Every finding on record at Axiom Healthcare of Flora

Based on interview, observation and record review, the facility failed to investigate a fall for 1 of 3 residents (R1) reviewed for accidents in a sample of 6.Findings include:R1's admission Record documents an admission date of 05/28/2025 with diagnoses including primary insomnia, major depressive disorder, recurrent, mild, vascular dementia, severe without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.R1's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 3, indicating that R1 is severely cognitively impaired.R1's Care Plan documents a focus area of My preferences are: I prefer to put myself on the floor and lay/sleep with a blanket at times. This focus area includes the following interventions: utilize fall mat on the floor next to bed with an initiation date of 6/12/26 and promote preferences of choice r/t (related to) putting self in floor to lay/sleep with blanket with an initiation date of 8/11/25.R1's Care Plan documents a focus area of I am at increased risk for falls with interventions including utilize fall mat on the floor next to bed with an initiation date of 6/12/26 and If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol with an initiation date of 9/4/25.R1's Progress Notes document on 6/6/2026 at 11:30pm, Resident was noted to be laying on the floor outside his room. CNA (Certified Nursing Assistant) x 2 went to assist resident back to bed. No injuries were noted to resident.R1's Progress Notes document on 6/10/2026 at 4:00pm, It was reported to me that resident had a bruise on his right buttock that was noticed during his shower. I assessed resident and noted bruising to coccyx, sacrum, right buttock/gluteal fold, right posterior thigh, and right hip. No complaints of pain. Resident is unable to tell me what happened, he replies I don't know. Measurements are 23cm (centimeters) x 35cm in total.On 6/23/26 at 1:35pm, with V6 (CNA) present, R1 was observed to have dark purple bruising at various stages of healing across his entire lower back that wrapped around to his right thigh and into his groin. R1 was also observed to have a large knot, approximately the size of a tennis ball on the right side of his lower back just above his buttocks. There was no new bruising noted to this area and R1 did not indicate that he was in pain when V6 palpated the area.On 6/22/26 at 1:30pm, V4 (Registered Nurse/RN) stated R1 has a history of putting himself on the floor and they don't write it up as a fall, it is in his care plan. V4 stated R1 was found in the hallway on 6/6/26 by staff and she assessed him for injuries, and he had none. V4 stated she had staff put R1 back to bed. V4 stated she did not classify it as a fall since he most likely intentionally put himself on the floor and does it often.On 6/22/26 at 2:12pm, V3 (Registered Nurse/RN) stated that if someone has an unwitnessed fall, they will immediately assess the resident get vitals, range of motion, skin assessment, do a risk management assessment and investigation and notify family, the resident's doctor and managers. V3 stated the process is similar for injuries/ bruises of unknown origin. V3 stated if the fall was not witnessed, they would also initiate neuro checks on the resident and send them out right away if any injury is suspected. V3 stated R1 does have a history of putting himself on the floor and was care planned for it. V3 stated she would initiate a fall investigation for any resident found on the floor in the hallway.On 6/22/26 at 2:12pm, V2 (Assistant Director of Nursing) stated that R1 has a behavior of crawling out of bed and on the floor. V2 stated he used to sleep on the floor at home all the time, V2 stated he is care planned for it. V2 stated she did not do an injury of unknown origin investigation because she is convinced it was from R1 crawling out of bed. V2 stated she did the fall risk management, and they got a fall mat just in case. V2 stated it was hard for her to say whether or not she would classify it as a fall because it is technically an intentional change in plane and she feels like it is more normal. V2 stated she did ask for clarification from corporate and they advised her to treat it as a fall moving forward. V2 stated if a resident was found on the floor in the hallway by staff and no one witnessed how they got there, it would be written up as a fall and staff are always to do neuro checks.On 6/22/26 at 2:23pm, V5 (Certified Nursing Assistant) stated she was changing R1 when they noticed the bruise on him. V5 stated they got the nurse immediately and they measured it and called the doctor and got some x-rays. V5 stated R1 did have a history of crawling out of bed but she has never seen him have bruising like that.On 6/23/26 at 2:12pm, V6 (Certified Nursing Assistant) stated that she takes care of R1 at times. V6 stated she took care of R1 at the previous facility he was at and he does have a history of crawling out of bed, he did it at the other facility. V6 stated he will get on his buttocks and kind of scoot. V6 stated he will scoot across the floor. V6 stated the day the bruising was noticed, it was very dark and all across his lower back, all down his right thigh and into his groin. V6 stated she has never seen any bruise like this from him crawling out of bed and she does not feel like that could have caused an injury like this.On 6/23/26 at 2:27pm, V1 (Administrator) stated there was no investigation into the progress note of R1 being found on the floor outside his room on 6/6/26. V1 stated when the bruise was discovered on R1's buttocks, V2 (Assistant Director of Nursing) was working the floor and assessed R1. V1 stated that V2 stated she talked to the floor staff, and it was discussed by IDT (Interdisciplinary Team), but she did not have a formal investigation. V1 stated if a resident was found on the floor outside their room, she would expect a fall investigation to be done.The facility policy titled Incident and Accident Report with a revision date of 4/7/2019 under policy it states The Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury or the potential to result in injury. Procedure step 5 documents All incident/accident reports are reviewed, signed, and investigated by: a. The Administrator; and b. The Director of Nursing or the Assistant Director of Nursing.

Based on observation, interview, and record review, the facility failed to ensure interventions to prevent falls were implemented for 3 of 3 (R1, R2, and R3) residents reviewed for falls in the sample of 12.Findings Include: 1. R1's Transfer/Discharge Report with a print date of 6/15/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include kidney failure, heart failure, atrial fibrillation, diabetes, and anxiety disorder.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact.R1's Fall Risk assessment dated [DATE] documents a score of 21.0, which indicates R1 is at high risk for falls.R1's current Care Plan documents a Focus area of, I am at risk for fall/injury from weakness and tiredness: Date Initiated: 05/07/2026 Revision on 06/10/2026. This Focus area includes the following interventions, .Fall Intervention: Staff not to leave resident unattended in bathroom. Date Initiated: 05/19/2026.Reeducate resident to ask for assistance/help when needed. Date Initiated: 05/07/2026.Observed for increased weakness and tiredness and encourage rest periods as needed. Date Initiated: 05/07/2026.R1's Alleged Fall reports document R1 had falls in the facility on 5/5, 5/18, 5/30, and 6/5/26. R1's current Care Plan does not document a new fall intervention for the falls on 5/30 and 6/5/26.On 6/15/26 at 3:13 PM, V8 (Registered Nurse/RN) stated she didn't take care of R1 very often but was working on 6/5/26 when he fell. V8 stated she implemented the intervention of a pressure pad alarm to prevent future falls.On 6/15/26 at 11:36 AM, V9 (Power of Attorney/POA) stated after R1's fall on 6/5/26, the facility implemented a bed/chair alarm but she thought they should have implemented it before that fall. On 6/15/26 at 2:19 PM, V3 (Certified Nursing Assistant/CNA) stated R1's fall interventions include using a gait belt, side rails, and a chair/bed alarm.On 6/15/26 at 2:17 PM, V4 (CNA) stated she thought R1's fall interventions were to use a gait belt, side rails, and a bed/chair alarm.R1's Alleged Fall report dated 5/30/26 documents R1 was found on the floor in bathroom and documents R1 stated he was trying to use the bathroom and slipped on his bottom. The report documents there were no injuries noted. Under Notes the report documents, Resident hospitalized r/t (related to) increased confusion, CHF (congestive heart failure), abnormal labs. Will re-evaluate resident upon return to facility.On 6/15/26 at 3:48 PM, V2 (Director of Nurses/DON) stated R1 had a fall on 5/30/26. This surveyor reviewed R1's Care Plan with V2 and she stated there was no new fall intervention implemented after the fall on 5/30/26. V2 reviewed R1's Alleged Fall report dated 5/30/26 and stated it documents R1 was sent to the hospital on 6/1/26 and that was the fall intervention. When asked if that was an appropriate intervention to prevent falls, V2 stated it was not.2. R2's Transfer/Discharge Report with a print date of 6/15/26 documents R2 was admitted to the facility on [DATE] with diagnoses that include dementia, hypertension, lack of coordination, and polyneuropathy.R2's MDS dated [DATE] documents a BIMS score of 13, indicating R2 is cognitively intact.R2's Fall Risk assessment dated [DATE] documents a score of 14.0, indicating R2 is at high risk of falls.R2's current Care Plan documents a Focus area of I have had an actual fall. Date Initiated: 03/10/2026. This Focus area includes the following interventions. 12/27/25 educate to use call light before ambulating and refer to therapy 1/12/26 educate staff to ensure walker is within reach at all times, 1/20/26 offer a later bedtime with staff assistance, 2/8/26 ensure walker is within reach, 2/22/26 pressure alarm while in bed and up in recliner, 5/19/26 signage up to remind resident to ask for assistance.R2's Alleged Fall report documents the following:1/12/26 R1 was yelling for assistance and was found on his floor right outside of the bathroom and stated he couldn't find his walker, needed to go to the bathroom, and lost his balance after leaving the bathroom.1/20/26 R1 was found on the floor and was unable to give a description of how he fell.2/8/26 R1 was found on the floor by an unnamed CNA and was unable to describe how he fell.2/22/26 R1 was found lying on his floor just outside the bathroom. R1 stated he was trying to get back to bed and slipped.On 6/15/26 at 1:35 PM, R2 was sitting in his recliner which is situated near the head of his bed. R2's over the bed table was sitting in front of him and his walker was sitting against the opposite wall approximately three feet from the foot of R2's recliner. There was no pressure alarm visible under R2. The pressure alarm was sitting on R2's bedside table on the other side of the bed, not within R2's reach.On 6/15/26 at 2:11 PM, R2's walker was in the same position approximately three feet from his recliner, where he was sitting and his pressure alarm was still on the bedside table on the other side of the bed.On 6/15/26 at 2:40 PM, V10 (Vice President of Operations) walked with this surveyor to R2's room. R2's walker remained in the same position approximately three feet from his recliner where he was sitting and the pressure alarm was still on the bedside table on the other side of the bed. When asked if he went to the bathroom independently, R2 stated he did. When asked how he got to the bathroom when his walker was not within reach, R2 stated he finagled it around. R2 stated he doesn't use the call light for assistance.On 6/15/26 at 2:48 PM, V6 (Licensed Practical Nurse/LPN) stated she had taken care of R2 a couple of times and didn't know what his fall interventions were.On 6/15/26 at 3:04 PM, V7 (Certified Nursing Assistant/CNA) stated R2's fall interventions were to use a gait belt and walker. V7 stated she didn't know if R2 had a bed/chair alarm. V7 stated R2's walker was usually sitting by his dresser (where it was located during this surveyor's observations on 6/15/26) or in his closet. When asked if R2 used the walker, V7 stated he used it to go to the bathroom. V7 stated R2's walker was usually in reach but sometimes they moved it when they transferred R2's roommate.On 6/15/26 at 2:17 PM, V4 (CNA) stated R2 was at risk of falls, and his fall interventions were to use a walker with a gait belt and a staff member to assist as needed. V4 stated R2 also had side rails, and they left his door and privacy curtain open so they could check on him frequently when they walked by his room. V4 stated R2 did not have a bed/chair alarm as a fall intervention.On 6/15/26 at 2:19 PM, V3 (CNA) stated R2 was a fall risk and listed his fall interventions as side rails, walker, gait belt, open door and privacy curtain with frequent checks. V3 denied R2 having a bed/chair alarm as a fall intervention.On 6/15/26 at 3:48 PM, V2 (Director of Nurses) stated R2's fall interventions included a call don't fall sign, keep walker in reach, and a pressure alarm. When this surveyor asked V2 why R2 had the same intervention of keep walker in reach implemented after his falls on 1/12 and 2/8/26, V2 stated she wasn't an employee at the facility at that time, but she wouldn't have implemented the same intervention twice. This surveyor reviewed the observation of the pressure alarm being on R2's nightstand and not under him when sitting in his recliner, V2 stated sometimes he takes off the alarm, but he wouldn't have been able to get it off and then get it to the bedside table on the other side of the bed. V2 stated she would expect new and appropriate interventions to be initiated after a fall and would expect the interventions to be implemented.3. R3's admission Record with a print date of 6/17/26 documents R3 was admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of bone, heart disease, and diabetes.R3's MDS dated documents a BIMS score of 15, indicating R3 is cognitively intact.R3's Fall Risk assessment dated [DATE] documents a score of 3.0, indicating R3 is not at risk for falls. R3's current Care Plan does not document a Focus area or interventions to prevent falls.R3's Alleged Fall report dated 4/23/26 documents R3 was found sitting on the floor and reported her walker tipped over and she fell against the door frame and slid to the floor. There is no fall intervention documented in this report.On 6/15/26 at 10:32 AM, R3 stated she hadn't had any falls while in the facility.On 6/15/26 at 2:08 PM, V10 (Vice President of Operations) stated R3 did not have a fall Focus area or interventions to prevent falls on her current care plan.On 6/15/26 at 3:13 PM, V2 (Director of Nursing) stated R3 had one or two falls since being at the facility. V2 reviewed R3's current Care Plan and stated there was no Focus area or interventions in place to prevent falls and she would expect there to be.The facility Fall Prevention Program dated 11/28/12 documents, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness.

