/4/25, read the text message, and called V7. V2 said V7 was exhibiting slurred speech while on the phone. V2 then called V5 (LPN) who was also working and asked V5 to check on V7. V5 told V2 that V7 was stumbling and had slurred speech. V2 told V5 to stay with V7 and to not let V7 have contact with any residents and to not let V7 go into the medication cart. V2 notified V1 (Administrator) and V2 and V1 drove to the facility. When V2 and V1 arrived at the facility at approximately 1:20 AM on 1/5/25, they asked V7 if V7 would consent to a drug test and V7 asked if cannabis would count. V2 informed V7 that cannabis would count to which V7 responded that V7 would test positive. V7's Screening Result Form dated 1/5/25 shows V7 had positive results for amphetamines, benzodiazepines, cocaine, and methamphetamine. V7's Pre-Employment Screening Result Form dated 6/26/24 shows V7 has prescriptions of amphetamines and benzodiazepines and V7 was educated about these medications while working. On 1/9/25 at 10:54 AM, V2 said when the drug results were read to V1 and V7, V7 admitted to doing a bump of cocaine over the holidays with V7's sister but denied having done any drugs on 1/4/25 or using methamphetamine. V1 and V2 sent V7 home with V9 (Certified Nursing Assistant- CNA) who said she is neighbors with V7. When V7 left the facility, V2 provided R1 and R2 with their evening medications that were missed. On 1/9/25 at 12:37 PM, V10 (Nurse Practitioner) said V2 notified V10 of the delayed medications and due to the half-life of the medications, them being delayed caused none of the residents any negative outcomes or side effects. V10 also assessed both residents after the incident and had no concerns. On 1/9/25 at 12:50 PM, R1 and R2 stated they did not experience any side effects from the missed medications on 1/4/25. On 1/9/25 at 2:10 PM, V2 stated it is the expectation that staff should not be under the influence of drugs or alcohol while they are on the clock and R1 and R2 should have received their medications during the evening medication pass.

Based on observation, interview, and record review, the facility failed to ensure the walk in freezer was repaired and in safe working condition. This failure has the potential to affect all 24 residents residing in the facility. The findings include: The CMS-671 form completed by the facility on 9/9/24, shows there are 24 residents residing in the facility. During the kitchen tour on 9/9/24 at 9:10 AM, thick frost was noted on the packages of food in the walk in freezer and frozen water was pooled on a box of cookies and a box of diced turkey on the shelf below the fans. A large puddle of water was on the floor between the walk in freezer and the walk in cooler coming from water dripping from the connecting door. V5, Dietary Manager, said the freezer was down and they had a repair company out to fix it about a month ago. V5 said they are waiting on a part to fix the freezer. On 9/9/24 at 12:46 PM, V20, Freezer repair company representative, said they provided an estimate to fix the facility's freezer on 7/30/24. V20 said they have not been waiting for parts to fix the facility's freezer since they provided the estimate on 7/30/24; they needed the facility to approve the estimate before they could order the parts. On 9/10/24 at 2:27 PM, V1, Administrator, said she has been aware there was a problem with the walk in freezer since July when the repair company was in the facility. The freezer repair company's estimate dated 7/30/24 shows they arrived to find the walk in freezer not temping and the condenser short cycling due to a compromised pressure transducer. The thermostat was in rough shape and the door closer was not working as intended. They provided a quote to remove and replace the electronic control, transducer, and temperature control on the walk in freezer.