Based on interview, and record review the facility failed to prevent a fall from a wheelchair for 1 (R1) of 3 residents reviewed for accidents in the sample of 3. This failure resulted in R1 falling forward out of the wheelchair onto the floor resulting in an acute comminuted fracture of the distal left clavicle.The findings include:R1's admission Record documents an admission date of 6/20/2025 and included diagnoses of cardiac arrhythmia, essential hypertension, personal history of transient ischemic attack, hyperlipidemia, unspecified atrial fibrillation, gastro-esophageal reflux disease, gastritis, and age-related osteoporosis. R1's admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating R1 has moderate cognitive impairment. This same MDS under Functional Abilities and Goals documented R1 has no physical impairments on upper or lower body extremities and uses a wheelchair for mobility. This section also documents R1 needs supervision / touch assistance to wheel 50 feet with two turns once seated in wheelchair and R1 needs partial / moderate assistance to wheel 150 feet once seated in wheelchair. R1's Care Plan dated 07/28/2025 documented a Focus Area of I have had an actual fall with serious injury fractured left clavicle. Interventions listed include therapy evaluation for wheelchair positioning, and foot pedals related to the fall, continue interventions on the at-risk plan and physical therapy consult for strength and mobility. The facility's Report to Illinois Department of Public Health Regional Office with a date of 07/28/2025 documented Description of Occurrence: fall from wheelchair. Under Follow Up/Final Report Summary it is documented that R1 fell out of the wheelchair after toe caught on the floor while being pushed by staff. R1 had been holding her feet up and dropped her feet when the toe caught on the floor. R1 received a fracture to the left clavicle and orthopedics are following. There was no surgery required; R1 has to wear an immobilizer to the left shoulder as tolerated. R1 is working with therapy, and therapy will address wheelchair positioning. R1's Progress Note authored by V3 (Licensed Practical Nurse/LPN) dated 07/28/2025 with at time of 9:52 AM documented R1 had a fall this morning. V4 (Certified Nurse Assistant/CNA) was pushing R1 to the bathroom to get R1 changed and ready for the day. R1 dropped her feet she had lifted while V4 was pushing her and caught them under the wheelchair a little bit causing her to fall onto her knees out of the wheelchair and then fell onto her left side. R1 did not hit head as witnessed by this nurse. ROM (Range of Motion) is WNL (Within Normal Limits), denied pain, VS (Vital Signs) WNL, small, reddened area L (left) knee.R1's Progress Note authored by V3 dated 07/28/2025 with a time of 2:15 PM documented R1 complained of pain to this nurse of left shoulder. Tylenol administered and portable STAT 2 view L shoulder et (and) L arm x-ray called and ordered per physician.R1's Progress Note authored by V6 (LPN) dated 07/29/2025 with a time of 3:18 AM documented X-Ray company called to report possible fracture of left clavicle. V2 (Director of Nursing/DON) and nurse practitioner notified. New order received to send resident to local emergency department for evaluation and treatment.R1's Progress Note authored by V3 dated 07/29/2025 with a time of 10:20 AM documented in part, R1 arrived back from local hospital emergency department with fracture of left clavicle. New order for left arm sling to be worn at all times besides showering until follow up appointment with orthopedics.R1's Progress Note authored by V2 (DON) dated 07/29/2025 with a time of 11:19 AM documented, this note is a summary of the IDT (Interdisciplinary Team) Fall Committee Meeting Note. Please see assessment for full details. Summary of incident: CNA was pushing resident down the hallway to take her to the restroom. Resident dropped her feet and got them caught and she fell forward onto her knees out of the wheelchair and then fell on her left side. Did not hit her head. Root cause of fall determined by IDT: (this section is left blank). New interventions and/or changes suggested by the IDT at this time: refer to OT (Occupational Therapy) for wheelchair positioning and foot pedals for w/c (wheelchair). R1's Patient Report with a date of 07/28/2025 and a time of 8:35 PM documented under impression, (R1) has a deformity of the distal left clavicle, consistent with nondisplaced fracture. R1's Witnessed Fall report dated 07/28/2025 documented under Incident Description - CNA was pushing resident down the hallway to take her to the restroom. Resident dropped her feet and got them caught and she fell forward onto her knees out of the wheelchair and then fell to her left side. Did not hit her head.On 08/07/2025 at 11:44 AM, R1 was sitting in the dining room with a sling in place to her left arm. There were no wheelchair pedals noted to R1's wheelchair. R1 stated that she fell out of her wheelchair about two weeks ago. R1 stated her pain is ok and not a problem. R1 stated the girl was pushing her too fast in the wheelchair. R1 stated I told her to slow down, my knees don't work, and I couldn't hold up my legs any longer. R1 stated her legs got heavy and dropped down causing her to fall out of the wheelchair. R1 stated she has fallen a few times and fears getting hurt from falling. R1 stated she wheels the wheelchair with her hands and doesn't always use her feet. R1 stated that therapy gave her this new wheelchair after the fall. R1 stated that her old wheelchair was too heavy. R1 stated that the facility has never placed foot pedals on her wheelchair.On 08/07/2025 at 12:03 PM, V3 (LPN) stated on the morning of 07/28/2025, she was receiving report on the hall and saw R1 being pushed by V4 (CNA) in a wheelchair to the shower room. V3 stated that R1 had her feet up and then they dropped. V3 stated R1's feet went under the wheelchair and R1 fell forward onto the ground. V3 stated that V4 did not see R1's feet drop because she was pushing her from behind. V3 stated that R1 has never used foot pedals on her wheelchair because R1 uses her feet to self-propel around the facility. V3 stated that V4 was pushing R1's wheelchair at a normal pace. V3 stated she did not hear R1 tell V4 to slow down. V3 stated that after the fall, she immediately assessed R1 for injuries and her range of motion was within normal limits. V3 stated several hours later R1 complained about pain in the shoulder area. V3 stated she gave her Tylenol and called the doctor to get an order for an X-ray. V3 stated that R1 doesn't complain of pain and is doing ok with the sling on.On 08/07/2025 at 12:42 PM, V5 (Therapy Director) stated that she does not recommend or use wheelchair pedals because they are a restraint. V5 stated that if a resident can self-propel a wheelchair, then you cannot place foot pedals on the wheelchair. V5 stated that R1 moves herself around the facility usually without staff assistance. V5 stated she was never made aware by facility staff that R1 was supposed to be evaluated for foot pedals. V5 stated she was never really told about the incident with R1 falling out of her wheelchair and was not told that the intervention was to have Occupational Therapy evaluate foot pedals. V5 stated she is unsure why staff would be pushing R1's wheelchair. V5 stated that staff are able to get foot pedals anytime they feel the need to. On 08/07/2025 at 12:53 PM, V4 (CNA) stated that she was the CNA that was pushing R1's wheelchair when she fell out of it. V4 stated that R1 was on her way to the bathroom and was having trouble getting there by herself. V4 stated that she decided to help R1 by pushing her since she was struggling. V4 stated suddenly R1's legs dropped, and her foot went under the wheelchair causing her to fall out of the wheelchair. V4 stated that R1 usually propels herself in the wheelchair to the restroom and only needs help with care. V4 stated that she is not sure why R1 dropped her legs and never heard R1 say to slow down.On 08/07/2025 at 12:56 PM, V5 (Therapy Director) stated she looked back in her notes and on 08/06/2025, she started educating staff on proper pushing of residents in wheelchair and wheelchair safety. V5 stated that she put foot pedals in R1's room in case she is sick or too weak to hold her legs up and needing assistance with her wheelchair. V5 stated that even if she would have completed the evaluation, she would not recommend foot pedals for a resident who uses her feet to self-propel around the facility. On 08/07/2025 at 12:59 PM, V2 (DON) stated that if foot pedals are not a restraint, then why in nursing school where we told that if they were on, they had to be down otherwise they could not be on. V2 stated the manufacturer of wheelchairs states that if the foot pedals are on a wheelchair, they have to be down, that foot pedals cannot be on a wheelchair and folded up.On 08/07/2025 at 1:05 PM, V1 (Administrator) stated that she went back to review morning meeting minutes. V1 stated that on 07/28/2025 and again on 07/29/2025, R1's fall was discussed. V1 stated that on 07/29/2025, therapy was told in morning meeting that R1's wheelchair needed to evaluate for foot pedals. On 08/07/2025 at 2:12 PM, R1 was observed to be self-propelling her wheelchair in the hallway. R1 was scooted up in the wheelchair seat to the edge and was bent forward. R1 would move her feet and rock her upper body at the same time to propel her wheelchair. R1's left foot was observed to be dragging occasionally on the floor while she was self-propelling. R1's left foot would appear to get stuck on the floor while she was self-propelling her wheelchair though the hallway corridor. On 08/07/2025 at 2:46 PM, V1 (Administrator) stated that R1 fell on [DATE] and didn't complain of pain until later in the afternoon. V1 stated that R1 was sent out after the results of the x-rays came back to the facility. V1 stated that on 07/29/2025 in morning meeting, R1's fall was discussed again, and the intervention chosen was to have therapy evaluate R1 related to wheelchair positioning and the need for foot pedals. V1 stated she was not aware until today that therapy had not evaluated R1 for foot pedals. V1 stated that R1 has continued working with therapy after the fall. V1 stated that her understanding of the fall was V4 was pushing R1 to the bathroom and R1's legs dropped. V1 stated that it was explained to her while investigating the fall that R1's toe got caught causing her to fall out of the wheelchair. V1 stated that prior to the fall, R1 rarely asked staff to help her in the wheelchair. V1 stated that staff education started on 07/31/2025 by V2 (DON) and on 08/06/2025 by V5 (Therapy Director). V1 stated that R1 has foot pedals in her room that staff can use when they need too. V1 stated the education that was done was wheelchair positioning, taking your time while pushing a resident in a wheelchair, and use foot pedals when needed. V1 stated that R1 will see the orthopedic doctor on 08/13/2025.On 08/07/2025 at 2:57 PM, V2 (DON) stated that not all staff have been educated on wheelchair safety yet. V2 stated that some staff haven't worked or forgot to sign the education sheet when they were in serviced. V2 stated she was not aware that therapy had not evaluated R1's wheelchair for foot pedals. V2 stated that R1's interventions are making sure staff are more aware of resident's positioning while in wheelchair while transporting and to follow up with therapy. V2 stated the education she completed with staff was on proper wheelchair safety and while pushing a resident in the wheelchair to remind them to keep their feet up. V2 stated that if a resident can't keep their feet elevated while pushing them in a wheelchair, the resident should already have foot pedals on the wheelchair. V2 stated that R1 has had minimal pain since the incident and continues to self-propel herself in the wheelchair throughout the facility.Facility policy titled Fall Prevention Program with a revision date of 11-21-17 documents under purpose To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.

Based on observation, interview, and record review, the facility failed to ensure bed rails/side rails were installed in accordance with doctor's orders to prevent injury for 1 of 5 resident (R4, R5, R6, R9, and R10) reviewed for bed rails in the sample of 17. The failure resulted in R4 sustaining a fracture of left humerus bone in left upper arm. Findings include: R4's admission record documented R4 was admitted to the facility on [DATE] and included diagnoses of nondisplaced [NAME] fracture of right tibia, multiple fractures of ribs, left side, multiple fractures of ribs, right side, mood disorder, alcohol abuse, anxiety, insomnia, and chronic obstructive pulmonary disease. R4's Minimum Data Set (MDS) dated [DATE], documents R4 has a Brief Interview for Mental Status score (BIMS) of 14 indicating R4 is cognitively intact. MDS section GG documents R4 has no impairment in upper or lower extremity range of motion. It documents that R4 uses a manual wheelchair for mobility. MDS documents that R4 is dependent for shower/bathing, upper and lower body dressing, and personal hygiene. MDS documents that R4 is dependent for rolling left and right in bed, and for changing positions from lying to sitting to standing and vice versa. MDS documents that R4 is dependent for transfers from bed to wheelchair and back and for toileting. MDS section P (physical restraints) documents that bed rails are not used. R4's care plan dated 3/29/25, documents R4 has a focus area that R4 has been assessed to need bedrails with a date of 4/24/25 initiation. Interventions for this focus area with a date initiation of 4/24/25 are to, Assess quarterly and with change in condition for risks and benefits. Attempt alternatives prior to bed rail utilization. Check bed and bed rail routinely for maintenance and functionality. Consider reduction/removal of rails when appropriate/requested. R4's side rail assessment in her dated 3/29/25, documents that R4 has no conditions that put this person at risk with a rail. Side rail assessment further documents that there are no determined risks for use of side rails. Side rail assessment documents that the least restrictive rail device that was appropriate for R4 is half rail-right and half rail-left. R4's Electronic Health Record (EHR) documented under Orders tab an order dated 4/9/25 ordered by V5, NP (nurse practitioner) for side rails bilaterally (both sides) to be used for positioning. Size of rails was not specified in the order. R4's Facility Injury report dated 5/13/25 by V12's Licensed Practical Nurse (LPN) documents under description, found resident in bed in supine position with LUE (left upper extremity) in between side rail, very painful to touch, arm easily removed, deformity observed to upper arm, extremely painful, ambulance called. Resident description, I was reaching for something and got stuck. This report documents that side rails were in up position and that R4 was reaching for something with arm through side rail. R4's EInteract Transfer form dated 5/13/25 documents R4 was transferred to local hospital on 5/13/25 from facility for complaint of severe left arm pain. The form documents R4 had a pain level of a 10 at the time. R4's Local hospital's emergency department records dated 5/13/25 documents, Pt (patient) got arm stuck in rails. Emergency department records also documents R4's pain was severe enough she was administered Fentanyl 100mcg (microgram) in route to local hospital from facility. R4's Local hospital emergency room records dated 5/13/25 at 7:50 PM, documents that R4 had a diagnosis of fracture of shaft of left humerus (bone in upper arm). emergency room records documents Pt. (Patient) felt a pop in left arm pulling herself across bed. X-ray report from local hospital records dated 5/13/25 documents fracture of humeral shaft with markedly displaced overlapping ends. R4's Hospital's discharge records document R4 was discharged back to the facility on 5/19/25. On 5/20/25 at 7:50 PM, V15, (Certified Nurse's Aide/CNA) stated that the day R4 had her accident related to the side rails, V15 had just helped R4 with a shower and toileting. V15 stated that she had left the room to assist someone else. Within a few minutes of leaving R4's room she stated she heard someone yelling for help down the hallway. V15 stated that she located the yelling at R4's room went in and found R4 lying in bed with her arm through the side rail. V15 stated, It (left arm) looked disfigured. R4 told me she heard a pop. V15 stated that R4 wiggles and worms a lot in bed. V15 stated that R4 uses her bed rails to help her roll and turn in bed. V15 stated that the nursing staff in coordination with the resident or resident's family makes the decision whether to use bed rails on a resident's bed. V15 stated that the style of bed rails on R4's bed at the time of the incident were quarter rails. On 5/21/25 at 1:05 PM, V15 (CNA) showed this surveyor how R4 had her entire arm between the two top pieces of tubing of the bed rail. V15 stated that R4's arm was easily removed from the rails, and it wasn't wedged or stuck when she found R4. V15 stated that R4 had told her she was reaching for her TV remote when she got her arm stuck in the rail. V1's (Administrator) written statement included in the facility's investigation of incident regarding R4 dated 5/13/25 at 3:45 PM, documents that she was present at the time of R4's injury related to side rails. V1's statement documents that R4 was diagnol (sic) in her bed, her arm through the bed rail @ (at) a 90 (degrees symbol), wrist downward and top of wrist touching inside of rail. V1 documents that she asked R4 what happened and R4 told her that she was reaching for her TV remote on nightstand and heard a pop and felt pain. V1 documents that R4 told her that she hadn't done anything to make her arm pop. V1 documents that R4 told her she had not hit her arm on the side rail to her knowledge. R4's final report via email sent into Illinois Department of Public Health dated 5/20/25 at 7:53 PM documents, On 5/13/25 at 3:45 PM, R4 was found with her arm in compromised position. Injury to left arm. Pain and unable to perform range of motion. R4 was sent to the emergency room for treatment. At the hospital R4 was diagnosed with an displaced overriding mid shaft humerus fracture. This report includes a typed statement from V1's (Administrator) that includes, Intervention put in place to change side rails from ¼ to ½ bilateral side rails to prevent further injury and allow (R4) to have better ROM (range of motion). Care plans (sic) and orders have been updated to reflect current status. On 5/20/25 at 10:33 AM, this surveyor observed R4 rolling herself around in her wheelchair using both arms. Noted that there was a brace/soft cast on hand and forearm of left arm. On 5/20/25 at 10:33, AM R4 stated that she had broken her left upper arm three different times. R4 stated that this time she was playing with the kids and they hit her with a soft ball causing it to break. Another time, also while playing with the kids, they hit her with a bowling ball and broke the same arm. R4 stated that she broke her left arm the first time by getting it caught in the bed rail, but that had happened a couple of years ago. It was observed by this surveyor that R4 is oriented to person and time, but not to place and that R4 is a poor historian. On 5/21/25 at 9:05 AM, V5 (Nurse Practitioner) stated she has only seen R4 a few times. V5 stated she does give orders for bed rails, and she does specify what size to be placed on the resident's bed. V5 stated that she did not remember what size she originally ordered for R4 or if she was the one that had ordered them because she had just started on March 10th of 2025. V5 stated that she thinks residents are assessed three times per year to decide if they still need the rails ordered for them. V5 stated that she sees all the residents in the facility once per month, and at that time she herself would assess resident's need for side rails. V5 stated she was not sure why R4 had quarter rails on her bed instead of half rails (that were recommended in the side rail assessment dated [DATE]) at the time of her injury. V5 stated that she did believe R4 should continue to have side rails because R4 has a history of a stroke that's caused weakness, and she needs them to help her turn and reposition herself in bed. V5 stated that however she's not sure if the benefits outweigh the risks for use of side rails for R4 because of her restlessness at night and her recent fracture of the left arm related to side rails. On 05/15/25 2:07PM, V6 (Maintenance Supervisor) stated that he just removed 1/4 rails off R4's bed today. He said that he was told to take them off and he did it today. He said that they weren't half rails that R4 had they were quarter rails. On 05/15/25 at 2:10PM observed R4's bed and rails that were taken off by V6. Bed rails were quarter rails that raise up and lay down next to bed. V6 said those are the rails that fit the bed. On 05/15/25 at 2:50PM, V1 stated that R4 takes her arms and puts them through the side rails and moves her arms all around in the side rails often. V1 said that she doesn't know if R4 has some psychosis or something going on. V1 said that she does unusual things like this at times. On 5/21/25 at 9:45 AM, V2 (Licensed Practical Nurse (LPN)/MDS Coordinator) stated that R4's MDS section P doesn't list side rails as a restraint because they aren't being used as one but only to promote bed mobility. V2 stated that's the way she was trained to fill out the MDS. If side rails weren't being used as a restraint, they were not listed in section P of the MDS. V2 stated that residents are assessed upon admission, then quarterly, and as needed for need for side rails. V2 stated the nurses do a side rail assessment to determine if residents need them, then notify the practitioner for orders, and maintenance installs them on the bed. V2 stated that she believes R4 does need side rails to help her with her bed mobility and to assist with transfers in and out of bed. V2 stated that when the nurses did the side rail assessment for R4 they did determine she needed half rails, and then passed it onto maintenance that side rails needed installing on R4's bed. V2 stated that she didn't believe the nurses told maintenance specifically what size side rails to put on R4's bed. V2 stated that she isn't sure if the benefits outweigh the risks for R4's side rails. V2 stated that she doesn't believe that changing from quarter side rails to half side rails will decrease the risk of injury to R4 related to side rails due to R4's cognition. V2 stated that R4 is often confused about where she is at. That R4 often yells out at night and bangs on and rattles her side rails when she gets confused. V2 stated that after R4's injury the only new intervention put in place regarding side rails was to change them from quarter size to half size rails. On 5/21/25 at 1:47 PM, V11 (Registered Nurse/RN) stated that she had never had training on how to assess a resident's need for side rails. V11 stated that she goes by the side rail assessment and what the results of that recommend. V11 said that to determine the risks versus benefits for using side rails for a specific resident she would consider the resident's cognition, ability to reposition self, and so on. On 5/21/25 at 1:55 PM, V12 (LPN) stated that she doesn't remember receiving any training on completing side rail assessments. V12 stated that to determine need for side rails for each resident she goes by what the answers to the questions on the side rail assessment recommends. V12 stated they also take into consideration resident's need for side rails by their mobility in bed. If the resident is independent in bed mobility, they install them to assist with bed mobility. On 5/21/25 at 2:00 PM observed R4 lying in bed. She was in a supine position. She was able to use her right arm and hand to grab hold of her side rail on the right side to change position in bed. This surveyor asked her what if she needed to roll to the left side since there is no rail on that side, and she stated that she just hopes she doesn't need or want to. R4 stated that overall, the side rails help her to move in bed and protect her from rolling out of bed. On 5/21/25 at 10:08 AM, V6 (Maintenance Supervisor) stated that the nurses are supposed to fill out a work order when side rails are to be installed on a resident's bed. V6 stated that he didn't know he was supposed to ask what style or size of bed rails to install for a specific resident. He stated that in the past he has put on the bed rails that fit the particular bed frame. On 5/21/25 at 12:35 PM, V6 showed this surveyor the same style and make of bed that R4 was reportedly using at time of her injury. The rails on that bed did have some play in them causing a gap of approximately 1.5 inches with pressure applied by this surveyor. There was only three quarters of an inch gap if not applying pressure to the side rail. V6 stated that installing bed rails are very simple. The rails slide on and then there's two nut and bolts tightened down to secure them. V6 stated that he didn't have instructions to install them, but they are simple to install. On 5/21/25 at 2:05 PM, V6 stated he found the instructions for installation of side rails for the bed R4 was using, but not all the beds. V6 stated that according to the manufacturer's instructions he had been installing them correctly. Facility's bed rail policy dated 4/10/18 documents, The facility shall ensure the bed is appropriate for the resident and that bed rails are properly installed and maintained.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 5 residents (R1) reviewed for care plans in a sample of 5. Findings include: R1's admission record dated [DATE], documents an admitted [DATE] with diagnoses in part of unspecified dementia, depression, hypertension, polyneuropathy, idiopathic urticaria, and hyperlipidemia. R1's MDS (Minimum Data Set) dated [DATE] documents in Section C a BIMS (brief interview for mental status) score of 7 which indicates severely impaired cognition. Section D - Mood documents no mood indicators present. Section E- Behaviors documents no behavioral indicators. Section GG- Functional Abilities documents toileting as partial/moderate assistance, Shower/bathe as substantial/maximal assistance, personal hygiene as partial/moderate assistance. Sit to stand as substantial/maximal assistance. Section V Care Area Assessment Summary Documents Cognitive loss/Dementia as Care Area triggered, ADL (Activities of Daily Living)/rehabilitation potential care area triggered, Urinary incontinence and indwelling catheter as a care area triggered. Nutritional status as a care area triggered, Pressure ulcers as a care area triggered. R1's current Care Plan documents a Focus area of R1 (I) am a Full Code. Attempt resuscitation, CPR (Cardiopulmonary Resuscitations), including intubation and mechanical ventilation with a date initiated of [DATE]. A focus area of R1 (I) was recently admitted to facility. Has a need to adjust to situation and life changes. Interest includes music, dogs, and going outside with a date initiated [DATE]. A focus area of R1 (I) have expressed a desire to remain for permanent placement with a date initiated of [DATE] and revision date of [DATE]. Another focus area of R1 (I) have had an actual fall with (specify: no injury, minor injury, serious injury) poor balance with a date initiated of [DATE]. No other focus areas noted on care plan. On [DATE] at 11:45AM, V3 (MDS/Care Plan Coordinator) stated she has not had the time to finish and complete R1's comprehensive care plan. V3 stated she should have had focus areas addressed on the care plan regarding cognition, ADL functions, Urinary Incontinence, Nutrition, and Pressure ulcer risk everything that triggered in Section V of the Admission MDS dated [DATE]. V3 stated that she has been working the floor often and doing other duties and has not had time to work on completing R1's care plan. V3 stated that she did have a care plan meeting with R1 and his power of attorney (POA) on [DATE]. V3 said that her and V5 (Social Service Director) were the ones who had the meeting with the R1 and his POA. On [DATE] at 1:00PM, V8 (Registered Nurse/RN) stated that she has cleaned R1's nails multiple times, but that R1 has a problem with digging in his rectum and trying to dig poop out with his fingers. V8 stated that this has been going on the past couple of weeks. V8 stated that they got a medication for R1 to see if he is constipated. V8 stated that R1 also has a problem with refusing care often. V8 said that R1 will refuse showers at times, refuse to get up to go to the bathroom and refuse to get out of bed. V8 said that they did start R1 on a antidepressant as well to help with his mood. On [DATE] at 2:41PM, V7 (RN) stated that R1 will dig in his rectum often and get feces on his hands. V7 said they try to clean R1's nails often. V7 stated that R1 will refuse care often such as showers, toileting and getting out of bed. V7 said that they did get R1 a medication to help him have bowel movements to see if this helps with him digging in his rectum. V7 said that she is never invited to attend care plan meetings. On [DATE] at 10:50AM, V11 (Certified Nurse Assistant/CNA) stated that R1 will refuse care often. V11 said that R1 will be incontinent of bowel and stick his hands in it. V11 said that R1 will refuse to get out of bed and refuse to go to the bathroom. V11 stated she is never invited to attended care plan meeting. On [DATE] at 11:00AM, V12 (CNA) stated that R1 refuses care often. V12 stated that he knows that R1 will dig in his rectum often and then get feces on his hands. V12 stated that he reports the behavior to his nurse. V12 stated that he has never been invited to attend care plan meetings. On [DATE] at 11:02AM, V13 (CNA) stated that R1 will refuse care often. V13 said that R1 will refuse to get out of bed. On [DATE] at 11:10AM, what V3 (MDS/CPC) stated that she does know that R1 refuses care often. V3 said staff has said that R1 is refusing care. V3 stated that she is going to work on R1's care plan and make sure she addresses all R1's triggered care areas and address his refusal of care and other problem areas such as R1 digging poop out of his rectum and getting BM (bowel movement) under his nails and on his hands. V3 said she was going to start working on R1's care plan right away. The facility policy titled Comprehensive Care Plan with a revision date of [DATE] documents in part under purpose 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. Guidelines documents in part under A comprehensive care plan must be: developed within 7 days after completion of the comprehensive assessment, Prepared by an interdisciplinary team that includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutritional service staff, and to the extent practicable, the participation of the resident and the resident's representative.

Based on interview and record review the facility failed to ensure medications were properly labeled and not accessible to residents and unlicensed staff for 1 (R1) of 4 residents reviewed for medication storage in the sample of 4. The Findings Include: R1's Admission Record documented that R1 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses listed as acute cystitis, pain in left knee, need for assistance with personal care, unspecified osteoarthritis, type 2 diabetes mellitus, essential hypertension, pain in joint and localized edema. R1's MDS (Minimum Data Set) with a date of 02/04/2025, documented as an admission set coded section C0500 BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. R1's Order Summary Report with a print date of 02/07/2025 documented an order for diclofenac sodium (topical Nonsteroidal Anti-inflammatory Drug/NSAID) external gel 1%, apply to left knee, four times a day for left knee pain with a start date of 01/29/2025. On 02/06/2025 at 9:06 A.M. R1 stated there was a cup of cream left at his bedside that V11 (Certified Nurse Assistant/CNA) applied to his abdominal fold. R1 stated that as soon as it was placed on his skin, he knew it was the wrong cream because he felt tingly and hot. R1 stated that V11 immediately cleaned it off and V12 (Registered Nurse) applied the appropriate cream to his abdominal folds. On 02/06/2024 at 12:34 P.M. V2 (Director of Nursing) stated that she thinks what happened with R1 and the cream incident was the nurse left the diclofenac sodium gel in a cup that she had used on his knee. The nurse did not discard the cup with the excess gel in it. V2 stated that during the day on 02/01/2025, the CNA's were in the room providing care to R1 and just automatically placed the cream in his abdominal folds not knowing what it was. V2 stated that it is her expectation that cream not be left at the bedside in unlabeled cups. On 02/06/2025 at 1:31 P.M. V11 (Certified Nurse Assistant) stated on 02/01/2025 she was providing care to R1. V11 stated that R1 was a little red under his abdominal fold and she noticed a cup of cream on the bedside table. V11 stated the cup was not labeled with what the contents were. V11 stated that she just picked up the cream and applied it to R1. V11 stated that she thought the cream in the cup was the barrier cream to be applied to R1's abdominal fold. V11 stated that R1 said that it didn't feel right and that it felt tingly / stinging. V11 stated that she immediately wiped it off and told the nurse. V11 stated that V12 then applied cream to R1. On 02/06/2025 at 2:07 P.M. V10 (Registered Nurse) stated that she was working the night shift on 1/31/2025 and had put the gel on R1's knee. V10 stated there had been an emergency and she left the cup sitting in R1's room with the leftover gel in it. V10 stated with the distraction of the emergency she forgot to go back and get the cup and throw it away. On 02/06/2025 at 2:17 P.M. V12 (Registered Nurse) stated she was the nurse taking care of R1 when V11 put cream on his abdominal fold. V12 stated V11 was in the room providing care to R1 when she put cream that was in an unlabeled cup on R1's abdominal fold. V12 stated that the resident immediately told the staff that it was stinging and they wiped it off. V12 stated the cream was on R1 for 2-3 minutes max. V12 stated that R1's skin had no adverse effects from the wrong cream being put on. V12 stated the correct treatment of the barrier cream was then applied. V12 stated that it is the facility policy to not leave medications in cups at the bedside. The facility policy titled Storage of Medications (undated) documented under Policy - Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure step 1 documents The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medications from one container to another or return partially used medication to the original container.