Based on interview and record review the facility failed to obtain treatment orders for a resident with a stage 3 pressure injury. This applies to 1 of 2 residents (R5) reviewed for pressure injury in the sample of 12. The findings include: R5's face sheet shows she was admitted to the facility on [DATE] with diagnoses including septic shock and a stage 3 pressure injury to her left heel and sacrum. Hospital discharge records for R5 show prior to admission to the facility she was in a local community hospital with a diagnosis of septic shock due to a left heel ulcer which had been debrided and antibiotic therapy provided while she was at the hospital. An initial nursing admission assessment for R5 dated 8/21/24 and not signed, shows she has a left heel ulcer measuring 1.6 centimeters (cm.) x 1.8 cm. The same assessment shows she has 3 open areas to her sacrum/coccyx and right and left buttocks measuring: 2.0 x1.0 cm. and 1.5 cm x 2.0 cm. and 1.0 cm. x 1.0 cm. R5's current Physician Order Summary (POS) and Treatment Administration Record (TAR) from 8/1/24-8/31/24 shows no active treatment orders for her coccyx and sacrum until 8/26/24, which was to initiate Medi-honey and Xero foam every other day and apply zinc ointment to her buttocks two times a day. There were no orders for her left heel ulcer until 8/26/24 when an order was entered to clean left ulcer with normal saline and apply iodoform, (sp.) xeroform and foam dressing daily. On 9/10/24 at 09:46 AM, V9 (Wound Nurse) said she initially saw R5 when she was admitted on [DATE] and assessed the wounds. R5 did not see the facility wound care physician until 8/29/24 because he was out of town. V9 said she thought there were orders prior to 8/26/24 for her sacral/buttocks and heel but verified with this surveyor by review of the POS and TAR that no orders were obtained until 8/26/24. V9 said R5 currently still has the pressure area to her heel but it has improved a lot. On 9/10/24 at 11:02 AM, V2 (DON) said she had reviewed R5's discharge orders from the hospital and she did not see any treatment orders for R5's pressure injuries. V2 said no treatment orders were obtained until 8/26/24 when V9 caught this and called the facility wound physician for orders. On 9/10/24 at 11:45 AM, V7 (Wound Care Physician) said he is treating R5 at the facility and she currently has only a pressure injury to her left heel. V7 said he was messaged or called on 8/26/24 for treatment orders for R5's pressure to her heel and coccyx. V7 said 5 days is not acceptable to wait to begin treatment to her heel wound because it could have deteriorated in that time. V7 said the hospital should have sent treatment orders with her on admission but someone from the facility should have caught it before 5 days. V7 said sometimes residents at the facility see him and sometimes they see outside providers so that could have been part of the problem also. On 09/10/24 at 12:24 PM, V8 (Podiatrist/surgeon) said he saw V5 in the hospital for a foot ulcer and he debrided the wound. V8 said he was at the facility yesterday but could not recall without his list in front of him if he saw V5 or not. V8 said there should be some treatment orders for R5 prior to 5 days because the dressing would need to be changed, and in the hospital, it was being changed every other day. V8 said in wounds like this I defer treatment to the facility wound physician who see residents regularly because I only go to the facility on e time a month. The facility provided Pressure Ulcers/Skin Breakdown policy last revised Aril 2018 shows, the physician will order pertinent treatments including dressings and topical agents to manage pressure injuries.

Based on observation, interview, and record review the facility failed to ensure dietary supplements were provided for 2 of 5 residents (R28, R5) reviewed for weight loss in the sample of 12. The findings include: 1.) R28's face sheet shows he was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition and muscle weakness. R28's active care plan shows he has malnourishment and will be consulted by the dietician. R28's Weight Summary shows his weight was 110.2 on 8/27/24 and was 101.4 on 9/6/24 which is a 7.99% and 8.8 pound (lb.) significant weight loss in 10 days. R28's Nutrition note completed on 9/6/24 by V4 (Dietician) shows he has sustained a significant weight loss and Magic Cup a dietary supplement had been ordered to be given with lunch. R28 declined any additional supplements. R28's active Physician Order Summary and meal ticket both show he should receive magic cup with lunch effective 9/1/24. On 9/9/24 the noon meal service was observed and R28 was in the dining room he did not receive a magic cup during the meal service. At 12:33 PM, V6 (Cook) confirmed that all trays had been passed and the noon meal service was complete. On 9/10/24 at 1:07 PM, V4 said R28 was admitted to the facility with poor nutrition and is underweight and she is concerned about it. V4 said she personally adds supplement orders to the resident meal tickets herself and then the kitchen staff pass the supplements with the trays. 2.) R5's Weight Summary shows she weighed 160.2 lbs. on 8/21/24 when she was admitted to the facility. Her weight on 9/5/24 was 146.0 lbs. Which is a significant weight loss of 8.9% and 14.2 lbs. in 15 days. R5's Nutrition note completed on 9/6/24 by V4 shows had a significant weight loss and will be given Mighty Shake two times a day for weight support which began on 8/27/24. R5's active Physician Order Summary shows she should receive mighty shakes 2 times a day at lunch and dinner. R5's meal ticket shows she should receive 6 ounces of vanilla mighty shake at lunch. On 9/9/24 R5 was eating lunch in her room. At 12:20 PM, and again at 12:35 PM and 12:40 PM, R5 was observed and finished with her meal and had not been given her mighty shake with lunch. On 9/10/24 at 1:07 PM, V4 said she provides supplements for residents with weight loss, and she expects them to be given. The facility provided Supplement policy dated 2021 shows nutritional supplements should be given as ordered.

Based on interview and record review the facility failed to ensure there was no delay in obtaining a medication from the pharmacy and failed to obtain a medication from the pharmacy for 2 of 5 residents (R235 and R11) reviewed for pharmacy services in the sample of 12. The findings include: 1. R235's Face Sheet showed R235 had a primary diagnosis of polyneuropathy (a nerve disease that affects many nerves). On 09/09/24 at 12:05 PM, R235 said he had neuropathy (nerve pain) in his hands and feet. R235 described the pain as if his hands and feet were on fire. R235 said there was a delay in starting medication for the nerve pain. R235 said it took the facility over a day to get the medication. R235 was not sure why there was a delay. R235 said the facility did provide other interventions while waiting for the pain medication to treat the neuropathy. R235's Progress Notes dated 9/4/24 entered by V10 (Nurse Practitioner) showed R235 reported he had neuropathy and was agreeable to try pregabalin (medication to treat the nerve pain). R235's Progress Note dated 9/4/24 at 12:49 PM showed a nurse practitioner gave an order for pregabalin. R235's Progress Note dated 9/4/24 at 12:59 PM, showed a nurse practitioner was informed a prescription needed to be sent to the pharmacy for the pregabalin. R235's Clinical Physician Orders showed an order for pregabalin with a start date of 9/4/25 at 8:00 PM. R235's Progress Note dated 9/4/24 at 10:11 PM, showed the pharmacy had not received the prescription for the pregabalin. On 09/09/24 at 01:22 PM, V17 (Licensed Practical Nurse- LPN) said she went to give R235 his pregabalin on 9/4/24 at 8:00 PM and it was not available. V17 said she contacted pharmacy and was informed the pharmacy had not received the prescription for the pregabalin. V17 said the medication was not available in the medication dispensing machine at the facility. On 09/09/24 at 12:35 PM, V18 (Pharmacist) said the pharmacy received the prescription for pregabalin on 9/4/24 at 11:27 PM. V18 said the medication was filled on 9/5/24 and it was delivered to the facility on [DATE] at 2:29 AM. V18 said the pharmacy makes one daily routine delivery to the facility. V18 added that the daily pharmacy delivery leaves the pharmacy at midnight. According to V18, the pregabalin prescription came in too late to make the delivery on 9/5/24. V18 said the normal time frame for a medication to be delivered to the facility is 24 hours. R235's Medication Administration Record (MAR) indicated R235 received the first dose of pregabalin on 9/5/24 at 7:00 PM (before the medication was delivered to the facility). On 9/9/24 at 2:21 PM, V19 (LPN) said she was the one that documented on the MAR that R235 received a dose of pregabalin on 9/5/24 at 7:00 PM. V19 said she made an error on R235's MAR by marking that the pregabalin was given. V19 said she did not give R235 the pregabalin on 9/5/24 at 7:00 PM because the medication was not available. R235's Controlled Drug Receipt/Record/Disposition Form for the pregabalin indicated R235 received his first dose on 9/6/24 at 8:00 AM (about 43 hours after the Progress Note dated 9/4/23 at 12: 49 PM indicating an order for pregabalin was given). On 09/09/24 at 01:48 PM, V2 (Director of Nursing) said a new medication is usually started the next day. V2 said when a medication is ordered the pharmacy will deliver the medication the next day in the early morning. The facility's Pharmacy Policy and Procedures Manual showed medications and related products are received from the dispensing pharmacy in a timely basis. 40085 2.) On 9/9/24 at 12:08 PM, R11 said she has had a problem with thrush in her mouth and had previously been on a medication she swished in her mouth. R11 said the nurses told me several days ago she was going to get it again but has yet to see it. R11's Electronic Medical Record (EMR) shows a note documented on 9/6/24 at 10:06 PM, by V10 (Nurse Practitioner), for R11 to start on Miracle mouth wash 4 times a day for 10 ten days. R11's Medication Administration Record (MAR) and Physician Order Summary (POS) both show an order for Miracle mouth wash (Hydrocortisone, Benadryl, and Nystatin) equal parts 10 ml (milliliters) swish and spit QID (4 times a day) for oral thrush for 10 days. The order has a start date of 9/7/24 and a stop date of 9/9/24. The MAR shows no doses were given 9/7/24 or 9/8/24. The MAR and POS next show the order was restarted on 9/10/24 and discontinued on 9/10/24 with no doses signed off in the MAR. A nursing note completed by V12 (Licensed Practical Nurse) on 9/10/24 at 9:47 AM states, Pharmacy did not send patient's miracle mouth wash. NP (Nurse Practitioner) notified and assisted with updating order. Order faxed to pharmacy, will send tonight. Patient to start medication tomorrow morning. NP verified and patient aware of order. On 9/10/24 at 10:36 AM, V13 (Pharmacist) said they had no order request from the facility for R11 to receive Miracle mouth wash. V13 said if the facility does not properly enter the order into the computer correctly as a pharmacy order they pharmacy will not get it unless the facility prints the order off and faxes it to them. V13 said had he gotten this order they would have sent the medication out to the facility with the next delivery. On 9/10/24 at 10:40 AM, R11 was in the hallway talking with V11 (Nurse Practitioner) V11 told R11 the hold up with starting her mouth rinse was due to the order not being sent to the pharmacy. On 9/10/24 at 10:47 AM, V11 said R11 did not get the medication that was ordered due to the facility not entering it correctly, so the order was just faxed to the pharmacy today by V12 (LPN). V11 said R11 does have oral thrush and a small sore inside her mouth. On 9/10/24 at 11:05 AM, V2 (Director of Nursing) said she was also not aware until today that orders have to be faxed to the pharmacy if they are not entered as a pharmacy order. V2 said this was the reason R11 did not receive her mouth wash yet. The facility Ordering and Receiving Non-Controlled Medications from The Dispensing Pharmacy dated 10/25/24 shows a nurse should promptly report any discrepancies of omissions of medications to the pharmacy and charge nurse supervisor.