Based on interview, observation, and record review, the facility failed to implement Enhanced Barrier Precautions per current standard of practice for 2 (R22 and R25) of 2 residents reviewed for infection control in the sample of 25 Findings Included: 1. R25's Admission Record documented an Initial admitted [DATE]. R25's Admission Record also included diagnoses of retention of urine, unspecified, type 2 diabetes mellitus without complications, hypo-osmolality, and hyponatremia. R25's Physician Orders dated 10/1/24 documented a foley catheter in place. R25's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R25 was cognitively intact. On 10/22/2024 at 9:37 AM, prior to entering R25's room, there was no signage noted nor any Personal Protective Equipment (PPE) observed to be present or available by R25's room to indicate that enhanced barrier precautions were in place. On 10/22/2024 at 9:39AM, R25 sitting on her bed and appeared to have an indwelling catheter in place. R25 was alert and oriented and stated she had an indwelling catheter in place. R25's indwelling catheter bag was observed next to R25's bed. On 10/22/2024 at 12:26 PM, V5 (Registered Nurse/RN) stated that there is no resident on isolation or transmission-based precautions in the facility at this time. On 10/22/2024 at 1:29 PM, V3 (Certified Nurse Assistant/CNA) and V4 (CNA) gathered catheter care supplies for R25. During initial set up for R25's catheter care, V3 gathered a basin, towels, wash cloths, soap, trash bag and extra gloves. V3 and V4 did not wear a barrier gown during catheter care for R25. On 10/22/2024 at 1:32 PM, V3 and V4 both stated, there are no residents on isolation or transmission-based precautions in the facility. 2. R22's Admission Record documented an Initial admitted [DATE]. R22's Admission Record also included diagnoses of retention of urine, unspecified, chronic kidney disease, stage 3, unspecified and type 2 diabetes mellitus with diabetic neuropathy, unspecified. R22's Physician Orders dated 9/20/24 documented a foley catheter in place. R22's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R2 was cognitively intact. On 10/22/2024 at 9:45 AM, prior to entering R22's room, there was no signage noted nor any PPE observed to be present or available by R22's room to indicate that enhanced barrier precautions were in place. On 10/22/2024 at 9:46 AM, R22 was lying in bed and had an indwelling catheter bag hanging on the side of her bed. R22 was alert and oriented and stated she had an indwelling catheter in place. On 10/22/2024 at 1:50 PM, V2 (Director of Nursing-DON/Registered Nurse-RN) stated, she was unaware of any enhanced barrier precautions policy or procedures, and she would need to reach out to (the) corporate office. On 10/22/24 at 2:22 PM, V2 stated she received the Enhanced Barrier Precautions (EBP) policy and procedure from the facility's corporate office. V2 stated the facility did not know about EBP prior to receiving the EBP policy today. On 10/24/2024 at 10:15 AM, V1 (Administrator) stated the facility had not been made aware of the Enhanced Barrier Precautions policy and procedure prior to 10/22/2024. On 10/22/2024 a Matrix for Providers (form CMS 802) was provided by the facility with two residents marked for indwelling catheters and no residents marked with transmission-based precautions. The facility policy titled Enhanced Barrier Precautions (undated) documents Enhance Barrier Precautions (EBP) should be used when contact precautions do not apply, for residents with any of the following: Open wounds that require a dressing change, indwelling medical devices and infection or colonized with a MDRO (Multidrug-Resistant Organisms). According to https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Under Implementation, the following is documented: When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves.

Based on interview and record review the facility failed to have a licensed administrator licensed in accordance with state law. This failure has the potential to affect all 33 residents residing in the facility. Findings include: On [DATE] V1's Administrator license that was posted on the wall titled Licensed Nursing Home Administrator Temporary documented an expiration date of [DATE]. On [DATE] at 3:37 PM, V1 (Administrator) via phone stated her temporary license expired on [DATE]. V1 stated temporary license are only valid for 2 years. V1 stated she received her temporary license in 2021. V1 was asked if she was working under a Licensed Administrator and V1 stated I didn't know. On [DATE] at 3:46 PM, V3 (Regional Director of Operations/RDO) stated she will become the Regional Director for this facility in November. V3 stated V4 is the RDO for this facility currently. V3 stated there is no licensed administrator employed at this facility at this time. V3 stated V4 does not utilize her Administrator license for this facility. On [DATE] at 3:00PM, V2 (Director of Nursing/DON) stated V1 does not have a license and her temporary licensed has expired. V2 stated it is due to V1 not passing the exam to acquire an Administrator License. V2 stated V1 is out today with illness. V2 stated the Regional Administrator is on vacation and is unavailable. V2 stated the facility has not had any issues related to the administrator issues that she is aware of. The Facility Census sheet dated [DATE] documents there are 33 residents residing in the facility. Illinois Administrative Code title 77, 399.510 documents a) There shall be an administrator licensed under the Nursing Home Administrators licensing and Disciplinary Act .full-time for each licensed facility.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for 2 of 25 residents (R20, R33) reviewed for care plans in a sample of 25. Findings include: 1. R33's Face Sheet documents an admitted [DATE]. R33's Physician Order Sheet documents diagnoses including Anemia Thrombocytopenia and CVA (Cerebral Vascular Accident). R33's Baseline Care Plan documents an admitted [DATE]. R33's Baseline Care Plan has three falls, follow up interventions from 09/26/23 written on it. There was no Comprehensive Care Plan for R33 provided for review. On 11/01/23 at 10:30 AM V4 (Care Plan Coordinator) stated they do not have a comprehensive care plan for R33 or any other care plan besides the baseline care plan for R33. V4 stated, they do not have access to their computer system and did not think to make a paper copy of the care plan for the newer admissions. V4 said they typically only print off their care plans once a year and then just write on them any updates, so she wrote the updated fall interventions on R33's Baseline Care Plan. V4 stated the Certified Nurse Aides (CNA's) can find the different information they need for care in the resident's charts and different information gets passed during shift change meeting. On 11/02/23 at 2:15 PM V2 (Director of Nursing) stated, R33 has had weight loss, he is a tube feed, he does need assistance with ADLs (Activities of Daily Living), he had a stroke and does need assistance. On 10/30/23 at 11:00 AM R33 stated, he had a stroke, and he can't do anything anymore, all he can do is lay here. 44492 2. R20's Face Sheet documents that R20 was admitted to the facility on [DATE] with diagnoses of hip fracture, chronic deep vein thrombus (dvt), cellulitis, hiatal hernia, spinal stenosis, hypothyroidism, hypertension, urinary retention, pressure injury of left thoracic region of back, Stage 3. R20's Minimum Data Set (MDS) dated [DATE] documents Section C, Brief Interview for Mental Status (BIMS) score is 15, cognitively intact, Section GG, Functional Abilities and Goals, Partial/Moderate Assistance with eating, Dependent with oral hygiene, toileting, bathing, dressing, bed mobility, transfers. On 11/01/2023, at 12:30 PM, there was no Comprehensive Care Plan for R20 available for review. On 11/01/2023, at 1:30 PM, V4 (MDS Coordinator/LPN) stated that the facility's computer system has been down, and she has not been able to complete the care plan. On 11/02/2023, at 8:45 AM, V4 was observed writing out R20's Comprehensive Care Plan and was given to surveyor for review.

Based on interview, and record review the facility failed to implement new and applicable interventions to prevent further falls for 1 of 3 residents (R9) reviewed for falls in a sample of 25. Findings include: R9's Face Sheet documents an admitted [DATE]. R9's Physician Order Sheet dated 11/01/23 documents diagnoses including: [NAME] korsakoff syndrome, hypertension, anxiety, dementia with behaviors, and a left hip fracture. R9's Minimum Data Set (MDS) dated [DATE] documents a Brief interview for Mental Status (BIMS) of 11 indicating R9's cognition is moderately impaired. Section GG documents R9's Functional Abilities as: Partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for chair/bed - to - chair transfers, toilet transfers and sit to stand. R9's care plan dated 01/03/23 under the category titled, Falls documents an intervention dated 11/24/22 of first toileted after meals, 11/29/22 remove food from room when finished, on 12/24/22 an intervention of: encourage and assist placement of proper non-skid footwear, on 12/27/22 the intervention of: toilet every 2 hours is documented, on 03/29/23 the fall intervention documented is: skilled therapy eval (evaluation) & tx (treatment). The same care plan for R9 dated 01/03/23 under the category titled, ADL (Activities of Daily Living) Function Rehab. (Rehabilitation) documents: a fall on 01/30/23 due to transferring self to bed with an intervention of re-education, rehab, and therapy PT/OT (Physical therapy/Occupational therapy) and a fall on 02/09/23 due to transferring self to bathroom with an intervention of toileting program. The facility document dated, May 2023 titled, Fall Analysis Log documents a fall by R9 on 05/10/23 at 9:21 AM with a root cause of: self-transfer without asking for asst (assistance) with an intervention listed as: visual aid in place for assistance with transfers and a fall by R9 on 05/18/23 at 19:20 (7:20 PM) with the root cause documented as: resident room took self to bathroom, pulling up pants, fell lost balance not asking for assistance with no new intervention documented. R9's care plan dated 01/03/23 under the category titled, Cognitive Loss/Dem (Dementia) documents: 05/18/23; follow up for the fall with the intervention documented as: noncompliance to staff assist (assistance) R/T (related to) transfers and ambulation. The facility document dated, July 2023 titled, Fall Analysis Log documents a fall by R9 on 07/24/23 at 05:25 (5:25 AM) with the place of fall listed as shower room, injury type listed as left knee abrasion, and the root cause listed as: cognition, unwillingness to wait for assistance with the intervention in place listed as: alarm mat on floor and the new intervention listed as: never leave alone in bathroom unattended. R9's care plan dated 01/03/23 under the category titled, Cognitive Loss/Dem (Dementia) documents: 07/28/23; follow up to the fall on 07/24/23 with the intervention documented as: never leave in bathroom unattended, the root cause listed as unwilling to wait. The facility document dated, October 2023 titled, Fall Analysis Log documents a fall by R9 on 10/01/23 at 16:00 (4:00 PM) with the place of fall listed as: residents room and the injury type listed as: redness to right side of rib cage with the root cause listed as: transferring self to wc (wheelchair) to get socks/balance with the intervention in place listed as: alarm mat on floor (d/c) (discontinued) and the new intervention documented as: frequently used items in reach/CNA (Certified Nurse Aide) apply socks in AM. R9's care plan dated 01/03/23 under the category titled, Cognitive Loss/Dem (Dementia) documents: 10/03/23; follow up to the fall on 10/01/23 with the root cause listed as balance and the intervention documented as: frequently used items in reach/CNA (Certified Nurse Aide) applies socks when getting dressed in the AM. The facility document dated, October 2023 titled, Fall Analysis Log documents a fall by R9 on 10/07/23 at 20:00 (8:00 PM) with the place of fall listed as: residents room and the injury type listed as: leg pain right femoral neck fracture, hospital listed as: ER (emergency room ), root cause is listed as: balance with the intervention in place documented as: frequently used items in reach, and the new intervention documented as: follow up to ortho (orthopedic) due to fracture to see about tx (treatment) plan. R9's care plan dated 01/03/23 under the category titled, Cognitive Loss/Dem (Dementia) documents: 10/09/23; follow up to the fall on 10/07/23 with the root cause listed as balance and the intervention documented as: follow up with ortho regarding the compression Fx (fracture) to the (R) (right) hip to see about tx (treatment) plan. On 11/02/23 at 1:20 PM R9 stated, when he fell in the bathroom, he can't say how long he waited but it seemed like a really long time. He tries to wait but sometimes it seems like a really long time or sometimes he gets impatient now because his hip still hurts, and he wants to get the weight off of it. On 11/02/23 at 2:10 PM V2 (Director of Nursing/DON) stated, there should not be the same interventions used more than once, she does see where placing nonskid footwear on R9's feet was an intervention used on 12/24/22 and again on 10/03/23 and CNAs should put socks, or socks and shoes, on the residents when they are assisting them to get dressed in the morning. Sending a resident to the orthopedic doctor is not a good intervention, it does not help prevent any falls. The toileting program is usually toilet every two hours, but most residents need to use the toilet after they eat and that intervention was used on 11/24/22 and 12/27/22 respectively, then on 02/09/23 the intervention of a toileting program was used. R9's cognition level is not the same as it used to be after he has had some falls. R9 is now an assist of two people. After the hip fracture he does have some pain and does not like to wait even more than before. V2 stated with the continued falls apparently R9's interventions are not working. The facility document titled, Fall Prevention dated 11/10/18 documents: policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility.