Based on interview and record review the facility failed to ensure PRN (as needed) psychotropic medication had a stop date not greater than 14 days for 1 of 5 residents (R11) reviewed for psychotropic medications in the sample of 12. The findings include: R11's Physician Order Summary and Medication Administration Record both show an active order prescribed by V11 (Nurse Practitioner) on 9/5/24 for Ativan 0.5 MG (milligrams) every 12 hours as needed for anxiety with no stop date. On 9/10/24 at 2:25 PM, V2 (Director of Nursing) said PRN orders for psychotropic medications including Ativan should have a stop date of 14 days. The facility provided Time Limited Orders policy effective 10/25/24 shows PRN Anxiolytics (Ativan) should have a stop date of 14 days.

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment for a resident on enhanced barrier precautions for 1 of 12 residents (R15) reviewed for infection control in the sample of 12. The findings include: R15's Clinical Physician Orders showed R15 had an order for enhanced barrier precautions because R15 had an indwelling urinary catheter. On 09/09/25 at 9:20 AM, on the outside of R15's room was a sign indicating R15 was on enhanced barrier precautions. The sign indicated staff were to wear gloves and gown for high-contact resident care activities. High-contact activities included transferring and care of a medical device such as a urinary catheter. On 09/09/24 at 09:29 AM, R15 was in his room sitting in a wheelchair. R15's indwelling urinary catheter drainage bag was hanging on the wheelchair. V14 (Physical Therapist Assistant) was in the room. V14 moved R15's indwelling urinary catheter drainage bag from the wheelchair to a walker. V14 did not have on gloves or a gown. V14 assisted R15 to stand and walk. On 09/10/24 at 11:58 PM, V15 (Certified Nursing Assistant- CNA) assisted R15 to stand and walk. V15 hung R15's indwelling urinary catheter drainage bag on a walker. V15 did not have on gloves or a gown. On 09/10/24 at 10:03 AM, V16 (CNA) said for a resident on enhanced barrier precaution for an indwelling urinary catheter staff should put on gloves and a gown before handling the indwelling urinary catheter. V16 said enhanced barrier precautions are infection control interventions to limit the spread of infections. The facility's Enhanced Barrier Precautions policy with a reviewed date of 4/1/24 showed enhanced barrier precautions is an approach of targeted gown and glove use designed to reduce transmission of bacteria. Enhanced barrier precautions apply to residents with indwelling medical devices such as an indwelling urinary catheter. The same policy showed when a resident is placed on enhanced barrier precautions gown and gloves will be used during high contact resident care activities such as transferring and device care/use.

Based on interview and record review, the facility failed to notify a resident's family member after the resident experienced a fall. This applies to 1 of 5 (R3) residents reviewed for falls in the sample of 6. The findings include: R3's Fall Investigation report dated 2/2/24, completed by V2 (Director of Nursing), shows R3 sustained a witnessed fall in the dining room on 2/2/24 at 8:40 AM. On 2/6/24 at 1:05 PM, V7 (R3's Family Member) said the facility did not let her know of R3's fall on 2/2/24. V7 said she attended R3's care plan meeting on 2/2/24 with members from the facility and was never informed about R3's fall that occurred earlier that morning. On 2/6/24 at 1:25 PM, V2 said she was the witness of R3's fall and completed R3's fall report. V2 said she attempted to call V7, but V7 did not answer and V2 could not leave a message. V2 intended to call V7 back and never did. V2 said that notifying the resident's family member should be done immediately after the resident has been assessed and the physician has been notified and given orders.

Based on interview and record review the facility failed to assess a shearing/pressure injury for 1 of 3 residents (R1) reviewed for pressure injury in the sample of 3. The findings include: R1's progress note dated 4/18/23 showed R1 had a shearing wound to the back of his right thigh, testicles, and buttocks. The note indicated the skin was unopened. The note did not include wound measurements. R1's Nurse Practitioner's progress note dated 4/18/23 indicated staff found a bed sore on R1's coccyx. On 8/9/23 at 1:38 PM, V2 (Director of Nursing) said a wound assessment with measurements should be done when a skin issue is found. V2 said wound assessments are done to track the progress of the wound. On 8/9/23 at 2:34 PM, V2 said there were no documented skin assessments for R1's shearing wound. On 8/9/23 at 3:39 PM, V1 (Administrator) said the facility was lacking a wound assessment of R1's shearing wound. The facility's Skin Breakdown - Clinical Protocol policy dated April 2018 showed, .nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.