Based on interview and record review the facility failed to attempt GDR (gradual dose reduction) of psychotropic medications and failed to adequately monitor the medications effectiveness for 2 of 4 residents (R22, R18) reviewed for psychotropic medications in a sample of 25 1. Per R22's Face sheet, R22 was admitted to this facility on 9/27/2021 with diagnosis of Parkinson's Psychosis, Schizophrenia and Anxiety among others. R22's current physician's order sheet (11/1/23-11/30/23) documents R22 is ordered the anti-psychotic medication known as Haldol Decanoate 50mg (milligrams) injection every month and Haldol 5 mg tablets by mouth four times per day. Both medications are prescribed for the diagnosis of Parkinson's Psychosis and Schizophrenia. Pharmacy recommendations for R22, dated 12/14/2022, 5/4/2023 and 10/4/2023 all document requests for R22's doctor to evaluate R22's need for a gradual dose reduction attempts for Haldol Decanoate 50mg injection every month and Haldol 5mg tablet by mouth four times per day. The recommendation dated 12/14/2022, under physician's response documents I decline the recommendations and do not wish to implement any changes due to: Did not prescribe. To start seeing new provider for psych. The recommendations dated 5/4/2023 and 10/4/2023 are not signed and are left blank under physician's response. There were no Behavioral Tracking Sheets available for R22 for review upon request. On 11/2/2023 at 2:00pm, V1 (Administrator) and V4 (Care Plan Coordinator) said the facility has failed to monitor and track R22's targeted behaviors/symptoms being treated by the anti-psychotic medication Haldol (monthly injection and daily oral tablets) for the past year. V1 said they would immediately put appropriate monitoring in place. V1 said she could not find when a gradual dose reduction for R22's Haldol was attempted, but it has not been attempted over the past year. V1 said R22 was last seen by her new mental health provider on 5/9/2023, but a gradual dose reduction of R22's medications was not attempted and an order to continue with current medications was prescribed. 44492 R18's Face Sheet documents an admitted to the facility of 6/12/2018 with diagnoses of anxiety, depression, panic attacks, and PTSD (Post Traumatic Stress Disorder). R18's Minimum Data Set (MDS) dated [DATE] documents in Section C, Brief Interview for Mental Status (BIMS) score is 14, indicating R18 is cognitively intact. R18's Physician's Orders dated 11/01/2023 - 11/30/2023 documents Xanax 0.5mg (milligrams) daily (Anxiety/PTSD), Xanax 0.25mg at noon (Anxiety), Zoloft 150mg daily (Depression), Buspirone 7.5mg twice daily (Anxiety). On 11/01/2023, at 2:00 PM, V1 (Administrator) stated that R18 is not due for a gradual dose reduction for her Xanax and Buspirone per the facility's pharmacy gradual dose reduction tracking report dated 10/04/2023. The facility's pharmacy gradual dose reduction (GDR) tracking report dated 10/04/2023 documents R18's Xanax last GDR was 7/03/2021 and next GDR is dated for 10/04/2024; R18's Buspirone start date of 9/18/2021. The facility provided no documentation of any GDR attempt for Buspirone. R18's Behavior Tracking reviewed for the last six months with only months May, June, October, & November 2023 available for review. The facility provided no documentation for months July, August, and September 2023 for behavior tracking for R18. The Pharmacy Policy titled Gradual Dose Reduction/Tapering in a Nursing Facility (revision date 05/2009) documents under frequency of GDR/tapering, within the first year in which a resident is admitted on a psychopharmacological medication or after the facility has initiated a psychopharmacological medication, taper twice in two separate quarters with at least one month between attempts; After the first year, once per year. The facility's Psychotropic Medication Policy dated 6/17/2022, documents under Procedure: 8. The Behavioral Tracking sheet of the facility will be implemented to ensure behaviors are being monitored. 9. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. Any resident receiving psychotropic medications will be reviewed at a minimum of every quarter by the interdisciplinary team. 10. Reductions shall be attempted at least twice in one year, unless the physician documents the need to maintain the resident regimen according to the Regulatory Guidelines for such.

Based on interview and record review the facility failed to designate a Director of Nursing for the facility. This failure has the potential to affect all 34 residents residing in the facility. Findings Include: On 09/13/22 at 10:20 AM, V1 (Administrator) acknowledges the facility does not have a Registered Nurse (RN) working in the Director of Nursing (DON) role for the facility. V1 states that V2 (Minimum Data Set / Care Plan Coordinator) who has a Licensed Practical Nursing license works to fill the DON duties at this time. V1 states the facility has sought to hire a DON, but been unsuccessful, but that they have an interview schedule for 9/14/22. On 9/15/22 at 1:30 PM, V2 stated that they have not had a DON for a couple months but is unsure of her last date on the schedule. V2 stated that she is trying to help V1 with those DON duties but that she is a Licensed Practical Nurse (LPN) so she is limited. V1 (Administrator) was unable to verify prior to exit the last date of employment of DON due to having to quarantine after testing positive for COVID. The resident census and conditions list provided by the facility on 9/15/22 documents 34 residents reside at the facility.

Based on interview, observation, and record review, the facility failed, according to its policy, to notify a resident's representative of positive COVID tests of a resident and a staff member. This has the ability to affect all 34 residents living at the facility. Findings include: On 09/13/22 at 7:55am, V1, Administrator, stated the facility currently had one resident, R1, who was in isolation due to testing positive for COVID on 09/12/22. On 09/13/22 at 2:55pm, V8 stated she is the Power of Attorney (POA) for R17. V8 stated within the past year, the facility has not been notifying her of positive cases of COVID within the resident population nor the staff members. On 09/14/22 at 3:10pm, the door to R1's room had a red sign on it which read, Isolation: See nurse before entering. R1, who was alert and oriented to person, place, and time, confirmed he has been in isolation for testing positive for COVID on 09/12/22. On 09/15/22 at 12:48PM, V1 Administrator, was interviewed by phone. V1 stated she was not at the facility as on 09/14/22 she tested positive for COVID. V1 stated she is currently the only staff member out with COVID. V1 stated she was not sure if staff had notified residents and their representatives of a COVID positive staff member and resident. V1 stated these notifications are to be recorded in the Nursing Progress Notes. V1 stated she was not sure if the facility was still required to notify residents and their representatives of COVID cases. R17's Face Sheet listed V8 as R17's POA. R17's Nursing Progress Notes for September 2022 had no documentation to substantiate V8 was contacted about R1 nor V1 having tested positive for COVID. A COVID 19 Control Measures Policy with a revision date of 2/21/22 documented, Written notification should be initiated and completed by 5pm the following day to each resident of the facility, residents family/representatives, and to all staff members upon the identification of a single confirmed Covid infection of a resident or staff member. A Resident Census and Conditions form dated 09/13/22 documented a total of 34 residents living at the facility.

Based on interview and record review the facility failed to ensure call lights were answered timely for 2 of 2 (R23 and R281) residents reviewed for dignity in the sample of 27. Findings Include: 1. R23's undated facility face sheet documents R23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's MDS (Minimum Data Set) dated 7/5/22 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R23 is cognitively intact. This same MDS documents under section G that R23 requires one-person physical assistance for toileting. On 9/13/22 at 10:41 AM R23 was observed sitting on her bed in her room. There was a bedside commode observed sitting next to R23's bed. R23 stated it takes a while for staff to assist her when she pushes her call light. R23 stated she has wet the bed while waiting for them. When asked how long it took them to answer her call light R23 stated it sometimes takes over an hour. R23 stated she has been left on the bedside commode for that long and it hurts her bottom when that happens. On 9/16/22 at 9:53 AM R23 was observed being assisted by V9 (Registered Nurse). R23 required assistance to reposition in bed and to go from a sitting to laying position. R23's buttocks were free of skin breakdown. 2. R281's undated New Admission Information form documents R281 was admitted to the facility on [DATE]. R281's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R281's facility Cognitive assessment dated [DATE] documents a BIMS score of 13, which indicates R281 is cognitively intact. R281's Assist Report dated 9/22 documents R281 requires one-person physical assist to toilet and transfer. On 09/13/22 at 12:30 PM R281 stated they don't answer his call light quickly. R281 stated he pissed his pants when they took too long to get to him. The facility Resident Council Meeting minutes dated 4/28/22 document Nursing: Requested more help. Have to turn on call lights well before they need help because of length of time it takes to answer call lights. Sometimes have to do for themselves. Resident Council Memorandum dated 4/28/22 documents under Department Response: We have just hired a DON (Director of Nurses) and have been sending out tons of help wanted ads for the department. Also hired a night shift aide. The Resident Council Meeting minutes dated 5/25/22 document under new/business/concerns: .call lights . with no department response documented on the resident council memorandum. The facility resident council dated 6/27/22 documents call lights taking a while . The Resident Council Meeting minutes dated 8/25/22 documents, .Doing well other than respond (sic) to call lights. There is no documentation of department responses for the 6/27/22 and 8/25/22 meeting. On 9/16/22 at 1:36 PM, V13 (Regional Director of Operations) stated she was not able to locate any department responses or Quality Assurance reviews related to the resident concerns of call lights not being answered in the resident council meetings. The facility Resident Rights dated 11/18 documents under Your rights to dignity and respect Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on interview and record review, the facility failed to involve a resident's representative in care planning for one resident of 27 residents (R17) reviewed for care plans in the sample of 27. Findings include: On 09/13/22 at 02:55 PM, V8, R17's Power of Attorney (POA) stated in the past year she has received no invitations to participate in R17's care planning meetings, either by phone or in person. R17's Face Sheet listed V8 as R17's POA. R17's Care Plan documented that it was reviewed and updated on 07/11/22. There was no documentation on the care plan to indicate V8 was involved in its development. On 09/15/22 at 12:11 PM, V2, Minimum Data Set Coordinator/Care Plan Coordinator/Licensed Practical Nurse, stated she has not sent out any care plan invitations in the past year. V2 stated this is due to her having to perform other duties such as working on the floor and helping to cover Director of Nurses (DON) duties since the facility is without a DON. A Comprehensive Care Planning Policy with a revision date of 07/20/22 documented, The resident/guardian/representative of upcoming care conferences(shall be notified of the care plan meeting) and (staff should)accommodate(their) schedule as appropriate . Notify the resident/guardian/representative when significant changes are made to (the care plan) and (the representative should be )afforded the opportunity to sign after significant changes are made to the CCP (Comprehensive Care Plan). Documentation of the notification of the resident/guardian/responsible party of significant changes to the CCP can be accomplished via signature on the IDT (Interdisciplinary Team) Progress Note, on the New Care Plan page, on Care Plan Summary/Participation Record or documentation in the Nurse ' s Notes or Social Services notes if updates (are) given per phone, (the representative)refused to sign, or attempts to contact (the representative) have been unsuccessful.

Based on interview and record review, the facility failed to ensure residents were safe from abuse for 1 of 4 residents (R25) reviewed for abuse in a sample of 27. The findings include: R25's Face Sheet documents he was admitted to this facility on 05/23/14 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R25's September physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1/2 tablets (75 mg) by mouth once daily. R25's nurses notes dated 03/14/22 by V14 (Registered Nurse - RN) document the following - 8:30 PM - Roommate hit resident in face with hat 8 times and notified of this per CNA (Certified Nursing Assistant) .writer immediately went to room and denies pain and no signs or symptoms of pain noted and no injuries noted. 8:31 PM - Writer notified V1 (Administrator) of resident-to-resident altercation. 8:43 PM - V11 (Physician) notified of incident. 8:45 PM - (Local) police called and notified of incident. 8:47 PM - V15 (Family Member/POA - Power of Attorney) notified of incident. 8:55 PM - Police here to speak with resident. R12's nurses notes dated 3/14/22 by V14 document the following: 8:30 PM .notified writer (R12) took his hat and hit roommate with hat x (times) 3. Writer immediately went to room and asked resident what happened, and he stated, I hit him with my hat because he was snoring. Writer explained to resident to not hit other people and he voiced understanding no injuries noted to other resident. 8:31 PM V1 notified of resident-to-resident altercation. 8:43 PM V11 notified of incident. 8:45 PM V12 (Family) notified of incident. 8:45 PM (local) police notified of incident. 8:55 PM Police officer here and spoke with resident.9:13 PM (R12) moved to room (number) no adverse reactions noted to [MEDICATION(S)]. On 09/16/22 at 1:17 PM, V14 stated she calls V1 for every incident of abuse because V1 is the abuse coordinator. V14 confirmed she did speak with V1 on the phone on 03/14/22 regarding the incident between R12 and R25. V14 stated she filled out her paperwork and did her part, then V1 does the rest, so she's not sure what happened after that. On 09/16/22 at 1:40 PM, V1 stated she does not remember the incident between R12 and R25 on 03/14/22, nor does she have any recollection of V14 reporting this incident to her. V1 confirmed she had not done an abuse investigation for R12 and R25. When asked if she remembered the police coming into the building on 03/14/22 and talking to R12 and R25, she stated, No, I don't remember. During the course of this survey the facility could not provide any reproducible evidence that the altercation between R12 and R25 had been investigated. The facility's Abuse Prevention Program policy dated 05/2017 includes - This facility affirms the right of our residents to be free from abuse .This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents .This facility is committed to protecting our residents from abuse by anyone including; but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual .Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .

Based on interview and record review the facility failed to implement their abuse policy by failing to notify the Illinois Department of Public Health, notify the local police, and initiate abuse investigations for allegations of abuse for 3 of 4 residents (R25, R12 and R20) residents reviewed for abuse in the sample of 27. The findings include: 1. R25's Face Sheet documents he was admitted to this facility on 05/23/14 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R25's September physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1/2 tablets (75 mg) by mouth once daily. R25's nurses notes dated 03/14/22 by V14 (Registered Nurse - RN) document the following - 8:30 PM - Roommate hit resident in face with hat 8 times and notified of this per CNA (Certified Nursing Assistant) .writer immediately went to room and denies pain and no signs or symptoms of pain noted and no injuries noted. 8:31 PM - Writer notified V1 (Administrator) of resident-to-resident altercation. 8:43 PM - V11 (Physician) notified of incident. 8:45 PM - (Local) police called and notified of incident. 8:47 PM - V15 (Family Member/POA - Power of Attorney) notified of incident. 8:55 PM - Police here to speak with resident. R12's nurses notes dated 3/14/22 by V14 document the following: 8:30 PM .notified writer (R12) took his hat and hit roommate with hat x (times) 3. Writer immediately went to room and asked resident what happened, and he stated, I hit him with my hat because he was snoring. Writer explained to resident to not hit other people and he voiced understanding no injuries noted to other resident. 8:31 PM V1 notified of resident-to-resident altercation. 8:43 PM V11 notified of incident. 8:45 PM V12 (Family) notified of incident. 8:45 PM (local) police notified of incident. 8:55 PM Police officer here and spoke with resident.9:13 PM (R12) moved to room (number) no adverse reactions noted to [MEDICATION(S)]. On 09/16/22 at 1:17 PM, V14 stated she calls V1 for every incident of abuse because V1 is the abuse coordinator. V14 confirmed she did speak with V1 on the phone on 03/14/22 regarding the incident between R12 and R25. V14 stated she filled out her paperwork and did her part, then V1 does the rest, so she's not sure what happened after that. On 09/16/22 at 1:40 PM, V1 stated she does not remember the incident between R12 and R25 on 03/14/22, nor does she have any recollection of V14 reporting this incident to her and confirmed she had not done an abuse investigation for R12 and R25 nor reported it to the department . When asked if she remembered the police coming into the building on 03/14/22 and talking to R12 and R25, she stated, No, I don't remember. When asked who is responsible for doing the abuse investigations for the facility, V1 stated she was the one who did them, but just did not remember this one. During the course of this survey the facility could not provide any reproducible evidence that the altercation between R12 and R25 had been investigated. 2. R20's profile face sheet documents an original admitted [DATE]. R20's most recent MDS (Minimum Data Set) section C notes that she has a BIMS (Brief Interview Mental Status) of 15, indicating that she is cognitively intact. On 9/15/22 at 12:00 PM, V5 (Family) stated that R20 had an electric razor that was delivered from her sister in the mail and has not been found. V5 went on to state that R20 received the package and left for [CONDITION(S)] and when she returned the razor was missing. V5 reported this missing item to V3 (Social Services) and filled out a grievance log for the missing item and has never been updated or told where the investigation is at, other than when she asks staff about the razor missing, they state that V1 (Administrator) took that over after the grievance was filed. V5 stated that this occurred at the end of May or the beginning of June. On 9/15/22 at 12:00 PM, R20 stated that she received an electric razor in the mail from her sister in late May or early June. The day that it was delivered to her she left for [CONDITION(S)] and when she returned it was nowhere to be found. The facility has not followed up with her in regard to whether they will replace the razor or what the investigation determined regarding the lost item. R20 also went on to state that no one was ever followed up on with her missing $10 that she reported and filled out a grievance for either. When asked if she was reimbursed R20 stated no, nothing. On 9/15/22 at 12:39 PM, V1 (administrator) stated on a phone interview that there has been no investigation initiated or reported to Illinois Department of Public Health IDPH) involving misappropriation of items or potential theft of money for R20 nor was the physician, family or police notified. When asked why no investigations were started V1 stated that she gave R20 $10 back and no one ever saw the razor, so she was waiting on the family to provide proof of purchase and shipment before she did anything else. None of these things V1 mentioned are documented anywhere. On 9/15/22 at 1:00PM, V3 (Social Services) stated that she had filled out a grievance form with V5 in early June regarding R20's missing razor and placed the grievance in V1 (Administrator) door as she is told to do. V3 stated that is what she does with all grievances. After the top portion of the resident complaint/grievance form is filled out she then places it in V1's door for her to determine what the next action will be. V3 is unaware if anything has happened since she turned over the grievance. V3 also confirmed at this time that R20 did fill out a grievance regarding the missing money and that was turned over to V1 as well. On 9/15/22 at 1:00 PM, V4 (Business Office Manager) stated that she had heard that R20 was missing a razor, but it has never been found to her knowledge. On 9/15/22 at 1:45PM, review of IDPH data base of reported incidents of abuse allegations, documents no reports involving R20's missing money or razor. The facility's Abuse Prevention Program policy dated 05/2017 documents in part- This facility affirms the right of our residents to be free from abuse .This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents .This facility is committed to protecting our residents from abuse by anyone including; but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual .IV. Internal Reporting Requirements and Identification of Allegations .Supervisors shall immediately inform the administrator or his/her designated representative .of all reports of potential/alleged mistreatment, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator of designee shall initiate an investigation .VI. Internal Investigation of Allegations and Response, 1. Appointing an investigator. Once the administrator or designee receives an allegation of mistreatment, neglect or abuse .and misappropriation of resident property, the administrator will appoint a person to take charge of the investigation .5. Final Investigation Report .the investigator or designee with report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident .the administrator or designee with review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident. The administrator or designee is responsible for informing the resident or their representative of the result of the investigation and of any corrective action taken . VII. 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to a least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion), Otherwise, the report must be made not later than 24 hours after forming the suspicion 4. Informing Law Enforcement Authorities .If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately (not later than two hours after forming the suspicion in the event of serious bodily injury or suspected criminal sexual abuse) notify local law enforcement as soon as possible but no later than 24 hours .

Based on interview and record review the facility failed to notify the local police on an allegations of misappropriation of resident property for 1 of 3 (R20) reviewed for abuse allegations in a sample of 27. The Findings Include: R20's profile face sheet documents an original admission date of 7/13/18. R20's most recent MDS (Minimum Data Set) section C notes that she has a BIMS (Brief Interview Mental Status) of 15, indicating that she is cognitively intact. On 9/15/22 at 12:00 PM, V5 (Family) stated that R20 had an electric razor that was delivered from her sister in the mail and has not been found. V5 went on to state that R20 received the package and left for dialysis and when she returned the razor was missing. V5 reported this missing item to V3 (Social Services) and filled out a grievance log for the missing item and has never been updated or told where the investigation is at, other than when she asks staff about the razor missing, they state that V1 (Administrator) took that over after the grievance was filed. V5 stated that this occurred at the end of May or the beginning of June. On 9/15/22 at 12:00 PM, R20 stated that she received an electric razor in the mail from her sister in late May or early June. The day that it was delivered to her she left for dialysis and when she returned it was nowhere to be found. The facility has not followed up with her in regard to whether they will replace the razor or what the investigation determined regarding the lost item. R20 also went on to state that no one was ever followed up on with her missing $10 that she reported and filled out a grievance for either. When asked if she was reimbursed R20 stated 'no, nothing.' On 9/15/22 at 12:39 PM, V1 (administrator) stated on a phone interview that there has been no investigation initiated or reported to Illinois Department of Public Health involving misappropriation of items or potential theft of money for R20 nor was the physician, family or police notified. When asked why no investigations were started V1 stated that she gave R20 $10 back and no one ever saw the razor, so she was waiting on the family to provide proof of purchase and shipment before she did anything else. None of these things V1 mentioned are documented anywhere. On 9/15/22 at 1:00PM, V3 (Social Services) stated that she had filled out a grievance form with V5 in early June and placed the grievance in V1 (Administrator) door as she is told to do. V3 stated that is what she does with all grievances. After the top portion of the resident complaint/grievance form is filled out she then places it in V1's door for her to determine what the next action will be. V3 is unaware if anything has happened since she turned over the grievance. V3 also confirmed at this time that R20 did fill out a grievance regarding the missing money and that was turned over to V1 as well. The Facility Abuse and Prevention Program Policy dated 5/2017 documents in part, VII. 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to a least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion), Otherwise, the report must be made not later than 24 hours after forming the suspicion 4. Informing Law Enforcement Authorities .If there is any reasonable suspicion of a crime, as defined by local law, the administrator shall immediately (not later than two hours after forming the suspicion in the event of serious bodily injury or suspected criminal sexual abuse) notify local law enforcement as soon as possible but no later than 24 hours .

Based on interview and record review the facility failed to report allegation of abuse to the Department of Public Health for 3 of 4 residents (R25, R12, R20) reviewed for abuse in a sample of 27. The findings include: R25's nurses notes dated 03/14/22 by V14 (Registered Nurse - RN) document the following - 8:30 PM - Roommate hit resident in face with hat 8 times and notified of this per CNA (Certified Nursing Assistant) .writer immediately went to room and denies pain and no signs or symptoms of pain noted and no injuries noted. 8:31 PM - Writer notified V1 (Administrator) of resident-to-resident altercation. 8:43 PM - V11 (Physician) notified of incident. 8:45 PM - (Local) police called and notified of incident. 8:47 PM - V15 (Family Member/POA - Power of Attorney) notified of incident. 8:55 PM - Police here to speak with resident. R12's nurses notes dated 3/14/22 by V14 document the following: 8:30 PM .notified writer (R12) took his hat and hit roommate with hat x (times) 3. Writer immediately went to room and asked resident what happened, and he stated, I hit him with my hat because he was snoring. Writer explained to resident to not hit other people and he voiced understanding no injuries noted to other resident. 8:31 PM V1 notified of resident-to-resident altercation. 8:43 PM V11 notified of incident. 8:45 PM V12 notified of incident. 8:45 PM (local) police notified of incident. 8:55 PM Police officer here and spoke with resident.9:13 PM (R12) moved to room (number) no adverse reactions noted to [MEDICATION(S)]. On 09/16/22 at 1:17 PM, V14 stated she calls V1 for every incident of abuse because V1 is the abuse coordinator. V14 confirmed she did speak with V1 on the phone on 03/14/22 regarding the incident between R12 and R25. V14 stated she filled out her paperwork and did her part, then V1 does the rest, so she's not sure what happened after that. On 09/16/22 at 1:40 PM, V1 stated she does not remember the incident between R12 and R25 on 03/14/22, nor does she have any recollection of V14 reporting this incident to her and confirmed she had not done an abuse investigation for R12 and R25 nor reported it to the Department. When asked if she remembered the police coming into the building on 03/14/22 and talking to R12 and R25, she stated, No, I don't remember. When asked who is responsible for doing the abuse investigations for the facility, V1 stated she was the one who did them, but just did not remember this one. R20's profile face sheet documents an original admitted [DATE]. R20's most recent MDS (Minimum Data Set) section C notes that she has a BIMS (Brief Interview Mental Status) of 15, indicating that she is cognitively intact. On 9/15/22 at 12:00 PM, V5 (Family) stated that R20 had an electric razor that was delivered from her sister in the mail and has not been found. V5 went on to state that R20 received the package and left for [CONDITION(S)] and when she returned the razor was missing. V5 reported this missing item to V3 (Social Services) and filled out a grievance log for the missing item and has never been updated or told where the investigation is at, other than when she asks staff about the razor missing, they state that V1 (Administrator) took that over after the grievance was filed. V5 stated that this occurred at the end of May or the beginning of June. On 9/15/22 at 12:00 PM, R20 stated that she received an electric razor in the mail from her sister in late May or early June. The day that it was delivered to her she left for [CONDITION(S)] and when she returned it was nowhere to be found. The facility has not followed up with her in regard to whether they will replace the razor or what the investigation determined regarding the lost item. R20 also went on to state that no one was ever followed up on with her missing $10 that she reported and filled out a grievance for either. When asked if she was reimbursed R20 stated 'no, nothing.' On 9/15/22 at 12:39 PM, V1 (administrator) stated on a phone interview that there has been no investigation initiated or reported to Illinois Department of Public Health involving misappropriation of items or potential theft of money for R20. When asked why no investigations were started V1 stated that she gave R20 $10 back and no one ever saw the razor, so she was waiting on the family to provide proof of purchase and shipment before she did anything else. None of these things V1 mentioned are documented anywhere. On 9/15/22 at 1:00PM, V3 (Social Services) stated that she had filled out a grievance form with V5 in early June and placed the grievance in V1 (Administrator) door as she is told to do. V3 stated that is what she does with all grievances. After the top portion of the resident complaint/grievance form is filled out she then places it in V1's door for her to determine what the next action will be. V3 is unaware if anything has happened since she turned over the grievance. V3 also confirmed at this time that R20 did fill out a grievance regarding the missing money and that was turned over to V1 as well. On 9/15/22 at 1:45PM, review of IDPH data base of reported incidents of abuse allegations, documents no reports involving R20's missing money or razor. The facility's Abuse Prevention Program policy dated 05/2017 documents in part- .VII. 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to a least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion), Otherwise, the report must be made not later than 24 hours after forming the suspicion