Based on observation, interview and record review, the facility failed to ensure a resident's pain level was controlled. This resulted in the resident experiencing severe pain. This applies to 1 of 2 residents (R138) reviewed for pain in the sample of 17. The findings include: R138's Admission Record sheet shows he was admitted on [DATE]. The same document shows his diagnoses includes right knee joint replacement surgery, depression, and anxiety. On 8/01/23 at 2:34 PM, R138 was in his room with the ice water pump attached to his right knee. R138 had periods of facial grimacing when he moved his leg. On 8/01/23 at 2:34 PM, R138 said, he just had a right knee replacement and he is in severe pain. R138 said, the only thing the nursing staff will give him is Acetaminophen. R138 rated his pain at an 8 during our interview. R138 said, he tells everyone he can, both the nurses and CNA's (Certified Nursing Assistants) that he is in pain. R138 said, he told the nursing staff he needed something stronger. On 8/02/23 at 8:30 AM, V13 Agency LPN (Licensed Practical Nurse) asked R138 about his pain level and he said, it was at an 8 out of 10. R138 told V13 didn't want to take the Acetaminophen because R138 said they didn't work, however V13 encouraged him to take them anyway. R138 took the Acetaminophen. V13 did not discuss other options with R138 about pain relief. Tramadol and oxycodone were available. On 8/2/23 at 1:30 PM, V13 was not in the facility for an interview. On 8/02/23 at 10:00 AM, R138 said, V13 never came back to him to ask if the Acetaminophen was effective. R138 said it was not effective. R138 said, none of the nursing staff ask me if pain medication is effective, and they use letters like PRN and never explained what it means. R138 said he would ask the nursing staff if he could have a stronger pain pill and they all gave him different answers. R138 said staff didn't communicate very well. On 8/02/23 at 1:37 PM, V14 RN said, the nurse should assess the resident for pain and ask their pain level, then medicate the resident with ordered pain meds and then re-assess to see if pain level is improved. V14 said if the pain has not improved, the nurse can see if the resident has any other options, or the nurse can call the Physician to see if they want to order something stronger. On 8/03/23 10:12 AM, V10 NP said, it's her expectation that the nurse will assess the resident for pain, and medicate the resident with whatever is ordered on the MAR. V10 said the nurse should re-assess the resident to see if the medication decreased their pain. V10 said if the resident remains in pain after all the medication options the Physician or NP (Nurse Practitioner) should be contacted. A failure to properly assess pain could cause the resident to experience severe pain. The initial visit from V10 NP/APN (Nurse practitioner/Advanced Practice Nurse) dated 8/3/23 shows R138 had is a total right knee replacement on 7/25/23. The same document shows a nurse contacted her on 8/2/23 in the evening about the residents pain. V10 documented that R138 feels he is confused as to what and when he can get pain medication. R138's Nursing Progress Notes shows he was admitted on [DATE], with a pain rating at 9 out of 10. R138's 7/31/23 (3:33 PM) Comprehensive Pain Assessment shows he is in constant, throbbing pain, rated at a 10 out of 10. R138 verbalized his pain as severe and makes it hard for him to sleep. R138's 8/1/23 Care Plan shows R138 is at risk for pain and discomfort due to being a post-operative patient. Interventions includes to administer medications and monitor for its effectiveness, and notify the Physician if pain is not resolved. R138's MAR (Medication Administration Record) his pain was never less than a 8 out of 10. The Pain Management Policy and Procedure (revised 3/1/23) shows the Facility's policy is to provide effective pain management for residents experiencing acute or chronic pain. Basic Concepts of Pain Management #4 shows, the resident has the right to expect a rapid and effective response to a complaint of pain. Treat the pain, re-assess and continue to treat the pain until the resident is comfortable.

Based on observation, interview and record review the facility failed to separate Coronavirus 19 (COVID-19) positive residents and COVID-19 negative residents and failed to keep the doors of the COVID-19 positive residents closed to prevent the spread of COVID-19. The facility failed to wear appropriate PPE (personal protective equipment) to prevent the spread of COVID-19. The facility failed to notify the local health department of COVID-19 positive staff members and residents. Facility documentation at the time of the survey showed 21 residents and 26 staff members had contracted COVID-19. These failures had the potential to affect all 26 residents in the facility and resulted in Immediate Jeopardy to their health and safety. The Immediate Jeopardy began on [DATE] when the facility began receiving positive COVID-19 results. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was informed of the Immediate Jeopardy on [DATE] at 9:15 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE] however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility's Resident Roster dated [DATE] shows that there are 26 residents residing in the facility. The Roster shows that 21 residents are COVID-19 positive and 5 residents are COVID-19 negative. The undated list provided by the facility on [DATE] shows that there are 26 staff members that tested positive for COVID-19. An email dated [DATE] to the Illinois Department of Public Health shows that on [DATE], one resident and one staff member had expired that had COVID-19. 1. On [DATE] at 9:33 AM, there was a red square tag hanging on the name plate of rooms that housed R4 and R5 and the room that housed R3. V5 (Certified Nursing Assistant) said that means those residents are COVID-19 positive. The doors to both of these rooms were open. In the same hallway, the doors to rooms that housed COVID-19 negative residents were also open. On [DATE] at 10:15 AM, R3 who is COVID-19 positive was sitting in her wheelchair in the doorway of her room. R3 did not have a mask on. On [DATE] at 9:42 AM, V5 went into a room with a COVID-19 positive resident and provided care. At 11:39 AM, V5 went into a room with a COVID-19 negative resident. At 10:12 AM, V6 (Registered Nurse) went into a room with a COVID-19 negative resident and at 10:38 AM went into a room with a COVID-19 positive resident. On [DATE] at 11:40 AM, the COVID-19 positive residents R3, R4 and R5 remained in rooms with their doors open. The same staff were taking care of COVID-19 negative and positive residents. On [DATE] at 9:45 AM, V9 (Infection Control Nurse) said that a resident who tests positive for COVID-19 should be immediately put on isolation and moved to the COVID-19 unit. V9 said that the door to COVID-19 positive resident rooms should be closed at all times to prevent the spread of infection. V9 said that she is unsure why R3, R4 and R5 are still on that hall. V9 said that all residents were tested on [DATE] and the results came back on [DATE] at which time all the positive residents (18 residents) were moved to the hallways designated for the COVID-19 unit. On [DATE] at 9:30 AM, V7 (Unit Manager) said that R3, R4 and R5 were retested on [DATE] and came back positive this morning ([DATE]). V7 said that she is not sure what they are going to do with them yet. On [DATE] at 11:16 AM, V4 (Chief Operating Officer) said that R3, R4 and R5 were not positive last night but this morning, they were positive after re-testing. V4 said, I'm not sure what the plan is for them yet. R3, R4 and R5's COVID-19 testing shows that they were re-tested on [DATE] and R4 and R5's COVID-19 positive test result were resulted at 8:29 PM on [DATE]. R3's COVID-19 test result was resulted at 9:09 PM on [DATE]. The facility floor plan shows that R3, R4 and R5 all Covid-19 positive, were in rooms at the beginning of a hallway and at the end of the hallway and the rooms in between those rooms housed R6-R10 who were all COVID-19 negative. The Resident Roster dated [DATE] shows that the facility COVID-19 unit has 3 open female beds and one open male bed. This was verified with V8 at 12:51 PM on [DATE]. The Resident Roster also shows that there are 5 open beds on the hall that is located right before the shut fire doors where the COVID unit is located. On [DATE] at 4:00 PM, V4 (Chief Operations Officer) said that they had plenty of staff yesterday ([DATE]) and had additional staff available. V4 said that there was two nurses and two CNAs on the COVID-19 unit and one nurse and one CNA on the other hall. On [DATE] at 10:00 AM, V6 said that there are 5 residents that do not have COVID-19 and 3 resident that are COVID-19 positive that are on her assignment today. At 10:09 AM, V5 said that she is caring for all the residents down the hall including the COVID-19 positive patients. The facility's COVID-19 Response Policy reviewed on [DATE] shows, Residents with confirmed COVID 19 or displaying respiratory symptoms should receive all services in room with door closed .Facilities should use separate staffing teams for COVID 19 positive patients, to the best of their ability .Facilities should designate separate spaces within the facilities to keep COVID 19 positive patients, where possible The facility's undated COVID-19 Testing Patients and Staff Policy shows, Any resident identified to be positive for COVID-19 (symptomatic or asymptomatic) will be immediately placed on droplet/contact precautions and moved to the COVID-19 designated area. 2. R6's census report shows that she was admitted to the facility on [DATE]. On [DATE] at 9:33 AM, R6's room did not have a sign on the door showing that she was on a 14 day quarantine. V12 (Physical Therapy Assistant) was in R6's room. V12 was sitting on R6's bed with no gown on. At 11:37 AM, V6 (Registered Nurse) was in R6's room with no