Based on interview and record review the facility failed to initiate, thoroughly investigate, and maintain documentation of a thorough investigation for an allegations of abuse for 3 of 4 residents (R25, R12,R20) reviewed for abuse in a sample of 27. The Findings Include: R25's Face Sheet documents he was admitted to this facility on 05/23/14 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R25's September physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1/2 tablets (75 mg) by mouth once daily. R25's nurses notes dated 03/14/22 by V14 (Registered Nurse - RN) document the following - 8:30 PM - Roommate hit resident in face with hat 8 times and notified of this per CNA (Certified Nursing Assistant) .writer immediately went to room and denies pain and no signs or symptoms of pain noted and no injuries noted. 8:31 PM - Writer notified V1 (Administrator) of resident to resident altercation. 8:43 PM - V11 (Physician) notified of incident. 8:45 PM - (Local) police called and notified of incident. 8:47 PM - V15 (Family Member/POA - Power of Attorney) notified of incident. 8:55 PM - Police here to speak with resident. R12's nurses notes dated 3/14/22 by V14 document the following: 8:30 PM .notified writer (R12) took his hat and hit roommate with hat x (times) 3. Writer immediately went to room and asked resident what happened, and he stated, I hit him with my hat because he was snoring. Writer explained to resident to not hit other people and he voiced understanding no injuries noted to other resident. 8:31 PM V1 notified of resident-to-resident altercation. 8:43 PM V11 notified of incident. 8:45 PM V12 notified of incident. 8:45 PM (local) police notified of incident. 8:55 PM Police officer here and spoke with resident.9:13 PM (R12) moved to room (number) no adverse reactions noted to [MEDICATION(S)]. On 09/16/22 at 1:17 PM, V14 stated she calls V1 for every incident of abuse because V1 is the abuse coordinator. V14 confirmed she did speak with V1 on the phone on 03/14/22 regarding the incident between R12 and R25. V14 stated she filled out her paperwork and did her part, then V1 does the rest, so she's not sure what happened after that. On 09/16/22 at 1:40 PM, V1 stated she does not remember the incident between R12 and R25 on 03/14/22, nor does she have any recollection of V14 reporting this incident to her and confirmed she had not done an abuse investigation for R12 and R25. When asked if she remembered the police coming into the building on 03/14/22 and talking to R12 and R25, she stated, No, I don't remember. When asked who is responsible for doing the abuse investigations for the facility, V1 stated she was the one who did them, but just did not remember this one. R20's profile face sheet documents an original admitted [DATE]. R20's most recent MDS (Minimum Data Set) section C notes that she has a BIMS (Brief Interview Mental Status) of 15, indicating that she is cognitively intact. On 9/15/22 at 12:00 PM, V5 (Family) stated that R20 had an electric razor that was delivered from her sister in the mail and has not been found. V5 went on to state that R20 received the package and left for [CONDITION(S)] and when she returned the razor was missing. V5 reported this missing item to V3 (Social Services) and filled out a grievance log for the missing item and has never been updated or told where the investigation is at, other than when she asks staff about the razor missing, they state that V1 (Administrator) took that over after the grievance was filed. V5 stated that this occurred at the end of May or the beginning of June. On 9/15/22 at 12:00 PM, R20 stated that she received an electric razor in the mail from her sister in late May or early June. The day that it was delivered to her she left for [CONDITION(S)] and when she returned it was nowhere to be found. The facility has not followed up with her in regard to whether they will replace the razor or what the investigation determined regarding the lost item. R20 also went on to state that no one was ever followed up on with her missing $10 that she reported and filled out a grievance for either. When asked if she was reimbursed R20 stated 'no, nothing.' On 9/15/22 at 12:39 PM, V1 (administrator) stated on a phone interview that there has been no investigation initiated or reported to Illinois Department of Public Health involving misappropriation of items or potential theft of money for R20. When asked why no investigations were started V1 stated that she gave R20 $10 back and no one ever saw the razor so she was waiting on the family to provide proof of purchase and shipment before she did anything else. None of these things V1 mentioned are documented anywhere. On 9/15/22 at 1:00PM, V3 (Social Services) stated that she had filled out a grievance form with V5 in early June and placed the grievance in V1 (Administrator) door as she is told to do. V3 stated that is what she does with all grievances. After the top portion of the resident complaint/grievance form is filled out she then places it in V1's door for her to determine what the next action will be. V3 is unaware if anything has happened since she turned over the grievance. V3 also confirmed at this time that R20 did fill out a grievance regarding the missing money and that was turned over to V1 as well. On 9/15/22 at 1:00 PM, V4 (Business Office Manager) stated that she had heard the razor was missing but it has never been found to her knowledge. On 9/15/22 at 1:45PM, review of IDPH data base of reported incidents of abuse allegations, documents no reports involving R20's missing money or razor. The facility's Abuse Prevention Program policy dated 05/2017 includes - .IV. Upon learning of the report, the administrator of designee shall initiate an investigation .VII. 1. External Reporting of Potential Abuse - Initial Reporting of Allegation: The facility must ensure that all alleged violations involving .neglect or abuse .misappropriation of resident property .are reported immediately to .other officials in accordance with State law through established procedures .the report must be made to .the Illinois Department of Public Health .not later than 24 hours after forming the suspicion. A written report must be sent to the Department of Public Health. The written report should contain the following information, if known at the time of the report; Name, age, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential mistreatment, neglect, and abuse of residents and misappropriation of resident property and that an investigation is being conducted.

Based on observation, interview, and record review, the facility failed to assess a resident's pain, document the effectiveness of pain medication, notify the physician that pain medications were ineffective, and provide non pharmacological interventions to assist with pain relief for one (R1) of two residents reviewed for pain in the sample of 28. This failure resulted in psychosocial and physical harm as evidenced by R1 expressing that the pain was so severe that R1 wanted to die, of which the facility did not notify R1's physician. Findings include: On 06/15/21 at 11:12am, R1 was observed in her room laying on her bed. R1 was alert and oriented to self. R1 was moaning loudly and yelling My leg hurts! V14, Registered Nurse, stated she had just given R1 [MEDICATION(S)] about 20 minutes prior to try to manage R1's pain. V14 stated R1 has pain as a result of end stage [CONDITION(S)]. V14 stated R, at times, has pain that is difficult to manage. V14 stated additionally, R1 displays behaviors of yelling out. V14 stated at times she is not sure if R1 is in pain or is just acting out. V14 did not offer to reassess R1 or provide non pharmacological interventions to help reduce R1's pain. R1's Face Sheet documents a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's May 2021 Physicians Order Sheet (POS) documents a 05/08/21 order for Comfort Care.R1's June 2021 Physicians Order Sheet documented a 06/07/21 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/16/21 at 1:40pm, V19 and V20, both Certified Nursing Assistants, both stated R1 does not display acting out behaviors which could be confused with pain. Both stated when R1 is in pain, she can tell you. R1's 03/03/21 Minimum Data Set (MDS) documented a Brief Interview for Mental Status Score of 9, indicating R1 has moderate deficits in cognitive functioning. The same MDS documented, Should a pain assessment interview be conducted? Yes. Pain presence and frequency: Hurting almost constantly within the past five days. Pain intensity: 6(0-10 scale). On 06/17/21 at 11:21am, V10, Resident Care Coordinator/ Licensed Practical Nurse, stated the facility has contacted R1's physician numerous times about R1's unresolved pain, but they have not heard anything back. V10 was unable to provide the documentation to substantiate this. V10 stated staff should be checking R1's pain, at minimum, once every 8 hour shift. V10 stated R1 is receiving comfort care measures related to end stage [CONDITION(S)]. R1's Nurses Note dated 06/12/21 stated, Crying out, told CNA (Certified Nursing Assistant) it hurts, I want to die. [MEDICATION(S)] given again (12:40 am) and again at (2:45am) because (R1) was still crying out. R1's June 2021 Pain Management Flow Sheet had no corresponding entry for that date to indicate the intensity of the pain, what interventions were utilized to try to manage it, and the effectiveness of these interventions. There was no documentation to indicate R1's physician had been notified of R1's verbalization of wanting to die. An 06/15/21 2:15am Nurses Note documented, Lots of crying out between midnight shift and 2:00am, pain medicine given. There was no corresponding entry on the above referenced Pain Management Flow Sheet on 06/15/21 to indicate the intensity of the pain, what interventions were utilized to try to manage it, and the effectiveness of these interventions. R1's June 2021 Pain Management Flow Sheet and Nurses Notes documented that there were zero days in which R1's pain was assessed each shift, and R1's pain was not assessed at all on 06/07/21, 06/09/21, 06/15/21, and 06/16/21. This flow sheet documented that on 06/14/21 at 3:15pm, R1 was In pain all over, 10(0-10), crying and shaking with the effectiveness listed as Some better. There was no documentation as to what interventions were utilized. The corresponding MAR (Medication Administration Record) documented that R1 received [MEDICATION(S)] at 3:15pm. The next entry on this form documented that on 06/14/21 at 6:00pm, R1 was still experiencing generalized pain at a level of 10, was crying and shaking, received pain medication, and the effectiveness was Better. The corresponding MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no corresponding documentation to indicate why R1 did not receive the pain medication when it could have been given at 5:15pm. There was no documentation to indicate R1's physician had been notified on the above referenced dates that R1 was continuing to experience pain in spite of the [MEDICATION(S)] dose being increased on 06/07/21. An 06/17/21 Nurses Note stated, (R1's Physician) here today, assessed resident, (and) requested monitoring for pain .Continue current treatment. The facility's 12/07/17 Pain Prevention and Treatment Policy documented, It is the facility's policy to assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize ADL(Activities of Daily Living) functioning and enhance quality of life .Assessment of pain will be completed with changes in the residents condition, self-reporting of pain, or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the pain management flow sheet. The facility's undated Comfort Care Policy stated, It is the policy of (the facility) to offer comfort care to residents when it has been determined by a consensus of the resident and/or the residents family, in consultation with the primary physician and staff caring for the resident, that further aggressive treatment will provide more of a burden to the resident than it will benefit him or her. Measures: 5) Assess for pain, nausea, shortness of breath, fear, and anxiety. Notify physician for appropriate orders.

Based on observation, record review and interview the facility failed to provide pain relief during a wound treatment to a non verbal resident ,who was showing signs of pain and distress at that time and failed to follow their policy for [DIAGNOSES REDACTED] for 1 of 2 residents (R5, R7) reviewed for diabetes and pain in the sample of 12. This failure caused R5 to suffer undue pain. Findings include: 1.On 8/23/16 at 1:30 PM, R5 had a [DEVICE] dressing change performed by E17, (Licensed Practical Nurse/Treatment Nurse). The physician's orders [REDACTED]. As the procedure was being performed by E17, the resident, R5, was noted to be wincing, moaning, and breathing rapidly while the right outer ankle area was being cleansed, and as the new dressing was being applied. At this time, E17 instructed R5 to breathe deeply. The physician's orders [REDACTED]. In addition, R5 has an order for [REDACTED]. During the procedure, E17 said that the wound area was very sensitive for the resident, yet no pain medication was offered or received prior to the procedure. R5 was identified as a non interviewable resident by E13 during the facility tour on 8/22/16 at 9:45 AM. R5 had a 7/26/16 Brief Interview for Mental Status, (BIMS), score of 2, which indicates severe cognitive impairment, and would likely not request pain medication. 2. The August, 2016 physician's orders [REDACTED]. The PO's state to notify the physician if the blood sugar (BS) is greater than 400. The PO's do not give parameters for low blood sugars. The Facility's undated Emergency Care Policy, page 23, under [DIAGNOSES REDACTED] states, Blood glucose levels that fall below 50, or below 60 with symptoms, shall be considered hypoglycemic and may warrant prompt action .4. Continue to evaluate until resident is asymptomatic. a. If no improvement within 15 minutes, repeat initial treatment. If no improvement within 30 minutes of initial treatment, notify physician immediately for further instruction 5. If glucose level is less than 60 and the resident is symptomatic, give 4 ounces fruit juice immediately and notify the physician for further instruction if no specific physician orders [REDACTED]. R7 stated on 08/22/16 at 3:30PM that her BS was 57 around 5AM today. R7 stated that a nurse gave her cheese and crackers at that time. R7 stated that she didn't feel good and was tired with the low BS. R7 also stated that her BS had been running low lately. At this time, R7 stated, Aren't they supposed to recheck my blood sugar when it is low? R7 said that the staff do not recheck her BS after a low reading. R7 stated on 08/24/16 at 9:00AM that she was low again this morning and was short of breath and needed her nebulizer treatment. The August 2016 Medication Administration Record [REDACTED]. R7 stated that her low blood sugar symptoms are not always the same. Review of the May-August, 2016 Medication Administration Record [REDACTED] 05/01/16 at 5AM BS 62 05/12/16 at 5AM BS 58 05/20/16 at 5AM BS 67 05/21/16 at 5AM BS 64 05/22/16 at 5AM BS 67 05/24/16 at 5AM BS 32 05/26/16 at 5AM BS 59 06/04/16 at 5AM BS 64 06/07/16 at 5AM BS 57 06/29/16 at 5AM BS 52 07/02/16 at 5AM BS 73 07/04/16 at 5AM BS 73 08/09/16 at 5:AM BS 67 08/15/16 at 5AM BS 56 08/22/16 at 5AM BS 57 08/24/16 at 5AM BS 64 There is no documentation found in the medical records to show that E19 (Physician) was notified of the low blood sugars, and no documentation detailing the treatment used for the low blood sugars, including the BS of 32 on 05/24/16. E20 (Nurse for Medical Director-E19) stated on 08/24/16 at 12:50PM that E19 has given the Facility a policy for blood sugars for all of his residents. The Sliding Scale Protocol dated 06/03/15 and signed by E19 was observed hanging at the nurse's station. This policy states, For BS less than 70, follow hypoglycemic protocol. E2 (Director of Nurses) stated at this time that she gives the residents a little Med Pass if the blood sugar is low or gives them small candy bars. Also, at this time, E13 (Licensed Practical Nurse) stated that she gives the resident some Med Pass or orange juice for a low BS. E2 and E13 each stated that they do not always document a low BS in the nurse's notes and do not always recheck the blood sugar.