gown on and at 11:39 AM, V5 assisted R6 to the bathroom. On [DATE] at 10:40 AM, V3 (Registered Nurse-Admissions) said that new admit and re-admit residents are put on quarantine for 14 days. On [DATE] at 9:45 AM, V9 (Infection Control Nurse) said that new admissions are put on quarantine for 14 days. A sign is put on their door that says, See nurse before entering so staff know that they are on quarantine. Staff should be wearing a face shield or goggles, mask, gloves and gown when they enter the room. The facility's COVID-19 Policy-Admissions of Patients reviewed [DATE] shows, Patients admitting from area hospitals will be on a transition unit for up to 14 days after admission .This acts as a stepdown until to allow time to pass and to monitor if patients are presenting with any COVID 19 symptoms .Upon admission and if the patient is asymptomatic, they will be on the quarantine unit this is on a precautionary basis, we will observe standard precautions, including face mask and eye protection while caring for these residents. The Centers for Disease Control Infection Control for Nursing Homes revised on [DATE] shows, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown . HCP (Health Care Personnel) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. 3. On [DATE] at 12:35 PM, V17 (Local Health Department Communicable Disease Supervisor) said that the facility contacted her on [DATE] and said that they had one positive staff member (V14, Admissions Liaison). V17 said that at that time she sent the facility an email with a link to fill out with information about the outbreak and a link that needed to be filled out and submitted with every positive staff and resident case on it. On [DATE] at 1:22 PM, V17 said that she still has not received any reports from the facility documenting their positive cases and did not hear from the facility on [DATE] when V13's (Physical Therapy Student) test result came back positive, nor have the form filled out for her. On [DATE] at 3:07 PM, V1 (Administrator) said that V2 (Director of Nursing) notified the local health department on [DATE] at 7:40 PM after receiving V14's (Admissions Liaison) positive test result on [DATE]. V1 said when she heard about V13's (Physical Therapy Student) positive test result, she called the local health department but does not have any record of when she called. The facility's Policy Regarding Notification of Positive COVID-19 Results updated [DATE] shows, Within 3 hours, the facility will notify the local health department telephonically of: Any resident or staff member who has lab confirmed COVID-19 .Immediate written notification shall be provided to IDPH and the local health department upon the confirmation of COVID-19 infection of a resident or staff member The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. On [DATE] the facility stopped accepting new admissions. 2. On [DATE] the facility began discharging COVID negative residents. 3. On [DATE] the last COVID negative resident was discharged ; as of this date all COVID positive residents were separated from COVID negative residents. 4. On [DATE] the facility notified the local health department of all COVID positive residents and staff. 5. On [DATE] the facility began training of staff and developed a plan to educate staff who were not on duty. Training included: New admission quarantine; Health Dept Notification; Proper PPE usage; hand washing 6. On [DATE] the facility developed plans to separate COVID positive residents from COVID negative residents; develop a plan to quarantine new admissions and use appropriate PPE; Develop a plan to notify the local health dept.; develop a plan to ensure all COVID regulations are implemented.

Based on interview and record review, the facility failed to perform COVID-19 testing on all staff and residents as soon as an outbreak was identified. The facility failed to test for COVID-19 according to their policy and the county positivity rate. Facility documents at the time of the survey showed 21 residents and 26 staff members had contracted COVID-19. These failures had the potential to affect all 26 residents in the facility and resulted in an Immediate Jeopardy to their health and safety. The Immediate Jeopardy began on [DATE] when the facility began receiving positive COVID-19 results. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was informed of the Immediate Jeopardy on [DATE] at 9:15 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The Resident Roster dated [DATE] shows that there are 26 residents residing in the facility. The Roster shows that 21 residents are positive for COVID-19 and 5 residents are negative. The undated list provided by the facility on [DATE] shows that there are 26 staff members that tested positive for COVID-19. An email dated [DATE] to the Illinois Department of Public Health shows that on [DATE], one resident and one staff member had expired that had COVID-19. V13's (Physical Therapy Student) Clinical Practicum Time Log shows that she worked on [DATE] from 8:00 AM to 5:30 PM and again on [DATE] from 7:30 AM to 4:15 PM. V13's COVID-19 testing performed on [DATE] at 3:26 AM (according to V13, it should be PM) was resulted positive on [DATE] at 3:06 PM. The report shows that the results were released to V1 (Administrator) at 3:06 PM on [DATE]. On [DATE] at 2:03 PM, V13(Physical Therapy Student) said that she is a student and does therapy under the direction of her preceptor with residents daily. V13 said that she did her weekly COVID-19 testing on [DATE] at the end of her work day. V13 said that she worked again on [DATE] and took care of patients on that day. V13 said that probably around 3:30 PM when she was almost done seeing patients, the facility notified her that her test from [DATE] came back positive and she had to leave. V13 said that the only symptom that she had was a runny nose but she attributed it to the weather changing and allergies [REDACTED].