Based on observation, interview and record review, the facility failed to identify and prevent the formation of a new pressure ulcer and failed to perform the correct treatment during wound care for 2 of 4 residents (R1, R4) reviewed for pressure ulcers in the sample of 12. This failure resulted in R1 acquiring an avoidable Stage II pressure ulcer. The findings include: 1. On 8/22/16 at 1:30 PM, R1 was in his bed and E6 (Certified Nurse Aide) came into the room to remove R1's pants and turned R1 onto his right side. R1 had an open area on his left upper buttock very close to the coccyx area. On 8/22/16 at 2:45 PM, E14 (Licensed Practical Nurse) stated that R1 doesn't have a dressing change and they have been putting a cream on R1's buttocks as a preventative measure and they do a daily skin assessment. On 8/22/16 at 2:30 PM, E17 (Licensed Practical Nurse/Wound Care Nurse) stated that she checks wounds weekly and looked at R1 last week on 8/16/16. E17 stated that R1's upper left buttock was very red, but not open at that time and she would be looking at R1 on 8/23/16. E17 was not aware that R1's reddened area was now open and R1's Nurses Notes have no documentation that E19 (Medical Director) was contacted about the wound being opened. R1's Care Plan dated 4/18/16 documents under Problem/Need; Pressure Ulcers; R1 is High Risk for pressure ulcers per the Braden Risk Assessment with a score of 15. The same Care Plan reads; Approaches/Interventions, High-Risk-daily skin check with documentation. Assess skin- If open or bruised areas noted, report to MD and responsible party. R1's Treatment Record dated 8/2016, documents that R1's skin was assessed on 8/16/16 and 8/22/16, not daily. E19 was notified of the new pressure ulcer on R11's left upper buttock and a new physician's orders [REDACTED]. 2. The Facility's undated Resident's With Decubitus list documents R4 has a facility Acquired Stage II Pressure Ulcer. The 07/29/16 Progress Notes state R4 has decubitus on left buttock worsened and was starting to get black tissue at one edge of the small open area last Friday (07/22/16). The document states, today, wound shows a completely black center with small amount of yellow excudate around edge and a large amount of red angry tissue surrounding wound bed. Area is completely moist, warm to touch, and much worse. The document further states, Treatment changed back to Santyl to the BLACK TISSUE ONLY and [MEDICATION NAME] to the tissue surrounding the black. This report also states, Has also developed a new decub on right buttock that is a Stage II. E17 (Licensed Practical Nurse-LPN) was observed on 08/23/16 at 12:10PM performing a dressing change to a Stage II pressure ulcer on R4. After cleansing the wound per physician's orders [REDACTED]. At this time, E17 stated the two ointments mix together. This surveyor asked E17 where the black tissue was and E17 stated it was just inside the margins and under the wound edges and added the black tissue has decreased. During this observation, this surveyor did not see any black tissue. E2 (Director of Nurses) stated on 08/24/16 at 11:00AM that she does do the wound care treatment on R4 at times and the Santyl Ointment is to be put on the black tissue only. E2 stated the last time she looked at the wound there was still black tissue and if the black tissue is gone the Santyl needs to be discontinued. E20 (Nurse for E19-Medical Director) stated on 08/24/16 at 12:50PM that she saw the wound herself on 07/29/16 and she was very specific as to where the Santyl Ointment is to be placed. E20 added she even wrote in the notes BLACK TISSUE ONLY in all capitalization and stated if the black tissue is gone the Santyl should not be used. The August, 2016 Treatment Administration Record (TAR) states the Santyl was applied to the Left Buttocks from 08/01/16-08/23/16 (with 08/15 and 08/17 not signed out) and discontinued on 08/24/16. There is no documentation found stating when the black tissue was no longer seen during the treatments and no documentation detailing the wound appearance. The wound measurements are recorded on an untitled paper signed by E17 with the pressure ulcer measurements being 1.7 centimeters (cm) x 1.2cm on 08/02/16 and 1.7cm x 1.5cm on 08/23/16. The documentation does not detail the wound appearance. E13 (Licensed Practical Nurse) stated on 08/29/16 at 12:00PM she is not exactly sure when the black tissue was completely gone and stated the black tissue wasn't there on 08/24/16 when the Santyl was discontinued. E13 stated she works the day shift and usually does this treatment. The TAR states E17 did the treatment on R4's pressure ulcer on 08/20, 08/21, and 08/22/16. E2 stated on 08/29/16 at 12:10PM there is no documentation or follow up care found regarding the Stage II pressure ulcer on the right buttocks that is noted in the 07/29/16 Progress Notes. At this time, E13 stated there is an area on the right buttocks that comes and goes and she is not aware of it being a current problem. E21 (Certified Nurses Aide-CNA) stated on 08/29/16 at 1:10PM she cares for R4 often and does incontinence care frequently. E21 added Hospice does the bathing. E21 stated R4 does have an area on her right buttocks that comes and goes and the CNA's do use a protective barrier ointment to the area. E21 stated that area is very small like a pea and is like a sheer reddened area. E21 stated it has not been open that she can recall since 07/29/16. This surveyor observed the area on 08/29/16 at 1:35PM with E21. There was an approximate dime sized light pink area noted on the right upper buttocks. At this time, E21 stated she has not needed to report this area to the nurse recently.

Based on observation, record review and interview the facility failed to monitor pressure wounds to ensure effective treatment and promote healing for 1 of 6 sampled residents (R1) reviewed for pressure wounds in the sample of 15. This failure resulted in R1 developing additional pressure areas on their buttocks with complaints of pain. Findings include: 1. A nursing note on 11-25-13 at 10:30AM noted two open areas on the right inner buttocks. The notes indicates the medical doctor and power of attorney was notified and awaiting orders. A nursing note on 11-25-13 and on 11-26-13 on the 10PM to 6AM shift notes two open areas to inner buttocks, treatment continues. Review of the medical record on 12-16-13 indicated no new order was obtained for the open areas on the inner buttocks. The facility's Weekly Wound Form for November and December 2013 lacks any documentation for the wounds on R1's inner buttocks. R1 receives Hospice services two times a week and this was initiated 1-14-13. A Hospice note on 11-25-13 indicates new open areas on the right upper buttock and right lower buttock: A) Type is pressure ulcers, both a stage II, surrounding tissue denuded, wound tissue beefy red. Barrier cream applied to areas at this time and E3, (Registered Nurse), to notify the medical doctor of new areas and obtain treatment for [REDACTED]. Hospice notes for a routine visit on 11-25-13 documents new areas on the right upper buttock area as 1.4 centimeters (cm) long, .8 cm width, and no depth. The right lower buttock measured .7cm long, 1.0 cm wide and no depth. This note also states to measure weekly. There is no further documentation on measurements by Hospice or by the facility staff. Hospice notes for a routine visit on 12-16-13 documents a right upper buttock stage two pressure ulcer not healing with a small amount of bleeding and the right lower buttock stage two not healing with a small amount of bleeding. This note also adds a new location wrongly identifying it as three pin point areas the left upper buttock. The 3 areas were on the right upper buttock and each approximately 1/2 centimeter in size. The November and December 2013 Treatment Records indicate no new treatment orders were obtained after the open areas were noted on the right inner buttock. The Treatment Record includes a treatment dated 9-25-13 to "apply [MEDICATION NAME] cream, A and D Ointment, mix together, clean dry areas on skin buttocks, axilla, ABD folds, lower breast and cover." This treatment was initialed as being done on the 6-2 shift, 2-10 shift, and 10-6 shift. . On 12-16-13 at 3PM, a cream mixture was observed being applied by Z1 (Hospice Nurse), to R1's buttocks. At this time an open area was observed on the mid left buttock, three areas on the right upper buttock and one area on the mid right buttock. (Total of 5 areas.) Both buttocks were beefy red and denuded. Bloody drainage was observed on the incontinent pad. E4, (Registered Nurse, (RN), was present and stated the facility staff apply this cream mixture after R1 has a bowel movement. R 1 stated at this time that her bottom hurts. At 12:15PM on 12-17-13, E5, (Licensed Practical Nurse, (LPN), stated she measured R1's open areas that morning and noted 6 areas. The medical record notes a physician's orders [REDACTED]. The failure to aggressively monitor and treat wounds for R1 was reviewed with E1, (Administrator), and E2, (Director of Nursing) at 3:30PM on 12-17-13.

Based on interview and record review the facility failed to provide ongoing assessment, effective interventions and supervision for 5 of 5 residents (R1, R2, R3, R4 and R5) identified as high risk for falls and reviewed for falls and accidents in the sample of 5. These failures resulted in a fractured femur for R1 and a fractured humeral head for R2. Findings include: 1. R1 is an [AGE] year old female with an original admitted to this facility of 5/23/2008, according to Admission Records dated 5/23/2008. The Physician order [REDACTED]. PHC - Fall Risk assessment dated [DATE] indicates that R1 is a high risk for falls. A review of R1's record notes a Post Fall Screen document dated 6/8/2009 which describes a fall R1 sustained on 6/5/2009 when she slid out of the chair attempting to transfer self to the toilet. A Quality Care Reporting Form and Investigation Report For Falls form both dated 3/30/2011 indicate R1 fell from her wheelchair when possibly reaching for something. This form indicates the only fall prevention technique in place prior to the fall was a body alarm. The nurses's note for 3/30/2011 state this fall resulted in pain to both knees, and a nurses's note dated 3/31/2011 states R1 complained of pain to her left leg shin/calf area. On 4/26/2011 the Quality Care Report and Investigation Report for Falls both dated 4/26/2011 note R1 was attempting to toilet self and fell from her wheelchair. The only fall prevention techniques in use prior to the fall included frequent monitoring and alarm. This incident of 4/26/2011 resulted in R1 sustaining a fracture to her left femur as noted on the Imaging Report from Clay County Hospital dated 5/4/2011. The facility conducted interviews of staff present on duty during the fall of 4/26/2011. E4 (Licensed Practical Nurse/LPN) wrote she E4 responded to a call for help from R1. E4 stated she "found patient in a squatting position between the toilet and the wall, hollering saying her knee was broken." E4 assisted in moving R1 to the toilet and then back into her wheelchair. E4 called the physician's office and family, and per physician orders [REDACTED]. E5 (Certified Nurse Assistant/CNA) wrote her statement dated 4/27/2011 that she heard R1 ask for help. R1 was in the bathroom squatting against the bathroom door. E5 stated she assisted R1 to the toilet then back into her wheelchair. E5 stated " I did not hear the alarm on her." E6 (Certified Nurse Assistant/CNA) wrote in her statement signed and dated 4/27/2011 that R1 had rolled herself down the hall and was last seen sitting in the doorway to her room. E6 said she heard a noise and responded finding R1 "squatted in the floor by the toilet, her chair alarm was not going off." E3 (Licensed Practical Nurse/LPN, Assistant Resident Service Coordinator) was interviewed during the initial tour at 10:45 am and on 7/29/2011 E3 wrote a statement dated 7/29/2011 of the incident of 4/26/2011. E3 wrote E4 "came to me and requested I look at resident whom just had a fall, and is complaining about her left knee then right knee." E3 states when she reached R1, R1 was in her wheelchair and complained of pain to her left knee showing facial signs of pain. E3 added E4 said "see I'm not sure she wasn't on the ground." During an interview on 7/29/2011 at 11:00 am with E1 (Administrator), when asked whether it was determined whether R1's current condition was related to the fall of 4/26/2011, E1 stated no. E1 said she had spoken with Z4 (Physician) again on 7/28/2011 when he was present at the facility making rounds and asked if R1's current condition was caused by the fall of 4/26/2011. E1 said Z4 repeated R1's medical condition has just deteriorated she has respiratory problems, heart problems, GI problems, these are all reasons her fractured femur was not repaired, she is poor risk for surgery. According to E1, Z4 stated he thought R1 possibly had a stroke which counts for the change in her condition, these statements are reflected in Z4's Plan/Treatment notes on R1 dated 4/29/2011. 2. R2 a [AGE] year old woman admitted to this facility on 4/7/2008 according to Admission Records dated 4/7/2008. The Physician order [REDACTED]. A review of R2's record notes the PHC-Fall Risk Assessments dated 6/6/2011 and 7/21/2011 identifies her as high risk for falls. R2's Care Plan dated 6/6/2011 identifies a problem area as high risk for falls.The Quality Care Reporting Form and the Investigation Report For Falls both dated 7/16/2011 note R2 fell from her reclining chair sustaining a left humeral head fracture abrasion to her head, contusion, neck injury, and pain to the left clavicle. The area under fall prevention techniques in use prior to the fall is blank. During an interview on 7/28/2010 at 11:00 am with E3 (LPN) she stated that R2 slept in her reclining chair all the time because that is what she chooses to do. E3 added R1 was trying to reach for a pillow and fell out of the chair. The Clay County Hospital History and Physical Progress note dated 7/16/2011 states R2's fall occurred when the nurses were dealing with another resident and R2 had to urinate and decided to attempt to ambulate from her chair to the bathroom and fell hitting her head and neck. During an interview on 7/29/2011 at 11:30 am with E1(Administrator), when asked about R2 sleeping all the time in the reclining chair, E1 stated "yes because that is where she wants to sleep." The Final Report of Incident dated 7/19/2011 sent to the Illinois Department of Public Health states Investigation/Conclusion, upon return to our facility the cushion in recliner will be removed and an electric lift chair assessment will be done before resident uses the lift chair. R2 was readmitted to the facility on [DATE] and it was noted during this complaint investigation on 7/28/2011 and 7/29/2011 the cushion was on the chair, R2 was using the chair and the electric lift chair and E1 did not provide documentation that the assessment had been completed. 3. R3 is an [AGE] year old female admitted to this facility on 9/26/07 according to Admission Records dated 9/26/2007. The Physician order [REDACTED]. R3 is mobile with the use of a wheeled walking assistive device. The Quality Care Reporting Form and the Investigation Report for Falls both dated 6/15/2011 note that on 6/15/2011 R3 was being assisted with personal care by E7 (Certified Nurses Assistant) and while standing "being cleaned by staff", R3 slid to the floor. Incident Investigation Form (not dated) completed by E7 states transferring from walker to bed and resident slid to the floor, nurse came to help, resident was not hurt. The Care Plan dated 5/25/2011 identifies R2 with a problem of high risk for falls related to the use of the wheeled walking device. One of the approaches to be used for this problem is resident will have 2 assist when transferring. During an interview with E1 (Administrator) on 7/28/2011 at 3:00 pm E1 stated E7 was transferring R3 from the walking device to the bed when R3 slid to the floor. When asked about 2 staff for transfers E1 stated yes there should have been 2 staff to transfer. 4. R4 a [AGE] year old male moved into the facility on [DATE] according to Admission records dated 8/1/2005. The Physician order [REDACTED]. The Fall Risk assessment dated [DATE] identifies R4 as high risk for falls. The Care Plan dated 5/10/2011 notes R4 as high risk for falls with an approach for the use of a mechanical lift for transfers, and R4 is dependent of all activities of daily living. The Quality Care Reporting Form and the Investigation Report for Falls both dated 6/30/2011 note R4 was getting ready to be showered when staff tried to remove a soiled adult incontinent brief while R4 remained in the sitting position, staff did not use the mechanical lift for R4. When staff yanked the brief from under R4 he was flipped over in the chair striking his head on the floor. During an interview with E1 (Administrator) on 7/28/2011 at 3:00 pm E1 stated staff did not let R4's head hit the floor and as the chair began to fall over staff let the chair down easy to the floor. In a statement written by R4 he writes "there was a depends stuck under me, E8 (Certified Nurse Aide) was pulling on it and the third time she yanked and it flipped my chair, I landed on my back and smacked my head, I didn't hurt yesterday but hurt today." 5. R5 an [AGE] year old female was admitted to the facility on [DATE] according to Admission records dated 9/10/2010. The Physician order [REDACTED]. The Fall Risk assessment dated [DATE] identifies R5 as high risk for falls. The Care Plan dated 5/19/2011 notes R5 to have a problem with impaired physical mobility with approaches to include assist to transfer using one staff and gait belt, and to ambulate to all destinations with wheeled walking device with stand by assist of one. The Quality Care Reporting Form and Investigation Report for Falls both dated 5/7/2011 note R5 was not wearing adequate footwear prior to the fall, she was wearing booties. R5 was walking to the bathroom, got up to toilet self, and although the nurse was present in the room was not providing stand by assist, as R5 lost her balance the nurse assisted R5 to the floor. No injury was noted. During an interview with E1 on 7/28/2011 at 3:00 pm E1 stated R5 wants to be as independent as possible.