>V14's (Admissions Liaison) COVID-19 rapid testing performed on [DATE] at 6:37 PM from a local clinic was resulted as positive. V2's (Director of Nursing) COVID-19 testing performed on [DATE] was negative. V2 did not have another COVID-19 test until [DATE] at 3:57 PM (9 days later) which came back positive. V2 had a rapid test done at the facility on ,[DATE] at 9:48 PM that came back positive (less than 48 hours from previous test). On [DATE] at 2:40 PM, V2 said that her last day of working was on [DATE]. V2 verified that she had a test on ,[DATE] from a local clinic and on ,[DATE] which was a nasal swab done at the facility and no other test was done in between. The COVID-19 Laboratory 14-day test positivity rate for the facility's county was 10.3% for the week ending [DATE]. The facility's COVID-19 Testing Patients and Staff policy shows that a county positivity rate above 10% requires twice a week testing. On [DATE] at 9:45 AM, V9 (Infection Control Nurse) said that the first COVID-19 positive case in the facility was V13 (Physical Therapy Student). Once the test was resulted as positive, V13 was sent home. V9 said that they just continued doing the twice a week testing for the staff and did not test any of the residents. V9 said that they started facility-wide resident testing once R11 and R12's COVID-19 test came back positive on [DATE]. V9 said that last week (,[DATE]-,[DATE]) they started twice a week testing for all staff due to the high county positivity rate. V9 said that staff testing should have at least 48 hours in between tests. R11's COVID-19 test result showed that testing was performed on [DATE] at 12:54 AM and resulted positive at 11:41 AM on [DATE]. R12's COVID-19 test result show that testing was performed on [DATE] at 12:51 AM and resulted positive at 11:36 AM. R1, R2, R3, R4 and R13's COVID-19 testing shows that it was performed on [DATE], 3 days after the first staff member had tested positive. On [DATE] at 4:00 PM, V4 (Chief Operations Officer) said that they have plenty of rapid and send out testing supplies available to use when needed. V4 said that he was unsure why residents and staff were not testing immediately after the first positive staff member was resulted positive. V4 asked, Is that proper protocol? On [DATE] at 11:03 AM, V8 (Assistant Administrator) said that all residents were tested on [DATE]. V8 said that she is not sure why they were not tested on [DATE] after the first staff member tested positive. On [DATE] at 4:07 PM, V1 (Administrator) said that they started testing all the residents on [DATE] due to V14's (Admissions Liaison) positive test result on [DATE]. V1 said that she was under the impression that they did not have to do resident testing after V13's (Physical Therapy Student) test came back positive on [DATE] because she was not in the building 48 hours prior to her test that was positive. (V13 worked on [DATE] and [DATE] when her test was positive on [DATE] but didn't get results until [DATE], which means that all the residents and staff were exposed to her during her shift on [DATE]). The Centers for Disease Control (CDC) Testing Guidelines for Nursing Homes updated on [DATE] shows, Perform expanded [MEDICAL CONDITION] testing of all residents in the nursing home if there is an outbreak in the facility (i.e., a new [DIAGNOSES REDACTED]-CoV-2 infection in any HCP or any nursing home-onset [DIAGNOSES REDACTED]-CoV-2 infection in a resident). A single new case of [DIAGNOSES REDACTED]-CoV-2 infection in any HCP or a nursing home-onset [DIAGNOSES REDACTED]-CoV-2 infection in a resident should be considered an outbreak. When one case is detected in a nursing home, there are often other residents and HCP who are infected with [DIAGNOSES REDACTED]-CoV-2 who can continue to spread the infection, even if they are asymptomatic. Performing [MEDICAL CONDITION] testing of all residents as soon as there is a new confirmed case in the facility will identify infected residents quickly, in order to assist in their clinical management and allow rapid implementation of IPC interventions (e.g., isolation, cohorting, use of personal protective equipment) to prevent [DIAGNOSES REDACTED]-CoV-2 transmission. The CDC's Interim Guidance on Testing Healthcare Personnel for [DIAGNOSES REDACTED]-CoV-2 updated on [DATE] shows, Testing asymptomatic HCP without known or suspected exposure to [DIAGNOSES REDACTED]-CoV-2 for early identification in special settings . Currently, testing asymptomatic HCP without known or suspected exposure to [DIAGNOSES REDACTED]-CoV-2 is recommended for HCP working in nursing homes is part of the recommended reopening process .In this situation, initial [MEDICAL CONDITION] testing of all HCP in nursing homes, along with weekly [MEDICAL CONDITION] testing thereafter is recommended. State and local officials may adjust the recommendation for weekly [MEDICAL CONDITION] testing of HCP based on the prevalence of [MEDICAL CONDITION] in their community; for example, performing weekly testing in areas with moderate-to-substantial community transmission and less frequent testing in areas with minimal-to-no community transmission .Healthcare personnel (HCP): HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1.On [DATE] the facility tested all residents. 2. On [DATE] the facility began training of staff and developed a plan to educate staff who were not on duty. Training included: COVID-19 regulations, agency training, Notifying local health department; Family notification; when testing will be done; 3. On [DATE] the facility developed plans for testing of staff based on county positivity rate and developed plans to ensure COVID regulations implemented.